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Intraductal Papillary Mucinous Neoplasms and the Risk of Diabetes Mellitus in Patients Undergoing Resection vs. Observation
Julie N. Leal*, T. P. Kingham, Michael D'Angelica, Ronald P. Dematteo, William R. Jarnagin, Peter J. Allen
Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
Background: Management of intraductal papillary mucinous neoplasms of the pancreas (IPMN) is controversial, and decisions regarding operative intervention should consider the risk of malignancy relative to the potential for long-term complications such as diabetes mellitus (DM).
Objective(s): To determine the prevalence of DM in patients diagnosed with IPMN and to compare rates of new or progressive DM between patients undergoing pancreatectomy versus observation.
Methods: Patients diagnosed with IPMN from January 2000 to September 2013, were identified from an institutional database and retrospectively analyzed. Patients in whom DM status was unknown/not ascertainable were excluded. In addition to standard clinicopathologic variables, serum glucose, diabetic status, and 3-D pancreatic volume data were obtained. Patients undergoing pancreatectomy were compared to those managed with radiographic surveillance. Observed patients were defined as having IPMN if radiographic imaging was consistent with this process and cyst fluid carcinoembryonic antigen (CEA) was elevated (>192 ng/ml).
Results: During the study period, 135 patients meeting inclusion criteria were identified; 104(77%) underwent pancreatectomy and 31(23%) were observed. Baseline demographic and clinicopathologic characteristics are outlined in Table 1. Prevalence of DM at baseline was not different between patients who underwent pancreatectomy (17.3%, 18/104) and those submitted to observation (22.6%, 7/31), p=0.51. Similarly, baseline serum glucose levels (114.6+/-44.1 mg/dL resected vs. 118.0+/-37.2 mg/dL observed, p=0.74) and BMI (26.5+/-10.1 kg/m2 resected vs. 27.2+/-5.4 kg/m2 observed, p=0.57) were not different between groups. Median follow up for the cohort was 53 (2.0-156.0) months. During this time, new or progressive DM (requiring change in oral medication or addition of insulin) occurred in 38 patients (28.1%) overall with no difference observed between patients who underwent resection (30/104, 28.8%) and those observed (8/31, 25.8%), p=0.74. Among the resected group, pancreatic remnant volumes were not different between those who did (1.2+/-0.66 mL*m2/kg) and did not (1.4+/-0.73 mL*m2/kg) develop new or progressive DM, p=0.59.
Conclusions: In this cohort of patients with IPMN and moderate follow-up, rates of new or progressive DM did not differ between resected and observed groups. These data suggest that underlying pancreatic pathology in patients with IPMN may contribute to the development of DM independent of extent of pancreatectomy. Larger studies are necessary to confirm these findings.
Characterisitics of Patients with IPMN
| Variable | All Patients with IPMN | Resected | Observed | p-value | | N | 135 | 104 | 31 | | | Sex | | | | | | Male | 46 | 36 | 10 | 0.81 | | Female | 89 | 68 | 21 | | | Age at Diagnosis | 65.0 +/- 17.3 | 64.0 +/- 18.7 | 68.4 +/- 10.9 | 0.22 | | BMI (kg/m<sup2> | 26.6 +/- 5.1 | 26.5 +/- 10.1 | 27.2 +/- 5.4 | 0.57 | | Location of Cyst | | | | | | Head | 80 | 63 | 17 | 0.06 | | Body | 29 | 18 | 11 | | | Tail | 26 | 23 | 3 | | | Cyst Size (mm) | 24.1 +/- 9.9 | 25.7 +/- 10.1 | 18.9 +/- 7.3 | 0.001 | | Pancreas Volume at Diagnosis (mL) | 76.1 +/- 22.1 | 75.0 +/- 21.6 | 77.7 +/- 23.1 | 0.61 | | Volume Normalized to BMI | 2.9 +/- 0.88 | 2.8 +/- 0.91 | 2.9 +/- 0.81 | 0.87 | | Pancreatic Remnant Volume (mL) | 36.4 +/- 20.3 | 36.4 +/- 20.3 | - | - | | Volume Normalized to BMI | 1.3 +/- 0.71 | 1.3 +/- 0.71 | - | - | | Diabetic Status | | | | | | DM at Baseline | 25 | 18 | 7 | 0.51 | | New DM | 24 | 18 | 6 | 0.79 | | Progression of DM | 14 | 12 | 2 | 0.45 | | New/Progression DM | 38 | 30 | 8 | 0.74 | | Glucose (mg/dL) | | | | | | At Diagnosis | 115.1 +/- 42.9 | 114.6 +/- 44.1 | 118.0 +/- 37.2 | 0.74 | | Post Operative | 139.8 +/- 49.2 | 139.8 +/- 49.2 | - | | | At last Follow Up | 123.8 +/- 37.9 | 125.9 +/- 38.4 | 102.6 +/- 25.7 | 0.10 | | Follow-up Time (months) | 53 (2-156) | 55 (2-154) | 45 (12-107) | 0.26 |
Table 1: Demographic and clinicopathologic characteristics for patients with IPMN stratified by resection versus observation (DM= diabetes mellitus, Data presented as- frequency, mean +/-standard deviation, median (min-max))
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