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Hi everyone and welcome back to Behind the Night and another HPD episode.

Today we're extremely excited to discuss a recent article published in JAMA Surgery in July 2021 titled

progression for assistability of branch duct, introductory papillary nuisance neoplasms after observation and surgery.

We're thrilled to bring you the first author of the paper, Dr. Giovanni Marke Gianni of the Pancras Institute in Verona, Italy, for an interview later in the episode.

Our most recent clinical challenges in surgery episode was about IPMNs.

So if you haven't listened to that episode first, we'd highly recommend that you do that first as a review.

Otherwise, let's dive into an overview of the article before interview. Beth, do you want to take us through the overall objectives and the methods of the study?

Yeah, absolutely. So the overall goal of the study is to balance two fundamental challenges of studying IPMNs.

The first would be without considering the overall denominator of IPMNs and considering only those who undergo resection were likely overestimating the risk of regression to malignant disease.

The second is that by expanding the study pool to those who do not have a pathologically confirmed IPMN, we likely underestimate the risk of malignant neoplasms.

So this study is a multi-center retrospective study of centers in Italy, Korea, Singapore, and the US that specifically assessed what dynamic variables are associated with malignant progression and pathologically proven IPMNs under at least a year of initial surveillance.

So all patients undergoing surgery for a branch checked IPMN from January 1st, 2000 to December 31st, 2019 with an initial 12 month surveillance period were considered for inclusion.

The indications for surgery were based in the initial part of the study on no guidelines. However, from 2006, the Sunday criteria were generally applied.

And from 2012 to their revision in 2017, the Fucaoka guidelines were used.

Just a reminder for the listeners, the Fucaoka guidelines carry a few basic principles. First, you have to think about worrisome features versus high-risk stigmata.

The high-risk stigmata mainly include the masses that you're concerned contain cancer. So those are ones with main ducts greater than 10 millimeters without another explaining factor like a main duct stone cyst with an enhancing mural nodule that's greater than 5 millimeters or something that's hard causing obstructive jaundice.

Worrisome features include some more borderline criteria like a thicker enhancing wall or a wall with a solid component, one with a mural nodule that's smaller than 5 millimeters, a main duct that's enlarged but not quite to that 10 millimeter marks of 5 to 9 millimeters or a duct with an abrupt change in caliber.

There's some other things like growth. So if the cyst grows more than 5 millimeters over two years, if the patient has elevated CA 1999 or they have a history of acute pancreatitis, because again, you're thinking about that being a harder mask that's obstructing the duct.

Thanks for going over that, Lexi. I always forget them and have to review them with the table next to me.

So in this study, patients were generally followed postoperatively with an MRI abdomen with Clangio pancreatography six months after diagnosis, and then every 12 months thereafter in the absence of any concerns for progression pathologic evaluation determined presence of high grade dysplasia or invasive personoma.

And both of these were considered malignant for the sake of the study, a binary logistic regression model was used to estimate the effect size of the association between considered risk factors and the development of pathologic outcomes.

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