IPMN is a condition with a malignant potential, with varying degrees of dysplastic changes that may eventually progress to invasive carcinoma [1, 2]. The mean frequency of invasive carcinoma and HGD in main duct (MD)- IPMN is 61.6%, with current guidelines from international societies recommending surgical resection for all patients fit for surgery [3, 4]. Few studies have investigated mixed-type (MT)-IPMN as a single entity, although malignancy rates appear in line with MD-IPMN [5].

Therapeutic decisions regarding IPMN can be challenging, since the assessment of the extent of malignancy and obtaining a definite diagnosis can often be difficult [6]. Total pancreatectomy provides the most complete oncologic resection, but postoperative morbidity and impact in quality of life associated with this procedure is significant [7]. A recent study reported overtreatment or too extensive resection of MD-IPMN in 19% of patients [8]. However, the risk of disease recurrence or progression is not negligible, with Majumder et al. [9] recently reporting a 10-year incidence of pancreatic cancer of 21.2% in the follow-up. Current European guidelines state that pancreatoscopy may be used in selected cases to provide information on the location and extent of MD-IPMN [4]. Some studies previously evaluated the role of single-operator pancreatoscopy in the evaluation of patients with suspected IPMN, with conflicting results. Arnelo et al. [10] prospectively evaluated patients with radiological suspicion of IPMN and pancreatoscopy was judged to have provided additional information in 39 of the 41 patients (95%), affecting clinical decisions in 76% of them. Nagayoshi et al. [11] evaluated 17 patients with IPMN, with pancreatoscopy-guided biopsies having a 25% sensitivity and 100% specificity for detecting malignancy. Pancreatoscopy was useful in the determination of the operative excision line in 3 patients. In contrast, in a more recent study by Ohtsuka et al. [12], pancreatoscopy only changed the surgical management in 1 of 7 patients and, similarly to our case, failed to detect 1 concomitant pancreatic ductal adenocarcinoma. These data and the presented case highlight the fact that, despite there being a possible role for peroral pancreatoscopy in the preoperative assessment of MDand MT-IPMN, some questions remain, especially regarding the diagnostic ability for targeting biopsy and accurate assessment of surgical margins, meaning an intraoperative frozen section is still needed to obtain negative surgical margins [12]. More prospective studies are necessary in order to assess the specific role of this exam in the diagnostic algorithm of these lesions.

References

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9 Majumder S, Philip NA, Singh Nagpal SJ, Takahashi N, Mara KC, Kendrick ML, et al. High-grade dysplasia in resected main-duct intraductal papillary mucinous neoplasm (MD-IPMN) is associated with an increased risk of subsequent pancreatic cancer. Am J Gastroenterol. 2019 Mar;114(3):524–9.

10 Arnelo U, Siiki A, Swahn F, Segersvärd R, Enochsson L, del Chiaro M, et al. Single-operator pancreatoscopy is helpful in the evaluation of suspected intraductal papillary mucinous neoplasms (IPMN). Pancreatology. 2014 Nov-Dec;14(6):510–4.

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12 Ohtsuka T, Gotoh Y, Nakashima Y et al. Role of SpyGlass-DStm in the preoperative assessment of pancreatic intraductal papillary mucinous neoplasm involving the main pancreatic duct. Pancreatology. 2018;18(5):566–71.

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The authors have no ethical conflicts to disclose.

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The authors have no conflicts of interest to declare.