Incidental Mucinous Neoplasms of the Pancreas: Performance of the AGA, European, and IAP Guidelines in Advising Further Management after Endoscopic ultrasound-guided fine-needle Aspiration Biopsy.

Objectives: We compared the performance of AGA-2015, ESG-2018, and IAP-2024 guidelines in referring patients for surgery versus surveillance when applied to incidental after diagnosis by EUS-FNA.

Methods: Single-center, retrospective study with prospective data collection. PLs identified incidentally on CT or MRI/MRCP performed for other diseases with inconclusive imaging results were eligible for analysis. After EUS-FNA and microhistological diagnosis, each of the guidelines was applied; sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were compared.

Results: 140 asymptomatic patients (mean age 64.7 y, 61% female) had a confirmed diagnosis of MN. Of these, 42 (30%) had "high rik stigmata" and 16 (11.4%) were malignant. AGA-2015, ESG-2018, and IAP-2024, criteria would have advised surgery unnecessarily in 66%, 15%, and 46%, respectively (P<0.001). AGA-2015, ESG-2018, and IAP-2024, and criteria failed to identify 59%, 46.1%, and 33.3% of HGD/IC, respectively (P=1.00).

Conclusion: The AGA-2015 criteria were highly specific, while IAP-2024 had superior sensitivity. All had moderate sensitivity to indicate surgery, and all missed similar numbers of malignant lesions. Performing EUS-FNA before application of guidelines seems appropriate to guide further management of asymptomatic PLs, preventing unnecessary surgery and referring patients appropriately for surveillance. The ESG-2018 guideline proved most accurate for this purpose.