Pancreatic intraductal papillary mucinous neoplasms: Current diagnosis and management

Table 2 Indications for surgery in intraductal papillary mucinous neoplasms according to the International, European and American Gastroenterological Association guidelines[5,8,13,20-22,41]

Guidelines	Indications for surgery
IAP (2006)	Symptoms; Cyst size ≥ 3 cm; Mural nodule; MPD ≥ 5 mm; Positive cytology
AGA (2015)	High risk features: Cyst size ≥ 3 cm; Presence of solid component; Dilated MPD
	HGD or cancer on cytology
IAP (2017)	High risk stigmata: Jaundice; Enhancing mural nodule ≥ 5 mm; MPD ≥ 10 mm
	HGD or cancer on cytology
	Worrisome features: Cyst size ≥ 3 cm; Acute pancreatitis (due to IPMN)
	Enhancing mural nodule ≥ 5 mm; Thickened and enhancing cyst wall
	MPD dilation 5-9 mm; Abrupt change of MPD caliber with distal pancreatic atrophy; Presence of lymphadenopathy; Elevated serum CA 19-9; Cyst growth rate > 5 mm/2 yr
European (2018)	Absolute indications: Jaundice; Enhancing mural nodule ≥ 5 mm; MPD ≥ 10 mm; HGD or cancer on cytology; Solid mass
	Relative indications: Cyst size ≥ 4 cm; Enhancing mural nodule ≥ 5 mm/years; Acute pancreatitis (due to IPMN); New onset of diabetes; Rapidly increasing cyst size; Elevated serum levels of CA19-9

IPMN: Intraductal papillary mucinous neoplasm; IAP: International Association of Pancreatology; AGA: American Gastroenterological Association; MPD: Main pancreatic duct; HGD: High grade dysplasia.