Current Guidelines for the Management of Branch Duct Intraductal Papillary Mucinous Neoplasms

The management of pancreatic cystic neoplasms has been constantly evolving and changing over the past 2 decades [1-3]. This is mainly due to the rapid advancement of knowledge in this field resulting in particular: 1) the improved understanding of the natural history and biological behavior of the different pathological entities which comprise pancreatic cystic neoplasms and 2) more accurate preoperative diagnosis of these neoplasms as a result of a better understanding of their individual morphological characteristics on imaging and the introduction of newer diagnostic modalities such as endoscopic ultrasonography with fine needle aspirate (EUS-FNA) [2-4]. In general, the management approach has trended from that of aggressive surgical resection [5] to a more selective approach whereby most cystic neoplasms are now managed via surveillance [1,6-8]. Since the landmark paper by Compagno and Oertel [9]; the general consensus was that all mucinous neoplasms were potentially malignant or malignant and should be surgically resected whereas serous cystic neoplasms were benign and could be managed conservatively [2,10,11]. Subsequently, investigators recognized that mucinous neoplasms were actually composed of 2 distinct pathological entities i.e. mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs) [10,12,13]. More recently, it was recognized that IPMNs could be classified into branch-duct (BD), main-duct (MD) and mixed-duct types (MT) [14,15]. BD-IPMNs were found to be associated with a less aggressive biological behavior when compared to MD/MT-IPMN and many investigators have since demonstrated that selected BD-IPMNs could be managed conservatively [1,6,8,14-16].