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Reply to Lorenzo et al.
We thank Dr. Lorenzo and colleagues for their interest in our study, which involved the follow up of 379 patients with serous cystic neoplasms (SCNs) . During the study period, 60 patients (15.8 %) underwent either surgical resection (n = 40; 10.5 %) or endoscopic treatment (n = 20; 5.3 %). Among these 60 patients, those with an uncertain diagnosis underwent surgery, and only symptomatic patients with pathologically confirmed SCNs (5.3 %) underwent endoscopic treatment.
Although the authors mention the current treatment strategy for SCN (surgical resection or endoscopic emptying), we are not sure that any guideline has yet recommended endoscopic emptying as a type of management . SCNs have very low malignant potential, therefore surgery is not usually indicated ; nevertheless, for various reasons, many cases of SCN are surgically resected .
We think the current guidelines do not fully reflect the complexity of pancreatic cysts and real-world data. Endoscopic emptying, such as endoscopic ultrasound-guided pancreatic cyst ablation (EUS-PCA), can be considered. However, EUS-PCA is limited in patients with multiseptated pancreatic cystic lesions (PCLs) because the lesions do not permit the uniform application or retention of a liquid ablative agent  . In these multiseptated PCLs, such as microcystic SCNs, EUS-RFA can be considered as an alternative for palliation. Even if only a partial response was shown in 62 % of patients without complete response, their symptoms still improved after ablation. Owing to the relatively large size of the cysts (median 50 mm [interquartile range 34–52.5 mm]), the ablation effect was limited and, to avoid complications, we tried RFA only inside the cystic tumors, not at the margin, which also affected the result. If ablation were performed in smaller lesions, a better therapeutic effect would be expected.
We fully agree that RFA should be used in a responsible manner and do not want to overemphasize its use. However, we still believe that, with this trial and the ensuing debate, medicine can make progress.
1 Equal first authors
26 May 2021 (online)
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