Intraductal Papillary Mucosal Neoplasm (IPMN)

Intraductal Papillary Mucosal Neoplasms (IPMNs) are precancerous cysts or neoplasms arising within the pancreatic ducts. "Papillary" refers to a type of cell structure within these mucous-producing cysts. An IPMN may develop anywhere within the ductal region of the pancreas. IPMNs are surprisingly common in both men and women, and increase in prevalence with advancing age. They arfe slow-growing neoplasms and patients often have an excellent prognosis following treatment.

Because most IPMNs show high-grade dysplasia (abnormal cellular growth), surgery is first-line therapy to prevent them from developing into cancerous tumor(s). Virginia Mason gastroenterologists work closely with specialists throughout the medical center to offer patients state-of-the-art care for IPMN treatment. For more information or to schedule an appointment, call (206) 223-2319.

Symptoms of IPMN

IPMNs often produce no symptoms. Many are found incidentally during imaging studies for other reasons. IPMNs and other disorders of the bile duct oftentimes have the same symptoms because most of them block the biliary ducts from releasing bile or digestive enzymes into the small intestine.

When IPMNs produce symptoms, the most common are: 

  • Abdominal pain on the right side of the body (where the liver, gallbladder and pancreas are located)
  • Nausea, vomiting
  • Yellow skin or eyes (from the build up of bilirubin, a waste product)
  • Pancreatitis
  • Fatigue
  • Weight loss
  • Fever
  • Night sweats
  • Loss of appetite
  • Light-colored stools

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Diagnosing an IPMN

Your gastroenterologist may suspect an IPMN based on your medical history, your appearance, and your description of your symptoms. A number of excellent tests and procedures are available to guide him or her in the diagnosis:

  • BLOOD TESTS
    Your blood may be tested for bilirubin, a waste product in blood from the normal breakdown of red blood cells. A build-up of bilirubin in blood can cause yellow skin and eyes (jaundice). In addition to a bilirubin test, your blood may be tested for the presence of elevated white blood cells used by the body to fight infection, and for abnormal levels of pancreatic and liver enzymes. Your gastroenterologist also may order a CA 19-9 blood test to test for a tumor marker (CA 19-9) common in biliary tract disorders.
     
  • ABDOMINAL ULTRASOUND
    This non-invasive procedure uses sound waves rather than x-rays to produce images. The images can reveal a narrowing within the common bile duct. During this procedure, an ultrasound probe is passed over the abdomen and images are sent to a computer monitor. Abdominal ultrasound is commonly used in women who are pregnant.
     
  • ABDOMINAL CT SCAN OR MRI A CT scan or MRI of the abdomen can identify narrowing within the biliary tract. Both scans are noninvasive procedures, during which the bile duct images are shown on a computer monitor.
     
  • ERCP
    Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized endoscopic technique used to study the ducts of the gallbladder, pancreas and liver, and has the added benefit of being a therapeutic tool. ERCP has been in use for more than 30 years, and is considered the standard modality for diagnosing and treating disorders of the biliary tract.
     
    During this procedure, and after first receiving a mild sedative and an anesthetic to numb the throat, an endoscope containing a miniature camera is passed down your esophagus and into the biliary tract. When your gastroenterologist sees the biliary and pancreatic ducts, he or she then passes a catheter (a narrow plastic tube) containing a contrast dye through the endoscope. The dye is injected into the pancreatic and biliary ducts and X-rays are taken that are viewed on a computer monitor. The procedure takes 60 to 90 minutes and is performed in the Endoscopy Suite within Virginia Mason's Section of Gastroenterology and Hepatology.
     
    Your gastroenterologist can treat a bile duct disorder at the same time it is being diagnosed by passing miniaturized instruments through the ERCP. Special preparations are required for this endoscopic procedure.
     
  • ERCP WITH ENDOSCOPIC ULTRASOUND
    Increasingly, gastroenterologists at Virginia Mason are using endoscopic ultrasound (EUS) in place of X-rays for better viewing of the bile and pancreatic ducts. During this procedure, an ultrasound probe is passed through the ERCP, which sends images to a computer monitor.
     
  • FINE NEEDLE ASPIRATION BIOPSY
    Your gastroenterologist may want to take a fine needle aspiration (FNA) biopsy or tissue sample through the endoscope to help in the diagnosis. Or, he or she may perform a FNA with a thin needle passed through the abdominal skin (percutaneously). The percutaneous procedure, with needle placement near the pancreatic duct, is guided by ultrasound or CT scan.
     
  • MRCP
    Magnetic resonance cholangiopancreatography is newer technology being employed at Virginia Mason. This noninvasive diagnostic procedure is performed in Radiology using MRI technology (magnets and radio waves) to produce computer images of the bile ducts. A contrast dye is injected first through the abdominal skin to enhance the images. Patients are not required to undergo endoscopy preparation and they do not undergo sedation. MRCP is being used primarily in patients who may have failed or who are not good candidates for ERCP, in those who do not want to undergo an endoscopic procedure, and in individuals considered to be at low risk of having a pancreatic duct or bile duct disorder. While ERCP allows for therapeutic options with cholangioscopy, MRCP is a diagnostic tool only.

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Treating IPMNs

An IPMN may develop anywhere within the pancreas: at the main duct within the head of the pancreas, along the duct that extends to the tail, or within ductal branches that run deep within the organ. Surgery is recommended to remove the cyst(s) in most cases. Virginia Mason is a very high volume hospital for the surgical treatment of pancreatic neoplasms and cancer.

The surgical procedure will depend on the location of the IPMN within the pancreas. An IPMN in the tail of the pancreas is treated with a surgical procedure called distal pancreatectomy. An IPMN found in the head of the pancreas is treated with a pancreaticoduodenectomy or Whipple procedure. In rare cases, the entire pancreas is removed in patients with IPMNs in a procedure called a pancreatectomy.

IPMNs discovered within the ductal branches are more difficult to treat and, instead of surgery, often are watched closely with imaging scans for signs of growth. These branch duct type IPMNs have been found in studies to be less aggressive than main duct IPMNs.

When indicated, surgeons at Virginia Mason are using minimally invasive surgical techniques, such as laparoscopy — a type of endoscopic procedure — for treating diseases and disorders of the pancreas.

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