What is it about?
This is a meta-analysis estimating the rates of overall and IPMN-related deaths among patient with IPMNs with morphological criteria suggesting absolute or relative indication for surgery who have not been operated for any reason (e.g. age or comorbidities, patients' choice, physicians' recommendation).
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Why is it important?
Pooling together all available evidence, we have found that in series of patients with high-risk IPMNs who were observed instead of being referred for surgery, mortality due to background conditions was three times superior than that related to IPMNs' progression and invasion. This was particularly true for branch-duct IPMNs, while main-duct IPMNs carry a 6-fold higher rate of disease-specific mortality. These data support a new perspective in the management of IPMN patients, beyond a static "to operate or not" strategy based on morphological criteria: to never start surveillance in unfit-for-surgery patients and to continue an intensive observation even in patients with high-risk IPMNs until their personalised risk/benefit ratio is in favour of surgery.
Perspectives
Attempting this synthesis, we found a disppointing lack of evidence on the natural history of non-operated IPMNs. Moreover, we feel that guidelines are extremelly “cyst-centric”, while our data show that factors beyond IPMN features have a definite impact on the risk of death. Future studies need to concentrate on how to integrate morphological features (including newer prognostic data, e.g. molecular fingerprinting) with patient's characteristics (genetic and environmental background and life-expectancy) in order to build a personalized strategy. Given the low annual rate of IPMNs progression and invasion, multicentric experiences with long follow-up intervals are required.
Giuseppe Vanella
Sapienza, University of Rome at Sant'Andrea Hospital
Read the Original
This page is a summary of: Meta-analysis of mortality in patients with high-risk intraductal papillary mucinous neoplasms under observation, British Journal of Surgery, February 2018, Wiley,
DOI: 10.1002/bjs.10768.
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