Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis

Crippa, Stefano; Bassi, Claudio; Salvia, Roberto; Malleo, Giuseppe; Marchegiani, Giovanni; Rebours, Vinciane; Lévy, Philippe; Partelli, Stefano; Suleiman, Shadeah; Banks, Peter A.; Ahmed, Nazir; Chari, Suresh T.; Castillo, Carlos Fernández del; Falconi, Massimo

doi:10.1136/gutjnl-2015-310162

Cited by 186 publications

(133 citation statements)

References 32 publications

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“…Whereas the development of WF during this period is concerning, 80% of them are accounted for by cysts growing to greater than 3 cm in size which does not automatically portend malignancy or a worse outcome. In fact one study of untreated presumed BDIPMN with WF showed a 5 year disease specifi c survival of 96% ( 22 ). However, what is concerning from this paper is the late development of HRS, which accounted for two of the three patients who developed malignancy in this study.…”

Section: Pancreas and Biliary Tractcontrasting

confidence: 46%

“…One large cohort of presumed BD-IPMN patients followed for longer than 5 years had a 0, 1, and 15% risk of malignancy based on the presence of 0, 1 or 2 "high risk features" (cyst size >3 cm, dilated main pancreatic duct and mural nodule), with patients aft er 5 years surveillance being eight times more likely to die from causes other than from pancreatic cancer arising from their cyst. Th is concept of using the presence or absence of WF/HRS to make long-term decisions about surveillance is then further supported by several recent large studies of patients with presumed BD-IPMNs without WF surveyed for long period of time (up to 7 years), in which the 5 year disease specifi c survival is between 96-98% compared with a 28-60% risk of IPMN-related death in patient with HRS (22)(23)(24). Even in groups of elderly patients with WF, the 5-year disease specifi c survival is reported at 96% ( ref.…”

mentioning

confidence: 85%

“…Even in groups of elderly patients with WF, the 5-year disease specifi c survival is reported at 96% ( ref. 22 ). Overall these studies suggests that there may be value in using cyst morphology as a way of further risk stratifying these patients long term and then contemplating ceasing surveillance in certain low risk subgroups.…”

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confidence: 99%

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Editorial: Stopping Pancreatic Cyst Surveillance?

Farrell¹

2017

American Journal of Gastroenterology

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Abstract:The management of patients with pancreatic cysts, especially presumed branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), remains a challenge. BD-IPMNs carry a very low risk of malignancy and occur in predominantly older individuals who often die from causes not related to their pancreatic disease. The specifi c decision to stop surveillance of presumed low risk BD-IPMNs (those without either worrisome features (WF) or high risk stigmata (HRS)) is controversial, and needs to balance the real risk of malignancy or developing malignancy and IPMNrelated mortality, with the patient's life expectancy, quality of life expectations, and mortality from non-pancreatic-related causes. With improved life expectancy, improved survival from non-pancreatic malignancies, rising health costs, and growing detection of ever smaller presumed BD-IPMNs, this issue is becoming ever more critical. Am J Gastroenterol 2017; 112:1162-1164 doi: 10.1038/ajg.2017 Th e management of patients with pancreatic cysts, especially presumed branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), remains a challenge ( 1 ). BD-IPMNs carry a very low risk of malignancy and occur in predominantly older individuals who oft en die from causes not related to their pancreatic disease. Th e specifi c decision to stop surveillance of presumed low risk BD-IPMNs (those without either worrisome features (WF) or high risk stigmata (HRS)) is controversial, and needs to balance the real risk of malignancy or developing malignancy (0.007 per person-years of follow-up) and IPMN-related mortality (0.9%), with the patient's life expectancy, quality of life expectations, and mortality from non-pancreatic-related causes ( 2,3 ). With improved life expectancy, improved survival from non-pancreatic malignancies, rising health costs, and growing detection of ever smaller presumed BD-IPMNs, this issue is becoming ever more critical.Factors favoring ongoing indefi nite surveillance for presumed BD-IPMNs include the persistence of the malignant risk, the unpredictable natural history of an individual pancreatic cyst, the lack of understanding about the biology driving malignant progression, and the growing concern for concomitant pancreatic ductal adenocarcinoma elsewhere in the pancreatic gland ( 1,3 ). However, the arguments in favor of stopping surveillance are oft en equally strong, including the overall likely low rates of malignant change, economic and social cost off sets associated with indefi nite surveillance imaging, lack of eff ective treatment, and good outcomes for patients who develop malignancy during surveillance, risks associated with invasive surveillance imaging such as endoscopic ultrasound, and the high rates of morbidity and mortality associated with surgical resection. Putting aside that BD-IPMNs are diffi cult to accurately diagnose, and that there is currently no standardization for measuring them during surveillance, several factors do exist to help guide decision making about cessation of low risk presumed BD-IPMN sur...

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Section: Pancreas and Biliary Tractcontrasting

confidence: 46%

mentioning

confidence: 85%

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Editorial: Stopping Pancreatic Cyst Surveillance?

Farrell¹

2017

American Journal of Gastroenterology

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“…Additionally, there have been some retrospective studies of PC concomitant with IPMN (Table 2). 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 These studies demonstrated that the frequency of PC concomitant with IPMN ranged from 1.1% to 11.2%. As for branch duct IPMN, two working groups of JPS reported that seven PC cases were detected in 349 branch duct IPMN cases during the follow‐up period,17 and that PC concomitant with IPMN may be diagnosed earlier than ordinary PC 18.…”

Section: Risk Factors and Early Diagnosismentioning

confidence: 83%

Early diagnosis of pancreatic cancer: Current trends and concerns

Hanada

Amano

Abe

2017

Annals of Gastroent Surgery

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Early detection of pancreatic cancer (PC) is essential for a better prognosis. Some recent studies have demonstrated that a slight dilatation of the main pancreatic duct (MPD) and small cystic lesions were detected initially in most cases diagnosed at an early stage. Detecting these abnormal findings in cases with high risk factors through an effective screening system including image diagnosis, some biological markers, or familial cancer registrations should contribute to early diagnosis of PC. It has been reported that endoscopic ultrasonography (EUS) is essential for detecting tumors <10 mm with a favorable prognosis. Additionally, EUS‐guided fine‐needle aspiration biopsy is useful for confirming final histological diagnosis. For the diagnosis of stage 0 PC, local irregular stenosis of MPD should be an important initial abnormal sign detected by EUS or magnetic resonance cholangiopancreatography. Cytodiagnosis multiple times using pancreatic juice obtained by endoscopic nasopancreatic drainage should be essential for the final diagnosis. Recently, activities of regional networks between specialist doctors in medical centers and general practitioners for early diagnosis of PC have been reported in Japan. In the future, these activities may play an important role in the early diagnosis of PC.

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“…Th ey then followed the patients for the long term through the Kaiser Permanente system noting the risk of pancreatic cancer and all-cause mortality. Importantly, this study cohort was assembled from 2005 extending to 2015, during which time recommendations and consensus mortality for Whipple resection is 0-2% ( 14-16 ), yet results from a study using the National Inpatient Sample of >100,000 patients reported a mortality of 4.8% ( 17 ) and other recent studies note rates of 4-8% (18)(19)(20). Finally, patient wishes must be incorporated.…”

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confidence: 99%

Editorial: Management of the Small Asymptomatic Pancreatic Cyst: Somehow Along the Way We Forgot About the Patient

Wilcox

2017

American Journal of Gastroenterology

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The incidentally identifi ed pancreatic cyst is an increasing burden for both physicians and patients alike. Although we recognize that most of these lesions are benign and may not progress, a subset of these lesions are premalignant, may have frank cancer, and may progress over time. Most occur in older patients who have associated comorbidity. Recent studies highlight neoplastic features of these cysts that when present may warrant surgery or close long-term follow-up; however, there has been little study on the natural history factoring in patient comorbidity and pancreatic cancer-free survival. This retrospective cohort study underscores the importance of patient comorbidity in our management algorithm, and these data should prompt subsequent guidelines to factor in such comorbidity.

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Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis

Cited by 186 publications

References 32 publications

Editorial: Stopping Pancreatic Cyst Surveillance?

Editorial: Stopping Pancreatic Cyst Surveillance?

Early diagnosis of pancreatic cancer: Current trends and concerns

Editorial: Management of the Small Asymptomatic Pancreatic Cyst: Somehow Along the Way We Forgot About the Patient

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