Assessing the validity of the international evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas

Abstract

Introduction Intraductal papillary mucinous neoplasms (IPMN) are pancreatic tumours with an associated risk of malignant transformation. These can be divided in main duct (MD-IPMN) and small branch IPMN (BD-IPMN). Due to the increasing use of imaging techniques, the incidence of IPMN diagnosis has risen. The International Evidence-Based Kyoto Guidelines (IKG), the latest update of the International Guidelines, were developed to refine the management of IPMN. IKG incorporate high-risk stigmata (HRS) and worrisome features (WF) in the decision-making process. This study evaluates the accuracy of these guidelines in identifying patients requiring surgery. Methods A retrospective cohort study was conducted at São João University Hospital, considering adult patients who underwent pancreatic surgery for IPMN between 2010 and 2024. Data on demographic characteristics, imaging findings, surgical procedures, and histopathological outcomes were collected. Criteria for surgery, according to the IKG, were retrospectively applied. The diagnostic performance of IKG was assessed through sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy. Results The study includes 106 patients (mean age: 67±10 years), 18.9% of them had histologically confirmed malignant IPMN. The sensitivity of IKG in detecting malignancy was 100%, while specificity was 19.8%. The PPV and NPV were 22.5% and 100%, respectively. The most predictive factors for malignancy were: presence of lymphadenopathy, abrupt changes in main pancreatic duct calibre, and elevated serum CA 19-9. It was observed an association between the number of WF and the rate of malignancy. Discussion/Conclusion The IKG demonstrated excellent sensitivity in selecting patients for surgery, ensuring that all malignant cases were identified. However, the low specificity suggests a need for reviewing the criteria to minimize overtreatment. Future guidelines should focus on integrating patient-specific factors, such as age and comorbidities, into decision-making algorithms, to optimize management strategies, and to considerate the weight and number of WF present.