Risk Assessment of Pancreatic Cysts: Benign and Malign Entwined
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EDITORIAL
Risk Assessment of Pancreatic Cysts: Benign and Malign Entwined María‑Victoria Alvarez‑Sánchez1 · Bertrand Napoléon2
© Springer Science+Business Media, LLC, part of Springer Nature 2020
The widespread availability of high-resolution cross-sectional imaging has increased the discovery rate for pancreatic cystic lesions (PCLs), a challenging entity. PCLs encompass a spectrum ranging from benign lesions to malignant disease. Though the awareness of possible malignant potential has historically led to surgical resection for their treatment, pancreatic surgery, despite recent advances, still carries significant morbidity. Therefore, the management of PCLs has transitioned toward a more selective approach with the aim of avoiding costly life-long surveillance or unnecessary burdensome surgery for benign cysts while considering appropriate surveillance for low-risk lesions and surgical treatment for cysts at high risk of current or future malignancy. Nevertheless, all diagnostic tests routinely available in clinical practice underperform in regard to differentiating benign to potentially malignant cystic tumors and to detecting high-grade dysplasia (HGD) or invasive cancer in PCLs. Several scientific societies developed clinical guidelines in order to assist physicians in the decision-making process. Guidelines from the American College of Gastroenterology (ACG), the European Study Group on Pancreatic Cysts, and the updated guidelines from the International Association of Pancreas (IAP) are the most recent and widely used [1–3]. All of these recommendations use a combination of symptoms, morphological features, and high-risk cytological features of the fine-needle aspirate in order to predict risk. Nonetheless, these guidelines are mostly based on expert opinion and supported by low-quality evidence. Every step toward improved risk stratification assessing the accuracy of established risk factors and investigating new markers
* María‑Victoria Alvarez‑Sánchez [email protected] 1
Department of Gastroenterology, Complejo Hospitalario Universitario de Pontevedra, Instituto de Investigación Sanitaria Galicia Sur, Avenida Mourente s/n, 36071 Pontevedra, Spain
Department of Gastroenterology, Ramsay Générale de Santé Private Hospital Jean Mermoz, 69008 Lyon, France
2
represents a significant advance in the clinical management of pancreatic cysts. In this issue of Digestive Diseases and Sciences, Sun et al. analyzed clinical, biological and morphological features associated with advanced PCLs (PCLs with HGD/ invasive cancer) in a large surgical cohort of 353 patients [4]. In accordance with guidelines, the presence of mural nodules or solid components, a dilation of the main pancreatic duct (MPD) > 10 mm, and elevated serum CA 19.9 were each independently associated with advanced PCLs, adding evidence to current recommendations. Actually, mural nodules and main pancreatic duct dilation are considered the strongest predictors independently associated with HGD and invasive cancer. A recent
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