World Journal of Surgery

, Volume 39, Issue 8, pp 2006–2013 | Cite as

Clinicopathological Meaning of Size of Main-Duct Dilatation in Intraductal Papillary Mucinous Neoplasm of Pancreas: Proposal of a Simplified Morphological Classification Based on the Investigation on the Size of Main Pancreatic Duct

  • Mee Joo Kang
  • Jin-Young Jang
  • Selyeong Lee
  • Taesung Park
  • Seung Yeoun Lee
  • Sun-Whe Kim
Original Scientific Report



The 2012 consensus guideline on intraductal papillary mucinous neoplasm of the pancreas (IPMN) described a three-stage criteria involving main pancreatic duct (MPD) size with definitions of malignancy relevant for treatment decisions. Re-evaluation and simplification of this classification for clinicians are warranted.


Data from the Seoul National University Hospital of 375 consecutive patients with pathology-confirmed IPMN after surgery were analyzed. The association between clinicopathologic characteristics of IPMN and MPD size was assessed. The cut-off value of MPD size for a current definition of malignancy prediction was calculated.


Diagnostic accuracy for malignancy was highest when the cut-off value of MPD size was 7 mm (area under the curve = 0.7126). Dichotomizing IPMN into MPD ≤7 mm versus MPD >7 mm, patient age (p = 0.039), sex (p = 0.001), presence of mural nodule (p < 0.001), and invasiveness risk (13.2 vs. 39.8 %, p < 0.001) resulted in significantly different results. Mural nodule-negative patients with MPD >7 mm had a significantly lower 5-year survival rate than those with MPD ≤7 mm (78.4 vs. 91.4 %, p = 0.006). Among patients with MPD size ≤7 mm, elevated serum CA 19-9 and mural nodule were independent risk factors of malignancy. Patients with MPD size ≤7 mm without these risk factors had malignancy risk of 2.6 %.


Using the definition of malignancy provided in the 2012 guideline, the MPD size >7 mm criterion was statistically driven. The current morphologic classification of IPMN can be simplified as branch-duct-predominant IPMN (MPD ≤7 mm)’ and main-duct-predominant IPMN (MPD >7 mm). Patients who are determined to have main-duct-predominant IPMN and branch-duct-predominant IPMN with elevated serum CA 19-9 or mural nodule are recommended to undergo surgical treatment.


Main Pancreatic Duct Intraductal Papillary Mucinous Neoplasm Mural Nodule Main Pancreatic Duct Dilatation Worrisome Feature 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was supported by a grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (No. HI14C2640).

Conflicts of interest

The authors disclose no conflicts.

Supplementary material

268_2015_3062_MOESM1_ESM.tif (71 kb)
Supplement Figure 1 Maximum balanced accuracy obtained when the cut-off value of 0.24 is used as the prediction probability for malignancy (TIFF 71 kb)
268_2015_3062_MOESM2_ESM.tif (63 kb)
Supplement Figure 2 Sensitivity, specificity and balanced accuracy of malignancy prediction at the main duct diameter of 7 mm were 53.8, 80.7 and 67.2 %, respectively (TIFF 63 kb)


  1. 1.
    Tanaka M, Chari S, Adsay V et al (2006) International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 6:17–32PubMedCrossRefGoogle Scholar
  2. 2.
    Tanaka M, Fernandez-Del Castillo C, Adsay V et al (2012) International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 12:183–197PubMedCrossRefGoogle Scholar
  3. 3.
    Salvia R, Fernández-del Castillo C, Bassi C et al (2004) Main-duct intraductal papillary mucinous neoplasms of the pancreas. Ann Surg 239:678–687PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Shimizu Y, Yamaue H, Maguchi H et al (2013) Predictors of malignancy in intraductal papillary mucinous neoplasm of the pancreas: analysis of 310 pancreatic resection patients at multiple high-volume centers. Pancreas 42:883–888PubMedCrossRefGoogle Scholar
  5. 5.
    Anand N, Sampath K, Wu BU (2013) Cyst features and risk of malignancy in intraductal papillary mucinous neoplasms of the pancreas: a meta-analysis. Clin Gastroenterol Hepatol 11:913–921PubMedCrossRefGoogle Scholar
  6. 6.
    Kawamoto S, Lawler LP, Horton KM et al (2006) MDCT of intraductal papillary mucinous neoplasm of the pancreas: evaluation of features predictive of invasive carcinoma. AJR Am J Roentgenol 186:687–695PubMedCrossRefGoogle Scholar
  7. 7.
    Bournet B, Kirzin S, Carrere N et al (2009) Clinical fate of branch duct and mixed forms of intraductal papillary mucinous neoplasia of the pancreas. J Gastroenterol Hepatol 24:1211–1217PubMedCrossRefGoogle Scholar
  8. 8.
    Sahani DV, Kadavigere R, Blake M et al (2006) Intraductal papillary mucinous neoplasm of pancreas: multi-detector row CT with 2D curved reformations—correlation with MRCP. Radiology 238:560–569PubMedCrossRefGoogle Scholar
  9. 9.
    Akita H, Takeda Y, Hoshino H et al (2011) Mural nodule in branch duct-type intraductal papillary mucinous neoplasms of the pancreas is a marker of malignant transformation and indication for surgery. Am J Surg 202:214–219PubMedCrossRefGoogle Scholar
  10. 10.
    Schmidt CM, White PB, Waters JA et al (2007) Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg 246:644–651; discussion 651–644PubMedCrossRefGoogle Scholar
  11. 11.
    Waters JA, Schmidt CM, Pinchot JW et al (2008) CT vs MRCP: optimal classification of IPMN type and extent. J Gastrointest Surg 12:101–109PubMedCrossRefGoogle Scholar
  12. 12.
    Kang MJ, Jang JY, Kim SJ et al (2011) Cyst growth rate predicts malignancy in patients with branch duct intraductal papillary mucinous neoplasms. Clin Gastroenterol Hepatol 9:87–93PubMedCrossRefGoogle Scholar
  13. 13.
    Hwang DW, Jang JY, Lee SE et al (2012) Clinicopathologic analysis of surgically proven intraductal papillary mucinous neoplasms of the pancreas in SNUH: a 15-year experience at a single academic institution. Langenbecks Arch Surg 397:93–102PubMedCrossRefGoogle Scholar
  14. 14.
    Sadakari Y, Ienaga J, Kobayashi K et al (2010) Cyst size indicates malignant transformation in branch duct intraductal papillary mucinous neoplasm of the pancreas without mural nodules. Pancreas 39:232–236PubMedCrossRefGoogle Scholar
  15. 15.
    Lee CJ, Scheiman J, Anderson MA et al (2008) Risk of malignancy in resected cystic tumors of the pancreas ≤3 cm in size: is it safe to observe asymptomatic patients? A multi-institutional report. J Gastrointest Surg 12:234–242PubMedCrossRefGoogle Scholar
  16. 16.
    Irie H, Honda H, Aibe H et al (2000) MR cholangiopancreatographic differentiation of benign and malignant intraductal mucin-producing tumors of the pancreas. AJR Am J Roentgenol 174:1403–1408PubMedCrossRefGoogle Scholar
  17. 17.
    Nakagohri T, Kinoshita T, Konishi M et al (2007) Surgical outcome of intraductal papillary mucinous neoplasms of the pancreas. Ann Surg Oncol 14:3174–3180PubMedCrossRefGoogle Scholar
  18. 18.
    Mimura T, Masuda A, Matsumoto I et al (2010) Predictors of malignant intraductal papillary mucinous neoplasm of the pancreas. J Clin Gastroenterol 44:e224–e229PubMedCrossRefGoogle Scholar
  19. 19.
    Sugiyama M, Izumisato Y, Abe N et al (2003) Predictive factors for malignancy in intraductal papillary-mucinous tumours of the pancreas. Br J Surg 90:1244–1249PubMedCrossRefGoogle Scholar
  20. 20.
    Nara S, Onaya H, Hiraoka N et al (2009) Preoperative evaluation of invasive and noninvasive intraductal papillary-mucinous neoplasms of the pancreas: clinical, radiological, and pathological analysis of 123 cases. Pancreas 38:8–16PubMedCrossRefGoogle Scholar
  21. 21.
    Nagai K, Doi R, Doi R, Ito T et al (2009) Single-institution validation of the international consensus guidelines for treatment of branch duct intraductal papillary mucinous neoplasms of the pancreas. J Hepatobiliary Pancreat Surg 16:353–358PubMedCrossRefGoogle Scholar
  22. 22.
    Kim SC, Park KT, Lee YJ et al (2008) Intraductal papillary mucinous neoplasm of the pancreas: clinical characteristics and treatment outcomes of 118 consecutive patients from a single center. J Hepatobiliary Pancreat Surg 15:183–188PubMedCrossRefGoogle Scholar
  23. 23.
    Adsay NV, Kloppel G, Fukushima N et al (2010) Intraductal neoplasms of the pancreas. In: Bosman FT, Carneiro F, Hruban RH (eds) WHO classification of tumours of the digestive system. IARC Press, LyonGoogle Scholar
  24. 24.
    Ohno E, Hirooka Y, Itoh A et al (2009) Intraductal papillary mucinous neoplasms of the pancreas: differentiation of malignant and benign tumors by endoscopic ultrasonography findings of mural nodules. Ann Surg 249:628–634PubMedCrossRefGoogle Scholar
  25. 25.
    Einstein DM, Singer AA, Chilcote WA et al (1991) Abdominal lymphadenopathy: spectrum of CT findings. Radiographics 11:457–472PubMedCrossRefGoogle Scholar
  26. 26.
    Arikawa S, Uchida M, Uozumi J et al (2011) Utility of multidetector row CT in diagnosing branch duct IPMNs of the pancreas compared with MR cholangiopancreatography and endoscopic ultrasonography. Kurume Med J 57:91–100PubMedCrossRefGoogle Scholar
  27. 27.
    Serikawa M, Sasaki T, Fujimoto Y et al (2006) Management of intraductal papillary-mucinous neoplasm of the pancreas: treatment strategy based on morphologic classification. J Clin Gastroenterol 40:856–862PubMedCrossRefGoogle Scholar
  28. 28.
    Levy P, Jouannaud V, O’Toole D et al (2006) Natural history of intraductal papillary mucinous tumors of the pancreas: actuarial risk of malignancy. Clin Gastroenterol Hepatol 4:460–468PubMedCrossRefGoogle Scholar
  29. 29.
    Crippa S, Fernandez-Del Castillo C, Salvia R et al (2010) Mucin-producing neoplasms of the pancreas: an analysis of distinguishing clinical and epidemiologic characteristics. Clin Gastroenterol Hepatol 8:213–219PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Takano S, Fukasawa M, Maekawa S et al (2014) Deep sequencing of cancer-related genes revealed GNAS mutations to be associated with intraductal papillary mucinous neoplasms and its main pancreatic duct dilation. PLoS ONE 9:e98718PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Dal Molin M, Matthaei H, Wu J et al (2013) Clinicopathological correlates of activating GNAS mutations in intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Ann Surg Oncol 20:3802–3808PubMedCrossRefGoogle Scholar
  32. 32.
    He J, Cameron JL, Ahuja N et al (2013) Is it necessary to follow patients after resection of a benign pancreatic intraductal papillary mucinous neoplasm? J Am Coll Surg 216:657–665; discussion 665–657PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Kang MJ, Jang JY, Lee KB et al (2013) Long-term prospective cohort study of patients undergoing pancreatectomy for intraductal papillary mucinous neoplasm of the pancreas: implications for postoperative surveillance. Ann Surg 260:356–363CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2015

Authors and Affiliations

  • Mee Joo Kang
    • 1
  • Jin-Young Jang
    • 1
  • Selyeong Lee
    • 2
  • Taesung Park
    • 2
  • Seung Yeoun Lee
    • 3
  • Sun-Whe Kim
    • 1
  1. 1.Department of Surgery and Cancer Research InstituteSeoul National University College of MedicineSeoulSouth Korea
  2. 2.Department of StatisticsSeoul National University College of Natural SciencesSeoulKorea
  3. 3.Department of Mathematics and StatisticsSejong University College of Natural SciencesSeoulKorea

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