Branch duct intraductal papillary mucinous neoplasms: Does cyst size change the tip of the scale? A critical analysis of the revised international consensus guidelines in a large single-institutional series

Klaus Sahora, Mari Mino-Kenudson, William Brugge, Sarah P. Thayer, Cristina R. Ferrone, Dushyant Sahani, Martha B. Pitman, Andrew L. Warshaw, Keith D. Lillemoe, Carlos F. Fernandez-del Castillo

Research output: Contribution to journalArticle

157 Scopus citations

Abstract

Objective: The aim of this study was to critically analyze the safety of the revised guidelines, with focus on cyst size and worrisome features in the management of BD-IPMN. Background: The Sendai guidelines formanagement of branch duct (BD) intraductal papillary mucinous neoplasm (IPMN) espouse safety of observation of asymptomatic cysts smaller than 3 cm without nodules (Sendai negative). Revised international consensus guidelines published in 2012 suggest a still more conservative approach, even for lesions of 3 cm or larger. By contrast, 2 recent studies have challenged the safety of both guidelines, describing invasive carcinoma or carcinoma in situ in 67% of BD-IPMN smaller than 3 cm and in 25% of "Sendai-negative" BD-IPMN. Methods and Results: Review of a prospective database identified 563 patients with BD-IPMN. A total of 240 patients underwent surgical resection (152 at the time of diagnosis and 88 after being initially followed); the remaining 323 have been managed by observation with median follow-up of 60 months. No patient developed unresectable BD-IPMN carcinoma during follow-up. Invasive cancer arising in BD-IPMN was found in 23 patients of the entire cohort (4%), and an additional 21 patients (3.7%) had or developed concurrent pancreatic ductal adenocarcinoma. According to the revised guidelines, 76% of resected BD-IPMN with carcinoma in situ and 95% of resected BD-IPMN with invasive cancer had high-risk stigmata or worrisome features. The risk of high-grade dysplasia in nonworrisome lesions smaller than 3 cm was 6.5%, but when the threshold was raised to greater than 3 cm, it was 8.8%, and 1 case of invasive carcinoma was found. Conclusions: Expectant management of BD-IPMN following the old guidelines is safe, whereas caution is advised for larger lesions, even in the absence of worrisome features.

Original languageEnglish (US)
Pages (from-to)466-474
Number of pages9
JournalAnnals of surgery
Volume258
Issue number3
DOIs
StatePublished - Sep 2013

Keywords

  • Guidelines
  • Intraductal papillarymucinous neoplasm
  • Malignancy
  • Pancreas
  • Pancreatic cystic neoplasm
  • Surgery

ASJC Scopus subject areas

  • Surgery

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    Sahora, K., Mino-Kenudson, M., Brugge, W., Thayer, S. P., Ferrone, C. R., Sahani, D., Pitman, M. B., Warshaw, A. L., Lillemoe, K. D., & Fernandez-del Castillo, C. F. (2013). Branch duct intraductal papillary mucinous neoplasms: Does cyst size change the tip of the scale? A critical analysis of the revised international consensus guidelines in a large single-institutional series. Annals of surgery, 258(3), 466-474. https://doi.org/10.1097/SLA.0b013e3182a18f48