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Pancreatic Neoplasms: HELP
Articles by Alexandra M. Roch
Based on 22 articles published since 2010
(Why 22 articles?)
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Between 2010 and 2020, A. Roch wrote the following 22 articles about Pancreatic Neoplasms.
 
+ Citations + Abstracts
1 Review Management of Mixed-Type Intraductal Papillary Mucinous Neoplasm. 2016

Roch, Alexandra M / Schmidt, Christian Max. ·Department of Surgery, Indiana University School of Medicine, 980 W Walnut Street R3-C541, Indianapolis, IN 46202, USA. · IU Health Pancreatic Cyst and Cancer Early Detection Center, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 129, Indianapolis, IN 46202, USA. Electronic address: maxschmi@iupui.edu. ·Adv Surg · Pubmed #27520858.

ABSTRACT:

2 Clinical Trial Does PET with CT Have Clinical Utility in the Management of Patients with Intraductal Papillary Mucinous Neoplasm? 2015

Roch, Alexandra M / Barron, Morgan R / Tann, Mark / Sandrasegar, Kumar / Hannaford, Katheryn N / Ceppa, Eugene P / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Maximillian. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. · Department of Radiology and Imaging Science, Indiana University School of Medicine, Indianapolis, IN. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address: maxschmi@iupui.edu. ·J Am Coll Surg · Pubmed #26095551.

ABSTRACT: BACKGROUND: Intraductal papillary mucinous neoplasms (IPMNs) are well-established pancreatic precancerous lesions. Indications for resection are outlined in the 2012 International Consensus Guidelines (ICG). Because of the low specificity of the ICG, many patients will undergo potentially unnecessary surgery for nonmalignant IPMNs. Several retrospective studies have reported that positron emission tomography (PET) with CT (PET/CT) is highly sensitive and specific in detecting malignant IPMNs. We hypothesized that PET/CT complements the ICG in identification of malignant IPMNs. STUDY DESIGN: From 2009 to 2013, patients with a suspected clinical or cytopathologic diagnosis of IPMN were prospectively enrolled in a clinical trial at a single center. Results of preoperative PET/CT on determination of IPMN malignancy (ie, high-grade dysplastic and invasive) was compared with surgical pathology. PET/CT uptake was considered increased if the standardized uptake value was ≥3. RESULTS: Of the 67 patients enrolled, 50 patients met all inclusion criteria. Increased PET/CT uptake was associated with significantly more malignant and invasive IPMNs (80% vs 13%; p < 0.0001 and 40% vs 3%; p = 0.004). When patients were divided into branch duct and main duct IPMNs, increased PET/CT uptake was also associated with more malignancy (60% vs 0%; p = 0.006 for branch duct IPMN and 100% vs 23%; p = 0.003 for main duct IPMN). Patients with ICG criteria (eg, worrisome features and high-risk stigmata) and increased PET/CT uptake had more malignant and invasive IPMNs than patients with ICG criteria, but no increased uptake (78% vs 17%; p = 0.001 and 33% vs 3%; p = 0.03). The sensitivity and specificity of the ICG criteria for detecting malignancy were 92% and 27%, respectively, and PET/CT was less sensitive (62%) but more specific (95%). When PET/CT was added to ICG criteria, the association resulted in 78% sensitivity and 100% specificity. CONCLUSIONS: The addition of PET/CT to preoperative workup improves the performance of the ICG for predicting malignant risk in patients with IPMN.

3 Article Cystic pancreatic neuroendocrine tumors: A more favorable lesion? 2019

Carr, Rosalie A / Bletsis, Panagiotis / Roch, Alexandra M / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max / Ceppa, Eugene P. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. Electronic address: eceppa@iupui.edu. ·Pancreatology · Pubmed #30704851.

ABSTRACT: BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are predominantly solid lesions with malignant potential. Cystic PNETs are a small subset in which data are scarce. The aim of this study was to compare clinical and biologic differences between cystic and solid PNETs. METHODS: Patients with PNETs undergoing pancreatectomy between 1988 and 2016 at a high-volume center were reviewed retrospectively. Demographic, clinical, and histopathologic data were collected and analyzed. RESULTS: 347 patients with PNETs were identified; 27% (n = 91) were cystic. Patients with cystic PNETs were generally older (59 vs. 55 years, p = 0.05). Cystic PNETs were more commonly non-functional (95% vs. 82%, p = 0.004), asymptomatic (44% vs. 28%, p = 0.009), and located in the pancreatic body/tail (81% vs. 60%, p < 0.001) than solid PNETs. Although cystic and solid PNETs had similar sizes and pathologic stage at the time of resection, Ki-67 proliferation index (Ki-67 ≤ 9%: 98% vs. 85%; p = 0.007), and histologic grade (grade I: 84% vs. 59%; p = 0.009) had less aggressive features in cystic PNETs. CONCLUSION: In addition to reporting a higher than previously published incidence of cystic PNET (27%), this study found significant differences in multiple clinicopathologic variables between cystic and solid PNETs. Cystic PNET may be a distinct and possibly less aggressive subtype of PNET yet have similar pathologic stage, recurrence, and survival to solid PNETs. Cystic PNETs require further attention to better understand the true natural history.

4 Article Are BRCA1 and BRCA2 gene mutation patients underscreened for pancreatic adenocarcinoma? 2019

Roch, Alexandra M / Schneider, Justine / Carr, Rosalie A / Lancaster, William P / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max / Ceppa, Eugene P. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana. ·J Surg Oncol · Pubmed #30636051.

ABSTRACT: BACKGROUND: Breast cancer (BRCA) mutations account for the highest proportion of hereditary causes of pancreatic ductal adenocarcinoma (PDAC). Screening is currently recommended only for patients with one first-degree relative or two family members with PDAC. We hypothesized that screening all BRCA1/2 patients would identify a higher rate of pancreatic abnormalities. METHODS: All BRCA1/2 patients at a single academic center were retrospectively reviewed (2005-2015). Pancreatic abnormalities were defined on cross-sectional imaging as pancreatic neoplasm (cystic/solid) or main-duct dilation. RESULTS: Two hundred and four patients were identified with BRCA mutations. Forty-seven (40%) had abdominal imaging (20 computerized tomography and 27 magnetic resonance imaging). Twenty-one percent had pancreatic abnormalities (PDAC [n = 2] and intraductal papillary mucinous neoplasm [IPMN; n = 8]). The prevalence of pancreatic abnormalities and IPMN was higher in BRCA2 patients than in the general population (21% vs 8% and 17% vs 1%; P = 0.0007 and P < 0.0001, respectively), with no influence of family history. Similarly, BRCA1 patients had an increased prevalence of IPMN (8.3% vs 1%; P < 0.0001). CONCLUSIONS: In this series, 4% and 17% of BRCA2 patients developed PDAC and IPMN, respectively. Eight percent of BRCA1 patients developed IPMN. Under current recommended screening, 60% of BRCA1/2 patients had incompletely pancreatic assessment. With no influence of family history, this study suggests all BRCA1/2 patients should undergo a high-risk screening protocol that will identify a higher rate of precancerous pancreatic neoplasms amenable to curative resection.

5 Article Cancer history: A predictor of IPMN subtype and dysplastic status? 2018

Carr, Rosalie A / Kiel, Brandon A / Roch, Alexandra M / Ceppa, Eugene P / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. Electronic address: maxschmi@iupui.edu. ·Am J Surg · Pubmed #29174163.

ABSTRACT: INTRODUCTION: The aim of this study was to determine the association of PMH and FH of pancreatic (PDAC) and non-pancreatic cancers with IPMN malignant risk. METHODS: A retrospective review of a prospective database of IPMN patients undergoing resection was performed to assess FH and PMH. RESULTS: FH of PDAC was present in 13% of 362 included patients. Of these, 8% had at least one first degree relative (FDR) with PDAC. The rate of PDAC positive FH in non-invasive versus invasive IPMN patients was 14% and 8%, respectively (p = 0.3). In main duct IPMN patients, FH (44%) and PMH of non-pancreatic cancer (16%) was higher than that seen in branch duct IPMN (FH 29%; PMH 6%; p = 0.004 and 0.008). CONCLUSIONS: FH of PDAC is not associated with IPMN malignant progression. FH and PMH of non-pancreatic cancer is associated with main duct IPMN, the subtype with the highest rate of invasive transformation.

6 Article Indication for en bloc pancreatectomy with colectomy: when is it safe? 2018

Schwartz, Patrick B / Roch, Alexandra M / Han, Jane S / Vaicius, Alex V / Lancaster, William P / Kilbane, E Molly / House, Michael G / Zyromski, Nicholas J / Schmidt, C Max / Nakeeb, Atilla / Ceppa, Eugene P. ·Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH541, Indianapolis, IN, 46202, USA. · Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH541, Indianapolis, IN, 46202, USA. eceppa@iupui.edu. ·Surg Endosc · Pubmed #28664444.

ABSTRACT: INTRODUCTION: Aggressive en bloc resection of adjacent organs is often necessary to resect pancreatic or colonic lesions. However, it is debated whether simultaneous pancreatectomy with colectomy (P+C) is warranted as it potentially increases morbidity and mortality (MM). We hypothesized that MM would be increased in P+C, especially in cases of pancreatitis. METHODS: All patients who underwent pancreatectomy (P) and simultaneous pancreatectomy with colectomy (P+C) at a high-volume center from November 2006 to 2015 were prospectively collected using ACS-NSQIP at our institution. Patients with additional multivisceral or enucleation procedures were excluded. Data were augmented to 90-day outcomes using our institutional database. RESULTS: Forty-three patients with a mean age of 62 years (27:16 male: female) underwent P+C, accounting for 2.39% (43/1797) of pancreatectomies performed. Pancreatoduodenectomy (PD) was performed in 61% (n = 26), distal pancreatectomy (DP) in 37% (n = 16), and total pancreatectomy (TP) in 2% (n = 1) of patients. The 30- and 90-day MM were higher in P+C than P (30-day: 54 vs. 37%, p = 0.037 and 9 vs. 2%, p = 0.022; 90-day: 61 vs. 42%, p = 0.019 and 14 vs. 3%, p = 0.002). Logistical regression modeling revealed an association between 90-day mortality and colectomy (p = 0.013, OR = 3.556). When P+C MM were analyzed according to intraoperative factors, there was no significant difference according to type of pancreatectomy (PD vs. DP vs. TP), origin of primary lesion (pancreas vs. colon), surgical indication (malignant vs. non-malignant), or case status (planned colectomy vs. intraoperative decision). CONCLUSIONS: Addition of colectomy to pancreatectomy substantially increased MM. Subanalysis revealed that type of resection performed, etiology, and planning status did not account for increased risk when performing P+C. However, colectomy was found to be an independent risk factor for mortality. Therefore, patients should be informed of the risk of increased postoperative complications until a further study can identify potential patients or perioperative factors that can be used for risk stratification.

7 Article Prospective Evaluation of Associations between Cancer-Related Pain and Perineural Invasion in Patients with Resectable Pancreatic Adenocarcinoma. 2017

Carr, Rosalie A / Roch, Alexandra M / Zhong, Xin / Ceppa, Eugene P / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max / House, Michael G. ·Department of General Surgery, Indiana University School of Medicine, 515 Barnhill Drive, Indianapolis, IN, 46202, USA. · Department of General Surgery, Indiana University School of Medicine, 515 Barnhill Drive, Indianapolis, IN, 46202, USA. michouse@iupui.edu. ·J Gastrointest Surg · Pubmed #28785934.

ABSTRACT: INTRODUCTION: Perineural invasion is a unique characteristic of pancreatic adenocarcinoma biology and is present in the majority of resected pathologic specimens. The purpose of this study was to understand the relationships between preoperative pain and perineural invasion in patients with pancreatic adenocarcinoma. METHODS: Fifty-two chemotherapy naive patients undergoing resection for pancreatic adenocarcinoma from 2012 to 2014 completed a previously validated Brief Pain Inventory survey for preoperative clinical pain scoring. Preoperative pain was correlated with multiple clinicopathologic features. RESULTS: Preoperative pain was not associated with pathologic cancer stage, lymph node status, lymph node positivity ratio, resection margin status, or tumor location within the pancreas. In the subgroup of pancreatic head cancers, pain interference with affect was associated with the absence of perineural invasion (p = 0.02). Patients with stage I cancer had higher pain interference scores than those with stage II cancer (p = 0.02). CONCLUSIONS: Preoperative pain does not predict the presence of perineural invasion or other pathologic prognostic factors in patients with resectable pancreatic adenocarcinoma. Higher pain scores in pancreatic head cancers correlated with absence of perineural invasion and early cancer stage. The effects of preoperative pain on quality and interference of daily life deserve further investigation in larger prospective studies involving patients with pancreatic cancer.

8 Article Smoking and IPMN malignant progression. 2017

Carr, R A / Roch, A M / Shaffer, K / Aboudi, S / Schmidt, C M / DeWitt, J / Ceppa, E P / House, M G / Zyromski, N J / Nakeeb, A / Schmidt, C M. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. · Department of Medicine, Division of Gastroenterology, Indiana University Hospital, Indianapolis, IN, USA. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. Electronic address: maxschmi@iupui.edu. ·Am J Surg · Pubmed #28129918.

ABSTRACT: BACKGROUND: Patients with intraductal papillary mucinous neoplasm (IPMN) are at risk for invasive pancreatic cancer. We aim to characterize the impact of smoking on IPMN malignant progression. METHODS: Patients undergoing pancreatic resection for IPMN (1991-2015) were retrospectively reviewed using a prospectively collected database. RESULTS: Of 422 patients identified, 324 had complete data for analysis; 55% were smokers. Smoking status did not impact IPMN malignant progression (smokers/non-smokers: 22%/18% invasive grade; p = 0.5). Smokers were younger than non-smokers at the time of IPMN diagnosis (63 versus 68 years; p = 0.001). This association also held in the invasive IPMN subgroup (65 versus 72 years, p = 0.01). Despite this observation, rate of symptoms at diagnosis, cancer stage, and median survival were the same between smokers and non-smokers. CONCLUSION: Although smoking is not associated with IPMN malignant progression, invasive IPMN is diagnosed at a younger age in smokers. These data suggest tobacco exposure may accelerate IPMN malignant progression.

9 Article Management of Undifferentiated Solitary Mucinous Cystic Lesion of the Pancreas: A Clinical Dilemma. 2017

Roch, Alexandra M / Bigelow, Katherine / Schmidt, Christian M / Carr, Rosalie A / Jester, Andrea L / Ceppa, Eugene P / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address: maxschmi@iupui.edu. ·J Am Coll Surg · Pubmed #28126546.

ABSTRACT: BACKGROUND: Management of solitary mucinous cystic lesions of the pancreas (MCLs) relies on correct differentiation between branch duct intraductal papillary mucinous neoplasm (BD-IPMN) and mucinous cystic neoplasm (MCN). Current international consensus guidelines recommend resection for MCN, and unifocal BD-IPMN can be followed in the absence of worrisome features/high-risk stigmata. We hypothesized that preoperative differentiation of solitary MCLs is suboptimal, and that all solitary MCLs should be treated similarly. STUDY DESIGN: A retrospective review of an institutional database (2003 to 2016) identified 711 patients who underwent resection for pancreatic cyst. Only lesions that met cytologic or biochemical criteria for diagnosis of MCLs were included. Mucinous cystic neoplasms were defined by presence of ovarian stroma on pathology. Patients with formal preoperative diagnosis of BD-IPMN (multifocality, GNAS mutation) were excluded. RESULTS: One hundred and eighty solitary MCLs were identified on preoperative imaging (mean age 54 years, 24% men). On surgical pathology, 108 were MCNs and 72 BD-IPMNs. There was no difference in invasive rate (7 of 108 [6.5%] MCNs vs 4 of 72 [5.6%] BD-IPMN; p ≈ 1). Pancreatic ductal connectivity was reported on imaging/endoscopy in 10 of 108 (9%) MCNs and 22 of 72 (31%) BD-IPMNs, representing 67% accuracy in differentiating MCNs from BD-IPMNs. On multivariate analysis, typical risk factors failed to predict invasiveness in either MCNs or BD-IPMNs. When all undifferentiated solitary MCLs were analyzed together, older age (p = 0.03) and cyst size (p = 0.04) were associated with increased invasive rate in multivariate analysis. CONCLUSIONS: Unreliable differentiation and limited ability to predict invasiveness make solitary MCLs clinically challenging. With similar invasive rates, MCN and unifocal BD-IPMNs should be merged into one new entity for management, the undifferentiated solitary MCL.

10 Article Management of branch-duct intraductal papillary mucinous neoplasms: a large single-center study to assess predictors of malignancy and long-term outcomes. 2016

Ridtitid, Wiriyaporn / DeWitt, John M / Schmidt, C Max / Roch, Alexandra / Stuart, Jennifer Schaffter / Sherman, Stuart / Al-Haddad, Mohammad A. ·Indiana University School of Medicine, Indianapolis, Indiana, USA; Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand. · Indiana University School of Medicine, Indianapolis, Indiana, USA. · Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. ·Gastrointest Endosc · Pubmed #26905937.

ABSTRACT: BACKGROUND AND AIMS: Management of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) remains challenging. We determined factors associated with malignancy in BD-IPMNs and long-term outcomes. METHODS: This retrospective cohort study included all patients with established BD-IPMNs by the International Consensus Guidelines (ICG) 2012 and/or pathologically confirmed BD-IPMNs in a tertiary care referral center between 2001 and 2013. Main outcome measures were the association between high-risk stigmata (HRS)/worrisome features (WFs) of the ICG 2012 and malignant BD-IPMNs, performance characteristics of EUS-FNA for the diagnosis of malignant BD-IPMNs, and recurrence and long-term outcomes of BD-IPMN patients undergoing surgery or imaging surveillance. RESULTS: Of 364 BD-IPMN patients, 229 underwent imaging surveillance and 135 underwent surgery. Among the 135 resected BD-IPMNs, HRS/WFs on CT/magnetic resonance imaging (MRI) were similar between the benign and malignant groups, but main pancreatic duct (MPD) dilation (5-9 mm) was more frequently identified in malignant lesions. On EUS-FNA, mural nodules, MPD features suspicious for involvement, and suspicious/positive malignant cytology were more frequently detected in the malignant group with a sensitivity, specificity, and accuracy of 33%, 94%, and 86%; 42%, 91%, and 83%; and 33% 91%, and 82%, respectively. Mural nodules identified by EUS were missed by CT/MRI in 28% in the malignant group. Patients with malignant lesions had a higher risk of any IPMN recurrence during a mean follow-up period of 131 months (P = .01). CONCLUSIONS: Among HRS and WFs of the ICG 2012, an MPD size of 5 to 9 mm on CT/MRI was associated with malignant BD-IPMNs. EUS features including mural nodules, MPD features suspicious for involvement, and suspicious/malignant cytology were accurate and highly specific for malignant BD-IPMNs. Our study highlights the incremental value of EUS-FNA over imaging in identifying malignant BD-IPMNs, particularly in patients without WFs and those with smaller cysts. Benign IPMN recurrence was observed in some patients up to 8 years after resection.

11 Article Intraductal papillary mucinous neoplasm of the pancreas, one manifestation of a more systemic disease? 2016

Roch, Alexandra M / Rosati, Carlo Maria / Cioffi, Jessica L / Ceppa, Eugene P / DeWitt, John M / Al-Haddad, Mohammad A / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA. · Division of Gastroenterology, Department of Medicine, Indiana University Hospital, Indianapolis, IN, USA. · Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. · Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA. Electronic address: maxschmi@iupui.edu. ·Am J Surg · Pubmed #26830712.

ABSTRACT: BACKGROUND: Several studies have demonstrated a high prevalence of extrapancreatic malignancies, and an association with autoimmune pancreatitis in patients with intraductal papillary mucinous neoplasm (IPMN). We hypothesized that IPMNs were associated with an increase rate of systemic diseases. METHODS: From 1996 to 2013, a retrospective analysis of a prospectively collected database was performed and supplemented with electronic medical charts review. RESULTS: Two hundred twenty extrapancreatic malignancies were found in 185 patients (22%) compared with expected 5% in the general population. Colorectal, lung, and renal cell carcinoma had significant observed/expected ratios (P < .0001). One hundred ten synchronous autoimmune diseases were found in 96 patients (11%). Systemic lupus erythematosus, rheumatoid arthritis, and inflammatory bowel disease showed statistically significant observed/expected ratios (P < .0001, .01, and <.0001, respectively). There was no impact of immunosuppressive treatment on the IPMN subtype and malignancy rate. CONCLUSIONS: IPMN are associated with surprisingly high rates of autoimmune diseases suggesting that IPMN might be 1 manifestation of a more systemic disease.

12 Article Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreatoduodenectomy for Pancreatic Adenocarcinoma. 2016

Roch, Alexandra M / House, Michael G / Cioffi, Jessica / Ceppa, Eugene P / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA. · Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA. maxschmi@iupui.edu. ·J Gastrointest Surg · Pubmed #26768008.

ABSTRACT: INTRODUCTION: Several studies have confirmed the safety of pancreatoduodenectomy with portal/mesenteric vein resection and reconstruction in select patients. The effect of vein invasion and extent of invasion on survival is less clear. The purpose of this study was to examine the association between tumor invasion of the portal/mesenteric vein and long-term survival. METHODS: A retrospective review of a prospectively maintained database of patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at a single academic medical center (2000-2014) was performed. Survival was compared using the Kaplan-Meier method and log-rank test. P < 0.05 was considered statistically significant. RESULTS: After non-pancreatic periampullary adenocarcinomas and patients with non-segmental (lateral wall only) resection of portal/mesenteric vein were excluded, there were 567 eligible patients. Of these, segmental vein resection was performed in 90 (16 %) with end-to-end primary anastomosis (67) or interposition graft reconstruction (23). Patients with vein resection more likely received neoadjuvant systemic therapy (59 vs. 4 %, p < 0.0001). Histopathology of patients undergoing vein resection revealed a distribution of T stage toward larger tumors and higher rates of perineural invasion. Portal/mesenteric vein resection, however, was not associated with differences in hospital stay, postoperative complications, or operative mortality. Patients with or without vein resection had comparable overall survival rates at 1-, 3-, and 5-years. On final surgical histopathology, only 52 of 90 (58 %) vein resections had adenocarcinoma involvement of the venous wall. Of these, depth of invasion was at the level of the adventitia (9), media/intima (34), and full thickness/intraluminal (9). Venous wall invasion (52) did not significantly influence overall survival (14 vs. 21 months, p = 0.08) but was associated with significantly shorter median disease-free survival (11.3 vs. 15.8 months, p = 0.03), predominantly due to local recurrence. The extent of invasion (adventitia, media/intima, full thickness/intraluminal) did not impact overall survival or disease-free survival (14.4 vs. 15.5 vs. 7.4 months, p = 0.08 and 11.2 vs. 12.2 vs. 5 months, 0.59, respectively). Portal/mesenteric vein resection, histopathologic invasion, or the extent of invasion were not independent predictors of overall survival in Cox regression analysis. CONCLUSION: Although Portal/mesenteric vein resection is associated with increased 90-day mortality, venous resection is not prognostic of overall survival. Although a subgroup analysis showed that a direct tumor invasion into the vein wall on final histopathology was associated with a higher rate of local recurrence but with no difference in overall survival (even when stratified according to extent of venous wall invasion), larger studies with an increased power will be needed to confirm these findings.

13 Article Identification of Patients with Family History of Pancreatic Cancer--Investigation of an NLP System Portability. 2015

Mehrabi, Saeed / Krishnan, Anand / Roch, Alexandra M / Schmidt, Heidi / Li, DingCheng / Kesterson, Joe / Beesley, Chris / Dexter, Paul / Schmidt, Max / Palakal, Mathew / Liu, Hongfang. ·Department of Health Sciences Research, Mayo Clinic, Rochester, MN. · School of Informatics and Computing, Indiana University, Indianapolis, IN. · Department of Surgery, Indiana University, Indianapolis, IN. · Regenstrief Institute Inc., Indianapolis, IN. ·Stud Health Technol Inform · Pubmed #26262122.

ABSTRACT: In this study we have developed a rule-based natural language processing (NLP) system to identify patients with family history of pancreatic cancer. The algorithm was developed in a Unstructured Information Management Architecture (UIMA) framework and consisted of section segmentation, relation discovery, and negation detection. The system was evaluated on data from two institutions. The family history identification precision was consistent across the institutions shifting from 88.9% on Indiana University (IU) dataset to 87.8% on Mayo Clinic dataset. Customizing the algorithm on the the Mayo Clinic data, increased its precision to 88.1%. The family member relation discovery achieved precision, recall, and F-measure of 75.3%, 91.6% and 82.6% respectively. Negation detection resulted in precision of 99.1%. The results show that rule-based NLP approaches for specific information extraction tasks are portable across institutions; however customization of the algorithm on the new dataset improves its performance.

14 Article Invasive, mixed-type intraductal papillary mucinous neoplasm: superior prognosis compared to invasive main-duct intraductal papillary mucinous neoplasm. 2015

Ceppa, Eugene P / Roch, Alexandra M / Cioffi, Jessica L / Sharma, Neil / Easler, Jeffrey J / DeWitt, John M / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address: eceppa@iupui.edu. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. · Gastroenterology, Parkview Health System, Fort Wayne, IN. · Department of Medicine, Division of Gastroenterology, Indiana University Hospital, Indianapolis, IN. ·Surgery · Pubmed #26173683.

ABSTRACT: PURPOSE: It is unclear whether the duct involvement subtypes of intraductal papillary mucinous neoplasm (IPMN), ie, main (MD), mixed (MT), and branch (BD), confer any survival advantage when invasive IPMN occurs. We hypothesized that invasive MT-IPMN was associated with a better prognosis than invasive MD-IPMN. METHODS: A retrospective review of a prospectively maintained database was performed of patients who underwent resection for IPMN at a single academic institution from 1992 to 2014. Characterization of IPMN subtype was assessed on final operative pathology. Statistics included univariate analysis, Kaplan-Meier survival curves, and Cox regression for independent predictors of increased survival. RESULTS: Of 390 patients eligible for study, 74 had invasive IPMN (IPMC). Of these, 71 patients had complete data and were included in the analysis (17 MD-IPMC, 39 MT-IPMC, and 15 BD-IPMC). Median follow-up was 20 months (range, 2-174). MT-IPMC was associated with significantly greater overall survival (OS) (47 months) compared with MD-IPMC (12 months) (P = .049), but not with BD-IPMC (44 months) (P = .67). Multivariate Cox regression yielded a family history of pancreatic cancer, absence of jaundice, N0 status, negative margins, absence of lymphovascular invasion, and MT subtype as independent predictors of greater OS (P = .035, .015, .013, .036, .045, .043, respectively). No characteristic of IPMN (including MD diameter, solid component/mural nodule) was predictive of OS. CONCLUSION: MT-IPMC appeared to be associated with a greater OS compared with pure MD-IPMC. This begs the question of a different underlying biology of MT-IPMN and argues against classification of all main duct involved IPMN into a single category.

15 Article Extended distal pancreatectomy for pancreatic adenocarcinoma with splenic vein thrombosis and/or adjacent organ invasion. 2015

Roch, Alexandra M / Singh, Harjot / Turner, Alexandra P / Ceppa, Eugene P / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, Christian Max. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. Electronic address: maxschmi@iupui.edu. ·Am J Surg · Pubmed #25547091.

ABSTRACT: BACKGROUND: Patients with adenocarcinoma of the pancreatic body/tail and associated vascular thrombosis or adjacent organ invasion are suboptimal candidates for resection. We hypothesized that extended distal pancreatectomy (EDP) for locally advanced adenocarcinoma is associated with a survival benefit. METHODS: We retrospectively reviewed a prospectively collected database of patients who underwent distal pancreatectomy (DP) for adenocarcinoma at a single academic institution (1996 to 2011) with greater than or equal to 2 years of follow-up. RESULTS: Among 680 DP patients, 93 were indicated for pancreatic adenocarcinoma. Splenic vein thrombosis (n = 26) did not significantly affect morbidity, mortality, or survival. Standard DP was performed in 70 patients and 23 underwent EDP with no difference in morbidity/mortality. Patients with EDP had a survival comparable with patients with standard DP (disease-free survival 18 vs 12 months = .8; overall survival 23 vs 17 months, P =.6). There was no difference in survival between EDP patients with versus without pathologic invasion of adjacent organs, but a trend favored those without. CONCLUSION: EDP is safe and should be considered in fit patients with locally advanced adenocarcinoma.

16 Article Automated pancreatic cyst screening using natural language processing: a new tool in the early detection of pancreatic cancer. 2015

Roch, Alexandra M / Mehrabi, Saeed / Krishnan, Anand / Schmidt, Heidi E / Kesterson, Joseph / Beesley, Chris / Dexter, Paul R / Palakal, Mathew / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. ·HPB (Oxford) · Pubmed #25537257.

ABSTRACT: INTRODUCTION: As many as 3% of computed tomography (CT) scans detect pancreatic cysts. Because pancreatic cysts are incidental, ubiquitous and poorly understood, follow-up is often not performed. Pancreatic cysts may have a significant malignant potential and their identification represents a 'window of opportunity' for the early detection of pancreatic cancer. The purpose of this study was to implement an automated Natural Language Processing (NLP)-based pancreatic cyst identification system. METHOD: A multidisciplinary team was assembled. NLP-based identification algorithms were developed based on key words commonly used by physicians to describe pancreatic cysts and programmed for automated search of electronic medical records. A pilot study was conducted prospectively in a single institution. RESULTS: From March to September 2013, 566,233 reports belonging to 50,669 patients were analysed. The mean number of patients reported with a pancreatic cyst was 88/month (range 78-98). The mean sensitivity and specificity were 99.9% and 98.8%, respectively. CONCLUSION: NLP is an effective tool to automatically identify patients with pancreatic cysts based on electronic medical records (EMR). This highly accurate system can help capture patients 'at-risk' of pancreatic cancer in a registry.

17 Article Abnormal serum pancreatic enzymes, but not pancreatitis, are associated with an increased risk of malignancy in patients with intraductal papillary mucinous neoplasms. 2014

Roch, Alexandra M / Parikh, Janak A / Al-Haddad, Mohammad A / DeWitt, John M / Ceppa, Eugene P / House, Michael G / Nakeeb, Attila / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. · Department of Medicine, Division of Gastroenterology, Indiana University Hospital, Indianapolis, IN. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address: maxschmi@iupui.edu. ·Surgery · Pubmed #25239347.

ABSTRACT: INTRODUCTION: Pancreatitis is associated with intraductal papillary mucinous neoplasm (IPMN). This association is in part due to inflammation from pancreatic ductal obstruction. Although the correlation between pancreatitis and the malignant potential of IPMN is unclear, the 2012 International Consensus Guidelines (ICG) consider pancreatitis a "worrisome feature." We hypothesized that serum pancreatic enzymes, markers of inflammation, are a better predictor of malignancy than pancreatitis in patients with IPMN. METHODS: Between 1992 and 2012, 364 patients underwent resection for IPMN at a single university hospital. In the past decade, serum amylase and lipase were collected prospectively as an inflammatory marker in 203 patients with IPMN at initial surveillance and "cyst clinic" visits. The latest serum pancreatic enzyme values within 3 months preoperatively were studied. Pancreatitis was defined according to the 2012 revision of the Atlanta Consensus. RESULTS: Of the 203 eligible patients, there were 76 with pancreatitis. Pancreatitis was not associated with an increased rate of malignancy (P = .51) or invasiveness (P = .08). Serum pancreatic enzymes categorically outside of normal range (high or low) were also not associated with malignancy or invasiveness. In contrast, as a continuous variable, the higher the serum pancreatic enzymes were, the greater the rate of invasive IPMN. Of the 127 remaining patients without pancreatitis, serum pancreatic enzymes outside of normal range (low and high) were each associated with a greater rate of malignancy (P < .0001 and P = .0009, respectively). Serum pancreatic enzyme levels above normal range (high) were associated with a greater rate of invasiveness (P = .02). CONCLUSION: In patients with IPMN without a history of pancreatitis, serum pancreatic enzymes outside of the normal range are associated with a greater risk of malignancy. In patients with a history of pancreatitis, there is a positive correlation between the levels of serum pancreatic enzymes and the presence of invasive IPMN. These data suggest serum pancreatic enzymes may be useful markers in stratification of pancreatic cancer risk in patients with IPMN.

18 Article The natural history of main duct-involved, mixed-type intraductal papillary mucinous neoplasm: parameters predictive of progression. 2014

Roch, Alexandra M / Ceppa, Eugene P / Al-Haddad, Mohammad A / DeWitt, John M / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Max. ·*Department of Surgery, Indiana University School of Medicine, Indianapolis; and †Department of Medicine, Division of Gastroenterology, Indiana University Hospital, Indianapolis. ·Ann Surg · Pubmed #25203885.

ABSTRACT: OBJECTIVE: As such, the natural history of MPD-involved IPMN is poorly understood. BACKGROUND: The high-risk of malignancy associated with main pancreatic duct (MPD)-involved intraductal papillary mucinous neoplasm (IPMN) has been established by surgical series. The International Consensus Guidelines recommend surgical resection of MPD-involved IPMN in fit patients. METHODS: A review of a prospectively collected database (1992-2012) of patients with IPMN undergoing primary surveillance was performed. Invasive progression was defined as invasive carcinoma on pathology and/or positive cytopathology. Analyses included univariate, logistic regression, and receiver operating characteristic curve analyses. RESULTS: A total of 503 patients with IPMN underwent primary surveillance, 70 for MPD-involved, mixed-type IPMN. Indications for intensive surveillance of these 70 high-risk patients were comorbidities, patient choice, and early/borderline MPD dilation (42%, 51%, and 7%, respectively). Mean follow-up was 4.7 years. Nine patients (13%) progressed at a mean of 3.5 (range, 1-9) years during follow-up. Univariate analyses yielded weight loss, interval (from isolated branch-duct IPMN) to MPD involvement, diffuse MPD dilation, increase of MPD diameter, absence of extra pancreatic cysts, elevated serum CA19-9 levels, and elevated serum alkaline phosphatase levels as significant. Maximum MPD and/or branch-duct diameter were not significant. In logistic regression, diffuse MPD dilation, serum CA19-9 and serum alkaline phosphatase levels, and absence of extra pancreatic cysts were predictors of invasiveness. The receiver operating characteristic curve indicated that the combination of these 4 factors achieved an accuracy of 98% in predicting progression. CONCLUSIONS: Primary surveillance of mixed-type IPMN may be a reasonable strategy in select patients. Diffuse MPD dilation, serum CA19-9, serum alkaline phosphatase, and absence of extrapancreatic cysts predict patients likely to progress during primary surveillance.

19 Article International Consensus Guidelines parameters for the prediction of malignancy in intraductal papillary mucinous neoplasm are not properly weighted and are not cumulative. 2014

Roch, Alexandra M / Ceppa, Eugene P / DeWitt, John M / Al-Haddad, Mohammad A / House, Michael G / Nakeeb, Atilla / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. ·HPB (Oxford) · Pubmed #25077378.

ABSTRACT: BACKGROUND: The International Consensus Guidelines (ICG) stratify risk for malignancy in patients with intraductal papillary mucinous neoplasm (IPMN) into three progressive categories according to whether patients show 'no criteria', 'worrisome features' (WFs) or 'high-risk stigmata' (HRS). OBJECTIVES: This study was conducted to test the hypothesis that type (clinical versus radiological) and quantity of ICG WFs and HRS carry unequal weight and are not cumulative in the prediction of risk for malignancy or invasiveness in IPMN. METHODS: A retrospective review of a prospectively maintained database of patients who underwent surgical resection for IPMN at a single, university-based medical centre during 1992-2012 was performed. Differences that achieved a P-value of <0.05 were considered significant. RESULTS: Of 362 patients, 340 were eligible for entry into the study and were categorized as demonstrating no criteria (n = 70), WFs (n = 185) or HRS (n = 85). Patients in the WFs group had higher rates of malignant and invasive IPMN than those in the no-criteria group [26.5% versus 4.3% (P < 0.0001) and 15.7% versus 4.3% (P = 0.02), respectively]. Patients in the HRS group had higher rates of malignant and invasive IPMN than those in the WFs group [56.5% versus 26.5% (P = 0.0001) and 42.4% versus 15.7% (P = 0.0001), respectively]. When radiological parameters only were considered for WFs versus HRS, no difference was found in rates of malignant or invasive IPMN. By contrast, when clinical parameters only were considered, patients in the HRS group had higher rates of malignant or invasive IPMN [66.7% versus 8.1% (P = 0.04) and 66.7% versus 2.7% (P = 0.01), respectively]. There was no stepwise increase in rates of malignant or invasive IPMN with the number of WFs. However, patients with only one WF had a lower risk for malignancy than patients with two or more WFs. CONCLUSIONS: The type and quantity of ICG WFs and HRS carry unequal weight and are not cumulative in the prediction of risk for malignancy or invasiveness in IPMN.

20 Article Nonoperative management of main pancreatic duct-involved intraductal papillary mucinous neoplasm might be indicated in select patients. 2014

Roch, Alexandra M / DeWitt, John M / Al-Haddad, Mohammad A / Schmidt, Christian M / Ceppa, Eugene P / House, Michael G / Zyromski, Nicholas J / Nakeeb, Attila / Schmidt, C Maximillian. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. · Department of Medicine, Division of Gastroenterology, Indiana University Hospital, Indianapolis, IN. · Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address: maxschmi@iupui.edu. ·J Am Coll Surg · Pubmed #24862887.

ABSTRACT: BACKGROUND: Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. STUDY DESIGN: From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter ≥5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. RESULTS: Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). CONCLUSIONS: Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.

21 Article Does preoperative cross-sectional imaging accurately predict main duct involvement in intraductal papillary mucinous neoplasm? 2014

Barron, M R / Roch, A M / Waters, J A / Parikh, J A / DeWitt, J M / Al-Haddad, M A / Ceppa, E P / House, M G / Zyromski, N J / Nakeeb, A / Pitt, H A / Schmidt, C Max. ·Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. ·J Gastrointest Surg · Pubmed #24402606.

ABSTRACT: Main pancreatic duct (MPD) involvement is a well-demonstrated risk factor for malignancy in intraductal papillary mucinous neoplasm (IPMN). Preoperative radiographic determination of IPMN type is heavily relied upon in oncologic risk stratification. We hypothesized that radiographic assessment of MPD involvement in IPMN is an accurate predictor of pathological MPD involvement. Data regarding all patients undergoing resection for IPMN at a single academic institution between 1992 and 2012 were gathered prospectively. Retrospective analysis of imaging and pathologic data was undertaken. Preoperative classification of IPMN type was based on cross-sectional imaging (MRI/magnetic resonance cholangiopancreatography (MRCP) and/or CT). Three hundred sixty-two patients underwent resection for IPMN. Of these, 334 had complete data for analysis. Of 164 suspected branch duct (BD) IPMN, 34 (20.7%) demonstrated MPD involvement on final pathology. Of 170 patients with suspicion of MPD involvement, 50 (29.4%) demonstrated no MPD involvement. Of 34 patients with suspected BD-IPMN who were found to have MPD involvement on pathology, 10 (29.4%) had invasive carcinoma. Alternatively, 2/50 (4%) of the patients with suspected MPD involvement who ultimately had isolated BD-IPMN demonstrated invasive carcinoma. Preoperative radiographic IPMN type did not correlate with final pathology in 25% of the patients. In addition, risk of invasive carcinoma correlates with pathologic presence of MPD involvement.

22 Article Obesity increases malignant risk in patients with branch-duct intraductal papillary mucinous neoplasm. 2013

Sturm, Emily C / Roch, Alexandra M / Shaffer, Kristina M / Schmidt, Christian M / Lee, Se-Joon / Zyromski, Nicholas J / Pitt, Henry A / Dewitt, John M / Al-Haddad, Mohammad A / Waters, Joshua A / Schmidt, C Max. ·Department of Surgery, Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, IN. ·Surgery · Pubmed #24074418.

ABSTRACT: BACKGROUND: Obesity is an established risk factor for pancreatic adenocarcinoma. No study has examined specifically the influence of obesity on malignant risk in patients with intraductal papillary mucinous neoplasm (IPMN), a group at substantial risk of pancreatic adenocarcinoma. We hypothesize that obesity is associated with a greater frequency of malignancy in IPMN. METHODS: Data on patients undergoing resection for IPMN between 1992 and 2012 at a high-volume university institution were collected prospectively. Clinicopathologic and demographic parameters were reviewed. Patients were classified according to World Health Organization categories of body mass index (BMI). Malignancy was defined as high-grade dysplastic or invasive IPMN. RESULTS: We collected data on 357 patients who underwent resection for IPMN. Of these, 274 had complete data for calculation of preoperative BMI and 31% had malignant IPMN. Of 254 patients with a BMI of <35 kg/m(2), 30% had malignant IPMN versus 50% in patients with BMI of ≥35 (P = .08). In branch-duct IPMN, patients with a BMI of <35 had 12% of malignant IPMN compared with 46% in severely obese patients (P = .01). Alternatively, in main-duct IPMN, no difference was found in the malignancy rate (48% vs 56%; P = .74). CONCLUSION: These findings suggest that obesity is associated with an increased frequency of malignancy in branch-duct IPMN. Obesity is a potentially modifiable risk factor that may influence oncologic risk stratification, patient counseling, and surveillance strategy.