Aim: Aim of the present study is to describe the natural history of IPMNs observed at a high-volume center for thirty years. Methods: Growth rates were analyzed through a linear-mixed model. The development of worrisome features (WF), high-risk stigmata (HRS), pancreatic cancer (PC), survival and risk for surgery were analyzed. Results: From a total of 2189 observed patients, 1529 were included. The overall growth rate was 1mm/year. For about half of cases no dimensional change was documented. The presence of high risk stigmata (HRS), age < 75 years, and cyst size >30mm at diagnosis were associated to a faster growth rate. During follow-up, IPMNs developed WF in 6.5% of cases and HRS in 0.6%. Overall, 3.5% of patients developed PC after a median time of 28 months. Of these PC patients, 72% previously developed HRS/WF. Of 1043 initially observed indolent branch duct (BD) IPMNs, 16 eventually developed PC with 10% occurring after 15 years of follow-up. HRS and growth rate were independent predictors of PC. Growth rate was the only difference between IPMNs developing PC and those remained stable after more than 5 years of follow-up (n=399). The mean estimated disease specific survival (DSS) for the overall population exceeded 19 years. Conclusions: IPMN of the pancreas is the indolent precursor of PDAC that will not show a detectable growth during follow-up in half of the cases. Those rapidly growing (>2.75 mm/year) will likely progress to pancreatic cancer through the development of WF and HRS during the first year of follow-up.