Annals of Surgical Oncology

, Volume 20, Issue 2, pp 440–447 | Cite as

Malignant Progression in IPMN: A Cohort Analysis of Patients Initially Selected for Resection or Observation

  • J. LaFemina
  • N. Katabi
  • D. Klimstra
  • C. Correa-Gallego
  • S. Gaujoux
  • T. P. Kingham
  • R. P. DeMatteo
  • Y. Fong
  • M. I. D’Angelica
  • W. R. Jarnagin
  • R. K. Do
  • M. F. Brennan
  • Peter J. Allen
Pancreatic Tumors

Abstract

Background

Intraductal papillary mucinous neoplasms (IPMN) may represent a field defect of pancreatic ductal instability. The relative risk of carcinoma in regions remote from the radiographically identified cyst remains poorly defined. This study describes the natural history of IPMN in patients initially selected for resection or surveillance.

Methods

Patients with IPMN submitted to resection or radiographic surveillance were identified from a prospectively maintained database. Comparisons were made between these two groups.

Results

From 1995 to 2010, a total of 356 of 1,425 patients evaluated for pancreatic cysts fulfilled inclusion criteria. Median follow-up for the entire cohort was 36 months. Initial resection was selected for 186 patients (52 %); 114 had noninvasive lesions and 72 had invasive disease. A total of 170 patients underwent initial nonoperative management. Median follow-up for this surveillance group was 40 months. Ninety-seven patients (57 % of those under surveillance) ultimately underwent resection, with noninvasive disease in 79 patients and invasive disease in 18. Five of the 18 (28 %) invasive lesions developed in a region remote from the monitored lesion. Ninety invasive carcinomas were identified in the entire population (25 %), ten of which developed the invasive lesion separate from the index cyst, representing 11 % with invasive disease.

Conclusions

Invasive disease was identified in 39 % of patients with IPMN selected for initial resection and 11 % of patients selected for initial surveillance. Ten patients developed carcinoma in a region separate from the radiographically identified IPMN, representing 2.8 % of the study population. Diagnostic, operative, and surveillance strategies for IPMN should consider risk not only to the index cyst but also to the entire gland.

References

  1. 1.
    Fernandez-del Castillo C, Targarona J, Thayer SP, et al. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg. 2003;138:427–3.Google Scholar
  2. 2.
    Loftus EV Jr, Olivares-Pakzad BA, Batts KP, et al. Intraductal papillary–mucinous tumors of the pancreas: clinicopathologic features, outcome, and nomenclature. Members of the Pancreas Clinic, and pancreatic surgeons of Mayo Clinic. Gastroenterology. 1996;110:1909–18.PubMedCrossRefGoogle Scholar
  3. 3.
    Rivera JA, Fernandez-del Castillo C, Pins M, et al. Pancreatic mucinous ductal ectasia and intraductal papillary neoplasms. A single malignant clinicopathologic entity. Ann Surg. 1997;225:637–44.PubMedCrossRefGoogle Scholar
  4. 4.
    Sohn TA, Yeo CJ, Cameron JL, et al. Intraductal papillary mucinous neoplasms of the pancreas: an increasingly recognized clinicopathologic entity. Ann Surg. 2001;234:313–21.PubMedCrossRefGoogle Scholar
  5. 5.
    Tanaka M, Kobayashi K, Mizumoto K, Yamaguchi K. Clinical aspects of intraductal papillary mucinous neoplasm of the pancreas. J Gastroenterol. 2005;40:669–75.PubMedCrossRefGoogle Scholar
  6. 6.
    Tanno S, Nakano Y, Koizumi K, et al. Pancreatic ductal adenocarcinomas in long-term follow-up patients with branch duct intraductal papillary mucinous neoplasms. Pancreas. 2010;39:36–40.PubMedCrossRefGoogle Scholar
  7. 7.
    Yopp AC, Katabi N, Janakos M, et al. Invasive carcinoma arising in intraductal papillary mucinous neoplasms of the pancreas: a matched control study with conventional pancreatic ductal adenocarcinoma. Ann Surg. 2011;253:968–74.PubMedCrossRefGoogle Scholar
  8. 8.
    Bernard P, Scoazec JY, Joubert M, et al. Intraductal papillary-mucinous tumors of the pancreas: predictive criteria of malignancy according to pathological examination of 53 cases. Arch Surg. 2002;137:1274–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Conlon KC. Intraductal papillary mucinous tumors of the pancreas. J Clin Oncol. 2005;23:4518–23.PubMedCrossRefGoogle Scholar
  10. 10.
    Rodriguez JR, Salvia R, Crippa S, et al. Branch-duct intraductal papillary mucinous neoplasms: observations in 145 patients who underwent resection. Gastroenterology. 2007;133:72–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Salvia R, Crippa S, Falconi M, et al. Branch-duct intraductal papillary mucinous neoplasms of the pancreas: to operate or not to operate? Gut. 2007;56:1086–90.PubMedCrossRefGoogle Scholar
  12. 12.
    Schmidt CM, White PB, Waters JA, et al. Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg. 2007;246:644–51.PubMedCrossRefGoogle Scholar
  13. 13.
    Sohn TA, Yeo CJ, Cameron JL, et al. Intraductal papillary mucinous neoplasms of the pancreas: an updated experience. Ann Surg. 2004;239:788–97.PubMedCrossRefGoogle Scholar
  14. 14.
    Sugiyama M, Izumisato Y, Abe N, et al. Predictive factors for malignancy in intraductal papillary–mucinous tumours of the pancreas. Br J Surg. 2003;90:1244–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Hruban RH, Takaori K, Canto M, et al. Clinical importance of precursor lesions in the pancreas. J Hepatobiliary Pancreat Surg. 2007;14:255–63.PubMedCrossRefGoogle Scholar
  16. 16.
    White R, D’Angelica M, Katabi N, et al. Fate of the remnant pancreas after resection of noninvasive intraductal papillary mucinous neoplasm. J Am Coll Surg. 2007;204:987–93.PubMedCrossRefGoogle Scholar
  17. 17.
    Tada M, Kawabe T, Arizumi M, et al. Pancreatic cancer in patients with pancreatic cystic lesions: a prospective study in 197 patients. Clin Gastroenterol Hepatol. 2006;4:1265–70.PubMedCrossRefGoogle Scholar
  18. 18.
    Uehara H, Nakaizumi A, Ishikawa O, et al. Development of ductal carcinoma of the pancreas during follow-up of branch duct intraductal papillary mucinous neoplasm of the pancreas. Gut. 2008;57:1561–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Tanno S, Nakano Y, Sugiyama Y, et al. Incidence of synchronous and metachronous pancreatic carcinoma in 168 patients with branch duct intraductal papillary mucinous neoplasm. Pancreatology. 2010;10:173–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Ingkakul T, Sadakari Y, Ienaga J, et al. Predictors of the presence of concomitant invasive ductal carcinoma in intraductal papillary mucinous neoplasm of the pancreas. Ann Surg. 2010;251:70–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Allen PJ. The management of intraductal papillary mucinous neoplasms of the pancreas. Surg Oncol Clin N Am. 2010;19:297–310.PubMedCrossRefGoogle Scholar
  22. 22.
    Allen PJ, D’Angelica M, Gonen M, et al. A selective approach to the resection of cystic lesions of the pancreas: results from 539 consecutive patients. Ann Surg. 2006;244:572–82.PubMedGoogle Scholar
  23. 23.
    Brugge WR, Lauwers GY, Sahani D, et al. Cystic neoplasms of the pancreas. N Engl J Med. 2004;351:1218–26.PubMedCrossRefGoogle Scholar
  24. 24.
    Nagula S, Kennedy T, Schattner MA, et al. Evaluation of cyst fluid CEA analysis in the diagnosis of mucinous cysts of the pancreas. J Gastrointest Surg. 2010;14:1997–2003.PubMedCrossRefGoogle Scholar
  25. 25.
    Pelaez-Luna M, Chari ST, Smyrk TC, et al. Do consensus indications for resection in branch duct intraductal papillary mucinous neoplasm predict malignancy? A study of 147 patients. Am J Gastroenterol. 2007;102:1759–64.PubMedCrossRefGoogle Scholar
  26. 26.
    Tang RS, Weinberg B, Dawson DW, et al. Evaluation of the guidelines for management of pancreatic branch-duct intraductal papillary mucinous neoplasm. Clin Gastroenterol Hepatol. 2008;6:815–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Fernandez-del Castillo C, Adsay NV. Intraductal papillary mucinous neoplasms of the pancreas. Gastroenterology. 2010;139:708–13, 713e1–2.Google Scholar
  28. 28.
    Spinelli KS, Fromwiller TE, Daniel RA, et al. Cystic pancreatic neoplasms: observe or operate. Ann Surg. 2004;239:651–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Walsh RM, Vogt DP, Henderson JM, et al. Natural history of indeterminate pancreatic cysts. Surgery. 2005;138:665–70.PubMedCrossRefGoogle Scholar
  30. 30.
    Traverso LW, Peralta EA, Ryan JA Jr, Kozarek RA. Intraductal neoplasms of the pancreas. Am J Surg. 1998;175:426–32.PubMedCrossRefGoogle Scholar
  31. 31.
    Schmidt CM, Lillemoe KD. IPMN—controversies in an “epidemic.” J Surg Oncol. 2006;94:91–3.PubMedCrossRefGoogle Scholar
  32. 32.
    Irie H, Yoshimitsu K, Aibe H, et al. Natural history of pancreatic intraductal papillary mucinous tumor of branch duct type: follow-up study by magnetic resonance cholangiopancreatography. J Comput Assist Tomogr. 2004;28:117–22.PubMedCrossRefGoogle Scholar
  33. 33.
    Salvia R, Fernandez-del Castillo C, Bassi C, et al. Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg. 2004;239:678–85.PubMedCrossRefGoogle Scholar
  34. 34.
    Tanaka M, Chari S, Adsay V, et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology. 2006;6:17–32.PubMedCrossRefGoogle Scholar
  35. 35.
    Sahani DV, Saokar A, Hahn PF, et al. Pancreatic cysts 3 cm or smaller: how aggressive should treatment be? Radiology. 2006;238:912–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • J. LaFemina
    • 1
  • N. Katabi
    • 2
  • D. Klimstra
    • 2
  • C. Correa-Gallego
    • 1
  • S. Gaujoux
    • 1
  • T. P. Kingham
    • 1
  • R. P. DeMatteo
    • 1
  • Y. Fong
    • 1
  • M. I. D’Angelica
    • 1
  • W. R. Jarnagin
    • 1
  • R. K. Do
    • 3
  • M. F. Brennan
    • 1
  • Peter J. Allen
    • 1
  1. 1.Department of Surgical OncologyMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  2. 2.Department of PathologyMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  3. 3.Department of RadiologyMemorial Sloan-Kettering Cancer CenterNew YorkUSA

Personalised recommendations