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Neoplasm of pancreatic duct — Clinical Guidelines

Overview

Intraductal papillary mucinous neoplasms (IPMNs) are cystic lesions of the pancreatic ducts that can harbor or progress to invasive pancreatic cancer. Accurate diagnosis and risk stratification are crucial for determining appropriate management strategies.

Diagnosis

Key Imaging Features: High-resolution imaging techniques, including endoscopic ultrasound (EUS), are essential for evaluating IPMNs 3.

Worrisome Features: Presence of high-risk stigmata and worrisome features identified by the International Consensus Fukuoka Guidelines (ICG2017) aids in identifying advanced neoplasia 1.

Cytopathology: The Papanicolaou Society of Cytopathology System (PSCPC) for risk stratification is valuable, though evidence is limited 4.

Deep Learning: Emerging use of deep learning algorithms for classification using MRI shows promise in identifying neoplasia 5.

Pathological Grading: Consensus among pathologists is crucial for accurate grading and typing of IPMNs, though variability exists 6.

Management

Surgical Treatment: Recommended for high-risk IPMNs to prevent progression to invasive cancer 3.

Surveillance: Appropriate for low-risk lesions to monitor for changes 3.

Endoscopic Sampling: EUS-guided sampling is recommended as first-line for pathological diagnosis of pancreatic solid lesions 8.

On-Site Cytopathology Evaluation: Can improve diagnostic yield and reduce inadequate specimens during EUS-FNA 12.

Special Populations

No Specific Guidelines: Abstracts do not provide specific recommendations for pregnancy, pediatrics, elderly, or comorbid conditions related to IPMN management.

Key Recommendations

Utilize high-resolution imaging techniques, particularly EUS, for accurate evaluation of IPMNs (Evidence: Strong 3).

Apply the International Consensus Fukuoka Guidelines (ICG2017) to identify high-risk stigmata and worrisome features for risk stratification (Evidence: Moderate 1).

Perform EUS-guided sampling as the first-line procedure for obtaining a pathological diagnosis in pancreatic solid lesions (Evidence: Strong 8).

Consider on-site cytopathology evaluation during EUS-FNA to enhance diagnostic accuracy and reduce inadequate samples (Evidence: Moderate 12).

Tailor management between surgical intervention and surveillance based on risk stratification outcomes (Evidence: Expert opinion).

References

1 Ohno E, Balduzzi A, Hijioka S, De Pastena M, Marchegiani G, Kato H et al.. Association of high-risk stigmata and worrisome features with advanced neoplasia in intraductal papillary mucinous neoplasms (IPMN): A systematic review. Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.] 2024. link 2 Osmani AH. Spindle Cell Neoplasms of Pancreas. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 2024. link 3 Crippa S, Arcidiacono PG, De Cobelli F, Falconi M. Review of the diagnosis and management of intraductal papillary mucinous neoplasms. United European gastroenterology journal 2020. link 4 Sung S, Del Portillo A, Gonda TA, Kluger MD, Tiscornia-Wasserman PG. Update on risk stratification in the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology categories: 3-Year, prospective, single-institution experience. Cancer cytopathology 2020. link 5 Corral JE, Hussein S, Kandel P, Bolan CW, Bagci U, Wallace MB. Deep Learning to Classify Intraductal Papillary Mucinous Neoplasms Using Magnetic Resonance Imaging. Pancreas 2019. link 6 Furukawa T, Fukushima N, Itoi T, Ohike N, Mitsuhashi T, Nakagohri T et al.. A Consensus Study of the Grading and Typing of Intraductal Papillary Mucinous Neoplasms of the Pancreas. Pancreas 2019. link 7 Franses JW, Ting DT. In Reply. The oncologist 2018. link 8 Dumonceau JM, Deprez PH, Jenssen C, Iglesias-Garcia J, Larghi A, Vanbiervliet G et al.. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated January 2017. Endoscopy 2017. link 9 Williams DS. Intraductal Papillary Mucinous Neoplasm. Journal of insurance medicine (New York, N.Y.) 2016. link 10 Ezzat S. PANCREATIC INCIDENTALOMAS: IS IT NET OR NOT?. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2016. link 11 Holt BA, Hearn G, Hawes R, Tharian B, Varadarajulu S. Development and evaluation of a 3D printed endoscopic ampullectomy training model (with video). Gastrointestinal endoscopy 2015. link 12 Wani S, Mullady D, Early DS, Rastogi A, Collins B, Wang JF et al.. The clinical impact of immediate on-site cytopathology evaluation during endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: a prospective multicenter randomized controlled trial. The American journal of gastroenterology 2015. link 13 Mosteiro L, Corominas-Cishek A, Muñiz G, Pérez A, Barturen A, Casado I et al.. Ultrasound-guided endoscopic fine needle aspiration cytology in pancreatic lesions: a series of 43 cases with histologic correlation from a single institution. Analytical and quantitative cytopathology and histopathology 2014. link 14 Grodski S, Christophi C. Distal pancreatectomy with preservation of the spleen and splenic vessels. ANZ journal of surgery 2001. link 15 Chott A, Klöppel G, Buxbaum P, Heitz PU. Neuron specific enolase demonstration in the diagnosis of a solid-cystic (papillary cystic) tumour of the pancreas. Virchows Archiv. A, Pathological anatomy and histopathology 1987. link 16 Shorten SD, Hart WR, Petras RE. Microcystic adenomas (serous cystadenomas) of pancreas. A clinicopathologic investigation of eight cases with immunohistochemical and ultrastructural studies. The American journal of surgical pathology 1986. link 17 Nguyen GK. Cytology of hyperplastic endocrine cells of the pancreas in fine needle aspiration biopsy. Acta cytologica 1984. link 18 Tomita T, Friesen SR, Kimmel JR, Doull V, Pollock HG. Pancreatic polypeptide-secreting islet-cell tumors. A study of three cases. The American journal of pathology 1983. link

Neoplasm of pancreatic duct