Progression vs Cyst Stability of Branch-Duct Intraductal Pap
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The findings of this JAMA study suggest that the management of intraductal papillary mucinous neoplasms (IPMNs) under surveillance should be based on the evaluation of dynamic variables assessed through repeated observations.

This study was aimed to identify dynamic variables associated with the development of malignant neoplasms by combining pathological features with data from preoperative repeated observations.

The Crossover Observational Multicentric Study included a retrospective cohort of patients with branch-duct IPMNs (BD IPMNs) enrolled in a surveillance program. Patients underwent a minimum of 12 months of preoperative surveillance. A total of 292 patients were included in the analysis (137 women and 155 men; median age, 64 years).

--During surveillance, 27 patients developed a worrisome feature after 5 years, and 46 of 276 developed high-risk stigmata (HRS).

--At the final pathological evaluation, 107 patients had HGD or invasive cancer, and 16 had IPMNs with concomitant pancreatic ductal adenocarcinoma.

--Rates of HGD and invasive cancer at pathological evaluation significantly differed between those without worrisome features and those developing HRS from a previous worrisome feature.

--Developing an additional worrisome feature during surveillance or an HRS from a baseline worrisome feature was associated with HGD at final pathological evaluation.

--Among HRS, the development of jaundice on a low-risk cyst was independently associated with invasive cancer.

These findings suggest that in BD IPMNs under surveillance, harboring a stable worrisome feature carries the lowest risk of malignant disease. The development of additional worrisome features or HRS is associated with the presence of HGD, whereas the occurrence of jaundice is associated with invasive cancer.