Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Universita' Politecnica delle Marche, Ancona, Italy.
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Gastroenterology. 2017 Nov;153(5):1284-1294.e1. doi: 10.1053/j.gastro.2017.07.019. Epub 2017 Jul 21.
BACKGROUND & AIMS: Little is known about the development of branch duct intraductal papillary mucinous neoplasms (BD-IPMNs). We evaluated long-term outcomes of a large cohort of patients with BD-IPMNs to determine risk of malignancy and define a subset of low-risk BD-IPMNs.
We performed a retrospective analysis of data from 577 patients with suspected or presumed BD-IPMN under surveillance at the Massachusetts General Hospital. Patients underwent cross-sectional imaging analysis at 3 months or later after their initial diagnosis. The diagnosis of BD-IPMN was based on the presence of unilocular or multilocular cysts of the pancreas and a non-dilated main pancreatic duct (<5 mm). We collected demographic, clinical, and pathology data. Cysts were characterized at the time of diagnosis and during the follow-up period. Follow-up duration was time between initial cyst diagnosis and date of last visit or death for patients without development of pancreatic cancer, date of surgery for patients with histologically confirmed malignancy, or date of first discovery of malignancy by imaging analysis for patients with unresectable tumors or who underwent neoadjuvant treatment before surgery. The primary outcome was risk of malignancy, with a focus on patients followed for 5 years or more, compared with that of the US population, based on standardized incidence ratio.
Of the 577 patients studied, 479 (83%) were asymptomatic at diagnosis and 363 (63%) underwent endoscopic ultrasound at least once. The median follow-up time was 82 months (range, 6-329 months) for the entire study cohort; 363 patients (63%) underwent surveillance for more than 5 years, and 121 (21%) for more than 10 years. Malignancies (high-grade dysplasia or invasive neoplasm) developed after 5 years in 20 of 363 patients (5.5%), and invasive cancer developed in 16 of 363 patients (4.4%). The standardized incidence ratio for patients with BD-IPMNs without worrisome features of malignancy at 5 years was 18.8 (95% confidence interval, 9.7-32.8; P < .001). One hundred and eight patients had cysts ≤1.5 cm for more than 5 years of follow-up; only 1 of these patients (0.9%) developed a distinct ductal adenocarcinoma. By contrast, among the 255 patients with cysts >1.5 cm, 19 (7.5%) developed malignancy (P = .01).
In a retrospective analysis of patients with BD-IPMNs under surveillance, their overall risk of malignancy, almost 8%, lasted for 10 years or more, supporting continued surveillance after 5 years. Cysts that remain ≤1.5 cm for more than 5 years might be considered low-risk for progression to malignancy.
关于分支胰管内乳头状黏液性肿瘤（BD-IPMN）的发展知之甚少。我们评估了大量BD-IPMN 患者的长期结果，以确定恶性肿瘤的风险，并确定一组低风险的 BD-IPMN。
我们对在马萨诸塞州综合医院接受监测的 577 名疑似或假定的 BD-IPMN 患者的数据进行了回顾性分析。患者在初次诊断后 3 个月或更长时间进行横断面成像分析。BD-IPMN 的诊断基于胰腺的单房或多房性囊肿和非扩张的主胰管（<5mm）的存在。我们收集了人口统计学、临床和病理学数据。在诊断时和随访期间对囊肿进行了特征描述。随访时间为从最初的囊肿诊断到无胰腺癌发展的患者的最后一次就诊或死亡时间、有组织学证实恶性肿瘤的患者的手术时间、或无法切除肿瘤的患者的首次发现恶性肿瘤的影像学分析时间或接受新辅助治疗后手术前的时间。主要结果是恶性肿瘤的风险，重点是随访 5 年或以上的患者与美国人群相比的标准化发病比。
在 577 名研究患者中，479 名（83%）在诊断时无症状，363 名（63%）至少进行了一次内镜超声检查。整个研究队列的中位随访时间为 82 个月（范围为 6-329 个月）；363 名患者（63%）进行了超过 5 年的监测，121 名患者（21%）进行了超过 10 年的监测。在 363 名患者中，有 20 名（5.5%）在 5 年后出现恶性肿瘤（高级别异型增生或浸润性肿瘤），16 名（4.4%）出现浸润性癌。5 年时无恶性肿瘤特征的 BD-IPMN 患者的标准化发病比为 18.8（95%置信区间为 9.7-32.8；P<0.001）。108 名患者的囊肿>1.5 cm 且随访时间>5 年；其中只有 1 名患者（0.9%）发生了明显的导管腺癌。相比之下，在 255 名囊肿>1.5 cm 的患者中，有 19 名（7.5%）发生了恶性肿瘤（P=0.01）。
在对接受监测的 BD-IPMN 患者的回顾性分析中，他们的恶性肿瘤总体风险为近 8%，持续了 10 年以上，支持在 5 年后继续监测。对于>5 年仍保持在 1.5 cm 以下的囊肿，可能被认为进展为恶性肿瘤的风险较低。
