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Chad A. Wiesenauer, MD; C. Max Schmidt, MD, PhD; Oscar W. Cummings, MD; Constantin T. Yiannoutsos, PhD; Thomas J. Howard, MD; Eric A. Wiebke, MD; Robert J. Goulet, Jr, MD; Lee McHenry, MD; Stuart Sherman, MD; Glen A. Lehman, MD; Harvey Cramer, MD; James A. Madura, MD

Arch Surg. 2003;138:610-618.

Hypothesis  Malignant intraductal papillary mucinous neoplasms (IPMNs) can be predicted before surgery.

Design  Retrospective review of a prospectively collected database.

Setting  Academic, urban, tertiary care hospital.

Patients  Sixty-four consecutive patients with a pathological diagnosis of IPMN.

Interventions  All 64 patients underwent surgical intervention for IPMN between December 8, 1988, and October 16, 2002.

Main Outcome Measures  Reliable predictors of malignancy.

Results  The 64 patients underwent 69 operations: 39 pancreaticoduodenectomies, 18 distal pancreatectomies, 7 total pancreatectomies, 4 neck and/or body pancreatectomies, and 1 cystgastrostomy with pancreatic biopsy. Twenty-three of 69 specimens were malignant—12 in situ (high-grade dysplasia) and 11 invasive. In a univariate analysis of 12 clinical signs or symptoms recorded, diabetes mellitus and jaundice showed a significant association with malignancy of IPMN. Of 24 serum chemistry studies, hematologic studies, and tumor marker analyses (in serum, bile, and pancreatic fluid), elevation of serum alkaline phosphatase and glucose levels showed correlation with malignancy. Computed tomography, ultrasound, and endoscopic retrograde cholangiopancreatography findings did not distinguish between benign and malignant tumors. Atypia on preoperative cytologic analysis was specific for malignancy (93%) but lacked the same degree of sensitivity (40% in situ, 91% invasive, and 67% overall).

Conclusions  Malignancy of IPMNs is suggested by new-onset diabetes mellitus, jaundice, and elevations in serum glucose or alkaline phosphatase levels. Atypia on preoperative cytologic testing is the finding most predictive of malignancy. The absence of these features does not predict benign disease. These findings may help guide patient and physician decision making.

From the Departments of Surgery (Drs Wiesenauer, Schmidt, Howard, Wiebke, Goulet, and Madura), Biochemistry and Molecular Biology (Dr Schmidt), Pathology (Dr Cummings), Biostatistics (Dr Yiannoutsos), Gastroenterology Medicine (Drs McHenry, Sherman, and Lehman), and Cytopathology (Dr Cramer) and the Indiana University Cancer Center (Drs Schmidt, Cummings, Howard, Wiebke, Goulet, and Madura), Indiana University School of Medicine; The Walther Oncology Center (Dr Schmidt); and the Richard L. Roudebush Veterans Affairs Medical Center (Drs Schmidt and Wiebke), Indianapolis.

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