Portuguese Pancreatic Club Perspective on the Surveillance Strategy for Intraductal Papillary Mucinous Neoplasms: When and How to Do It?

BACKGROUND

Pancreatic cysts are increasingly recognized nowadays, with estimated prevalence that may reach 50% in aging populations. Most cysts are of benign origin, and only a small proportion has malignant potential, including intraductal papillary mucinous neoplasms (IPMNs). Since pancreatic cysts are common, the most important goal was to identify the small percentage at high risk of developing malignancy. The increased detection and awareness of IPMNs led to the development of several consensus and guidelines, with only the most recent being evidence-based.

SUMMARY

Current consensus guidelines recommend risk assessment to prioritize high-risk patients for malignancy. In the Fukuoka/Kyoto guidelines, the predictive factors of malignancy are called "high-risk stigmata" and "worrisome features." Conversely, other guidelines consider the terms "absolute indication" and "relative indication" for surgery, as well as criteria for referral to multidisciplinary groups. In case of non-resected IPMNs, criteria for surveillance depend on cyst size, with magnetic resonance imaging pointed as the most consensual modality for follow-up, although the recommended imaging modality varies among consensus. In some situations, namely, older age, frailty/comorbidities, or stability of cyst size, follow-up discontinuation may be considered.

KEY MESSAGE

Performance of surveillance guidelines is measured by the ability to identify patients with high-grade dysplasia/early stage-invasive cancer. Guidelines with more intense protocols will likely lead to fewer missed cancers, balanced by a greater number of benign resections. Multidisciplinary management preferably in reference centers is of utmost importance given the indolent and complex nature of the disease, and a global evidence-based guideline that combines the several guidelines' groups is mandatory to uniformize care. In this review, the Portuguese Pancreatic Club summarizes the risk assessment and surveillance strategy of a patient with an IPMN according to different guidelines in order to create an updated perspective and to guide clinical care.