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Asymptomatic pancreatic cystic neoplasms: maximizing survival and quality of life using Markov-based clinical nomograms Weinberg BM; Spiegel BM; Tomlinson JS; Farrell JJGastroenterology 2010[Feb]; 138 (2): 531-40BACKGROUND & AIMS: The natural history and management of pancreatic cysts, especially for branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), remain uncertain. We developed evidence-based nomograms to assist with clinical decision making. METHODS: We used decision analysis with Markov modeling to compare competing management strategies in a patient with a pancreatic head cyst radiographically suggestive of BD-IPMN, including the following: (1) initial pancreaticoduodenectomy (PD), (2) yearly noninvasive radiographic surveillance, (3) yearly invasive surveillance with endoscopic ultrasound, and (4) "do nothing." We derived probability estimates from a systematic literature review. The primary outcomes were overall and quality-adjusted survival. We depicted the results in a series of nomograms accounting for age, comorbidities, and cyst size. RESULTS: Initial PD was the dominant strategy to maximize overall survival for any cyst greater than 2 cm, regardless of age or comorbidities. In contrast, surveillance was the dominant strategy for any lesion less than 1 cm. However, when measuring quality-adjusted survival, the do-nothing approach maximized quality of life for all cysts less than 3 cm in patients younger than age 75. Once age exceeded 85 years, noninvasive surveillance dominated. Initial PD did not maximize quality of life in any age group or cyst size. CONCLUSIONS: Management of pancreatic cysts can be guided using novel Markov-based clinical nomograms, and depends on age, cyst size, comorbidities, and whether patients value overall survival vs quality-adjusted survival. For patients focused on overall survival, regardless of quality of life, surgery is optimal for lesions greater than 2 cm. For patients focused on quality-adjusted survival, a 3-cm threshold is more appropriate for surgery except for the extreme elderly.|*Markov Chains[MESH]|*Nomograms[MESH]|*Quality of Life[MESH]|Aged[MESH]|Aged, 80 and over[MESH]|Algorithms[MESH]|Cohort Studies[MESH]|Decision Support Techniques[MESH]|Endosonography[MESH]|Humans[MESH]|Pancreatic Cyst/*diagnosis/*mortality[MESH]|Pancreatic Neoplasms/*diagnosis/*mortality[MESH]|Pancreaticoduodenectomy[MESH]|Prognosis[MESH]|Survival Rate[MESH] |
