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VALIDITY OF THE SURGICAL INDICATION FOR INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS OF THE PANCREAS ADVOCATED BY THE REVISED INTERNATIONAL CONSENSUS FUKUOKA GUIDELINES
Yusuke Watanabe*, Sho Endo, Kazuyoshi Nishihara, Toru Nakano
Department of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
Background: Although understanding of intraductal papillary mucinous neoplasm (IPMN) has significantly evolved based on accumulating evidence, including the 2006 international consensus guidelines for the management of IPMN (Sendai Guidelines) and the guidelines revised in 2012 (Fukuoka Guidelines; FG), accurate preoperative prediction for advanced IPMN, including high-grade dysplasia (HGD) and invasive carcinoma, is still challenging. The surgical indication of the FG overestimated the preoperative risk of advanced IPMN. To address this issue, the long-awaited revision of FG (RFG) was published in 2017. The aim of this study was to investigate the validity of the surgical indication for IPMN advocated by the RFG.
Methods: The medical records of 63 patients who underwent pancreatectomy for IPMN were retrospectively reviewed. Low-grade dysplasia was regarded as a benign IPMN, and HGD and invasive carcinoma were regarded as advanced disease.
Results: Thirteen patients had main-duct IPMN, 25 had mixed IPMN, and 25 had branch-duct IPMN, with advanced IPMN frequencies of 69%, 24%, and 31%, respectively. Thirty-three patients had high-risk stigmata, 29 had worrisome features, and one had no risk factor. Nineteen (58%) patients with high-risk stigmata and 2 (7%) with worrisome features had advanced IPMN. All patients with invasive carcinoma had high-risk stigmata and 16 patients had enhanced mural nodule (MN) ≥ 5 mm. The sensitivity, specificity, accuracy, and positive and negative predictive values of high-risk stigmata for advanced IPMN advocated by the RFG were 90%, 67%, 75%, 58%, and 93%, respectively. For comparison, high-risk stigmata advocated by the FG were also assessed by using the same study population. The sensitivity, specificity, accuracy, and positive and negative predictive values of high-risk stigmata advocated by the FG were, 90%, 60%, 68%, 53%, and 93%, respectively. The sensitivity and specificity of enhanced MN ≥ 5 mm for predicting invasive carcinoma were 94% and 87%, respectively, Diameter of main pancreatic duct did not correlate with the prevalence of advanced IPMN.
Conclusion: Surgical indication for IPMN advocated by the RFG was improved compared with the FG. The introduction of the size threshold of enhanced MN ≥ 5 mm into the criteria increased specificity and positive predictive value without jeopardizing sensitivity, especially in patients with invasive carcinoma. The three high-risk stigmata carry unequal weight and surgical indication for IPMN may be decidable by using only enhanced MN ≥ 5 mm. When the type of IPMN was classified strictly based on the definition of the guidelines, about half of IPMNs were mixed type, and most of the mixed IPMNs were benign. Surgical indication of mixed IPMN should be reconsidered as an independent morphological type.
Histological categories according to the morphological type of intraductal papillary mucinous neoplasm
| | MD-IPMN
(n = 13) | Mixed IPMN
(n = 25) | BD-IPMN
(n = 25) | |
| | n | % | n | % | n | % | P value |
| Invasive carcinoma | 8 | 69 | 3 | 12 | 6 | 24 | 0.02 |
| High-grade dysplasia | 0 | 0 | 3 | 12 | 1 | 4 | |
| Low-grade dysplasia | 5 | 38 | 19 | 76 | 18 | 72 | |
MD main duct, BD, branch-duct, IPMN intraductal papillary mucinous neoplasm
Overall patient characteristics
| | Overall patients
(n = 63) | Patients with high-risk stigmata
(n = 33) | Patients with worrisome features
(n = 29) | |
| Value | % | Value | % | Value | % | P value |
| Operation | | | | | | | 0.75 |
| Pancreatoduodenectomy | 32 | 51 | 18 | 55 | 13 | 45 | |
| Distal pancreatectomy | 29 | 46 | 14 | 42 | 15 | 52 | |
| Total pancreatectomy | 2 | 3 | 1 | 3 | 1 | 3 | |
| Type of IPMN | | | | | | | <0.01 |
| MD-IPMN | 13 | 21 | 11 | 33 | 2 | 7 | |
| Mixed IPMN | 25 | 40 | 14 | 42 | 11 | 38 | |
| BD-IPMN | 25 | 40 | 8 | 24 | 16 | 55 | |
| Presence of enhanced mural nodule | 27 | 43 | 24 | 73 | 3 | 10 | <0.01 |
| Size of enhanced mural nodule, mm | 10 (0-40) | | 10 (0-40) | | 0 (0-4) | | <0.01 |
| Enhanced mural nodule ≥ 5 mm | 22 | 35 | 22 | 67 | 0 | 0 | <0.01 |
| Detection of mural nodule using EUS* | 42 | 78 | 25 | 89 | 17 | 68 | 0.09 |
| Size of mural nodule measured using EUS, mm* | 8 (0-39) | | 10.5 (0-39) | | 2 (0-16) | | <0.01 |
| Mural nodule measured using EUS ≥ 5 mm* | 33 | 61 | 23 | 82 | 10 | 40 | <0.01 |
| Histological category | | | | | | | <0.01 |
| Invasive carcinoma | 17 | 27 | 17 | 52 | 0 | 0 | |
| High-grade dysplasia | 4 | 6 | 2 | 6 | 2 | 7 | |
| Low-grade dysplasia | 42 | 67 | 14 | 42 | 27 | 93 | |
The values are expressed as median (range) or number of patients MD main-duct, BD branch-duct, IPMN intraductal papillary mucinous neoplasm, EUS endoscopic ultrasonography *EUS was performed in 54 of 63 patients. Of the 54 patients who underwent EUS, 28 patients with high-risk stigmata, 25 with worrisome features, and 1 without risk factor.
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