Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA.
Department of Radiology, Virginia Mason Medical Center, Seattle, WA, USA.
Surg Endosc. 2018 May;32(5):2420-2426. doi: 10.1007/s00464-017-5941-y. Epub 2017 Dec 29.
The role of EUS in managing asymptomatic pancreatic cystic lesions (PCLs) remains unresolved. We retrospectively evaluated EUS in risk stratification of PCLs when adhering to the most recent AGA guidelines.
Asymptomatic PCLs that were evaluated by EUS from January 2014 to December 2014 were retrospectively reviewed including associated cytology, fluid analysis, and relevant surgical pathology. Cross-sectional imaging reports were reviewed blindly by an expert radiologist using AGA risk stratification terminology. Accepted imaging high-risk features (HRF) included cyst diameter > 3 cm, dilated upstream pancreatic ducts, and a solid component in the cyst.
We reviewed 125 patients who underwent EUS. Expert review of cross-sectional imaging resulted in a different interpretation 25% of the time including 1 malignant cyst. Ninety-three patients (75%) had no HRFs on cross-sectional imaging; 28 patients (22%) were diagnosed with 1 HRF and 4 patients (3%) had 2 HRFs. Adhering to AGA guidelines using 2 HRF as threshold for use of EUS, the diagnosis of malignant and high-risk premalignant lesions (including pancreatic adenocarcinoma, mucinous cystadenoma, neuroendocrine tumors, and IPMN with dysplasia) had a 40% sensitivity and 100% specificity. Had EUS been utilized based on a threshold of 1 HRF on imaging, malignant and high-risk premalignant lesions would have been identified with 80% sensitivity and 95% specificity. By adding EUS to radiographic imaging, the specificity for detecting carcinomas (p = 0.0009) and detection of all premalignant lesions (p = 0.003) statistically improved. Furthermore, EUS allowed 14 patients (11%) to avoid further surveillance by lowering their risk stratification.
EUS remains an essential risk stratification modality for incidental PCLs. Current guideline suggestions of its utility may be too stringent. Our study justifies expert radiology review when managing PCLs. Further studies are required to identify the optimal approach to PCL management.
EUS 在管理无症状胰腺囊性病变（PCL）中的作用仍未解决。我们回顾性评估了遵循最新 AGA 指南时 EUS 在 PCL 风险分层中的作用。
回顾性分析 2014 年 1 月至 2014 年 12 月期间接受 EUS 评估的无症状 PCL，包括相关细胞学、液体分析和相关手术病理学。使用 AGA 风险分层术语，由一名专家放射科医生对横截面成像报告进行盲法审查。公认的成像高危特征（HRF）包括囊肿直径>3cm、上游胰管扩张和囊肿内实性成分。
我们回顾了 125 例接受 EUS 的患者。专家对横截面成像的审查结果有 25%的时间存在不同的解释，包括 1 例恶性囊肿。93 例患者（75%）在横截面成像上无 HRF；28 例患者（22%）被诊断为 1 个 HRF，4 例患者（3%）有 2 个 HRF。根据 AGA 指南，将 2 个 HRF 作为 EUS 使用的阈值，恶性和高危癌前病变（包括胰腺腺癌、黏液性囊腺瘤、神经内分泌肿瘤和伴异型增生的 IPMN）的诊断敏感性为 40%，特异性为 100%。如果根据影像学上的 1 个 HRF 阈值使用 EUS，则可以识别 80%的恶性和高危癌前病变，特异性为 95%。通过将 EUS 添加到影像学检查中，检测癌的特异性（p=0.0009）和所有癌前病变的检出率（p=0.003）均有统计学提高。此外，EUS 使 14 例患者（11%）降低了风险分层，从而避免了进一步的监测。
EUS 仍然是偶然发现的 PCL 进行风险分层的重要手段。当前指南对其效用的建议可能过于严格。我们的研究证明了在管理 PCL 时进行专家放射学审查是合理的。需要进一步研究以确定 PCL 管理的最佳方法。
