Background/Aims: Branch-type intraductal papillary mucinous neoplasms (BT-IPMNs) are a subset of non-inflammatory mucinous lesions of the pancreas. Selected BT-IPMNs can be managed conservatively by surveillance because of their lower malignant potential. This review aims to update the reader on advances in our knowledge of BT-IPMNs since the consensus guidelines published in 2006. Methods: A Pubmed search for BT-IPMNs was undertaken and relevant papers were reviewed. Results: Due to the relative scarcity of this condition, still little is known about the natural history, the best method of surveillance or the surgical and non-surgical options. Conclusion: A national database of BT-IPMNs would enable a large enough cohort of patients to be followed up and valid conclusions drawn regarding the best method of treatment or surveillance.

1.
Kloppel G, Solcia E, Longnecker DS, Capella C, Sobin LH: World Health Organisation International Typing of Tumours of the Exocrine Pancreas. Berlin, Springer, 1999, pp 1–61.
2.
Sohn TA, Yeo CJ, Cameron JL: Intraductal papillary mucinous neoplasms of the pancreas: an increasingly recognised clinicopathological entity. Ann Surg 2001;234:313–322.
3.
Ohhashi K, Murakami F, Maruyama M: Four cases of mucous secreting pancreas cancer. Prog Dig Endosc 1982;203:348–351.
4.
Tanaka M, Chari S, Adsay V, Fernandez-del Castillo C, Falconi M, Shimizu M, Yamaguchi K, Yamao K, Matsuno S: International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 2006;6:17–32.
5.
Bassi C, Sarr MG, Lillemoe KD, Reber HA: Natural history of intraductal papillary mucinous neoplasms (IPMN): current evidence and implications for management. J Gastrointest Surg 2008;12:645–650.
6.
Gill KR, Pelaez-Luna M, Keaveny A, Woodward TA, Wallace MB, Chari ST, Smyrk TC, Takahashi N, Clain JE, Levy MJ, Pearson RK, Petersen BT, Topazian MD, Vege SS, Kendrick SS, Farnell MB, Raimondo M: Branch duct intraductal papillary mucinous neoplasm of the pancreas in solid organ transplant recipients. Am J Gastroenterol 2009;104:1256–1261.
7.
Huang ES, Gazelle GS, Hur C: Consensus guidelines in the management of branch duct intraductal papillary mucinous neoplasm: a cost-effectiveness analysis. Dig Dis Sci 2010;55:852–860.
8.
Tang RS, Weinberg B, Dawson DW, Reber HA, Hines OJ, Tomlinson JS, Chaudhari V, Raman S, Farrell JJ: Evaluation of the guidelines for management of pancreatic branch-duct intraductal papillary mucinous neoplasm. Clin Gastroenterol Hepatol 2008;6:815–819.
9.
Rautou PE, Levy P, Vullierme MP: Morphologic changes in branch duct papillary mucinous neoplasms of the pancreas; a midterm follow-up study. Clin Gastroenterol Hepatol 2008;6:807–814.
10.
Jang JY, Kim SW, Lee SE, Yang SH, Lee KU, Lee YJ, Kim SC, Han DJ, Choi DW, Choi SH, Cho BH, Yoon DS, Lee WJ, Lee HE, Kang GH, Lee J: Treatment guidelines for branch duct type intraductal papillary neoplasms of the pancreas: when can we operate or observe? Ann Surg Oncol 2008;15:199–205.
11.
Woo SM, Ryu JK, Lee SH, Yoon WJ, Kim YT, Yoon YB: Branch duct intraductal papillary mucinous neoplasms in a retrospective series of 190 patients. Br J Surg 2009;96:405–411.
12.
Uehara H, Nakaizumi A, Ishikawa O, Lishi H, Tatsumi K, Takakura R, Ishida T, Takano Y, Tanka S, Takenaka A: Development of ductal carcinoma of the pancreas during follow-up of branch duct intraductal papillary mucinous neoplasm of the pancreas. Gut 2008;57:1561–1565.
13.
Yamaguchi K, Ohuchida J, Ohtsuka T: Intraductal papillary-mucinous tumor of the pancreas concomitant with ductal carcinoma of the pancreas. Pancreatology 2002;2:484–490.
14.
Tanno S, Nakano Y, Sugiyama Y, Nakamura K, Sasajima J, Koizumi K, Yamazaki M, Nishikawa T, Mizukami Y, Yanagawa N, Fujii T, Obara T, Okumura T, Kohgo Y: Incidence of synchronous and metachronous pancreatic carcinoma in 168 patients with branch ductal intraductal papillary mucinous neoplasm. Pancreatology 2010;10:173–178.
15.
Tada M, Kawabe T, Arizumi M: Pancreatic cancer in patients with pancreatic cystic lesions; a prospective study in 197 patients. Clin Gastroenterol Hepatol 2006;4:1265–1270.
16.
Tada M, Omata M, Ohto M: Ras gene mutations in intraductal papillary mucinous neoplasms of the pancreas: analysis in five cases.Cancer 1991;67:634–637.
17.
Mizuno O, Kawamoto H, Yamamoto N, Horiguchi S, Tsutsumi K, Fujii M, Kato H, Hirao K, Kuriahara T, Ishida E, Ogawa T, Okada H, Yamamoto K: Single-pattern convergence of K-ras mutation correlates with surgical indication of intraductal papillary mucinous neoplasms. Pancreas 2010;39:617–621.
18.
Jang JY, Park YC, Song YS, Lee SE, Hwang DW, Lim CS, Lee HE, Kim WH, Kim SW: Increased K-ras mutation and expression of S100A4 and MUC2 protein in the malignant intraductal papillary mucinous tumor of the pancreas. J Hepatobiliary Pancreat Surg 2009;16:668–674.
19.
Luttges J, Zamboni G, Longnecker DS: The immunohistochemical mucin expression pattern distinguishes different types of intraductal papillary mucinous neoplasms of the pancreas and determines their relationship to mucinous non-cystic carcinoma and ductal adenocarcinoma. Am J Surg Pathol 2001;25:942–948.
20.
Ikeuchi N, Itoi T, Sofuni A, Itokawa F, Tsuchiya T, Kuriahara T, Ishil K, Tsuji S, Umeda J, Moriayasu F, Tshuchida A, Kasuya K: Prognosis of cancer with branch duct type IPMN of the pancreas. World J Gastroenterol 2010;16:1890–1895.
21.
Sugiyama M, Atomi Y: Extrapancreatic neoplasms occur with unusual frequency in patients with intraductal papillary mucinous tumors of the pancreas. Am J Gastroenterol 1999;94:470–473.
22.
Eguchi H, Ishikawa O, Ohhashi K, Tomimaru Y, Sasakai Y, Yamada T, Tsukuma H, Nakaizumi A, Imaoka S: Patients with pancreatic intraductal papillary mucinous neoplasms are at high risk of colorectal cancer development. Surgery 2006;139:749–754.
23.
Reid-Lombardo KM, Mathis KL, Wood CM, Harmsen WS, Sarr MG: Frequency of extrapancreatic neoplasms in intraductal papillary mucinous neoplasm of the pancreas: implications for management. Ann Surg 2010;251:64–69.
24.
Lee SY, Choi DW, Jang KT, Lee KT, Choi SH, Heo JS, Lee JK, Paik SW, Rhee JC: High expression of intestinal-type mucin (MUC2) in intraductal papillary mucinous neoplasms coexisting with extrapancreatic gastrointestinal cancers. Pancreas 2006;32:186–189.
25.
Correa-Gallego C, Ferrone CR, Thayer SP, Wargo JA, Warshaw AL, Fernández-Del Castillo C: Incidental pancreatic cysts: do we really know what we are watching? Pancreatology 2010;10:144–150.
26.
Bournet B, Kirzin S, Carrere N, Portier G, Otal P, Selves J, Musso C, Suc B, Moreau J, Fourtanier G, Pradier B, Lazaorthes F, Excourrou J, Buscail L: Clinical fate of branch duct and mixed forms of intraductal papillary mucinous neoplasia of the pancreas. J Gastroenterol Hepatol 2009;24:1211–1217.
27.
Salvia R, Partelli C, Crippa S, Landoni L, Capelli P, Manfredi R, Bassi C, Pederzoli P: Intraductal papillary mucinous neoplasms of the pancreas with multifocal involvement of branch ducts. Am J Surg 2009;198:709–714.
28.
Hirano S, Kondo S, Tanaka E, Shichinohe T, Suzuki O, Shimizu M, Itoh T: Role of CT in detecting malignancy during follow-up of patients with branch-type IPMN of the pancreas. Hepatogastroenterol 2009;56:515–518.
29.
Kang MJ, Jang JY, Kim SJ, Lee KB, Ryu JK, Kim YT, Yoon YB, Kim SW: Cyst growth rate predicts malignancy in patients with branch duct intraductal papillary mucinous neoplasms. Clin Gastroenterol Hepatol 2011;9:87–93.
30.
Gupta R, Mortele KJ, Tatli S, Girshamn J, Glickman JN, Levy AD, Ertuk SM, Hefess CS, Banks PA, Silverman SG: Pancreatic intraductal papillary mucinous neoplasms: role of CT in predicting pathologic subtypes. AJR Am J Roentgenol 2008;191:1458–1464.
31.
Kawamoto S, Lawler LP, Horton KM, Eng J, Hruban RH, Fishman EK: MDCT of intraductal papillary mucinous neoplasm of the pancreas: evaluation of features predictive of invasive carcinoma. AJR Am J Roentgenol 2006;186:687–695.
32.
Sahani DV, Kadavigere R, Blake M, Fernandez-del Castillo C, Lauwyeres GY, Han PF: Intraductal papillary mucinous neoplasm of pancreas: multi-detector row CT with 2D reformations: correlation with MRCP. Radiology 2006;238:560–568.
33.
Waters JA, Schmidt CM, Pinchot JW, White PB, Cummings OW, Pitt HA, Sandraseragan K, Akishik F, Howard TJ, Nakeeb A, Zyromski NJ, Lillemoe KD: CT vs MRCP: optimum classification of IPMN type and extent. J Gastrointest Surg 2008;12:101–109.
34.
Yoon LS, Catalano OA, Fritz S, Ferrone CR, Hahn PF, Sahani DV: Another dimension in magnetic resonance cholangiopancreatography for the evaluation of intraductal papillary mucinous neoplasm of the pancreas. J Comput Assist Tomogr 2009;33:363–368.
35.
Kobayashi G, Fujita N, Noda Y, Ito K, Horaguchi J, Takasawa O, Akaishi S, Tsuchiya T, Kobari M: Mode of progression of intraductal papillary mucinous tumour of the pancreas: analysis of patients with follow-up by EUS. J Gastroenterol 2005;40:744–751.
36.
Schoedel KE, Finkelstein SD, Ohori NP: K-Ras and micro satellite marker analysis of fine-needle aspirates from intraductal papillary mucinous neoplasms of the pancreas. Diagn Cytopathol 2006;34:605–608.
37.
Maire F, Voitot H, Aubert A, Palazzo L, O’Toole D, Couvelard A, Levy P, Vidaud M, Sauvanet A, Ruszniewski P, Hammel P: Intraductal papillary mucinous neoplasms of the pancreas: performance of pancreatic fluid analysis for positive diagnosis and the prediction of malignancy. Am J Gastroenterol 2008;103:2871–2873.
38.
Belletrutti PJ, DiMaio CJ, Nagula S, Schattner MA, Markowitz AJ, Allen PJ, et al: Pancreatic cyst fluid CEA concentration >1000 ng/ml is not an indicator of malignancy. Gastroenterology 2010;138:S549.
39.
Nagula S, Kennedy TJ, Schattner MA, Brennan MF, Gerdes H, Markowitz AJ, et al: Performance characteristics of cyst fluid CEA analysis for the diagnosis of mucinous cysts of the pancreas. Gastroenterology 2009;136:A148.
40.
Pais SA, Attasaranya S, Leblanc JK, Sherman S, Schmidt CM, DeWitt J: Role of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms: correlation with surgical histopathology. Clin Gastroenterol Hepatol 2007;5:489–495.
41.
Correa-Gallego C, Warshaw AL, Fernandez-del Castillo C: Fluid CEA in IPMNs: a useful test or the flip of a coin? Am J Gastroenterol 2009;104:796–797.
42.
Maker AV, Lee LS, Rat CP, Clancy TE, Swanson RS: Cytology from pancreatic cysts has marginal utility in surgical decision-making. Ann Surg Oncol 2008;15:3187–3192.
43.
Hong HS, Yun M, Cho A, Choi JY, Kim MJ, Kim KW, Choi YJ, Lee JD: The utility of F-18 FDG PET/CT in the evaluation of pancreatic intraductal mucinous neoplasm. Clin Nucl Med 2010;35:766–779.
44.
Sperti C, Bissoli S, Pasquali C, Frison L, Liessi G, Chierchetti F, Pedrazzoli S: 18-fluorodexoyglucose positron emission tomography enhances computed tomography diagnosis of malignant intraductal papillary mucinous neoplasms of the pancreas. Ann Surg 2007;246:932–939.
45.
Tomimaru Y, Takeda Y, Tatsumi M, Kim T, Kobayashi S, Marubashi S, Eguchi H: Utility of 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography in differential diagnosis of benign and malignant intraductal papillary mucinous neoplasm of the pancreas. Oncol Rep 2010;24:613–620.
46.
Sata N, Kurihara K, Koizumi M, Tsukahara M, Yoshizawa K, Nagai H: CT virtual pancreatoscopy: a new method for diagnosing intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Abdom Imaging 2006:31:321–326.
47.
Wasif N, Bentrem DJ, Farrell JJ, Ko CY, Hines OJ, Reber HA, Tomlinson JS: Invasive intraductal papillary mucinous neoplasm versus sporadic pancreatic adenocarcinoma: a stage-matched comparison of outcomes. Cancer 2010;116:3369–3377.
48.
Cheon YK, Cho YD, Jeon SR, Moon JH, Jeong SW, Hur KY, Jin SY, Lee JS: Pancreatic resection guided by preoperative intraductal ultrasonagraphy for intraductal papillary mucinous neoplasm. Am J Gastroenterol 2010;105:1963–1969.
49.
Okada K, Imaizumi T, Hirabayashi K, Matsuyama M, Yazawa N, Dowaki S, Tobita K, Ohtani Y, Kawaguchi Y, Tanaka M, Inokuchi S, Makuuchi H: The distance of tumor spread in the main pancreatic duct of an intraductal papillary-mucinous neoplasm: where to resect and how to predict it. J Hepatobiliary Pancreat Surg 2010;17:516–522.
50.
Paik KY, Choi SH: Experience of limited pancreatic head resection for management of branch duct intraductal papillary mucinous neoplasm in a single center. World J Gastroenterol 2009;15:2904–2907.
51.
Nakao A, Fernandez-Cruz L: Pancreatic head resection with segmental duodenectomy: safety and long-term results. Ann Surg 2007;246:929–931.
52.
Yamaguchi K, Shimizu S, Yokohata K, Noshiro H, Chijiiwa K, Tanaka M: Ductal branch-oriented minimal pancreatectomy: two cases of successful treatment. J Hepatobiliary Pancreat Surg 1999;6:69–73.
53.
Warshaw AL, Rattner DW, Fernandez-del Castillo C, Z’graggen K: Middle segment pancreatectomy: a novel technique for conserving pancreatic tissue. Arch Surg 1998;133:327–331.
54.
Nakagohri T, Kinoshita T, Konishi M, Takahashi S, Gotohda N, Kobayashi S, Kojima M, Miyauchi H, Asano T: Inferior head resection of the pancreas for intraductal papillary mucinous neoplasms. J Hepatobiliary Pancreat Sci 2010;17:798–802.
55.
Bassi C: Middle segment pancreatectomy: a useful tool in the management of pancreatic neoplasms. J Gastrointest Surg 2007;11:421–424.
56.
Hayashi T, Ishiwatari H, Ihara H, Kawano Y, Takada K, Miyanishi K, Kobune M, Takimoto R, Sonoda T, Takayama T, Kato J, Niitsu Y: Suppressive effect of sulindac on branch duct-intraductal papillary mucinous neoplasms. J Gastroenterol 2009;44:964–975.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.