EUS-Guided Radiofrequency Ablation for IPMNs with Worrisome Features: Promise or Illusion?

Aims Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) are precancerous cystic lesions. Surgery is advised for high-risk stigmata (HRS) or multiple worrisome features (WF) but entails substantial morbidity, and many resections reveal only low-grade dysplasia. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is a minimally invasive alternative, yet long-term data are limited ([ Table 1 ]). Table 1 WF/HRS at baseline and local control/complete response after EUS-RFA in BD-IPMN (N=52) Mural nodule≥5mm 22 (42%) 21/22 2/22 HRS Obstructive jaundice 0 (0%) 0 0 Main pancreatic duct≥10mm 0 (0%) 0 0 WF Rapid growth (≥5 mm over 2 years) 24 (46%) 24/24 5/24 Mural nodule≤5mm 10 (192%) 10/10 0 Cyst≥30mm 12 (23%) 12/12 0 Pancreatitis due to the IPMN 13 (25%) 12/13 0 Thickened/enhancing cyst wall 10 (19%) 10/10 1/10 Main duct size 5-9mm 6 (11.5%) 6/6 0 Abrupt change in caliber of main pancreatic duct with distal pancreatic atrophy 2 (4%) 2/2 1/2 New onset diabetes at diagnosis 2 (4%) 2/2 0 Number of HRS and WF per treated IPMN 0 1 1/1 1/1 1 26 26/26 7/26 2 12 11/12 1/12 3 9 9/9 0/9 4 3 3/3 0/3 5 1 1/1 0/1 Methods We retrospectively analyzed a prospectively maintained cohort of consecutive patients who underwent EUS-RFA for BD-IPMNs with WF/HRS at a tertiary referral center (2015–2024). Eligible patients were inoperable or declined surgery. Outcomes included technical success, adverse events (AEs), local control (resolution of WF/HRS with no cancer arising from the treated lesion), radiologic response, and pancreas-wide events. Results Fifty patients (62 procedures; 58 lesions) were treated. Mean follow-up was 4.1±2.8 years after RFA (9 years from IPMN diagnosis). Technical success was 100%. AEs occurred in 27%, mostly mild abdominal pain; significant AEs occurred in 8% (acute pancreatitis); there were no procedure-related deaths. Local control was achieved in 98% of lesions; 17% showed complete radiologic disappearance and 86% decreased in size. No treated lesion progressed to cancer. Pancreas-wide disease control was maintained in 80% of patients; four (8%) developed pancreatic cancer remote from the treated cyst. Smaller cyst size and fewer WF were associated with better outcomes. Conclusions EUS-RFA is feasible, safe, and provides durable local control of BD-IPMNs with WF/HRS in patients unsuitable for surgery or declining resection. These results support EUS-RFA as a promising therapeutic option in carefully selected patients. Larger prospective studies are needed to refine selection criteria and confirm long-term oncologic benefit. Article published online: 05 June 2026 © 2026. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany