title: The natural history of main duct-involved, mixed-type intraductal papillary mucinous neoplasm: parameters predictive of progression.
abstract: OBJECTIVE
  As such, the natural history of MPD-involved IPMN is poorly understood.
  
  
  BACKGROUND
  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.
  
  
  METHODS
  A review of a prospectively collected database (1992-2012) of patients with IPMN undergoing primary surveillance was performed. Invasive progression was defined as invasive carcinoma on pathology and/or positive cytopathology. Analyses included univariate, logistic regression, and receiver operating characteristic curve analyses.
  
  
  RESULTS
  A total of 503 patients with IPMN underwent primary surveillance, 70 for MPD-involved, mixed-type IPMN. Indications for intensive surveillance of these 70 high-risk patients were comorbidities, patient choice, and early/borderline MPD dilation (42%, 51%, and 7%, respectively). Mean follow-up was 4.7 years. Nine patients (13%) progressed at a mean of 3.5 (range, 1-9) years during follow-up. Univariate analyses yielded weight loss, interval (from isolated branch-duct IPMN) to MPD involvement, diffuse MPD dilation, increase of MPD diameter, absence of extra pancreatic cysts, elevated serum CA19-9 levels, and elevated serum alkaline phosphatase levels 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 levels, and absence of extra pancreatic cysts were predictors of invasiveness. The receiver operating characteristic curve indicated that the combination of these 4 factors achieved an accuracy of 98% in predicting progression.
  
  
  CONCLUSIONS
  Primary surveillance of mixed-type IPMN may be a reasonable strategy in select patients. Diffuse MPD dilation, serum CA19-9, serum alkaline phosphatase, and absence of extrapancreatic cysts predict patients likely to progress during primary surveillance.
authors.affiliation: *Department of Surgery, Indiana University School of Medicine, Indianapolis; and †Department of Medicine, Division of Gastroenterology, Indiana University Hospital, Indianapolis.
authors.forename: Alexandra M
authors.initials: AM
authors.lastname: Roch
authors.forename: Eugene P
authors.initials: EP
authors.lastname: Ceppa
authors.forename: Mohammad A
authors.initials: MA
authors.lastname: Al-Haddad
authors.forename: John M
authors.initials: JM
authors.lastname: DeWitt
authors.forename: Michael G
authors.initials: MG
authors.lastname: House
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Zyromski
authors.forename: Attila
authors.initials: A
authors.lastname: Nakeeb
authors.forename: C Max
authors.initials: CM
authors.lastname: Schmidt
mesh_terms: D002288:Adenocarcinoma, Mucinous / Q000097:blood / Q000473:pathology* / Q000628:therapy; D000236:Adenoma / Q000097:blood / Q000473:pathology* / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000469:Alkaline Phosphatase / Q000097:blood; D014408:Biomarkers, Tumor / Q000097:blood; D018395:CA-19-9 Antigen / Q000097:blood; D021441:Carcinoma, Pancreatic Ductal / Q000097:blood / Q000473:pathology* / Q000628:therapy; D018450:Disease Progression; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D010183:Pancreatic Ducts / Q000000981:diagnostic imaging / Q000473:pathology*; D010190:Pancreatic Neoplasms / Q000097:blood / Q000473:pathology* / Q000628:therapy; D049268:Positron-Emission Tomography; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D014408:Biomarkers, Tumor; D018395:CA-19-9 Antigen; D000469:Alkaline Phosphatase