Pancreatic Cystic Lesions and Endoscopic Ultrasound Diagnostic Equipment: A Literature Review
, Francesco Savino, Marco Pedote, Vito Affatato, Fabio Castellano, Andrea Iannone, Martino Mezzapesa, Antonella Contaldo, Giuseppe Losurdo * and Mariabeatrice Principi
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe review represents an overview of Endoscopic Ultrasound diagnostic tools for pancreatic cystic lesions study. The narrative review is complete and reasonably well written.
I report few comments to complete the clarity of contents.
- In page 2 line 46 you report: “ERCP with pancreatoscopy is useful to obtain a sampling in IPMN-MD”. ERCP is an adjunctive method to study IPMN MD in selected cases due to complications and high risks. I rather advise to you to report: “ERCP with pancreatoscopy COULD BE useful IN SELECTED CASES to obtain a sampling in IPMN-MD”.
- In page 2 line 49 I advise to you to add to the sentence “EUS is useful especially for confirming the presence of mural nodules, sampling cyst fluid and studying indeterminate cysts after cross-sectional imaging and to detect high grade dysplasia/malignant forms”: EUS is useful especially for confirming the presence of mural nodules, THE THICKENING AND ENHANCEMENT OF THE SEPTA, sampling cyst fluid and studying indeterminate cysts after cross-sectional imaging and to detect high grade dysplasia/malignant forms”. EUS represents an high accuracy method, also for septa definition. Please I kindly ask to report this.
- In page 2 line 71 I advise to add to the presence of worrisome feature “and high risk stigmata” as reported in guidelines you reported.
- Page 2 line 96 as in the previous comment I would report that CH-EUS represents a fundamental tool to evaluate enhancing nodules but also the cystic septa evaluation. Please, I kindly advise to add this.
- In page 4 line 16 you report the report of strain elastography histogram. I advise to you to add the sentence “obtaining a semi-quantitative evaluation of the stiffness of the tissue” because this method add to strain ratio a semiquantitative and more specific measure of tissue stiffness.
- In page 6 lines 242-244 you reported: “They are among the first FNB 242 needles used and still widely used. They showed a histological yield of 89.4% with 93% 243 accuracy”. Please, kindly insert the specific sentence to explain it.
- In page 8 line 323 you reported that “MCN expected level of amylase is usually low” In my opinion you can add “MCN expected level of amylase is usually low as SCA.
Table and figure are clear.
Author Response
The review represents an overview of Endoscopic Ultrasound diagnostic tools for pancreatic cystic lesions study. The narrative review is complete and reasonably well written.
I report few comments to complete the clarity of contents.
In page 2 line 46 you report: “ERCP with pancreatoscopy is useful to obtain a sampling in IPMN-MD”. ERCP is an adjunctive method to study IPMN MD in selected cases due to complications and high risks. I rather advise to you to report: “ERCP with pancreatoscopy COULD BE useful IN SELECTED CASES to obtain a sampling in IPMN-MD”.
We performed the requested change.
In page 2 line 49 I advise to you to add to the sentence “EUS is useful especially for confirming the presence of mural nodules, sampling cyst fluid and studying indeterminate cysts after cross-sectional imaging and to detect high grade dysplasia/malignant forms”: EUS is useful especially for confirming the presence of mural nodules, THE THICKENING AND ENHANCEMENT OF THE SEPTA, sampling cyst fluid and studying indeterminate cysts after cross-sectional imaging and to detect high grade dysplasia/malignant forms”. EUS represents an high accuracy method, also for septa definition. Please I kindly ask to report this.
We performed the requested change.
In page 2 line 71 I advise to add to the presence of worrisome feature “and high risk stigmata” as reported in guidelines you reported.
We performed the requested change.
Page 2 line 96 as in the previous comment I would report that CH-EUS represents a fundamental tool to evaluate enhancing nodules but also the cystic septa evaluation. Please, I kindly advise to add this.
We performed the requested change.
In page 4 line 16 you report the report of strain elastography histogram. I advise to you to add the sentence “obtaining a semi-quantitative evaluation of the stiffness of the tissue” because this method add to strain ratio a semiquantitative and more specific measure of tissue stiffness.
We performed the requested change.
In page 6 lines 242-244 you reported: “They are among the first FNB 242 needles used and still widely used. They showed a histological yield of 89.4% with 93% 243 accuracy”. Please, kindly insert the specific sentence to explain it.
As requested, we added a reference to support the statement.
In page 8 line 323 you reported that “MCN expected level of amylase is usually low” In my opinion you can add “MCN expected level of amylase is usually low as SCA.
We performed the requested change.
Table and figure are clear.
We thank the reviewer for the kind appreciation of our manuscript.
Reviewer 2 Report
Comments and Suggestions for AuthorsThis article is interesting which summarizes recent advancement of EUS modalities to diagnose pancreatic cystic lesions.
Major
- This article focuses not only on the cystic lesion but also on solid tumor. Elastography, EUS-FNB, etc., including too many explanations about the usefulness of these modalities in solid pancreatic tumor. Please delete these parts to emphasize the usefulness of EUS modalities in PCL.
- Please refer to the recent article of I-EUS classification and terminology (Isayama H, eta al. Dig Endosc. 2025 Jan;37(1):5-17. doi: 10.1111/den.14927. Epub 2024 Oct 4. PMID: 39364550.) EUS-FNA should be changed into EUS-sampling including tissue acquisition and fluid sampling.
- IPMN has two types of cancer development, cancer derived from IPMN and concomitant ductal adenocarcinoma (so-called pancreatic cancer). Surveillance of IPMN, we should focus on both mural nodules and concomitant solid tumor or newly developed pancreatic duct stenosis which suggesting the development of early pancreatic cancer. Please mention about this issue and strategies to detect concomitant pancreatic cancer in IPMN. In addition, please refer following articles.
- Tada M, et al. Pancreatic cancer in patients with pancreatic cystic lesions: a prospective study in 197 patients. Clin Gastroenterol Hepatol. 2006 Oct;4(10):1265-70. doi: 10.1016/j.cgh.2006.07.013. Epub 2006 Sep 18. PMID: 16979953.
- Oyama H, et al. Long-term Risk of Malignancy in Branch-Duct Intraductal Papillary Mucinous Neoplasms. Gastroenterology. 2020 Jan;158(1):226-237.e5. doi: 10.1053/j.gastro.2019.08.032. Epub 2019 Aug 29. PMID: 31473224.
- The authors should make summery table of both EUS diagnostic modalities and features of each PCL. Table of the EUS modalities may include indications, features, usefulness and key finding in each PCL. Table of the PCL may include key findings for differential diagnosis, signs of malignancies and required modality of EUS. Tables are crucial for citation from the readers.
Author Response
This article focuses not only on the cystic lesion but also on solid tumor. Elastography, EUS-FNB, etc., including too many explanations about the usefulness of these modalities in solid pancreatic tumor. Please delete these parts to emphasize the usefulness of EUS modalities in PCL.
We thank the reviewer for the useful suggestion. We performed the requested change and deleted explanations about solid pancreatic tumors.
Please refer to the recent article of I-EUS classification and terminology (Isayama H, eta al. Dig Endosc. 2025 Jan;37(1):5-17. doi: 10.1111/den.14927. Epub 2024 Oct 4. PMID: 39364550.) EUS-FNA should be changed into EUS-sampling including tissue acquisition and fluid sampling.
We performed the requested change. We decided to create a new section called “EUS-sampling” with three subsections: “Tissue acquisition”, “Fluid-sampling” and “DNA markers”
IPMN has two types of cancer development, cancer derived from IPMN and concomitant ductal adenocarcinoma (so-called pancreatic cancer). Surveillance of IPMN, we should focus on both mural nodules and concomitant solid tumor or newly developed pancreatic duct stenosis which suggesting the development of early pancreatic cancer. Please mention about this issue and strategies to detect concomitant pancreatic cancer in IPMN. In addition, please refer following articles.
Tada M, et al. Pancreatic cancer in patients with pancreatic cystic lesions: a prospective study in 197 patients. Clin Gastroenterol Hepatol. 2006 Oct;4(10):1265-70. doi: 10.1016/j.cgh.2006.07.013. Epub 2006 Sep 18. PMID: 16979953.
Oyama H, et al. Long-term Risk of Malignancy in Branch-Duct Intraductal Papillary Mucinous Neoplasms. Gastroenterology. 2020 Jan;158(1):226-237.e5. doi: 10.1053/j.gastro.2019.08.032. Epub 2019 Aug 29. PMID: 31473224.
We performed the requested change and added the two suggested articles, as ref. 35 and 36. We discussed about this issue also in the section “tissue acquisition” and “DNA markers”
The authors should make summary table of both EUS diagnostic modalities and features of each PCL. Table of the EUS modalities may include indications, features, usefulness and key finding in each PCL. Table of the PCL may include key findings for differential diagnosis, signs of malignancies and required modality of EUS. Tables are crucial for citation from the readers.
We created a new table and a new figure: one about different types and features of each PCL; another one about the modalities of sampling
Round 2
Reviewer 2 Report
Comments and Suggestions for AuthorsThis manuscript improved after the revision.
The reviewer thanked to the authors for accepting our proposal.
