Differential Diagnosis of Neoplastic Pancreatic Cysts - Tel
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Transcript Differential Diagnosis of Neoplastic Pancreatic Cysts - Tel
Differential Diagnosis of
Neoplastic Pancreatic Cysts:
The Role of EUS with Guided FNA
E.M.Santo,Y.Ron,O.Barkay,Y.Kopelman,M.Leshno,S.Marmor
Dep. of Gastroenterology & Hepatology,
Dep.of Pathology
Tel-Aviv Sourasky Medical Center
1
Introduction
Cystic lesions constitute about 10 %
of pancreatic tumors
Significant increase in detection due
to widespread use of US,CT
Most lesions discovered incidentally
2
Clinical Presentation
Asymptomatic
Abdominal pain
Jaundice
Pancreatitis
3
Clinical Presentation
Asymptomatic
Ca in situ / invasive cancer – 17%
Lesion with malignant potential – 42%
Fernandez Del Castillo et al. Arch Surg 2003
4
Classification
Non neoplastic (pseudocysts)
Non Mucinous
Neoplastic
Mucinous
5
Classification
Non Mucinous Cysts
1.
Serous cystadenoma
2.
Cystic endocrine tumors
3.
Other
6
Classification
Mucinous Cysts
1.
Mucinous cystadenoma
2.
Malignant mucinous cystic tumors
3.
Intraductal papillary mucinous
neoplasms - IPMN
7
8
Diagnosis
CT –
microcystic appearance, central
fibrosis- Serous
Unilocular, macrocystic, peripheral
calcification- Mucinous
MRCP – MPD dilatation, mural nodules
ductal connection - IPMN
9
Diagnosis
EUS - highly sensitive
FNA – fluid characteristics, tumor
markers, cytology
CEA in fluid - most accurate marker
10
EUS – Serous cyst
11
EUS – Mucinous cyst
12
AIM
Evaluation
of the various parameters
(clinical,morphological,fluid content,
cytology) and their contribution to the
ability to distinguish between serous
and mucinous cystic tumors
13
AIM
Validation
of the current criteria used
to distinguish between various cystic
tumors (gold standard based on
surgical pathology )
Establishing
new criteria with higher
sensitivity and specificity
14
AIM
Provide
an algorithm for the diagnosis
and treatment of pancreatic cystic
lesions
15
Heuristics used in our Institute
for Dx of Serous cysts
-
-
Clinical
Microcystic morphology
CEA level < 5 ng / ml
Histology- cuboidal, non secreting
cells
16
Heuristics used in our Institute
for Dx of Mucinous cysts
-
-
Clinical
Morphology – unilocular, thick
septa, solid component
High viscosity (mucinous) fluid
CEA - >140 ng/ml
Histology – columnar secreting
epithelium
17
Methods
18
Methods
Retrospective study
170 patients between 1977-2006
155 patients ,195 EUS exams
40 patients – EUSx2 or more
101 women, 54 men
Mean age – 64.3±14 years
19
Methods
Demographic data
Clinical presentation
Imaging – US, CT , EUS
FNA
Surgical findings
Follow up on all patients (office
visits ,
data from family physicians, gastroenterologists,
patient’s families)
20
Methods
EUS
Cyst location, size, morphology
FNA – fluid:
- characteristics
- cytology
- tumor markers –CEA,CA19-9,CA72-4,MCA
Cyst wall sampling (cell block)
21
Results
22
Results
Clinical Presentation
No.
%
Incidental finding
103
69.3
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
Abdominal pain
23
Results
Location
No.
Head
52
Neck
14
%
33.5
9.0
Body
41
26.5
Tail
25
16.1
Other
23
14.8
24
Results
– 37 patients had surgery with histological
findings.
– 140 patients had FNA but results were
available for 80 patients.
25
Results
Surgical Pathology
No.
%
Non neoplastic
6
4
13
11
2
1
16.2
10.8
35.1
29.7
5.4
2.7
Serous
Mucinous
Mucinous ca.
IPMN
Neuroendocrine
26
Results
FNA Histology
No.
%
Non neoplastic
12
27
25
14
2
16.0
33.8
31.3
17.5
2.5
Serous
Mucinous
Carcinoma
Neuroendocrine
27
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
kappa=0.33.
– Sensitivity and specificity of FNA are 59%
and 80% respectively.
28
Results
Mean of Ln(CEA)* levels were 2.6 and 5.8
for non mucinous and mucinous cases
respectively (p<0.0001)
No statistically significant difference with
all the other tumor markers tested
Rate of solid component in cyst – the
difference was not statistically significant
(p=0.14)
No difference concerning cyst size or
morphology
*CEA is highly skewed distributed and therefore we
transformed the CEA level to Ln(CEA)
29
BoxPlot
12.00
10.00
Ln(CEA)lnCEA
8.00
6.00
4.00
2.00
0.00
-2.00
Non-mucinous
0
Mucinous
1
Class
30
Logistic regression results
95% C.I.for OR
Variable
B
S.E.
p-value
OR
Lower
Upper
log10CEA
1.818
0.727
0.012
6.2
1.48
25.6
-0.041
0.022
0.06
0.96
0.92
1.01
Age
Note that CA-19 is highly correlated with CEA, and when CEA
levels are unavailable the CA-19 level should play a role in the
diagnostic process.
31
ROC of CEA classification of
Mucinous vs. Serous
ROC Curve
A Threshold
of CEA=58
ng/ml yields
86.4% and
87.5%
sensitivity and
specificity
respectively
0.8
Sensitivity
sensitivity
1.0
0.6
0.4
0.2
0.0
0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
1-specificity
AUC=0.902 (CI=(0.79-1.0))
32
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 (or CA 19-9 levels) can
significantly increase the diagnostic
yield
33
A Practical Decision
Algorithm based on the
Threshold Decision Model
Source: NEJM 1980; 302:1109-17
34
For a patient with a pancreatic cyst there are
several management options:
• Wait and watch approach with a follow up.
• An initial EUS-FNA is performed and patients with
increased cyst fluid CEA or positive cytology
undergo a surgical resection.
• Surgical resection of all cysts without prior EUS
evaluation.
35
Beside the preferences of the patient, the following
parameters are relevant to the decision process:
• Age of the patient
• 60 year
• 61-75 year
• > 75 year
• Co-morbidity status (CV diseases, diabetes, other
neoplastic diseases)
• No co-morbidity
• Co-morbidity
• Test results (CT, EUS)
36
Natural history of mucinous cystic neoplasm
78 years old woman with incidental finding - 1977
CEA in cyst
90
CA19-9 in blood
Cyst size (mm)
Cyst size
10000
80
9000
70
8000
7000
60
6000
50
5000
40
4000
30
3000
20
2000
10
1000
0
0
year
1997 1998 1999 2000 2001 2003 2005
37
Age
<=60
Yes
Co-morbidity
Positive
Cytology or
CEA>60
60 - 75
Yes
Yes
Complexity
of Surgical
resection
Compliance
= Surgical Resection
Yes
Yes
Yes
No
Yes
5< CEA<60
No
Yes
No
No
>75
No
No
No
No
= Wait and Watch
= Debate
38
Age
<=60
Co-morbidity
Yes
60 - 75
No
>75
No
Yes
Positive
Cytology or
CEA>60
Yes
Yes
Complexity
of Surgical
resection
= Surgical Resection
= Wait and Watch
No
No
= Debate
39
Age
<=60
>75
No
Yes
Co-morbidity
Positive
Cytology or
CEA>60
60 - 75
Yes
No
= Surgical Resection
Yes
= Wait and Watch
No
= Debate
40
41