Pancreatic Intraductal Papillary Mucinous Neoplasm - Where Is the Challenge?

Abstract

Cystic lesions of the pancreas are increasingly recognized due to the widespread use of modern abdominal imaging technologies. The majority of these lesions display pseudocysts and mucinous cystic neoplasms. In contrast to pseudocysts, it is well established that mucinous cystic neoplasms of the pancreas exhibit a significant potential for malignant transformation over time. Among mucinous cystic tumors, the most frequently observed entity is pancreatic intraductal papillary mucinous neoplasm (IPMN). IPMNs are characterized by cystic dilation of pancreatic ducts and the production of mucus and by an adenoma-carcinoma sequence eventually culminating in invasive carcinoma in some patients. Due to the high risk of harboring malignancy, there is international consensus that IPMNs with involvement of the main pancreatic duct should be recommended for surgical resection. To date, the indication for surgery of branch-duct IPMNs is controversially discussed because of the overall lower risk of malignant transformation compared to main-duct IPMNs. Particularly for small and asymptomatic side-branch IPMNs, the indication for surgical resection remains challenging. In addition to the international consensus guidelines, a number of potential preoperative features predicting malignant transformation have been discussed recently. Moreover, novel surgical pancreatic parenchyma-sparing techniques such as enucleations or segmental pancreatic resections have been reported in order to treat IPMNs. The present article aims to demonstrate the current scientific knowledge in this field and to highlight the current controversy.

National trends in resection of cystic lesions of the pancreas

“…11,12 Despite these guidelines, the optimal management of CLP remains controversial. 4,6,[13][14][15][16][17] Given this controversy, the influence of advancing technology and changing recommendations on management of CLP in the real world is unclear. Previous literature examining current practice is limited to the experiences of high volume, singleinstitution centers.…”

DNA Cytometry for Differentiation Between Low- and Mediumgrade Dysplasia in Intraductal Papillary Mucinous Neoplasms

“…However, some authors still recommend a generous indication for pancreatic resection in patients with IPMN. Their argument is based on the assumption that a subset of even BD-IPMNs are at high risk of malignant transformation and these lessors should therefore be removed by resection (19)(20)(21). Another clinical point which is debated controversially is how to proceed in patients after pancreatic head resection for MD-IPMN with the additional manifestation of BD-IPMN in the pancreatic remnant.…”

Intraductal papillary mucinous neoplasm of the pancreas: Cytomorphology, imaging, molecular profile, and prognosis

“…The management of IPMN is complicated and requires a multidisciplinary approach. The most important goal in the surgical resection of pancreatic lesions is to prevent malignant transformation 53,62 . Approximately 30% of IPMN cases demonstrate invasive adenocarcinoma on surgical resection 35 .…”