Evaluation of the AGA guidelines

Adler_headshotGIE Associate Editor Dr. Doug Adler highlights this article from the June issue: “American Gastroenterological Association guidelines are inaccurate in detecting pancreatic cysts with advanced neoplasia: clinicopathologic study of 225 patients with supporting molecular data.”

The study is a clear rebuttal of the much-read, much-discussed, and highly controversial AGA guideline on pancreatic cysts, demonstrating the limitations of the guideline and emphasizing that some of the concerns about it were founded. The authors propose an increased reliance on molecular testing, which, while encouraging, is still only  rarely performed.

This is the first major “shot across the bow” regarding the AGA guideline, and I suspect other studies that will ultimately support and contradict the guideline are in the works.

Guidelines for the evaluation and management of pancreatic cysts are in flux right now and the ideal management pathway has yet to be elucidated.

Read the article abstract here.


Figure 1. The proposed pancreatic cyst pathway is an algorithmic approach to the management of pancreatic cysts. Referral for EUS-FNA is based on the presence of specific MRI criteria. In addition, EUS-FNA includes cytopathologic evaluation, CEA analysis, and molecular testing for KRAS, GNAS, VHL, TP53, PIK3CA, and PTEN. Selection criteria for surgery should be a demonstration of either a malignant neoplasm (eg, adenocarcinoma, cystic PanNET, etc) or a mucinous cyst ≥ 3 cm with concerning features. A mucinous cyst is defined by mucinous cytopathology, elevated CEA, and/or detection of KRAS and/or GNAS mutations by molecular testing. Concerning features include an associated main duct dilatation, the presence of a definitive mural nodule, and/or the combination of TP53 and either PIK3CA or PTEN mutations.

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