Differential Diagnosis of Neoplastic Pancreatic Cysts: The Role of EUS with Guided FNA - PowerPoint PPT Presentation

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Differential Diagnosis of Neoplastic Pancreatic Cysts: The Role of EUS with Guided FNA

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Title: Differential Diagnosis of Neoplastic Pancreatic Cysts: The Role of EUS with Guided FNA


1
Differential Diagnosis of Neoplastic Pancreatic
CystsThe Role of EUS with Guided FNA

E.M.Santo,Y.Ron,O.Barkay,Y.Kopelman,M.Leshno,S.Mar
mor
Dep. of Gastroenterology Hepatology, Dep.of
Pathology Tel-Aviv Sourasky Medical Center
2
Introduction
  • Significant increase in detection due
  • to widespread use of US,CT
  • Most lesions detected incidentally
  • The prevalence of pancreatic cyst is
  • Cystic lesions constitute about 10 of
    pancreatic tumors

3
Clinical Presentation
  • Most are asymptomatic
  • Lesion with malignant potential 42
  • Ca in situ / invasive cancer 17

Fernandez Del Castillo et al. Arch Surg 2003
4
Classification
  • Non neoplastic (pseudocysts)
  • Non Mucinous
  • Serous cystadenoma
  • Cystic endocrine tumors
  • Others
  • Neoplastic
  • Mucinous
  • Mucinous cystadenoma
  • Malignant mucinous cystic tumors
  • Intraductal papillary mucinous neoplasms - IPMN

5
Diagnosis
  • EUS - highly sensitive
  • FNA fluid characteristics, tumor markers,
    cytology
  • CEA in fluid - most accurate marker

6
AIM
  • To describe a single center experience with EUS
    guided FNA in cystic pancreatic lesions
  • To determine the ability of EUS guided FNA to
    differentiate between serous and mucinous cystic
    tumors

7
Methods
8
Methods
  • Retrospective study
  • 170 patients between 1997-2006
  • 155 patients ,195 EUS exams
  • 40 patients EUSx2

9
Methods
  • Demographic data
  • Clinical presentation
  • Imaging US, CT , EUS
  • FNA
  • Surgical findings
  • Follow up on all patients (office visits , data
    from family physicians, gastroenterologists,
    patients families)

10
Methods
  • EUS
  • Cyst location, size, morphology
  • FNA fluid
  • - characteristics
  • - cytology
  • - tumor markers CEA,CA19-9,CA72-4,MCA
  • Cyst wall sampling (cell block)

11
Results
12
(No Transcript)
13
Results
101 women, 54 men Mean age 64.314 years
Clinical Presentation No.
Incidental finding 103 69.3
Abdominal pain 29 19.6
Weight loss 2 1.4
Jaundice 2 1.4
Abdominal pain/weight loss 5 3.4
Dyspepsia 2 1.4
Diarrhea 2 1.4
Diarrhea/weight loss 3 2.0
14
Results
FNA Histology No.
Non neoplastic 12 16.0
Serous 27 33.8
Mucinous 25 31.3
Carcinoma 14 17.5
Neuroendocrine 2 2.5
15
Results
Surgical Pathology No.
Non neoplastic 6 16.2
Serous 4 10.8
Mucinous 13 35.1
Mucinous ca. 11 29.7
IPMN 2 5.4
Neuroendocrine 1 2.7
16
EUS-FNA vs. Surgical biopsy
  • 32 patients had both FNA and surgical biopsy.
  • The agreement rate was 66 of the cases regarding
    mucinous vs. non-mucinous with kappa0.33.
  • Sensitivity and specificity of FNA are 59 and
    80 respectively.

17
Results
  • Mean of Ln(CEA) levels were 2.6 and 5.8 for non
    mucinous and mucinous cases respectively
    (plt0.0001)
  • No statistically significant difference with all
    the other tumor markers tested
  • Rate of solid component in cyst the difference
    was not statistically significant (p0.14)
  • No difference concerning cyst size or morphology

CEA is highly skewed distributed and therefore
we transformed the CEA level to Ln(CEA)
18
BoxPlot
Ln(CEA)
Non-mucinous
Mucinous
19
ROC of CEA classification of Mucinous vs. Serous
A Threshold of CEA58 ng/ml yields 86.4 and
87.5 sensitivity and specificity respectively
sensitivity
1-specificity
AUC0.902 (CI(0.79-1.0))
20
Conclusions
  • EUS is a useful tool but it can not alone
    distinguish between cystic lesions with variable
    malignant potential
  • EUS-FNA alone is also limited in its ability to
    correctly diagnose a cystic lesion sensitivity
    59 specificity 80
  • Combination of parameters cytology and CEA
    levels can significantly increase the diagnostic
    yield

21
Thank You
22
Criteria used in our Institute for Dx of Serous
cysts
  • Clinical
  • Microcystic morphology
  • CEA level lt 5 ng / ml
  • Histology- cuboidal, non secreting cells

23
Criteria used in our Institute for Dx of Mucinous
cysts
  • Clinical
  • Morphology unilocular, thick septa, solid
    component
  • High viscosity (mucinous) fluid
  • CEA - gt140 ng/ml
  • Histology columnar secreting epithelium

24
Treatment
  • Serous cyst - follow up only
  • Mucinous cyst surgery
  • Diagnosis indeterminate - surgery
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