Intraductal Papillary Mucinous Neoplasms of the Pancreas: Strategic Considerations

Abstract

Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms with the potential for progression to pancreatic cancer. Recognized by the global medical community just over two decades ago, IPMN have gained great epidemiological and clinical relevance thanks to the widespread use of cross-sectional abdominal imaging, which has led to a surge in the number of incidental pancreatic cysts being diagnosed. As our understanding of this disease has improved, we now know that some IPMN have a very elevated risk of cancer and require surgical resection, while others are low-risk lesions and can be followed. The approach to IPMN must therefore strike a balance between preventing the over-utilization of surgery and the timely recognition and treatment of patients with high-risk lesions. Several clinical, radiographic, and laboratory parameters have been proposed to risk-stratify IPMN, leading to the publication of management guidelines that do not always converge in their recommendations. The goal of this clinical therapeutic review is to describe the strategic approach to IPMN at the Massachusetts General Hospital, and how our current understanding, management algorithm, and future directions have been informed by research efforts at our institution and other centers.

McCune–Albright syndrome and type 1 diabetes mellitus: a novel presentation

“…Furthermore, activating GNAS mutations in codon 201 have been reported in pancreatic tumors, specifically in intraductal papillary mucinous neoplasms (IPMNs) . Despite involving pancreatic exocrine tissue, an increased incidence of nonautoimmune DM in patients with IPMNs has been identified . One suggested reason for this is that IPMN results in obstruction of the pancreatic ductal system, with induction of low‐grade pancreatitis distal to the lesion, parenchymal atrophy, and ultimately, endocrine dysfunction .…”

“…17 Despite involving pancreatic exocrine tissue, an increased incidence of nonautoimmune DM in patients with IPMNs has been identified. [18][19][20] One suggested reason for this is that IPMN results in obstruction of the pancreatic ductal system, with induction of low-grade pancreatitis distal to the lesion, parenchymal atrophy, and ultimately, endocrine dysfunction. 21 Although the exact etiology of DM in these patients remains unclear, there appears to be an indirect relationship between increased GNAS expression with IPMN development and nonautoimmune DM.…”

Postoperative venous thromboembolism and mortality in patients with pancreatic surgery

“…VTE in NACPN is an underexplored but increasingly prevalent diagnosis. Widely available abdominal imaging with computed tomography has led to a recent surge in the number of IPMN and neuroendocrine tumors being diagnosed . Approxomately 25% of all pancreatic neoplasms surgically resected are IPMNs .…”

“…NACPN is a heterogeneous group that includes intraductal papillary mucinous neoplasms (IPMN), neuroendocrine tumors, cystic lesions, and squamous cell carcinoma of the pancreas. IPMN is a cystic neoplasm frequently involving the main pancreatic duct that has the potential for progression to malignancy . As NACPN lesions generally have favorable prognoses with surgical intervention, the impact of postoperative VTE in NACPN needs to be evaluated .…”

Surgery of Cystic Tumors of the Pancreas - Why, When, and How

“…The risk of recurrence of non-invasive IPMN is much lower when compared to invasive IPMN and is estimated around 5-9% [34]. The recurrence of non-invasive lesions is almost always non-invasive and occurs after a median of more than 4 years after resection [35]. Therefore, and because of the elevated risk of concomitant pancreatic ductal adenocarcinoma, continuing surveillance of surgically fit patients is also suggested after resection of non-invasive lesions.…”