Who should a patient with Intraductal Papillary Mucinous Neoplasm (IPMN) be referred to?

Referral Pathway for Patients with IPMN

Patients with Intraductal Papillary Mucinous Neoplasm (IPMN) should be referred to a multidisciplinary pancreatic team led by a gastroenterologist with expertise in pancreatic diseases, with subsequent surgical consultation for high-risk lesions. 1

Initial Evaluation and Referral

• First-line referral: Gastroenterology specialist with expertise in pancreatic diseases for comprehensive evaluation, risk stratification, and management planning 1
• The gastroenterologist should coordinate:
  • Advanced imaging (MRI/MRCP as preferred modality with 96.8% sensitivity and 90.8% specificity) 1
  • Endoscopic ultrasound (EUS) with potential fine needle aspiration (FNA) for concerning lesions
  • Risk assessment based on IPMN type and features

Risk Stratification for Surgical Referral

High-Risk Features (Immediate Surgical Referral)

• Main duct IPMN (all cases)
• Mixed-type IPMN (all cases)
• Branch duct IPMN with any of:
  • Jaundice
  • Enhancing mural nodule ≥5 mm or solid component
  • Main pancreatic duct ≥10 mm
  • Cyst size ≥3 cm with worrisome features 2, 1

Worrisome Features (Consider Surgical Referral)

• Main pancreatic duct dilation 5-9.9 mm
• Cyst growth rate ≥5 mm/year
• Elevated serum CA 19-9 (>37 U/mL)
• Enhancing mural nodules <5 mm
• Cyst diameter ≥40 mm 1

Multidisciplinary Management

Gastroenterology Role

• Initial evaluation and diagnosis
• Risk assessment and classification
• EUS with potential FNA for cytology
• Surveillance of low-risk lesions
• Coordination of multidisciplinary care

Surgical Consultation

• Required for all high-risk IPMNs
• Evaluation of surgical candidacy
• Planning appropriate surgical approach based on:
  • Location of lesion
  • Patient's age and comorbidities
  • Extent of disease 1

Surveillance Protocol

• Low-risk BD-IPMN (<2 cm without worrisome features):
  • MRI/MRCP every 6-12 months by gastroenterology
• Intermediate-risk BD-IPMN (2-3 cm without worrisome features):
  • MRI/MRCP every 3-6 months by gastroenterology 1
• Post-surgical surveillance:
  • IPMN with invasive carcinoma: Follow as pancreatic cancer
  • IPMN with high-grade dysplasia: Every 6 months for 2 years, then yearly 1

Important Considerations

• Long-term surveillance is critical as IPMNs can progress even after 10 years of stability, with pancreatic cancer risk 9 times higher than the general population 3
• Patients with resected IPMNs require continued surveillance due to 5-10% risk of developing metachronous lesions 1
• Family history of pancreatic cancer does not alter the referral pathway but may influence surveillance intensity 1

Pitfalls to Avoid

• Delaying surgical referral for main duct or mixed-type IPMNs, which have higher malignancy risk
• Using CT as primary surveillance tool instead of MRI/MRCP (lower sensitivity)
• Inadequate follow-up duration, as IPMNs can progress to malignancy even after long periods of stability 1, 3
• Failure to recognize that approximately one-third of IPMNs are associated with invasive carcinoma 2

By following this structured referral pathway with appropriate risk stratification, patients with IPMNs can receive optimal care that balances the need for early intervention in high-risk cases while avoiding unnecessary surgery for low-risk lesions.