From the AGA Journals

Fukuoka, Sendai guidelines identified advanced pancreatic neoplasias

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Molecular markers may supersede these guidelines in the end

This study by Kaimakliotis et al. highlights the limitations in the current diagnostic and management algorithm for mucinous cystic lesion of the pancreas. Although both the Sendai and Fukuoka guidelines accurately detected patients with advanced neoplasia with a sensitivity higher than 90%, the specificity of both guidelines in detecting advanced neoplasia did not exceed 22%. The updated Fukuoka guidelines were not superior to the Sendai guidelines in detecting advanced neoplasia.

Dr. Mohamed O. Othman

The worrisome group in the Fukuoka guidelines was introduced to decrease the unnecessary resection of benign pancreatic cystic lesions and surveillance with endoscopic ultrasound (EUS) imaging is recommended for this group. If a definite mural nodule, dilated pancreatic duct, or positive cytology is found on follow-up EUS, then the patient should be triaged for surgery. Lumping the low-risk lesions and the worrisome lesions of the Fukuoka guidelines into one group resulted in increasing the specificity of detecting advanced neoplasia to 73% at the expense of sensitivity, which dropped to 55.6%, which may result in missing many cases of advanced neoplasia.

Prospective evaluation of the performance of the updated Fukuoka guidelines with particular attention to the worrisome group is needed. Ultimately, molecular markers that can predict the risk of progression to malignancy will be validated and will most likely replace the current experts’ opinion and consensus guidelines.

Dr. Mohamed O. Othman is director of advanced endoscopy, assistant professor of medicine, gastroenterology section, Baylor College of Medicine, Houston. He has no relevant conflicts of interest.




Both the Sendai and Fukuoka guidelines correctly identified all patients whose cystic pancreatic lesions were advanced neoplasias, but the “high-risk” criteria for both guidelines missed some high-grade dysplasias, researchers reported in the October issue of Clinical Gastroenterology and Hepatology.

“The updated Fukuoka guidelines are not superior to the Sendai guidelines in identifying neoplasias,” said Dr. Pavlos Kaimakliotis and his associates at the University of Pennsylvania in Philadelphia. The single-center retrospective study showed that both guidelines can help triage patients with suspected pancreatic mucinous cystic neoplasms, but “have low specificity and positive predictive value, underscoring the pressing need to develop more accurate predictors of malignancy,” the researchers said. “On the basis of our data, we recommend that the Fukuoka guidelines be used only as a framework for the work-up of a patient with a suspected pancreatic mucinous cystic neoplasm, and that management be adapted in the context of the individual patient.”

Developed in 2006, the Sendai consensus guidelines (Pancreatology 2006;6:17-32) reliably detected patients with malignant mucinous lesions of the pancreas, but poor specificity led to many needless resections, noted the investigators. The revised Fukuoka guidelines (Pancreatology 2012;12:183-97), improved specificity by classifying cysts measuring more than 3 cm as worrisome, rather than high risk. Notably, cyst size did not predict advanced neoplasia in the study, even though several consensus guidelines recommend resection when cysts exceed 3 cm, the investigators said. “Other studies have demonstrated similar results, with rates of advanced neoplasia of 25%-34% in cysts less than 3 cm in size,” they added (Clin Gastro Hepatol. 2015 Mar 15. doi: 10.1016/j.cgh.2015.03.01).

The study included 194 patients with suspected pancreatic mucinous cystic neoplasias assessed by cross-sectional imaging prior to surgical resection between 2000 and 2008. Surgical pathology revealed advanced neoplasias among 18.5% of patients. Overall median cyst size was 33 mm, said the investigators. All patients with invasive cancers met the high-risk criteria in both guidelines, but three patients in the Sendai low-risk group and two patients in the Fukuoka low-risk group had high-grade dysplasias, they said. The Sendai consensus guidelines identified patients with advanced neoplasia with about 92% sensitivity, 21% specificity, 21% positive predictive value, and 92% negative predictive value, while the Fukuoka had about 55% sensitivity, 73% specificity, 32% positive predictive value, and 88% negative predictive value. However, the guidelines did not statistically differ in their ability to predict neoplasia, the researchers said.

“In the course of reviewing our data, we have become increasingly conservative in the management of patients with pancreatic cysts,” the researchers commented. “This approach has been underscored by the low number of cases of advanced neoplasia, even among those who would be considered high risk on the basis of the updated guidelines, in surgically resected patients. With the elimination of cyst size as a high-risk predictor of malignancy for mucinous cysts, cognizance that smaller cysts can also harbor malignancy should come.”

The researchers reported no funding sources and declared no conflicts of interest.

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