Elsevier

Pancreatology

Volume 12, Issue 3, May–June 2012, Pages 198-202
Pancreatology

Original article
The long term risk of malignancy in patients with branch duct intraductal papillary mucinous neoplasms of the pancreas

https://doi.org/10.1016/j.pan.2012.03.056Get rights and content

Abstract

In patients (pts) with branch duct intraductal papillary mucinous neoplasms of the pancreas (BD-IPMN), the risk of malignant progression is well described at short- and mid-term. Few data beyond 5 years are available.

Patients and methods

Prospective study in consecutive patients (pts) with BD-IPMN and follow-up (F/U) ≥60 months to assess long term risk of malignant progression. All computed tomographies and magnetic resonance cholangiopancreatographies performed every 1 or 2 years (depending on the maximum size of cyst) were read by the same radiologist. EUS was performed in case of occurrence of main pancreatic duct (MPD) dilation or mural nodule >5 mm. Size increase was considered significant if >5 mm. Size variation, criteria suggestive of malignancy, operative therapy and pathology were recorded.

Results

53 pts were included (median age at diagnosis: 61 years, median F/U: 84 months (range: 60–132) including 5 F/U >120 months). Lesions were stable in 38 pts (72%). Size increased in 8 pts (15%) (median increase : 11 (5–33) mm) without mural nodule (MN). One of those was operated on (low-grade dysplasia). A MN appeared in 5 pts (9%). ≥5 mm in 2 pts (5 and 15 mm) who were operated on (intermediate-grade dysplasia in both). The 3 remaining pts (MN < 5 mm) were carefully followed-up. Invasive advanced carcinoma occurred in 2 pts, both after 84 months F/U. In one of these, no imaging changes were noted 12 months before diagnosis of malignancy.

Conclusion

In BD-IPMN, the risk of malignant evolution persists after 60 months F/U including invasive carcinomas. F/U imaging surveillance is still necessary beyond this delay in patients fit for potential surgery.

Introduction

Intraductal papillary mucinous neoplasms of the pancreas (IPMN) are premalignant lesions that might follow the lineage “dysplasia of increasing grade – invasive carcinoma”. Until 2000, the management of this disease was almost exclusively surgical irrespective of symptoms and imaging findings. Considering both the low-grade of dysplasia in the majority of surgical specimens and the morbidity and mortality of pancreatic resection, several groups decided to follow some highly selected patients without operative therapy. Preoperative risk factors of high-grade dysplasia or invasive carcinoma were therefore described allowing, as far as possible, a safe strategy of surveillance without resection [1], [2], [3], [4], [5], [6], [7]. This non-operative strategy was acknowledged by the 2006 Consensus Meeting held in Sendaï [8]. Two factors predictive of malignant transformation have been described: mural nodules and main pancreatic duct (MPD) involvement. The natural history of IPMN involving only branch ducts (BD) or MPD is markedly different with a 5-year actuarial risk of at least high-grade dysplasia being 15 and 63%, respectively [1].

Whether the risk of malignant transformation beyond 5 years is stable, increases slightly or dramatically is unknown. The aim of this study was to assess the risk of malignant evolution beyond 5 years of follow-up in BD-IPMN patients treated conservatively and carefully followed-up with a standardised prospective protocol.

Section snippets

Inclusion and exclusion criteria

All consecutive patients with BD-IPMN diagnosed and followed-up in our institution for more than 5 years between 1989 and 2010 were included. Those with signs suggesting malignant transformation at initial work-up or during the first 60 months of follow-up and those with a follow-up less than 60 months were excluded.

All patients were informed of the goals of surveillance program and gave their consent. As no therapeutic or follow-up procedures were modified by inclusion in this study, no ethic

Patients

Among our series of patients with BD-IPMN, 53 had no criteria suggestive of malignancy 60 months after diagnosis and were followed-up beyond that time in a prospective surveillance programme. Patients' characteristics are summarised in Table 1. Five patients had a follow-up >120 months. No major symptoms indicating surgery occurred in any patient.

Imaging and diagnostic findings

At the time of inclusion (that is after 60 months of follow-up), no patient had MPD involvement, development of mural nodules, or development of a

Discussion

IPMN are widely recognised as a premalignant condition leading to pancreatic adenocarcinoma. They are more and more often incidentally discovered after an abdominal imaging procedure has been performed for another condition. Until 2000, all patients with IMPN were operated on except those with general contraindication or refusal. Since that time, several groups have started to follow patients and risk factors for malignancy were progressively described. There is a consensus that MPD involvement

Conflict of interest

No conflicts of interest exist.

Author's contribution

Wafaa Khanoussi: Study design and concept, acquisition of the data, data analysis, statistical analysis and manuscript drafting.

Marie-Pierre Vullierme: Data analysis, acquisition of the data and manuscript drafting.

Vinciane Rebours: statistical analysis and manuscript drafting.

Frédérique Maire: Acquisition of the data.

Olivia Hentic: Acquisition of the data.

Frederique Maire: Acquisition of the data.

Alain Aubert: Acquisition of the data.

Alain Sauvanet: Acquisition of the data.

Safi Dokmak:

References (16)

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