Bassi Claudio, Sarr Michael G, Lillemoe Keith D, Reber Howard A
Department of Surgery and Gastroenterology, G.B. Rossi BorgoRoma Hospital, University of Verona, 37134 Verona, Italy.
J Gastrointest Surg. 2008 Apr;12(4):645-50. doi: 10.1007/s11605-007-0447-x. Epub 2007 Dec 19.
Intraductal papillary mucinous neoplasms (IPMNs) show varying degrees of dysplasia throughout the neoplasm that can range from adenoma to invasive carcinoma, with dysplastic changes of borderline neoplasms and carcinoma in situ in between. An understanding of the natural history, and especially the required time to transform into either carcinoma in situ or an invasive adenocarcinoma, is critically important for management policy. This topic serves as the rationale for the present analysis. At the beginning of February 2007, using the key word "IPMN" in PubMed, we initially selected 119 publications using the principal criteria as defined by the WHO classification. We identified 20 appropriate original reports and one consensus paper. Neither randomized control trials (RCT) or systematic reviews of RCTs (level 1 evidence) nor cohort studies or reviews of cohort studies (level 2 evidence) have been published. Only one report fit the criteria for level 3 evidence (case control study). Nineteen papers satisfied criteria for level 4 (cases series) and two for level 5 (expert opinion publication). After additional review and analysis, we considered only six reports to be "cornerstone papers" of merit for the final review. Clues to the natural history of IPMNs can be gained by using several methods to examine the articles: (a) to verify different prognoses between main and side branch duct subtypes; (b) to compare the average age of patients with benign vs. malignant IPMNs; (c) to summarize the findings of nonoperative, observational studies based on follow up by clinical, biochemical, and imaging techniques without operative resection; (d) to determine the prognostic importance of the status of the resection margin; and (e) to follow patients clinically after surgical resection. Although important aspects of the natural history of IPMN are still unknown, the following conclusions can be drawn: (1) Branch-duct IPMNs are less aggressive than main-duct IPMNs. (2) Malignancy is more common in older patients. (3) Malignancy (invasive or carcinoma in situ) is found in about 70% of resected main-duct IPMNs. (4) After resection of noninvasive IPMNs (branch- and main-duct varieties), recurrence is rare (<8%). (5) After resection of invasive IPMN, recurrence occurs in 50-65% of patients.
导管内乳头状黏液性肿瘤（IPMNs）在整个肿瘤中表现出不同程度的发育异常，范围从腺瘤到浸润性癌，其间存在交界性肿瘤和原位癌的发育异常改变。了解其自然史，尤其是转变为原位癌或浸润性腺癌所需的时间，对于管理策略至关重要。本主题是本次分析的理论基础。2007年2月初，我们在PubMed中使用关键词“IPMN”，最初根据世界卫生组织分类定义的主要标准筛选出119篇出版物。我们确定了20篇合适的原始报告和1篇共识论文。尚未发表随机对照试验（RCT）或RCT的系统评价（1级证据），也没有队列研究或队列研究的综述（2级证据）。只有1篇报告符合3级证据标准（病例对照研究）。19篇论文符合4级标准（病例系列），2篇符合5级标准（专家意见出版物）。经过进一步审查和分析，我们仅将6篇报告视为最终审查的有价值的“基石论文”。通过几种方法检查文章可以获得IPMNs自然史的线索：（a）验证主支和分支导管亚型之间的不同预后；（b）比较良性与恶性IPMNs患者的平均年龄；（c）总结基于临床、生化和影像学技术随访而非手术切除的非手术观察性研究结果；（d）确定切缘状态的预后重要性；（e）手术切除后对患者进行临床随访。尽管IPMN自然史的重要方面仍不清楚，但可以得出以下结论：（1）分支导管IPMNs的侵袭性低于主导管IPMNs。（2）恶性肿瘤在老年患者中更常见。（3）在切除的主导管IPMNs中，约70%发现恶性肿瘤（浸润性或原位癌）。（4）切除非侵袭性IPMNs（分支和主导管类型）后，复发很少（<8%）。（5）切除侵袭性IPMN后，50 - 65%的患者会复发。
