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Natural History of Patients Followed Radiographically With Mucinous Cystic Neoplasms of the Pancreas
Linda Ma*, Michael D'Angelica, Ronald P. DeMatteo, Peter Kingham, Vinod Balachandran, William R. Jarnagin, Peter Allen
Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY

OBJECTIVE: The aim of this study was to evaluate the outcome of patients presumed to have IPMN (elevated cyst fluid carcinoembryonic antigen CEA ≥192 ng/mL), who were initially selected for radiographic surveillance.
METHODS: All patients who had a cystic lesion of the pancreas and had a cyst fluid CEA ≥192 ng/mL and evaluated at our institution over the past 15 years were included. Patients with less than 6 month follow-up were excluded. Patients were stratified by treatment strategy: those who underwent initial surgical resection (within six months of first radiographic diagnosis), and those who were recommended for radiographic surveillance. The natural history and disease progression of these two groups was examined.
RESULTS: During the 15 year study period, 227 patients were identified who had a documented cyst fluid CEA ≥192 ng/mL (median 961, interquartile range 448-3474 ng/mL) and met inclusion criteria. The majority of these 227 patients had branch-duct IPMN (190/227, 83%), 26 were main-duct (11%), and 11 were mixed-type (5%). The minority of patients underwent immediate resection (63/227, 28%). Within the group of 164 patients who were selected for initial radiographic surveillance, 87% were branch-duct lesions, median cyst diameter was 1.9 cm (range 0.4-10.8 cm), median cyst fluid CEA was 813 ng/ml (interquartile range 414-2823 ng/mL), and 87% met consensus criteria for radiographic surveillance (142 patients met consensus guidelines, 22 were outside of consensus guidelines). With a median follow-up of 56 months, 48 of the 164 patients (29%) have undergone resection. There were three cases (2%) of high-grade dysplasia, and two cases of invasive carcinoma (1%) found on pathology. Three of these five cases of high-risk disease were in the 22 patients who were followed outside of guidelines.
CONCLUSIONS: Appropriately selected patients with small branch-duct IPMNs can be safely followed with serial surveillance with a low risk of malignant progression.

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