Neutrophil-to-lymphocyte ratio and mural nodule height as predictive factors for malignant intraductal papillary mucinous neoplasms

Clinical and Molecular Attributes and Evaluation of Pancreatic Cystic Neoplasm

Intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) are all considered "Pancreatic cystic neoplasms (PCNs)" and show a varying risk of developing into pancreatic ductal adenocarcinoma (PDAC). These lesions display different molecular characteristics, mutations, and clinical manifestations. A lack of detailed understanding of PCN subtype characteristics and their molecular mechanisms limits the development of efficient diagnostic tools and therapeutic strategies for these lesions. Proper in vivo mouse models that mimic human PCNs are also needed to study the molecular mechanisms and for therapeutic testing. A comprehensive understanding of the current status of PCN biology, mechanisms, current diagnostic methods, and therapies will help in the early detection and proper management of patients with these lesions and PDAC. This review aims to describe all these aspects of PCNs, specifically IPMNs, by describing the future perspectives.

MRI-Based Pancreatic Atrophy Is Associated With Malignancy or Invasive Carcinoma in Intraductal Papillary Mucinous Neoplasm

Background

Abrupt change in the caliber of the main pancreatic duct (MPD) with distal pancreatic atrophy (PA) was considered as one of worrisome features in the International Association of Pancreatology guideline and American College of Gastroenterology guideline for the management of intraductal papillary mucinous neoplasms (IPMNs). However, this feature was not included in other guidelines. Moreover, the association between PA alone and malignancy in IPMNs has not been fully evaluated. In the present study, we investigated the role of image-based PA in identifying malignant IPMNs or invasive carcinoma.

Methods

A total of 186 patients with IPMNs were included for analysis. The tumor size, location, MPD diameter, presence of a mural nodule (MN), and PA were evaluated using magnetic resonance imaging. Demographic information and serum carbohydrate antigen 19-9 and carcinoembryonic antigen (CEA) levels were also collected. IPMNs with high-grade dysplasia and associated invasive carcinoma were regarded as malignant IPMNs.

Results

PA was observed in 34 cases (18.3%). The occurrence of malignant IPMNs or invasive carcinoma in patients with PA were significantly higher than in those without PA (52.9% vs. 22.3%; 44.1% vs. 8.9%, all P < 0.01). Multivariate logistic regression analysis showed that PA was an independently associated factor for malignant IPMNs [odds ratio (OR) = 2.69, 95% confidence interval (CI): 1.07-6.78] or invasive carcinoma (OR = 7.78, 95%CI: 2.62-23.10) after modified with confounders. Subgroup analysis in MPD-involved IPMNs also indicated that PA was an independently associated factor for invasive carcinoma (OR = 9.72, 95%CI: 2.43-38.88). PA had a similar performance with MPD plus MN [the area under the curve (AUC) was both 0.71] in identifying malignancy. PA had a higher performance in identifying invasive carcinoma in MPD-involved IPMNs than MN (AUC = 0.71 vs. 0.65, P = 0.02).

Conclusion

Our data showed that imaging-based PA was associated with malignancy or invasive carcinoma regardless of abrupt change in the caliber of MPD in IPMNs. PA had an acceptable performance in identifying malignant IPMNs.

The tumor‐to‐liver ratio of the standardized uptake value is a useful FDG‐PET/CT parameter for predicting malignant intraductal papillary mucinous neoplasm of the pancreas

Background

The present study aimed to investigate the efficacy of positron emission tomography with 18Fluoro‐deoxyglucose (FDG‐PET/CT) for predicting malignant intraductal papillary mucinous neoplasm (IPMN).

Methods

The records of 88 patients pathologically diagnosed with IPMN after surgery at Ehime University Hospital and Ehime Prefectural Central Hospital from April 2009 to December 2020 were retrospectively reviewed. The patients’ characteristics, blood chemistry, and imaging examinations were evaluated as potential predictors of malignant IPMN. Of the PET/CT results, the maximum standardized uptake value (SUVmax) of the tumor, the tumor‐to‐blood pool ratio of the SUV (TBR), and the tumor‐to‐liver ratio of the SUV (TLR) were compared.

Results

On pathology, the diagnosis was adenoma (IPMA) in 40 patients, high‐grade dysplasia (HGD) in 26 patients, and carcinoma (IPMC) in 22 patients. HGD and IPMC were defined as malignant IPMN. On multivariate analyses, TLR ≥ 1.3 and high‐risk stigmata were independent predictors of malignant IPMN (P = .001 and P = .007, respectively). When both HRS and TLR ≥ 1.3 were present, the positive predictive value for malignancy was 88.2%. Furthermore, TLR was significantly higher for patients with IPMC than with HGD (P = .039).

Conclusion

TLR can be a useful predictor for differentiating benign from malignant IPMN and may be associated with postoperative outcomes.

The prognostic roles of the prognostic nutritional index in patients with intraductal papillary mucinous neoplasm

The preoperative accurate diagnosis is difficult in the patients with intraductal papillary mucinous neoplasm (IPMN). The aim of the present study was to elucidate the roles of systemic inflammation responses and nutritional status indexes in IPMN. High-grade dysplasia was classified as a malignant neoplasm in the study. We retrospectively reviewed 155 patients who underwent pancreatectomy. The correlation between the clinical factors and several indexes of a systemic inflammation response and nutritional status was analyzed. Among the biomarkers, prognostic nutritional index (PNI) value of malignant IPMN patients was significantly lower than that of benign IPMN patients (P = 0.023), whereas PNI was not significant predictor for malignant IPMN. The multivariate analysis showed that a PNI < 43.5 (odds ratio [OR] 16.1, 95% CI 1.88–138.5, P = 0.011) and a carbohydrate antigen (CA) 19–9 level > 22.5 U/mL (OR 6.64, 95% CI 1.73–25.6, P = 0.006) were significant independent predictors of the presence of lymph node metastasis (LNM). Our scoring system developed based on these two factors. Patients with a score of 0 had no LNM and zero disease-related death. The present study suggested the roles of PNI on the IPMN patients who undergo curative pancreatectomy.