Objective: To evaluate the performance of the European Evidence-based
Guidelines on Pancreatic Cystic Neoplasms (EEGPCN)(2018) and International Association of Pancreatology(IAP)
Guideline(Version 2017) in predicting high grade dysplasia/invasive carcinoma-intraductal papillary mucinous neoplasm(HGD/INV-IPMN). Methods: A retrospective analysis of 363 patients,who underwent surgical resection in Changhai Hospital affiliated to Navy Medical University from January 2012 to December 2018 and were pathologically identified as (intraductal papillary mucinous neoplasm, IPMN),was performed. The patients,including 230 males and 133 females,aging (61.7±10.1) years(range:19 to 83 years). The proportion of HGD/INV-IPMN who met with the absolute indication(AI) of EEGPCN and high risk stigma(HRS) of IAP were compared. The binary Logistic regression analysis was used to find the independent risk factors of HGD/INV-IPMN.Eight combinations of risk factors derived from relative indication/worrisome feature or risk factors in this study,were made to evaluate the diagnostic efficacy. The area under curve(AUC) of receiver operating characteristics was used to evaluate the the cutoff value of risk factors(①CA19-9≥37 U/ml,②diameter of main pancreatic duct 5.0-9.9 mm,③enhancing mural nodule<5 mm,④(acute) pancreatiti,⑤acyst diameter ≥40 mm,⑤bcyst diameter ≥30 mm, ⑥thickened or enhancing cyst walls,⑦neutrophile granulocyte to lymphocyte ratio(NLR)≥2, ⑧cyst located in head, uncinate or neck,⑨carcinoembryonic antigen(CEA) ≥5 μg/L) number for predicting HGD/INV-IPMN.The accuracy,sensitivity,specificity,positive predictive value,negative predictive value,true positive,true negative,false positive,false negative,positive likelihood ratio,negative likelihood ratio,Youden index and F1 score were calculated. Results: Ninety-two patients(49.5%) of 186 ones who met AI and 85 patients(48.3%) of 176 ones who met HRS were respectively confirmed as HGD/INV-IPMN. In those patients who were not met AI,tumor location,thickened/enhancing cyst wall,CA19-9 elevated,NLR≥2 and CEA elevated were significantly (P<0.05) correlated with HGD/INV-IPMN. And tumor location(head/uncinate/neck vs. body/tail,OR=3.284,95%CI:1.268-8.503,P=0.014),thickened/enhancement cyst wall (with vs.without,OR=2.713,95%CI:1.177-6.252,P=0.019),CA19-9(≥37 U/L vs.<37 U/L, OR=5.086,95%CI:2.05-12.62,P<0.01) and NLR(≥2 vs.<2,OR=2.380,95%CI:1.043-5.434,P=0.039) were the independent risk factors of HGD/INV-IPMN. Patients with ≥4 risk factors of 9 in combination Ⅷ(①②③④⑤b⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the moderate accuracy(71.0%),moderate sensitivity (62.0%) and moderate specificity (73.0%). Patients with ≥4 risk factors of 9 in Combination Ⅶ(①②③④⑤a⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the highest specificity(83.0%) and patients with ≥3 risk factors of 8 in combination Ⅵ(①②③④⑤b⑥⑧⑨) were diagnosed as HGD/INV-IPMN with the highest sensitivity(74.0%). The AUC for diagnosis of HGD/INV-IPMN in combination Ⅵ,Ⅶ and Ⅷ were 0.72,0.75 and 0.75,respectively. Older patients and younger patients could respectively refer to combination Ⅶ and combination Ⅵ to improve the management of IPMN. Conclusions: Patients who meet AI of EEGPCN should undertake resection, otherwise the method we explored is recommended. The method of improvement for diagnosis of HGD/INV-IPMN is relatively applicable and efficient for decision-making of surgery, especially for younger patients with decreasing of missed diagnosis and elder patients with decreasing of misdiagnosis.
目的: 探讨不同指南推荐方法诊断胰腺导管内乳头状黏液瘤(IPMN)伴高级别异型增生(HGD)或浸润癌(INV)的效能。 方法: 回顾性分析2012年1月至2018年12月于海军军医大学长海医院肝胆胰外科行胰腺切除术且术后病理学检查诊断为IPMN的363例患者资料。男性230例,女性133例,年龄(61.7±10.1)岁(范围:19~83岁)。低级别异型增生(LGD)-IPMN 228例,HGD/INV-IPMN 135例。比较欧洲胰腺囊性肿瘤循证指南(EEGPCN)绝对手术指征(AI)和国际胰腺病协会(IAP)指南高危特征(HRS)的诊断效能。采用Logistic回归分析法分析HGD/INV-IPMN的独立相关因素。结合EEGPCN相对手术指征(RI)或IAP指南令人焦虑特征(WF)及HGD/INV-IPMN相关危险因素,利用受试者工作特征(ROC)曲线的曲线下面积(AUC)评价8 种组合(组合Ⅰ~Ⅷ)((1)CA19-9≥37 U/ml;(2)主胰管最大径5.0~9.9 mm;(3)强化附壁结节<5 mm;(4)病变相关的急性胰腺炎;(5)a病变最大径≥40 mm;(5)b病变最大径≥30 mm;(6)病变囊壁增厚或强化;(7)中性粒细胞和淋巴细胞比值(NLR)≥2;(8)肿瘤位于胰头颈钩突部;(9)血清癌胚抗原≥5 μg/L)诊断HGD/INV-IPMN的效能。评价诊断效能的参数还包括准确率、灵敏度、特异度等。 结果: 可纳入AI或HRS的HGD/INV-IPMN 患者比例分别为49.5%(92/186)和48.3%(85/176)。未纳入AI的患者,肿瘤部位、囊壁增厚或强化、CA19-9升高、NLR≥2及癌胚抗原升高与HGD/INV-IPMN相关(P值均<0.05),其中肿瘤部位(胰头颈钩突部比胰体尾,OR=3.284,95%CI:1.268~8.503,P=0.014)、囊壁增厚或强化(有比无,OR=2.713,95%CI:1.177~6.252,P=0.019)、CA19-9(≥37 U/L比<37 U/L,OR=5.086,95%CI:2.05~12.62,P<0.01)和NLR(≥2比<2,OR=2.380,95%CI:1.043~5.434,P=0.039)是HGD/INV-IPMN的独立相关因素。综合评价诊断效能,危险因素组合Ⅷ((1)(2)(3)(4)(5)b(6)(7)(8)(9)≥4/9)的准确率最高(71.0%),特异度(73.0%)和灵敏度(62.0%)适中,AUC为0.75;组合Ⅶ((1)(2)(3)(4)(5)a(6)(7)(8)(9)≥4/9)的特异度最高(83.0%),AUC为0.75;组合Ⅵ((1)(2)(3)(4)(5)b(6)(8)(9)≥3/8)的灵敏度最高(74.0%),AUC为0.72。 结论: 符合EEGPCN AI的IPMN患者,建议积极手术治疗,否则建议采用本研究不同危险因素组合诊断HGD/INV-IPMN,以相对准确且简单地帮助外科医师判断不同年龄段患者的手术时机,避免LGD-IPMN患者接受过度治疗和降低HGD/INV-IPMN的漏诊率。.