Current recommendations for surveillance and surgery of intraductal papillary mucinous neoplasms may overlook some patients with cancer

J Gastrointest Surg. 2015 Feb;19(2):258-65. doi: 10.1007/s11605-014-2693-z. Epub 2014 Nov 6.


Background: The 2012 Sendai Criteria recommend that patients with 3 cm or larger branch duct intraductal papillary mucinous neoplasms (BD-IPMN) without any additional "worrisome features" or "high-risk stigmata" may undergo close observation. Furthermore, endoscopic ultrasound (EUS) is not recommended for BD-IPMN <2 cm. These changes have generated concern among physicians treating patients with pancreatic diseases. The purposes of this study were to (i) apply the new Sendai guidelines to our institution's surgically resected BD-IPMN and (ii) reevaluate cyst size cutoffs in identifying patients with lesions harboring high-grade dysplasia or invasive cancer.

Methods: We retrospectively reviewed 150 patients at a university medical center with preoperatively diagnosed and pathologically confirmed IPMNs. Sixty-six patients had BD-IPMN. Pathologic grade was dichotomized into low-grade (low or intermediate grade dysplasia) or high-grade/invasive (high-grade dysplasia or invasive cancers). Fisher's exact test, chi-square test, student's t test, linear regression, and receiver operating characteristic (ROC) analyses were performed.

Results: The median BD-IPMN size on imaging was 2.4 cm (interquartile range 1.5-3.0). Fifty-one (77 %) low-grade and 15 (23 %) high-grade/invasive BD-IPMN were identified. ROC analysis demonstrated that cyst size on preoperative imaging is a reasonable predictor of grade with an area under the curve of 0.691. Two-thirds of high-grade/invasive BD-IPMN were <3 cm (n = 10). Compared to a cutoff of 3, 2 cm was associated with higher sensitivity (73.3 vs. 33.3 %) and negative predictive value (83.3 vs. 80 %, NPV) for high-grade/invasive BD-IPMN. Mural nodules on endoscopic ultrasound (EUS) or atypical cells on endoscopic ultrasound-fine needle aspiration (EUS-FNA) were identified in all cysts <2 and only 50 % of those <3 cm. Forty percent of cysts >3 cm were removed based on size alone.

Discussion/conclusions: Our results suggest that "larger" size on noninvasive imaging can indicate high-grade/invasive cysts, and EUS-FNA may help identify "smaller" cysts with high-grade/invasive pathology.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Carcinoma, Pancreatic Ductal / diagnostic imaging
  • Carcinoma, Pancreatic Ductal / pathology
  • Carcinoma, Pancreatic Ductal / therapy*
  • Cysts / diagnostic imaging*
  • Cysts / pathology*
  • Endoscopic Ultrasound-Guided Fine Needle Aspiration
  • Female
  • Humans
  • Male
  • Middle Aged
  • Neoplasm Grading
  • Neoplasms, Cystic, Mucinous, and Serous / diagnostic imaging
  • Neoplasms, Cystic, Mucinous, and Serous / pathology*
  • Neoplasms, Cystic, Mucinous, and Serous / therapy*
  • Pancreatectomy
  • Pancreatic Ducts
  • Pancreatic Neoplasms / diagnostic imaging
  • Pancreatic Neoplasms / pathology*
  • Pancreatic Neoplasms / therapy*
  • Practice Guidelines as Topic
  • Predictive Value of Tests
  • ROC Curve
  • Retrospective Studies
  • Tumor Burden
  • Watchful Waiting