Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ.
Ann Surg. 2023 Jul 1;278(1):110-117. doi: 10.1097/SLA.0000000000005672. Epub 2022 Aug 11.
To determine whether the morphologic features of the main pancreatic duct (MPD) of main-duct-involved-intraductal papillary mucinous neoplasm (IPMN) (ie, main duct or mixed main duct/side branch) have implications for the risk of malignancy and extent of resection.
International consensus guidelines acknowledge the presence of various MPD morphologies (ie, diffuse vs segmental main-duct-involved-IPMN) without a precise definition of each entity and with limited data to guide treatment strategy.
All consecutive main-duct-involved-IPMN patients (2005-2019) with a MPD diameter ≥5 mm by cross-sectional imaging were reviewed from a prospective institutional database. Morphologic features of the MPD were correlated with the identification of high-grade dysplasia or pancreatic ductal adenocarcinoma (HGD/PDAC) by logistic regression modeling. In patients who underwent partial pancreatectomy, preoperative MPD morphologic features were correlated with the future development of HGD/PDAC in the pancreatic remnant by Cox hazards modeling.
In a cohort of 214 main-duct-involved-IPMN patients, the overall rate of HGD/PDAC was 54.2%. MPD morphologic characteristics associated with HGD/PDAC included: maximal MPD diameter (5-10 mm: 29.8%; 10-14 mm: 59.0%; 15-19 mm: 78.6%; ≥20 mm: 95.8%; P <0.001), segmental extent of maximal dilation (<25%: 28.2%; 25%-49%: 54.9%; 50%-74%: 63.1%; ≥75%: 67.9%; P =0.002), and nonsegmental MPD diameter (<5 mm: 21.5% vs ≥5 mm: 78.5%, P <0.001). Diffuse MPD dilation involving ≥90% extent was rare (5.6%). After a median follow-up of 50 months, 7 (7.2%) patients who underwent partial pancreatectomy for IPMN without associated PDAC developed HGD/PDAC in the pancreatic remnant. Maximal MPD diameter, segmental extent of maximal dilation, or nonsegmental MPD diameter were not associated with the development of HGD/PDAC in the pancreatic remnant. However, a mural nodule on preoperative imaging was associated with the development of HGD/PDAC in the pancreatic remnant.
"Diffuse" involvement with homogenous dilation of the MPD was rare. For the majority of patients with segmental main-duct-involved-IPMN, the MPD morphology conferred malignancy risk. Duct morphology was not predictive for the development of HGD or invasive disease in the pancreatic remnant, implying the safety of limited pancreatic resection for initial surgical management.
确定主胰管（MPD）的形态特征是否与主胰管受累型胰管内乳头状黏液性肿瘤（IPMN）（即主胰管或混合主胰管/分支）的恶性程度和切除范围有关。
国际共识指南承认 MPD 存在各种形态（即弥漫性与节段性主胰管受累 IPMN），但没有对每种形态进行精确定义，且用于指导治疗策略的数据有限。
回顾性分析了 2005 年至 2019 年期间，通过横断面成像发现 MPD 直径≥5mm 的连续主胰管受累 IPMN 患者的前瞻性机构数据库。采用逻辑回归模型将 MPD 的形态特征与高级别异型增生或胰腺导管腺癌（HGD/PDAC）的检出相关联。在接受部分胰腺切除术的患者中，采用 Cox 风险模型将术前 MPD 形态特征与胰腺残端未来发生 HGD/PDAC 的情况相关联。
在 214 例主胰管受累 IPMN 患者中，总体 HGD/PDAC 发生率为 54.2%。与 HGD/PDAC 相关的 MPD 形态特征包括：最大 MPD 直径（5-10mm：29.8%；10-14mm：59.0%；15-19mm：78.6%；≥20mm：95.8%；P<0.001）、最大扩张的节段性程度（<25%：28.2%；25%-49%：54.9%；50%-74%：63.1%；≥75%：67.9%；P=0.002）和非节段性 MPD 直径（<5mm：21.5%比≥5mm：78.5%，P<0.001）。弥漫性 MPD 扩张累及≥90%的情况很少见（5.6%）。中位随访 50 个月后，7 例（7.2%）在接受部分胰腺切除术治疗 IPMN 但未伴发 PDAC 的患者，胰腺残端发生 HGD/PDAC。最大 MPD 直径、最大扩张的节段性程度或非节段性 MPD 直径与胰腺残端 HGD/PDAC 的发生均无相关性。然而，术前影像学上存在壁结节与胰腺残端 HGD/PDAC 的发生相关。
“弥漫性”累及伴 MPD 均匀扩张的情况很少见。对于大多数节段性主胰管受累 IPMN 患者，MPD 形态特征提示恶性风险。MPD 形态不能预测胰腺残端的高级别异型增生或浸润性疾病，这表明初始手术治疗时采用有限的胰腺切除术是安全的。
