Recognizing IPMN-derived pancreatic cancer as a specific entity requiring prospective clinical studies: a call for international collaboration

Intraductal papillary mucinous neoplasms (IPMNs) are frequently diagnosed with the widespread implementation of cross-sectional imaging. These neoplasms continue to pose unique diagnostic and clinical challenges, because their natural course may remain stable at low-grade dysplasia or progress into invasive cancer.

Once an IPMN-derived pancreatic cancer is diagnosed, management strategies are generally based on the more developed literature for pancreatic intraepithelial neoplasia (PanIN)-derived pancreatic cancer. Although for multiple phases of care, including surgical technique, pathological staging, perioperative chemotherapy, and postoperative surveillance, this may suffice, recent evidence has indicated that PanIN- and IPMN-derived pancreatic cancer are biologically distinct, with the latter associated with a better prognosis.¹ It is thus conceivable that IPMN-derived pancreatic cancer should be also treated, staged, and followed up differently.

In the past, knowledge on IPMN-derived pancreatic cancer was limited to small case series limiting translation into clinical practice. More recently, international collaboration has led to significant developments.^2-4 These consortia have advanced our limited understanding of the natural course, staging, and management. First, the expert proposed sub-staging classification of T1 IPMN-derived pancreatic cancer appears to be valid and should be implemented in future guidelines.⁵ Second, the treatment of IPMN dysplasia at the margin presents a unique scenario, with evidence supporting reresection of high-grade dysplasia or invasive cancer when present at the frozen margin.⁶ Third, regarding adjuvant chemotherapy, it is becoming increasingly clear that, unlike in PanIN-derived pancreatic cancer, there may be a subset of patients with IPMN-derived pancreatic cancer who do not require adjuvant chemotherapy.^2-4 Albeit exciting, before changing practice with confidence, prospective evidence is urgently needed.

Given the distinction of IPMN-derived pancreatic cancer, multicenter collaborations are likely the best way to study and improve how we treat these patients. The recently initiated international PANC-PALS consortium would be well suited to initiate and perform such studies together with leading experts in the field of IPMN.⁷ We call on centers to continue to collaborate to explore this field such that high-level evidence can be generated and specific guidelines that are divergent from those for PanIN-derived pancreatic cancer can be developed to provide optimized care for these unique patients.

Collaborators

PANC-PALS consortium members: Camila Hidalgo Salinas, Ingmar F. Rompen, Brady A. Campbell, D. Brock Hewitt, Lois A. Daamen, Greg D. Sacks, Katherine Morgan, Jin He.

Author contributions

Joseph Habib, MD (Conceptualization; Writing—original draft), Ammar A. Javed, MD (Conceptualization; Writing—original draft), I. Quintus Molenaar, MD, PhD (Conceptualization; Writing—review & editing), Christopher L. Wolfgang, MD, PhD (Conceptualization; Writing—review & editing), and Marc G. Besselink, MD, PhD (Conceptualization; Supervision; Writing—review & editing).

Funding

None declared.

Conflicts of interest

No conflict of interests for all authors.

Data availability

This correspondence contains no data.