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The Natural History of Main Duct Involved, Mixed-Type Intraductal Papillary Mucinous Neoplasm: Parameters Predictive of Progression
Alexandra M Roch*, Eugene P Ceppa*, Mohammad A Al-Haddad*, John M DeWitt*, David V Feliciano, C Max Schmidt
Indiana School of Medicine, Indianapolis, IN
OBJECTIVE(S):
The high-risk of malignancy associated with main pancreatic duct (MPD) involved intraductal papillary mucinous neoplasm (IPMN) has been established by surgical series. The International Consensus Guidelines recommend surgical resection of MPD-involved IPMN in fit patients. As such, the natural history of MPD-involved IPMN is poorly understood.
METHODS:
Review of a prospectively collected database (1992-2012) of patients with IPMN undergoing primary surveillance was performed. Malignant progression was defined as malignancy on pathology/cytopathology. Analyses included univariate, logistic regression and receiver operating characteristics (ROC) curves.
RESULTS:
503 patients with IPMN underwent primary surveillance, 70 for MPD-involved, mixed-type (MT) IPMN. Indications for intensive surveillance of these 70 high-risk patients were comorbidities, patient choice and early/borderline MPD dilation (42%, 51%, 7%). Mean follow-up was 4.7 years. 9 patients (13%) progressed at a mean of 3.5 years (range 1-9) during follow-up . Univariate analyses yielded weight loss, interval (from isolated BD-IPMN) to MPD involvement, diffuse MPD dilation, increase of MPD diameter, elevated serum CA19-9 and elevated serum alkaline phosphatase as significant. Maximum MPD and/or branch-duct diameter were not significant. In logistic regression, diffuse MPD dilation, serum CA19-9 and serum alkaline phosphatase were predictors of malignancy. Extrapancreatic cysts predicted benign behavior. ROC curve indicated the combination of these 4 factors achieved an accuracy of 98% in predicting progression.
CONCLUSIONS:
Primary surveillance of MT-IPMN may be a reasonable strategy in select patients. Diffuse MPD dilation, serum CA19-9 and serum alkaline phosphatase predict patients likely to progress during primary surveillance, whereas the presence of extrapancreatic cysts appears protective.
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