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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.110 no.7 Madrid jul. 2018 


Accuracy of malignancy criteria for an intraductal papillary mucinous neoplasm. Should we have blind faith in consensus guidelines?

Juan-Carlos Sebastián-Tomás1  , Carmen Payá-Llorente1  , Inmaculada Ortiz-Tarín1 

1Servicio de Cirugía General y del Aparato Digestivo. Hospital Universitario Doctor Peset. Valencia, Spain

Key words: Intraductal papillary mucinous neoplasm; Pancreatic cystic neoplasm; Criteria of malignancy

Dear Editor,

Based on a recent review with regard to recommendations for an intraductal papillary mucinous neoplasm (IPMN) 1, we want to highlight the fact that different studies have limitations when identifying potentially life threatening branch-duct IPMN. Both the Fukuoka criteria published in 2017 2 and the American Gastroenterological Association guidelines in 2015 3 have a high specificity and positive predictive values 1,4 (Table 1). However, the lack of criteria for malignancy does not completely reduce the risk of high grade dysplasia (HGD) or invasive carcinoma (IC). The 5-year IC risk for IPMN without malignancy criteria is 2-3% 1.

Table 1 The accuracy of malignancy criteria for IPMN according to retrospective studies and their major limitations 

The cyst size value for malignancy remains controversial. In the study reported by Sahora et al. 5, HGD was present in 6.5% of patients without malignancy criteria and a cyst size < 3 cm. Moreover, only a cyst size > 3 cm increased the possibility of IC up to 18%. Consequently, cyst size must be treated with caution and a close follow-up should be implemented. A rapid rate of cyst growth > 5 mm/2 years is included as a worrisome feature in the last review of Fukouka guidelines 2.

Endoscopic ultrasonography with fine needle aspiration is currently a fundamental diagnostic method for the management of IPMN. Both an elevated serum level of carbohydrate antigen 19-9 and high grade epithelial atypia are included in the 2017 Fukuoka guidelines 2.

Therefore, we want to highlight that although the different guidelines published for the diagnosis and management of this neoplasm are a starting point for the evaluation of our patients, we need to be careful when applying the different algorithms proposed in the international consensus guidelines.


1. Moris M, Wallace MB. Intraductal papillary mucinous neoplasms and mucinous cystadenomas: current status and recommendations. Rev Esp Enferm Dig 2017;109(5):358-67. DOI: 10.17235/reed.2017.4630/2016 [ Links ]

2. Tanaka M, Fernández-Del Castillo C, Kamisawa T, et al. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017;17(5):738-53. DOI: 10.1016/j.pan.2017. 07.007 [ Links ]

3. Vege SS, Ziring B, Jain R, et al. American Gastroenterological Association Institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015;148(4):819-22. DOI: 10.1053/j.gastro.2015.01.015 [ Links ]

4. Kaimakliotis P, Riff B, Pourmand K, et al. Sendai and Fukuoka Consensus Guidelines identify advanced neoplasia in patients with suspected mucinous cystic neoplasms of the pancreas. Clin Gastroenterol Hepatol 2015;13(10):1808-15. DOI: 10.1016/j.cgh.2015.03.017 [ Links ]

5. Sahora K, Mino-Kenudson M, Brugge W, et al. Branch duct intraductal papillary mucinous neoplasms: does cyst size change the tip of the scale? A critical analysis of the revised international consensus guidelines in a large single-institutional series. Ann Surg 2013;258(3):466-75. DOI: 10.1097/SLA.0b013e3182a18f48 [ Links ]