Original article—liver, pancreas, and biliary tract
Morphologic Changes in Branch Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Midterm Follow-Up Study

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Background & Aims: Because there is a low risk of malignancy for intraductal papillary and mucinous neoplasms of the pancreas (IPMNs) confined to branch ducts (BD), patient follow-up evaluation without surgery is possible. The aim of this study was to assess time-related morphologic changes and risk of progress to malignancy in patients with BD IPMN. A prospective design was used in an academic tertiary referral center. Methods: All consecutive patients seen from 1999 to 2005 with highly suspected IPMNs confined to BD without criteria suggesting a malignant development (mural nodule, cyst wall thickness >2 mm, BD diameter >30 mm, or main pancreatic duct involvement) were followed up prospectively using computerized tomography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography. Results: A total of 121 patients (median age, 63 y) were included. After a median follow-up period of 33 months, no morphologic changes had occurred in 88 patients. The size of the cyst increased in 30 of the 33 remaining patients, and 12 developed criteria suggesting a malignant development. Surgery, performed in 8 of 12 patients, found 4 IPMN-adenomas, 1 borderline-IPMN, and 4 IPMN carcinoma in situ. The 4 remaining patients did not undergo surgery because of severe comorbid conditions in 2, change in reference hospital in 1, and a mural nodule considered being sequelae of previous fine-needle aspiration in 1 patient. The only factor associated with signs suggesting malignant development was an increase in cyst size to more than 5 mm during the follow-up evaluation. Conclusions: In patients with IPMNs confined to BD, morphologic changes are rare events, justifying a nonsurgical approach. Careful follow-up evaluation remains necessary, particularly in patients with an increase in BD size.

Section snippets

Inclusion Criteria

All consecutive patients diagnosed in our department from January 1999 to August 2005 with highly suspected IPMN confined to BD were considered for inclusion in this study. Diagnosis was highly suspected when patients with normal MPD had 1 or several BD dilatation(s) or pancreatic cystic lesions communicating with pancreatic ducts, observed with at least 2 of the following imaging techniques: CT scan, MRCP, endoscopic retrograde cholangiopancreatography (ERCP), or EUS.

Exclusion Criteria

We excluded patients from

Characteristics of the Overall Population

Among the 189 patients diagnosed with strongly suspected IPMN confined to BD, 52 were excluded because of follow-up periods of less than 1 year. Sixteen additional patients were excluded because of thickening of the duct wall or a mural nodule (n = 13) or BD dilatation of more than 30 mm (n = 3) was present at diagnosis. The study included 121 patients whose characteristics are summarized in Table 1. Twenty-four of these patients also were included in the study by Levy et al.4

Radiologic Data at Diagnosis

A median number of

Discussion

In 1999, we decided not to perform surgery on patients without or with mildly symptomatic IPMN confined to BD in the absence of radiologic criteria suggesting malignancy. This decision was made based on the low percentage of IPMN-carcinoma in situ or invasive carcinoma observed in the pathologic samples of patients with IPMN that only involved BD. Prophylactic pancreatectomy clearly was inappropriate and too aggressive in these patients.9, 10, 26 The present article evaluates the morphologic

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