Letter to the Editor: De-escalation of branch duct intraductal papillary mucinous neoplasms surveillance.

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.