SSAT - NEUTROPHIL-TO-LYMPHOCYTE RATIO AND MURAL NODULE HEIGHT AS PREDICTIVE FACTORS FOR MALIGNANT INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS

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NEUTROPHIL-TO-LYMPHOCYTE RATIO AND MURAL NODULE HEIGHT AS PREDICTIVE FACTORS FOR MALIGNANT INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS
Yusuke Watanabe^*, Kazuyoshi Nishihara, Toru Nakano
Department of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan

Background: The specificity and positive predictive value of high-risk stigmata (HRS) advocated by the International Consensus Guidelines 2012 for predicting malignant intraductal papillary mucinous neoplasms (IPMNs) remain unsatisfactory. Accurate preoperative prediction of malignant IPMNs is challenging, and improved markers for malignant IPMN prediction are needed. The aim of this study was to investigate the validity of the preoperative neutrophil-to-lymphocyte ratio (NLR) and mural nodule height measured by endoscopic ultrasonography as additional malignant IPMN markers for the guidelines.
Methods: The medical records of 59 consecutive patients with IPMN diagnosed histologically after pancreatectomy between 2006 and 2016 were retrospectively reviewed. Endoscopic ultrasonography was performed in 50 of the 59 patients. Malignant IPMN included high-grade dysplasia as well as invasive carcinoma.
Results: Twenty patients had malignant IPMN, while 39 had benign IPMN. Thirty-five patients had HRS, and 18 (51%) of the patients with HRS had malignant IPMN. The sensitivity, specificity and positive and negative predictive values of HRS for malignant IPMN were 90%, 56%, 51% and 92%, respectively. NLRs tended to be higher in patients with malignant IPMN (median, 2.23; range, 1.05-10.63)) than in those with benign IPMN (median, 2.04; range, 0.58-5.68; P = 0.15). Mural nodules were detected by endoscopic ultrasonography in 40 patients. Mural nodule heights were significantly greater in patients with malignant IPMN (median, 16 mm; range, 2-39 mm) than in those with benign IPMN (median, 8 mm; range, 2-30 mm; P <0.01). The optimal cut off values for the NLR and the mural nodule height were calculated by receiver operating characteristic curve analysis to be 3.60 and 11 mm, respectively. The sensitivity, specificity and positive and negative predictive values of NLR ≥ 3.60 for predicting malignant IPMN were 40%, 92%, 72% and 75%, respectively, and those of the mural nodule height ≥ 11 mm were 73%, 76%, 65% and 83%, respectively. Univariate analysis revealed that main duct type IPMN (P <0.01), presence of enhanced solid component (P <0.01), abrupt change in caliber of main pancreatic duct (P <0.01), NLR ≥ 3.60 (P <0.01) and mural nodule height ≥ 11 mm (P <0.01) were significant preoperative factors for predicting malignant IPMN. Multivariate analysis demonstrated that presence of enhanced solid component (odds ratio, 8.20; 95% confidence interval, 1.14-90.97) and mural nodule height ≥ 11 mm (odds ratio, 6.51; 95% confidence interval, 1.4-59.36) were independent factors.
Conclusion: The NLR and mural nodule height might be useful markers for predicting which IPMNs must be surgically resected. The NLR should be added to the list of worrisome features, and mural nodule height should be added to HRS criteria.

Univariate and multivariate analysis for predicting malignant intraductal papillary mucinous neoplasms
Factors Univariate analysis Multivariate analysis
Odds ratio 95% CI P value Odds ratio 95% CI P value
Main duct IPMN 7.15 1.94-30.95 <0.01 15.52 0.59-2340.47 0.11
High-risk stigmata
Obstructive jaundice NA NA 0.34
Enhanced solid component 31.17 7.81-168.31 <0.01 8.20 1.14-90.97 0.04
MPD diameter ≥ 10 mm 0.96 0.28-3.06 1.00 0.29 0.01-7.70 0.48
Worrisome features
History of pancreatitis 0.51 0.07-2.37 0.41
Cyst diameter ≥ 30 mm 0.57 0.19-1.71 0.31
Thickened and enhanced cyst wall 0.97 0.19-4.18 0.97
MPD diameter of 5-9 mm 1.58 0.53-4.85 0.41
Non-enhanced mural nodule 0.58 0.11-2.29 0.46
Abrupt cahnge in caliber of MPD with distal pancreatic atrophy NA NA <0.01
Lymphadenopathy NA NA 0.33
NLR ≥ 3.60 8.00 1.97-41.29 <0.01 5.35 0.43-155.00 0.20
Mural nodule height ≥ 11 mm 8.71 2.01-37.76 <0.01 6.51 1.04-59.36 0.04

CI, confidence interval; NA, not available; IPMN, intraductal papillary mucinous neoplasm; MPD, main pancreatic duct; NLR, neutrophil-to-lymphocyte ratio

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