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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.
Klaus Sahora*, Mari Mino-Kenudson*, Sarah Thayer*, Cristina Ferrone*, William Brugge*, Dushyant Sahani*, Martha Pitman*, Andrew Warshaw, Keith Lillemoe, Carlos Fernandez-Del Castillo
Massachusetts General Hospital, Boston, MA

OBJECTIVE(S):
The Sendai guidelines for management of branch-duct (BD) IPMN espouse safety of observation of asymptomatic cysts < 3cm without nodules (Sendai negative). Revised international consensus guidelines published in 2012 suggest a still more conservative approach in the management of BD-IPMN, even for lesions ≥ 3cm. By contrast, two recent studies have challenged the safety of both guidelines, describing malignancy (invasive carcinoma or carcinoma-in-situ) in a) 67% of BD-IPMN <3cm and b) 24.6% of “Sendai negative” BD-IPMN. The aim of the present study was to critically analyze the safety of the revised guidelines in the management of BD-IPMN, with focus on cyst size and worrisome features.
METHODS and RESULTS:
Review of a prospective database identified 563 patients with BD-IPMN. 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. Malignancy was found in 57 pts of the entire cohort (10%). 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. However, 11% of resected BD-IPMN with no worrisome features harbored malignancy. The risk of malignancy in those non-worrisome lesions was 7% in BD-IPMN <3cm and 18% in lesions ≥ 3cm.
CONCLUSIONS:
Expectant management of BD-IPMN following the old guidelines is safe, whereas caution is advised in larger lesions, even in the absence of worrisome features.


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