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  • Review Article
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Intraductal papillary mucinous neoplasms of the pancreas—a surgical disease

Nature Reviews Gastroenterology & Hepatology volume 9, pages 253–259 (2012)Cite this article

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Abstract

Cystic pancreatic neoplasms are increasingly recognized, with intraductal papillary mucinous neoplasms of the pancreas (IPMNs) being the most frequently observed type. IPMNs are characterized by mucin production and epithelial growth within the pancreatic ducts, and are generally differentiated according to location: main pancreatic duct, its major side branches, or both (mixed type). IPMNs vary from benign to malignant and are considered precursor lesions of pancreatic adenocarcinoma. However, the exact time to neoplastic transformation and whether all IPMNs progress to malignant tumors is unclear. Surgical resection is warranted for all main-duct and mixed-type IPMNs (they harbor a high risk of malignancy of ∼70%). By contrast, branch-duct IPMNs progress to cancer in only ∼30% of cases. Thus, according to current guidelines (Sendai criteria), asymptomatic side-branch IPMNs <3 cm in size without suspicious radiological features (such as size progression) can be treated conservatively. Lately, even this approach has become controversial, owing to a number of Sendai-negative IPMNs showing malignant transformation. Although most IPMNs should be resected by standard oncological procedures (including lymphadenectomy), small Sendai-negative IPMNs can be treated with limited resections. This Review summarizes current knowledge of the treatment of IPMNs, with a particular focus on surgical approaches to this disease.

Key Points

  • According to modern thin-slice abdominal imaging or endoscopic ultrasonography, intraductal papillary mucinous neoplasms of the pancreas (IPMNs) can be distinguished into three types: main duct, branch duct, or mixed

  • Currently, all three IPMN types are considered precursors to invasive adenocarcinoma of the pancreas with varying risks of malignant transformation

  • Owing to their high rates of malignancy, main-duct IPMNs and mixed-type IPMNs should be oncologically resected whenever the patient is an adequate candidate for surgery

  • According to current treatment guidelines (Sendai criteria), asymptomatic branch-duct IPMNs <3 cm in size without suspicious radiological features can be treated conservatively

  • Surgery for small branch-duct IPMNs remains controversial; malignant transformation even in small branch-duct IPMNs without suspicious features is increasingly reported, in which case, the Sendai criteria should be re-evaluated

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Figure 1: Surgical treatment of main-duct IPMN.
Figure 2: Surgical treatment of a branch-duct IPMN.

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  1. Department of General and Visceral Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, 69120, Germany

    Jens Werner, Stefan Fritz & Markus W. Büchler

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All authors researched data for the article, and reviewed and edited the manuscript before submission. J. Werner and B. W. Büchler made equal contributions to discussion of content, and J. Werner and S. Fritz wrote the article.

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Werner, J., Fritz, S. & Büchler, M. Intraductal papillary mucinous neoplasms of the pancreas—a surgical disease. Nat Rev Gastroenterol Hepatol 9, 253–259 (2012). https://doi.org/10.1038/nrgastro.2012.31

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