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

Irene C. Perez; Andrew Bigelow; Vanessa M. Shami; Bryan G. Sauer; Andrew Y. Wang; Daniel S. Strand; Alexander J. Podboy; Todd W. Bauer; Victor M. Zaydfudim; Allan Tsung; Ross C. D. Buerlein

doi:10.14701/ahbps.24-049

Ann Hepatobiliary Pancreat Surg

Published online June 20, 2024; https://doi.org/10.14701/ahbps.24-049

Irene C. Perez¹, Andrew Bigelow², Vanessa M. Shami², Bryan G. Sauer², Andrew Y. Wang², Daniel S. Strand², Alexander J. Podboy², Todd W. Bauer³, Victor M. Zaydfudim³, Allan Tsung³, Ross C. D. Buerlein²

¹Department of Internal Medicine, University of Virginia Health System, Charlottesville, VA, USA,
²Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA,
³Division of Surgical Oncology, University of Virginia Health System, Charlottesville, VA, USA

Correspondence to: Ross C. D. Buerlein, MD
Division of Gastroenterology and Hepatology, Digestive Health Center, University of Virginia Health System, Main Floor 1215 Lee St, Charlottesville, VA 22903, USA
Tel: +1-434-243-2090, Fax: +1-434-244-9445, E-mail: rcb9n@uvahealth.org, ORCID: https://orcid.org/0000-0002-1033-9783

Irene C. Perez’s current affiliation: Division of Gastroenterology and Hepatology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.

Received February 27, 2024; Revised April 28, 2024; Accepted April 30, 2024.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.; Keywords : Pancreatic intraductal neoplasms; Pancreatic cyst; CA-19-9 antigen