Pancreatology xxx (2017) 1e16 Contents lists available at ScienceDirect Pancreatology journal homepage: www.elsevier.com/locate/pan Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas * Masao Tanaka a, , Carlos Fernandez-del Castillo b, Terumi Kamisawa c, Jin Young Jang d, Philippe Levy e, Takao Ohtsuka f, Roberto Salvia g, Yasuhiro Shimizu h, Minoru Tada i, Christopher L. Wolfgang j a Department of Surgery, Shimonoseki City Hospital, Shimonoseki, Japan b Pancreas and Biliary Surgery Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA c Department of Gastroenterology, Komagome Metropolitan Hospital, Tokyo, Japan d Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea e Pole^ des Maladies de l'Appareil Digestif, Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, Clichy Cedex, France f Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan g Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy h Dept. of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan i Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan j Cameron Division of Surgical Oncology and The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA article info abstract Article history: The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, Received 1 July 2017 the indications for resection of branch duct IPMN have changed from early resection to more deliberate Received in revised form observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline 12 July 2017 proposed by the American Gastroenterological Association in 2015 restricted indications for surgery Accepted 12 July 2017 more stringently and recommended physicians to stop surveillance if no significant change had occurred Available online xxx in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non- malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of Keywords: International guidelines surveillance, has generated substantial debate. Based on a consensus symposium held during the Intraductal papillary mucinous neoplasm meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group Pancreatic cancer has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, sur- Surveillance veillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required. © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved. Introduction is unclear what proportion of these incidentally-discovered pancreatic cysts represents IPMN, surgical series have shown that Increased detection of pancreatic cysts due to improvement and most of the larger ones indeed are branch duct IPMN (BD-IPMN). expanded use of computed tomography (CT) and magnetic reso- Early on, the malignant potential of this entity led to surgical nance imaging (MRI) has led to a surge in interest on intraductal resection of most pancreatic cysts, and although in very few centers papillary mucinous neoplasms (IPMN) of the pancreas. Although it this continues to be the case, following the publication of the In- ternational Association of Pancreatology (IAP) Sendai guidelines in 2006 [1] and the subsequent Fukuoka guidelines in 2012 [2], a more conservative attitude is followed. As a consequence, currently the * Corresponding author. Shimonoseki City Hospital, 1-13-1 Koyo-cho, Shimono- seki 750-8520, Japan. majority of newly-diagnosed BD-IPMNs do not undergo surgery. E-mail address: [email protected] (M. Tanaka). However, it is also recognized that a proportion of these evolve over http://dx.doi.org/10.1016/j.pan.2017.07.007 1424-3903/© 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved. Please cite this article in press as: Tanaka M, et al., Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.07.007 Downloaded for AdminAigo AdminAigo ([email protected]) at Italian Association of Gastroenterology (AIGO) from ClinicalKey.com by Elsevier on August 07, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. 2 M. Tanaka et al. / Pancreatology xxx (2017) 1e16 time and can become malignant, and also, that patients with IPMN IPMN, and mixed type, based on imaging studies and/or histology are at an increased risk of developing conventional pancreatic (Fig. 1). MD-IPMN is characterized by segmental or diffuse dilation ductal adenocarcinoma (PDAC) elsewhere in the gland. Because of of the main pancreatic duct (MPD) of >5 mm without other causes this, surveillance is carried out on most of these patients. Deter- of obstruction. A low threshold for MPD dilation (5 mm) was mining which patients are at a higher risk of harboring or devel- adopted in the previous guidelines, increasing the sensitivity for oping invasive carcinoma or high-grade dysplasia (HGD) and radiologic diagnosis of MD-IPMN without losing specificity [4e8]. therefore should undergo resection, and how to follow the However, MPD dilation of 5e9 mm is not an immediate surgical remaining ones is the matter of extensive studies throughout the indication but considered one of “worrisome features” mentioned world, as well as a source of controversy. In 2015, the American later, while an MPD diameter of 10 mm is one of the “high-risk Gastroenterological Association (AGA) published another new stigmata”. Pancreatic cysts of >5 mm in diameter that communi- guideline that has different and more conservative criteria for in- cate with the MPD should be considered as BD-IPMN, with pseu- dications of resection and recommends stopping surveillance after docyst being in the differential diagnosis for patients with a prior 5 years if no significant change is observed or if a cyst is resected history of pancreatitis. Mixed type patients meet the criteria for and found to be benign [3]. Not unexpectedly, the AGA guideline both MD-IPMN and BD-IPMN. has generated intense debate in the field of pancreatology. There are considerable differences in the proportions of each During the 20th meeting of the International Association of type and the risks of invasive carcinoma and HGD [1e19]. The Pancreatology (IAP 2016) in Sendai, Japan, a symposium focused on differences are partly caused by variation in the type definitions, surveillance of BD-IPMN was held. The symposium also addressed since the correlation between the histologic and radiologic criteria the significance of mural nodule size to predict invasive carcinoma is only around 70% [7,20]. For example, a BD-IPMN in the head of and HGD in BD-IPMN. The present revision is aimed particularly at the pancreas can cause MPD dilation throughout the pancreas these controversial items. The other parts of the Fukuoka guidelines because of ductal hypertension related to mucin, protein plugs, and are left unchanged or updated by adding recent literature. focal pancreatitis, and on the other hand there can be main duct Mucinous cystic neoplasm (MCN) has been excluded from the involvement by neoplasm without significant duct dilation [21]. revised guidelines, given that there are very few remaining points However, since the classification is important for clinicians to plan of controversy regarding this entity. the management, it should be based on the preoperative radiologic All the authors contributed equally to the guidelines. M. Tanaka, images, and the pathological classification can be specified a C. Fernandez-del Castillo and T. Kamisawa chaired this working posteriori. group of the IAP and played a pivotal role in the preparation of the manuscript. The remaining authors are listed in alphabetical order. Definition of malignant IPMN Classification IPMNs exhibit a spectrum of neoplastic transformation, not only within each category but also often within the same case, ranging Criteria for distinction of BD-IPMN and main duct IPMN (MD-IPMN) from innocuous lesions that used to be called “hyperplasia” or adenoma (currently classified as “low-grade dysplasia”) to invasive IPMNs can be classified into three types, i.e., MD-IPMN, BD- carcinomas [22,23]. The definition of “malignancy” has been Fig. 1. Magnetic resonance cholangiopancreatograms demonstrating the three morphological types of intraductal papillary mucinous neoplasm. a. Main duct type with a mural nodule (arrow). b. Branch duct type. c. Mixed type. Please cite this article in press as: Tanaka M, et al., Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.07.007 Downloaded for AdminAigo AdminAigo ([email protected]) at Italian Association of Gastroenterology