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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
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 for management 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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“While the goal of surgery is to resect lesions with advanced neoplasia (high-grade dysplasia and/or adenocarcinoma), approximately 42–63% of resected IPMNs were found to have only low-grade dysplasia [12,13,14,15,16,17].”
From Artificial Intelligence in the Diagnosis and Treatment of Pancreatic Cystic Lesions and Adenocarcinoma (2023) · cites this paper as [15]
In the citing paper
“up to 78% of individuals with branch duct intraductal papillary mucinous neoplasms that undergo surgical resection do not have high-grade dysplasia or pancreatic ductal adenocarcinoma and in hindsight did not require surgery.40”
From Early detection of pancreatic cancer (2020) · cites this paper as [40]
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Metadata
- Authors
- 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.
- Affiliations
- Harvard University (US)
- Corresponding author
- Sahora, Klaus
- Thayer, Sarah P.
- Ferrone, Cristina R.
- Warshaw, Andrew L.
- Lillemoe, Keith D.
- ORCID
- Venue
- Annals of Surgery
- Published
- 2013-09
- Volume
- 258
- Issue
- 3
- Pages
- 466-475
- ISSN
- 0003-4932 (ISSN-L)
- OpenAlex
- W1979727565
- Cited by
- 285
- References
- 18
- Citations by year
- 2026: 12 · 2025: 10 · 2024: 11 · 2023: 23 · 2022: 8 · 2021: 12 · 2020: 26 · 2019: 14 · 2018: 29 · 2017: 39 · 2016: 38 · 2015: 37 · 2014: 26
- FWCI
- 18.04
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Surgery (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Oncology › Pancreatic and Hepatic Oncology Research
- Health Sciences › Medicine › Surgery › Salivary Gland Tumors Diagnosis and Treatment
- Health Sciences › Medicine › Oncology › Neuroendocrine Tumor Research Advances
- Keywords
- branch duct intraductal papillary mucinous neoplasm, expectant management, cyst size, worrisome features, high-grade dysplasia, invasive carcinoma, carcinoma in situ, pancreatic ductal adenocarcinoma, pancreatic cysts, surgical resection
- MeSH terms
- Adenocarcinoma, Adult, Aged, Aged, 80 and over, Carcinoma in Situ, Female, Follow-Up Studies, Humans, Male, Middle Aged, Pancreatectomy, Pancreatic Cyst, Pancreatic Ducts, Pancreatic Neoplasms, Retrospective Studies, Survival Rate, Practice Guidelines as Topic, Tumor Burden, Kaplan-Meier Estimate, Watchful Waiting, Neoplasm Grading
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