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2023年IAP京都指南“担忧特征”对主胰管未扩张胰腺黏液囊性肿瘤恶变诊断效能研究
李勃, 康晓超, 时霄寒, 经纬, 郑楷炼, 高绥之, 史美龙, 袁帅, 尹笑逸, 周玉坤, 王蓓蕾, 郭世伟, 金钢
中国实用外科杂志 ›› 2026, Vol. 46 ›› Issue (2) : 262-267.
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2023年IAP京都指南“担忧特征”对主胰管未扩张胰腺黏液囊性肿瘤恶变诊断效能研究
Diagnostic performance of the number of worrisome features in the 2023 International Association of Pancreatology Kyoto Guideline for malignancy in mucin-producing pancreatic cystic neoplasms without main pancreatic duct dilation
目的 评估2023年版国际胰腺病协会（IAP）京都指南“担忧特征（WF）”在主胰管未扩张的胰腺黏液囊性肿瘤（mPCN）恶变诊断中的应用价值。方法 回顾性分析2012年1月至2023年12月于海军军医大学第一附属医院肝胆胰脾外科接受胰腺手术且术后病理诊断为分支型胰腺导管内乳头状黏液瘤（BD-IPMN）或胰腺黏液囊腺瘤（MCN）的374例病人的临床资料，评估WF在MCN、BD-IPMN和最大径<30 mm mPCN中的恶变诊断效能，评价恶变诊断效能的参数包括敏感度、特异度、受试者工作特征曲线下面积（AUC）、约登指数和F1值。结果 所有病人中MCN 164例，BD-IPMN 210例。多因素logistic分析结果显示，CA19-9水平≥37 kU/L（OR=8.35，95%CI 2.23-31.25，P=0.002）、增强附壁结节（OR=7.60，95%CI 1.33-43.27，P=0.022）、钙化（OR=13.49，95%CI 2.77-65.75，P=0.001）和腹痛（OR=8.89，95%CI 2.30-34.34，P=0.002）是MCN恶变的独立危险因素；CA19-9水平≥37 kU/L（OR=3.25，95%CI 1.61-6.59，P=0.001）和远端胰腺萎缩（OR=2.99，95%CI 1.31-6.85，P=0.009）是BD-IPMN恶变的独立危险因素；CA19-9水平≥37 kU/L（OR=5.21，95%CI 2.13-12.73，P<0.001）、囊壁增厚或强化（OR=3.57，95%CI 1.43-8.92，P=0.007）、远端胰腺萎缩（OR=7.42，95%CI 2.53-21.74，P<0.001）和最大径增长速度≥2.5 mm/年（OR=2.85，95%CI 1.23-6.59，P=0.014）是最大径<30 mm mPCN恶变的独立危险因素。WF≥3个诊断MCN恶变的效能最佳，AUC为0.859；WF≥2个诊断BD-IPMN和最大径<30 mm的效能最佳，AUC分别为0.734和0.791。结论 2023年IAP京都指南WF数量可用于主胰管未扩张mPCN恶变的诊断，对MCN恶变诊断的效能最佳。
Objective To evaluate the application value of worrisome features (WF) from the 2023 Kyoto Guidelines in diagnosing malignancy for mucin-producing pancreatic cystic neoplasms (mPCNs) without main pancreatic duct dilation. Methods A retrospective analysis was conducted on the clinical data of 374 patients who underwent pancreatic surgery at the Department of Hepatobiliary Pancreatic Surgery, First Hospital Affiliated to Naval Medical University, between January 2012 and December 2023, with postoperative pathological confirmation of branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) or pancreatic mucinous cystic neoplasm (MCN). The diagnostic performance of malignancy for MCN, BD-IPMN and <30 mm mPCN was evaluated by sensitivity, specificity, area under the receiver operating characteristic curve (AUC), Youden index, and F1-score. Results Among all patients, there were 164 cases of MCN and 210 cases of BD-IPMN. Results of multivariable logistic analysis showed that CA19-9≥37 kU/L (OR=8.35, 95%CI 2.23-31.25, P=0.002), enhancing mural nodule (OR=7.60, 95%CI 1.33-43.27, P=0.022), calcification (OR=13.49, 95%CI 2.77-65.75, P=0.001), and abdominal pain (OR=8.89, 95%CI 2.30-34.34, P=0.002) were independent risk factors for malignancy of MCN. CA19-9≥37 kU/L (OR=3.25, 95%CI 1.61-6.59, P=0.001) and distal pancreatic atrophy (OR=2.99, 95%CI 1.31-6.85, P=0.009) were independent risk factors for malignancy of BD-IPMN. CA19-9≥37 kU/L (OR=5.21, 95%CI 2.13-12.73, P<0.001), thickened or enhanced cyst wall (OR=3.57, 95%CI 1.43-8.92, P=0.007), distal pancreatic atrophy (OR=7.42, 95%CI 2.53-21.74, P<0.001), and growth rate of diameter ≥2.5 mm/year (OR=2.85, 95%CI 1.23-6.59, P=0.014) were independent risk factors for malignancy in <30 mm mPCN. The presence of ≥3 WFs demonstrated the best diagnostic performance for malignancy of MCN, with an AUC of 0.859. The presence of ≥2 WFs showed the best diagnostic performance for malignancy of BD-IPMN and <30 mm mPCN with AUCs of 0.734 and 0.791, respectively. Conclusion The number of WFs from the 2023 Kyoto Guidelines can be used for diagnosing malignancy in mPCN without main pancreatic duct dilation, with the highest diagnostic performance observed for MCN malignancy.
胰腺黏液囊性肿瘤 / 胰腺导管内乳头状黏液瘤 / 胰腺黏液囊腺瘤 / 手术指征 / 2023年国际胰腺病协会京都指南
pancreatic cystic neoplasm / intraductal papillary mucinous neoplasm of pancreas / mucinous cystic neoplasm of pancreas / surgery indication / 2023 International Association of Pancreatology Kyoto Guidelines
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| [2] |
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| [3] |
Despite the low malignant potential of pancreatic mucinous cystic neoplasms (MCNs), surgery is still performed. The aim of this pragmatic study was to assess the outcome of surgery and surveillance for patients presenting with a presumed MCN at the first evaluation.Data for patients with a presumed MCN observed from 2000 to 2016 at the Verona Pancreas Institute and San Raffaele Hospital were extracted from prospective databases. The endpoints were risk of malignancy at pathology and rate of misdiagnosis for the surgical series, expressed as an odds ratio (OR) with 95 per cent confidence interval, and disease-specific survival (DSS) for the surveillance cohort investigated by the Kaplan-Meier method.A total of 424 patients were identified. In the surgical series (229 patients), the rate of misdiagnosis was 19.2 per cent. The rate of malignant MCNs was 10.9 per cent (25 patients). The overall rate of malignancy, including misdiagnoses, was 11.3 per cent (26 patients). Predictors of malignancy were mural nodules (OR 27.75, 95 per cent c.i. 4.44-173.61; P < 0.001), size at least 50 mm (OR 13.39, 2.01 to 89.47; P = 0.007), and carbohydrate antigen 19.9 level (OR 3.98, 1.19 to 13.30; P = 0.025). In the absence of mural nodules and enhancing walls, none of the resected presumed MCNs smaller than 50 mm were malignant. Only patients with high-risk stigmata undergoing surgery experienced a significantly reduced 5-year DSS compared with all other patients (88 versus 100 per cent; P = 0.031).Presumed MCNs with mural nodules, enhancing walls or cysts of 50 mm or larger should be considered for upfront surgical resection owing to the high risk of malignancy. In the absence of these features, the incidence of malignancy is negligible, favouring surveillance in selected patients given the low risk of malignancy and the high rate of misdiagnosis.Pancreatic mucinous cystic neoplasms (MCNs) are well known preneoplastic lesions. Despite the low rate of cancer, lesions without radiological features of malignancy are resected systematically. In the absence of mural nodules, enhancing walls or cyst size 50 mm or more, the incidence of malignancy is negligible. Given the high risk of misdiagnosis, in the absence of such radiological features, surveillance of presumed MCNs seems safer.© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.
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The international consensus guidelines for management of intraductal papillary mucinous neoplasm and mucinous cystic neoplasm of the pancreas established in 2006 have increased awareness and improved the management of these entities. During the subsequent 5 years, a considerable amount of information has been added to the literature. Based on a consensus symposium held during the 14th meeting of the International Association of Pancreatology in Fukuoka, Japan, in 2010, the working group has generated new guidelines. Since the levels of evidence for all items addressed in these guidelines are low, being 4 or 5, we still have to designate them "consensus", rather than "evidence-based", guidelines. To simplify the entire guidelines, we have adopted a statement format that differs from the 2006 guidelines, although the headings are similar to the previous guidelines, i.e., classification, investigation, indications for and methods of resection and other treatments, histological aspects, and methods of follow-up. The present guidelines include recent information and recommendations based on our current understanding, and highlight issues that remain controversial and areas where further research is required.Copyright © 2012 IAP and EPC. Published by Elsevier B.V. All rights reserved.
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The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN have changed from early resection to more deliberate observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline proposed by the American Gastroenterological Association in 2015 restricted indications for surgery more stringently and recommended physicians to stop surveillance if no significant change had occurred in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non-malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of surveillance, has generated substantial debate. Based on a consensus symposium held during the meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, surveillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required.Copyright © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.
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European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms[J]. Gut, 2018, 67(5): 789-804. DOI: 10.1136/gutjnl-2018-316027.
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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After the World Health Organization established a precise definition of mucinous cystic neoplasm (MCN) in 2000, based on the presence of ovarian‐type stroma, its clinical features became more apparent. Surgery for MCN, which primarily affects middle‐aged women with long life expectancies, is likely to negatively impact the patient's quality of life. Although recent studies have reported a low proportion of advanced neoplasia among resected MCN (≤15%), many clinicians still recommend surgery for patients with presumed MCN without considering risk stratification for advanced neoplasia. Recent studies have demonstrated that, when appropriate patient groups are established based on high‐risk characteristics, there is no difference in long‐term prognosis between a surveillance strategy and surgery. Additionally, while most guidelines do not recommend post‐resection surveillance for MCN, research indicates that surveillance of non‐resected MCN is more cost‐effective than surgery when considering the expenses of post‐pancreatectomy diabetic care. It is time to carefully consider a surveillance strategy, despite the significant misdiagnosis rates associated with MCN diagnosis based solely on imaging without histology.
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The current management of pancreatic mucinous cystic neoplasms (MCN) is defined by the consensus European, International Association of Pancreatology and American College of Gastroenterology guidelines. However, the criterion for surgical resection remains uncertain and differs between these guidelines. Therefore through this systematic review of the existing literature we aimed to better define the natural history and prognosis of these lesions, in order to clarify recommendations for future management.A systematic literature search was performed (PubMed, EMBASE, Cochrane Library) for studies published in the English language between 1970 and 2015.MCNs occur almost exclusively in women (female:male 20:1) and are mainly located in the pancreatic body or tail (93-95%). They are usually found incidentally at the age of 40-60 years. Cross-sectional imaging and endoscopic ultrasound are the most frequently used diagnostic tools, but often it is impossible to differentiate MCNs from branch duct intraductal papillary mucinous neoplasms (BD-IPMN) or oligocystic serous adenomas pre-operatively. In resected MCNs, 0-34% are malignant, but in those less than 4 cm only 0.03% were associated with invasive adenocarcinoma. No surgically resected benign MCNs were associated with a synchronous lesion or recurrence; therefore further follow-up is not required after resection. Five-year survival after surgical resection of a malignant MCN is approximately 60%.Compared to other pancreatic tumors, MCNs have a low aggressive behavior, with exceptionally low rates of malignant transformation when less than 4 cm in size, are asymptomatic and lack worrisome features on pre-operative imaging. This differs significantly from the natural history of small BD-IPMNs, supporting the need to differentiate mucinous cyst subtypes pre-operatively, where possible. The findings support the recommendations from the recent European Consensus Guidelines, for the more conservative management of MCNs.Copyright © 2016 IAP and EPC. Published by Elsevier B.V. All rights reserved.
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With advances in cross-sectional imaging, pancreatic cysts are more frequently diagnosed and have become a common indication for pancreatectomy. The impact of pancreatectomy in these patients is important. The purpose of this study was to assess short-term outcomes, long-term nutritional status, quality of life (QOL), and pancreas function after pancreatectomy for cystic neoplasms.At a single institution, patients at least 3 y post-pancreatectomy for benign cystic neoplasms were identified. Using a validated questionnaire, short-term outcomes, long-term outcomes including endocrine and exocrine insufficiency, long-term nutritional status, and preoperative and postoperative QOL were compared based on operation and indication for resection.Among 102 eligible patients, 70 had valid contact information and 51 (72.9%) agreed to participate. Median follow-up was 6 (4-8) y. Patients undergoing pancreatoduodenectomy for benign cysts had higher morbidity than a similar cohort resected for pancreatic adenocarcinoma (patients with at least 1 ≥ grade 2 complication [49.0% versus 31.6%, P = 0.038]). After long-term follow-up, pancreatectomy did not significantly affect perceived QOL. Half of patients had mild-moderate or severe malnourishment, but pancreatic enzyme replacement was reported by only 4 (7.8%) patients. New-onset diabetes was present in 15 (29.4%) patients with median time-to-diagnosis of 6 (1-12) mo after resection.Pancreatectomy for benign cysts did not negatively impact patients' perceived QOL. However, after long-term follow-up, malnutrition and pancreatic insufficiency occurred in a significant percentage and may be greater than previously estimated. Consideration of short- and long-term outcomes should factor into preoperative counseling, especially in cysts with minimal risk of progression to malignancy.Copyright © 2019. Published by Elsevier Inc.
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| [12] |
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| [13] |
李勃, 史美龙, 康晓超, 等. 基于年龄分层的胰腺导管内乳头状黏液瘤手术指征再评估: 2023年京都指南应用研究[J]. 中国实用外科杂志, 2025, 45(1): 113-120. DOI: 10.19538/j.cjps.issn1005-2208.2025.01.01.
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| [14] |
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| [15] |
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| [16] |
中国医师协会胰腺病学专业委员会. 中国胰腺囊性肿瘤诊断指南(2022年)[J]. 临床肝胆病杂志, 2023, 39(2): 290-298. DOI:10.3969/j.issn.1001-5256.2023.02.007.
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To perform a comparative analysis of surgically resected mucinous cystic neoplasm (MCN) of pancreas and branch-duct type intraductal papillary mucinous neoplasms (BD-IPMN) considering clinico-radiological high-risk predictors for malignant tumors using the current management guidelines.224 patients who underwent surgical resection and had histopathologically confirmed MCNs (benign 73; malignant 17) or BD-IPMNs (benign 110; malignant 24) and had pre-operative CT or MRI were retrospectively reviewed. Tumors classified as either high-grade dysplasia or invasive carcinoma were considered malignant, whereas those with low-grade dysplasia were considered benign. Imaging features were analyzed by two radiologists based on selected high-risk stigmata or worrisome features proposed by prevalent guidelines except tumors with main pancreatic duct dilatation (> 5 mm) were excluded.MCNs and BD-IPMNs showed significant differences in aspects like tumor size, location, the presence and size of enhancing mural nodules, the presence of wall or septal thickening, and multiplicity. Multivariate analyses revealed tumor size (OR, 1.336; 95% CI, 1.124-1.660, p = 0.002) and the presence of enhancing mural nodules (OR, 67.383; 95% CI, 4.490-1011.299, p = 0.002) as significant predictors of malignant MCNs. The optimal tumor size differentiating benign from malignant tumor was 8.95 cm, with a 70.6% sensitivity, 89% specificity, PPV of 27.6%, and NPV of 96.9%, demonstrating superior specificity than the guideline-suggested threshold of 4.0 cm. For malignant BD-IPMNs, the presence of enhancing mural nodules (OR, 15.804; 95% CI, 4.439-56.274, p < 0.001) and CA 19 - 9 elevation (OR, 19.089; 95%CI, 2.868-127.068, p = 0.002) as malignant predictors, with a size of enhancing mural nodule threshold of 5.5 mm providing the best malignancy differentiation.While current guidelines may be appropriate for managing BD-IPMNs, our results showed a notably larger optimal threshold size for malignant MCNs than that suggested by current guidelines. This warrants reconsidering existing guideline thresholds for initial risk stratification and management of MCNs.© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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