Please cite this article in press as: Barresi L, et al. Tissue acquisition in pancreatic cystic lesions. Dig Liver Dis (2018), https://doi.org/10.1016/j.dld.2018.08.003 ARTICLE IN PRESS G Model YDLD-3829; No. of Pages 7 Digestive and Liver Disease xxx (2018) xxx–xxx Contents lists available at ScienceDirect Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld Liver, Pancreas and Biliary Tract Tissue acquisition in pancreatic cystic lesions Luca Barresi * , Matteo Tacelli, Dario Ligresti, Mario Traina, Ilaria Tarantino Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy a r t i c l e i n f o Article history: Received 5 June 2018 Received in revised form 31 July 2018 Accepted 2 August 2018 Available online xxx Keywords: Pancreatic cysts Endoscopic ultrasound Fine needle aspiration Tissue acquisition in pancreatic cysts a b s t r a c t Despite the progress achieved by scientific research in recent years, pancreatic cystic lesions (PCLs) remain a challenging clinical problem. A significant percentage of benign PCLs are still wrongly sent to surgery, with all the related risks of a high number of surgery-related complications and mortality. Diagnosis of the type of PCL, and risk stratification for malignancy are essential for a correct management of these lesions. Several guidelines have identified some clinical and morphological aspects suggesting the need for more accurate exams. Endoscopic ultrasound fine needle aspiration (EUS-FNA) of cystic fluid for cytology is the advised method of tissue acquisition in several guidelines, and the most used technique around the world. However sensitivity and adequacy of this technique are limited by the low amount of cells dispersed in cystic fluid. Alternative techniques have been tested to target the cystic walls in an attempt to obtain microhistologic specimens in order to augment the probability of obtaining an adequate diagnostic sample. The aim of this review is to offer a critical overview of the existing literature on tissue acquisition in PCLs, and emphasize advantages and disadvantages of each technique, and unclear areas that need to be investigated with future research. © 2018 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. 1. Introduction In recent years, pancreatic cystic lesions (PCLs) have become a trending topic in the fields of gastroenterology, surgery, pathol- ogy, and radiology. This is clear if one looks at the number of yearly scientific publications. An example is the fact that in 2016 the num- ber of scientific articles published under the term “pancreatic cyst” was 303, while in the 1980s the number was about a third of that. Cystic lesions are becoming progressively more common because of the increase of the average life span in the general population, and also because there is a higher rate of prescriptions for abdomi- nal imaging exams, with more developed technological devices. At present, the estimated prevalence, variable with the imaging tech- nique used, is about 15% (2–38%) [1]. With current knowledge, the differential diagnosis of pancreatic cysts can be considered a proba- bilistic puzzle of epidemiological, clinical, radiological, endoscopic, cystic fluid analysis, and cytological features. There have been many recent attempts, particularly in the cyto-histology field, to estab- * Corresponding author at: Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Via Tricomi 5, 90127, Palermo, Italy. E-mail address: lbarresi@ismett.edu (L. Barresi). lish a better diagnosis. Our aim in this review is to summarize the current literature on tissue acquisition techniques in PCLs. 2. Current knowledge Cystic neoplasms of the pancreas are a biologically hetero- geneous group of lesions, characterized by both a different epidemiological distribution and a different malignant potential, ranging from completely benign to clearly malignant [2]. Because of this malignant potential, in most PCLs for which there is no surgical indication, there must be a periodic follow-up program [3]. Consid- ering the high prevalence of PCLs, the number of radiological and endoscopic ultrasound (EUS) tests that must be performed annually is very high, with great costs for health systems, and a conges- tion of waiting lists [4]. Despite worldwide efforts to improve the management of these patients, the number of patients undergoing surgery for benign or low/intermediate-grade dysplasia, remains high, though less with respect to the past [5,6]. It is thus neces- sary to find a method for discriminating degenerated or potentially evolutionary lesions from other PCLs. EUS with/without fine needle aspiration (FNA) has a central role in distinguishing different types of PCLs. This exam, in fact, allows endoscopists to evaluate the cyst from a morphological point of view, which in some rare cases can be diagnostic alone (e.g., https://doi.org/10.1016/j.dld.2018.08.003 1590-8658/© 2018 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.