Elsevier

Pancreatology

Volume 12, Issue 3, May–June 2012, Pages 183-197
Pancreatology

Review article
International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas

https://doi.org/10.1016/j.pan.2012.04.004Get rights and content

Abstract

The international consensus guidelines for management of intraductal papillary mucinous neoplasm and mucinous cystic neoplasm of the pancreas established in 2006 have increased awareness and improved the management of these entities. During the subsequent 5 years, a considerable amount of information has been added to the literature. Based on a consensus symposium held during the 14th meeting of the International Association of Pancreatology in Fukuoka, Japan, in 2010, the working group has generated new guidelines. Since the levels of evidence for all items addressed in these guidelines are low, being 4 or 5, we still have to designate them “consensus”, rather than “evidence-based”, guidelines. To simplify the entire guidelines, we have adopted a statement format that differs from the 2006 guidelines, although the headings are similar to the previous guidelines, i.e., classification, investigation, indications for and methods of resection and other treatments, histological aspects, and methods of follow-up. The present guidelines include recent information and recommendations based on our current understanding, and highlight issues that remain controversial and areas where further research is required.

Introduction

Since the publication of the international consensus guidelines for management of intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN) of the pancreas in 2006 [1], these entities have been drawing increasing attention. As a consequence, a considerable amount of information has been added to the literature during the subsequent 5 years. In particular, new information has been obtained regarding endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) of the cyst contents, the indications for resection of branch duct IPMN (BD-IPMN) have changed from rather early resection to more deliberate observation, and some reports have documented the occurrence of concomitant pancreatic ductal adenocarcinoma (PDAC) in patients with BD-IPMN. All this new knowledge makes an update of the guidelines imperative. During the 14th meeting of the International Association of Pancreatology (IAP) held in Fukuoka, Japan, in 2010, we arranged a symposium where recent progress in preoperative diagnosis and management was presented. All the speakers in the symposium, including eight initial members and six new members of the working group, have generated new guidelines based on an elaborate list of items to be addressed. Since the levels of evidence for all items addressed in these guidelines are low, being 4 or 5, we still have to designate them “consensus”, rather than “evidence-based”, guidelines. We have made a series of recommendations for all items in Table 1. However, since the grades of the recommendations are low, we have avoided repetition of grade C in almost all of the items.

All the authors contributed equally to the guidelines. M. Tanaka chaired and C. Fernandez-del Castillo co-chaired this working group of the IAP, and these two authors played a major role in the preparation of the manuscript. The remaining authors are listed in alphabetical order.

Section snippets

Criteria for distinction of BD-IPMN and main duct IPMN (MD-IPMN)

IPMNs can be classified into three types, i.e., MD-IPMN, BD-IPMN, and mixed type, based on imaging studies and/or the histology (Fig. 1) [1]. MD-IPMN is characterized by segmental or diffuse dilation of the main pancreatic duct (MPD) of >5 mm without other causes of obstruction. According to recent reports, a low threshold for MPD dilation (5 mm) can be adopted, which increases the sensitivity for radiologic diagnosis of MD-IPMN without losing specificity [2], [3], [4], [5], [6], [7], [8], [9],

Work-up for cystic lesions of the pancreas

Cystic lesions are increasingly being recognized by imaging studies, and the frequency of pancreatic cyst detection by MRI (19.9% [28]) is higher than by CT (1.2% [29] and 2.6% [30]). A cyst with invasive carcinoma is uncommon in patients with an asymptomatic pancreatic cyst, particularly one of <10 mm in size, and therefore no further work-up may be needed at that point, although follow-up is still recommended [31], [32]. For cysts greater than 1 cm, pancreatic protocol CT or

Indications for resection of MD-IPMN

According to published series of ≥50 cases (Table 2), the mean frequency of malignancy in MD-IPMN is 61.6% (range, 36–100%) and the mean frequency of invasive IPMN is 43.1% (range, 11–81%) [2], [3], [4], [5], [6], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Considering these high incidences of malignant/invasive lesions and the low 5-year survival rates (31–54%) [3], [4], [5], [12], [13], [14], surgical resection is strongly recommended for all surgically fit patients. However, MPD

Methods of pancreatectomy for invasive and non-invasive MCNs and IPMNs

Although preoperative and intraoperative assessment of the dysplasia grades of MCNs and IPMNs can be difficult, US, CT, MRI, and EUS will identify most tumors with a significant invasive component [104]. In such patients, pancreatoduodenectomy, left pancreatectomy, or total pancreatectomy according to the site and extent of the disease with lymph node dissection remains the standard treatment [105], [106]. Limited resections or even focal non-anatomic resections (excision, enucleation,

Types of invasive carcinoma of malignant IPMN

It is now well established that the type of invasive carcinoma, colloid versus tubular, has major prognostic implications and should therefore be part of the reporting of IPMNs [140], [141], [142], [143]. Colloid carcinomas are characterized by “intestinal” differentiation, evidenced by diffuse and specific expression of CDX2 and MUC2, and have a better prognosis than tubular carcinomas [142]. It is conceivable that these histological differences may drive the use of distinct adjuvant

Follow-up of non-resected IPMN

The decision to follow an IPMN is a matter of clinical judgment based on the patient age, family history, symptoms, comorbidities, perceived pancreatic cancer risk, and patient preference. There is little evidence in the literature to guide the frequency and type of surveillance for IPMNs.

At baseline, history/physical examination and MRI/MRCP (or pancreatic protocol CT) surveillance, and EUS when the presence of a mural nodule is suspected, are recommended. If the expertise is available,

Conclusions

Our understanding of IPMNs of the pancreas continues to evolve. Although many new publications are available since the first guidelines were published 6 years ago, the vast majority of the data are retrospective and uncontrolled, and long-term follow-up has been limited, meaning that our knowledge of the natural history of this disease is still incomplete. In this revision, the criterion for characterizing MD-IPMN has been lowered to MPD dilation of >5 mm, without losing specificity for

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