Consequences of a Surveillance Strategy for Side-branch Intraductal Pancreatic Mucinous Neoplasms: Long-term Follow-up of One Thousand Cysts.

IF 7.5 1区 医学 Q1 SURGERY
Annals of surgery Pub Date : 2024-10-01 Epub Date: 2024-06-06 DOI:10.1097/SLA.0000000000006383
Chase J Wehrle, Mir Shanaz Hossain, Breanna Perlmutter, Jenny H Chang, Daniel Joyce, Robert Simon, Toms Augustin, R Matthew Walsh
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引用次数: 0

Abstract

Objective: To quantify the rate of progression in surveilled cysts and assess what factors should indicate delayed resection.

Background: Side-branch intraductal papillary mucinous neoplasms (SB-IPMNs) are increasingly discovered, making it challenging to identify which patients require resection, thus avoiding inappropriate treatment. Most incidental lesions are surveyed, yet the consequences of that decision remain uncertain.

Methods: A prospectively maintained database of pancreatic cystic neoplasms was queried for patients with SB-IPMN. Patients with ≥2 imaging studies >6 months apart were included. Clinically relevant progression (CR-progression) was defined by symptoms, worrisome/high-risk stigmata, or invasive cancer (IC). Growth ≥5 mm in 2 years is considered CR-progression; size ≥3 cm alone is not.

Results: Between 1997 and 2023, 1337 patients were diagnosed with SB-IPMN. Thirty-seven (2.7%) underwent up-front surgery; 1000 (75.0%) had >6 months of surveillance.The rate of CR-progression was 15.3% (n = 153) based on size increase (n = 63, 6.3%), main-duct involvement (n = 48, 4.8%), symptoms (n = 8, 5.0%), or other criteria (n = 34, 3.4%). At a median follow-up of 6.6 years (interquartile range: 3.0-10.26), 17 patients (1.7%) developed IC. Those with CR-progression developed IC in 11.1% (n = 17) and high-grade dysplasia (HGD) in 6.5% (n = 10). Nearly half of the cancers were not contiguous with the surveyed SB-IPMN.Size ≥3 cm was not associated with HGD/IC ( P = 0.232). HGD/IC was least common in CR-progression determined by size growth (6.3%) versus main-duct involvement (24%) or other (43%, P < 0.001)Patients with CR-progression demonstrated improved survival (overall survival) with resection on time-to-event ( P < 0.001) and multivariate Cox regression (hazard ratio = 0.205, 0.096-0.439, P < 0.001) analyses. Overall survival was not improved with resection in all patients ( P = 0.244).

Conclusions: CR-progression for SB-IPMNs is uncommon, with the development of cancer anywhere in the pancreas being rare. Initial size should not drive resection. Long-term and consistent nonoperative surveillance is warranted, with surgery currently reserved for CR-progression, knowing that the majority of these still harbor low-grade pathology.

侧支导管内胰腺黏液性肿瘤监测策略的后果:一千个囊肿的长期随访。
目的:我们的目的是量化受监控囊肿的进展率,并评估哪些因素应提示延迟切除:侧支导管内乳头状粘液瘤(SB-IPMNs)的发现率越来越高,这使得确定哪些患者需要切除从而避免不适当的治疗具有挑战性。大多数偶发病灶都进行了调查,但这一决定的后果仍不确定:方法:在一个前瞻性维护的胰腺囊性肿瘤数据库中查询 SB-IPMN 患者。方法:在一个前瞻性数据库中查询了 SB-IPMN 患者。临床相关进展(CR-Progression)由症状、令人担忧/高风险迹象或浸润性癌症(IC)定义。2 年内生长≥5 毫米被认为是 CR-进展;单是大小≥3 厘米则不被认为是 CR-进展:1997-2023年间,1337名患者被诊断为SB-IPMN。根据体积增大(63 例,6.3%)、主干受累(48 例,4.8%)、症状(8 例,5.0%)或其他标准(34 例,3.4%),CR 进展率为 15.3%(153 例)。中位随访 6.6 年(IQR 3.0-10.26),17 名患者(1.7%)出现了 IC。CR 进展期患者中有 11.1%(17 人)发展为 IC,6.5%(10 人)发展为高级别发育不良(HGD)。近一半的癌症与所调查的 SB-IPMN 不毗连。大小≥3 厘米与 HGD/IC 无关(P=0.232)。HGD/IC在根据大小增长(6.3%)与主干受累(24%)或其他(43%,PC结论)确定的CR进展中最不常见:SB-IPMNs的临床相关进展并不常见,在胰腺的任何部位发生癌变都很罕见。最初的肿瘤大小不应影响切除手术。应进行长期、持续的非手术监测,目前手术仅用于 CR 进展期,因为大多数此类肿瘤仍存在低级别病理。
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来源期刊
Annals of surgery
Annals of surgery 医学-外科
CiteScore
14.40
自引率
4.40%
发文量
687
审稿时长
4 months
期刊介绍: The Annals of Surgery is a renowned surgery journal, recognized globally for its extensive scholarly references. It serves as a valuable resource for the international medical community by disseminating knowledge regarding important developments in surgical science and practice. Surgeons regularly turn to the Annals of Surgery to stay updated on innovative practices and techniques. The journal also offers special editorial features such as "Advances in Surgical Technique," offering timely coverage of ongoing clinical issues. Additionally, the journal publishes monthly review articles that address the latest concerns in surgical practice.
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