Long-Term Risk of Pancreatic Malignancy in Patients with Branch Duct Intraductal Papillary Mucinous Neoplasm in A Referral Center.Pergolini I, Sahora K, Ferrone CR, Morales-Oyarvide V, Wolpin BM, Mucci LA, Brugge WR, Mino-Kenudson M, Patino M, Sahani DV, Warshaw AL, Lillemoe KD, Fernández-Del Castillo C. Gastroenterology. 2017 Jul 21. [Epub ahead of print]

BACKGROUND & AIMS:Little is known about development of branch duct intraductal papillary mucinous neoplasms (BD-IPMNs). We evaluated long-term outcomes of a large cohort of patients with BD-IPMNs to determine risk of malignancy and define a subset of low-risk BD-IPMNs.

METHODS:We performed a retrospective analysis of data from 577 patients with suspected or presumed BD-IPMN under surveillance at the Massachusetts General Hospital. Patients underwent cross-sectional imaging analysis at 3 months or later after their initial diagnosis. The diagnosis of BD-IPMN was based on the presence of unilocular or multilocular cysts of the pancreas and a non-dilated main pancreatic duct (smaller than 5 mm). We collected demographic, clinical, and pathology data. Cysts were characterized at time of diagnosis and during the follow-up period. Follow-up duration was time between initial cyst diagnosis and the date of last visit or death for patients without development of pancreatic cancer, date of surgery for patients with histologically confirmed malignancy, or date of first discovery of malignancy by imaging analysis for patients with unresectable tumors or who underwent neaoadjuvant treatment before surgery. The primary outcome was risk of malignancy, with a focus on patients followed for 5 years or more, compared to that of the United States population, based on standardized incidence ratio.RESULTS:Of the 577 patients studied, 479 (83%) were asymptomatic at diagnosis and 363 (63%) underwent endoscopic ultrasound at least once. The median follow-up time was 82 months (range, 6-329 months) for the entire study cohort; 363 patients (63%) underwent surveillance for more than 5 years, and 121 (21%) for more than 10 years. Malignancies (high-grade dysplasia or invasive neoplasm) developed after 5 years in 20/363 patients (5.5%), and invasive cancer developed in 16/363 patients (4.4%). The standardized incidence ratio for patients with BD-IPMNs without worrisome features of malignancy at 5 years was 18.8 (95% CI, 9.7-32.8; P<.001). One hundred eight patients had cysts of 1.5 cm or smaller for more than 5 years of follow up; only 1 of these patients (0.9%) developed a distinct ductal adenocarcinoma. By contrast, among the 255 patients with cysts larger than 1.5 cm, 19 (7.5%) developed malignancy (P=.01).CONCLUSIONS:In a retrospective analysis of patients with BD-IPMNs under surveillance, their overall risk of malignancy, almost 8%, lasted for 10 years or more, supporting continued surveillance after 5 years. Cysts that remain 1.5 cm or smaller for more than 5 years might be considered low-risk for progression to malignancy.

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