Management of Asymptomatic IPMN in the Elderly

Abstract

Intraductal papillary mucinous neoplasm (IPMN) comprises a spectrum of mucin-producing cystic neoplasms of pancreatic ductal origin that range from benign adenoma to invasive carcinoma. The 2012 Updated Consensus Guidelines recommend resection of all main duct IPMN (MD-IPMN) with a main pancreatic duct diameter of >= 10 mm, and for branch duct IPMN (BD-IPMN) with high-risk stigmata. These broad categories include many patients who do not harbor an invasive carcinoma, and additional investigations such as cyst fluid analysis, pancreatic juice cytology or FNA of associated solid components may be employed to further characterize the malignant nature of an asymptomatic IPMN. There are limited data on the natural history of patients falling within resection criteria who do not undergo surgery, but the available studies suggest comparable disease-specific and overall survivals in older patients who are managed with observation/surveillance versus resection. Mortality for major pancreatic resection is 0-4 \% in high-volume centers, and morbidity ranges from 16 \% to 53 \%, both of which are increased in patients >70 years old. Quality of life data extrapolated from non-IPMN post-pancreatectomy patients suggests that most domains return to preoperative levels within 3 months, and that malignancy is associated with poor quality of life at 2 years. Non-operative management of IPMN meeting resection criteria may be appropriate for select older patients based on co-morbidities or patient preference.