Ann Hepatobiliary Pancreat Surg.  2024 Nov;28(4):483-493. 10.14701/ahbps.24-049.

Comparative accuracy of four guidelines to predict high-grade dysplasia or malignancy in surgically resected pancreatic intraductal papillary mucinous neoplasms: Small nuances between guidelines lead to vastly different results

• Perez IC
• Bigelow A
• Shami VM
• Sauer BG
• Wang AY
• Strand DS
• Podboy AJ
• Bauer TW
• Zaydfudim VM
• Tsung A
• Buerlein RCD

• KMID: 2561581
• DOI: http://doi.org/10.14701/ahbps.24-049

Abstract

Backgrounds/Aims
The guidelines regarding the management of intraductal papillary mucinous neoplasms (IPMNs) all have slightly different surgical indications for high-risk lesions. We aim to retrospectively compare the accuracy of four guidelines in recommending surgery for high-risk IPMNs, and assess the accuracy of elevated CA-19-9 levels and imaging characteristics of IPMNs considered high-risk in predicting malignancy or high-grade dysplasia (HGD).
Methods
The final histopathological diagnosis of surgically resected high-risk IPMNs during 2013−2020 were compared to preoperative surgical indications, as enumerated in four guidelines: the 2015 American Gastroenterological Association (AGA), 2017 International Consensus, 2018 European Study Group, and 2018 American College of Gastroenterology (ACG). Surgery was considered “justified” if histopathology of the surgical specimen showed HGD/malignancy, or there was postoperative symptomatic improvement.
Results
Surgery was postoperatively justified in 26/65 (40.0%) cases. All IPMNs with HGD/malignancy were detected by the 2018 ACG and the combined (absolute and relative criteria) 2018 European guidelines. The combined (“high-risk stigmata” and “worrisome features”) 2017 International guideline missed 1/19 (5.3%) IPMNs with HGD/malignancy. The 2015 AGA guideline missed the most cases (11/19, 57.9%) of IPMNs with HGD/malignancy. We found the features most-associated with HGD/malignancy were pancreatic ductal dilation, and elevated CA-19-9 levels.
Conclusions
Following the 2015 AGA guideline results in the highest rate of missed HGD/malignancy, but the lowest rate of operating on IPMNs without these features; meanwhile, the 2018 ACG and the combined (absolute and relative criteria) 2018 European guidelines result in more operations for IPMNs without HGD/malignancy, but the lowest rates of missed HGD/malignancy in IPMNs.

Keyword

Pancreatic intraductal neoplasms; Pancreatic cyst; CA-19-9 antigen

Figure

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  Fig. 1 Missed HGD/malignant IPMNs and overtreatment of IPMNs per guideline. The rate of missed lesions with HGD/malignancy (total of 19 cases with HGD/malignancy) is shown by the dark blue bar graph for each guideline, while the rate of overtreatment per the total number of cases recommended for surgery based on each guideline is shown by the light blue bar graph. HGD, high-grade dysplasia; ACG, American College of Gastroenterology; AGA, American Gastroenterological Association; Euro., European; Euro. (combined), European combined absolute and relative criteria; Int., international; IPMNs, intraductal papillary mucinous neoplasms.

Reference

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