HPB
http://dx.doi.org/10.1016/j.hpb.2016.06.007
ORIGINAL ARTICLE
Outcome of long interval radiological surveillance of side branch pancreatic duct-involved intraductal papillary mucinous neoplasm in selected patients Yazan S. Khaled1,2, Muhammed Mohsin1, Kavi Fatania1, Ada Yee1, Robert Adair1, Maria Sheridan1, Christian Macutkiewicz1, Amer Aldouri1 & Andrew M. Smith1,2 1
The Pancreato-Biliary Unit, St James’s University Teaching Hospital, and 2The University of Leeds, Leeds, UK
Abstract Introduction: Side branch IPMN (SB-IPMN) of the pancreas has a malignancy rate between 10 and 20%. We hypothesized that surveillance at longer intervals on selected patients with SB-IPMN might be indicated. Methods: This is a retrospective study of prospectively collected data of 276 patients presenting from 2000 to 2010. After 2007, we opted to screen our patients with longer intervals, initially at 12 months then 24 months using MR if no “worrisome features” were present. Results: Complete data sets for 261 patients were analysed and patients were aged 78 (40–91) years. 232 patients had sole SB-IPMN while 92% were incidental (n = 209) and 8% were symptomatic (n = 24). Single SB-IPMN accounted for 84% (n = 195) of all cases; maximum diameter of 15.5 (5–60) mm. The median follow up duration was 46 (32–53) months. Short interval radiological surveillance (3–9 months) was 39% (n = 90), while long interval surveillance (12–36 months) was performed in 61% (n = 142). The rate of pancreatic resection, due to concern for the development of pancreatic cancer, in the short and long interval surveillance groups was 4.4% (n = 4) and 3.5% (n = 5) respectively; p = 0.78. Conclusion: Our data suggests no difference in outcome between long and short interval MR surveillance of SB-IPMN patients. Received 15 March 2016; accepted 13 June 2016
Correspondence: Andrew M. Smith, St James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK. Tel: +44 1132433144. Fax: +44 1132448182. E-mail: [email protected]
Introduction Pancreatic intra-ductal papillary mucinous neoplasms (IPMNs) are a heterogeneous group of mucin-producing intraductal epithelial tumours.1 IPMNs are precursors for invasive carcinoma and can present on a spectrum of cellular atypia ranging from hyperplasia, low-grade dysplasia to invasive adenocarcinomas. There are main-duct (MD), side-branch (SB) or mixed type IPMNs based on imaging and histopathology.2,3 MDIPMNs have higher rates of invasive malignancy (mean frequency 43.1%; [11–81%]) demanding their resection, compared to BD-IPMNs (mean frequency 17.7% [1.4–36.7%]).4 The increased use of cross sectional imaging has led to an increased detection rate of IPMNs, particularly incidental findings of asymptomatic cysts.5,6
HPB 2016, 18, 879–885
In 2006, the international consensus guidelines for the management of SB-IPMNs and mucinous cystic neoplasms (‘Sendai consensus guidelines’) proposed that in asymptomatic patients devoid of non-enhancing mural nodules or 5 mm on CT/MRI or EUS without other causes of obstruction and were excluded from the analysis. Similarly, IPMN with features of both MD- and SB-IPMN (mixed type, n = 29) and SB-IPMN with worrisome features (n = 30) were also excluded. SB-IPMNs were reserved for the remaining patients who were included in the analysis. The principal imaging modality to assess pancreatic cysts was MRI with magnetic resonance cholangiopancreatography (MRCP). EUS, with or without fine-needle aspiration for cyst fluid analysis and cytology, was performed at the surgeon’s discretion. Patients were excluded from the study if the follow up period was less than 12 months. Long interval radiological surveillance protocol Patients were screened at maximum 12 monthly intervals regular intervals with MRI if asymptomatic and devoid of mural nodules or
http://dx.doi.org/10.1016/j.hpb.2016.06.007
ORIGINAL ARTICLE
Outcome of long interval radiological surveillance of side branch pancreatic duct-involved intraductal papillary mucinous neoplasm in selected patients Yazan S. Khaled1,2, Muhammed Mohsin1, Kavi Fatania1, Ada Yee1, Robert Adair1, Maria Sheridan1, Christian Macutkiewicz1, Amer Aldouri1 & Andrew M. Smith1,2 1
The Pancreato-Biliary Unit, St James’s University Teaching Hospital, and 2The University of Leeds, Leeds, UK
Abstract Introduction: Side branch IPMN (SB-IPMN) of the pancreas has a malignancy rate between 10 and 20%. We hypothesized that surveillance at longer intervals on selected patients with SB-IPMN might be indicated. Methods: This is a retrospective study of prospectively collected data of 276 patients presenting from 2000 to 2010. After 2007, we opted to screen our patients with longer intervals, initially at 12 months then 24 months using MR if no “worrisome features” were present. Results: Complete data sets for 261 patients were analysed and patients were aged 78 (40–91) years. 232 patients had sole SB-IPMN while 92% were incidental (n = 209) and 8% were symptomatic (n = 24). Single SB-IPMN accounted for 84% (n = 195) of all cases; maximum diameter of 15.5 (5–60) mm. The median follow up duration was 46 (32–53) months. Short interval radiological surveillance (3–9 months) was 39% (n = 90), while long interval surveillance (12–36 months) was performed in 61% (n = 142). The rate of pancreatic resection, due to concern for the development of pancreatic cancer, in the short and long interval surveillance groups was 4.4% (n = 4) and 3.5% (n = 5) respectively; p = 0.78. Conclusion: Our data suggests no difference in outcome between long and short interval MR surveillance of SB-IPMN patients. Received 15 March 2016; accepted 13 June 2016
Correspondence: Andrew M. Smith, St James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK. Tel: +44 1132433144. Fax: +44 1132448182. E-mail: [email protected]
Introduction Pancreatic intra-ductal papillary mucinous neoplasms (IPMNs) are a heterogeneous group of mucin-producing intraductal epithelial tumours.1 IPMNs are precursors for invasive carcinoma and can present on a spectrum of cellular atypia ranging from hyperplasia, low-grade dysplasia to invasive adenocarcinomas. There are main-duct (MD), side-branch (SB) or mixed type IPMNs based on imaging and histopathology.2,3 MDIPMNs have higher rates of invasive malignancy (mean frequency 43.1%; [11–81%]) demanding their resection, compared to BD-IPMNs (mean frequency 17.7% [1.4–36.7%]).4 The increased use of cross sectional imaging has led to an increased detection rate of IPMNs, particularly incidental findings of asymptomatic cysts.5,6
HPB 2016, 18, 879–885
In 2006, the international consensus guidelines for the management of SB-IPMNs and mucinous cystic neoplasms (‘Sendai consensus guidelines’) proposed that in asymptomatic patients devoid of non-enhancing mural nodules or 5 mm on CT/MRI or EUS without other causes of obstruction and were excluded from the analysis. Similarly, IPMN with features of both MD- and SB-IPMN (mixed type, n = 29) and SB-IPMN with worrisome features (n = 30) were also excluded. SB-IPMNs were reserved for the remaining patients who were included in the analysis. The principal imaging modality to assess pancreatic cysts was MRI with magnetic resonance cholangiopancreatography (MRCP). EUS, with or without fine-needle aspiration for cyst fluid analysis and cytology, was performed at the surgeon’s discretion. Patients were excluded from the study if the follow up period was less than 12 months. Long interval radiological surveillance protocol Patients were screened at maximum 12 monthly intervals regular intervals with MRI if asymptomatic and devoid of mural nodules or
