New guidelines for use of endoscopic ultrasound for evaluation and risk stratification of pancreatic cystic lesions may be too conservative
The role of EUS in managing asymptomatic pancreatic cystic lesions (PCLs) remains unresolved. We retrospectively evaluated EUS in risk stratification of PCLs when adhering to the most recent AGA guidelines.
Asymptomatic PCLs that were evaluated by EUS from January 2014 to December 2014 were retrospectively reviewed including associated cytology, fluid analysis, and relevant surgical pathology. Cross-sectional imaging reports were reviewed blindly by an expert radiologist using AGA risk stratification terminology. Accepted imaging high-risk features (HRF) included cyst diameter > 3 cm, dilated upstream pancreatic ducts, and a solid component in the cyst.
We reviewed 125 patients who underwent EUS. Expert review of cross-sectional imaging resulted in a different interpretation 25% of the time including 1 malignant cyst. Ninety-three patients (75%) had no HRFs on cross-sectional imaging; 28 patients (22%) were diagnosed with 1 HRF and 4 patients (3%) had 2 HRFs. Adhering to AGA guidelines using 2 HRF as threshold for use of EUS, the diagnosis of malignant and high-risk premalignant lesions (including pancreatic adenocarcinoma, mucinous cystadenoma, neuroendocrine tumors, and IPMN with dysplasia) had a 40% sensitivity and 100% specificity. Had EUS been utilized based on a threshold of 1 HRF on imaging, malignant and high-risk premalignant lesions would have been identified with 80% sensitivity and 95% specificity. By adding EUS to radiographic imaging, the specificity for detecting carcinomas (p = 0.0009) and detection of all premalignant lesions (p = 0.003) statistically improved. Furthermore, EUS allowed 14 patients (11%) to avoid further surveillance by lowering their risk stratification.
EUS remains an essential risk stratification modality for incidental PCLs. Current guideline suggestions of its utility may be too stringent. Our study justifies expert radiology review when managing PCLs. Further studies are required to identify the optimal approach to PCL management.
KeywordsPancreatic cysts EUS Guidelines
Compliance with ethical standards
Dr. Nadav Sahar, Dr. Anthony Razzak, Dr. Zaheer S. Kanji, Dr. David L. Coy, Dr. Richard Kozarek, Dr. Andrew S. Ross, Dr. Michael Gluck, Dr. Michael Larsen, Dr. Shayan Irani, and Dr. S. Ian Gan have no conflicts of interest or financial ties to disclose.
- 6.Tada M, Kawabe T, Arizumi M, Togawa O, Matsubara S, Yamamoto N, Nakai Y, Sasahira N, Hirano K, Tsujino T, Tateishi K, Isayama H, Toda N, Yoshida H, Omata M (2006) Pancreatic cancer in patients with pancreatic cystic lesions: a prospective study in 197 patients. Clin Gastroenterol Hepatol 4:1265–1270CrossRefPubMedGoogle Scholar
- 7.Tanaka M, Chari S, Adsay V, Fernandez-del Castillo C, Falconi M, Shimizu M, Yamaguchi K, Yamao K, Matsuno S (2006) International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 6:17–32CrossRefPubMedGoogle Scholar
- 8.Tanaka M, Fernandez-del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, Kimura W, Levy P, Pitman MB, Schmidt CM, Shimizu M, Wolfgang CL, Yamaguchi K, Yamao K (2012) International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 12:183–197CrossRefPubMedGoogle Scholar
- 10.Singhi AD, Zeh HJ, Brand RE, Nikiforova MN, Chennat JS, Fasanella KE, Khalid A, Papachristou GI, Slivka A, Hogg M, Lee KK, Tsung A, Zureikat AH, McGrath K (2016) American Gastroenterological Association guidelines are inaccurate in detecting pancreatic cysts with advanced neoplasia: a clinicopathologic study of 225 patients with supporting molecular data. Gastrointest Endosc 83:1107–1117.e1102CrossRefPubMedGoogle Scholar
- 14.Goh BK, Thng CH, Tan DM, Low AS, Wong JS, Cheow PC, Chow PK, Chung AY, Wong WK, Ooi LL (2014) Evaluation of the Sendai and 2012 International Consensus Guidelines based on cross-sectional imaging findings performed for the initial triage of mucinous cystic lesions of the pancreas: a single institution experience with 114 surgically treated patients. Am J Surg 208:202–209CrossRefPubMedGoogle Scholar
- 15.Ge PS, Muthusamy VR, Gaddam S, Jaiyeola DM, Kim S, Sedarat A, Donahue TR, Hosford L, Wilson RH, Grande DP, Keswani RN, Kushnir VM, Mullady D, Edmundowicz SA, Early DS, Komanduri S, Wani S, Watson RR (2017) Evaluation of the 2015 AGA guidelines on pancreatic cystic neoplasms in a large surgically confirmed multicenter cohort. Endosc Int Open 5:E201-e208PubMedPubMedCentralGoogle Scholar