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Abstract: Branch duct intraductal papillary mucinous tumors (IPMTs) are increasingly being described and represent a challenge for the physician. If on one hand the most recent imaging modalities, especially CT and MR, allow for a correct diagnosis, on the other IPMTs can manifest with different degrees of cellular atypia and therefore it is really important to be able to establish the biological behavior of the lesion. Sixty-five patients were included in this study: 29 of them underwent surgery, while the other 36 were followed-up with cross-sectional imaging. Among the patients submitted to surgery, 11 had benign lesions and 18 malignant lesions. The overall values of sensitivity, specificity, and accuracy in the diagnosis of malignancy for all the cross-sectional imaging techniques were, respectively, 61%, 81%, and 69%. Among the followed-up patients, who had an MRCP diagnosis of branch duct IPMT with imaging features indicative of benignity, only two showed modifications over the follow-up period. Even considering some important biases (small number of patients, relatively short follow-up), interesting conclusions can be drawn: the imaging diagnosis of malignancy is trustable, while that of benignity cannot be relied upon, but if the signs of malignancy are absent the slow growth of the lesions justifies watchful follow-up in the correct clinical setting.