Faculty Bibliography
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ASO Author Reflections: Decision Analysis in the Era of Evolving Guidelines for Branch-Duct IPMN
PMID: 42143653
ISSN: 1534-4681
CID: 6037602
HPB : the official journal of the International Hepato Pancreato Biliary Association. 2026.DOI: 10.1016/j.hpb.2026.04.453
Contemporary challenges in long-term survival prediction in resected pancreatic ductal adenocarcinoma: a transatlantic multicenter development and validation of prognostic models
BACKGROUND:Predicting long-term survival (>5 years; LTS) in resected pancreatic ductal adenocarcinoma (PDAC) remains challenging. The aim of this study was to train and evaluate LTS prediction models. METHODS:We retrospectively included patients with PDAC who underwent resection between 2012 and 2019 from the databases at New York University, the Johns Hopkins Hospital, University of Verona Hospital Trust, and the Dutch Pancreatic Cancer Group. Two models were developed for the (1) post-operative and (2) post-adjuvant treatment phase. Training involved the full dataset followed by internal-external cross validation. RESULTS:4084 patients with resected PDAC were included. The estimated rate of LTS in (1) was 22% (95% CI: 21-24%) and in (2) 24% (95% CI: 22-26%). For model (1) 5-year performance metrics were an AUC of 0.68 (0.60-0.75), O/E ratio of 0.91 (0.45-1.82), and slope of 1.07 (0.56-2.05). Model (2) achieved 5-year AUC of 0.70 (0.64-0.75), O/E ratio of 0.96 (0.60-1.54), and slope of 1.16 (0.60-1.23). CONCLUSIONS:Our models achieved only modest performance despite a large, granular dataset and rigorous statistical methods, demonstrating the need for novel prognostic biomarkers.
PMID: 42168042
ISSN: 1477-2574
CID: 6038642
Postpancreatectomy liver injury: A relevant entity in the modern era of pancreatic cancer surgery with hepatic vessel resection. A monocentric retrospective cohort study
BACKGROUND:Advances in pancreatic cancer surgery involve hepatotoxic chemotherapies and hepatic vasculature resections, increasing the risk of clinically relevant postpancreatectomy liver injury. The study aimed to analyze the incidence and impact of clinically relevant postpancreatectomy liver injury after pancreatectomy with hepatic vessel resection. METHODS:In this single-institutional study, patients undergoing pancreatectomy with resection of hepatic vessels (portal vein/superior mesenteric vein, celiac axis, and hepatic arteries) were analyzed. Arterial lactate, total bilirubin, alanine aminotransferase, aspartate aminotransferase, international normalized ratio, and Doppler ultrasound-derived resistive index were assessed postoperatively. Postoperative outcomes were assessed through 90 days. Clinically relevant postpancreatectomy liver injury was defined as American Association for the Study of Liver Diseases-defined liver failure and/or need for invasive treatment of liver complications. RESULTS:Among 116 patients (67% portal vein/superior mesenteric vein resection alone, 7% celiac axis/hepatic arteries alone, 26% portal vein/superior mesenteric vein + celiac axis/hepatic artery resection), 15 (13%) developed clinically relevant postpancreatectomy liver injury. Mortality was significantly higher in the clinically relevant postpancreatectomy liver injury group (47% vs 3%; P < .001). The proper hepatic artery resistive index was lower in the clinically relevant postpancreatectomy liver injury group (0.52 vs 0.65; P = .034), whereas the following 48-hour-peak blood tests were significantly higher in this group: Lac, bilirubin, aspartate aminotransferase, and alanine aminotransferase (all P < .01). Combined portal vein/superior mesenteric vein + celiac axis/hepatic arteries and elevated alanine aminotransferase 48-hour peak above 1680 U/L remained significantly associated with the occurrence of clinically relevant postpancreatectomy liver injury in multivariable analyses. Forty percent of clinically relevant postpancreatectomy liver injury occurred in the absence of vascular complications. CONCLUSION/CONCLUSIONS:Clinically relevant postpancreatectomy liver injury is associated with significant mortality. Low resistive index and markedly elevated biochemical markers within the first 48 hours correlate with clinically relevant postpancreatectomy liver injury and may be used to trigger earlier intervention. Given the associated morbidity and mortality, defining, preventing, and mitigating clinically significant postpancreatectomy liver injury is of the utmost importance.
PMID: 42173064
ISSN: 1532-7361
CID: 6038802
Decision Modeling to Guide Management of Pancreatic IPMNs: Immediate Surgery or Initial Surveillance?
BACKGROUND:Most branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) are indolent, but distinguishing those harboring high-grade dysplasia or invasive cancer remains difficult. This analysis focuses not on incidental small BD-IPMNs but on the subset whose cyst characteristics bring surgery into the decision-making discussion. Surgery prevents malignant progression but carries morbidity; surveillance avoids overtreatment but risks delayed cancer detection. Current guidelines rely on fixed thresholds that may not reflect individual variation. Our study compared immediate surgery and initial surveillance in patients with BD-IPMNs, using a decision-analytic model that incorporates patient-specific risk factors. METHODS:A Markov decision model compared immediate surgery with initial surveillance, incorporating age, comorbidities, and cyst location. Health states reflected progression from low-grade to high-grade dysplasia and invasive cancer, postoperative complications, recurrence, and quality-of-life decrements. Transition probabilities were derived from published studies and American College of Surgeons (ACS)-National Surgical Quality Improvement Program data. The primary outcome was quality-adjusted life-years (QALYs). RESULTS:For a 60-year-old patient with mild comorbidities and a pancreatic head BD-IPMN, immediate surgery provided 16.8 QALYs versus 16.3 with surveillance (incremental gain, 0.5 QALYs). Lifetime cancer probability was lower with surgery (24.5% vs 33.5%), as was cancer-related mortality (9.3% vs 20.3%), though surgery resulted in more resections for low-grade dysplasia (55.0% vs 15.3%). Age, baseline cancer probability, and perioperative mortality were the strongest determinants of the preferred strategy. CONCLUSIONS:Among patients with BD-IPMNs being considered for surgery, immediate resection offers a modest benefit for younger, healthier individuals, whereas surveillance remains appropriate for older or comorbid patients. These findings support individualized, risk-based management rather than universal application of guideline thresholds.
PMID: 42012736
ISSN: 1534-4681
CID: 6032502
Shared Decision-Making in IPMN of the Pancreas: A Framework for Surgical Decisions Under Uncertainty
BACKGROUND:Management of intraductal papillary mucinous neoplasms (IPMNs) requires choosing between surgical resection and active surveillance, yet current diagnostic tools cannot reliably distinguish which lesions harbor high-grade dysplasia or invasive cancer. As a result, many patients undergo major pancreatic surgery for low-grade disease, while others are observed until progression emerges. This uncertainty contributes to substantial variation in surgeon risk estimates, intervention thresholds, and treatment recommendations. Patients likewise differ in their tolerance for cancer risk, views on surgical morbidity, perceived burden of ongoing surveillance, and desired role in decision-making, making IPMN a distinctly preference-sensitive clinical scenario. Although recent international guidelines acknowledge the importance of incorporating patient values into management decisions, practical frameworks for doing so remain underdeveloped. METHODS:We performed a narrative review of the literature examining sources of uncertainty in IPMN management, variation in surgeon and patient risk perception, and existing approaches to shared decision-making (SDM) in preference-sensitive surgical decisions. We also evaluated communication strategies and decision-support tools relevant to improving decision quality in the setting of uncertain malignant potential. RESULTS:Evidence demonstrates substantial heterogeneity in both clinician and patient interpretation of malignancy risk, operative morbidity, and acceptable thresholds for surgical intervention. Surgeons and patients often weigh competing risks diff erently, contributing to variation in management recommendations even when clinical characteristics are similar. SDM provides a structured approach to integrating individualized malignancy risk estimates, discussion of treatment trade-off s, and elicitation of patient values. Conceptual frameworks and emerging decision-support tools suggest that SDM may improve calibration of risk perception, reduce unwarranted variation in care, and enhance alignment between treatment decisions and patient preferences. CONCLUSIONS:IPMN management represents a high-stakes clinical decision made under conditions of incomplete information. SDM off ers a pragmatic strategy to integrate clinical evidence with patient values when choosing between resection and surveillance. Incorporating SDM into routine IPMN care may improve decision quality, promote transparency in risk communication, and support more patient-centered recommendations while preserving clinical judgment.
PMID: 42012737
ISSN: 1534-4681
CID: 6032512
ASO Visual Abstract: Decision Modeling to Guide Management of Pancreatic IPMNs: Immediate Surgery or Initial Surveillance?
PMID: 42036592
ISSN: 1534-4681
CID: 6028932
ASO Author Reflections: Arterial Reconstruction in Pancreatic Cancer: Shifting from Anatomical Feasibility Towards Biological Selection
PMID: 41811393
ISSN: 1534-4681
CID: 6015622
Re-evaluating routinely collected clinical and laboratory parameters in the preoperative risk assessment of intraductal papillary mucinous neoplasms: model development and internal validation
BACKGROUND:Accurate preoperative malignancy risk assessment in intraductal papillary mucinous neoplasm (IPMN) is essential to balance timely intervention for high-grade dysplasia or invasive cancer (HGD/IC) against avoiding unnecessary or premature surgery in low-grade IPMN. This study aimed to externally validate the 2023 International Association of Pancreatology (IAP)/Kyoto guidelines and develop a combined prediction model incorporating routinely collected clinical data and laboratory parameters. METHODS:We conducted a retrospective cohort study of 194 patients who underwent resection for IPMN between 2012 and 2024. We evaluated the predictive performance of the current IAP/Kyoto criteria ("Kyoto model"), developed a clinical model using routinely available laboratory and clinical variables, and integrated both into a combined model. Model performance was assessed using discrimination and calibration metrics, with internal validation via bootstrapping and five-fold cross-validation. RESULTS:The Kyoto model demonstrated modest discrimination (AUC 0.62). The clinical model, incorporating neutrophil-to-lymphocyte ratio (NLR), smoking history, blood glucose, CA19-9, and alkaline phosphatase, achieved an optimism-corrected AUC of 0.76. Compared to the Kyoto model, the combined model (AUC 0.77) significantly improved discrimination and calibration (p < 0.001). At a predicted probability threshold of >0.75, the combined model achieved a 90% specificity and 91% positive predictive value for HGD/IC, identifying a high-risk subgroup suitable for surgical intervention. CONCLUSIONS:Integrating routinely collected clinical and laboratory parameters with guideline-based imaging features shows promise to enhance preoperative identification of high-risk IPMN in patients already being considered for surgical resection. The combined model offers a practical, high-specificity tool to support surgical decision-making in this selected population, though its performance metrics should not be extrapolated to unselected surveillance cohorts. External validation is required before broader clinical implementation.
PMID: 41820087
ISSN: 1424-3911
CID: 6015002
The OligoPanc project: an interdisciplinary expert consensus statement on oligometastatic pancreatic cancer
Currently, no consensus exists regarding the definition of oligometastatic pancreatic ductal adenocarcinoma, its necessary diagnostic measures, and potential treatment approaches. To address these knowledge gaps, the OligoPanc project brought together an interdisciplinary group of experts to establish consensus using a modified Delphi process and clinical vignettes. Participants agreed that the number of metastatic lesions and the number of affected organs are key elements in defining oligometastatic pancreatic ductal adenocarcinoma. Specifically, up to three lesions in a single organ, either the liver or the lung, define oligometastatic pancreatic ductal adenocarcinoma and could be either synchronous or metachronous. Necessary diagnostics include a triple-phase contrast-enhanced CT scan of the chest and abdomen and MRI of the liver with a hepatocyte-specific contrast agent. In unclear cases, [18F]fluorodeoxyglucose-PET CT or MRI can be considered. A multidisciplinary tumour board is essential. Patient-intrinsic factors, including age, do not define oligometastatic disease but should be considered for any treatment decision. Systemic treatment before any local consolidative treatment, including surgery, stereotactic ablative radiotherapy, or other locally ablative techniques, is mandatory. The proposed definition should be incorporated into future trials to improve comparability and enable validation.
PMID: 41785904
ISSN: 1474-5488
CID: 6009122
ASO Visual Abstract: Evaluating the Kyoto Guidelines' Worrisome Features and High-Risk Stigmata to Predict High Grade Dysplasia and Invasive Cancer in Intraductal Papillary Mucinous Neoplasms
PMID: 41678048
ISSN: 1534-4681
CID: 6002412
