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Should All Branch-Duct IPMN's Be Resected?
Jennifer K. Plichta*, Zachary C. Fridirici, Anjali S. Godambe, Sherri Yong, Sam Pappas, Gerard Abood, Gerard V. Aranha
Department of Surgery, Loyola University Medical Center, Maywood, IL
Introduction: Intraductal papillary mucinous neoplasia (IPMN) arising in the main pancreatic duct has been consistently shown to be associated with a higher risk of malignancy. However, the relationship between branch-duct IPMN and malignancy remains controversial and difficult to assess.
Methods: Between 1/1/1999 and 5/1/2013, we retrospectively identified 84 consecutive patients with IPMN who underwent attempted curative resection. Clinicopathologic factors and cancer-related outcomes were assessed.
Results: 84 patients were identified, 43 males and 41 females, median age of 71.5 years. Although 32 lesions were found incidentally, the majority were symptomatic (abdominal pain and/or weight loss). Prior to surgery, 55 patients underwent endoscopic ultrasounds and 58 underwent biopsy. Only 12 lesions were specified as branch-duct pre-operatively, which inconsistently correlated with the surgical specimen (p=0.65). The majority of patients (62%) underwent pancreaticoduodenectomy, and the remainder had either distal pancreatectomy (36%) or central pancreatectomy (2%). Pathologic evaluation identified 28 branch-duct lesions and 54 main-duct lesions, of which 38 had concurrent branch-duct lesions; duct of origin data was unavailable for 2 specimens. Of the 82 patients where the duct was specified, 33 had associated invasive (n=28) or in-situ (n=5) carcinoma. There was no correlation between branch-duct origin and invasive carcinoma (main-duct 19 of 54, branch-duct 9 of 28, p=0.78). Multivariate analysis including tumor size did not influence this outcome (OR 1.14, CI 0.4-3.3). Malignant tumor size did not significantly differ by duct of origin (main-duct 3.3cm, branch-duct 3cm, p=0.2). Furthermore, 2 of 9 malignant branch duct lesions were <2cm in size on pre-operative imaging. Of the 6 patients with branch duct lesions ≥3cm on pre-operative imaging, only 50% harbored invasive malignancy. The presence of symptoms preoperatively was significantly associated with malignancy (51% vs. 22%, p=0.01). Weight loss or jaundice on initial presentation was associated with a subsequent diagnosis of malignancy among patients with branch-duct lesions (both p<0.05). Of the 28 patients with invasive carcinoma, branch-duct lesions were significantly associated with the presence of positive lymph nodes, perineural invasion, and lymphovascular invasion (all p<0.05).
Conclusions: Our data suggests that branch-duct lesions are as equally likely to be associated with invasive malignancy as main duct lesions, and may demonstrate more aggressive characteristics when invasion occurs. The malignant potential of IPMN remains clinically elusive based on current clinical strategies, particularly in regards to invasive characteristics of side-branch IPMN. Therefore, surgical resection is recommended for all IPMN lesions in order to reliably assess for concurrent malignancy.
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