Overview and comparison of guidelines for management of pancreatic cystic neoplasms

Table 1 Variables considered in the initial evaluation of pancreatic cystic neoplasms

		European	ACG	AGA	IAP	ACR
Symptoms	Jaundice	AI	HR	HR	HR	HR
	Pancreatitis	RI	HR		WF
Imaging based cyst characteristics	Main pancreatic duct dilation	> 10 mm AI 5-10 mm RI	> 5 mm HR	HR	> 10 mm HR 5-10 mm WF	> 10 mm HR 7-10 mm WF
	Associated mass		HR	HR	HR	HR
	Mural nodule	> 5 mm AI < 5 mm RI	HR	HR	> 5 mm HR < 5 mm WF	WF
	Cyst size	≥ 4 cm RI	≥ 3 cm HR		> 3 cm WF	> 3 cm WF
	Parenchymal atrophy				WF
	Lymphadenopathy				WF
Serum based	CA19-9	RI	HR		WF
	New onset diabetes	RI

AI: Absolute indication; RI: Relative indication; HR: High risk; WF: Worrisome features.

Table 2 Approach to surveillance of pancreatic cysts without high risk or worrisome features at diagnosis

Size	IAP (Fukuoka) 2012	IAP (Fukuoka) 2017	ACG 2018	ACR 2018	European 2018	AGA 2015
< 1 cm	CT/MRI in 2-3 yr	CT/MRI in 6 mo then every 2 yr	MRI q 2 yr (lengthen after4)	MRI/CT q1 year for cysts < 1.5 cm and q6 mo for cysts 1.5-2.5 cm × 4 and then lengthen interval; stop after stability over 10 yr1	Surveillance q 6 mo × 2 with MRI and/or EUS, CA19-9; if stable lifelong surveillance is recommended with annual MRI/EUS, CA19-9	MRI in 1 yr, then every 2 for 5 yr Stop if stable
1-2 cm	CT/MRI annually × 2 yr, then lengthen interval if stable	CT/MRI in 6 m × 1 yr A Annually × 2 yr, then lengthen interval if stable	MRI q 1 yrs FOR 3 yr Then q 2 yr FOR 4 yr
2-3 cm	EUS in 3-6 mo, then lengthen interval, alternate MRI with EUS as appropriate	EUS in 3-6 mo, then lengthen interval, alternate MRI with EUS as appropriate	EUS/MRI q 6mo for 3 yr then yearly for 4 yr	For cysts > 2.5 cm q6 mo MRI/CT and then stop if stable for over 10 yr; for patients > 80 yr of age, q2 year imaging1
> 3 cm	Alternate MRI/EUS every 3-6 mo	Alternate MRI/EUS every 3-6 mo	EUS/MRI q 6mo for 3 yr then yearly for 4 yr

¹These guidelines use < 1.5 cm, 1.5-2.5 and > 2.5 as cut off values. CT: Computed tomography; MRI: magnetic resonance imaging; EUS: Endoscopic ultrasonography; ACG: American College of Gastroenterology; AGA: American Gastroenterological Association.

Table 3 Comparison of performance between pancreatic cyst guidelines

Studies	Comparisons	Outcome	Result	Performance
Sighinolfi et al[21], 2017	Fukouka, AGA, and Sendai Criteria1	Pancreatic Cyst with invasive cancer	AGA ROC 0.76, Fukouka ROC 0.78, Sendai ROC 0.65 (P < 0.001)	AGA and Fukuoka guidelines with higher diagnostic accuracy for neoplastic cysts compared to Sendai
Xu et al[20], 2017	AGA, Fukouka, and American College of Radiology1	Advanced neoplasia (HGD or cancer) in resected pancreatic cysts	(Sen, Spec, PPV, NPV) AGA; 7.3%, 88.2%, 10%, and 84.1% Fukouka: 73.2%, 45.6%, 19.5%, 90.4% ACR: 53.7%, 61%, 19.8%, and 88%	AGA with higher specificity, but lower sensitivity than Fukuoka and ACR
Ma et al[22], 2016	AGA and Fukouka2	Advanced neoplasia (HGD or cancer) in resected pancreatic cysts	Fukouka: 28.2%, 95.8%, 74.1%, 75.9% AGA: 35.2.%, 94%, 71.4%, 77.5%	No significant difference between the two guidelines
Singhi et al, 2016	AGA	Advanced neoplasia (HGD or cancer)	AGA: 62%, 79%, 57%, 82%	Low accuracy of AGA guidelines and continued surveillance of benign lesions (i.e., SCAs)
Lekkerkerker et al[23], 2017	Fukuoka, AGA, European Guidelines	Advanced neoplasia (in patients with suspected IPMN)	Accuracy Fukuoka: 54% AGA: 59% European: 53%	AGA guidelines would have rec’d against surgery in most patients with benign lesions and would have missed significantly more HGD/CA

¹These studies have considered high risk or worrisome features as sufficient for indication for resection (for example a cyst size > 3 cm would have qualified for an indication for surgery.

²In these studies the presence of high risks stigmata or worrisome features with positive EUS/FNA were required. EUS: Endoscopic ultrasonography; ACG: American College of Gastroenterology; AGA: American Gastroenterological Association.