PANCREAS

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

Roberto Salvia¹, Stefano Crippa¹, Massimo Falconi¹, Claudio Bassi¹, Alessandro Guarise², Aldo Scarpa³, Paolo Pederzoli¹

¹ Department of Surgery, University of Verona, Policlinico "GB Rossi", Piazzale LA Scuro, Verona, Italy
² Department of Radiology, University of Verona, Policlinico "GB Rossi", Piazzale LA Scuro, Verona, Italy
³ Department of Pathology, University of Verona, Policlinico "GB Rossi", Piazzale LA Scuro, Verona, Italy

Correspondence to:
Dr C Bassi
Department of Surgery, University of Verona, Policlinico "GB Rossi", Piazzale LA Scuro 10, 37134 Verona, Italy; claudio.bassi{at}univr.it

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.

Setting: An academic tertiary referral centre.

Patients: From 2000 to 2003, 109 patients with BD-IPMNs underwent trans-abdominal ultrasound and magnetic resonance cholangiopancreatography with secretin. 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.

Abbreviations: BD-IPMN, branch-duct intraductal papillary mucinous neoplasm; CA, carbohydrate antigen; CEUS, contrast-enhanced abdominal ultrasonography; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; IAP, International Association of Pancreatology; MD-IPMN, main-duct intraductal papillary mucinous neoplasm; MRCP, magnetic resonance cholangiopancreatography; US, ultrasound

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