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Original Investigation
January 25, 2017

Factors Associated With Invasive Intraductal Papillary Mucinous Carcinoma of the Pancreas

Author Affiliations
  • 1Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
  • 2Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
  • 3Department of Pathology, Kyoto First Red Cross Hospital, Kyoto, Japan
JAMA Surg. Published online January 25, 2017. doi:10.1001/jamasurg.2016.5054
Key Points

Questions  What clinical factors are associated with invasive intraductal papillary mucinous carcinoma?

Findings  In this cohort study with 286 patients, a high mural nodule size for all types of carcinoma and high carcinoembryonic antigen levels in the pancreatic juice for main duct and mixed type carcinoma were found to be independently associated with invasive intraductal papillary carcinoma. These factors had an accuracy of 86% for differentiating between invasive and noninvasive intraductal papillary mucinous neoplasms.

Meaning  The measurement of mural nodule size in all types of carcinoma and carcinoembryonic antigen levels in the pancreatic juice in main duct and mixed type carcinoma might play important roles in predicting invasive intraductal papillary mucinous carcinoma.

Abstract

Importance  Invasive intraductal papillary mucinous carcinoma has aggressive malignant behavior, including lymph node metastasis. It is important to identify factors associated with invasive intraductal papillary mucinous carcinoma to determine operative procedures, but they remain unclear.

Objective  To identify the specific factors associated with invasive intraductal papillary mucinous neoplasms for branch duct, main duct, and mixed type carcinomas.

Design, Setting, and Participants  Retrospective cohort study of 286 consecutive patients who underwent surgical resection for intraductal papillary mucinous neoplasm from July 1999 to December 2015 at a tertiary institute. We compared clinical features between 96 patients (33.6%) with invasive intraductal papillary mucinous carcinoma and 190 patients (66.4%) with noninvasive intraductal papillary mucinous neoplasm for each morphological type.

Main Outcomes and Measures  Factors associated with invasive intraductal papillary mucinous carcinoma. Mural nodule size was measured by endoscopic ultrasonography.

Results  Of the 286 patients included in the cohort, the median (range) age was 71 (28-86) years, and 162 (56.6%) were male. High mural nodule size was independently associated with invasive intraductal papillary mucinous carcinoma in all types (branch duct: odds ratio [OR], 1.992; 95% CI, 1.177-3.367; P =.01; main duct: OR, 1.443; 95% CI, 1.094-1.905; P =.01; and mixed: OR, 1.178; 95% CI, 1.057-1.312; P =.04). The cutoff values for intraductal papillary mucinous neoplasms, determined by a receiver operating characteristic, were 9 mm for branch duct and 6 mm for mixed and main duct carcinoma. A high carcinoembryonic antigen level in the pancreatic juice was independently associated with mixed (OR, 1.002; 95% CI, 1.000-1.003; P =.01) and main duct (OR, 1.002; 95% CI, 1.000-1.003; P =.048) carcinomas, and the cutoff values were determined to be 150 and 300 ng/mL, respectively (to convert to micrograms per liter, multiply by 1). In addition, both being female and having an elevated serum carbohydrate antigen 19-9 level were also found to be independently associated with mixed type invasive intraductal papillary mucinous carcinoma, and using any 2 among 4 identified factors yielded the highest accuracy (79.0%) for mixed type carcinomas. For all types, the accuracy for these factors was 86.0% for differentiating between invasive and noninvasive intraductal papillary mucinous neoplasms, which was superior to the accuracies using the “high-risk stigmata” factors or “worrisome features” suggested by the international consensus guideline in 2012 (66.1% and 39.9%, respectively).

Conclusions and Relevance  The measurement of mural nodule size in all types of carcinomas and carcinoembryonic antigen level in the pancreatic juice in mixed and main duct carcinomas might play important roles in predicting invasive intraductal papillary mucinous carcinoma, but further large studies are needed to confirm these results.

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