1. Home>
2. Specialties>
3. Gastroenterology>
4. Summary and Comment

Operative Therapy for Branch-Duct Intraductal Papillary Mucinous Neoplasms?

Conservative management worked well for asymptomatic patients without evidence of malignancy.

Intraductal papillary mucinous neoplasms (IPMNs) are premalignant lesions of the pancreatic duct epithelium. Although tumors that arise from the branch ducts (BD-IPMNs) seem to be less aggressive than those that arise from the main duct, debate continues about the most appropriate management strategy (surgery vs. "wait-and-see") for BD-IPMNs. To determine whether conservative management is appropriate for treating BD-IPMN patients, researchers in Italy prospectively assigned 109 patients to one of two treatment groups, based on their BD-IPMN characteristics.

BD-IPMNs were diagnosed based on the presence of a cystic lesion in any part of the pancreas that clearly communicated with the main pancreatic duct, as well as the absence of main pancreatic duct dilation identified by secretin-stimulated magnetic resonance cholangiopancreatography (MRCP). Patients were assigned to immediate surgery (group A) if they had cysts >3.5 cm, cysts with thick walls and nodules, cancer antigen (CA) 19-9 levels >25 U/L, recent-onset or worsening diabetes, jaundice, or any other symptom that suggested potential malignancy. The remaining patients, who had none of these characteristics, were assigned to a conservative management protocol (group B), which included clinical examination, laboratory analysis, contrast-enhanced abdominal ultrasound, and MRCP at 6 and 18 months, and MRCP alone at 12 and 24 months. After the first 24 months, full examinations were carried out yearly in group B, and any patients who developed features of malignancy underwent surgery.

Group A consisted of 20 patients (18.3% of the study population): 2 patients had invasive cancer, 1 had carcinoma in situ, 7 had borderline pathology, and 10 had adenomas. Fifteen had symptoms. During a mean follow-up of 44.5 months, only the two patients with invasive cancer died from disease-related causes. Group B consisted of 89 patients; 57 had multifocal disease, and 18 had whole-gland involvement. After a mean follow-up of 18.2 months, five patients (5.6%) underwent surgery because of increases in the size of their neoplasms; none of these patients developed symptoms, nodules or septa, or elevated CA19-9 levels. Three patients had adenomas, and two had borderline pathology. At 24 months after surgery, no recurrences had been recorded. All of the remaining 84 patients in group B were asymptomatic during a mean follow-up of 33 months.

Comment: A conservative approach to BD-IPMN is desirable, given that older patients generally develop BD-IPMNs, risks are associated with pancreatic surgery, and this type of neoplasm is known to evolve slowly. In this study, multifocal disease was present in 64% of patients in group B, and, among these, two thirds would have required total pancreatectomy or extensive resection to treat the disease. Careful nonoperative management seems to be safe and effective in patients who have asymptomatic BD-IPMNs without radiographic findings or tumor-marker elevations that suggest malignancy. However, longer follow-up is required to verify these findings.

— Stuart Sherman, MD

Published in Journal Watch Gastroenterology September 28, 2007

Citation(s):

Salvia R et al. Branch-duct intraductal papillary mucinous neoplasms of the pancreas: To operate or not to operate? Gut 2007 Aug; 56:1086.

• Original article (Subscription may be required)
• Medline abstract (Free)