Multidisciplinary Approach to Diagnosis and Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas  Dushyant V. Sahani, Dana J. Lin, Aradhana M. Venkatesan, Nisha Sainani, Mari Mino–Kenudson, William R. Brugge, Carlos Fernandez–Del–Castillo  Clinical Gastroenterology and Hepatology  Volume 7, Issue 3, Pages 259-269 (March 2009) DOI: 10.1016/j.cgh.2008.11.008 Copyright © 2009 AGA Institute Terms and Conditions

Figure 1 Morphologic classification of IPMN with schematics (left panels) and radiographic images (right panels), including (A and D) MRCP and (B and C) CT. (A) Branch duct IPMN is characterized by cystic dilatation of the side branches (arrow) with grape-like clusters of cysts communicating (thick arrow) through a narrow channel with the pancreatic duct that shows little to no dilation. (B) Diffuse main duct IPMNs shows a more or less uniform dilatation throughout the extent of the main pancreatic duct (arrowhead) and also may show a patulous ampulla of Vater. (C) Segmental main duct IPMN shows a localized dilatation (arrowhead) of the duct. (D) Mixed IPMN possesses both main pancreatic duct (thick arrow) and cystic branch duct dilatation (black and white arrows). Gallbladder filled with gallstones is also seen (asterisk). Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 2 Histopathologic range of IPMNs: (A) low-grade dysplasia, (B) moderate dysplasia, and (C) high-grade dysplasia. Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 3 Diffuse main duct IPMN in an 83-year-old man who presented with abdominal discomfort and weight loss. (A) Curved reformatted CT showing diffuse main duct dilatation (paired white arrows) with a mural nodule (black arrow) and bulging papilla (arrowhead). (B) MRCP showing a dilated main pancreatic duct with a mural nodule (black arrow). Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 4 EUS image and pathology specimen showing a mural nodule, an IPMN feature suggestive of malignancy. (A) EUS of a 66-year-old man with nonspecific symptoms and main duct IPMN depicts a dilated pancreatic duct (small arrow) with a mural nodule (large arrow). (B) Gross pathology specimen from resection of a 78-year-old woman who presented with weight loss shows a main duct IPMN with a mural nodule (arrow) in the main pancreatic duct. Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 5 EUS imaging with diagnostic needle aspiration in an asymptomatic 61-year-old woman with a branch duct IPMN in the pancreatic head. Note the placement of the biopsy needle within the fluid compartment (arrowhead) and the associated solid component (black arrow) of the lesion. Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 6 ERCP and MRCP were performed as part of the clinical treatment for a 67-year-old man who presented with abdominal pain. (A) ERCP clearly shows a clustered, septated cyst (arrow) with communication to the pancreatic duct. However, the distal pancreatic duct in the body and tail was not opacified owing to obstruction, likely by inspissated mucin. (B) MRCP performed subsequently delineated the entire main pancreatic duct and also showed the 2 branch duct IPMNs (arrows) communicating with the main pancreatic duct. Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 7 18-fluorodeoxyglucose PET-CT imaging of a malignant IPMN in a 77-year-old woman with pancreas divisum and abdominal pain. (A) Reformatted CT image shows a dilated distal pancreatic duct and an enhancing soft tissue mass in the proximal dorsal duct causing a prominently bulging duodenal papilla (arrow). Pathology showed malignant degeneration of diffuse IPMN. (B) Corresponding PET scan demonstrates increased FDG uptake in the region of soft tissue mass highlighting its hypermetabolic nature (arrows) and lack of activity in the dilated duct. (C) Axial fused PET-CT image shows the area of increased FDG uptake in the proximal dorsal duct with the soft tissue mass (arrow). Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 8 Algorithm for IPMN management. Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 9 Presurgical follow-up interval according to IPMN size. Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 10 A 3D MRCP image of a 56-year-old woman shows incidentally detected multifocal IPMN. A dilated main pancreatic duct (arrowhead) and multiple branch duct lesions (arrows) can be discerned. Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions

Figure 11 Development of pancreatic ductal adenocarcinoma in a 79-year-old man with IPMN. (A) Transverse contrast-enhanced CT shows an asymptomatic IPMN in the tail of the pancreas (arrow). (B) Four years post-resection, the patient presented with abdominal pain, pruritis, and obstructive jaundice. Transverse CT with contrast revealed ductal adenocarcinoma (arrow), seen as the heterogeneously enhancing lesion in the head of the pancreas. A biliary stent also is shown. Clinical Gastroenterology and Hepatology 2009 7, 259-269DOI: (10.1016/j.cgh.2008.11.008) Copyright © 2009 AGA Institute Terms and Conditions