Age-Stratified Surgical Strategies for Intraductal Papillary Mucinous Neoplasms:Reevaluating Indications Based on the 2023 Kyoto Guideline

LI Bo; SHI Mei-long; KANG Xiao-chao; YUAN Shuai; JING Wei; ZHENG Kai-lian; LI Penghao; JIANG Ai-jun; ZHOU Yu-kun; WANG Be-lei; SHI Xiao-han; GUO Shi-wei; JIN Gang

doi:10.19538/j.cjps.issn1005-2208.2025.01.18

Abstract：Objective The 2023 Kyoto Guidelines have proposed new consensus for the diagnosis and treatment of intraductal papillary mucinous neoplasm(IPMN)of the pancreas.However,the surgical indications for patients with worrisome features(WF)remain unclear,and the timing of surgery based on life expectancy requires further optimization.This study aims to explore personalized surgical decision-making based on patient age stratification.Methods A retrospective analysis was conducted on 542 patients who underwent pancreatic resection with postoperative pathology confirming IPMN at Changhai Hospital from January 2012 to December 2023.Active surgery was defined as the anticipated pathology diagnosis of intermediate-grade dysplasia(IGD),high-grade dysplasia(HGD),or invasive carcinoma(IC);routine surgery was defined as the anticipated pathology diagnosis of HGD or IC;and cautious surgery was defined as the anticipated pathology diagnosis of IC.Various parameters,including sensitivity,specificity,area under the receiver operating characteristic curve(AUC),Youden's index,and F1 score,were used to evaluate the predictive efficacy of different surgical indications.Results Among the 542 IPMN patients,371 had worrisome features(WF).Active surgery decisions were independently associated with maximum diameter ≥ 30 mm(OR=2.107,95％CI:1.297-3.425,P=0.003)and distal pancreatic atrophy(OR=1.672,95％CI:1.032-2.708,P=0.037).Routine surgery decisions were independently associated with CA19-9 ≥ 37 kU/L(OR=2.226,95％CI:1.377-3.600,P=0.001)and distal pancreatic atrophy(OR=2.807,95％CI:1.730-4.557,P＜0.001).Cautious surgery decisions were independently associated with CA19-9 ≥ 37k U/L(OR=2.850,95％CI:1.687-4.817,P＜0.001),cyst wall thickening or enhancement(OR=2.288,95％CI:1.368-3.828,P=0.002),and distal pancreatic atrophy(OR=3.311,95％CI:1.947-5.629,P＜0.001).Distal pancreatic atrophy and/or maximum diameter ≥ 30 mm were the best predictors for active surgery,while WF count ≥ 3 was the best predictor for cautious surgery.For routine surgery indications,CA19-9 ≥ 37 kU/L and/or distal pancreatic atrophy had moderate sensitivity(0.628)and specificity(0.616),with the highest F1 score(0.535).WF count≥3 predicted the highest specificity(0.707)and AUC(0.632)for postoperative pathology diagnosis.Conclusion The active surgery indication for WF-IPMN includes a maximum diameter≥30 mm and/or distal pancreatic atrophy.Distal pancreatic atrophy and/or CA19-9≥37 kU/L as routine surgery indications can help avoid missed diagnoses of malignancy.A WF count≥3 can help avoid overtreatment and is applicable to both routine and cautious surgical decisions.