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

Phillip S. Ge; V. Raman Muthusamy; Srinivas Gaddam; Diana-Marie Jaiyeola; Stephen Kim; Alireza Sedarat; Timothy R. Donahue; Lindsay Hosford; Robert H. Wilson; David P. Grande; Rajesh N. Keswani; Vladimir M. Kushnir; Daniel Mullady; Steven A. Edmundowicz; Dayna S. Early; Srinadh Komanduri; Sachin Wani; Rabindra R. Watson

doi:10.1055/s-0042-122010

Endoscopy International Open, Inhaltsverzeichnis

CC BY-NC-ND 4.0 · Endosc Int Open 2017; 05(03): E201-E208
DOI: 10.1055/s-0042-122010

Original article

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

Phillip S. Ge

¹Division of Digestive Diseases and Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States

,

V. Raman Muthusamy

¹Division of Digestive Diseases and Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States

,

Srinivas Gaddam

³Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States

,

Diana-Marie Jaiyeola

⁴Division of Gastroenterology, Northwestern Memorial Hospital, Chicago, Illinois, United States

,

Stephen Kim

¹Division of Digestive Diseases and Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States

,

Alireza Sedarat

¹Division of Digestive Diseases and Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States

,

Timothy R. Donahue

²University of California Los Angeles David Geffen School of Medicine - Department of Surgery, Los Angeles, California, United States

,

Lindsay Hosford

⁵Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States

,

Robert H. Wilson

⁵Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States

,

David P. Grande

⁴Division of Gastroenterology, Northwestern Memorial Hospital, Chicago, Illinois, United States

,

Rajesh N. Keswani

⁴Division of Gastroenterology, Northwestern Memorial Hospital, Chicago, Illinois, United States

,

Vladimir M. Kushnir

³Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States

,

Daniel Mullady

³Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States

,

Steven A. Edmundowicz

⁵Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States

,

Dayna S. Early

³Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States

,

Srinadh Komanduri

⁴Division of Gastroenterology, Northwestern Memorial Hospital, Chicago, Illinois, United States

,

Sachin Wani

⁵Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States

,

Rabindra R. Watson

¹Division of Digestive Diseases and Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States

› Institutsangaben

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

Volltext

Referenzen

References
1 Kimura W, Nagai H, Kuroda A. et al. Analysis of small cystic lesions of the pancreas. Int J Pancreatol 1995; 18: 197-206
2 Spinelli KS, Fromwiller TE, Daniel RA. et al. Cystic pancreatic neoplasms: observe or operate. Ann Surg 2004; 239: 651-657
3 Al-Haddad M, Schmidt MC, Sandrasegaran K. et al. Diagnosis and treatment of cystic pancreatic tumors. Clin Gastroenterol Hepatol 2011; 9: 635-648
4 Sarr MG, Murr M, Smyrk TC. et al. Primary cystic neoplasms of the pancreas. Neoplastic disorders of emerging importance-current state-of-the-art and unanswered questions. J Gastrointest Surg 2003; 7: 417-428
5 Zamboni G, Scarpa A, Bogina G. et al. Mucinous cystic tumors of the pancreas: clinicopathological features, prognosis, and relationship to other mucinous cystic tumors. Am J Surg Pathol 1999; 23: 410-422
6 Balcom JHt, Rattner DW, Warshaw AL. et al. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001; 136: 391-398
7 Kamata K, Kitano M, Kudo M. et al. Value of EUS in early detection of pancreatic ductal adenocarcinomas in patients with intraductal papillary mucinous neoplasms. Endoscopy 2014; 46: 22-29
8 Sedlack R, Affi A, Vazquez-Sequeiros E. et al. Utility of EUS in the evaluation of cystic pancreatic lesions. Gastrointest Endosc 2002; 56: 543-547
9 Brugge WR, Lewandrowski K, Lee-Lewandrowski E. et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004; 126: 1330-1336
10 Ahmad NA, Kochman ML, Lewis JD. et al. Can EUS alone differentiate between malignant and benign cystic lesions of the pancreas?. Am J Gastroenterol 2001; 96: 3295-3300
11 Centeno BA, Warshaw AL, Mayo-Smith W. et al. Cytologic diagnosis of pancreatic cystic lesions. A prospective study of 28 percutaneous aspirates. Acta Cytol 1997; 41: 972-980
12 Gaddam S, Ge PS, Keach JW. et al. Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study. Gastrointest Endosc 2015; 82: 1060-1069
13 Singhi AD, Nikiforova MN, Fasanella KE. et al. Preoperative GNAS and KRAS testing in the diagnosis of pancreatic mucinous cysts. Clin Cancer Res 2014; 20: 4381-4389
14 Lubezky N, Loewenstein S, Ben-Haim M. et al. MicroRNA expression signatures in intraductal papillary mucinous neoplasm of the pancreas. Surgery 2013; 153: 663-672
15 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
16 Tanaka M, Fernandez-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
17 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
18 Anand N, Sampath K, Wu BU. Cyst features and risk of malignancy in intraductal papillary mucinous neoplasms of the pancreas: a meta-analysis. Clin Gastroenterol Hepatol 2013; 11: 913-921
19 Nguyen AH, Toste PA, Farrell JJ. et al. Current recommendations for surveillance and surgery of intraductal papillary mucinous neoplasms may overlook some patients with cancer. J Gastrointest Surg 2015; 19: 258-265
20 Goh BK, Tan DM, Thng CH. et al. Are the Sendai and Fukuoka Consensus Guidelines for Cystic Mucinous Neoplasms of the pancreas useful in the initial triage of all suspected pancreatic cystic neoplasms? A single-institution experience with 317 surgically-treated patients. Ann Surg Oncol 2014; 21: 1919-1926
21 Pelaez-Luna M, Chari ST, Smyrk TC. et al. Do consensus indications for resection in branch duct intraductal papillary mucinous neoplasm predict malignancy? A study of 147 patients. Am J Gastroenterol 2007; 102: 1759-1764
22 Fritz S, Klauss M, Bergmann F. et al. Small (Sendai negative) branch-duct IPMNs: not harmless. Ann Surg 2012; 256: 313-320
23 Sawhney MS, Al-Bashir S, Cury MS. et al. International consensus guidelines for surgical resection of mucinous neoplasms cannot be applied to all cystic lesions of the pancreas. Clin Gastroenterol Hepatol 2009; 7: 1373-1376
24 Kaimakliotis P, Riff B, Pourmand K. et al. Sendai and Fukuoka Consensus Guidelines identify advanced neoplasia in patients with suspected mucinous cystic neoplasms of the pancreas. Clin Gastroenterol Hepatol 2015; 13: 1808-1815
25 Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148: 824-848
26 Vege SS, Ziring B, Jain R. et al. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148: 819-822
27 Fernandez-Del Castillo C, Tanaka M. Management of pancreatic cysts: the evidence is not here yet. Gastroenterology 2015; 148: 685-687
28 Canto MI, Hruban RH. Managing pancreatic cysts: less is more?. Gastroenterology 2015; 148: 688-691
29 Moayyedi P, Weinberg DS, Schunemann H. et al. Management of pancreatic cysts in an evidence-based world. Gastroenterology 2015; 148: 692-695
30 Harris RP. Incidental findings in the pancreas (and elsewhere): putting our patients (and ourselves) in a difficult situation. Ann Intern Med 2015; 162: 787-789
31 Singhi AD, Zeh HJ, Brand RE. et al. 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 2016; 83: 1107-1117
32 Ma GK, Goldberg DS, Thiruvengadam N. et al. Comparing American Gastroenterological Association Pancreatic Cyst Management Guidelines with Fukuoka Consensus Guidelines as predictors of advanced neoplasia in patients with suspected pancreatic cystic neoplasms. J Am Coll Surg 2016; 223: 729-737
33 Huang ES, Gazelle GS, Hur C. Consensus guidelines in the management of branch duct intraductal papillary mucinous neoplasm: a cost-effectiveness analysis. Dig Dis Sci 2010; 55: 852-860
34 Springer S, Wang Y, Dal Molin M. et al. A Combination of Molecular Markers and Clinical Features Improve the Classification of Pancreatic Cysts. Gastroenterology 2015; 149: 1501-1510
35 Shimizu Y, Yamaue H, Maguchi H. et al. Validation of a nomogram for predicting the probability of carcinoma in patients with intraductal papillary mucinous neoplasm in 180 pancreatic resection patients at 3 high-volume centers. Pancreas 2015; 44: 459-464