Optimal surveillance of intraductal papillary mucinous neoplasms of the pancreas focusing on remnant pancreas recurrence after surgical resection

Abstract

Background The international consensus guidelines for intraductal papillary mucinous neoplasm of the pancreas (IPMN) presented clinical features as indications for surgery. Whereas surveillance for recurrence, including de novo lesions, is essential, optimal surveillance protocols have not been established. Aim and methods This study aimed to assess the clinical features of recurrence at the remnant pancreas (Rem-Panc) and extra-pancreas (Ex-Panc) after surgery for IPMN. Ninety-one patients of IPMN that underwent detailed preoperative assessment and pancreatectomy were retrospectively analyzed, focusing especially on the type of recurrence. Results The IPMNs were finally diagnosed as low-grade dysplasia (LDA, n = 42), high-grade dysplasia (HAD, n = 19), and invasive carcinoma (IPMC, n = 30). Recurrence was observed in 26 patients (29%), of which recurrence was seen at Rem-Panc in 19 patients (21%) and Ex-Panc in 7 patients (8%). The frequency of Rem-Panc recurrence was 10% in LDA, 21% in HDA, and 37% in IPMC. On the other hand, Ex-Panc recurrence was observed only in IPMC (23%). Ex-Panc recurrence showed shorter median recurrence-free survival (RFS) and overall survival (OS) than Rem-Panc recurrence (median RFS 8 months vs. 35 months, p < 0.001; median OS 25 months vs. 72 months, p < 0.001). Regarding treatment for Rem-Panc recurrence, repeat pancreatectomy resulted in better OS than no repeat pancreatectomy (MST 36 months vs. 15.5 months, p = 0.033). On multivariate analysis, main duct stenosis or disruption as a preoperative feature (hazard ratio [HR] 10.6, p = 0.002) and positive surgical margin (HR 4.4, p = 0.018) were identified as risk factors for Rem-Panc recurrence. Conclusions The risk factors for Rem-Panc and Ex-Panc recurrence differ. Therefore, optimal surveillance on these features is desirable to ensure that repeat pancreatectomy for Rem-Panc recurrence can be an appropriate surgical intervention.

Novel Insights into Postoperative Surveillance in Resected Pancreatic Cystic Neoplasms—A Review

“…Recurrence may occur within the remaining pancreatic tissue, known as intrapancreatic recurrence, or outside the pancreas, termed extrapancreatic recurrence. This latter form has been reported in instances of IPMN associated with invasive carcinoma [29].…”

Virtual biopsy in abdominal pathology: where do we stand?

“… 50 Current guidelines recommend the maintenance of a balance between the risk of potential malignant transformation and the risks of pancreatic resection, 59 suggesting that only patients with high-grade dysplasia (HGD) should undergo surgery. 60 In this context, the VB system to pre-operatively assess IPMN grade could support the decision process, reducing the drawbacks of an invasive biopsy. An example is given by Tobaly et al, 50 who developed a CT-based model to differentiate between LGD, HGD, and invasive IPMN.…”

Current considerations on intraductal papillary neoplasms of the bile duct and pancreatic duct

“…After curative resection, IPNB malignancies exhibit a better prognosis than original cholangiocarcinomas[ 8 ], and IPMNs exhibit a better prognosis than pancreatic ductal adenocarcinomas[ 35 ]; however, the recurrence rate is up to 27% for IPNB[ 15 ] and up to 43% for IPMN[ 36 ]. Thus, regular follow-up is mandatory for early recurrence detection and reoperation in the pancreatic remnant[ 37 ].…”