From the Guidelines
Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas should be considered as having malignant potential and managed accordingly, with surgical resection recommended for high-risk lesions and surveillance for lower-risk lesions. These cystic lesions arise from the pancreatic ductal epithelium and produce mucin, existing on a spectrum from benign to malignant 1. The risk of malignancy varies based on several factors, including:
- Location: main duct IPMNs carry higher risk than branch duct IPMNs
- Size: lesions >3 cm pose greater concern
- Presence of worrisome features on imaging, such as:
- Mural nodules
- Dilated main pancreatic duct
- Rapid growth According to the European evidence-based guidelines on pancreatic cystic neoplasms 1, jaundice, the presence of an enhancing mural nodule (≥5 mm) or a solid component, positive cytology, or a MPD measuring ≥10 mm are highly predictive of malignancy and should be evaluated in all patients fit for surgery. Management typically involves either surgical resection for high-risk IPMNs or surveillance with regular imaging (MRI or endoscopic ultrasound) for lower-risk lesions 1. The surveillance interval depends on the size and characteristics of the IPMN, typically ranging from 6 months to 2 years. Any patient with an IPMN diagnosis should be evaluated by a multidisciplinary team including gastroenterologists, surgeons, and radiologists to determine the appropriate management strategy based on their specific risk factors and overall health status 1.
From the Research
Characteristics of Intraductal Papillary Mucinous Neoplasms
- Intraductal Papillary Mucinous Neoplasms (IPMNs) are considered premalignant lesions, characterized by the papillary growth of the ductal epithelium with rich mucin production 2.
- IPMNs are divided into main duct type (MD-IPMN), branch duct type (BD-IPMN), and mixed type (MT-IPMN) based on the involvement of the pancreatic duct system 2, 3.
Malignant Potential
- MD-IPMNs present a higher risk of malignant progression than BD-IPMNs 2.
- The management of BD-IPMNs is still controversial and depends on several cyst and patient features, including tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, and the presence of symptoms 3, 4.
- IPMNs with invasive carcinoma have clinical outcomes that approach those of conventional pancreatic ductal adenocarcinoma 5.
Diagnosis and Management
- Magnetic Resonance Imaging (MRI) and endoscopic ultrasound (EUS) are useful diagnostic techniques for IPMNs 2, 3.
- Surgery is recommended for MD-IPMN, while the management of BD-IPMN involves surgery or surveillance depending on various factors, including patient age and comorbidities 3, 4.
- Current guidelines for the diagnosis and management of IPMNs include the Sendai International Association of Pancreatology guidelines, American Gastroenterological Association guidelines, and European evidence-based guidelines 3, 6.
Benign vs. Malignant
- While IPMNs are considered premalignant lesions, not all IPMNs are malignant, and the natural history of IPMNs is still not completely understood 6.
- The choice between non-operative and surgical management depends on the distinction between benign and invasive IPMN forms, assessment of malignancy risk, patient's wellness, and preferences 2.