Review articleInternational consensus guidelines 2012 for the management of IPMN and MCN of the pancreas
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
References (200)
- et al.
International Association of Pancreatology. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas
Pancreatology
(2006) - et al.
CT vs MRCP: optimal classification of IPMN type and extent
J Gastrointest Surg
(2008) - et al.
Branch-duct intraductal papillary mucinous neoplasms: observations in 145 patients who underwent resection
Gastroenterology
(2007) - et al.
Managing incidental findings on abdominal CT: White paper of the ACR incidental findings committee
J Am Col Radiol
(2010) - et al.
Natural course and outcome of cystic lesions in the pancreas
Am J Surg
(2009) - et al.
Pancreatic mucinous cystic neoplasm defined by ovarian stroma: demographics, clinical features, and prevalence of cancer
Clin Gastroenterol Hepatol
(2004) - et al.
The role of pancreatic cyst fluid molecular analysis in predicting cyst pathology
Clin Gastroenterol Hepatol
(2005) - et al.
Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study
Gastrointest Endosc
(2009) - et al.
Multidisciplinary approach to diagnosis and management of intraductal papillary mucinous neoplasms of the pancreas
Clin Gastroenterol Hepatol
(2009) - et al.
Risk of malignancy in resected cystic tumors of the pancreas < or =3 cm in size: is it safe to observe asymptomatic patients? A multi-institutional report
J Gastrointest Surg
(2008)
Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study
Gastroenterology
Fernández-del Castillo C. Incidental pancreatic cysts: do we really know what we are watching?
Pancreatology
Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis
Gastrointest Endosc
Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions
Am J Gastroenterol
Intraductal papillary mucinous tumors of the pancreas: the preoperative value of cytologic and histopathologic diagnosis
Gastrointest Endosc
Cytological and cyst fluid analysis of small (≤3 cm) branch duct intraductal papillary mucinous neoplasms adds value to patient management decisions
Pancreatology
Pancreatic juice cytology in IPMN of the pancreas
Pancreatology
Fate of the remnant pancreas after resection of noninvasive intraductal papillary mucinous neoplasm
J Am Coll Surg
Study of recurrence after surgical resection of intraductal papillary mucinous neoplasm of the pancreas
Gastroenterology
Surgical management of intraductal papillary mucinous neoplasm (IPMN) of the pancreas
J Gastrointest Surg
Total pancreatectomy: indications, different timing, and perioperative and long-term outcomes
Surgery
Patient outcomes after total pancreatectomy: a single centre contemporary experience
HPB (Oxford)
Cyst growth rate predicts malignancy in patients with branch duct intraductal papillary mucinous neoplasms
Clin Gastroenterol Hepatol
Natural history of intraductal papillary mucinous tumors of the pancreas: actuarial risk of malignancy
Clin Gastroenterol Hepatol
Pancreatic-duct-lavage cytology in candidates for surgical resection of branch-duct intraductal papillary mucinous neoplasm of the pancreas: should the international consensus guidelines be revised?
Gastrointest Endosc
Morphologic changes in branch duct intraductal papillary mucinous neoplasms of the pancreas: a midterm follow-up study
Clin Gastroenterol Hepatol
Asymptomatic pancreatic cystic neoplasms: maximizing survival and quality of life using Markov-based clinical nomograms
Gastroenterology
Management of intraductal papillary-mucinous neoplasm of the pancreas: treatment strategy based on morphologic classification
J Clin Gastroenterol
Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology
Ann Surg
Intraductal papillary mucinous neoplasms of the pancreas: clinicopathologic characteristics and long-term follow-up after resection
World J Surg
Clinicopathologic analysis of surgically proven intraductal papillary mucinous neoplasms of the pancreas in SNUH: a 15-year experience at a single academic institution
Langenbecks Arch Surg
Predictors of malignant intraductal papillary mucinous neoplasm of the pancreas
J Clin Gastroenterol
Clinical fate of branch duct and mixed forms of intraductal papillary mucinous neoplasia of the pancreas
J Gastroenterol Hepatol
MDCT of intraductal papillary mucinous neoplasm of the pancreas: evaluation of features predictive of invasive carcinoma
Am J Roentgenol
Mucin-producing neoplasms of the pancreas: an analysis of distinguishing clinical and epidemiologic characteristics
Clin Gastroenterol Hepatol
Predictive factors for malignancy in intraductal papillary-mucinous tumours of the pancreas
Br J Surg
Intraductal papillary mucinous neoplasms of the pancreas: an updated experience
Ann Surg
Main-duct intraductal papillary mucinous neoplasms of the pancreas
Ann Surg
Cystic neoplasm of the pancreas: a Japanese multiinstitutional study of intraductal papillary mucinous tumor and mucinous cystic tumor
Pancreas
Long-term follow up results of intraductal papillary mucinous tumors of pancreas
J Gastroenterol Hepatol
Experience with 208 resections for intraductal papillary mucinous neoplasm of the pancreas
Arch Surg
Intraductal papillary mucinous neoplasm of the pancreas: clinical characteristics and treatment outcomes of 118 consecutive patients from a single center
J Hepatobiliary Pancreat Surg
Intraductal papillary mucinous neoplasms of the pancreas: differentiation of malignant and benign tumors by endoscopic ultrasonography findings of mural nodules
Ann Surg
Preoperative evaluation of invasive and noninvasive intraductal papillary-mucinous neoplasms of the pancreas: clinical, radiological, and pathological analysis of 123 cases
Pancreas
Treatment guidelines for branch duct type intraductal papillary mucinous neoplasms of the pancreas: when can we operate or observe?
Ann Surg Oncol
Cyst size indicates malignant transformation in branch duct intraductal papillary mucinous neoplasm of the pancreas without mural nodules
Pancreas
Prediction of invasive carcinoma in branch type intraductal papillary mucinous neoplasms of the pancreas
J Gastroenterol
Intraductal papillary mucinous neoplasm of the pancreas (IPMN): clinico-pathological correlations and surgical indications
World J Surg Oncol
Intraductal papillary mucinous neoplasms of the pancreas: a plea for prospective differentiation between main-duct and side-branch tumors
Ann Surg Oncol
Intraductal neoplasm of the pancreas
Cited by (1843)
Early Cancerous Lesions of the Pancreas and Ampulla: Current Concepts and Challenges
2024, Gastroenterology Clinics of North AmericaPremalignant Lesions in the Kidney Transplant Candidate
2024, Seminars in Nephrology