From the Guidelines
Operate on Intraductal Papillary Mucinous Neoplasms (IPMNs) if they meet the following criteria:
- Size greater than 4 cm
- Presence of mural nodules, especially those ≥5 mm
- Main pancreatic duct (MPD) dilation greater than or equal to 10 mm
- Cyst growth rate greater than or equal to 5 mm per year
- Presence of symptoms such as abdominal pain, jaundice, or weight loss
- Cytology or biopsy results indicating high-grade dysplasia or invasive cancer In patients with a high-risk stigmata, such as an enhancing mural nodule, surgery should be considered regardless of symptoms 1. For patients with a low-risk IPMN, surveillance with imaging every 6-12 months is recommended.
Key Indications for Surgery
- Absolute indications:
- Positive cytology for malignancy or high-grade dysplasia
- Solid mass
- Jaundice (tumor-related)
- Enhancing mural nodule (≥5 mm)
- MPD dilatation ≥10 mm
- Relative indications:
- Growth rate ≥5 mm/year
- Increased levels of serum CA 19.9 (>37 U/mL)
- MPD dilatation between 5 and 9.9 mm
- Cyst diameter ≥40 mm
- New onset of diabetes mellitus
- Acute pancreatitis (caused by IPMN)
- Enhancing mural nodule (<5 mm) These criteria are based on the European evidence-based guidelines on pancreatic cystic neoplasms 1, which emphasize the importance of considering multiple risk factors when evaluating IPMNs for surgical resection.
Evaluation and Management
Each cyst should be evaluated individually for the presence of features associated with malignancy, and cysts without concerning features can undergo surveillance 1. In cases of multifocal IPMN, each lesion should be evaluated for surgical resection as a single entity according to the criteria reported, and a tailored surgical approach can be planned 1. The main goal of surgery is to resect IPMNs when high-grade dysplasia is present, and before patients develop pancreatic cancer, with a cut-off point of MPD dilatation >5 mm being reasonable for considering surgical resection 1.
From the Research
Criteria for Surgical Intervention in IPMN
The criteria for surgical intervention in Intraductal Papillary Mucinous Neoplasm (IPMN) are based on several factors, including:
- Size of the cyst: A cyst size of 3 cm or larger is considered a high-risk feature for branch duct IPMN (BD-IPMN) 2, 3, 4
- Presence of worrisome features: Such as mural nodules, thickened cyst walls, main pancreatic duct dilatation, and high-grade dysplasia in cytology 2, 3, 5, 4
- Presence of high-risk stigmata: Such as obstructive jaundice, a history of pancreatitis, and a high CA 19-9 serum level 3, 5
- Type of IPMN: Main duct IPMN (MD-IPMN) carries a higher risk of malignancy and is recommended for surgical resection regardless of symptoms 3, 5, 6
- Patient's age and comorbidities: Should be taken into consideration when deciding on surgical intervention 5
Specific Guidelines
- The 2012 Sendai Criteria recommend surgical resection for patients with MD-IPMN or mixed-type IPMN, and for patients with BD-IPMN who have a cyst size of 3 cm or larger, or who have worrisome features or high-risk stigmata 2, 5
- The revised international consensus Fukuoka guidelines (2012 and 2017) recommend surgical resection for patients with MD-IPMN or mixed-type IPMN, and for patients with BD-IPMN who have a cyst size of 3 cm or larger, or who have worrisome features or high-risk stigmata 5
- The European evidence-based guidelines (2018) recommend surgical resection for patients with MD-IPMN or mixed-type IPMN, and for patients with BD-IPMN who have a cyst size of 3 cm or larger, or who have worrisome features or high-risk stigmata 5
Cyst Size and Surgical Intervention
- A study found that two-thirds of high-grade/invasive BD-IPMN were less than 3 cm in size, suggesting that a cyst size of 2 cm may be a more appropriate cutoff for surgical intervention 2
- Another study found that an MPD diameter of 7.2 mm or greater was an independent prognostic factor for malignant neoplasms in MD-IPMN or mixed-type IPMN, and recommended lowering the accepted criteria for MPD diameter when selecting patients for resection versus surveillance 6
- A retrospective analysis of patients with BD-IPMN found that most cysts were indolent, but some rapidly grew and progressed, and recommended individualized surveillance protocols based on initial cyst size and rate of growth 4