Thirty years of experience with intraductal papillary mucinous neoplasm of the pancreas: from discovery to international consensus

Abstract

Background: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is characterized by intraductal papillary proliferation of mucin-producing epithelial cells that exhibit various degrees of dysplasia. IPMN is classified as the main duct type (MD-IPMN) and the branch duct type (BD-IPMN) according to the location of involvement, and into four histological subtypes (gastric, intestinal, pancreatobiliary, and oncocytic) according to the histomorphological and immunohistochemical characteristics. Mucin core protein expression correlates with the biological behavior and prognosis of the tumor. DNA analysis has shown that IPMN is associated with a number of gene mutations, but the roles of many of these mutations require further investigation. Most patients with MD-IPMN undergo tumor resection. Patients with BD-IPMN who do not undergo resection may develop malignant change, and concomitant separate pancreatic cancer occurs in 2-10% of patients with IPMN. Patients with a strong family history may develop multiple BD-IPMNs as well as concomitant pancreatic cancer. Malignant changes are relatively easy to detect, especially by endoscopic ultrasonography (EUS), but the optimal surveillance protocol is currently unclear.

Key messages: The 2012 guidelines for the management of IPMN recommend that patients with 'high-risk stigmata' (obstructive jaundice, enhanced solid component, and main pancreatic duct size ≥10 mm) should undergo resection. Patients with 'worrisome features' (cyst size ≥3 cm, thickened enhanced cyst walls, non-enhanced mural nodules, main pancreatic duct size 5-9 mm, abrupt change in main pancreatic duct caliber with distal pancreatic atrophy, lymphadenopathy, and clinical acute pancreatitis) should be evaluated by EUS. EUS is a more sensitive test than computed tomography or magnetic resonance imaging for the early detection of malignancy.

Conclusions: Most patients with MD-IPMN should undergo tumor resection. Patients with BD-IPMN who do not undergo resection should undergo careful surveillance including EUS for the early detection of malignant change and separate pancreatic cancer.