Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Opinion
  • Published:

Controversies in the management of pancreatic IPMN

Nature Reviews Gastroenterology & Hepatology volume 8, pages 56–60 (2011)Cite this article

Subjects

Abstract

Although considerable progress has been made in our understanding of intraductal papillary mucinous neoplasm (IPMN) of the pancreas, some issues still remain to be resolved. Uncertainty exists regarding the classification of IPMNs. The necessity of the mixed-type category of IPMN and whether such lesions should be defined radiographically or histologically needs to be determined. The preoperative distinction of branch duct IPMNs from nonmucinous cysts should be further investigated so that potentially malignant lesions can be identified and management strategies guided effectively. The role and safety of cystic fluid analysis remains to be clarified in this context. With regard to the diagnosis of malignancy in branch duct IPMNs, criteria for identifying malignancy need to be re-evaluated. The presence of mural nodules is a very reliable predictor; however, controversy exists over the value of size as a reliable indicator. Criteria with increased specificity are needed, perhaps including histological subtype of lesion, to reduce the false-positive rate of the present criteria. Finally, the best modality and interval for surveillance of branch duct IPMNs requires determination because of its significance in terms of malignant transformation, development of distinct ductal adenocarcinoma and disease recurrence after resection.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Algorithm for the management of branch duct intraductal papillary mucinous neoplasms according to the 2006 international guidelines for the management of these neoplasms.3

Similar content being viewed by others

References

  1. Ohhashi, K. et al. A case of cystadenocarcinoma of the pancreas forming bilio-pancreatic fistula [Japanese]. Prog. Dig. Endosc. 17, 261–264 (1980).

    Google Scholar 

  2. Klöppel, G. et al. Histological Typing of Tumours of the Exocrine Pancreas, 2nd edn (Springer-Verlag, Berlin, 1996). [Series title World Health Organization International Histological Classification of Tumours].

    Book  Google Scholar 

  3. Tanaka, M. et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 6, 17–32 (2006).

    Article  PubMed  Google Scholar 

  4. Tanaka, M. Intraductal papillary mucinous neoplasm of the pancreas: diagnosis and treatment. Pancreas 28, 282–288 (2004).

    Article  PubMed  Google Scholar 

  5. Crippa, S. et al. Mucin-producing neoplasms of the pancreas: an analysis of distinguishing clinical and epidemiologic characteristics. Clin. Gastroenterol. Hepatol. 8, 213–219 (2010).

    Article  PubMed  Google Scholar 

  6. Lewandrowski, K. B., Southern, J. F., Pins, M. R., Compton, C. C. & Warshaw, A. L. Cyst fluid analysis in the differential diagnosis of pancreatic cysts. A comparison of pseudocysts, serous cystadenomas, mucinous cystic neoplasms, and mucinous cystadenocarcinoma. Ann. Surg. 217, 41–47 (1993).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. van der Waaij, L. A., van Dullemen, H. M. & Porte, R. J. Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointest. Endosc. 62, 383–389 (2005).

    Article  PubMed  Google Scholar 

  8. Linder, J. D., Geenen, J. E. & Catalano, M. F. Cyst fluid analysis obtained by EUS-guided FNA in the evaluation of discrete cystic neoplasms of the pancreas: a prospective single-center experience. Gastrointest. Endosc. 64, 697–702 (2006).

    Article  PubMed  Google Scholar 

  9. Attasaranya, S. et al. Endoscopic ultrasound-guided fine needle aspiration and cyst fluid analysis for pancreatic cysts. JOP 8, 553–563 (2007).

    PubMed  Google Scholar 

  10. Brugge, W. R. et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 126, 1330–1336 (2004).

    Article  PubMed  Google Scholar 

  11. Sawhney, M. S. et al. Comparison of carcinoembryonic antigen and molecular analysis in pancreatic cyst fluid. Gastrointest. Endosc. 69, 1106–1110 (2009).

    Article  PubMed  Google Scholar 

  12. Leung, K. K. et al. Pancreatic cystic neoplasm: the role of cyst morphology, cyst fluid analysis, and expectant management. Ann. Surg. Oncol. 16, 2818–2824 (2009).

    Article  PubMed  Google Scholar 

  13. Haab, B. B. et al. Glycosylation variants of mucins and CEACAMs as candidate biomarkers for the diagnosis of pancreatic cystic neoplasms. Ann. Surg. 251, 937–945 (2010).

    Article  PubMed  Google Scholar 

  14. Sperti, C., Pasquali, C., Pedrazzoli, S., Guolo, P. & Liessi, G. Expression of mucin-like carcinoma-associated antigen in the cyst fluid differentiates mucinous from nonmucinous pancreatic cysts. Am. J. Gastroenterol. 92, 672–675 (1997).

    CAS  PubMed  Google Scholar 

  15. Khalid, A. et al. Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study. Gastrointest. Endosc. 69, 1095–1102 (2009).

    Article  PubMed  Google Scholar 

  16. Alles, A. J., Warshaw, A. L., Southern, J. F., Compton, C. C. & Lewandrowski, K. B. Expression of CA 72-4 (TAG-72) in the fluid contents of pancreatic cysts. A new marker to distinguish malignant pancreatic cystic tumors from benign neoplasms and pseudocysts. Ann. Surg. 219, 131–134 (1994).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Bernard, P. et al. Intraductal papillary-mucinous tumors of the pancreas: predictive criteria of malignancy according to pathological examination of 53 cases. Arch. Surg. 137, 1274–1278 (2002).

    Article  PubMed  Google Scholar 

  18. Jang, J. Y. et al. Multicenter analysis of clinicopathologic features of intraductal papillary mucinous tumor of the pancreas: is it possible to predict the malignancy before surgery? Ann. Surg. Oncol. 12, 124–132 (2005).

    Article  PubMed  Google Scholar 

  19. Schmidt, C. M. et al. Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann. Surg. 246, 644–651 (2007).

    Article  PubMed  Google Scholar 

  20. Matsumoto, T. et al. Optimal management of the branch duct type intraductal papillary mucinous neoplasms of the pancreas. J. Clin. Gastroenterol. 36, 261–265 (2003).

    Article  PubMed  Google Scholar 

  21. Nagai, K. et al. Intraductal papillary mucinous neoplasms of the pancreas: clinicopathologic characteristics and long-term follow-up after resection. World J. Surg. 32, 271–278 (2008).

    Article  PubMed  Google Scholar 

  22. Sugiyama, M. & Atomi, Y. Intraductal papillary mucinous tumors of the pancreas: imaging studies and treatment strategies. Ann. Surg. 228, 685–691 (1998).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Rodriguez, J. R. et al. Branch-duct intraductal papillary mucinous neoplasms: observations in 145 patients who underwent resection. Gastroenterology 133, 72–79 (2007).

    Article  PubMed  Google Scholar 

  24. Sadakari, Y. et al. Cyst size indicates malignant transformation in branch duct intraductal papillary mucinous neoplasm of the pancreas without mural nodules. Pancreas 39, 232–236 (2010).

    Article  PubMed  Google Scholar 

  25. Tang, R. S. et al. Evaluation of the guidelines for management of pancreatic branch-duct intraductal papillary mucinous neoplasm. Clin. Gastroenterol. Hepatol. 6, 815–819 (2008).

    Article  PubMed  Google Scholar 

  26. Salvia, R. et al. Branch-duct intraductal papillary mucinous neoplasms of the pancreas: to operate or not to operate? Gut 56, 1086–1090 (2007).

    Article  PubMed  Google Scholar 

  27. Nakamura, A. et al. New classification of pancreatic intraductal papillary-mucinous tumour by mucin expression: its relationship with potential for malignancy. J. Pathol. 197, 201–210 (2002).

    Article  PubMed  Google Scholar 

  28. Furukawa, T. et al. Classification of types of intraductal papillary-mucinous neoplasm of the pancreas: a consensus study. Virchows Arch. 447, 794–799 (2005).

    Article  PubMed  Google Scholar 

  29. Ban, S. et al. Intraductal papillary mucinous neoplasm (IPMN) of the pancreas: its histopathologic difference between 2 major types. Am. J. Surg. Pathol. 30, 1561–1569 (2006).

    Article  PubMed  Google Scholar 

  30. Ishida, M. et al. Characteristic clinicopathological features of the types of intraductal papillary-mucinous neoplasms of the pancreas. Pancreas 35, 348–352 (2007).

    Article  PubMed  Google Scholar 

  31. Sadakari, Y. et al. Invasive carcinoma derived from the nonintestinal type intraductal papillary mucinous neoplasm of the pancreas has a poorer prognosis than that derived from the intestinal type. Surgery 147, 812–817 (2010).

    Article  PubMed  Google Scholar 

  32. Hibi, Y. et al. Pancreatic juice cytology and subclassification of intraductal papillary mucinous neoplasms of the pancreas. Pancreas 34, 197–204 (2007).

    Article  PubMed  Google Scholar 

  33. Ohuchida, K. et al. Quantitative analysis of MUC1 and MUC5AC mRNA in pancreatic juice for preoperative diagnosis of pancreatic cancer. Int. J. Cancer 118, 405–411 (2006).

    Article  CAS  PubMed  Google Scholar 

  34. Kobayashi, G. et al. Mode of progression of intraductal papillary-mucinous tumor of the pancreas: analysis of patients with follow-up by EUS. J. Gastroenterol. 40, 744–751 (2005).

    Article  PubMed  Google Scholar 

  35. Nagai, E., Ueki, T., Chijiiwa, K., Tanaka, M. & Tsuneyoshi, M. Intraductal papillary mucinous neoplasms of the pancreas associated with so-called “mucinous ductal ectasia”. Histochemical and immunohistochemical analysis of 29 cases. Am. J. Surg. Pathol. 19, 576–589 (1995).

    Article  CAS  PubMed  Google Scholar 

  36. Tanno, S. et al. Natural history of branch duct intraductal papillary-mucinous neoplasms of the pancreas without mural nodules: long-term follow-up results. Gut 57, 339–343 (2008).

    Article  CAS  PubMed  Google Scholar 

  37. Schnelldorfer, T. et al. Experience with 208 resections for intraductal papillary mucinous neoplasm of the pancreas. Arch. Surg. 143, 639–646 (2008).

    Article  PubMed  Google Scholar 

  38. Tanaka, M. et al. Segmental balloon cytology for preoperative localization of in situ pancreatic cancer. Gastrointest. Endosc. 46, 447–449 (1997).

    Article  CAS  PubMed  Google Scholar 

  39. Yamaguchi, K. et al. Pancreatic cyst as a sentinel of in situ carcinoma of the pancreas. Report of two cases. Int. J. Pancreatol. 22, 227–231 (1997).

    CAS  PubMed  Google Scholar 

  40. Yamaguchi, K., Ohuchida, J., Ohtsuka, T., Nakano, K. & Tanaka, M. Intraductal papillary-mucinous tumor of the pancreas concomitant with ductal carcinoma of the pancreas. Pancreatology 2, 484–490 (2002).

    Article  PubMed  Google Scholar 

  41. Uehara, H. et al. Development of ductal carcinoma of the pancreas during follow-up of branch duct intraductal papillary mucinous neoplasm of the pancreas. Gut 57, 1561–1565 (2008).

    Article  CAS  PubMed  Google Scholar 

  42. Ingkakul, T. et al. Predictors of the presence of concomitant invasive ductal carcinoma in intraductal papillary mucinous neoplasm of the pancreas. Ann. Surg. 251, 70–75 (2010).

    Article  PubMed  Google Scholar 

  43. Kanno, A. et al. Prediction of invasive carcinoma in branch type intraductal papillary mucinous neoplasms of the pancreas. J. Gastroenterol. 45, 952–959 (2010).

    Article  PubMed  Google Scholar 

  44. Tanno, S. et al. Incidence of synchronous and metachronous pancreatic carcinoma in 168 patients with branch duct intraductal papillary mucinous neoplasm. Pancreatology 10, 173–178 (2010).

    Article  PubMed  Google Scholar 

  45. Ikeuchi, N. et al. Prognosis of cancer withbranch duct type IPMN of the pancreas. World J. Gastroenterol. 16, 1890–1895 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  46. Eguchi, H. et al. Role of intraoperative cytology combined with histology in detecting continuous and skip type intraductal cancer existence for intraductal papillary mucinous carcinoma of the pancreas. Cancer 107, 2567–2575 (2006).

    Article  PubMed  Google Scholar 

  47. Shi, C. et al. Increased prevalence of precursor lesions in familial pancreatic cancer patients. Clin. Cancer Res. 15, 7737–7743 (2009).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Poley, J. W. et al. The yield of first-time endoscopic ultrasonography in screening individuals at a high risk of developing pancreatic cancer. Am. J. Gastroenterol. 104, 2175–2181 (2009).

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 812-8582, Fukuoka, Japan

    Masao Tanaka

Authors
  1. Masao Tanaka
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

The author declares no competing financial interests.

Supplementary information

Supplementary Table

(DOC 106 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tanaka, M. Controversies in the management of pancreatic IPMN. Nat Rev Gastroenterol Hepatol 8, 56–60 (2011). https://doi.org/10.1038/nrgastro.2010.193

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2010.193

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing