Branch-duct intraductal papillary mucinous neoplasms of the pancreas: to operate or not to operate?

Abstract

Background: Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) of the pancreas are reported to be less aggressive than the main-duct type. Hence, less aggressive treatment has been proposed for the former. Aim: To evaluate the effectiveness of a follow-up protocol for BD-IPMNs. Design: Prospective study. Patients who presented malignancy-related parameters (size .3.5 cm, nodules, thick walls, carbohydrate antigen 19.9 level .25 U/l, recent-onset or worsened diabetes) and/or complained of symptoms were submitted to surgery (arm A). All asymptomatic patients without suspicion of malignancy were followed up according to a 6-month clinical-radiological protocol (arm B). Main outcome measures: The effectiveness of conservative management of BD-IPMNs. Results: 20 (18.3%) patients underwent surgery (arm A); pathological diagnosis of BD-IPMNs was always confirmed. 89 (81.7%) patients were followed up for a median of 32 months (arm B); of these, 57 (64%) patients had multifocal disease. After a mean follow-up of 18.2 months, 5 (5.6%) patients showed an increase in lesion size and underwent surgery. The pathological diagnosis was branch-duct adenoma in three patients and borderline adenoma in two. Conclusions: Surgery is indicated in ,20% of cases of BD-IPMNs, and, in the absence of malignancy-related parameters, careful non-operative management seems to be safe and effective in asymptomatic patients. Although observation for a longer time is needed to confirm these results, our findings support the guidelines recently recommended by the International Association of Pancreatology.

Differences between main-duct and branch-duct intraductal papillary mucinous neoplasms of the pancreas

“…In most series, the median age of patients at the diagnosis is 65-70 years [6,[8][9][10][11][12][13][14][15][16][17][18][19] . However, while a few studies made a clear distinction between MD-IPMNs and BD-IPMNs, most series include both subgroups.…”

“…By contrast, in BD-IPMNs the frequency of malignancy is significantly lower (between 6% and 46%, with a mean of 25%) and that of invasive cancer ranges from 0 to 30% (mean of 15%) [6,8,9,[10][11][12][13][14][15][16] . In the combined experience of Massachusetts General Hospital and University of Verona, 145 patients underwent surgical resection for BDIPMNs [9] .…”

“…Main-duct IPMNs (MD-IPMNs) are characterized by involvement of the main pancreatic duct with or without associated involvement of the branch ducts (combined IPMNs); they usually present as a dilated (≥ 1 cm) main pancreatic duct or as cystic dilation of the main duct and its branches; branch-duct IPMNs (BDIPMNs) originate in the side branches of the pancreatic ductal system, appearing as a cystic lesion that always communicates with a non-dilated main pancreatic duct [6] . In the last ten years, the diagnosis of IPMNs has significantly increased [7,8] . This can be related to improved Elijah Dixon, MD, BSc, MSc (Epi), FRCSC, FACS, Assistant Professor, Series Editor incomplete but a better awareness of the distinction between the main and branch duct variants have contributed to a better understanding.…”

Pancreatic Mucinous Lesions: How Dangerous are they?

“…Whether or not an exact diagnosis is achieved may not turn out to be as important as the risk stratification based on imaging characteristics. A few recent prospective long-term follow-up studies showed that patients with presumed BD-IPMN in the absence of concerning radiographic features can be safely followed [15][16][17]. More importantly, the patients that developed suspicious radiologic findings (e.g.…”

“…More importantly, the patients that developed suspicious radiologic findings (e.g. mural nodules or increase in cyst size) during close follow-up underwent surgical resection and none had invasive cancer [15][16][17].…”