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Kwan MC, Pitman MB, Fernandez-Del Castillo C, Zhang ML. Revisiting the performance of cyst fluid carcinoembryonic antigen as a diagnostic marker for pancreatic mucinous cysts: a comprehensive 20-year institutional review. Gut 2024; 73:629-638. [PMID: 38195219 DOI: 10.1136/gutjnl-2023-331138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/27/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE Elevated pancreatic cyst fluid carcinoembryonic antigen (CEA) has been routinely used to classify mucinous cysts. This study incorporates original data that established the CEA ≥192 ng/mL threshold with over 20 years of additional data and reassesses the diagnostic performance of CEA for differentiating mucinous from non-mucinous cysts. DESIGN 1169 pancreatic cysts (1999-2021) with CEA results were identified. 394 cases had histological confirmation as the diagnostic standard. Additionally, 237 cysts without histological confirmation demonstrated KRAS, GNAS, or RNF43 mutations by molecular testing and were combined with the histologically confirmed cysts for separate analysis on a total cohort of 631 cysts. RESULTS Median CEA was significantly higher in mucinous cysts (323.9 ng/mL, n=314) versus non-mucinous cysts (204.6 ng/mL, n=80) (p<0.001). Receiver operating characteristic curve analysis demonstrated an optimal CEA cut-off of 20 ng/mL (area under the curve: 80%), though the specificity was lower than desired (sensitivity 89%, specificity 64%). At the previously established threshold of 192 ng/mL, sensitivity and specificity were 56% and 78%, respectively. To achieve a specificity of 85% as originally reported, a CEA threshold of 250 ng/mL was needed; the 13 false positive cases at this threshold included 4 benign simple cysts, 2 squamoid cysts, 1 serous cystadenoma, 1 lymphoepithelial cyst and 5 more uncommon entities. All results remained similar within the total cohort after including additional cases with KRAS/GNAS/RNF43 mutations only. CONCLUSION Cyst fluid CEA continues to be a useful test in the diagnosis of mucinous pancreatic cysts but does not appear as specific as previously reported. Raising the CEA threshold to 250 ng/mL to maintain specificity for differentiating mucinous from non-mucinous cysts may be considered.
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Affiliation(s)
- Melanie C Kwan
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Martha Bishop Pitman
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Fernandez-Del Castillo
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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2
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Pflüger MJ, Jamouss KT, Afghani E, Lim SJ, Rodriguez Franco S, Mayo H, Spann M, Wang H, Singhi A, Lennon AM, Wood LD. Predictive ability of pancreatic cyst fluid biomarkers: A systematic review and meta-analysis. Pancreatology 2023; 23:868-877. [PMID: 37230894 DOI: 10.1016/j.pan.2023.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/10/2023] [Accepted: 05/13/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Mucinous pancreatic cysts harbor the potential to progress to highly lethal pancreatic ductal adenocarcinoma (PDAC). Since these precursor cysts require cancer surveillance or surgical resection, they need to be reliably distinguished from harmless pancreatic cysts. Current clinical and radiographic assessment is imperfect and the value of cyst fluid analysis for differential diagnosis is unclear. Therefore, we set out to investigate the value of cyst fluid biomarkers in distinguishing pancreatic cysts. METHODS We performed a systematic review of the current literature to identify articles that evaluated the diagnostic performance of clinically relevant and promising candidate cyst fluid biomarkers, with a particular emphasis on DNA-based biomarkers. Meta-analysis was performed for biomarkers targeted at identifying cyst type and presence of high-grade dysplasia or PDAC. RESULTS Data from a total of 42 studies was analyzed. Mutations in KRAS and/or GNAS allowed identification of mucinous cysts with a sensitivity of 79% and specificity of 98%. This exceeded the performance of the traditional biomarker carcinoembryonic antigen (CEA; sensitivity 58%, specificity 87%). Mutations in VHL were specific for serous cystadenomas (SCAs; sensitivity 56%, specificity 99%) and help to exclude mucinous cysts. Mutations in CDKN2A, PIK3CA, SMAD4, and TP53 each had high specificities of 97%, 97%, 98%, and 95%, respectively, to identify high-grade dysplasia or PDAC in mucinous cysts. CONCLUSIONS Cyst fluid analysis can be a valuable tool in the characterization of pancreatic cysts, with relevant clinical implications. Our results support the use of DNA-based cyst fluid biomarkers in the multidisciplinary diagnostic work-up of pancreatic cysts.
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Affiliation(s)
- Michael Johannes Pflüger
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Surgery CCM|CVK, Charité, Universitätsmedizin Berlin, Germany; Graduate School of Life Sciences, Utrecht University, The Netherlands
| | - Kevin Tony Jamouss
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elham Afghani
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Su Jin Lim
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Harrison Mayo
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Marcus Spann
- Johns Hopkins University School of Medicine, Welch Medical Library, Baltimore, MD, USA
| | - Hao Wang
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aatur Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Anne Marie Lennon
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA.
| | - Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA; Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Pancreatic cystic lesions. Differential diagnosis and treatment strategy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2022; 87:188-197. [DOI: 10.1016/j.rgmxen.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/05/2021] [Indexed: 11/20/2022]
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4
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Advances in the management of pancreatic cystic neoplasms. Curr Probl Surg 2020; 58:100879. [PMID: 34144739 DOI: 10.1016/j.cpsurg.2020.100879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/09/2020] [Indexed: 12/11/2022]
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Epidemiology, clinical features and diagnostic work-up of cystic neoplasms of the pancreas: Interim analysis of the prospective PANCY survey. Dig Liver Dis 2020; 52:547-554. [PMID: 32122771 DOI: 10.1016/j.dld.2020.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/07/2020] [Accepted: 02/09/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION A prospective survey to evaluate the diagnostic workup of cystic pancreatic neoplasms (CPNs) according to the Italian guidelines. METHODS An online data sheet was built. RESULTS Fifteen of the 1385 patients (1.1%) had non cystic neoplastic lesions. Forty percent (518/1295) had at least one 1st degree relative affected by a solid tumor of the digestive and extra-digestive organs. Symptoms/signs associated with the cystic lesion were present in 24.5% of the patients. The cysts were localized in the head of the pancreas in 38.5% of patients. Of the 2370 examinations (1.7 examinations per patient) which were carried out for the diagnosis, magnetic resonance imaging was performed as a single test in 48.4% of patients and in combination with endoscopic ultrasound in 27% of the cases. Of the 1370 patients having CPNs, 89.9% had an intraductal papillary mucinous neoplasm (IPMN) (70.1% a branch duct IPMN, 6.2% a mixed type IPMN and 4.6% a main duct IPMN), 12.7% had a serous cystadenoma, 2.8% a mucinous cystadenoma, 1.5% a non-functioning cystic neuroendocrine neoplasm, 0.7% a solid-pseudopapillary cystic neoplasm, 0.3% a cystic adenocarcinoma, and 1.2% an undetermined cystic neoplasm. Seventy-eight (5.7%) patients were operated upon after the initial work-up. CONCLUSIONS This prospective study offers a reliable real-life picture of the diagnostic work-up CPN.
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Pancreatic cystic neoplasms: current and future approaches to identify patients at risk. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Moyer MT, Maranki JL, DeWitt JM. EUS-Guided Pancreatic Cyst Ablation: a Clinical and Technical Review. Curr Gastroenterol Rep 2019; 21:19. [PMID: 31016391 DOI: 10.1007/s11894-019-0686-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE OF REVIEW Pancreatic cystic lesions represent a growing public health dilemma, particularly as our population ages and cross-sectional imaging becomes more sensitive. Mucinous cysts carry a clinically significant risk of developing pancreatic cancer, which carries an extremely poor prognosis. Determining which cysts will develop cancer may be challenging, and surgical resection of the pancreas carries significant morbidity. The goal of this paper is to review the rationale for cyst ablation and discuss prior and current research on cyst ablation techniques and efficacy. Indications, contraindications, and factors related to optimal patient selection are outlined. RECENT FINDINGS Endoscopic ultrasound-guided chemoablation of pancreatic cysts has been performed in neoplastic cysts, with varying levels of efficacy. Safety concerns arose due to the risk of pancreatitis in alcohol-based treatments; however, the most recent data using a non-alcohol chemoablation cocktail suggests that ablation is effective without the need for alcohol, resulting in a significantly more favorable adverse event profile. Endoscopic ultrasound-guided chemoablation of neoplastic pancreatic cysts is a promising, minimally invasive approach for treatment of cysts, with recent significant advances in safety and efficacy, suggesting that it should play a role in the treatment algorithm.
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Affiliation(s)
- Matthew T Moyer
- Division of Gastroenterology and Hepatology, Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA, USA.
| | - Jennifer L Maranki
- Division of Gastroenterology and Hepatology, Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA, USA
| | - John M DeWitt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Levink I, Bruno MJ, Cahen DL. Management of Intraductal Papillary Mucinous Neoplasms: Controversies in Guidelines and Future Perspectives. ACTA ACUST UNITED AC 2018; 16:316-332. [PMID: 30196428 PMCID: PMC6153570 DOI: 10.1007/s11938-018-0190-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management. Recent findings The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk. Summary International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).
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Affiliation(s)
- Ijm Levink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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de Biase D, Visani M, Acquaviva G, Fornelli A, Masetti M, Fabbri C, Pession A, Tallini G. The Role of Next-Generation Sequencing in the Cytologic Diagnosis of Pancreatic Lesions. Arch Pathol Lab Med 2018; 142:458-464. [PMID: 29565213 DOI: 10.5858/arpa.2017-0215-ra] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT - Integration of the analysis of genetic markers with endoscopic ultrasound-guided fine-needle aspiration and cytologic evaluation has increased the accuracy of the preoperative diagnosis of pancreatic lesions. The application of high-throughput gene panel analysis using next-generation sequencing platforms is now offering a great opportunity for further improvements. OBJECTIVE - To review the application of next-generation sequencing to the preoperative diagnosis of pancreatic lesions. DATA SOURCES - For data acquisition, a PubMed search using the terms next-generation sequencing, pancreas, pancreatic lesions, pancreatic tumors, and EUS-FNA was performed covering the years 2000-2017. CONCLUSIONS - KRAS remains the gene most widely studied for preoperative single-gene tests. Next-generation sequencing reliably allows analysis of multiple gene markers starting from limited amounts of DNA. The study of multigene panels has become a very attractive option for the management and preoperative risk stratification of patients with pancreatic cancer.
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Affiliation(s)
| | | | | | | | | | | | | | - Giovanni Tallini
- From the Department of Pharmacy and Biotechnology (Dipartimento di Farmacia e Biotecnologie)-Molecular Diagnostic Unit, Azienda USL di Bologna, University of Bologna, Bologna, Italy (Dr de Biase and Ms Pession); the Department of Medicine (Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale)-Molecular Diagnostic Unit, Azienda USL di Bologna, University of Bologna School of Medicine, Bologna, Italy (Drs Visani and Tallini and Ms Acquaviva); the Unit of Anatomic Pathology, Azienda USL-Maggiore Hospital, Bologna, Italy (Dr Fornelli); and the Units of Surgery (Dr Masetti) and Gastroenterology and Digestive Endoscopy (Dr Fabbri), Azienda USL Bologna Bellaria-Maggiore Hospitals, Bologna, Italy
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Routine Analysis of Lipase in Cyst Fluid Is Unnecessary and Does Not Help Discriminate Between Nonneoplastic and Neoplastic Cystic Pancreatic Lesions. Pancreas 2017; 46:e25-e27. [PMID: 28187114 DOI: 10.1097/mpa.0000000000000789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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11
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Saieg MA, Munson V, Colletti S, Nassar A. Impact of Pancreatic Cyst Fluid CEA Levels on the Classification of Pancreatic Cysts Using the Papanicolaou Society of Cytology Terminology System for Pancreaticobiliary Cytology. Diagn Cytopathol 2017; 45:101-106. [DOI: 10.1002/dc.23633] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/29/2016] [Accepted: 10/21/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Mauro Ajaj Saieg
- Department of Pathology; Santa Casa Medical School; Sao Paulo Brazil
- Department of Pathology; Fleury Laboratories; Sao Paulo Brazil
| | - Valerie Munson
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Jacksonville Florida
| | - Shanna Colletti
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Jacksonville Florida
| | - Aziza Nassar
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Jacksonville Florida
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12
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Soyer OM, Baran B, Ormeci AC, Sahin D, Gokturk S, Evirgen S, Basar R, Firat P, Akyuz F, Demir K, Besisik F, Kaymakoglu S, Karaca C. Role of biochemistry and cytological analysis of cyst fluid for the differential diagnosis of pancreatic cysts: A retrospective cohort study. Medicine (Baltimore) 2017; 96:e5513. [PMID: 28072692 PMCID: PMC5228652 DOI: 10.1097/md.0000000000005513] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Management of pancreatic cysts is based on neoplastic-nonneoplastic discrimination. Endoscopic ultrasound (EUS) enables to differentiate neoplastic-nonneoplastic lesions and also allows fine-needle aspiration (FNA). In this study, we aim to assess feasibility and clinical relevance of cytological and biochemical analysis in differential diagnosis of cystic pancreatic lesions in patients who had undergone endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) due to pancreatic cysts. METHODS Participants were 96 patients who had undergone EUS-FNA for differential diagnosis of pancreatic cysts. Pancreatic cysts were classified as benign-mucinous, nonmucinous, and malignant according to patient history, physical examination, EUS appearance, and cystic fluid assessment. Tumor markers (CEA, CA(cancer antigens) 72.4, CA 19-9) , amylase, lipase and cytological assesment were compared between 3 different groups. Receiver-operating characteristics (ROC) curves were constructed to identify appropriate cut-off values. RESULTS Fluid CEA and CA 72.4 levels for benign-mucinous and malignant cysts were significantly higher than for nonmucinous cysts (P ≤ 0.04). A cut-off CEA level of 207 ng/mL differentiated mucinous etiology with a sensitivity of 72.7%, specificity of 97.7%, and accuracy of 89.5%. The sensitivity, specificity, and accuracy of the CA 72.4 cut-off level of 3.32 ng/mL were 80%, 69.5%, and 73.6%, respectively. CONCLUSION Cyst fluid CEA and CA 72.4 levels have a high accuracy in discriminating mucinous from nonmucinous cysts. When combined with cytology their accuracy rate increases.
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Affiliation(s)
| | | | | | - Davut Sahin
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | | | | | - Pinar Firat
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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13
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You L, Ma L, Zhao W, Zhao Y, Dai M. Emerging role of tumor markers and biochemistry in the preoperative invasive assessment of intraductal papillary mucinous neoplasm of the pancreas. Clin Chim Acta 2016; 454:89-93. [DOI: 10.1016/j.cca.2015.12.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 12/09/2015] [Accepted: 12/30/2015] [Indexed: 01/06/2023]
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Abstract
Pancreatic cysts are being encountered frequently because of rapid advances in radiologic technology and an increased cross-sectional imaging demand. Management of pancreatic cystic tumors is challenging because most of them are asymptomatic; they are potentially malignant, and surgery has substantial morbidity and mortality. Endoscopic ultrasound (EUS)-guided fine-needle aspiration of pancreatic cystic tumors is accepted as a minimally invasive technique, which also enables injection of ablative agents into cysts under EUS guidance. In this review, the basic procedural steps and technical considerations of cyst ablation and their clinical issues including safety, feasibility, and therapeutic outcome will be summarized.
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Affiliation(s)
| | | | - Dong-Wan Seo
- Department of Internal Medicine, Division of Gastroenterology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
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Oppong KW, Dawwas MF, Charnley RM, Wadehra V, Elamin K, White S, Nayar M. EUS and EUS-FNA diagnosis of suspected pancreatic cystic neoplasms: Is the sum of the parts greater than the CEA? Pancreatology 2015; 15:531-537. [PMID: 26375415 DOI: 10.1016/j.pan.2015.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Carcinoembryonic antigen (CEA) is suggested as the single most useful EUS/EUS-FNA derived test for the diagnosis of mucinous pancreatic cysts. STUDY AIMS To investigate the yield and diagnostic performance of EUS/EUS-FNA on an intention to diagnose basis and to determine the utility of the recommended CEA and amylase cut-off values. PATIENTS AND METHODS A retrospective study of a prospectively maintained database of 433 procedures performed in a 10 year period. Diagnostic performance of EUS-FNA was determined in 133 procedures with a definite diagnosis. RESULTS CEA value was determined in significantly fewer procedures (58.6%) than EUS diagnosis was stated (83.4%; p < 0.0001), cyst fluid appearance recorded (89.4%) or adequate sample for cytology obtained (76.7%; p < 0.005). Median CEA was significantly higher in mucinous cysts than non-mucinous (175 ng/ml vs 3 ng/ml, p < 0.0001) and in malignant cysts compared to benign (8945 ng/ml vs 93 ng/ml, p < 0.001). On an intention-to-diagnose analysis, a CEA cut-off of 110 ng/ml was significantly less accurate (42.8%) than EUS diagnosis (67.7%), cytology (58.6%) or aspirate appearance (66.9%; p < 0.05 for all comparisons). However, the combination of EUS diagnosis, cytology and CEA provided higher sensitivity (91%), specificity (75%) and accuracy (85.7%) than each component test alone (p < 0.05 for all comparisons). Median amylase was significantly higher in benign compared to high-risk mucinous cysts ((11,429IU/L vs. 113IU/L; p < 0.05. CONCLUSION The combination of EUS, cytology and CEA performed well. Malignant cysts had a higher CEA value than benign cysts. On an intention to diagnose basis a CEA cut-off of 110 ng/ml performed poorly.
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Affiliation(s)
- K W Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK.
| | - M F Dawwas
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - R M Charnley
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - V Wadehra
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - K Elamin
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - S White
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - M Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
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Abstract
BACKGROUND Pancreatic cystic lesions (PCL) are common. They are increasingly detected as an incidental finding of transabdominal ultrasound or cross-sectional imaging. In contrast to other parenchymal organs, dysontogenetic pancreatic cysts are extremely rare. In symptomatic patients the most frequent PCL are acute and chronic pseudocysts. The majority of incidental cystic lesions, however, are neoplasias which have different risks of malignancy. METHODS PubMed was searched for studies, reviews, meta-analyses, and guidelines using the following key words: ('pancreatic cystic lesions' OR 'cystic pancreatic lesions' OR 'intraductal papillary mucinous neoplasia' OR 'mucinous cystic neoplasia' OR 'pancreatic cyst' OR 'pancreatic pseudocyst') AND (management OR treatment OR outcome OR prognosis OR diagnosis OR imaging OR 'endoscopic ultrasound' EUS-FNA OR EUS OR 'endoscopic ultrasonography' OR CT OR MRI). Retrieved papers were reviewed with regard to the diagnostic and therapeutic management of incidental PCL. RESULTS In addition to clinical criteria, transabdominal ultrasonography including contrast-enhanced ultrasonography, cross-sectional radiological imaging, and endoscopic ultrasound (EUS) are used for diagnostic characterization and risk assessment. EUS plays an outstanding role in differential diagnosis and prognostic characterization of incidental PCL. In a single examination it is possible to perform high-resolution morphological description, perfusion imaging, as well as fine-needle aspiration of cyst content, cyst wall, and solid components. An international consensus guideline has defined worrisome and high-risk criteria for the risk assessment of mucinous pancreatic cysts, which are mainly based on the results of EUS and cross-sectional imaging. Nevertheless, despite diagnostic progress and guideline recommendations, differential diagnosis and management decisions remain difficult. This review will discuss problems in and approaches to the diagnosis of incidental PCL. CONCLUSION An evidence-based algorithm for the diagnosis of incidental PCL is proposed.
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Affiliation(s)
- Christian Jenssen
- Department of Internal Medicine, Märkisch Oderland Hospital GmbH, Strausberg/Wriezen, Germany
| | - Stefan Kahl
- Department of Internal Medicine, DRK Kliniken Berlin - Köpenick, Berlin, Germany
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