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Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis
  1. Stefano Crippa1,2,
  2. Claudio Bassi3,
  3. Roberto Salvia3,
  4. Giuseppe Malleo3,
  5. Giovanni Marchegiani3,4,
  6. Vinciane Rebours5,
  7. Philippe Levy5,
  8. Stefano Partelli1,2,
  9. Shadeah L Suleiman6,
  10. Peter A Banks6,
  11. Nazir Ahmed7,
  12. Suresh T Chari7,
  13. Carlos Fernández-del Castillo4,
  14. Massimo Falconi1,2
  1. 1Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy
  2. 2Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy
  3. 3Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
  4. 4Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  5. 5Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, APHP, Université Paris Diderot, DHU UNITY, Clichy, France
  6. 6Center for Pancreatic Disease, Brigham and Woman's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  7. 7Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Professor Carlos Fernández-del Castillo, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Wang Ambulatory Care Center 460, 15 Parkman St, Boston, MA 02114, USA; cfernandez{at}


Objective To evaluate mid-term outcomes and predictors of survival in non-operated patients with pancreatic intraductal papillary mucinous neoplasms (IPMNs) with worrisome features or high-risk stigmata as defined by International Consensus Guidelines for IPMN. Reasons for non-surgical options were physicians’ recommendation, patient personal choice or comorbidities precluding surgery.

Methods In this retrospective, multicentre analysis, IPMNs were classified as branch duct (BD) and main duct (MD), the latter including mixed IPMNs. Univariate and multivariate analysis for overall survival (OS) and disease-specific survival (DSS) were obtained.

Results Of 281 patients identified, 159 (57%) had BD-IPMNs and 122 (43%) had MD-IPMNs; 50 (18%) had high-risk stigmata and 231 (82%) had worrisome features. Median follow-up was 51 months. The 5-year OS and DSS for the entire cohort were 81% and 89.9%. An invasive pancreatic malignancy developed in 34 patients (12%); 31 had invasive IPMNs (11%) and 3 had IPMN-distinct pancreatic ductal adenocarcinoma (1%). Independent predictors of poor DSS in the entire cohort were age >70 years, atypical/malignant cyst fluid cytology, jaundice and MD >15 mm. Compared with MD-IPMNs, BD-IPMNs had significantly better 5-year OS (86% vs 74.1%, p=0.002) and DSS (97% vs 81.2%, p<0.0001). Patients with worrisome features had better 5-year DSS compared with those with high-risk stigmata (96.2% vs 60.2%, p<0.0001).

Conclusions In elderly patients with IPMNs that have worrisome features, the 5-year DSS is 96%, suggesting that conservative management is appropriate. By contrast, presence of high-risk stigmata is associated with a 40% risk of IPMN-related death, reinforcing that surgical resection should be offered to fit patients.


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