Journal of Digestive Cancer Reports

Korean Society of Gastrointestinal Cancer Research (대한소화기암연구학회)
권호 표지
DOI QR코드

DOI QR Code

Management Strategy and Surveillance of Intraductal Papillary Mucinous Neoplasm-Gastroenterologist's Viewpoint

췌관 내 유두상 점액종양의 치료 전략과 추적 관찰-소화기내과의 관점

  • Kim, Tae Hyeon (Divison of Biliopancreas, Department of Internal Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine) ;
  • Chon, Hyung Ku (Divison of Biliopancreas, Department of Internal Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine)
  • 김태현 (원광대학교 의과대학 원광대학교병원 췌장담도내과) ;
  • 전형구 (원광대학교 의과대학 원광대학교병원 췌장담도내과)
  • Received : 2021.05.16
  • Accepted : 2021.05.18
  • Published : 2021.06.01
⟨ Previous Next ⟩

Abstract

The length, the frequency, and the methods of surveillance for intraductal papillary mucinous neoplasm (IPMN) of the pancreas are still debating. According to the recent guidelines, IPMN is stratified into "high-risk stigmata" or absolute indication and "worrisome features" or relative indication as a guide in managing these patients, either those with resection of the lesion or those under surveillance. The risk of malignant transformation was quite low for branch duct-IPMNs without worrisome features or high risk stigmata. However, because the incidence rate of pancreatic cancer in these patients increase linearly with time, continued long-term surveillance is therefore important for patients with low-risk, as well as higher-risk, IPMN. Considering the high prevalence of malignancy, main duct-IPMN should be treated by surgical resection. Among patients with these type IPMNs, segmental dilatation of the main pancreatic duct without any mural nodules and larger than 10 mm of main pancreatic duct might not be immediately resected and need very careful examination and observation. The risk related to a major pancreatic resection must balance the risk of surveillance in patients with IPMN of the pancreas who have co-morbidity and are elderly.

췌관 내 유두상 점액종양은 매우 다양한 자연경과와 예후를 가지고 있어 추적 검사방법, 간격, 기간 등이 아직도 논란이 되고 있다. 이 종양에 대한 진료지침들에서는 추적 검사를 받을 환자군과 수술적 치료가 필요한 군으로 분류하기 위하여 악성화 고위험 특징 또는 절대적 수술 적응증과 걱정스러운 특징 또는 상대적 수술 적응증으로 분류하였다. 걱정스러운 특징이나 고위험 특징이 없는 분지형 유두상 점액종양은 혼합형이나 주췌관 종양에 비하여 악성화 위험성이 매우 낮다고 보고되고 있다. 그러나 저위험 특징을 가진 환자들을 장기간 추적한 연구에서 시간이 지남에 따라서 췌장암 발생이 점점 높아지고 있다고 보고하고 있어 지속적인 장기간 추적 검사가 필요하다. 혼합형과 주췌관형 유두상 점액종양은 악성화 가능성이 매우 높아 수술적 치료가 필요하다고 알려져 있다. 무결절이고 주췌관 직경이 10 mm 미만으로 분절형 주췌관 확장을 가진 환자들은 악성화 가능성이 낮아서 즉각적인 수술보다는 주의 깊은 추적관찰을 고려해볼 수 있다. 고령이나 기저질환을 동반한 환자의 치료 방향을 결정할 때는 췌장암 발생의 위험도와 수술의 위험성을 균형있게 평가해야 한다.

Keywords

References

  1. Farrell JJ. Prevalence, diagnosis and management of pancreatic cystic neoplasms: current status and future directions. Gut Liver 2015;9:571-589. https://doi.org/10.5009/gnl15063
  2. Lee KS, Sekhar A, Rofsky NM, Pedrosa I. Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol 2010;105:2079-2084. https://doi.org/10.1038/ajg.2010.122
  3. Crippa S, Fernandez-Del Castillo C, Salvia R, et al. Mucin-producing neoplasms of the pancreas: an analysis of distinguishing clinical and epidemiologic characteristics. Clin Gastroenterol Hepatol 2010;8:213-219. https://doi.org/10.1016/j.cgh.2009.10.001
  4. Jang JY, Kim SW, Lee SE, et al. Treatment guidelines for branch duct type intraductal papillary mucinous neoplasms of the pancreas: when can we operate or observe? Ann Surg Oncol 2008;15:199-205. https://doi.org/10.1245/s10434-007-9603-5
  5. Nagai K, Doi R, Ito T, et al. Single-institution validation of the international consensus guidelines for treatment of branch duct intraductal papillary mucinous neoplasms of the pancreas. J Hepatobiliary Pancreat Surg 2009;16:353-358. https://doi.org/10.1007/s00534-009-0068-8
  6. Salvia R, Fernandez-del Castillo C, Bassi C, et al. Mainduct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg 2004;239:678-685; discussion 685-687. https://doi.org/10.1097/01.sla.0000124386.54496.15
  7. Kim TH, Song TJ, Lee SO, et al. Main duct and mixed type intraductal papillary mucinous neoplasms without enhancing mural nodules: duct diameter of less than 10 mm and segmental dilatation of main pancreatic duct are findings support surveillance rather than immediate surgery. Pancreatology 2019;19:1054-1060. https://doi.org/10.1016/j.pan.2019.09.010
  8. Abdeljawad K, Vemulapalli KC, Schmidt CM, et al. Prevalence of malignancy in patients with pure main duct intraductal papillary mucinous neoplasms. Gastrointest Endosc 2014;79:623-629. https://doi.org/10.1016/j.gie.2013.08.024
  9. Crippa S, Bassi C, Salvia R, et al. Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing nonoperative management: a mid-term follow-up analysis. Gut 2017;66:495-506. https://doi.org/10.1136/gutjnl-2015-310162
  10. Goh BK, Tan YM, Chung YF, et al. A review of mucinous cystic neoplasms of the pancreas defined by ovarian-type stroma: clinicopathological features of 344 patients. World J Surg 2006;30:2236-2245. https://doi.org/10.1007/s00268-006-0126-1
  11. Park JW, Jang JY, Kang MJ, Kwon W, Chang YR, Kim SW. Mucinous cystic neoplasm of the pancreas: is surgical resection recommended for all surgically fit patients? Pancreatology 2014;14:131-136. https://doi.org/10.1016/j.pan.2013.12.006
  12. Tanaka M, Fernandez-Del Castillo C, Kamisawa T, et al. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017;17:738-753. https://doi.org/10.1016/j.pan.2017.07.007
  13. European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018;67:789-804. https://doi.org/10.1136/gutjnl-2018-316027
  14. Ohtsuka T, Matsunaga T, Kimura H, et al. Role of pancreatic juice cytology in the preoperative management of intraductal papillary mucinous neoplasm of the pancreas in the era of international consensus guidelines 2012. World J Surg 2014;38:2994-3001. https://doi.org/10.1007/s00268-014-2684-y
  15. Aso T, Ohtsuka T, Matsunaga T, et al. "High-risk stigmata" of the 2012 international consensus guidelines correlate with the malignant grade of branch duct intraductal papillary mucinous neoplasms of the pancreas. Pancreas 2014;43:1239-1243. https://doi.org/10.1097/MPA.0000000000000199
  16. Kanno A, Satoh K, Hirota M, et al. Prediction of invasive carcinoma in branch type intraductal papillary mucinous neoplasms of the pancreas. J Gastroenterol 2010;45:952-959. https://doi.org/10.1007/s00535-010-0238-0
  17. Rodriguez JR, Salvia R, Crippa S, et al. Branch-duct intraductal papillary mucinous neoplasms: observations in 145 patients who underwent resection. Gastroenterology 2007;133:72-79; quiz 309-310. https://doi.org/10.1053/j.gastro.2007.05.010
  18. Kim TH, Woo YS, Chon HK, et al. Predictors of malignancy in "pure" branch-duct intraductal papillary mucinous neoplasm of the pancreas without enhancing mural nodules on CT imaging: a nationwide multicenter study. Gut Liver 2018;12:583-590. https://doi.org/10.5009/gnl17582
  19. Jung W, Park T, Kim Y, et al. Validation of a nomogram to predict the risk of cancer in patients with intraductal papillary mucinous neoplasm and main duct dilatation of 10mm or less. Br J Surg 2019;106:1829-1836. https://doi.org/10.1002/bjs.11293
  20. Pergolini I, Sahora K, Ferrone CR, et al. Long-term risk of pancreatic malignancy in patients with branch duct intraductal papillary mucinous neoplasm in a referral center. Gastroenterology 2017;153:1284-1294.e1. https://doi.org/10.1053/j.gastro.2017.07.019
  21. Lawrence SA, Attiyeh MA, Seier K, et al. Should patients with cystic lesions of the pancreas undergo long-term radiographic surveillance?: results of 3024 patients evaluated at a single institution. Ann Surg 2017;266:536-544. https://doi.org/10.1097/SLA.0000000000002371
  22. Crippa S, Pezzilli R, Bissolati M, et al. Active surveillance beyond 5 years is required for presumed branchduct intraductal papillary mucinous neoplasms undergoing non-operative management. Am J Gastroenterol 2017;112:1153-1161. https://doi.org/10.1038/ajg.2017.43
  23. Mukewar S, de Pretis N, Aryal-Khanal A, et al. Fukuoka criteria accurately predict risk for adverse outcomes during follow-up of pancreatic cysts presumed to be intraductal papillary mucinous neoplasms. Gut 2017;66:1811-1817. https://doi.org/10.1136/gutjnl-2016-311615
  24. Oyama H, Tada M, Takagi K, et al. Long-term risk of malignancy in branch-duct intraductal papillary mucinous neoplasms. Gastroenterology 2020;158:226-237.e5. https://doi.org/10.1053/j.gastro.2019.08.032
  25. Choi SH, Park SH, Kim KW, Lee JY, Lee SS. Progression of unresected intraductal papillary mucinous neoplasms of the pancreas to cancer: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2017;15:1509-1520.e4. https://doi.org/10.1016/j.cgh.2017.03.020
  26. Salvia R, Castillo CF, Bassi C, et al. Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg 2004;239:678-687. https://doi.org/10.1097/01.sla.0000124386.54496.15
  27. Suzuki Y, Atomi Y, Sugiyama M, et al. Cystic neoplasm of the pancreas: a Japanese multiinstitutional study of intraductal papillary mucinous tumor and mucinous cystic tumor. Pancreas 2004;28:241-246. https://doi.org/10.1097/00006676-200404000-00005
  28. Serikawa M, Sasaki T, Fujimoto Y, Kuwahara K, Chayama K. Management of intraductal papillary-mucinous neoplasm of the pancreas: treatment strategy based on morphologic classification. J Clin Gastroenterol 2006;40:856-862. https://doi.org/10.1097/01.mcg.0000225609.63975.6f
  29. Schmidt CM, White PB, Waters JA, et al. Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg 2007;246:644-651; discussion 651-654. https://doi.org/10.1097/SLA.0b013e318155a9e5
  30. Ceppa EP, Roch AM, Cioffi JL, et al. Invasive, mixed-type intraductal papillary mucinous neoplasm: superior prognosis compared to invasive main-duct intraductal papillary mucinous neoplasm. Surgery 2015;158:937-944; discussion 944-945. https://doi.org/10.1016/j.surg.2015.06.003
  31. Sahora K, Fernandez-del Castillo C, Dong F, et al. Not all mixed-type intraductal papillary mucinous neoplasms behave like main-duct lesions: implications of minimal involvement of the main pancreatic duct. Surgery 2014;156:611-621. https://doi.org/10.1016/j.surg.2014.04.023
  32. Crippa S, Pergolini I, Rubini C, et al. Risk of misdiagnosis and overtreatment in patients with main pancreatic duct dilatation and suspected combined/mainduct intraductal papillary mucinous neoplasms. Surgery 2016;159:1041-1049. https://doi.org/10.1016/j.surg.2015.11.003
  33. Hackert T, Fritz S, Klauss M, et al. Main-duct intraductal papillary mucinous neoplasm: high cancer risk in duct diameter of 5 to 9 mm. Ann Surg 2015;262:875-880; discussion 880-881. https://doi.org/10.1097/SLA.0000000000001462
  34. Vanella G, Crippa S, Archibugi L, et al. Meta-analysis of mortality in patients with high-risk intraductal papillary mucinous neoplasms under observation. Br J Surg 2018;105:328-338. https://doi.org/10.1002/bjs.10768