Review for 10.1186/s12876-020-01565-9 (2020)

Reviewer’s report
Title: 
Endoscopic Ultrasound with Fine Needle Aspiration is useful in
pancreatic cysts smaller than 3 cm
Version: 
0 
Date: 
03 Jul 2020
Reviewer's report:
This retrospective study aims at evaluating the role of EUS-FNA in small
(<3cm) pancreatic cysts. 
The hypothesis of this study was that a size > 3cm is too large to recommend
EUS-FNA because of the risk of malignancy even in smaller cysts. However,
size is only one of the "worrisome features" of pancreatic cystic lesions (mainly
for BD-IPMN and MCN), and EUS-FNA could be indicated even in smaller
cysts if other worrisome features are present (i.e., mural nodule or thickened
wall). In this study, the authors included several lesions that were smaller than
3cm but with other worrisome features/high-risk stigmata which guide the
management regardless of the lesion size and the FNA results.
Moreover, you included different cystic types (NET, IPMN, SCA, MCN) leading
to a heterogeneous group of patients. 
To test your hypothesis, a homogeneous
group of small cysts, without other reasons for EUS-FNA, should be evaluated.
Finally, size >3cm reported in current guidelines refers only to BD-IPMN and
cannot be applied even in other cyst types (e.g., cystic NET). Therefore, the
messages of your study are misleading.
The study endpoints are confusing, and not clearly stated. As well, some other
definitions should be included. For example, how the authors defined a mural
nodule? Did they perform contrast-enhanced EUS in each case to rule out mucin
plugs?
How can you be sure that those cysts diagnosed as pancreatic cancers on EUS-
FNA cytology were not retention cysts close to a pancreatic ductal carcinoma?
Symptoms (pain, weight loss, vomiting, jaundice, acute pancreatitis) are
themselves indications for surgery and highly suggestive of malignancy. 
What you mean with "cystic PDAC"? Do you mean PDAC with central
necrosis? If yes, why don't puncture the peripherical solid component?
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