Significant intra-pancreatic fat deposition is a crucial marker for worse survival in high-grade pancreatic neuroendocrine neoplasms.

• 27.6% of 87 patients had significant intra-pancreatic fat deposition (ipfd).
• Patients with ipfd showed a higher likelihood of tumors in the pancreatic head (75% vs. 49.2%, p = 0.030) and metabolic dysfunction-associated liver disease (20.8% vs. 3.2%, p = 0.023).
• Each unit increase in ipfd was linked to over double the risk of both overall (HR 2.134) and disease-specific survival (HR 2.167).

Surgeons should consider ipfd in risk stratification for treatment planning and patient counseling.