Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis

Gut. 2017 Mar;66(3):495-506. doi: 10.1136/gutjnl-2015-310162. Epub 2016 Jan 7.


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.


Publication types

  • Multicenter Study

MeSH terms

  • Age Factors
  • Aged
  • Carcinoma, Pancreatic Ductal / complications
  • Carcinoma, Pancreatic Ductal / pathology*
  • Disease Progression
  • Female
  • Follow-Up Studies
  • Humans
  • Jaundice / etiology
  • Male
  • Middle Aged
  • Neoplasm Invasiveness
  • Neoplasms, Cystic, Mucinous, and Serous / classification
  • Neoplasms, Cystic, Mucinous, and Serous / pathology*
  • Neoplasms, Cystic, Mucinous, and Serous / therapy*
  • Organ Size
  • Pancreatectomy
  • Pancreatic Ducts / pathology
  • Pancreatic Neoplasms / classification
  • Pancreatic Neoplasms / pathology*
  • Pancreatic Neoplasms / therapy*
  • Retrospective Studies
  • Risk Factors
  • Survival Rate
  • Watchful Waiting