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Branch duct intraductal papillary mucinous neoplasms: How ready are we to de-escalate surveillance?
Phillip J Hopley, Philip Whelan, Richard Jackson, Jonathan Evans, Timothy Andrews, Paula Ghaneh, Michael Raraty, William Greenhalf, Christopher M Halloran
Phillip J Hopley, Paula Ghaneh, William Greenhalf, Christopher M Halloran, Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 8TX, United Kingdom
Phillip J Hopley, Philip Whelan, Paula Ghaneh, Michael Raraty, Christopher M Halloran, Department of Pancreatic Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, United Kingdom
Richard Jackson, Institute of Population Health, University of Liverpool, Liverpool L7 8TX, United Kingdom
Jonathan Evans, Department of Radiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, United Kingdom
Timothy Andrews, Department of Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, United Kingdom
Author contributions: Hopley PJ and Halloran CM designed the study, drafted and critically reviewed the manuscript; Hopley PJ and Whelan P collected the data; Jackson R performed the statistical analysis; Evans J provided radiological interpretation; Andrews T provided pathological interpretation; all authors critically reviewed and approved of manuscript.
Institutional review board statement: This study was approved by the Yorkshire and Humber Research Ethics Committee, No. 19/YH/0250.
Informed consent statement: Informed consent was not required for the inclusion of participant data in the research database.
Conflict-of-interest statement: Dr. Halloran reports grants from National Health Service England, Cancer Research United Kingdom, Pancreatic Cancer United Kingdom, Liverpool University Hospitals NHS Foundation Trust, outside the submitted work; In addition, Dr. Halloran has a patent GB1806002.0 PCT/GB2019/050998 issued.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: Data available upon reasonable request to the corresponding author.
Corresponding author: Christopher M Halloran, MD, Professor, Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 8TX, United Kingdom.
halloran@liverpool.ac.uk
Received: October 29, 2025
Revised: December 20, 2025
Accepted: March 5, 2026
Published online: May 21, 2026
Processing time: 202 Days and 17.6 Hours
BACKGROUND
Surveillance of branch duct intraductal papillary mucinous neoplasm (BD-IPMN) is advised to detect pancreatic ductal adenocarcinoma. Unfortunately, current practice means individuals have multiple rounds of investigations as typically surveillance continues until malignant transformation is identified or the patient is considered unsuitable for surgical intervention. This has major financial stress to healthcare providers and psychological burden to the patient. As a supra-regional referral centre, our impression was that many of the BD-IPMN in our surveillance pathway have many relatively unproductive rounds of surveillance and sought to interrogate our 17-year experience of this and determine whether we could improve our pathway.
AIM
To identify phenotypic and biochemical markers which predict IPMN behaviour and identify strategies to minimise investigations and manage surveillance de-escalation.
METHODS
This study was a single centre observational study based around one of the highest volume supra-regional pancreatic referral units in the United Kingdom (Liverpool). Individuals with BD-IPMN who were referred for surveillance were managed under the Liverpool IPMN Surveillance Pathway. Presumed innocent BD-IPMN (without either worrisome or high-risk features) underwent imaging ± endoscopic ultrasound (EUS) examinations for any interval development of high-risk features or worrisome features or symptoms and were either returned to surveillance or underwent definitive care.
RESULTS
Of 1303 patients were included between 1 January 2007 and 31 December 2023, with 1191 (91%) entering surveillance. Median [interquartile range (IQR)] follow up was 9.74 (7.79-11.2) years. Histology was available in all 153 patients who underwent surgery. Serum cancer antigen 19-9 of 43 KU/L (area under the curve = 0.78, 95% confidence interval: 0.70-0.87) and cyst size 30 mm (area under the curve = 0.76, 95% confidence interval: 0.60-0.93) best predicted high-grade dysplasia/malignancy. 134 patients had surgery within 2 years of starting surveillance, median (IQR) time to surgery was 5.0 (2.7-11.3) months, including 32/34 (94%) of the operable pancreatic cancer group. 127 had 2 EUS vs 26 who had > 2 EUS, median (IQR) time to surgery of 4.2 (2.2-7.5) and 22.6 (9.0-57.1) months respectively. Surgery was rare after 2 years, due to individuals declining health, as were relevant finding beyond the 2nd EUS.
CONCLUSION
Surveillance could be de-escalated after two years, providing cyst size is < 30 mm and serum cancer antigen 19-9 is < 43 KU/L. As findings are rarer after 5-years, discharge could be considered.
Core Tip: This study reports outcomes of 1191 participants with branch duct intraductal papillary mucinous neoplasm under surveillance. There are three important findings: Firstly, surgery is front loaded and the opportunity to resect pancreatic ductal adenocarcinoma appears to occur early in surveillance. Secondly, the incremental return of continued investigations, resulting in risk reducing surgery, dramatically diminishes after two years. Lastly, patients who have been in surveillance for more than two years with a serum cancer antigen 19-9 < 43 KU/L and branch duct intraductal papillary mucinous neoplasm stability at < 30 mm have low rates of malignant transformation and surveillance can be de-escalated, with discharge considered at five years.
