Aims:
Accurate detection of advanced neoplasia (AN; high-grade dysplasia/cancer) in pancreatic cystic neoplasms (PCN) will improve outcome while minimizing unnecessary surgery. The European, American Gastroenterological Association (AGA) and International Association of Pancreatology (IAP) guidelines provide recommendations on surveillance and surgical intervention for PCN based on symptoms and risk of malignancy. We aimed to identify which guideline is the most accurate in predicting AN in IPMN.
Methods:
Patients who underwent surgery for PCN were extracted from our prospective database (2006-august 2018). We considered surgery justified for AN, pseudopapillary and neuroendocrine tumors and when symptoms improved. Patients with IPMN were evaluated separately. The final histopathological diagnosis was compared with the indication for surgery stated by different guidelines. Receiver operating characteristic (ROC) curves were calculated and compared to measure diagnostic value.
Results:
Overall, 210 patients underwent pancreatic resection for PCN. In hindsight, surgery was justified in 91 (43%) patients, based on histopathological outcomes and symptom improvement. Finally, 115 patients with IPMN were included in the analysis to identify accuracy of different guidelines for predicting AN. Of the 46 patients with AN, 44 (96%), 44 (96%) and 17 (39%) would have correctly been recommended for surgery according to European, IAP and AGA guidelines. The AGA guideline would have missed 29/46 (63%) patients with AN, including 16 with cancer. Of those without AN, 51 (74%), 56 (81%) and 5 (7%) patients would have been incorrectly recommended for surgery by the European, IAP and AGA guidelines. The ROC comparison analysis showed that the European was superior to IAP guideline (p = 0.021), versus no difference between European and AGA guideline (p = 0.392).
Conclusions:
ROC comparison analysis showed that the European guideline was superior in identifying AN in IPMN compared to IAP guideline, versus no difference between European and AGA guideline. Although fewer patients undergo unnecessary surgery based on AGA guideline, the risk of missing AN with this guideline is unacceptable high.
