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Introduction In recent years, the widespread utilisation of advanced imaging modalities has led to a surge in the detection rate of pancreatic cystic lesions, particularly intraductal papillary mucinous neoplasms (IPMN). Consequently, this review aims to provide a comprehensive examination of IPMN, focusing on elucidating its intricate facets including definition, epidemiology, pathogenesis, classification, imaging modalities for diagnosis, analysis of pancreatic cyst fluid, evaluation of malignant potential, and identification of pertinent features. Brief Overview of Current Knowledge: IPMN represents a diagnostic conundrum owing to its variable biological behaviour encompassing both benign and malignant spectra, necessitating meticulous evaluation and risk stratification. Various imaging techniques such as MRI, CT, EUS and abdominal ultrasonography serve pivotal roles in the diagnostic algorithm and risk assessment of IPMN. Additionally, the analysis of pancreatic cyst fluid, incorporating biomarkers and the string sign test, assumes a critical role in discerning mucinous from non-mucinous cysts and gauging malignant potential. Discriminating high-risk stigmata and worrisome features serve as a compass for clinical decision-making regarding the imperative of surgical intervention versus vigilant surveillance. Summary Despite persistent challenges, the ongoing evolution of diagnostic modalities and risk assessment methodologies augur well for refining therapeutic strategies and enhancing clinical outcomes in managing IPMN. This review underscores the imperative of sustained research endeavours in the realm of pancreatic oncology to enrich our comprehension of IPMN pathophysiology and to optimise clinical care paradigms. [ABSTRACT FROM AUTHOR]

Objective: Unusual or unexpected effect of treatment Background: Minimally invasive pancreatectomy has become the standard practice for the management of benign and malignant pancreatic tumors. Techniques such as robotic and laparoscopic approaches are known to reduce morbidity by offering benefits such as less blood loss, reduced pain, shorter hospital stays, and quicker recovery times. The indication for repeated minimally invasive pancreatectomy for recurrent or de novo pancreatic neoplasm after primary pancreatic surgery remains debated. Case Report: A 50-year-old woman was admitted to our hospital with a diagnosis of an intraductal papillary mucinous neoplasm in the pancreatic head. In 2010, she underwent laparoscopic single-branch resection for a branch-type tumor in the pancreatic uncinate process. During a 5-year follow-up, a de novo intraductal papillary mucinous neoplasm was detected, showing gradual growth and the presence of a mural nodule over the next 7 years. The patient’s CEA level was elevated to 7.0 ng/mL. Considering the tumor’s progression and the appearance of a mural nodule, we recommended a robot-assisted Whipple procedure. The operation began with laparoscopic adhesiolysis. After detachment of the adhesions and remobilization of the duodenum using the Kocher maneuver, the operation continued with the Da Vinci surgical system. The postoperative period was uneventful, and the patient was discharged on postoperative day 20. Pathological examination revealed intraductal papillary mucinous carcinoma in situ with negative resection margins. Conclusions: This case verifies the safety and feasibility of performing a robotic Whipple procedure for a newly diagnosed pancreatic neoplasm in patients who have previously undergone minimally invasive pancreatic surgery. [ABSTRACT FROM AUTHOR]

Modern series report a prevalence of pancreatic cysts in the general population of up to 50% in prospective studies. Of these, about half will be pancreatic cystic neoplasms (PCNs) that have varying degrees of malignant potential. Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are the most common PCNs and are known predecessors of pancreatic adenocarcinoma. Critically, they are one of the only radiographically identifiable precursors of pancreatic cancer and thus provide an opportunity for early cancer detection and surgical resection with curative intent. The combination of high prevalence and potential for malignant degeneration underscore the relevance of discussing the best management of IPMNs and improving the existing standard of care. Landmark data on IPMN prevalence, guidelines, surveillance, biomarkers, and immune landscape are highlighted.

Recently, the International Association of Pancreatology published a revised edition of the guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The guidelines mainly focus on five topics, i. e., revision of “high-risk stigmata” and “worrisome features”, surveillance of unresected IPMN, surveillance after resection of IPMN, revision of pathological aspects, and research on molecular markers in cyst fluid, in order to provide the best evidence-based reference for clinical practice. This article makes an excerpt of the key points in the guidelines. [ABSTRACT FROM AUTHOR]

Introduction In recent years, the widespread utilisation of advanced imaging modalities has led to a surge in the detection rate of pancreatic cystic lesions, particularly intraductal papillary mucinous neoplasms (IPMN). Consequently, this review aims to provide a comprehensive examination of IPMN, focusing on elucidating its intricate facets including definition, epidemiology, pathogenesis, classification, imaging modalities for diagnosis, analysis of pancreatic cyst fluid, evaluation of malignant potential, and identification of pertinent features. Brief Overview of Current Knowledge: IPMN represents a diagnostic conundrum owing to its variable biological behaviour encompassing both benign and malignant spectra, necessitating meticulous evaluation and risk stratification. Various imaging techniques such as MRI, CT, EUS and abdominal ultrasonography serve pivotal roles in the diagnostic algorithm and risk assessment of IPMN. Additionally, the analysis of pancreatic cyst fluid, incorporating biomarkers and the string sign test, assumes a critical role in discerning mucinous from non-mucinous cysts and gauging malignant potential. Discriminating high-risk stigmata and worrisome features serve as a compass for clinical decision-making regarding the imperative of surgical intervention versus vigilant surveillance. Summary Despite persistent challenges, the ongoing evolution of diagnostic modalities and risk assessment methodologies augur well for refining therapeutic strategies and enhancing clinical outcomes in managing IPMN. This review underscores the imperative of sustained research endeavours in the realm of pancreatic oncology to enrich our comprehension of IPMN pathophysiology and to optimise clinical care paradigms.

This study shows a case of neoadjuvant chemotherapy application for the management of a 34-year-old male patient diagnosed with invasive intraductal papillary mucinous neoplasm (IPMN), for which curative margin-negative resection initially seemed challenging. Five cycles of the FOLFIRINOX regimen (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) were administered preoperatively, resulting in a significant reduction of the intraductal mass size and deformity of the main vessels. The patient subsequently underwent a successful robotic pylorus-preserving pancreatoduodenectomy. Postoperatively, the patient received adjuvant chemotherapy with FOLFIRINOX, and after 5 months, showed no signs of tumor recurrence or specific complications. These findings suggest that neoadjuvant therapy can be a potentially effective strategy even in advanced invasive IPMN. Further research is necessary to establish guidelines for its application.

Introduction. Intraductal papillary mucinous neoplasms (IPMN) and neuroendocrine tumours (NET) may develop simultaneously in the pancreas. Neuroendocrine microadenomas (NMA) are precursor lesions for NET. The study aimed to determine the prevalence of NMA/NET in patients with IPMN in a series of resection specimens. Material and methods. Some 232 prospectively gathered specimens were included and examined histopathologically: 51 IPMN, 114 conventional pancreatic ductal carcinomas (PDAC) and 67 ampullary carcinomas (AMPCA). Results. NET were rare in the study samples (single cases among IPMN and AMPCA, and two cases among PDAC). In contrast, NMA were frequently found in IPMN specimens when compared to samples of PDAC and AMPCA (27.45%; 7.89%, and 7.46%, respectively, p < 0.001). Two NMA in IPMN group were related to ducts, but no case of composite (clonal) IPMN/NMA was found. Conclusions. IPMN specimens were enriched in NMA but not in NET. IPMN/NMA association may serve as a model of exocrine-neuroendocrine interaction. [ABSTRACT FROM AUTHOR]

Pancreatic cystic lesions are often asymptomatic, incidentally detected and include a range of entities with varying degrees of concern for malignancy. Among these, intraductal papillary mucinous neoplasms (IPMN) are considered premalignant pancreatic lesions, with a broad pathological spectrum ranging from lesions without dysplasia, which can be managed conservatively, to malignant lesions that require surgical resection. The increasing use of CT and MRI has led to increased recognition of this entity incidentally, with branch-duct IPMN representing the most common subtype and the most challenging lesions in terms of patient management. The main imaging modality involved in diagnosis and surveillance of IPMN is MRI. Radiologists play an important role in the management of patients with IPMN, including lesion detection, characterization, follow-up and prognostication, allowing early MRI identification of features that are concerning for malignancy. The main aim of this pictorial review is to illustrate MRI features of IPMN and to discuss risk stratification scores based on different guidelines, with a main focus on branch-duct IPMN. The secondary aims include the presentation of common and uncommon imaging evolution of BD-IPMN as well as the discussion on current controversies on the appropriate management of IPMN.

Background: Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant solid tumor that lacks early diagnostic methods. Recently, targeted immunotherapy and radiotherapy have been integrated with radionuclide-antibody conjugate drugs, which can be used for targeted diagnosis and dynamic imaging of tumors. CEACAM6 is overexpressed in pancreatic tumors and is a potential theranostic target for PDAC. We aimed to develop a novel targeted carrier for theranostics of PDAC and other solid tumors. Methods: Based on camelid heavy-chain-only antibodies, we developed a CEACAM6-targeting recombinant antibody NY004, and evaluated it as a novel antibody-carrier for imaging and therapy of cancer in tumor models. We labeled NY004 with theranostic nuclides and applied this self-developed antibody platform in diagnostic imaging and antitumor assessment in PDAC models. Results: Through microPET, IHC, and biodistribution assays, targeting and biodistribution of [89Zr]-NY004 in solid tumors including PDAC was examined, and the investigated tumors were all CEACAM6-positive malignancies. We found that NY004 was suitable for use as a drug carrier for radioimmunotheranostics. Our study showed that NY004 was characterized by high targeted uptake and a long retention time in PANC-1 tumors (up to 6 days post-injection), with good specificity and high imaging efficiency. Therapeutic evaluation of the radionuclide-labeled antibody drug [177Lu]-NY004 in PDAC tumor-bearing model revealed that NY004 had high and prolonged uptake in tumors, relatively low non-target organ uptake, and good anti-tumor efficacy. Conclusion: As a drug platform for radiotheranostics, CEACAM6-specific antibody NY004 met the requirements of easy-labeling, targeting specificity, and effective persistence in pancreatic adenocarcinoma tissues. Key Points: • [89Zr]-NY004 has good specificity and high imaging efficiency, and is characterized by high tumor-targeting uptake and a long tumor retention time as a PET molecular imaging tracer. • Therapeutic radionuclide-conjugated antibody drug [177Lu]-NY004 has high uptake and prolonged uptake duration in tumors, low non-target organ uptake, and significant tumor-inhibiting efficacy in PDAC model. • The self-developed antibody structure NY004 is a promising drug platform for radioimmunotheranostics of CEACAM6-positive tumors including pancreatic ductal adenocarcinoma. [ABSTRACT FROM AUTHOR]

Background and aims: Accurate evaluation of intraductal papillary mucinous neoplasm (IPMN) is necessary to inform clinical decision-making. But it is still difficult to distinguish benign and malignant IPMN preoperatively. This study aims to evaluate the utility of EUS to predict the pathology of IPMN. Methods: Patients with IPMN who underwent endoscopic ultrasound within 3 months before surgery were collected from six centers. Logistic regression model and random forest model were used to determine risk factors associated with malignant IPMN. In both models, 70% and 30% of patients were randomly assigned to the exploratory group and validation group, respectively. Sensitivity, specificity, and ROC were used in model assessment. Results: Of the 115 patients, 56 (48.7%) had low-grade dysplasia (LGD), 25 (21.7%) had high-grade dysplasia (HGD), and 34 (29.6%) had invasive cancer (IC). Smoking history (OR = 6.95, 95%CI: 1.98–24.44, p = 0.002), lymphadenopathy (OR = 7.91, 95%CI: 1.60–39.07, p = 0.011), MPD > 7 mm (OR = 4.75, 95%CI: 1.56–14.47, p = 0.006) and mural nodules > 5 mm (OR = 8.79, 95%CI: 2.40–32.24, p = 0.001) were independent risk factors predicting malignant IPMN according to the logistic regression model. The sensitivity, specificity, and AUC were 0.895, 0.571, and 0.795 in the validation group. In the random forest model, the sensitivity, specificity, and AUC were 0.722, 0.823, and 0.773, respectively. In patients with mural nodules, random forest model could reach a sensitivity of 0.905 and a specificity of 0.900. Conclusions: Using random forest model based on EUS data is effective to differentiate benign and malignant IPMN in this cohort, especially in patients with mural nodules. [ABSTRACT FROM AUTHOR]

Background: Pancreatic cystic lesions (PCLs) are followed for years due to older and likely biased works demonstrating a strong association with pancreatic carcinoma; more recent data are needed clarifying this relationship. Purpose: To determine the association between PCLs on MRI and a synchronous or future diagnosis of pancreatic carcinoma. Study type: Single‐center retrospective cohort. Population: A total of 192 patients (111 female, 58%) with median age 66 years (range 26–87 years) with PCLs on abdominal MRI from 2011 to 2016. Field Strength/Sequences: 1.5 T and 3 T, including T2WI, T1WI, diffusion weighted imaging and contrast‐enhanced T1WI. Assessment: Each PCL was reviewed independently by 2 of 10 fellowship‐trained abdominal radiologists. Fukuoka guideline worrisome features and high‐risk stigmata were evaluated. Follow‐up imaging and clinical notes were reviewed within a system that captures pancreatic carcinoma for the region, for a median follow‐up of 67 months (interquartile range: 43–88 months). Statistical Tests: Pancreatic carcinoma prevalence and incidence rate for future carcinoma with 95% confidence intervals (95% CI). Fisher exact test, logistic regression with odds ratios (OR) and the Wilcoxon rank‐sum test were used to assess PCL morphologic features with the Kolmogorov–Smirnov test used to assess for normality. P < 0.05 defined statistical significance. Results: The prevalence of pancreatic carcinoma on initial MRI showing a PCL was 2.4% (95% CI: 0.9%, 5.2%). Thickened/enhancing cyst wall was associated with pancreatic carcinoma, OR 52 (95% CI: 4.5, 1203). Of 189 patients with a PCL but without pancreatic carcinoma at the time of initial MRI, one developed high‐grade dysplasia and none developed invasive carcinoma for an incidence rate of 0.97 (95% CI: 0.02, 5.43) and 0 (95% CI: 0, 3.59) cases per 1000 person‐years, respectively. Data Conclusion: A low percentage of patients with a PCL on MRI had a pancreatic carcinoma at the time of initial evaluation and none developed carcinoma over a median 67 months of follow‐up. Evidence Level: 3 Technical Efficacy: 5 [ABSTRACT FROM AUTHOR]

/Purpose: Owing to the characteristics of IPMNs, which have variable skipped lesions along the main pancreatic duct (MPD), determining the surgical margins is very difficult. This study aimed to investigate the efficacy and potential oncologic impact of intraoperative pancreatoscopy (IOP) compared to frozen section biopsy (FSB) in pancreaticoduodenectomy (PD) for pancreatic head IPMNs. Data of patients who underwent PD for IPMNs of the pancreas between October 2007 and May 2020 were retrospectively reviewed. IOP was performed in selected patients with IPMNs with inconclusive MPD involvement based on preoperative evaluations. Patients were divided into two groups, IOP group, FSB group. Clinicopathologic features and oncologic outcomes were compared between two groups. 60 patients underwent PD (laparoscopic or robotic, 42; open, 18) for pancreatic head IPMNs. IOP was safely performed in 28 patients, including minimally invasive approach used in 21 patients (35%). IOP group had a significantly larger MPD size (9.15 ± 4.79 mm vs 6.43 ± 4.11 mm, p = 0.021). Based on IOP, the initial surgical plan could be changed in 5 patients (17.8%) for complete resection. Recurrence occurred in 2 patients in FSB group and 3 patients in IOP group during the follow-up period (33.2 months, [range, 3.5–131.4 months]). Overall disease-free survival rate did not significantly differ between two groups (p = 0.529). IOP can be safely performed in patients with pancreatic head IPMNs with MPD dilatation, even in the laparoscopic approach. Further studies evaluating the long-term oncologic effect of IOP for the management of IPMNs are required. [ABSTRACT FROM AUTHOR]

Abstract Background The international consensus guidelines for intraductal papillary mucinous neoplasm of the pancreas (IPMN) presented clinical features as indications for surgery. Whereas surveillance for recurrence, including de novo lesions, is essential, optimal surveillance protocols have not been established. Aim and methods This study aimed to assess the clinical features of recurrence at the remnant pancreas (Rem-Panc) and extra-pancreas (Ex-Panc) after surgery for IPMN. Ninety-one patients of IPMN that underwent detailed preoperative assessment and pancreatectomy were retrospectively analyzed, focusing especially on the type of recurrence. Results The IPMNs were finally diagnosed as low-grade dysplasia (LDA, n = 42), high-grade dysplasia (HAD, n = 19), and invasive carcinoma (IPMC, n = 30). Recurrence was observed in 26 patients (29%), of which recurrence was seen at Rem-Panc in 19 patients (21%) and Ex-Panc in 7 patients (8%). The frequency of Rem-Panc recurrence was 10% in LDA, 21% in HDA, and 37% in IPMC. On the other hand, Ex-Panc recurrence was observed only in IPMC (23%). Ex-Panc recurrence showed shorter median recurrence-free survival (RFS) and overall survival (OS) than Rem-Panc recurrence (median RFS 8 months vs. 35 months, p

BACKGROUND:Robotic total pancreatectomy (TP) represents a minimally invasive approach to a major intra-abdominal operation. Its utility, technique, and outcomes are evolving. METHODS:In this video, we describe a systematic approach to a robotic total pancreatectomy performed for multifocal intraductal papillary mucinous neoplasm (IPMN). Additionally, we reviewed the National Cancer Database (NCDB) to examine the outcomes of robotic TP compared to laparoscopic and open TP between 2010 and 2014. RESULTS:The patient is a 61-year-old female who was diagnosed with multifocal IPMN. A total of 6 robotic ports were placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed as follows: (1) Diagnostic laparoscopy; (2) Entry into the lesser sac; (3) Division of the short gastric vessels; (4) Exposure and dissection of the inferior pancreas border; (5) Dissection and transection of the splenic artery; (6) Mobilization of the pancreas tail/spleen; (7) Exposure of the splenic vein-superior mesenteric vein confluence; (8) Kocher maneuver; (9) Release of the ligament of Treitz and transection of the proximal jejunum; (10) Transection of the distal stomach; (11) Portal lymphadenectomy; (12) Dissection and transection of the gastroduodenal artery; (13) Superior mesenteric vein exposure/dissection of the uncinate process; (14) Hepaticojejunostomy; (15) Cholecystectomy; and (16) Gastrojejunostomy. NCDB database review of 73 patients who underwent robotic TP revealed similar rates of margin negative resections and retrieved lymph nodes between robotic, laparoscopic, and open TP, whereas robotic and laparoscopic TP were associated with shorter in-hospital stay and reduced mortality at 30 and 90 days compared to open TP. Overall median survival of pancreatic adenocarcinoma patients who underwent TP was similar between robotic, laparoscopic, and open approaches. CONCLUSION:Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal operation and is feasible in a stepwise, reproducible technique. It is associated with improved postoperative outcomes and equivalent oncologic outcomes compared to open TP.

Abstract Background The current guidelines of the American Joint Committee on Cancer (AJCC) for the staging of exocrine pancreatic tumors seem inapplicable to malignant pancreatic intraductal papillary mucinous neoplasms (IPMN). Therefore, we aimed to improve the accuracy of clinical staging and prognosis for malignant IPMN by modifiing current AJCC system. Methods We extracted data of 2001 patients with malignant IPMN from the Surveillance, Epidemiology, and End Results database between 2000 and 2016. Of these, 1401 patients were assigned to the primary cohort and 600 patients to the validation cohort. Results In Kaplan–Meier analysis of the primary cohort, the current AJCC guidelines were unable to distinguish between certain tumor substages (IA and IB in the 7th, IB and IIA in the 8th). The modified system that we regrouped based on the median overall survival and hazard ratios, was superior in tumor stage classifications. Age > 70 years, tumors located in the body or tail, high-grade differentiated tumors, surgery, chemotherapy, and tumor, lymph node, and metastasis (TNM) stage were identified as independent predictive factors for overall survival. Compared to that of TNM-based systems, the concordance index of the clinical predictive nomogram significantly improved (0.819; 95% confidence interval, 0.805–0.833), with excellent area under the receiver operating characteristic curves (1-, 3-, and 5-year: 0.881, 0.889, and 0.879, respectively). The calibration curves also showed good agreement between prediction and actual observation. The analysis of treatment modalities revealed that surgery resulted in better survival for all resectable malignant IPMN. The analysis of chemotherapy data reveals its potential in improving the prognosis of treatment for patients with locally advanced or distant metastases. Conclusions Our modified staging system improves the distinction of tumor stages. The nomogram was a more accurate and clinically reliable tool for prognosis prediction of patients with malignant IPMN.

Pancreatic cystic lesions are a frequent incidental finding in abdominal imaging. Despite its usually benign background, a small fraction exhibiting features suspicious for cancerous development demands continuous follow-up or surgical removal. Current guidelines advocate magnetic resonance imaging and endoscopic ultrasound to evaluate the risk of malignancy, whereas transabdominal ultrasound is perceived as subordinate imaging. The objective of this study was to analyze cyst detection rates of latest-generation ultrasound machines compared to magnetic resonance imaging, computed tomography, and endosonographic ultrasound and to determine inter-rater reliability. The results showed that large cysts facilitate their visualization by transabdominal ultrasound while detection rates are independent of the anatomical part of the pancreas in which they were sited. Changes in the pancreatic duct width, a connection to the pancreatic duct system, and the architectural characteristics of cysts are poorly recognized by transabdominal ultrasound compared to magnetic resonance imaging and endoscopic ultrasound. Computed tomography imaging is preferred over transabdominal ultrasound to detect calcifications and regional lymphadenopathy. Even if conducted by experienced investigators, transabdominal ultrasound examinations fail to agree with magnetic resonance imaging scans regarding cyst detection rates (κ = 0.093). [ABSTRACT FROM AUTHOR]

Abstract Cystic pancreatic lesions (CPLs) are frequently casual findings in radiological examinations performed for other reasons in patients with unrelated symptoms. As they require different management according to their histological nature, differential diagnosis is essential. Radiologist plays a key role in the diagnosis and management of these lesions as imaging is able to correctly characterize most of them and thus address to a correct management. The first step for a correct characterization is to look for a communication between the CPLs and the main pancreatic duct, and then, it is essential to evaluate the morphology of the lesions. Age, sex and a history of previous pancreatic pathologies are important information to be used in the differential diagnosis. As some CPLs with different pathologic backgrounds can show the same morphological findings, differential diagnosis can be difficult, and thus, the final diagnosis can require other techniques, such as endoscopic ultrasound, endoscopic ultrasound-fine needle aspiration and endoscopic ultrasound-through the needle biopsy, and multidisciplinary management is important for a correct management.

Background: The inframesocolic approach to the uncinate process of the pancreas has been rarely described in literature. To the best of our knowledge, no robotic cases have been reported. Methods: The case of a 74-year-old woman, with a 43-mm branch-duct intraductal papillary mucinous neoplasm with worrisome features within the uncinate process of the pancreas, is described. Results: After diagnostic work-up, due to the uncertain potential of malignancy and the strong motivation of the patient to undergo surgery, we performed a robotic enucleation through an inframesocolic approach. The neoplasm was more than 1 cm from the main pancreatic duct. Final pathological diagnosis revealed a low-grade dysplasia branch-duct intraductal papillary mucinous neoplasm. Conclusions: The inframesocolic approach could represent an easy way to access the uncinate process of the pancreas, allowing safe limited resection in selected cases such as small branch-duct IPMN or pancreatic neuroendocrine tumors. [ABSTRACT FROM AUTHOR]

Background: The international consensus guidelines for intraductal papillary mucinous neoplasm of the pancreas (IPMN) presented clinical features as indications for surgery. Whereas surveillance for recurrence, including de novo lesions, is essential, optimal surveillance protocols have not been established.Aim and Methods: This study aimed to assess the clinical features of recurrence at the remnant pancreas (Rem-Panc) and extra-pancreas (Ex-Panc) after surgery for IPMN. Ninety-one patients of IPMN that underwent detailed preoperative assessment and pancreatectomy were retrospectively analyzed, focusing especially on the type of recurrence.Results: The IPMNs were finally diagnosed as low-grade dysplasia (LDA, n = 42), high-grade dysplasia (HAD, n = 19), and invasive carcinoma (IPMC, n = 30). Recurrence was observed in 26 patients (29%), of which recurrence was seen at Rem-Panc in 19 patients (21%) and Ex-Panc in 7 patients (8%). The frequency of Rem-Panc recurrence was 10% in LDA, 21% in HDA, and 37% in IPMC. On the other hand, Ex-Panc recurrence was observed only in IPMC (23%). Ex-Panc recurrence showed shorter median recurrence-free survival (RFS) and overall survival (OS) than Rem-Panc recurrence (median RFS 8 months vs. 35 months, p < 0.001; median OS 25 months vs. 72 months, p < 0.001). Regarding treatment for Rem-Panc recurrence, repeat pancreatectomy resulted in better OS than no repeat pancreatectomy (MST 36 months vs. 15.5 months, p = 0.033). On multivariate analysis, main duct stenosis or disruption as a preoperative feature (hazard ratio [HR] 10.6, p = 0.002) and positive surgical margin (HR 4.4, p = 0.018) were identified as risk factors for Rem-Panc recurrence.Conclusions: The risk factors for Rem-Panc and Ex-Panc recurrence differ. Therefore, optimal surveillance on these features is desirable to ensure that repeat pancreatectomy for Rem-Panc recurrence can be an appropriate surgical intervention. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: To compare the performance of CT and MRI radiomics for predicting the malignant potential of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, and to investigate their value compared to the revised 2017 international consensus Fukuoka guidelines.Materials and Methods: Sixty patients with surgically confirmed IPMNs (37 malignant and 23 benign) were included. Radiomics features were extracted from arterial and venous phase images of CT and T2-weighted images of MRI, respectively. Intraclass correlation coefficients for the radiomics features were calculated to assess the interobserver reproducibility. The least absolute shrinkage and selection operator algorithm was used for feature selection. Radiomics models were constructed based on selected features with logistic regression (LR) and support vector machine (SVM). A clinical and imaging model was constructed based on independent predictors of the revised 2017 Fukuoka guidelines determined in multivariate logistic regression with forward elimination.Results: The reproducibility of MRI radiomics features was higher than that of CT radiomics features, regardless of arterial or venous phase features (all p < 0.001). MRI radiomics models achieved improved AUCs (0.879 with LR and 0.940 with SVM, respectively), than that of CT radiomics models (0.811 with LR and 0.864 with SVM, respectively). All radiomics models provided better predictive performance than the clinical and imaging model (AUC = 0.764).Conclusion: The MRI radiomics models with higher reproducibility radiomics features performed better than CT radiomics models for predicting the malignant potential of IPMNs. The performance of radiomics models was superior to the clinical and imaging model based on Fukuoka guidelines. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate whether an ultrashort-protocol (USP) MRI including only T2-weighted HASTE axial and 3D MRCP SPACE sequences adequately measures the largest diameter of the largest cyst and the main pancreatic duct (MPD) and identifies worrisome features (WF) and high-risk stigmata (HRS) when compared to longer protocols (LP, long protocol; SP, short protocol; S-LP, short or long protocol). We also calculated reductions in costs associated with USP. Methods: This retrospective study included 183 IPMN patients. Two radiologists compared two imaging sets (USP versus S-LP) per patient, comparing the mean values of the largest cyst and MPD and agreement regarding the presence or absence of cystic or MPD mural nodules and solid pancreatic tumors. The interobserver agreement for cystic mural nodules and WF/HRS was evaluated, using the Bland-Altman plot and Cohen's Kappa. Results: A total of 112 IPMN patients were evaluated. For detecting cysts or MPD nodules, WF/HRS, and solid pancreatic tumors, USP and S-LP coincided in 94.9%, 99.1%, 92.4%, and 99.1% of cases, respectively. Both USP and S-LP identified all true cystic mural nodules. The mean size of the largest cyst and MPD was 19.48/19.67 mm and 3.24/3.33 mm using USP versus S-LP, while the mean differences for USP versus S-LP were 0.19 mm and 0.08 mm. The USP cost was 39% of LP cost and 77% of SP. Interobserver agreement was moderate to strong. Conclusions: For IPMN surveillance, an ultrashort-protocol MRI provides nearly identical information to the more expensive longer protocols. [ABSTRACT FROM AUTHOR]

Background: The current guidelines of the American Joint Committee on Cancer (AJCC) for the staging of exocrine pancreatic tumors seem inapplicable to malignant pancreatic intraductal papillary mucinous neoplasms (IPMN). Therefore, we aimed to improve the accuracy of clinical staging and prognosis for malignant IPMN by modifiing current AJCC system.Methods: We extracted data of 2001 patients with malignant IPMN from the Surveillance, Epidemiology, and End Results database between 2000 and 2016. Of these, 1401 patients were assigned to the primary cohort and 600 patients to the validation cohort.Results: In Kaplan-Meier analysis of the primary cohort, the current AJCC guidelines were unable to distinguish between certain tumor substages (IA and IB in the 7th, IB and IIA in the 8th). The modified system that we regrouped based on the median overall survival and hazard ratios, was superior in tumor stage classifications. Age > 70 years, tumors located in the body or tail, high-grade differentiated tumors, surgery, chemotherapy, and tumor, lymph node, and metastasis (TNM) stage were identified as independent predictive factors for overall survival. Compared to that of TNM-based systems, the concordance index of the clinical predictive nomogram significantly improved (0.819; 95% confidence interval, 0.805-0.833), with excellent area under the receiver operating characteristic curves (1-, 3-, and 5-year: 0.881, 0.889, and 0.879, respectively). The calibration curves also showed good agreement between prediction and actual observation. The analysis of treatment modalities revealed that surgery resulted in better survival for all resectable malignant IPMN. The analysis of chemotherapy data reveals its potential in improving the prognosis of treatment for patients with locally advanced or distant metastases.Conclusions: Our modified staging system improves the distinction of tumor stages. The nomogram was a more accurate and clinically reliable tool for prognosis prediction of patients with malignant IPMN. [ABSTRACT FROM AUTHOR]

Background/Aims: We investigated chromosomal aberrations in patients with pancreatic ductal adenocarcinoma (PDAC) and intraductal papillary mucinous neoplasm (IPMN) by fluorescence in situ hybridization (FISH) to identify cytogenetic changes and molecular markers that may be useful for preoperative diagnosis. Methods: Tissue samples from 48 PDAC and 17 IPMN patients were investigated by FISH analysis using probes targeting chromosomes 7q, 17p, 18q, 20q, and 21q and the pericentromeric region of chromosome 18 (CEP18). Results: The PDAC samples harbored 17p deletion (95.8%), 18q deletion (83.3%), CEP18 deletion (81.2%), 20q gain (81.2%), 21q deletion (77.1%), and 7q gain (70.8%). The IPMN samples had 17p deletion (94.1%), CEP18 deletion (94.1%), 21q deletion (70.6%), 18q deletion (58.8%), 20q gain (58.8%), and 7q gain (58.8%). A significant difference in CEP18 gain was identified between the PDAC and IPMN groups (p=0.029). Detection of 17p or 18q deletion had the highest diagnostic accuracy (80.0%) for PDAC. Conclusions: Chromosomal alterations were frequently identified in both PDAC and IPMN with similar patterns. CEP18 gain and 17p and 18q deletions might be involved in the later stages of PDAC tumorigenesis. Chromosome 17p and 18q deletions might be excellent diagnostic markers.

Abstract Background Because of its rare indication and relatively simple reconstruction procedure (only choledochojejunostomy and gastrojejunostomy) compared to those for pancreatoduodenectomy, the technical tips and pitfalls of total pancreatectomy are rarely discussed. Herein, we discuss a rare case of gastric volvulus 1 year after total pancreatectomy and provide advice to prevent such cases. Case presentation A 66-year-old woman underwent total pancreatectomy with splenectomy for mixed-type intraductal papillary mucinous neoplasm of the pancreas. Choledochojejunostomy (retro-colic route) and gastrojejunostomy (ante-colic route, Billroth II method) were performed for reconstruction. The final diagnosis was mixed-type intraductal papillary mucinous adenoma of the pancreas without malignant neoplasm. She had no clinical symptoms, such as abdominal pain and fever, during postoperative follow-up. However, at 1 year postoperatively, she complained of abdominal pain. Contrast-enhanced abdominal computed tomography showed volvulus and perforation of the stomach. Emergent surgery was performed. The stomach fornix was located on the right side and was partly perforated. We resected the perforation site with a linear cutter® (New Type Linear Cutter, Ethicon, USA) and released the gastric volvulus. Moreover, we fixed the stomach to the left abdominal wall using non-absorbable thread. The cause of the perforation was clinically and pathologically unclear. Her serum albumin and cholinesterase levels temporarily decreased postoperatively, but gradually increased. A recurrence of volvulus-related symptoms has not been observed. Conclusions After total pancreatectomy with splenectomy, although the stomach is connected with the jejunum, it is typically fixed only by the pedicle of the left gastric artery and vein. In the present case, this anatomical change may have been a cause of the gastric volvulus. Thus, it might be better to fix the remnant stomach in total pancreatectomy with splenectomy.

Backgrounds/aims: The guidelines regarding the management of intraductal papillary mucinous neoplasms (IPMNs) all have slightly different surgical indications for high-risk lesions. We aim to retrospectively compare the accuracy of four guidelines in recommending surgery for high-risk IPMNs, and assess the accuracy of elevated CA-19-9 levels and imaging characteristics of IPMNs considered high-risk in predicting malignancy or high-grade dysplasia (HGD)., Methods: The final histopathological diagnosis of surgically resected high-risk IPMNs during 2013-2020 were compared to preoperative surgical indications, as enumerated in four guidelines: the 2015 American Gastroenterological Association (AGA), 2017 International Consensus, 2018 European Study Group, and 2018 American College of Gastroenterology (ACG). Surgery was considered "justified" if histopathology of the surgical specimen showed HGD/malignancy, or there was postoperative symptomatic improvement., Results: Surgery was postoperatively justified in 26/65 (40.0%) cases. All IPMNs with HGD/malignancy were detected by the 2018 ACG and the combined (absolute and relative criteria) 2018 European guidelines. The combined ("high-risk stigmata" and "worrisome features") 2017 International guideline missed 1/19 (5.3%) IPMNs with HGD/malignancy. The 2015 AGA guideline missed the most cases (11/19, 57.9%) of IPMNs with HGD/malignancy. We found the features most-associated with HGD/malignancy were pancreatic ductal dilation, and elevated CA-19-9 levels., Conclusions: Following the 2015 AGA guideline results in the highest rate of missed HGD/malignancy, but the lowest rate of operating on IPMNs without these features; meanwhile, the 2018 ACG and the combined (absolute and relative criteria) 2018 European guidelines result in more operations for IPMNs without HGD/malignancy, but the lowest rates of missed HGD/malignancy in IPMNs.

Objective: Rare coexistence of disease or pathology. Background: Intraductal papillary mucinous neoplasm of the pancreas (IPMN) and pancreatic ductal adenocarcinoma (PDAC) often coexist in the same pancreas. Almost all IPMNs involving PDACs concomitant with IPMN have been shown to be branch duct type IPMNs (BD-IPMNs), and their histological subtypes are gastric type. Therefore, PDACs concomitant with main duct type IPMNs (MD-IPMNs) are considered to be rare. We herein report a rare case preoperatively diagnosed as being a PDAC concomitant with MD-IPMN on the basis of imaging findings and histological findings of pancreatic specimens endoscopically obtained from 2 lesions. Case Report: A 67-year-old man was referred to our hospital due to an enlarged pancreas. Using imaging studies, a solid mass was found in the pancreatic head and intraductal papillary masses in the dilated main pancreatic duct of the body and tail with a fistula in the duodenum. On the basis of histological results using specimens endoscopically obtained from each of the 2 lesions, total pancreatectomy was planned due to suspected PDAC concomitant with an MD-IPMN. Finally, resected specimens were used to confirm the presence of a rare case of PDAC concomitant with MD-IPMN. Conclusions: We encountered a rare case of a PDAC concomitant with an MD-IPMN which could be preoperatively diagnosed by using imaging studies and histological specimens endoscopically obtained. In addition to invasive cancers derived from IPMNs, PDACs concomitant with IPMNs can rarely develop in the pancreas involving MD-IPMNs. [ABSTRACT FROM AUTHOR]

The pancreatic neuroendocrine tumors (PanNETs) most commonly present as solid neoplasms; however, very rarely, they may present primarily as cystic neoplasms. Most of the cystic PanNETs are non-secreting tumors, and the radiological features are not well defined. Hence pre-operative diagnosis is usually challenging and the tumors are misdiagnosed as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, serous cystic neoplasms, solid pseudopapillary neoplasms, and non-neoplastic cysts. However, the management depends on the accurate diagnosis of these cystic lesions, which poses a dilemma. Herein, we report the case of a cystic PanNET in the tail of the pancreas, which was clinically and radiologically misdiagnosed as a mucinous cystic neoplasm. This case is reported to highlight this issue to the medical community regarding the diagnostic difficulty in such rare non-functioning pancreatic neuroendocrine tumors.

Cystic pancreatic lesions (CPLs) are frequently casual findings in radiological examinations performed for other reasons in patients with unrelated symptoms. As they require different management according to their histological nature, differential diagnosis is essential. Radiologist plays a key role in the diagnosis and management of these lesions as imaging is able to correctly characterize most of them and thus address to a correct management. The first step for a correct characterization is to look for a communication between the CPLs and the main pancreatic duct, and then, it is essential to evaluate the morphology of the lesions. Age, sex and a history of previous pancreatic pathologies are important information to be used in the differential diagnosis. As some CPLs with different pathologic backgrounds can show the same morphological findings, differential diagnosis can be difficult, and thus, the final diagnosis can require other techniques, such as endoscopic ultrasound, endoscopic ultrasound-fine needle aspiration and endoscopic ultrasound-through the needle biopsy, and multidisciplinary management is important for a correct management. [ABSTRACT FROM AUTHOR]

Objectives: To assess the diagnostic performance of the 2017 international consensus guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare the diagnostic performance and intermodality agreement between contrast-enhanced CT and MRI. Methods: We retrospectively evaluated patients with surgical resection of IPMN of the pancreas who underwent preoperative CT and MRI between 2009 and 2019. Two radiologists evaluated the clinical and imaging features of IPMN of pancreas according to the 2017 international consensus guideline. Univariable and multivariable analyses were performed to identify significant predictors of malignancy in IPMN. The diagnostic abilities of CT and MRI were compared, and their intermodality agreement was determined. Results: Of 175 patients (mean age, 64 years; 116 males), 88 (50.3%) had malignant IPMN. On multivariable analysis, all three high-risk stigmata (main pancreatic duct [MPD] ≥ 10 mm, mural nodule ≥ 5 mm, and obstructive jaundice) and two worrisome features (MPD 5–9 mm and elevated carbohydrate antigen 19–9) were associated with malignant IPMN on CT and MRI (p < 0.05). A mural nodule < 5 mm on MRI was also associated with malignant IPMN (OR 5.3, p = 0.009). The diagnostic accuracy of high-risk stigmata showed no difference between CT and MRI (73.7% vs. 75.4%, p = 0.505), with good to excellent intermodality agreement. Conclusions: Current high-risk stigmata had the strongest association with malignant IPMN on CT and MRI. Although MRI is superior to CT for identifying mural nodules, diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI. Key Points: • The current high-risk stigmata in the 2017 International Consensus Guidelines had the strongest association with malignant IPMN on CT and MRI. • MRI is better than CT for identifying enhancing mural nodule. • Diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI. [ABSTRACT FROM AUTHOR]

Pancreatic neuroendocrine tumors (PanNETs) are rare pancreatic tumors. They usually exhibit parenchymal growing, however some cases can exhibit intraductal growing. PanNET with intraductal growth may cause intraductal papillary mucinous neoplasm (IPMN)- like clinic scenario by presenting as cystic formations secondary to duct obstruction. In our case, a 69-year- old man with a history of abdominal pain and nausea underwent a computed tomography scan that showed dilated pancreatic duct and cystic lesion which was 8 cm originating from the pancreas. Imaging and laboratory findings were considered to be consistent with an IPMN so the patient underwent distal pancreatectomy and splenectomy. However, the pathological examination of the surgical specimen showed a millimeter-sized PanNET located in pancreatic tail mimicking the IPMN by obstructing the pancreatic duct. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the predictors of intraductal papillary mucinous neoplasms of the pancreas (IPMNs) with high-grade dysplasia, using 2-dimensional (2D) analysis and 3-dimensional (3D) volume-of-interest-based apparent diffusion coefficient (ADC) histogram analysis. Material and methods: The data of 45 patients with histopathologically confirmed IPMNs with high-grade or lowgrade dysplasia were retrospectively assessed. The 2D analysis included lesion-to-spinal cord signal intensity ratio (LSR), minimum ADC value (ADCmin), and mean ADC value (ADCmean). The 3D analysis included the overall mean (ADCoverall mean), mean of the bottom 10th percentile (ADCmean0-10), mean of the bottom 10-25th percentile (ADCmean10-25), mean of the bottom 25-50th percentile (ADCmean25-50), skewness (ADCskewness), kurtosis (ADCkurtosis), and entropy (ADCentropy). Diagnostic performance was compared by analysing the area under the receiver operating characteristic curve (AUC). Inter-rater reliability was assessed by blinded evaluation using the intraclass correlation coefficient. Results: There were 16 and 29 IPMNs with high- and low-grade dysplasia, respectively. The LSR, ADCoverall mean, ADCmean0-10, ADCmean10-25, ADCmean25-50, and ADCentropy showed significant between-group differences (AUC = 72-93%; p < 0.05). Inter-rater reliability assessment showed almost perfect agreement for LSR and substantial agreement for ADCoverall mean and ADCentropy. Multivariate logistic regression showed that ADCoverall mean and ADCentropy were significant independent predictors of malignancy (p < 0.05), with diagnostic accuracies of 80% and 73%, respectively. Conclusion: ADCoverall mean and ADCentropy from 3D analysis may assist in predicting IPMNs with high-grade dysplasia. [ABSTRACT FROM AUTHOR]

The present study aims to compare low-kV CT reconstructed with MBIR technique with MRI in detecting high-risk stigmata and worrisome features in patients with pancreatic cystic lesions. We retrospective enrolled 75 patients who underwent low-kV CT with contrast media injection for general abdominal disorders and MRI with MRCP sequences. The reviewer, blinded to clinical and histopathological data, recorded the overall number of pancreatic cystic lesions, size, location, presence of calcifications, septa, or solid enhancing or non-enhancing components, main pancreatic duct (MPD) communication, and MPD dilatation. Mean differences with 95% limits of agreement, ICC, and κ statistics were used to compare CT and MRI. More pancreatic cystic lesions were detected with MRI than with CT, however, the ICC value of 0.81 suggested a good agreement. According to the evaluated target lesion, a very good agreement (ICC = 0.98) was found regarding the diameter (21.4 mm CT vs 21.8 mm MRI), the location (κ = 0.90), the detection of MPD dilatation (κ = 1), the presence of septa (κ = 0.86) and the MPD communication (κ = 0.87). A moderate agreement on the assessment of enhanced components was noted (κ = 0.44), while there was only a fair agreement about the presence of calcifications (κ = 0.87). MDCT can be considered almost equivalent to MRI with MRCP in the evaluation of worrisome features and high-risk stigmata, offering detailed morphologic features helpful for their characterization. Even if MRI is considered the reference standard in pancreatic cystic lesions characterization, CT can be considered a useful tool as a first-line imaging technique to identify worrisome features and high-risk stigmata. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the use of volumetric multiparametric MRI in differentiating pancreatic intraductal papillary mucinous neoplasms (IPMNs) from serous cystadenomas (SCAs) Methods: Included patients (123 patients with pancreatic cystic neoplasms (PCNs) measuring ≥ 10 mm) were stratified into two groups based on cyst type. Axial cyst size, region of interest (ROI)-based apparent diffusion coefficient (ADC) and volumetric data, including cyst volume, volumetric apparent diffusion coefficient (vADC), and volumetric venous enhancement (vVE) were extracted and compared between the two groups. Univariate and multiple logistic regression was used to develop models for distinguishing between IPMNs and SCAs. Results: Volume and size of the cysts, vVE and vADC and ROI-ADC were significantly different between the two groups. Cyst volume was significantly larger in SCAs (median = 14.1cm3, IQR 3.5–42.5) than in IPMNs (median = 2.5 cm3, IQR 1.1–6) (p < 0.001). IPMNs had a higher volumetric ADC value in comparison to SCAs (2925 ± 294 × 10–6 mm2/s vs 2521 ± 202 × 10–6 mm2/s, p < 0.001). However, IPMNs had lower vVE values compared to SCAs (37 signal intensity (SI) vs 86 SI, p < 0.001). Area under the ROC Curve (AUC) of the model that included vADC and cyst volume had 95% accuracy in distinguishing between the two groups. In comparison, the AUC of the model that included ROI-ADC and axial cyst size had 84% accuracy in distinguishing between the two groups. A threshold of 2615 × 10−6 mm2/s for volumetric ADC resulted in the identification of IPMNs from SCAs with sensitivity and specificity of 90.8% and 73.5%, respectively. Conclusion: IPMNs had smaller cyst volume, higher volumetric ADC and lower volumetric VE values compared to SCAs. Volumetric multiparametric MRI could be useful in differentiating between the IPMN and SCA groups. [ABSTRACT FROM AUTHOR]

Background: Autoimmune Pancreatitis (AIP) is a rare chronic inflammatory disease affecting the pancreas. Chronic pancreatic inflammation represents a risk factor for pre-neoplastic conditions such as Intraductal Papillary Mucinous Neoplasia (IPMN). Due to the rarity of AIP, the incidence, and clinical features of IPMN occurring in AIP patients remains unknown., Aims: In the present study we aimed to explore the relationship between AIP and IPMN and to characterize the clinical features and outcomes of IPMN occurring in the context of AIP., Methods: We retrospectively (2008-2020) analyzed the clinical and radiological records of a large single center cohort of patients with AIP and investigated the prevalence of IPMN. We then compared the clinical, laboratory and radiological characteristics of patients with IPMN and AIP with a cohort of patients with isolated IPMN., Results: Five hundred and nineteen patients were included in this retrospective study. Sixteen patients had concomitant IPMN and AIP(3%); 61 patients had isolated AIP (12%); 442 patients had isolated IPMN (85%). The prevalence of IPMN in patients with AIP was higher than that observed in the general population (21%vs8-10%). Worrisome Features and High-Risk Stigmata were more frequently observed in IPMN occurring together with AIP compared to isolated IPMN(p < 0.05). Based on radiological features IPMN in the context of AIP was more frequently of main-duct type compared to isolated IPMN(p < 0.05)., Conclusion: Our data suggest that AIP represents a chronic inflammatory condition that might favor IPMN development with high-risk features. Prolonged surveillance of these patients and longitudinal studies are required to further test the association with AIP and malignant and pre-malignant conditions., (Copyright © 2024 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: The management of invasive intraductal papillary mucinous cystic neoplasm (I-IPMN) does not differ from de novo pancreatic ductal adenocarcinoma (PDAC); however, I-IPMNs are debated to have better prognosis. Despite being managed similarly to PDAC, no data are available on the response of I-IPMN to neoadjuvant chemotherapy., Methods: All patients undergoing pancreatic resection for a pancreatic adenocarcinoma from 2011 to 2022 were included. The PDAC and I-IPMN cohorts were compared to evaluate response to neoadjuvant therapy (NAT) and overall survival (OS)., Results: This study included 1052 PDAC patients and 105 I-IPMN patients. NAT was performed in 25% of I-IPMN patients and 65% of PDAC patients. I-IPMN showed a similar pattern of pathological response to NAT compared with PDAC (p = 0.231). Furthermore, positron emission tomography (PET) response (71% vs. 61%; p = 0.447), CA19.9 normalization (85% vs. 76%, p = 0.290), and radiological response (32% vs. 37%, p = 0.628) were comparable between I-IPMN and PDAC. A significantly higher OS and disease-free survival (DFS) of I-IPMN was denoted by Kaplan-Meier analysis, with a p-value of < 0.001 in both plots. In a multivariate analysis, I-IPMN histology was independently associated with lower risk of recurrence and death., Conclusions: I-IPMN patients have a longer OS and DFS after surgical treatment when compared with PDAC patients. The more favorable oncologic outcome of I-IPMNs does not seem to be related to early detection, as I-IPMN histological subclass is independently associated with a lower risk of disease recurrence. Moreover, neoadjuvant effect on I-IPMN was non-inferior to PDAC in terms of pathological, CA19.9, PET, and radiological response and thus can be considered in selected patients., (© 2024. The Author(s).)