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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
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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
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Clinical Presentation
Most are asymptomatic

Lesion with malignant potential – 42%

Ca in situ / invasive cancer – 17%
Fernandez Del Castillo et al. Arch Surg 2003
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Classification

Non neoplastic (pseudocysts)
Non Mucinous

Neoplastic
• Serous cystadenoma
• Cystic endocrine tumors
• Others
Mucinous
• Mucinous cystadenoma
• Malignant mucinous cystic tumors
• Intraductal papillary mucinous
neoplasms - IPMN
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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
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Methods
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Methods




Retrospective study
170 patients between 1997-2006
155 patients ,195 EUS exams
40 patients – EUSx2
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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)
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Methods
EUS


Cyst location, size, morphology
FNA – fluid:
- characteristics
- cytology
- tumor markers –CEA,CA19-9,CA72-4,MCA

Cyst wall sampling (cell block)
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Results
11
12
Results
101 women, 54 men
Mean age – 64.3±14 years
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
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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
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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
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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.
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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)
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BoxPlot
12.00
10.00
6.00
4.00
2.00
Ln(CEA)
lnCEA
8.00
0.00
-2.00
Non-mucinousClass
0
1
Mucinous
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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))
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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
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Criteria used in our Institute
for Dx of Serous cysts
-
-
Clinical
Microcystic morphology
CEA level < 5 ng / ml
Histology- cuboidal, non secreting
cells
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Criteria 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
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Treatment

Serous cyst - follow up only

Mucinous cyst – surgery

Diagnosis indeterminate - surgery
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