title: Are the Current Guidelines for the Surgical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas Adequate? A Multi-Institutional Study.
abstract: BACKGROUND
  Controversy persists regarding the management of patients with intraductal papillary mucinous neoplasms (IPMN). International consensus guidelines stratify patients into high-risk, worrisome, and low risk categories.
  
  
  METHODS
  The medical records of 7 institutions were reviewed for patients who underwent surgical management of IPMN between 2000 and 2015.
  
  
  RESULTS
  There were 324 patients included in the analysis; 60.4% of patients had main-duct/mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (n = 136); 68.9% of patients with high-risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/IC. Multivariate analysis demonstrated that only 1 of 3 high-risk features and 2 of 7 worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI 0.65 to 0.94) and 0.69 (95% CI 0.39 to 0.91), respectively. In the absence of high-risk features, HGD/IC was still present in 57.4% of patients with 2 or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/IC in a linear fashion (odds ratio 1.39; 95% CI 1.08 to 1.80; p < 0.01).
  
  
  CONCLUSIONS
  These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH.
authors.forename: Gregory C
authors.initials: GC
authors.lastname: Wilson
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
authors.affiliation: Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors.forename: David
authors.initials: D
authors.lastname: Bentrem
authors.affiliation: Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Abbott
authors.affiliation: Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
authors.forename: Sharon
authors.initials: S
authors.lastname: Weber
authors.affiliation: Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
authors.forename: Clifford
authors.initials: C
authors.lastname: Cho
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY.
authors.forename: Robert C G
authors.initials: RC
authors.lastname: Martin
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Scoggins
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, NC.
authors.forename: Hong Jin
authors.initials: HJ
authors.lastname: Kim
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, FL.
authors.forename: Nipun B
authors.initials: NB
authors.lastname: Merchant
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Edwards
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH. Electronic address: ahmadsy@uc.edu.
authors.forename: Syed A
authors.initials: SA
authors.lastname: Ahmad
mesh_terms: D000328:Adult; D000368:Aged; D016208:Databases, Factual; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D009361:Neoplasm Invasiveness; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D018570:Risk Assessment