From the Guidelines
Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas should be managed based on risk stratification, with high-risk IPMNs requiring surgical resection and low-risk IPMNs being monitored with surveillance imaging, as recommended by the most recent guidelines 1.
Management of IPMNs
The management of IPMNs depends on the risk of malignant transformation, which varies by subtype.
- Main duct IPMNs have a higher risk of malignancy, with a risk of around 62% 1.
- Branch duct IPMNs have a lower risk of malignancy, but still require careful monitoring.
Risk Stratification
Risk stratification is based on imaging features, including:
- Cyst size
- Main duct involvement
- Mural nodules
- Dilated main pancreatic duct
- Concerning symptoms
Surveillance and Surgery
- Low-risk IPMNs can be monitored with surveillance imaging, usually MRI or endoscopic ultrasound every 6-12 months initially, then annually if stable.
- High-risk IPMNs generally require surgical resection, typically through pancreaticoduodenectomy (Whipple procedure) for head lesions or distal pancreatectomy for body/tail lesions.
Follow-up
All patients with IPMNs require long-term follow-up due to the risk of progression and development of separate pancreatic lesions over time.
Guidelines
The European evidence-based guidelines on pancreatic cystic neoplasms recommend a conservative approach for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule, and relative and absolute indications for surgery based on the risk of malignant transformation 1.
Recent Recommendations
The most recent guidelines recommend resection for main duct IPMNs and for branch duct IPMNs with high-risk features, such as an enhancing mural nodule >5 mm or a cyst diameter ≥40 mm 1.
Patient Counseling
Patients should be counseled about potential symptoms of progression, including new-onset diabetes, jaundice, weight loss, or abdominal pain.
Malignant Transformation
The risk of malignant transformation varies by subtype, with main duct IPMNs carrying a higher risk compared to branch duct IPMNs 1.
From the Research
Definition and Classification of Intraductal Papillary Mucinous Neoplasms (IPMNs)
- Intraductal papillary mucinous neoplasms (IPMNs) represent approximately 1% of all pancreatic neoplasms and 25% of cystic neoplasms 2.
- IPMNs are divided into three types: main duct-IPMN (MD-IPMN), branch duct-IPMN (BD-IPMN), and mixed type-IPMN 2.
Diagnosis of IPMNs
- Magnetic resonance imaging (MRI) is the most useful diagnostic tool for most IPMNs 2, 3.
- Endoscopic ultrasound (EUS) is also a primary investigation in diagnosing and following up on IPMN patients 3.
- The role of pancreatoscopy and the analysis of aspirated cystic fluid for cytology and DNA analysis is still to be established 3.
Management of IPMNs
- Management depends on the type and radiological features of IPMNs 2.
- Surgery is recommended for MD-IPMN 2, 3.
- For BD-IPMN, management involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, the presence of symptoms, and CA 19.9 serum level 2.
- The patient's age and comorbidities should also be taken into consideration 2.
Guidelines for IPMNs
- There are different guidelines regarding the diagnosis and management of IPMNs, including the Sendai International Association of Pancreatology guidelines, American Gastroenterological Association guidelines, revised international consensus Fukuoka guidelines, and European evidence-based guidelines 2.
- The Verona Evidence-Based Meeting 2020 was also presented and discussed 2.
Prognosis and Survival
- 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% 3.
- The follow-up of IPMN patients could vary from 6 months to 1 year and would depend on the risk stratification for invasive malignancy and the pathology of the resected specimen 3.
Current Research and Future Directions
- Currently, there is no reliable method of discerning between low-risk and high-risk IPMNs 4.
- Operative resection is utilized in an effort to resect those lesions with high-grade dysplasia (HGD) prior to the development of invasive disease 4.
- Current research is evolving in multiple directions, including the identification of reliable markers for predicting malignant transformation of IPMN and the development of preoperative models able to discern HGD in IPMN patients 4.