title: Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis.
abstract: 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.
  
  
  
  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.
  
  
  
  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).
  
  
  
  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.
authors.affiliation: Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.|Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Crippa
authors.affiliation: Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Bassi
authors.affiliation: Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Salvia
authors.affiliation: Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Malleo
authors.affiliation: Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.|Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Marchegiani
authors.affiliation: Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, APHP, Université Paris Diderot, DHU UNITY, Clichy, France.
authors.forename: Vinciane
authors.initials: V
authors.lastname: Rebours
authors.affiliation: Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, APHP, Université Paris Diderot, DHU UNITY, Clichy, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Levy
authors.affiliation: Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.|Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Partelli
authors.affiliation: Center for Pancreatic Disease, Brigham and Woman's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Shadeah L
authors.initials: SL
authors.lastname: Suleiman
authors.affiliation: Center for Pancreatic Disease, Brigham and Woman's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Banks
authors.affiliation: Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Nazir
authors.initials: N
authors.lastname: Ahmed
authors.affiliation: Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Suresh T
authors.initials: ST
authors.lastname: Chari
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Carlos
authors.initials: C
authors.lastname: Fernández-Del Castillo
authors.affiliation: Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.|Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Falconi
mesh_terms: D000367:Age Factors; D000368:Aged; D021441:Carcinoma, Pancreatic Ductal / Q000150:complications / Q000473:pathology*; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007565:Jaundice / Q000209:etiology; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D018297:Neoplasms, Cystic, Mucinous, and Serous / Q000145:classification / Q000473:pathology* / Q000628:therapy*; D009929:Organ Size; D010180:Pancreatectomy; D010183:Pancreatic Ducts / Q000473:pathology; D010190:Pancreatic Neoplasms / Q000145:classification / Q000473:pathology* / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D057832:Watchful Waiting
keywords: PANCREATIC CANCER; PANCREATIC SURGERY; PANCREATIC TUMOURS