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Original research
Impact of age, comorbidities and relevant changes on surveillance strategy of intraductal papillary mucinous neoplasms: a competing risk analysis
  1. Stefano Crippa1,
  2. Giovanni Marchegiani2,
  3. Giulio Belfiori1,
  4. Paola Vittoria Maria Rancoita3,
  5. Tommaso Pollini2,
  6. Anna Burelli2,
  7. Laura Apadula4,
  8. Maria Giovanna Scarale3,
  9. Davide Socci1,
  10. Marco Biancotto2,
  11. Giuseppe Vanella4,
  12. Paolo Giorgio Arcidiacono4,
  13. Gabriele Capurso4,
  14. Roberto Salvia2,
  15. Massimo Falconi1
  1. 1Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
  2. 2Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
  3. 3University Center of Statistics in the Biomedical Sciences, Vita Salute San Raffaele University, Milan, Italy
  4. 4Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
  1. Correspondence to Professor Massimo Falconi, Surgery, San raffaele Scientific Institute, Milan 20132, Italy; falconi.massimo{at}


Objective Cost-effectiveness of surveillance for branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) is debated. We combined different categories of risks of IPMN progression and of IPMN-unrelated mortality to improve surveillance strategies.

Design Retrospective analysis of 926 presumed BD-IPMNs lacking worrisome features (WFs)/high-risk stigmata (HRS) under surveillance. Charlson Comorbidity Index (CACI) defined the severity of comorbidities. IPMN relevant changes included development of WF/HRS, pancreatectomy or death for IPMN or pancreatic cancer. Pancreatic malignancy-unrelated death was recorded. Cumulative incidence of IPMN relevant changes were estimated using the competing risk approach.

Results 5-year cumulative incidence of relevant changes was 17.83% and 1.6% developed pancreatic malignancy. 5-year cumulative incidences for IPMN relevant changes were 13.73%, 19.93% and 25.04% in low-risk, intermediate-risk and high-risk groups, respectively. Age ≥75 (HR: 4.15) and CACI >3 (HR: 3.61) were independent predictors of pancreatic malignancy-unrelated death. 5-year cumulative incidence for death for other causes was 15.93% for age ≥75+CACI >3 group and 1.49% for age <75+CACI ≤3. 5-year cumulative incidence of IPMN relevant changes were 13.94% in patients with age <75+CACI ≤3 compared with 29.60% in those with age ≥75+CACI >3. In this group 5-year rate of malignancy-free patients was 95.56% with a 5-year survival of 79.51%.

Conclusion Although it is not uncommon the occurrence of changes considered by current guidelines as relevant during surveillance of low risk BD-IPMNs, malignancy rate is low and survival is significantly affected by competing patients’ age and comorbidities. IPMN surveillance strategy should be tailored based on these features and modulated over time.

  • abdominal MRI
  • pancreatic cancer
  • pancreatic surgery
  • pancreatic tumours
  • surveillance

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • SC, GM and GB are joint first authors.

  • RS and MF are joint senior authors.

  • X @StefanoCrippa6, @Gio_Marchegiani, @a_burez

  • Contributors SC, GM, GB: study design, data analysis, interpretation of results, manuscript and tables preparation; PMVR and MGS: statistical analysis, interpretation of results, figures and tables preparation; TP, AB, LA, DS, MB, GV: data acquisition and interpretation of results; GC and PGA: study design and methodological advice; RS: project supervision, study design, interpretation of results, manuscript preparation; MF: project supervision, study design, interpretation of results, manuscript preparation and guarantor of this project. All authors read and approved the final paper. SC, GM and GB share the first authorship. RS and MF are last authors.

  • Funding This work was supported by a Grant from Fondazione Nadia Valsecchi to Stefano Crippa.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.