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A National Perspective of Invasive Intraductal Papillary Mucinous Neoplasm (IPMN)
Russell Lewis*, Jeffrey Drebin, Douglas L. Fraker, Charles M. Vollmer
Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
Objectives: Great understanding of IPMN has occurred in the last two decades, however questions remain which cannot be adequately answered by currently available institution-based literature. Specifically, 1) What are predictors of survival in these malignancies? 2) What is the impact of adjuvant therapy in this cohort? 3) How do outcomes compare to standard pancreatic ductal adenocarcinoma (PDAC)? A large scale assessment of invasive IPMN using a national dataset would provide greater clarity to these clinical dilemmas.
Methods: Surgical patients from the National Cancer Database (NCDB) with histologically confirmed invasive IPMN were studied from 1998-2005 and compared to those with PDAC. Patients were excluded if they received preoperative systemic or radiation therapy, or if they died within 30 days of the operation. Survival was assessed using the log-rank test statistic and Cox regression.
Results: 1739 patients underwent pancreatic resection for invasive IPMN (54% N0, 70% R0, median tumor size=3.5cm). 31% of patients were Stage 1, 33% Stage 2, 20% Stage 3, 11% Stage 4, and 5% were unclassified. For the overall cohort, median, 1-yr, and 5-yr survivals were 26.7m, 74%, and 32%. Adjuvant therapy was used in 45% of patients (24% in Stage 1 vs. 58% in Stages II-IV). The majority of treated patients received combined Chemo/XRT (70%). When assessed by Cox regression, improved survival for invasive IPMN was associated with receipt of adjuvant therapy (HR= 0.76; p<0.001), treatment at academic facilities, low grade tumors, N0 status, R0 resection, lower AJCC stage, and younger age. Furthermore, Cox models by stage revealed a survival advantage associated with adjuvant therapy in patients with Stage II-IV disease (HR 0.66; p<0.001), but not in Stage I (HR 1.21; p=0.223). IPMN had significantly better stage-adjusted survival than PDAC (table).
Conclusions: Invasive IPMN appears to be more indolent than standard PDAC, even after stage adjustment. Overall, adjuvant therapy improves survival for invasive IPMN, especially in higher-staged disease (by 34%). However, this benefit is not evident in early stage disease, negating the necessity of post-operative therapy in these situations. Median Survival in IPMN and PDAC According to AJCC Stage | Stage | IPMN | PDAC | P-Value | | Median Survival (m) | | | I | 80.4 | 24.6 | <0.001 | | II | 24.1 | 17.6 | <0.001 | | III | 16.8 | 14.4 | 0.010 | | IV | 10.1 | 9.8 | 0.318 | | Overall | 26.7 | 16.2 | <0.001 |
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