Review for 10.1186/1471-230X-11-117 (2011)

Reviewer's report
Title:Multidisciplinary Approaches Vary as to the Role of Endoscopic Ultrasound
(EUS) - Guided Fine Needle Aspiration: Controversial Indications
Version: 2Date:18 May 2011
Reviewer: Silvia Carrara
Reviewer's report:
This is a multidisciplinary research study that compares different specialistic
approaches to the use of EUS-FNA for pancreatic and GI tract diseases.
The Authors focused on some controversies regarding the indications for
performing EUS-guided FNA and they proposed a 5 cases survey to oncologists,
surgeons and gastroenterologists.
1) The questions are well posed and defined:
A) two questions are dedicated to pancreatic adenocarcinoma: 1) Is it necessary
to obtain a tissue diagnosis of a pancreatic mass which appears operable and
has malignant features according to a CT scan or EUS? 2) Should one order
EUS-guided FNA of a CT-inoperable tumor, prior to initiating chemotherapy or
radiation therapy?
B) two questions are dedicated to pancreatic cystic lesions: 3) How to approach
an incidental finding of a pancreatic cyst in a woman with dyspepsia. 4)
Regarding a stable pancreatic cyst, is periodic radiological follow-up sufficient, or
is there a need for sampling the lesion for the existence of such indicators as
CEA, amylase and lipase?
C) the last question is about an other controversial issue, the GI tract
submucosal lesions: 5) when is EUS-guided FNA sampling of a submucosal GI
tract lesion indicated?
2) The methods are appropriated and well described.
3) The data are well described too and summarized in clear tables, easy to read.
4) The manuscript adhere to the relevant standards for reporting and data
deposition.
5) The discussion explains the results of the questionnaire but doesn’t refer to
guidelines and previous papers on the use of EUS-guided FNA. The Author
should discuss the data by comparing their results to previous studies.
For example, in 2006, a working algorithm formed by international consensus,
was crafted to begin standardizing the preoperative approach to pancreatic cystic
tumors, the most controversial issue (Tanaka M, Chari S, Adsay V, et al.
International consensus guidelines for management of intraductal papillary
mucinous neoplasms and mucinous cystic neoplasms of the pancreas.
Pancreatology 2006;6:17–32). The guidelines recommend some clinical and
imaging characteristics to differentiate among cystic lesions and they proposed
characteristics that predict the absence of malignancy in a suspected
premalignant cyst. Anyway, the guidelines often remain empirical, recently other
algorithms have been proposed, but they seem not always helpful in making a
positive preoperative diagnosis (Correa-Gallego C, Ferrone CR, Thayer SP, et al.
Incidental pancreatic cysts: do we really know what we are watching?
Pancreatology 2010;10:144–50. Pelaez-Luna M, Chari ST, Smyrk TC, et al. Do
consensus indications for resection in branch duct intraductal papillary mucinous
neoplasm predict malignancy? A study of 147 patients. Am J Gastroenterol
2007;102:1759–64).
The Author should extend the references and use other published studies to
support their hypothesis in the discussion and in the conclusions.
The Authors should also objectify which kind of FNA-related risks would keep the
physicians away from the decision to make an EUS-guided FNA.
6) The limitations of the study are clearly stated.
7) The authors acknowledged any work upon which they were building.
8) I would change the title, as in my opinion it doesn’t attract the attention as it
should, and it should be more easy to understand. I would propose something
like: “a multidisciplinary survey on the controversies surrounding the use of
EUS-guided FNA”.
9) The writing would be acceptable after major compulsory revisions (see point 5
and 8).
The issues are very interesting and the survey should be proposed to an
international panel of experts in order to obtain international multidisciplinary
guidelines.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests.