From the Guidelines
Pancreatic head IPMNs should be managed based on their risk features, with surgical resection recommended for those with high-risk characteristics, such as main pancreatic duct involvement or dilation ≥10 mm, presence of an enhancing mural nodule ≥5 mm, or positive cytology for malignancy/high-grade dysplasia, as outlined in the European evidence-based guidelines on pancreatic cystic neoplasms 1.
Key Considerations
- The management of pancreatic head IPMNs involves careful evaluation of their risk features to determine the need for surgical resection or surveillance.
- High-risk features that warrant surgery include main pancreatic duct involvement or dilation ≥10 mm, presence of an enhancing mural nodule ≥5 mm, or positive cytology for malignancy/high-grade dysplasia.
- Relative indications for surgery include growth rate ≥5 mm/year, increased levels of serum CA 19.9 (>37 U/mL), main pancreatic duct dilatation between 5 and 9.9 mm, cyst diameter ≥40 mm, new-onset of diabetes mellitus, acute pancreatitis (caused by IPMN), and enhancing mural nodules <5 mm.
Surveillance and Monitoring
- Surveillance with regular imaging is recommended for lesions without high-risk features, with MRI/MRCP every 3-6 months for the first year, then annually if stable.
- Endoscopic ultrasound with fine needle aspiration may be performed to assess concerning features and obtain fluid for cytology and tumor markers like CEA.
- Patients should be counseled about symptoms requiring immediate attention, including new-onset jaundice, significant weight loss, or worsening abdominal pain, as these may indicate malignant transformation.
Surgical Approach
- The oncologic resection including standard lymphadenectomy is the preferred procedure for IPMN with an absolute indication for resection, as recommended by the European evidence-based guidelines on pancreatic cystic neoplasms 1.
- In cases of multifocal IPMN, each lesion should be evaluated individually for the presence of features associated with malignancy, and a tailored surgical approach can be planned based on the appraisal of each lesion.
From the Research
Pancreatic Head IPMN
- Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are characterized by ductal dilation, intraductal papillary growth, and thick mucus secretion 2
- The reported incidence of malignancy varies from 57% to 92% in the main duct-IPMN (MD-IPMN) and from 6% to 46% in the branch duct-IPMN (BD-IPMN) 2
- Features of high-risk malignant lesions include obstructive jaundice in a patient with a cystic lesion in the pancreatic head, mass lesion of >30 mm, enhanced solid component, and main pancreatic duct (MPD) of size ≥10 mm 2
Diagnosis and Management
- Magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) are primary investigations in diagnosing and following up on IPMN patients 2
- Resection is recommended for most MD-IPMN, mixed variant, and symptomatic BD-IPMN 2, 3
- The 5-year survival of patients after surgical resection for noninvasive IPMN is reported to be at 77-100%, while for those with invasive carcinoma, it is significantly lower at 27-60% 2
- Management of BD-IPMN involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, and presence of symptoms 4
Guidelines and Recommendations
- The Sendai International Association of Pancreatology guidelines (2006) recommend surgical resection for all suspected branch-duct IPMN greater than 3 cm irrespective of symptoms, and those less than 3 cm with worrisome features 5
- The revised international consensus Fukuoka guidelines (2012,2017) and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas (2018) provide recommendations for the diagnosis and management of IPMNs 4
- The American Gastroenterological Association guidelines and the Verona Evidence-Based Meeting 2020 also provide guidance on the management of IPMNs 4