American Surgical Association

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Does Surgical Margin Impact Recurrence in Non-Invasive Intraductal Papillary Mucinous Neoplasms? A Multi-Institutional Study
Syed A. Ahmad1, Vikrom K. Dhar*1, Michael J. Edwards1, Sameer H. Patel*1, Dennis J. Hanseman*1, Daniel E. Abbott*2, Sharon M. Weber2, Hong J. Kim3, Robert CG Martin4, Charles R. Scoggins4, David J. Bentrem*5, Kamran Idrees*6, Shishir K. Maithel*7, David A. Kooby7, Nipun B. Merchant8
1University of Cincinnati College of Medicine, Cincinnati, OH;2University of Wisconsin School of Medicine and Public Health, Madison, WI;3University of North Carolina School of Medicine, Chapel Hill, NC;4University of Louisville School of Medicine, Louisville, KY;5Northwestern University Feinberg School of Medicine, Chicago, IL;6Vanderbilt University School of Medicine, Nashville, TN;7Emory University, Atlanta, GA;8University of Miami Miller School of Medicine, Miami, FL

OBJECTIVE(S): The relevance of margin positivity on recurrence after resection of intraductal papillary mucinous neoplasms (IPMNs) is poorly defined. Consequently, controversy remains regarding optimal surveillance recommendations.
METHODS: Patients undergoing surgery for non-invasive IPMN at 8 academic medical centers from the Central Pancreas Consortium were analyzed. A positive margin was defined as presence of IPMN or Pancreatic Intraepithelial Neoplasia.
RESULTS: 502 patients underwent surgery for IPMN; 329 (66%) did not have invasive cancer on final pathology and form the study cohort. Of these, 20% harbored carcinoma in-situ or high grade dysplasia. A positive margin was found in 20% of cases and was associated with multifocal disease (p<0.01). At a median follow-up of 36 months, 30 (9%) patients recurred, with 6% developing recurrent IPMN and 3% developing invasive cancer. On multivariate analysis, margin positivity was not associated with recurrence of either IPMN or invasive cancer (p>0.05). No association between margin status and development of recurrence at the margin was found. Overall, 87% of recurrences developed in the remnant pancreas away from the margin and median time to recurrence was 22 months. Of note, 17% of patients recurred > 5 years following surgery.
CONCLUSIONS: In the largest series examining the significance of margin status following surgery for IPMN, we have demonstrated that margin positivity in non-invasive IPMNs may not be associated with developing recurrence. Long-term surveillance is required for all patients, as a significant number of recurrences developed over 5 years after the index operation. These findings should guide future consensus recommendations.

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