title: Evaluation of AGA and Fukuoka Guidelines for EUS and surgical resection of incidental pancreatic cysts.
abstract: ObjectivesManagement of asymptomatic pancreatic cysts is challenging. Guidelines by the American Gastroenterological Association (AGA) and International Association of Pancreatology (Fukuoka) seek to identify high-risk patients. We assessed performance of these guidelines in selecting patients for endoscopic ultrasound (EUS) and/or surgery.MethodsPART I - We retrospectively studied 143 asymptomatic cysts with magnetic resonance imaging (MRI) followed by EUS. Appropriate selection for EUS was defined as: malignant cytology or surgical pathology, or development of concerning features on MRI as defined by the guidelines. PART II - We retrospectively studied 152 resected cysts to assess the performance of guidelines in selecting cysts for surgery using malignant histology as the outcome.ResultsPART I - Of 143 EUS, 43 (30.1 %) were male with median age 65.0 years (interquartile range [IQR] 58.0 - 73.0). AGA guideline demonstrated lower sensitivity (17.6 % versus 35.3 %,P= 0.03), higher specificity (94.5 % versus 66.1 %, p < 0.001), and higher accuracy (76.2 % versus 58.7 %,P= 0.002) than Fukuoka. There was no difference in positive predictive value (50.0 % versus 24.5 %,P= 0.15) and negative predictive value (78.6 % versus 76.6 %, p=0.75). PART II - Of 152 resected cysts, 45 (29.8 %) were male with median age 59.0 years (IQR 47.3 - 66.7). There was no difference in performance characteristics of the guidelines in selecting cysts for surgery. AGA and Fukuoka guidelines missed 25.0 % and 18.8 % of malignant cysts, respectively (P= 1.00).ConclusionsFor referral to EUS, the AGA guideline was highly specific compared to Fukuoka; both suffered from poor sensitivity, although the Fukuoka guideline was relatively more sensitive than AGA. For referral to surgery, both guidelines have modest sensitivity and specificity and miss a similar percentage of malignant lesions.
authors.affiliation: Texas Digestive Disease Consultants, Dallas, Texas, United States.
authors.forename: Alexander
authors.initials: A
authors.lastname: Lee
authors.affiliation: Brigham and Women's Hospital, Division of Gastroenteriology, Hepatology, and Endoscopy, Boston, Massachusetts, United States.
authors.forename: Vivek
authors.initials: V
authors.lastname: Kadiyala
authors.affiliation: Brigham and Women's Hospital, Division of Gastroenterology, Hepatology, and Endoscopy, Boston, Massachusetts, United States.
authors.forename: Linda S
authors.initials: LS
authors.lastname: Lee