Periodic surveillance of intraductal papillary mucinous neoplasms: gaps in evidence and future directions.

Intraductal papillary mucinous neoplasm (IPMN) is a well-established precursor to pancreatic cancer; however, its generally indolent biological behavior necessitates prolonged periodic surveillance in most patients. This review synthesizes current evidence and highlights unmet needs, while providing future perspectives on the clinical management of patients with IPMNs. In contrast to the relatively robust evidence regarding predictive factors for prevalent pancreatic carcinoma, substantial clinical and research gaps remain in periodic surveillance strategies for IPMN. Despite multiple international guidelines, unified risk-stratified surveillance protocols have yet to be established, particularly with respect to imaging modalities, surveillance intervals, and criteria for surveillance discontinuation. This lack of agreement is attributable, in part, to the paucity of large-scale longitudinal cohorts needed to develop robust risk prediction models. An additional challenge is the risk of carcinoma developing concomitantly with IPMN, which often progresses more rapidly with fewer appreciable early morphological changes than carcinoma derived from IPMN. Future research should focus on developing comprehensive risk stratification schemes based on large prospective cohorts to establish evidence-based criteria for surveillance intervals and discontinuation criteria. These efforts should also take into account the surveillance-related burden on patients and healthcare systems, including psychological distress and financial costs, as well as strategies for early detection of concomitant pancreatic carcinoma. Furthermore, integration of advanced biomarkers and artificial intelligence-based models is warranted.