Small and Stable Pancreatic Cysts Are Reassuring During Surveillance: Results From the PACYFIC Trial

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Identified Weaknesses

Rating Explanation

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Paper Summary

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Tiny and Steady Pancreatic Cysts: Probably Nothing to Worry About (Unless You Have Other Risk Factors)

In a large observational study of patients with pancreatic cysts, small (<15 mm) and slow-growing (<2.5 mm/year) cysts without other risk factors were associated with a very low risk of developing high-grade dysplasia or pancreatic cancer, similar to the risk in the general population. This suggests that less frequent surveillance may be adequate for these "low-risk" cysts. However, caution is warranted due to limitations related to non-standardized management, inconsistent imaging modality use, and potential referral bias.

Possible Conflicts of Interest

One author (Jeanin E. van Hooft) reported receiving lecture fees and consultancy fees from several medical device companies (Boston Scientific, Cook Medical, Fuji Film, Olympus). One author (Michael B. Wallace) declared consulting and research grant relationships with multiple companies including Verily, Boston Scientific, Olympus, Medtronic, and others, as well as stock/stock options in Virgo Inc. and Surgical Automations. One author (Silvia Carrara) reported receiving a lecture fee from Olympus. One author (Marco J. Bruno) reported consulting or receiving support for studies from Boston Scientific, Cook Medical, Pentax Medical, and Mylan/ChiRostim.

Identified Weaknesses

Non-standardized cyst management

The study relies on observational data from a registry, where cyst management was at the discretion of treating physicians and not standardized. This introduces variability and potential bias, as treatment and follow-up intensity might have been influenced by factors other than cyst size and growth.

Inconsistent use of imaging modalities

Different imaging modalities were used (EUS, MRI, CT), with some inconsistency in the modality used for follow-up of individual patients. This affects the reliability of growth measurements, as different modalities have different measurement biases.

Limited long-term follow-up

Only 27% of the cohort had a follow-up time exceeding 5 years, limiting the ability to draw conclusions about long-term risk and the possibility of discontinuing surveillance after a longer period of stability.

Potential referral bias

Referral bias is possible as a sizable portion of participating centers are tertiary care facilities. This might skew the sample towards more complex or concerning cases.

Surgical intervention as a diagnostic tool

The use of surgical intervention as a diagnostic tool is not ideal for assessing the true prevalence of HGD, as not all patients undergo resection.

Rating Explanation

This is a large, prospective, multi-center study that addresses an important clinical question regarding pancreatic cyst surveillance. While not groundbreaking in methodology, it provides valuable real-world data and has implications for clinical practice. The rating is slightly lowered due to the limitations related to non-standardized management, inconsistent imaging modality use, and potential referral bias. The disclosed conflicts of interest are also a minor concern but do not appear to severely compromise the study's validity.

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