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

151 Citations (Scopus)

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 1 2013

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Cysts
Guidelines
Neoplasms
Carcinoma in Situ
Safety
Observation
Carcinoma
Christianity
Mucinous Adenocarcinoma
Papillary Carcinoma
Adenocarcinoma
Databases

Keywords

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

ASJC Scopus subject areas

  • Surgery

Cite this

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

In: Annals of surgery, Vol. 258, No. 3, 01.09.2013, p. 466-474.

Research output: Contribution to journalArticle

Sahora, Klaus ; Mino-Kenudson, Mari ; Brugge, William ; Thayer, Sarah P. ; Ferrone, Cristina R. ; Sahani, Dushyant ; Pitman, Martha B. ; Warshaw, Andrew L. ; Lillemoe, Keith D. ; Fernandez-del Castillo, Carlos F. / 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. In: Annals of surgery. 2013 ; Vol. 258, No. 3. pp. 466-474.
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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.",
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AU - Brugge, William

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AU - Ferrone, Cristina R.

AU - Sahani, Dushyant

AU - Pitman, Martha B.

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