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Cyst Size Is Not the Only Important Predictor of Malignancy in Pancreatic Cysts
LETTERS
papillary mucinous neoplasms without worrisome imaging features. The risk of malignancy in small (<3 cm) lesions without concerning features was 6.5% compared with 18% in lesions > 3 cm without other worrisome radiologic features.6 Finally, it is important to note that serum CA 19-9 was performed in only 77 of 112 patients in this study and its lack of significance in predicting a malignant lesion could likely be due to a type II error.
Cyst Size Is Not the Only Important Predictor of Malignancy in Pancreatic Cysts Brian KP Goh, MBBS, MMed, MSc, FRCS Republic of Singapore I read with interest the recent study by Hoffman and colleagues,1 which aimed to determine the role of cyst size and serum tumor markers in predicting malignancy in pancreatic cystic neoplasms in their relatively small series of 112 patients. The authors found that cyst size > 3 cm, but not serum tumor markers, were predictive of malignancy and therefore they concluded that use of cyst size as a rationale for resection is justified. However, there are several inaccuracies and limitations in their study that are important to highlight. First, the authors state that according to the Sendai Consensus Guidelines, cyst size > 3 cm was the only criterion for resection in incidental cysts.1 This is not true because the Sendai Consensus Guidelines also included other criteria for resection such as a dilated main pancreatic duct, presence of mural nodules, and positive cyst fluid cytology.2-4 Second, although cyst size was found to be the only independent predictor of malignancy, it is important to highlight the fact that other important factors such as symptoms, jaundice, dilated pancreatic duct, and mural nodules were not included in their multivariate analysis. Although, cyst size is a wellknown predictor of malignancy in pancreatic cystic neoplasms, other criteria such as mural nodules have been shown to be of greater importance.5 The revised Fukuoka Consensus Guidelines de-emphasize the importance of cyst size alone.3,4,6 It is widely reported that most malignant cysts > 3 cm would also demonstrate other worrisome features such as mural nodules and pancreatic duct dilatation.3,4 It would be of great interest to know how many malignant cysts > 3 cm in this study did not have other worrisome radiologic features, as included in the Sendai Consensus Guidelines or the Fukuoka Consensus Guidelines. A recent large series from the Massachusetts General Hospital analyzing surgically resected, branch-duct, intraductal papillary mucinous neoplasms (BD-IPMN) seemed to support the importance of cyst size in predicting malignancy even in the absence of concerning imaging features. The authors reported 7 of 76 malignant branch-duct, intraductal
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
REFERENCES 1. Hoffman RL, Gates JL, Kochman ML, et al. Analysis of cyst size and tumor markers in the management of pancreatic cysts: support for the original Sendai criteria. J Am Coll Surg 2015;220: 1087e1095. 2. Goh BK, Tan DM, Ho MM, et al. Utility of the Sendai Consensus Guidelines for branch-duct intraductal papillary mucinous neoplasms: a systematic review. J Gastrointest Surg 2014;18:1350e1357. 3. Goh BK, Tan DM, Thng CH, et al. Are the Sendai and Fukouka Consensus Guidelines for cystic mucinous neoplasms of the pancreas useful in the initial triage of all suspected pancreatic cystic neoplasms? A single institution experience with 317 surgicallytreated patients. Ann Surg Oncol 2014;21:1919e1926. 4. Goh BK, Thng CH, Tan DM, et al. Evaluation of the Sendai and 2012 International Consensus Guidelines based on crosssectional imaging findings for the initial triage of mucinous cystic lesions of the pancreas: a single institution experience with 114 surgically-treated patients. Am J Surgery 2014;208:202e209. 5. Kim KW, Park SH, Pyo J, et al. Imaging features to distinguish malignant and benign branch-duct type intraductal papillary mucinous neoplasms of the pancreas. A meta-analysis. Ann Surg 2014;259:72e81. 6. Sahora K, Mino-Kenudson M, Brugge W, et al. Branch duct intraductal papillary mucinous neoplasms. Does cyst size change the tip of the scale? A critical analysis of the revised consensus guidelines in a large single-institution series. Ann Surg 2013;258:466e475.
Disclosure Information: Nothing to disclose.
Analysis of Cyst Size and Tumor Markers In reply to Goh Rebecca L Hoffman, MD, Jeffrey A Drebin, MD, PhD, FACS Philadelphia, PA We would like to thank Dr Goh for his interest in our article.1 In his letter, he begins by suggesting our series of 112 patients accumulated over a little more than 5 years by a single surgeon is “relatively small,” but then
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http://dx.doi.org/10.1016/j.jamcollsurg.2015.03.028 ISSN 1072-7515/15
papillary mucinous neoplasms without worrisome imaging features. The risk of malignancy in small (<3 cm) lesions without concerning features was 6.5% compared with 18% in lesions > 3 cm without other worrisome radiologic features.6 Finally, it is important to note that serum CA 19-9 was performed in only 77 of 112 patients in this study and its lack of significance in predicting a malignant lesion could likely be due to a type II error.
Cyst Size Is Not the Only Important Predictor of Malignancy in Pancreatic Cysts Brian KP Goh, MBBS, MMed, MSc, FRCS Republic of Singapore I read with interest the recent study by Hoffman and colleagues,1 which aimed to determine the role of cyst size and serum tumor markers in predicting malignancy in pancreatic cystic neoplasms in their relatively small series of 112 patients. The authors found that cyst size > 3 cm, but not serum tumor markers, were predictive of malignancy and therefore they concluded that use of cyst size as a rationale for resection is justified. However, there are several inaccuracies and limitations in their study that are important to highlight. First, the authors state that according to the Sendai Consensus Guidelines, cyst size > 3 cm was the only criterion for resection in incidental cysts.1 This is not true because the Sendai Consensus Guidelines also included other criteria for resection such as a dilated main pancreatic duct, presence of mural nodules, and positive cyst fluid cytology.2-4 Second, although cyst size was found to be the only independent predictor of malignancy, it is important to highlight the fact that other important factors such as symptoms, jaundice, dilated pancreatic duct, and mural nodules were not included in their multivariate analysis. Although, cyst size is a wellknown predictor of malignancy in pancreatic cystic neoplasms, other criteria such as mural nodules have been shown to be of greater importance.5 The revised Fukuoka Consensus Guidelines de-emphasize the importance of cyst size alone.3,4,6 It is widely reported that most malignant cysts > 3 cm would also demonstrate other worrisome features such as mural nodules and pancreatic duct dilatation.3,4 It would be of great interest to know how many malignant cysts > 3 cm in this study did not have other worrisome radiologic features, as included in the Sendai Consensus Guidelines or the Fukuoka Consensus Guidelines. A recent large series from the Massachusetts General Hospital analyzing surgically resected, branch-duct, intraductal papillary mucinous neoplasms (BD-IPMN) seemed to support the importance of cyst size in predicting malignancy even in the absence of concerning imaging features. The authors reported 7 of 76 malignant branch-duct, intraductal
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
REFERENCES 1. Hoffman RL, Gates JL, Kochman ML, et al. Analysis of cyst size and tumor markers in the management of pancreatic cysts: support for the original Sendai criteria. J Am Coll Surg 2015;220: 1087e1095. 2. Goh BK, Tan DM, Ho MM, et al. Utility of the Sendai Consensus Guidelines for branch-duct intraductal papillary mucinous neoplasms: a systematic review. J Gastrointest Surg 2014;18:1350e1357. 3. Goh BK, Tan DM, Thng CH, et al. Are the Sendai and Fukouka Consensus Guidelines for cystic mucinous neoplasms of the pancreas useful in the initial triage of all suspected pancreatic cystic neoplasms? A single institution experience with 317 surgicallytreated patients. Ann Surg Oncol 2014;21:1919e1926. 4. Goh BK, Thng CH, Tan DM, et al. Evaluation of the Sendai and 2012 International Consensus Guidelines based on crosssectional imaging findings for the initial triage of mucinous cystic lesions of the pancreas: a single institution experience with 114 surgically-treated patients. Am J Surgery 2014;208:202e209. 5. Kim KW, Park SH, Pyo J, et al. Imaging features to distinguish malignant and benign branch-duct type intraductal papillary mucinous neoplasms of the pancreas. A meta-analysis. Ann Surg 2014;259:72e81. 6. Sahora K, Mino-Kenudson M, Brugge W, et al. Branch duct intraductal papillary mucinous neoplasms. Does cyst size change the tip of the scale? A critical analysis of the revised consensus guidelines in a large single-institution series. Ann Surg 2013;258:466e475.
Disclosure Information: Nothing to disclose.
Analysis of Cyst Size and Tumor Markers In reply to Goh Rebecca L Hoffman, MD, Jeffrey A Drebin, MD, PhD, FACS Philadelphia, PA We would like to thank Dr Goh for his interest in our article.1 In his letter, he begins by suggesting our series of 112 patients accumulated over a little more than 5 years by a single surgeon is “relatively small,” but then
228
http://dx.doi.org/10.1016/j.jamcollsurg.2015.03.028 ISSN 1072-7515/15