Title: Differential Diagnosis of Neoplastic Pancreatic Cysts: The Role of EUS with Guided FNA
1Differential 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
2Introduction
- 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
3Clinical Presentation
- Most are asymptomatic
- Lesion with malignant potential 42
- Ca in situ / invasive cancer 17
Fernandez Del Castillo et al. Arch Surg 2003
4Classification
- Non neoplastic (pseudocysts)
- Non Mucinous
- Serous cystadenoma
- Cystic endocrine tumors
- Others
- Mucinous
- Mucinous cystadenoma
- Malignant mucinous cystic tumors
- Intraductal papillary mucinous neoplasms - IPMN
5Diagnosis
- EUS - highly sensitive
- FNA fluid characteristics, tumor markers,
cytology - CEA in fluid - most accurate marker
6AIM
- 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
7Methods
8Methods
- Retrospective study
- 170 patients between 1997-2006
- 155 patients ,195 EUS exams
- 40 patients EUSx2
9Methods
- 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)
10Methods
- EUS
- Cyst location, size, morphology
- FNA fluid
- - characteristics
- - cytology
- - tumor markers CEA,CA19-9,CA72-4,MCA
- Cyst wall sampling (cell block)
11Results
12(No Transcript)
13Results
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
14Results
FNA Histology No.
Non neoplastic 12 16.0
Serous 27 33.8
Mucinous 25 31.3
Carcinoma 14 17.5
Neuroendocrine 2 2.5
15Results
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
16EUS-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.
17Results
- 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)
18BoxPlot
Ln(CEA)
Non-mucinous
Mucinous
19ROC 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))
20Conclusions
- 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
21Thank 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
23Criteria 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
24Treatment
- Serous cyst - follow up only
- Mucinous cyst surgery
- Diagnosis indeterminate - surgery