Intraductal papillary mucinous neoplasm of the pancreas (IPMN): Evaluation and management
- Sunil G Sheth, MD
Sunil G Sheth, MD
- Assistant Professor of Medicine
- Harvard Medical School
- Douglas A Howell, MD, FASGE, FACG
Douglas A Howell, MD, FASGE, FACG
- Section Editor — EUS/ERCP
- Assistant Clinical Professor of Medicine, Tufts Medical School Director,
- Pancreaticobiliary Center Director, Advanced Interventional Endoscopy Fellowship, Maine Medical Center
- Tara S Kent, MD, FACS
Tara S Kent, MD, FACS
- Assistant Professor of Surgery
- Harvard Medical School
- Beth Israel Deaconess Medical Center
Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are potentially malignant intraductal epithelial neoplasms that are grossly visible (typically >10 mm) and are composed of mucin-producing columnar cells. The lesions show papillary proliferation, cyst formation, and varying degrees of cellular atypia [1,2].
IPMNs may involve the main pancreatic duct, the branch ducts, or both. Whereas patients with branch-duct lesions are at lower risk for developing malignancy (approximately 20 percent at 10 years), patients with IPMNs involving the main duct are at high risk (approximately 70 percent). As a result, these lesions need to be accurately diagnosed and characterized so that appropriate treatment can be recommended. (See "Intraductal papillary mucinous neoplasm of the pancreas (IPMN): Pathophysiology and clinical manifestations", section on 'Classification' and "Intraductal papillary mucinous neoplasm of the pancreas (IPMN): Pathophysiology and clinical manifestations", section on 'Pancreatic malignancy'.)
This topic will review the evaluation and management of IPMNs. The pathophysiology and clinical manifestations of IPMNs and an overview of the diagnostic approach to pancreatic cystic neoplasms are discussed separately. (See "Intraductal papillary mucinous neoplasm of the pancreas (IPMN): Pathophysiology and clinical manifestations" and "Classification of pancreatic cysts" and "Pancreatic cystic neoplasms: Clinical manifestations, diagnosis, and management".)
The approach to the diagnosis of pancreatic cystic neoplasms typically starts with cross-sectional imaging (magnetic resonance imaging with magnetic resonance cholangiopancreatography or computed tomography). Additional evaluation with endoscopic ultrasound with fine-needle aspiration may be needed to confirm a diagnosis or to assess for malignant features. The diagnostic approach to pancreatic cystic neoplasms is discussed separately. (See "Pancreatic cystic neoplasms: Clinical manifestations, diagnosis, and management".)
EVALUATION FOR MALIGNANCY
The evaluation of a patient with an intraductal papillary mucinous neoplasm (IPMN) aims to determine if the patient has or is at high-risk of developing a malignancy. Resection is typically recommended for IPMNs with high-grade dysplasia (carcinoma in situ), IPMNs that have progressed to invasive carcinoma (also referred to as invasive IPMN or malignant IPMN), and IPMNs with features concerning for malignancy or that are at high risk for developing malignancy. IPMNs not meeting these criteria are typically followed with surveillance imaging. (See 'Management' below.)
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- EVALUATION FOR MALIGNANCY
- Cross-sectional imaging
- Indications for additional evaluation
- Endoscopic ultrasound with fine-needle aspiration
- - Sonographic findings
- - Pancreatic and cyst fluid analysis
- Other tests
- High-grade dysplasia or invasive cancer
- - Surgical therapy
- - Adjuvant therapy
- IPMN without confirmed malignancy or high-grade dysplasia
- - Main-duct IPMN
- - Branch-duct IPMN
- - Combined main-duct and branch-duct IPMN
- Surveillance following surgery
- Surveillance for extrapancreatic malignancies
- Patients who do not undergo surgery
- Prognosis following surgery
- SUMMARY AND RECOMMENDATIONS