Initial Cyst Size Research Articles

ThP4.14 - Updated surveillance guidance for Intra-ductal Pancreatic Mucinous Neoplasm (IPMN) – a 10-year cohort study in a tertiary care Surgical unit

Abstract Aims To investigate the adequacy of current frequency of surveillance of IPMN in a single tertiary surgical unit Methods This was a retrospective cohort study over a 10-year period (2013-2023), patient age range 30-85 years old. The data collected included gender, age at diagnosis, size(mm) of largest cyst, high risks(HRF) or worrisome features(WRF) and interventions required. Analysis undertaken pertaining to the incidence of IPMN with malignant potential as well as progression of disease on surveillance. Results Total of 61 patients. On presentation - Cyst size <1cm – 51%, 1-2cm- 33%, 2-3cm- 16%. <1cm group - no growth on surveillance scans and no interventions required. 1-2cm group - 35% had HRF, 25% of which underwent surgical intervention. 15% showed WF of which 33% required surgical intervention. 2-3cm group - 20% of patients with WF showed growth in cyst size. 40% of patients with WF - underwent surgery. Conclusion The malignant potential of IPMN correlates with the initial cyst size. Guidelines recommend that cysts <1cm should be under 2-yearly surveillance. However, when compared to those with cyst>1cm, none of the patients with cyst size<1cm displayed progression. Therefore, we propose that for patients with an initial cyst size of less than 1cm, who are above the age of 70 and/or Performance status (PS) =>2 – no active surveillance is required. If the PS <2 and patients are less than 70 years old, we recommend 5-yearly surveillance. For patients with cyst size >1cm, we recommend adhering to the current guidance. With this revised guidance, already scarce resources may be better utilised.

Natural history and growth prediction model of pancreatic serous cystic neoplasms

ObjectiveSerous cystic neoplasms (SCN) are benign pancreatic cystic neoplasms that may require resection based on local complications and rate of growth. We aimed to develop a predictive model for the growth curve of SCNs to aid in the clinical decision making of determining need for surgical resection. MethodsUtilizing a prospectively maintained pancreatic cyst database from a single institution, patients with SCNs were identified. Diagnosis confirmation included imaging, cyst aspiration, pathology, or expert opinion. Cyst size diameter was measured by radiology or surgery. Patients with interval imaging ≥3 months from diagnosis were included. Flexible restricted cubic splines were utilized for modeling of non-linearities in time and previous measurements. Model fitting and analysis were performed using R (V3.50, Vienna, Austria) with the rms package. ResultsAmong 203 eligible patients from 1998 to 2021, the mean initial cyst size was 31 mm (range 5–160 mm), with a mean follow-up of 72 months (range 3–266 months). The model effectively captured the non-linear relationship between cyst size and time, with both time and previous cyst size (not initial cyst size) significantly predicting current cyst growth (p < 0.01). The root mean square error for overall prediction was 10.74. Validation through bootstrapping demonstrated consistent performance, particularly for shorter follow-up intervals. ConclusionSCNs typically have a similar growth rate regardless of initial size. An accurate predictive model can be used to identify rapidly growing outliers that may warrant surgical intervention, and this free model (https://riskcalc.org/SerousCystadenomaSize/) can be incorporated in the electronic medical record.

Watchful waiting for large primary nonparasitic splenic cysts.

Primary nonparasitic splenic cysts (NPSC) are typically diagnosed incidentally. The management of large (≥ 5 cm) asymptomatic cysts remains controversial; there is a lack of evidence guiding management. The purpose of this study was to describe the outcomes of nonoperative management of large NPSC. Patients diagnosed with NPSC between January 2004 and December 2019 were identified at our academic institution. Adult patients with an NPSC of at least 5 cm who had at least 1 additional hospital visit were included. Data are presented as medians with interquartile ranges (IQR). We identified 512 medical records that included the term splenic cyst during the study period. Sixty-eight of the patients had no reported cyst size, 410 had cysts smaller than 5 cm, 1 patient underwent an elective splenectomy at another institution and 12 patients were excluded for other reasons; 21 patients with cysts of at least 5 cm were included in the study. Eight symptomatic patients underwent surgery at our institution. Of these, 2 presented acutely: 1 with hemoperitoneum who required admission for transfusions and later underwent elective laparoscopic splenectomy and 1 with increasingly severe abdominal pain who underwent laparoscopic cyst unroofing. The remaining 6 symptomatic patients had elective surgery for pain (4 cyst unroofing, 1 total splenectomy, 1 partial splenectomy). Thirteen patients were asymptomatic (10 female, median age 49.2 [IQR 38.1 to 64.6] yr). Two of these patients chose to undergo elective surgery. The remaining 11 asymptomatic patients, with a median initial cyst size of 8.0 (IQR 5.3 to 10.8) cm, were followed for a median of 31.0 (IQR 23.5 to 71.0) months. There was no change in median cyst size (0 [IQR -1 to 0] cm), and none of these patients underwent intervention for their NPSC. Asymptomatic patients managed nonoperatively for large NPSC did not become symptomatic or require intervention during the study period. This supports watchful waiting with serial radiologic and clinical monitoring for asymptomatic large NPSC.

Factors Associated With the Risk of Progression of Low-Risk Branch-Duct Intraductal Papillary Mucinous Neoplasms

Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) are common pancreatic preneoplastic lesions, but their surveillance is not personalized. To investigate patient- and cyst-related factors associated with progression into worrisome features (WFs) or high-risk stigmata (HRS) categories of BD-IPMNs. Cyst- and patient-related factors of consecutive BD-IPMNs without WFs or HRS in 540 patients diagnosed from 2009 to 2018 with at least 12 months' surveillance until February 28, 2020, were registered in a 2-center ambispective cohort study in Italy. In a subgroup, the ABO blood group was studied for the first time in this setting. Cyst-related and patients-related factors and ABO blood group. The study outcome was the appearance of WFs or HRS according to the 2017 International Association of Pancreatology guidelines. Survival probability was calculated using Kaplan-Meier curve and risk factors identified by Cox proportional hazards regression. ABO blood group was inferred through genotypes with DNA extraction. Of 540 patients with BD-IPMNs (median age, 66 years [interquartile range, 58.5-72.0 years]; 337 women [62.4%]) undergoing surveillance for a median of 51.5 months (interquartile range, 28-84 months) for 2758 person-years, 130 patients (24.1%) experienced progression. Probability of progression was 3.7% at 1 year, 23.4% at 5 years, and 43.3% at 10 years; 15 patients (2.8%) underwent surgery, 7 patients (1.3%) had malignant histologic findings, and 3 patients (0.56%) died of pancreatic-associated disease. Initial cyst size greater than 15 mm (hazard ratio [HR], 2.05; 95% CI, 1.44-2.91), body mass index greater than 26.4 (HR, 1.72; 95% CI, 1.19-2.50), and heavy smoking (HR, 1.81; 95% CI, 1.14-2.86) were significant independent factors associated with progression risk. The AA blood genotype was also associated with progression risk (HR, 3.49; 95% CI, 1.04-11.71) compared with the OO genotype in the investigated subgroup. This analysis of factors associated with progression of BD-IPMNs according to recent guidelines suggests that cyst size alone is not a reliable factor for estimation of progression risk; however, along with other readily available data, size is helpful for planning personalized surveillance of BD-IPMNs.

S0106 Imaging Resource Utilization in the Surveillance of Presumed Branched Duct Intraductal Papillary Mucinous Neoplasm (BD-IPMN)

INTRODUCTION: Presumed mucinous cystic lesions are at increased (albeit low) risk of malignant transformation and require regular imaging for ongoing surveillance. A cost-effective evaluation of imaging resource utilization (IRU) is understudied due to a paucity of actual clinical utilization data and lack of consensus among current guidelines. We assessed the value proposition of IRU in surveillance of BD-IPMN, by defining populations utilizing high volumes of imaging, and identifying the predictors of high IRU. METHODS: This is a single-center cross-sectional study, of patients with presumed BD-IPMN under active surveillance as of January 2018. Patients were identified from a prospectively maintained pancreatic cyst neoplasm (PCN) database. Presumed diagnosis of mucinous cysts with identification of worrisome features (WF) and high-risk stigmata (HRS), was made based on the accepted criteria from the literature. IRU was calculated based on both noninvasive (CT/MRI) and minimally invasive (EUS) imaging used per month during surveillance. For analysis, the “High Resource Utilization” (HRU) group is defined as the top 10% of the population consuming higher imaging resources and compared them with rest of the surveillance population: “Low Resource Utilization” (LRU) group. The clinical variables were compared using chi-square analysis and student’s t test between two groups. RESULTS: 409 patients with presumed BD-IPMNs were followed for 41.60 ± 32.24 months. By definition, the rate of surveillance imaging utilization per month in HRU group was higher, 0.74 ± 0.42 vs 0.16 ± 0.09 (P < 0.001). Similarly, the rate of non-invasive imaging and EUS utilization was also higher in HRU group. The HRU group have a higher initial cyst size (18.33 ± 14.31 mm vs. 12.90 ± 9.08 mm) (P < 0.001), higher proportion of cysts with WF (17.5% vs 13.82%) (P < 0.001), or with HRS (7.5% vs 1.36%) (P < 0.001), compared with LRU group. Cyst growth rate per year (30.00% vs 4.88% (P < 0.001)) and per two years (35.00% vs 13.82% (P < 0.001)) displayed higher proportions of fast-growing cysts (>5 mm threshold) in the HRU group compared with LRU group. CONCLUSION: Higher IRU was found in a subset of presumed BD-IPMN population undergoing active surveillance using actual prospective clinical data. Predictors of this included larger initial cyst size, rapid cyst growth rate over one and two years, and the presence of WF and HRS. Further refinement of imaging guidelines is needed for accurate long term PCN surveillance balanced by cost-effective IRU.Table 1

Long-term follow-up study of the malignant transformation potential of the simple renal cysts.

BackgroundWe conducted a multi-center study to investigate the prevalence, the malignant transformation potential of the simple renal cysts and the factors that might predict malignancy.MethodsWe defined the simple renal cysts as Bosniak class I & II (including IIF) lesions. In the prevalence study, data from 115,132 ultrasonographies was collected from individuals who participated in a multiphasic health wellness screen. In the natural history and progression study, we retrospectively reviewed 333 participants with simple renal cysts and were followed for at the least 3 years with a mean of 6.3±2.9 years (ranged from 3 to 13 years).ResultsAbout 7.2% (8,303) of the individuals who participated in the study were found to have at the least one simple renal cyst. The incidence increased with age from 0.6% in the first decade to 28.0% in the eighth or later decade of life. The Bosniak class I lesion accounted for 7,559 or 91.0% of the cysts whereas 744 or 9.0% were class II. A slower growth rate was observed in the older age group. Twenty-four patients (7.2%) had their renal cysts upgraded according to the Bosniak classification. Gender, age, initial cyst size, number of cysts and bi-laterality failed to predict the malignancy tendency.ConclusionsMost of the cysts discovered were the Bosniak class I and II lesions and they rarely progress further. Treatment for the asymptomatic simple renal cyst is not warranted. Treatment decision-making based on older age or larger initial cyst size should not be recommended.

Progression of pancreatic cystic lesions without any risk features is associated with initial cyst size and obesity.

The clinical significance of incidental pancreatic cystic lesions (PCLs) remains unclear in those that are not accompanied by worrisome features or high-risk stigmata. We aimed to investigate the natural course of PCLs without any risk features and examine the clinical factors associated with their progression. We conducted a retrospective cohort study of 427 patients with PCLs, which were incidentally detected by computed tomography between January 2003 and December 2012. Progression of PCLs without any risk features and the clinical factors associated with their progression were investigated. The length of time to significant growth was also evaluated. Ninety-four (22.0%) of the 427 patients had asymptomatic PCLs that showed significant growth after a median surveillance period of 5.3years; approximately 27.7% of the patients showed significant size changes in the first 5years, while the remaining 72.3% showed significant changes after 5years. The cumulative rate of patients with significant growth was associated with initial cyst size and high body mass index. In the growth group, additional treatments were required for 12 patients, one of whom developed malignancy. Four patients in the stable group underwent additional treatment and showed no malignant change. One-fifth of the asymptomatic PCLs significantly increased in size after a long-term follow-up period, which was associated with initial cyst size and obesity. The size of PCLs mostly increased after 5years; although the malignancy risk of PCLs was low, it was still a concern.

Age, obesity, diabetes and initial cyst size are associated with the risk of progression of BD-IPMN undergoing follow-up

Age, obesity, diabetes and initial cyst size are associated with the risk of progression of BD-IPMN undergoing follow-up

39 – Age, Obesity, Diabetes and Initial Cyst Size are Associated with the Risk of Progression of Bd-Ipmn Undergoing Follow-Up

39 – Age, Obesity, Diabetes and Initial Cyst Size are Associated with the Risk of Progression of Bd-Ipmn Undergoing Follow-Up

The Effect of Initial Cyst Size on Visual and Anatomical Outcomes After Intravitreal Ranibizumab Treatment in Cystoid Macular Edema Due To Branch Retinal Vein Occlusion

The Effect of Initial Cyst Size on Visual and Anatomical Outcomes After Intravitreal Ranibizumab Treatment in Cystoid Macular Edema Due To Branch Retinal Vein Occlusion

When to Consider an Increase in Cyst Size in Patients With Pancreatic Cystic Neoplasms?

Introduction: Because of the interobserver variability in radiographic cyst size evaluation, a pancreatic cyst growth rate of ≥ 3mm/year warrants a shorter follow up interval by the current consensus. On the other hand, a 20% increase in the maximum diameter of the cyst size compared to the previous was also considered to be a significant interval change by the existing literature. We aim to determine the significance of an increase in cyst size of ≥ 3mm versus ≥ twenty percent with respect to the initial cyst size in patients with pancreatic cystic neoplasms (PCN). Methods: From the Mayo Clinic, Rochester database, we retrospectively identified 238 subjects with incidentally detected pancreatic cysts. We excluded the patients with inflammatory fluid collections secondary to acute pancreatitis. The study subjects were further classified into three groups according to the initial cyst size of <1cm (99 patients), 1-3 cm (124 patients), and ≥3cm (15 patients) respectively. A difference in 3mm versus twenty percent increase at follow-up from the initial cyst size was compared in each group. Results: Baseline characteristics of the included patients were summarized in the Table. The mean cyst size at baseline was 13.3±9.4 mm which were followed up for a mean duration of 95.5±29.2 months. During the follow up period, out of 238 patients, 104 patients showed ≥3mm cyst growth compared to 110 patients with ≥20% increase in cyst size. In patients with smaller cysts (<1cm), a higher proportion of patients (56.4% versus 47.1%, p < 0.0001) showed a twenty percent difference in cyst size compared to 3mm cyst growth [Figure]. Whereas in patients with cysts size ≥1cm, higher number of patients (48.1% versus 40%; p < 0.0001 for 1-3cm, 4.8% versus 3.6%; p = 0.004 for ≥ 3cm cyst size) showed a cyst growth of 3mm compared to twenty percent increase in cyst size. Conclusion: For any cyst size, an increase in 20% of the maximum diameter of the cyst size is reasonable to consider as a significant change to reduce the effect of measuring error.61_A Figure 1. Baseline characteristics of the patients61_B Figure 2. Proportion of patients with 3mm versus 20% cyst growth with respect to the baseline cyst size

Progression of pancreatic branch duct intraductal papillary mucinous neoplasms associates with cyst size

Backgrounds: Most guidelines for management of patients with intraductal papillary mucinous neoplasms (IPMN) vary in proposed surveillance intervals and durations—these are usually determined based on expert opinions rather than substantial evidence. We evaluated the progression of branch duct (BD)-IPMN under surveillance at a single center, and determined optimal follow-up intervals and duration. Methods: We performed a retrospective analysis of 1369 patients with BD-IPMN seen the Seoul National University Hospital in Korea from January 2001 through December 2016. We included only patients whose imaging studies showed classical features of BD-IPMN, and collected data from each patient over time periods of at least 3 years. Results: The median annual growth rate of the cyst was 0.8 mm over a median follow-up time of 61 months. During surveillance, 46 patients (3.4%) underwent surgery due to disease progression after a median follow-up time of 62 months. Worrisome features were observed in 210 patients (15.3%) during surveillance, including cyst size of 3 cm or more (n=112, 8.2%), cyst wall thickening (n=51, 3.7%), main pancreatic duct dilatation (n=77, 5.6%), and mural nodule (n=43, 3.1%). Along with annual rate of cyst growth, incidences of main pancreatic duct dilatation and mural nodules associated with the sizes of cysts at detection (P< .001). Conclusion: In a retrospective analysis of patients with BD-IPMN followed for more than 5 years, we found most cysts to be indolent, but some rapidly grew and progressed. Surveillance protocols should therefore be individualized, based on initial cyst size and rate of growth.

Issue Highlights

Issue Highlights

Predictors of Progression Among Low-Risk Intraductal Papillary Mucinous Neoplasms in a Multicenter Surveillance Cohort.

Our aim was to identify baseline characteristics associated with disease progression and malignant transformation in low-risk suspected intraductal papillary mucinous neoplasms (IPMNs). This is a retrospective cohort study of prospectively maintained databases of pancreatic cysts at 3 international, academic institutions. Five hundred fifty-nine adult patients with clinically suspected asymptomatic IPMN evaluated by radiologic studies or endoscopic ultrasound between 2003 and 2013 without worrisome features and under surveillance for 12 months or longer were included. We evaluated the relationship of baseline demographics and cyst features to disease progression (size increase, development of worrisome features, or high-grade dysplasia/cancer). After a median of 44 months follow-up, 269 (48%) patients experienced cyst size increase, 68 (12%) developed worrisome features, and 11 (2%) developed high-grade dysplasia/cancer. In multivariable Cox-regression analysis, no baseline characteristics were associated with size increase. An initial cyst size of 2 cm or greater, multifocality, history of prostate cancer, and smoking were the strongest predictors of development of new worrisome features. Univariable analysis found male sex, diabetes, and recent weight loss associated with development of high-grade dysplasia/cancer. Our study demonstrates that low-risk suspected IPMNs carry a small but clinically relevant risk of disease progression and provides data on baseline characteristics that may help in risk stratification.

Progression of Pancreatic Branch Duct Intraductal Papillary Mucinous Neoplasm Associates With Cyst Size

Most guidelines for management of patients with intraductal papillary mucinous neoplasms (IPMN) vary in proposed surveillance intervals and durations-these are usually determined based on expert opinions rather than substantial evidence. The progression of and optimal surveillance intervals for branch-duct IPMNs (BD-IPMN) has not been widely studied. We evaluated the progression of BD-IPMN under surveillance at a single center, and determined optimal follow-up intervals and duration. We performed a retrospective analysis of 1369 patients with BD-IPMN seen at Seoul National University Hospital in Korea from January 2001 through December 2016. We included only patients whose imaging studies showed classical features of BD-IPMN, and collected data from each patient over time periods of at least 3 years. We reviewed radiologic and pathologic findings, and performed linear and binary logistic regressions to estimate cyst growth. The median annual growth rate of the cyst was 0.8 mm over a median follow-up time of 61 months. During surveillance, 46 patients (3.4%) underwent surgery because of disease progression after a median follow-up time (in this group) of 62 months. Worrisome features were observed in 209 patients (15.3%) during surveillance, including cyst size of 3 cm or more (n = 109, 8.0%), cyst wall thickening (n = 51, 3.7%), main pancreatic duct dilatation (n=77, 5.6%), and mural nodule (n = 43, 3.1%). Along with annual rate of cyst growth, incidences of main pancreatic duct dilatation and mural nodules associated with the sizes of cysts at detection (P < .001). In a retrospective analysis of patients with BD-IPMN followed for more than 5 years, we found most cysts to be indolent, but some rapidly grew and progressed. Surveillance protocols should therefore be individualized based on initial cyst size and rate of growth.

Incidental, Small (< 3 cm), Unilocular, Pancreatic Cysts: Factors That Predict Lesion Progression during Imaging Surveillance.

ObjectiveTo explore the features that predict size increase and development of potential malignant features in incidentally detected, unilocular cystic pancreatic lesions (CPLs) less than 3 cm in diameter, during subsequent follow-up.Materials and MethodsWe retrieved data of patients diagnosed with unilocular CPLs less than 3 cm in diameter during the period from November 2003 through December 2014, using a computerized search. All serial CT and MR images were analyzed to identify the number, size, and location of CPLs; dilatation of the main pancreatic duct; and occurrence of worrisome features and high-risk stigmata of malignancy in the lesion. The characteristics of CPLs were compared between the increase (i.e., size increase during subsequent follow-up) and no-increase groups. For CPLs in the increase group, subgroup analysis was performed according to the lesion size at the last follow-up (< 3 cm vs. ≥ 3 cm).ResultsAmong 553 eligible patients, 132 (23.9%) had CPLs that increased in size, and 421 (76.1%) had CPLs that did not, during follow-up. Of the 132, 12 (9.1%) CPLs increased to diameters ≥ 3 cm at the final follow-up. Among the various factors, follow-up duration was a significant independent factor for an interval size increase of CPLs (p < 0.001). In the increase group, initial cyst size was a significant independent factor to predict later size increase to or beyond 3 cm in diameter (p < 0.001), and the initial cyst diameter ≥ 1.5 cm predicted such a growth with a sensitivity and specificity of 83% and 72%, respectively. No significant factors to predict the development of potential malignant features were identified.ConclusionFollow-up duration was associated with an interval size increase of CPLs. Among the growing CPLs, initial cyst size was associated with future lesion growth to and beyond 3 cm.

Chronic immunosuppression does not potentiate the malignant progression of mucinous pancreatic cystic lesions

BackgroundPremalignant mucinous pancreatic cystic lesions (mPCLs) are increasingly identified. AimsIn this study, we aim to assess the effect of selected immunosuppressive therapies on the progression of mPCLs, including side-branch intraductal papillary mucinous neoplasms and mucinous cystic neoplasms. MethodsWe performed a retrospective cohort study of patients with mPCLs diagnosed over a 24-year period who received chronic immunosuppression. Controls were matched on age at cyst diagnosis (±11 yrs) and cyst size (±8 mm). Measured outcomes included increase in cyst size, development of “worrisome features” as defined by consensus guidelines, progression to malignancy, and rate of surgical resection. Results39 patients (mean age 60 yrs) with mPCLs were on immunosuppression. Leading indications for immunosuppression were solid organ transplant (n = 14), inflammatory bowel disease (n = 6), and rheumatoid arthritis (n = 5). 33% were on biologics, 77% on antimetabolites and 79% on multiple medications. Mean cyst size increased from 12.6 mm to 17.8 mm over a median of 16.5 months. 6 patients elected for surgical resection, and none ultimately developed malignancy. 26 cases with follow-up were matched to control subjects, with no significant differences among cases and controls in initial cyst size (12.8 mm vs 11.9 mm, P = 0.69), mean size increase (6.9 mm vs 5 mm, P = 0.47), follow-up interval (24.3 months vs 21.5 months, P = 0.44). No significant differences in the rate of worrisome features, malignancy, or surgical resection. ConclusionsPatients with mPCLs exposed to immunosuppressive medications did not have higher rates of malignancy or development worrisome features in the short term. This suggests that patients with mPCLs can be initiated or maintained on these agents without changes to surveillance practices.

Increase in Branched Duct IPMN Lesion Size During Surveillance Is Not Associated With Other High-Risk Features: A Multi-Center Study

Introduction: Branched duct intraductal papillary mucinous neoplasms (BD-IPMNs) are the most common type of incidental pancreatic cysts. Cyst growth on follow-up imaging remains a concerning sign and usually prompts more rigorous surveillance or surgical resection. The significance of size changes of BD-IPMNs over time remains unclear. The aim of this study is to find predictors of cyst growth and whether rapid cyst growth is associated with increased risk of malignancy. Methods: This is a retrospective study of BD-IPMN patients managed at 2 high-volume referral centers. Patients were included if they were followed for more than 6 months and underwent pancreatic imaging at least twice. Cyst size on imaging studies was calculated by averaging the major and minor axis dimensions. Mean cyst growth rate percentage (MGRP) was calculated as: (final size − initial size)/(initial size)*(100/years) in order to reflect initial cyst size. Rapid cyst growth was defined as a mean cyst growth rate percentage (MGRP) ≥20% per year. Results: Between 1996 and 2013, 326 patients were diagnosed with BD-IPMNs; 168 met inclusion criteria and were followed for a median of 24 months (range: 6.1-114.5 months). Mean age was 64.7±12.1 years; 101 (60.1%) were men. Mean cyst size at baseline (MCSB) was 15.72±9.3 mm. During follow- up, 76 (45.2%) showed an increase in size, of which 27 cysts (35.5%) exhibited rapid growth, with MGRP ≥20% per year occurring in older patients (68.89 years vs. 63.88 years; p=0.04). Rapid cyst growth was not associated with family history of pancreatic disease, smoking, alcohol intake, development of interval symptoms, and cyst characteristics such as baseline size, multiplicity, location, presence of mural nodules or septae, and mean cyst fluid CEA level (4407.6 ng/mL vs. 1863.2 ng/mL; p=0.28). Cyst fluid from 107 cysts was sent for DNA analysis and showed K-ras mutations in 27. Compared to K-ras negative cysts neither MCSB (16.59 mm vs. 17.83 mm) nor MGRP (6.53% per year vs. 3.71% per year) was significantly different. Similar results were observed in cysts with high DNA levels (≥40 ng/uL) or ≥2 allelic imbalance mutations. Eighteen patients underwent surgery during follow-up; 15 (83.3%) patients had low-grade dysplasia (LGD), and 3 had advanced neoplasia (1 high-grade dysplasia and 2 with invasive carcinoma). None of the 3 cysts with advanced neoplasia had MGRP ≥20% per year. Conclusion: BD-IPMNs grow in a significant proportion of patients. However, a significant increase in cyst size was not associated with other high-risk patient or cyst characteristics. Cyst fluid tumor markers do not predict which lesions are likely to grow rapidly. Rapid growth of BD-IPMNs was not associated with advanced neoplasia on surgical pathology.

Clinical and Radiological Course of Simple Renal Cysts in Children

To evaluate the clinical and, particularly, radiological course of simple renal cysts in children. Children with simple renal cysts were retrospectively evaluated, especially for change in the cyst diameter during follow-up and complications. In addition, the rate of increase in cyst size per year was calculated, and those characteristics of the cyst were analyzed to predict aggressiveness. Simple renal cysts were detected in 45 (21 male) patients. Mean ages at diagnosis and follow-up period were 7.4 ± 4.9 and 2.9 ± 1.8 years, respectively. Forty-one of the 45 patients were followed up for longer than 1 year. Diameter of the cyst increased in 20 (49%), decreased in 4 (10%), unchanged in 13 (31%), and disappeared in 4 (10%) of patients. The average size increase and average rate of enlargement in simple cysts were 0.3 mm and 1.0% per year, respectively. Furthermore, in 19 (95%) patients, the cyst size increased in the first 2 years. Among baseline parameters, only initial cyst size was an independent predictor of annual growth rates (beta = 0.628; P <.001). The relationship between the initial cyst size and annual growth rates was determined as positive (r = 0.459, P = .003). Two patients with large cysts developed severe complication in the first 6 months. One of these underwent nephrectomy because of rapid increase in cyst diameter (170 mm), renal artery/vein compression, and massive hematuria. In the other patient with severe loin pain regarding simple cyst (73 mm), percutaneous aspiration was performed. Simple renal cysts in childhood tend to slowly increase in size. However, regular radiological follow-up might be important, especially in children with large size of cyst at diagnosis, because of more rapid increase in cyst size.

Proper management and follow-up strategy of branch duct intraductal papillary mucinous neoplasms of the pancreas

Background and aimIt has been reported that main duct intraductal papillary mucinous neoplasms are more invasive and have a worse prognosis than branch duct intraductal papillary mucinous neoplasms. Therefore, an aggressive surgical approach has mainly been recommended for all MD-IPMNs. However, the surgical management of BD-IPMNs has been controversial and the consensus guidelines are not specific for an indicator of malignancy in BD-IPMNs. The objective of this study was to determine the proper management and follow-up strategy of BD-IPMNs. MethodsWe monitored and analysed patients with presumed BD-IPMNs between March 1995 and March 2010. ResultThe mean value of the initial cyst size in all patients with BD-IPMNs was 2.19cm. Amongst 194 patients with BD-IPMNs, 34 underwent immediate surgical resection, 152 were followed conservatively. Amongst the 152 conservatively managed patients, 18 (11.8%) underwent surgical resection after a median follow-up of 12.7 months (range, 3–48 months). In 132 patients who were managed conservatively without surgery, the mean incremental rate of cyst size growth was 0.0038cm/month during a median of 30.7 months of follow-up and there were no IPMN-related deaths. ConclusionAmongst patients with BD-IPMNs, about 10% have surgery within approximately 1 year from the time of diagnosis because of the occurrence of new malignant stigmata. Therefore, a conservative approach without surgery and careful follow-up every 3 months or 6 months during the first year after diagnosis can be safely advocated in patients with BD-IPMNs larger than 10mm in size who have no risk factors for malignant IPMNs.