Maino C, Inchingolo R. Letter to the Editor: De-escalation of branch duct intraductal papillary mucinous neoplasms surveillance. World J Radiol 2026; 18(8): 123527 [DOI: 10.4329/wjr.123527]
Corresponding Author of This Article
Riccardo Inchingolo, MD, Professor, Interventional Radiology Unit, “F Miulli” Regional General Hospital, via di Santeramo, Acquaviva delle Fonti 70021, Italy. riccardoin@hotmail.it
Research Domain of This Article
Medicine, Research & Experimental
Article-Type of This Article
letter
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
Share the Article
Maino C, Inchingolo R. Letter to the Editor: De-escalation of branch duct intraductal papillary mucinous neoplasms surveillance. World J Radiol 2026; 18(8): 123527 [DOI: 10.4329/wjr.123527]
World J Radiol. Aug 28, 2026; 18(8): 123527 Published online Aug 28, 2026. doi: 10.4329/wjr.123527
Letter to the Editor: De-escalation of branch duct intraductal papillary mucinous neoplasms surveillance
Cesare Maino, Riccardo Inchingolo
Cesare Maino, Department of Radiology, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy
Riccardo Inchingolo, Interventional Radiology Unit, “F Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
Riccardo Inchingolo, Department of Medicine and Surgery, LUM University, Casamassima 70010, Italy
Author contributions: Maino C and Inchingolo R equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
AI contribution statement: The authors declare that no AI tools were used in the development or writing of this manuscript and take full responsibility for its integrity, accuracy, and originality.
Conflict-of-interest statement: All the authors are aware of the content of the manuscript and have no conflict of interest.
Corresponding author: Riccardo Inchingolo, MD, Professor, Interventional Radiology Unit, “F Miulli” Regional General Hospital, via di Santeramo, Acquaviva delle Fonti 70021, Italy. riccardoin@hotmail.it
Received: May 25, 2026 Revised: July 14, 2026 Accepted: July 28, 2026 Published online: August 28, 2026 Processing time: 99 Days and 6 Hours
Abstract
We comment on the recent observational study by Hopley et al reporting outcomes of 17-year branch duct intraductal papillary mucinous neoplasm surveillance and proposing de-escalation criteria based on cyst stability below 30 mm and serum carbohydrate antigen 19-9 below 43 KU/L after two years of follow-up. While acknowledging the clinical value of these findings, we raise several radiological concerns that deserve further consideration before these criteria can be safely implemented across institutions. Specifically, we discuss the absence of standardised imaging protocols and field strength reporting, the well-documented inter-observer variability in magnetic resonance imaging (MRI)-based cyst size measurement, the evolving radiological definitions of worrisome and high-risk features across guidelines updates, the complementary roles of MRI/ magnetic resonance cholangiopancreatography and endoscopic ultrasound, and the lack of a specified imaging algorithm for the de-escalated surveillance phase. These considerations are intended to help refine the safe implementation of the proposed de-escalation strategy rather than to argue against it.
Core Tip: The de-escalation criteria proposed by Hopley et al for branch duct intraductal papillary mucinous neoplasm surveillance are clinically pragmatic and broadly supported by the available evidence. However, their radiological methodology requires greater transparency. Inter-observer variability in magnetic resonance imaging cyst size measurement, the absence of standardised imaging protocols, evolving definitions of worrisome and high-risk features, and the lack of a specified post-de-escalation imaging algorithm represent important unresolved issues. A dedicated pancreatic radiologist within the multidisciplinary team and the adoption of structured reporting standards are essential prerequisites for the safe translation of these findings into routine clinical practice. Addressing these points is meant to strengthen, not undermine, the de-escalation strategy proposed by the authors.
