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Su1472 Follow up of Branch Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas With a Cyst Over 30mm in Diameter: A Single Center Experience
Su1471
(12) in HRS, 63.6% (49) in WF, 49.3% (113) in EHW, and ratio of multifocal IPMN was 31.3% in HRS, 40.3% in WF, and 29.7% in EHW. 2) MPD diameter and ectatic branch duct (EBD) diameter were the largest in HRS and the smallest in EHW significantly. Ratio of having mural nodule was in HRS as high as in WF, and that was larger in HRS and in WF than in EHW significantly. 3) Serum CEA level was higher in HRS and in WF than in EHW, and serum CA19-9 level was higher in HRS than in EHW. Ratio of having diabetes mellitus (DM) was significantly higher in HRS than in other 2 groups. 4) Ratio of symptomatic IPMN was higher both in HRS and WF than in EHW. 5) Ratio of imaging progression in HRS (75%) was the highest among 3 groups, and that in WF (20.8%) was higher than in EHW (11.8%). Ratio of MPD progression was in HRS (37.5%) higher than other 2 groups (WF 10.4%, EHW 4.4%). Ratio of mural nodule progression was in HRS (18.8%) as high as in WF (6.5%), and that in EHW (0%) was lower than other 2 groups. Ratio of solid component progression was the highest in HRS (50%) among 3 groups (WF 3.9%, EHW 1.8%). There was no significant difference among 3 groups in EBD progression (HRS 25%, WF 14.3%, EHW 9.6%). Time to imaging progression was 895days in HRS, 1022days in WF, 1345days in EHW, there was no significant difference among 3 groups. 6) Ratio of appearance of IC was significantly higher in HRS (50%) than in other 2 groups (WF 2.6%, EHW 1.3%). Time to appearance of IC was 859days in HRS, 848days in WF, 1647days in EHW, there was significant difference between HRS and EHW, and between WF and EHW. 7) ‘HRS' and ‘DM' were significant factor for appearance of IC by logistic regression analysis. Conclusions: HRS was significant risk factor for imaging progression and IC during followup of BD-IPMN, moreover cases with DM also significant risk factor of appearance of IC. Therefore we need to be cautious for appearance of IC in follow-up of BD-IPMN with ‘HRS' and ‘DM'. Characteristics
AGA Abstracts
Clinical Observation Is Possible for Branch Duct Type Intraductal Papillary Mucinous Neoplasms With Mural Nodules ≤6mm Toshifumi Kin, Hiroyuki Maguchi, Kuniyuki Takahashi, Akio Katanuma, Manabu Osanai, Kei Yane, Satoshi Ikarashi, Manabu Sen-yo, Ryuki Minami, Itsuki Sano, Hajime Yamazaki Introduction: The presence of mural nodule (MN) is an important factor for the management of branch duct type intraductal papillary mucinous neoplasm (BD-IPMN). International consensus guidelines 2012 recommend clinical follow-up to BD-IPMN without MNs. However, it is not clear whether BD-IPMNs with MNs need surgical treatment regardless of the height of MNs. Aim: To compare the pathological and follow-up outcomes between BDIPMNs with MNs ≤6mm in height (MN+) and those without MNs (MN-). Methods: The patients who were diagnosed as BD-IPMNs with MNs ≤6mm or without MNs since April 2004 to December 2013 were retrospectively analyzed. Inclusion criteria were the obtaining of contrast enhanced CT and EUS at initial diagnosis, and surgical resection in our center or follow-up with annual/semi-annual CT/MRCP. The cyst size and main pancreatic duct (MPD) diameter were measured by CT/MRCP, while MN height was measured by EUS. Tumor progression during follow-up was defined as follows; increased cyst size ≥10mm; increased MPD diameter ≥10mm; new development of MN or increased MN height ≥2mm. Evaluation points: 1) pathological diagnosis of resected BD-IPMN, 2) follow-up outcomes Results: Among 656 patients of BD-IPMNs diagnosed in our center, MN height was evaluated as less than or equal to 6mm in 511(78%; MN+ 50, MN- 352). After initial diagnosis, 17(3%; MN+ 8, MN- 9) of them underwent immediate resection and 385(75%; MN+ 42, MN- 343) of them received regular follow-up, who were eligible for this analysis. The median cyst size and MPD diameter were 20(10-70) mm and 3(2-12) mm, respectively. The median height of MNs in MN+ were 3(1-6) mm. 1) The pathological diagnosis of the patients with MN- were all low/intermediate-grade dysplasia (LID), while those of the patients with MN+ were LID in 5, high-grade dysplasia (HD) in 2, and invasive carcinoma (IC) in 1. There were no significant differences in pathological diagnosis between MN+ and MN- (p=0.17, chi-square test). 2) During a median follow-up period of 3.4(0.5-10.6) years, 49(13%; MN+ 9, MN- 40) patients exhibited tumor progression. The 5-years cumulative tumor progression rate was higher in MN+ than those in MN- (MN+ 19% vs MN- 9%; p<0.01, Log-rank test). Among 49 patients with tumor progression, 11(22%; MN+ 4, MN- 7) patients underwent surgical resection, whose pathological diagnosis were LID in 6(MN+ 2, MN- 4), HD in 3(MN+ 1, MN- 2), and IC with minimal invasion in 2(MN+ 1, MN- 1). The other 38 patients continued to be followed during a median period of 0.6(0.0-4.2) years. Meanwhile, concomitant pancreatic ductal adenocarcinoma (PDAC) was appeared in 9(2%; MN+ 1, MN- 8) patients. Conclusion: Although tumor progression rate was higher, BD-IPMN with MNs ≤6mm in height on EUS could be managed conservatively. However, careful attention should be paid to the development of PDAC during follow-up. Su1472 Follow up of Branch Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas With a Cyst Over 30mm in Diameter: A Single Center Experience Atsushi Kubo
significant factor for appearance of IC
Background; In the IPMN/MCN international consensus guidelines, branch duct IPMN (BDIPMN) without suspicious malignant findings have changed from rather early resection to more deliberate observation when a cyst is over 30mm in diameter. Follow-up result of BDIPMN with a cyst > 30mm has been limited, so the aim of this study was to clarify the natural history of BD-IPMN with a cyst > 30mm. Method; 719 patients with BD-IPMN were treated in our institute from January 1996 to December 2013 inclusive. 99 patients with BD-IPMNs with a cyst > 30mm and more than 1 year imaging follow-up were identified and their cases reviewed retrospectively. Evaluation points were 1) initial clinical data, 2) progression rate, 3) incidence of ordinary pancreatic cancer, and outcomes. Results; Of 99 patients, mean age was 72 years and male was 63%. Median observation period was 54.8 months (12.2-214.8 months).The initial median size of the cystic lesion is 33mm (30-65), the initial median diameter of the main pancreatic duct (MPD) is 3mm (2-15). 4 patients had mural nodules. 2) 51 patients exhibited progression with an increasing cyst size, MPD diameter, or appearance and/or enlargement of mural nodules. Surgical resection was performed in 9 of 51 patients with progression. Pathological diagnosis was 1 invasive IPMC, 2 carcinomas in site, and 6 adenomas. 3) Pancreatic cancer occurred in 4 patients. 3 of them were operated. 17 patients were died. Of 17 patients, 3 died of invasive IPMC, 2 of pancreatic cancer, 8 of cancer of other organs, and 4 of other benign disease. Conclusion; The progression rate of BD-IPMNs with a cyst > 30mm is extremely high during this followup periods, but few 5 patients died of IPMC and pancreatic cancer. This suggests that observation may be reasonable approach to BD-IPMN with a cyst > 30mm with careful imaging follow-up toward incidence of IPMC and pancreatic cancer.
Su1474 Outcome of Over 1 Year Follow up Cases in Multifocal Branch Duct Type IPMN Daisuke Masuda, Akira Imoto, Takeshi Ogura, Saori Onda, Tatsushi Sano, Wataru Takagi, Mohamed M. Malak, Yuichi Kojima, Sadaharu Nouda, Kazuki Kakimoto, Toshihiko Okada, Yosuke Abe, Toshihisa Takeuchi, Takuya Inoue, Kazuhide Higuchi
Su1473
Background and aim: International Consensus guideline 2012 for the management of IPMN and MCN of the pancreas was published, in which strategy of follow-up in branch duct IPMN (BD-IPMN) was shown. Multifocal IPMN has been reported to be invasive during follow-up BD-IPMN. We evaluated whether multifocal IPMN was invasive or not in this study. Patients & Methods: Total 322 BD-IPMN cases were enrolled (age 68.0 years old, gender male/female: 148/174, follow-up time: 1925 days). We divided this subject into 2 groups, ‘multifocal IPMN' or ‘unifocal IPMN', and evaluated characteristics and prognosis. BD-IPMN was devided into 3 subtypes, "high risk stigmata" (HRS), "worrisome features" (WF), and other cases except for HRS and WF (EHW) by clinical and imaging findings along international guideline. Results: 1) ‘Multifocal IPMN' (M-IPMN) was 104 patients, ‘Unifocal IPMN' (U-IPMN) was 218 patients. 2) Characteristics: Ratio that ‘location' of IPMN was pancreas head (Ph), that of having mural nodule and having non enhancing mural nodule were higher in Multi than in Uni. Serum CEA levels were both within normal limits with significant difference. 3) Imaging progression: Ratio of imaging progression was equel in both groups. There was also no significant difference about ratio of imaging progression of each subtypes. M-IPMN was 100%, while U-IPMN was 63.6% in HRS. M-IPMN was 22.6%, while U-IPMN was 19.6% in WF. M-IPMN was 14.7%, while U-IPMN was 9.9%
Risk Factor for Appearance of Invasive Carcinoma During Follow Up in Branch Duct Type IPMN Daisuke Masuda, Akira Imoto, Takeshi Ogura, Saori Onda, Tatsushi Sano, Wataru Takagi, Sadaharu Nouda, Kazuki Kakimoto, Toshihiko Okada, Mohamed M. Malak, Ken Kawakami, Yosuke Abe, Toshihisa Takeuchi, Takuya Inoue, Kazuhide Higuchi Background and aim: International Consensus guideline 2012 for the management of IPMN and MCN of the pancreas was published, in which strategy of follow-up in branch duct IPMN (BD-IPMN) was shown. We evaluated risk factor of invasive carcinoma (IC) in followed BD-IPMN. Patients & Methods: Total 322 BD-IPMN cases were enrolled (age 68.0 years old, gender male/female: 148/174, follow-up time: 1925 days). We divided this subject into 3 groups by imaging findings along IPMN guideline, "high risk stigmata" (HRS), "worrisome features" (WF), and other cases except for HRS and WF (EHW). We retrospectively compared with characteristics, ratio of imaging progression factor, and ratio of appearance of IC between 3 groups and evaluated risk factor for appearance of IC. Results: 1) HRS was 16, WF was 77, and EHW was 229. Ratio that location of IPMN was pancreas head (Ph) was 75.0%
AGA Abstracts
S-522
(12) in HRS, 63.6% (49) in WF, 49.3% (113) in EHW, and ratio of multifocal IPMN was 31.3% in HRS, 40.3% in WF, and 29.7% in EHW. 2) MPD diameter and ectatic branch duct (EBD) diameter were the largest in HRS and the smallest in EHW significantly. Ratio of having mural nodule was in HRS as high as in WF, and that was larger in HRS and in WF than in EHW significantly. 3) Serum CEA level was higher in HRS and in WF than in EHW, and serum CA19-9 level was higher in HRS than in EHW. Ratio of having diabetes mellitus (DM) was significantly higher in HRS than in other 2 groups. 4) Ratio of symptomatic IPMN was higher both in HRS and WF than in EHW. 5) Ratio of imaging progression in HRS (75%) was the highest among 3 groups, and that in WF (20.8%) was higher than in EHW (11.8%). Ratio of MPD progression was in HRS (37.5%) higher than other 2 groups (WF 10.4%, EHW 4.4%). Ratio of mural nodule progression was in HRS (18.8%) as high as in WF (6.5%), and that in EHW (0%) was lower than other 2 groups. Ratio of solid component progression was the highest in HRS (50%) among 3 groups (WF 3.9%, EHW 1.8%). There was no significant difference among 3 groups in EBD progression (HRS 25%, WF 14.3%, EHW 9.6%). Time to imaging progression was 895days in HRS, 1022days in WF, 1345days in EHW, there was no significant difference among 3 groups. 6) Ratio of appearance of IC was significantly higher in HRS (50%) than in other 2 groups (WF 2.6%, EHW 1.3%). Time to appearance of IC was 859days in HRS, 848days in WF, 1647days in EHW, there was significant difference between HRS and EHW, and between WF and EHW. 7) ‘HRS' and ‘DM' were significant factor for appearance of IC by logistic regression analysis. Conclusions: HRS was significant risk factor for imaging progression and IC during followup of BD-IPMN, moreover cases with DM also significant risk factor of appearance of IC. Therefore we need to be cautious for appearance of IC in follow-up of BD-IPMN with ‘HRS' and ‘DM'. Characteristics
AGA Abstracts
Clinical Observation Is Possible for Branch Duct Type Intraductal Papillary Mucinous Neoplasms With Mural Nodules ≤6mm Toshifumi Kin, Hiroyuki Maguchi, Kuniyuki Takahashi, Akio Katanuma, Manabu Osanai, Kei Yane, Satoshi Ikarashi, Manabu Sen-yo, Ryuki Minami, Itsuki Sano, Hajime Yamazaki Introduction: The presence of mural nodule (MN) is an important factor for the management of branch duct type intraductal papillary mucinous neoplasm (BD-IPMN). International consensus guidelines 2012 recommend clinical follow-up to BD-IPMN without MNs. However, it is not clear whether BD-IPMNs with MNs need surgical treatment regardless of the height of MNs. Aim: To compare the pathological and follow-up outcomes between BDIPMNs with MNs ≤6mm in height (MN+) and those without MNs (MN-). Methods: The patients who were diagnosed as BD-IPMNs with MNs ≤6mm or without MNs since April 2004 to December 2013 were retrospectively analyzed. Inclusion criteria were the obtaining of contrast enhanced CT and EUS at initial diagnosis, and surgical resection in our center or follow-up with annual/semi-annual CT/MRCP. The cyst size and main pancreatic duct (MPD) diameter were measured by CT/MRCP, while MN height was measured by EUS. Tumor progression during follow-up was defined as follows; increased cyst size ≥10mm; increased MPD diameter ≥10mm; new development of MN or increased MN height ≥2mm. Evaluation points: 1) pathological diagnosis of resected BD-IPMN, 2) follow-up outcomes Results: Among 656 patients of BD-IPMNs diagnosed in our center, MN height was evaluated as less than or equal to 6mm in 511(78%; MN+ 50, MN- 352). After initial diagnosis, 17(3%; MN+ 8, MN- 9) of them underwent immediate resection and 385(75%; MN+ 42, MN- 343) of them received regular follow-up, who were eligible for this analysis. The median cyst size and MPD diameter were 20(10-70) mm and 3(2-12) mm, respectively. The median height of MNs in MN+ were 3(1-6) mm. 1) The pathological diagnosis of the patients with MN- were all low/intermediate-grade dysplasia (LID), while those of the patients with MN+ were LID in 5, high-grade dysplasia (HD) in 2, and invasive carcinoma (IC) in 1. There were no significant differences in pathological diagnosis between MN+ and MN- (p=0.17, chi-square test). 2) During a median follow-up period of 3.4(0.5-10.6) years, 49(13%; MN+ 9, MN- 40) patients exhibited tumor progression. The 5-years cumulative tumor progression rate was higher in MN+ than those in MN- (MN+ 19% vs MN- 9%; p<0.01, Log-rank test). Among 49 patients with tumor progression, 11(22%; MN+ 4, MN- 7) patients underwent surgical resection, whose pathological diagnosis were LID in 6(MN+ 2, MN- 4), HD in 3(MN+ 1, MN- 2), and IC with minimal invasion in 2(MN+ 1, MN- 1). The other 38 patients continued to be followed during a median period of 0.6(0.0-4.2) years. Meanwhile, concomitant pancreatic ductal adenocarcinoma (PDAC) was appeared in 9(2%; MN+ 1, MN- 8) patients. Conclusion: Although tumor progression rate was higher, BD-IPMN with MNs ≤6mm in height on EUS could be managed conservatively. However, careful attention should be paid to the development of PDAC during follow-up. Su1472 Follow up of Branch Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas With a Cyst Over 30mm in Diameter: A Single Center Experience Atsushi Kubo
significant factor for appearance of IC
Background; In the IPMN/MCN international consensus guidelines, branch duct IPMN (BDIPMN) without suspicious malignant findings have changed from rather early resection to more deliberate observation when a cyst is over 30mm in diameter. Follow-up result of BDIPMN with a cyst > 30mm has been limited, so the aim of this study was to clarify the natural history of BD-IPMN with a cyst > 30mm. Method; 719 patients with BD-IPMN were treated in our institute from January 1996 to December 2013 inclusive. 99 patients with BD-IPMNs with a cyst > 30mm and more than 1 year imaging follow-up were identified and their cases reviewed retrospectively. Evaluation points were 1) initial clinical data, 2) progression rate, 3) incidence of ordinary pancreatic cancer, and outcomes. Results; Of 99 patients, mean age was 72 years and male was 63%. Median observation period was 54.8 months (12.2-214.8 months).The initial median size of the cystic lesion is 33mm (30-65), the initial median diameter of the main pancreatic duct (MPD) is 3mm (2-15). 4 patients had mural nodules. 2) 51 patients exhibited progression with an increasing cyst size, MPD diameter, or appearance and/or enlargement of mural nodules. Surgical resection was performed in 9 of 51 patients with progression. Pathological diagnosis was 1 invasive IPMC, 2 carcinomas in site, and 6 adenomas. 3) Pancreatic cancer occurred in 4 patients. 3 of them were operated. 17 patients were died. Of 17 patients, 3 died of invasive IPMC, 2 of pancreatic cancer, 8 of cancer of other organs, and 4 of other benign disease. Conclusion; The progression rate of BD-IPMNs with a cyst > 30mm is extremely high during this followup periods, but few 5 patients died of IPMC and pancreatic cancer. This suggests that observation may be reasonable approach to BD-IPMN with a cyst > 30mm with careful imaging follow-up toward incidence of IPMC and pancreatic cancer.
Su1474 Outcome of Over 1 Year Follow up Cases in Multifocal Branch Duct Type IPMN Daisuke Masuda, Akira Imoto, Takeshi Ogura, Saori Onda, Tatsushi Sano, Wataru Takagi, Mohamed M. Malak, Yuichi Kojima, Sadaharu Nouda, Kazuki Kakimoto, Toshihiko Okada, Yosuke Abe, Toshihisa Takeuchi, Takuya Inoue, Kazuhide Higuchi
Su1473
Background and aim: International Consensus guideline 2012 for the management of IPMN and MCN of the pancreas was published, in which strategy of follow-up in branch duct IPMN (BD-IPMN) was shown. Multifocal IPMN has been reported to be invasive during follow-up BD-IPMN. We evaluated whether multifocal IPMN was invasive or not in this study. Patients & Methods: Total 322 BD-IPMN cases were enrolled (age 68.0 years old, gender male/female: 148/174, follow-up time: 1925 days). We divided this subject into 2 groups, ‘multifocal IPMN' or ‘unifocal IPMN', and evaluated characteristics and prognosis. BD-IPMN was devided into 3 subtypes, "high risk stigmata" (HRS), "worrisome features" (WF), and other cases except for HRS and WF (EHW) by clinical and imaging findings along international guideline. Results: 1) ‘Multifocal IPMN' (M-IPMN) was 104 patients, ‘Unifocal IPMN' (U-IPMN) was 218 patients. 2) Characteristics: Ratio that ‘location' of IPMN was pancreas head (Ph), that of having mural nodule and having non enhancing mural nodule were higher in Multi than in Uni. Serum CEA levels were both within normal limits with significant difference. 3) Imaging progression: Ratio of imaging progression was equel in both groups. There was also no significant difference about ratio of imaging progression of each subtypes. M-IPMN was 100%, while U-IPMN was 63.6% in HRS. M-IPMN was 22.6%, while U-IPMN was 19.6% in WF. M-IPMN was 14.7%, while U-IPMN was 9.9%
Risk Factor for Appearance of Invasive Carcinoma During Follow Up in Branch Duct Type IPMN Daisuke Masuda, Akira Imoto, Takeshi Ogura, Saori Onda, Tatsushi Sano, Wataru Takagi, Sadaharu Nouda, Kazuki Kakimoto, Toshihiko Okada, Mohamed M. Malak, Ken Kawakami, Yosuke Abe, Toshihisa Takeuchi, Takuya Inoue, Kazuhide Higuchi Background and aim: International Consensus guideline 2012 for the management of IPMN and MCN of the pancreas was published, in which strategy of follow-up in branch duct IPMN (BD-IPMN) was shown. We evaluated risk factor of invasive carcinoma (IC) in followed BD-IPMN. Patients & Methods: Total 322 BD-IPMN cases were enrolled (age 68.0 years old, gender male/female: 148/174, follow-up time: 1925 days). We divided this subject into 3 groups by imaging findings along IPMN guideline, "high risk stigmata" (HRS), "worrisome features" (WF), and other cases except for HRS and WF (EHW). We retrospectively compared with characteristics, ratio of imaging progression factor, and ratio of appearance of IC between 3 groups and evaluated risk factor for appearance of IC. Results: 1) HRS was 16, WF was 77, and EHW was 229. Ratio that location of IPMN was pancreas head (Ph) was 75.0%
AGA Abstracts
S-522