Elsevier

Surgery

Volume 163, Issue 6, June 2018, Pages 1272-1279
Surgery

Pancreas
Systematic review, meta-analysis, and a high-volume center experience supporting the new role of mural nodules proposed by the updated 2017 international guidelines on IPMN of the pancreas

https://doi.org/10.1016/j.surg.2018.01.009Get rights and content

Abstract

Background

Mural nodules (MNs) have a predominant role in the 2016 revision of the international guidelines on intraductal papillary mucinous neoplasms (IPMN) of the pancreas. The aim of this study was to evaluate MNs as predictors of invasive cancer (iCa) or high-grade dysplasia (HGD) in IPMNs and to investigate the role of MN size in risk prediction.

Methods

A PRISMA-compliant systematic review of the literature and meta-analysis on selected studies were conducted. The random effect model was adopted, and the pooled SMD (standardized mean difference) obtained. The surgical series of IPMNs at a single high-volume institution was reviewed.

Results

This review included 70 studies and 2297 resected IPMNs. MNs have a positive predictive value for malignancy of 62.2%. The meta-analysis suggested that MN size has a considerable effect on predicting IPMNs with both iCa or HGD with a mean SMD of 0.79. All studies included in the meta-analysis used contrast-enhanced endosonography (CE-EUS) to assess MNs. Due to the heterogeneity of the proposed thresholds, no reliable MN size cut-off was identified. Of 317 IPMNs resected at our institution, 102 (32.1%) had a preoperative diagnosis of MN. Multivariate analysis showed that MN is the only independent predictor of iCa and HGD for all types of IPMNs.

Conclusion

MNs are reliable predictors of iCa and HGD in IPMNs as proposed by the 2016 IAP guidelines. CE-EUS seems to be the best tool for characterizing size and has the best accuracy for predicting malignancy. Further studies should determine potential MN dimensional cut-offs.

Section snippets

Systematic review

An electronic systematic and complete research following the PRISMA guidelines was carried out, involving all the available literature published until December 31, 2015. A thorough PubMed search was performed using the following keywords: “IPMN” or “Intraductal Papillary Mucinous Neoplasm” and “Nodule” or “Nodules.” The search was conducted independently by 3 of the authors.

The inclusion criteria were as follows: article in English with full-text available, surgical series with complete

Systematic review and meta-analysis

The PubMed search identified 301 articles, of which the full texts were available for 291, which were assessed for eligibility. After excluding articles not written in English, as well as case reports, reviews, and articles without surgical series, the systematic review eventually included 70 studies in the quantitative synthesis.9, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55,

Discussion

Given the lack of an effective screening strategy for pancreatic ductal adenocarcinoma in the general population, clinicians are aware that IPMNs represent the only option to identify individuals who are at higher risk of developing pancreatic cancer and therefore represent potential candidates for curative resection. However, the risks associated with pancreatic resection might overwhelm the potential benefit from the oncologic standpoint.71 In this regard, IPMNs cannot be compared with any

Acknowledgments

The authors wish to acknowledge Fondazione Italiana per le Malattie del Pancreas. The funding agencies had no role in the collection, analysis, and interpretation of data or in the writing of the manuscript.

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