Management of incidental pancreatic cysts: which guidelines?

evaluation and management of the asymptomatic pancreatic cyst. Ever more common, these cystic lesions frustrate gastro-enterologists, surgeons and patients alike. Existing consensus statements and societal guidelines have been based upon expert opinion and little evidence, frequently leaving physicians who care for these patients with more questions than answers. The recent American Gastroenterological Association (AGA) guidelines, which many view as controversial, have continued to stir this pot. From a historical perspective, pancreatic cyst guidelines have continued to evolve over the last decade. The first guidelines (American Society for Gastrointestinal Endoscopy, 2005) recommended endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of all cysts for cyst fluid analysis and cytolo-gy [1]. The Sendai guidelines (International Association of Pan-creatology, 2006) specifically addressed Intraductal papillary mucinous neoplasms and mucinous cystic neoplasms, and called for more selective use of EUS based on cyst size and presence of worrisome features [2]. The updated Fukuoka guidelines (International Association of Pancreatology, 2012) similarly recommended the presence of a worrisome feature for evaluation by EUS; cyst size became less of a concern. Worrisome features include cyst size size ≥ 30 mm, enhanced thickened cyst walls, non-enhanced mural nodules, main pancreatic duct (MPD) size 5 to 9 mm, abrupt change in MPD caliber with distal glandular atrophy, and lymphadenopathy. Criteria for surgical referral according to the Fukuoka guidelines are any high-risk stigmata which include obstructive jaundice in the setting of a pancreatic head cyst, presence of a mural nodule/solid component , MPD ≥ 10 mm or cytology suspicious or positive for malig-nancy [3]. The current AGA guidelines (2015) deal with management of asymptomatic cysts, without regard to cyst type. They recommend the presence of 2 high-risk stigmata (cyst size size ≥ 30 mm, dilated MPD, solid component) before an EUS examination be performed. For surgical referral, the AGA guidelines require malignant cytology on EUS-FNA or at least 2 high-risk features (cyst size size ≥ 30 mm, dilated MPD, solid component)[4]. Thus, with time and knowledge, guidelines have become more conservative with the recognition that the malignant risk of an asymptomatic cyst is very low. Accordingly, magnetic resonance imaging (MRI) for surveillance is increasingly recommended. In this edition of Endoscopy International Open, 2 articles pour more gas on the fire. Lee et al.'s retrospective 2-part study evaluates and compares the operating characteristics of the AGA and Fukuoka guidelines for detection of and surgical refer-ral for malignant pancreatic cysts [5]. An EUS database was used …