Journal of Gastrointestinal Surgery

, Volume 19, Issue 2, pp 258–265 | Cite as

Current Recommendations for Surveillance and Surgery of Intraductal Papillary Mucinous Neoplasms May Overlook Some Patients with Cancer

  • Andrew H. Nguyen
  • Paul A. Toste
  • James J. Farrell
  • Barbara M. Clerkin
  • Jennifer Williams
  • V. Raman Muthusamy
  • Rabindra R. Watson
  • James S. Tomlinson
  • O. Joe Hines
  • Howard A. Reber
  • Timothy R. Donahue
Original Article



The 2012 Sendai Criteria recommend that patients with 3 cm or larger branch duct intraductal papillary mucinous neoplasms (BD-IPMN) without any additional “worrisome features” or “high-risk stigmata” may undergo close observation. Furthermore, endoscopic ultrasound (EUS) is not recommended for BD-IPMN <2 cm. These changes have generated concern among physicians treating patients with pancreatic diseases. The purposes of this study were to (i) apply the new Sendai guidelines to our institution’s surgically resected BD-IPMN and (ii) reevaluate cyst size cutoffs in identifying patients with lesions harboring high-grade dysplasia or invasive cancer.


We retrospectively reviewed 150 patients at a university medical center with preoperatively diagnosed and pathologically confirmed IPMNs. Sixty-six patients had BD-IPMN. Pathologic grade was dichotomized into low-grade (low or intermediate grade dysplasia) or high-grade/invasive (high-grade dysplasia or invasive cancers). Fisher’s exact test, chi-square test, student’s t test, linear regression, and receiver operating characteristic (ROC) analyses were performed.


The median BD-IPMN size on imaging was 2.4 cm (interquartile range 1.5–3.0). Fifty-one (77 %) low-grade and 15 (23 %) high-grade/invasive BD-IPMN were identified. ROC analysis demonstrated that cyst size on preoperative imaging is a reasonable predictor of grade with an area under the curve of 0.691. Two-thirds of high-grade/invasive BD-IPMN were <3 cm (n = 10). Compared to a cutoff of 3, 2 cm was associated with higher sensitivity (73.3 vs. 33.3 %) and negative predictive value (83.3 vs. 80 %, NPV) for high-grade/invasive BD-IPMN. Mural nodules on endoscopic ultrasound (EUS) or atypical cells on endoscopic ultrasound-fine needle aspiration (EUS-FNA) were identified in all cysts <2 and only 50 % of those <3 cm. Forty percent of cysts >3 cm were removed based on size alone.


Our results suggest that “larger” size on noninvasive imaging can indicate high-grade/invasive cysts, and EUS-FNA may help identify “smaller” cysts with high-grade/invasive pathology.


Intraductal papillary mucinous neoplasm Branch duct intraductal papillary mucinous neoplasm Sendai criteria Pancreas 



Intraductal papillary mucinous neoplasms


Branch duct intraductal papillary mucinous neoplasms


Main duct intraductal papillary mucinous neoplasms


High-risk stigmata


Worrisome features


Receiver operating characteristic


Negative predictive value


Endoscopic ultrasound


Fine needle aspiration


Interquartile range


Area under the curve



Dr. Nguyen was supported by a T32 Training Award from the National Institute of Health (NIH T32DK07180-39) and the Gerald S. Levey Surgical Research Award.


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Copyright information

© The Society for Surgery of the Alimentary Tract 2014

Authors and Affiliations

  • Andrew H. Nguyen
    • 1
  • Paul A. Toste
    • 1
  • James J. Farrell
    • 2
  • Barbara M. Clerkin
    • 1
  • Jennifer Williams
    • 3
  • V. Raman Muthusamy
    • 4
  • Rabindra R. Watson
    • 4
  • James S. Tomlinson
    • 1
  • O. Joe Hines
    • 1
  • Howard A. Reber
    • 1
  • Timothy R. Donahue
    • 1
  1. 1.Department of SurgeryDavid Geffen School of Medicine at UCLALos AngelesUSA
  2. 2.Yale Center for Pancreatic DiseaseYale University School of MedicineNew HavenUSA
  3. 3.Department of SurgeryHarbor-UCLA Medical CenterTorranceUSA
  4. 4.UCLA Division of Digestive DiseasesDavid Geffen School of Medicine at UCLALos AngelesUSA

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