Evaluation of the 2015 AGA guidelines on pancreatic cystic neoplasms in a large surgically confirmed multicenter cohort

Abstract

Absract Background and study aims The American Gastroenterological Association (AGA) recently published guidelines for the management of asymptomatic pancreatic cystic neoplasms (PCNs). We aimed to evaluate the diagnostic characteristics of the AGA guidelines in appropriately recommending surgery for malignant PCNs. Patients and methods A retrospective multicenter study was performed of patients who underwent endoscopic ultrasound (EUS) for evaluation of PCNs who ultimately underwent surgical resection from 2004 – 2014. Demographics, EUS characteristics, fine-needle aspiration (FNA) results, type of resection, and final pathologic diagnosis were recorded. Patients were categorized into 2 groups (surgery or surveillance) based on what the AGA guidelines would have recommended. Performance characteristics for the diagnosis of cancer or high-grade dysplasia (HGD) on surgical pathology were calculated. Results Three hundred patients underwent surgical resection for PCNs, of whom the AGA guidelines would have recommended surgery in 121 (40.3 %) and surveillance in 179 (59.7 %) patients. Among patients recommended for surgery, 45 (37.2 %) had cancer, whereas 76 (62.8 %) had no cancer/HGD. Among patients recommended for surveillance, 170 (95.0 %) had no cancer/HGD; however, 9 (5.0 %) patients had cancer that would have been missed. For the finding of cancer/HGD on surgical pathology, the AGA guidelines had 83.3 % sensitivity (95 % CI 70.7 – 92.1), 69.1 % specificity (95 % CI 62.9 – 74.8), 37.2 % positive predictive value (95 % CI 28.6 – 46.4), 95.0 % negative predictive value (95 % CI 90.7 – 97.7), and 71.7 % accuracy (95 % CI 67.4 – 74.6). Conclusions The 2015 AGA guidelines would have resulted in 60 % fewer patients being referred for surgical resection, and accurately recommended surveillance in 95 % of patients with asymptomatic PCNs. Future prospective studies are required to validate these guidelines.Meeting presentations: Presented in part at Digestive Diseases Week 2016

Corrected: Correction: Long-term follow-up of low-risk branchduct IPMNs of the pancreas: is main pancreatic duct dilatation the most worrisome feature?

“…Similar results were provided by Ge et al in a multicenter study of 300 patients with PCNs (including 198 IPMNs), where retrospective application of the AGA guidelines had 83.3% sensitivity and 69.1% specificity for malignancy. Although the guidelines accurately recommended surveillance in 95% of patients, nine invasive cancers (5%) would have been missed 28 . If retrospectively applied to our subgroup of operated patients, the AGA guidelines would not have spared the two patients with low-/intermediate-grade dysplasia from overtreatment because of the copresence of mural nodule and cyst size ≥3 cm in one case and symptoms (acute pancreatitis) in the other.…”

Comparing accuracy of high-risk features for detecting advanced neoplasia in pancreatic cystic lesions: a systematic review and meta-analysis

“…All the 8 studies were retrospective cohort studies; they included 2 multicenter studies and 6 single-center studies. Seven studies were from the United States and one study was from Japan [ 18 - 25 ]. The quality of the studies was assessed using the Newcastle-Ottawa scale and is reported in .…”

“…Among these, Kohli et al [ 20 ], Sighinolfi et al [ 23 ] and Imbe et al [ 19 ] reported the location of the cyst, most commonly in the head of the pancreas (39.5%). The diagnosis of advanced neoplasia was made based on a histological evaluation of resected pancreas [ 18 , 21 , 23 ], cytological analysis of cells aspirated from pancreatic cysts [ 20 , 24 ], or a combination of the two [ 22 ]. Singhi et al also performed molecular testing on aspirated pancreatic cyst fluid to assess mutations in KRAS , GNAS , VHL , TP53 , PIK3CA , and PTEN genes [ 24 ].…”

A Blood-based Gene-expression Scoring System for Cancer Screening in Patients With Branch-duct Intraductal Papillary Mucinous Neoplasms

“…However, interpreting the results of these sophisticated modalities (e.g. endoscopic ultrasound or magnetic resonance imaging) requires expertise, and the diagnostic performance of the guidelines was reported to be varied in distinguishing benign IPMN and IPMC (sensitivity range from 7.3 to 83.3% and specificity range from 35.2 to 88.2%) (6)(7)(8)(9)(10). Regarding concomitant PDAC, little evidence exists for a screening program.…”