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Outcomes of Primary Surveillance for Intraductal Papillary Mucinous Neoplasm

  • 2011 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Limited data are available regarding the natural history of patients undergoing primary surveillance for intraductal papillary mucinous neoplasm (IPMN). We hypothesize that symptoms, radiologic characteristics, and cytopathology will predict cancer risk during surveillance.

Methods

Between March 2002 and March 2010, 522 patients were diagnosed with IPMN at a single, high-volume institution. Low versus high oncologic risk was stratified prospectively. Patients with under 3 months of surveillance were excluded.

Results

Two hundred ninety-two patients underwent primary surveillance for IPMN. Two hundred forty-four (84%) were classified as low-risk IPMN. Mean surveillance duration was 35 (4–99) months. Thirty (12%) patients initially stratified as low-risk developed a new indication for pancreatic resection. Only 28 underwent resection, and pathologic tissue analysis revealed 27 (96%) low-grade IPMN and one (4%) high-grade dysplastic IPMN. Overall, two (1%) patients initially determined to be low-risk developed invasive cancer. Forty-eight (16%) patients stratified as high-risk IPMN were initially managed nonoperatively. Of the 13 (27%) high-risk patients that died during follow-up, two (15%) died from pancreatic cancer.

Conclusions

Progression to pancreatic cancer during surveillance for low-risk IPMN was rare. Current indications for resection did not forecast malignancy. Poor operative candidates with high-risk IPMN progressed to invasive cancer more commonly, though a substantial portion succumbed to non-IPMN-related death.

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Authors and Affiliations

  1. Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

    Christy E. Cauley, Joshua A. Waters, Ryan P. Dumas, Juliana E. Meyer, Keith D. Lillemoe & C. Max Schmidt

  2. Indiana University School of Medicine, Indianapolis, IN, USA

    Mohammad A. Al-Haddad & John M. DeWitt

  3. Department of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA

    Christy E. Cauley, Joshua A. Waters, Ryan P. Dumas, Juliana E. Meyer, Mohammad A. Al-Haddad, John M. DeWitt, Keith D. Lillemoe & C. Max Schmidt

  4. Biochemistry and Molecular Biology, Indiana University School of Medicine, 980 W Walnut St C522, Indianapolis, IN, 46202, USA

    C. Max Schmidt

  5. Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

    Christy E. Cauley, Joshua A. Waters, Ryan P. Dumas, Juliana E. Meyer & Keith D. Lillemoe

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  1. Christy E. Cauley
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Discussant

Dr. Carlos Fernandez del Castillo (Boston, MA): Congratulations on a well-presented paper. This study, derived from a very large cohort of patients with IPMN, shows that at the time of diagnosis, only a third of patients undergo surgery. You have focused on the other two thirds. The majority of these patients, which were 244 in number, were deemed to have a very low risk of malignancy and were put under surveillance. Within a median follow-up of almost 3 years, two patients developed pancreatic cancer (less than 1%) and did not undergo surgery, and an additional 28 patients (11%) underwent resection for a variety of reasons, and none had invasive IPMN on pathology. These data are an important contribution to the field and are mostly in agreement with other studies that have followed up such patients. Although reassuring to the safety of follow-up of presumed branch duct IPMNs, we are all fully aware that much longer follow-up will be needed before we know the full story of this condition.

You also tell us about 48 patients who were deemed to have a high risk of harboring cancer within their IPMNs, but mostly because of advanced age or serious comorbidities did not undergo surgery but were still followed up. These comprise about 10% of the cohort. To my knowledge, no other series has focused on this subgroup. You had a mean follow-up of 42 months in them and show us that 15% of them died of pancreatic cancer, but that 5-year survival was 62%. This is very useful data for clinicians taking care of these patients.

I have two questions for you:

1. The average size of these asymptomatic cysts was 1.6 cm, which is quite small. Did all of these patients undergo EUS at the time of diagnosis, and if so, what kind of information did you obtain from this study?

2. Follow-up of this increasingly larger cohort of patients is a huge challenge. In what percent of them did you lose follow-up?

Closing Discussant

Dr. Christy E. Cauley: Thank you for your insightful comments and questions. As clinicians continue to accrue experience with these relatively uncommon pancreatic lesions, a number of questions have been answered, but still more remain unclear. Although the outcome of patients undergoing resection for IPMN has been well documented in the literature, those patients who undergo primary surveillance remain a largely unstudied group. With this substantial collection of low- and high-risk surveillance patients, we feel some remaining questions regarding the natural history of IPMN can be addressed. The findings in this study must be viewed in light of the indolent nature of IPMN and the relatively short median surveillance period. Given this limitation, we feel that your questions can be addressed with the following response.

Although the overall size of IPMN within the low-risk surveillance group was less than 2 cm, several patients were followed up with lesions measuring over 3 cm. Additionally, no relationship was revealed between the size or change in size of these lesions and the risk of malignancy. An important element of our risk stratification algorithm involves performing EUS to assess the lesion for high-risk features. Clearly, FNA may be difficult to perform for very small cysts; however, 83% of low-risk patients undergoing surveillance in this study underwent both EUS and FNA.

Within any study, particularly one focusing on surveillance, patient retention, and follow-up can be a challenge. This can be magnified in elderly patients who may be less interested in intense surveillance strategies. In our experience, 18% of low-risk patients and 21% of high-risk patients had three or more years with no recorded visits with gastroenterology or surgery and were considered lost to follow-up. It is feasible that some patients within this group may have developed undocumented disease progression.

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Cauley, C.E., Waters, J.A., Dumas, R.P. et al. Outcomes of Primary Surveillance for Intraductal Papillary Mucinous Neoplasm. J Gastrointest Surg 16, 258–266 (2012). https://doi.org/10.1007/s11605-011-1757-6

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  • DOI: https://doi.org/10.1007/s11605-011-1757-6

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