What to do next - IPMN Johns Hoplins University

- accurated diagnostic
- be referred to Dr. Dilip Prekh or Dr. Robert Selby
- referral though: 
       GI doctor Beblawi or Stubin
       Dr. Rao
       Family Doctor
       Through USC doctor Tylor or Dr. Starnes
- it is on the branch duct
- over 30mm
- is associated with main duct dilatation
- therefore according to the Management Guidelines it is possible a Whipple is required.

How are main duct type intraductal papillary mucinous neoplasms treated?


As many as 70% of main duct type intraductal papillary mucinous neoplasms harbor high-grade dysplasia (the step right before an invasive cancer develops) or an invasive cancer. Main duct type IPMNs are therefore significant lesions, and, in general, most main duct intraductal papillary mucinous neoplasms should be surgically resected if the patient can safely tolerate surgery (see reference 5). It is important that this surgery is carried out by surgeons with ample experience with pancreatic surgery (see reference 5).
Intraductal papillary mucinous neoplasms in the tail of the pancreas are usually resected using a procedure called a “distal pancreatectomy.” Surgeons at Johns Hopkins, including Drs. Martin Makary and Barish Edil, perform some distal pancreatectomies using minimally invasive procedures (laproscopic pancreatectomy). IPMNs in the head or uncinate process of the pancreas are usually resected using a Whipple procedure (pancreaticoduodenectomy). A total pancreatectomy (removal of the entire gland) may be indicated in the rare instances in which the intraductal papillary mucinous neoplasm involves the entire length of the pancreas.

How are branch duct type intraductal papillary mucinous neoplasms treated?

The management of branch duct IPMNs is more complicated than is the management of main duct type IPMNs. It is likely that many, if not most, branch duct IPMNs are harmless and the risks associated with surgery may outweigh the benefits of resecting small branch duct IPMNs. International consensus guidelines for the treatment of branch duct IPMNs were established in 2006. These guidelines try to balance the risks and benefits of treating patients with a branch duct type IPMN (see reference 5).

The guidelines suggest that asymptomatic patients with a branch duct IPMN that a) is less than 3 cm in size, b) not associated with dilatation (ballooning) of the main pancreatic duct, and c) does not contain a solid mass (mural nodule), can be followed safely without surgery. By contrast, the guidelines recommend the surgical resection of branch duct type IPMNs that cause symptoms, that are larger than 3 cm, that contain a mass (mural nodule), OR which are associated with dilatation of the main pancreatic duct. These guidelines have been supported by a number of recent papers (see reference 6-10). Unfortunately, some resected branch duct IPMNs that are less than 3 cm have been found to have cancer, so the guidelines do not perfectly distinguish patients with benign or malignant disease. Additionally, the size cutoff of 3 cm will either be further validated or changed based upon ongoing studies. Depending on the circumstances, sometimes branch duct IPMNs less than 3 cm are resected because of their rate of growth and or preferences of the patient and surgeon. As was true for main duct IPMNs, intraductal papillary mucinous neoplasms should be surgically resected only if the patient can safely tolerate surgery.

Branch duct IPMNs that are not surgically resected should be monitored radiographically to make sure that they do not grow. Growth of a branch duct IPMN or the development of a mass (mural nodule) may be an indication to surgically remove the IPMN.

Several imaging technologies can be used to monitor branch duct IPMNs for growth. These include computerized tomography (CT), endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP). In general, smaller branch duct IPMNs less than 1 cm in diameter can be followed with an annual exam. Patients with larger IPMNs should have an examination more frequently, some as frequently as every three months. If you have an IPMN, you should consult with a physician to determine the the most suitable methodology to follow your IPMN as well as the frequency of follow-up.

If I had an IPMN surgically removed, am I cured?

While patients who undergo resection of an IPMN not associated with an invasive cancer are “cured” of that lesion, IPMNs can be multiple and these patients remain at risk for developing a second lesion (see references 11,12). Your doctor may therefore recommend routine follow-up visits. Should you develop a second IPMN, management will depend on it’s characteristics.