Improving diagnostic accuracy and appropriate indications for surgery in pancreatic cystic neoplasms: the role of EUS

      Background and Aims

      Pancreatic cystic neoplasms (PCNs) represent a difficult preoperative diagnosis despite improvements in imaging. In this study, we compared preoperative and final pathologic diagnosis in a large cohort of resected PCNs, evaluating diagnostic accuracy with a specific focus on the value of EUS.

      Methods

      A retrospective analysis of patients undergoing resection between 2009 and 2019 for presumed PCNs was performed. Preoperative workup was reviewed by analyzing the role of imaging and EUS. Patients with a benign histology who did not show absolute indication were categorized as “delayable surgery.”

      Results

      Of 585 patients who were retrospectively analyzed, in 108 (18.5%) final histology did not confirm preoperative diagnosis. EUS was associated with a lower rate of incorrect diagnosis (16%; P = .03), but the risk of overtreatment was similar regardless of instrumental diagnostic path (33/131 vs 68/328, P = .298). Dilatation of the main pancreatic duct and cytologic sampling were the only variables independently associated with a correct diagnosis (P < .001 and P = .041, respectively). Based on clinical presentation and final histology, pancreatic resection could have been spared or delayed in 101 of 459 patients (22%), and this was influenced by age (odds ratio [OR], .97; P = .002), cyst larger than 30 mm (OR, 1.89; P = .005), and type of operation (OR, 3.46 [P < .001] and 3.18 [P = .023] for distal pancreatectomies and other resections, respectively).

      Conclusions

      The overall risk of unnecessary immediate surgery for PCNs is about 22% in a high-volume referral center. EUS with cytologic sampling is a useful procedure in the diagnostic management of PCNs, improving their diagnostic accuracy.

      Abbreviations:

      DP (distal pancreatectomy), HR (hazard ratio), HRS (high-risk stigmata), IPMN (intraductal papillary mucinous neoplasm), MCN (mucinous cystadenoma), MPD (main pancreatic duct), MRI (magnetic resonance imaging), PCN (pancreatic cystic neoplasm), PD (pancreatoduodenectomy), SCA (serous cystadenoma), SPN (solid pseudopapillary neoplasm), TP (total pancreatectomy), WF (worrisome feature)
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      References

        • Zerboni G.
        • Signoretti M.
        • Crippa S.
        • et al.
        Systematic review and meta-analysis: prevalence of incidentally detected pancreatic cystic lesions in asymptomatic individuals.
        Pancreatology. 2019; 19: 2-9
        • Farrell J.J.
        Prevalence, diagnosis and management of pancreatic cystic neoplasms: Current status and future directions.
        Gut Liver. 2015; 9: 571-589
        • Lawrence S.A.
        • Attiyeh M.A.
        • Seier K.
        • et al.
        Should patients with cystic lesions of the pancreas undergo long-term radiographic surveillance? Results of 3024 patients evaluated at a single institution.
        Ann Surg. 2017; 266: 536-544
        • Andrianello S.
        • Falconi M.
        • Salvia R.
        • et al.
        Surveillance of cystic lesions of the pancreas: whom and how to survey?.
        Visc Med. 2018; 34: 202-205
        • Tanaka M.
        • Fernández-del Castillo C.
        • Kamisawa T.
        • et al.
        Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.
        Pancreatology. 2017; 17: 738-753
        • Salvia R.
        • Malleo G.
        • Marchegiani G.
        • et al.
        Pancreatic resections for cystic neoplasms: from the surgeon’s presumption to the pathologist’s reality.
        Surgery. 2012; 152: S135-42
        • Correa-Gallego C.
        • Ferrone C.R.
        • Thayer S.P.
        • et al.
        Incidental pancreatic cysts: Do we really know what we are watching?.
        Pancreatology. 2010; 10: 144-150
        • Wesali S.
        • Demir M.A.
        • Verbeke C.S.
        • et al.
        EUS is accurate in characterizing pancreatic cystic lesions; a prospective comparison with cross-sectional imaging in resected cases.
        Surg Endosc. 2020; 35: 6650-6659
        • Lu X.
        • Zhang S.
        • Ma C.
        • et al.
        The diagnostic value of EUS in pancreatic cystic neoplasms compared with CT and MRI.
        Endosc Ultrasound. 2015; 4: 324-329
        • Lariño-Noia J.
        • Iglesias-Garcia J.
        • de la Iglesia-Garcia D.
        • et al.
        EUS-FNA in cystic pancreatic lesions: Where are we now and where are we headed in the future?.
        Endosc Ultrasound. 2018; 7: 102-109
        • Iwashita T.
        • Uemura S.
        • Mita N.
        • et al.
        Utility of endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration for the diagnosis and management of pancreatic cystic lesions: differences between the guidelines.
        Dig Endosc. 2020; 32: 251-262
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • et al.
        The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Int J Surg. 2014; 12: 1495-1499
        • Tanaka M.
        • Chari S.
        • Adsay V.
        • et al.
        International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas.
        Pancreatology. 2006; 6: 17-32
        • Tanaka M.
        • Fernández-Del Castillo C.
        • Adsay V.
        • et al.
        International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.
        Pancreatology. 2012; 12: 183-197
        • del Chiaro M.
        • Verbeke C.
        • Salvia R.
        • et al.
        European experts consensus statement on cystic tumours of the pancreas.
        Dig Liver Dis. 2013; 45: 703-711
        • Jais B.
        • Rebours V.
        • Malleo G.
        • et al.
        Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas).
        Gut. 2016; 65: 305-312
      1. Amin M.B. Edge S.B. Greene F.L. AJCC cancer staging manual. 8th ed. Springer, New York, NY2017
        • Gaujoux S.
        • Brennan M.F.
        • Gonen M.
        • et al.
        Cystic lesions of the pancreas: changes in the presentation and management of 1,424 patients at a single institution over a 15-year time period.
        J Am Coll Surg. 2011; 212: 590-600
        • Valsangkar N.P.
        • Morales-Oyarvide V.
        • Thayer S.P.
        • et al.
        851 resected cystic tumors of the pancreas: a 33-year experience at the Massachusetts General Hospital.
        Surgery. 2012; 152: S4-S12
        • del Chiaro M.
        • Segersvärd R.
        • Pozzi Mucelli R.
        • et al.
        Comparison of preoperative conference-based diagnosis with histology of cystic tumors of the pancreas.
        Ann Surg Oncol. 2014; 21: 1539-1544
        • Lekkerkerker S.J.
        • Besselink M.G.
        • Busch O.R.
        • et al.
        Comparing 3 guidelines on the management of surgically removed pancreatic cysts with regard to pathological outcome.
        Gastrointest Endosc. 2017; 85: 1025-1031
        • Abbott D.E.
        • Ahmad S.A.
        Comparison of the Sendai and Fukuoka consensus guidelines for the management of mucinous cystic lesions of the pancreas: Are we making progress?.
        Ann Surg Oncol. 2014; 21: 1770-1772
        • Du C.
        • Chai N.-L.
        • Linghu E.-Q.
        • et al.
        Comparison of endoscopic ultrasound, computed tomography and magnetic resonance imaging in assessment of detailed structures of pancreatic cystic neoplasms.
        World J Gastroenterol. 2017; 23: 3184-3192
        • Lu X.
        • Zhang S.
        • Ma C.
        • et al.
        The diagnostic value of EUS in pancreatic cystic neoplasms compared with CT and MRI.
        Endosc Ultrasound. 2015; 4: 324-329
        • Gerke H.
        • Jaffe T.
        • Mitchell R.
        • et al.
        Endoscopic ultrasound and computer tomography are inaccurate methods of classifying cystic pancreatic lesions.
        Dig Liver Dis. 2006; 38: 39-44
        • Ahmad N.A.
        • Kochman M.L.
        • Brensinger C.
        • et al.
        Interobserver agreement among endosonographers for the diagnosis of neoplastic versus non-neoplastic pancreatic cystic lesions.
        Gastrointest Endosc. 2003; 58: 59-64
        • Hirooka Y.
        • Goto H.
        • Itoh A.
        • et al.
        Case of intraductal papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination.
        J Gastroenterol Hepatol. 2003; 18: 1323-1324
        • Yamaguchi H.
        • Morisaka H.
        • Sano K.
        • et al.
        Seeding of a tumor in the gastric wall after endoscopic ultrasound-guided fine-needle aspiration of solid pseudopapillary neoplasm of the pancreas.
        Intern Med. 2020; 59: 779-782
        • Yoon W.
        • Daglilar E.
        • Castillo C.
        • et al.
        Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: the PIPE study.
        Endoscopy. 2014; 46: 382-387
        • Ngamruengphong S.
        • Xu C.
        • Woodward T.
        • et al.
        Risk of gastric or peritoneal recurrence, and long-term outcomes, following pancreatic cancer resection with preoperative endosonographically guided fine needle aspiration.
        Endoscopy. 2013; 45: 619-626
        • Khashab M.A.
        • Kim K.
        • Lennon A.M.
        • et al.
        Should we do EUS/FNA on patients with pancreatic cysts? The incremental diagnostic yield of EUS over CT/MRI for prediction of cystic neoplasms.
        Pancreas. 2013; 42: 717-721
        • Jang D.K.
        • Song B.J.
        • Ryu J.K.
        • et al.
        Preoperative diagnosis of pancreatic cystic lesions.
        Pancreas. 2015; 44: 1329-1333
        • Cho C.S.
        • Russ A.J.
        • Loeffler A.G.
        • et al.
        Preoperative classification of pancreatic cystic neoplasms: the clinical significance of diagnostic inaccuracy.
        Ann Surg Oncol. 2013; 20: 3112-3119
        • Genevay M.
        • Mino-Kenudson M.
        • Yaeger K.
        • et al.
        Cytology adds value to imaging studies for risk assessment of malignancy in pancreatic mucinous cysts.
        Ann Surg. 2011; 254: 977-983
        • del Chiaro M.
        • Beckman R.
        • Ateeb Z.
        • et al.
        Main duct dilatation is the best predictor of high-grade dysplasia or invasion in intraductal papillary mucinous neoplasms of the pancreas.
        Ann Surg. 2020; 272: 1118-1124
        • Witkowski E.R.
        • Smith J.K.
        • Tseng J.F.
        Outcomes following resection of pancreatic cancer.
        J Surg Oncol. 2013; 107: 97-103

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