Malignant Progression in IPMN: A Cohort Analysis of Patients Initially Selected for Resection or Observation
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ORIGINAL ARTICLE – PANCREATIC TUMORS
Malignant Progression in IPMN: A Cohort Analysis of Patients Initially Selected for Resection or Observation J. LaFemina1, N. Katabi2, D. Klimstra2, C. Correa-Gallego1, S. Gaujoux1, T. P. Kingham1, R. P. DeMatteo1, Y. Fong1, M. I. D’Angelica1, W. R. Jarnagin1, R. K. Do3, M. F. Brennan1, and Peter J. Allen1 Department of Surgical Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY; 2Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY; 3Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 1
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 Ó Society of Surgical Oncology 2012 First Received: 11 May 2012; Published Online: 31 October 2012 P. J. Allen e-mail: [email protected]
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.
Our understanding of intraductal papillary mucinous neoplasm (IPMN) has evolved since its first description in 1996, with increasing knowledge about outcomes associated with radiographic and histologic subtypes (i.e., tubular vs. colloid carcinoma).1–7 Although the molecular bases remain poorly understood, it is believed that main duct (MD)-IPMN and branch duct (BD)-IPMN carry a variable but measurable risk of cancer progression.6, 8–14 As IPMN has been proposed to represent a field defect o
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