Gastroenterology

Gastroenterology

Volume 126, Issue 5, May 2004, Pages 1330-1336
Gastroenterology

Clinical-liver, pancreas, and biliary tract
Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study

https://doi.org/10.1053/j.gastro.2004.02.013Get rights and content

Abstract

Background & Aims: Cysts of the pancreas display a wide spectrum of histology, including inflammatory (pseudocysts), benign (serous), premalignant (mucinous), and malignant (mucinous) lesions. Endoscopic ultrasonography (EUS) may offer a diagnostic tool through the combination of imaging and guided, fine-needle aspiration (FNA). The purpose of this investigation was to determine the most accurate test for differentiating mucinous from nonmucinous cystic lesions. Methods: The results of EUS imaging, cyst fluid cytology, and cyst fluid tumor markers (CEA, CA 72-4, CA 125, CA 19-9, and CA 15-3) were prospectively collected and compared in a multicenter study using histology as the final diagnostic standard. Results: Three hundred forty-one (341) patients underwent EUS and FNA of a pancreatic cystic lesion; 112 of these patients underwent surgical resection, providing a histologic diagnosis of the cystic lesion (68 mucinous, 7 serous, 27 inflammatory, 5 endocrine, and 5 other). Receiver operator curve analysis of the tumor markers demonstrated that cyst fluid CEA (optimal cutoff of 192 ng/mL) demonstrated the greatest area under the curve (0.79) for differentiating mucinous vs. nonmucinous cystic lesions. The accuracy of CEA (88 of 111, 79%) was significantly greater than the accuracy of EUS morphology (57 of 112, 51%) or cytology (64 of 109, 59%) (P < 0.05). There was no combination of tests that provided greater accuracy than CEA alone (P < 0.0001). Conclusions: Of tested markers, cyst fluid CEA is the most accurate test available for the diagnosis of mucinous cystic lesions of the pancreas.

Section snippets

Materials and methods

A multicenter trial, with institutional review board approval at each site, was initiated in July 1999 (see Appendix I). Patients (with or without symptoms) found to have a pancreatic cystic lesion of greater than 10 mm on transabdominal ultrasonography or computed tomography (CT) scanning were eligible. Exclusion criteria included the following: Protime (PT-INR) >1.5, partial thromboplastin time (PTT) >50, platelets <50,000, acute pancreatitis, or the presence of a pancreatic abscess. The

EUS methods

All patients underwent an EUS examination, performed using a linear echoendoscope as previously described.16 The results of the examination prospectively reported the location, size, and morphology (see below) of the cystic lesion. The cystic lesion was aspirated under EUS guidance using 1 passage of a 19- or 22-gauge needle (Wilson Cook Inc., Winston-Salem, North Carolina; or Mediglobe, Tempe, AZ) occluded with a stylet. An oral quinolone was administered for 2–3 days after the procedure.

Results

Three hundred forty-one consecutive patients were enrolled in the trial over 2 years and underwent EUS and FNA. None of the patients had an infective complication of the EUS-guided FNA. Two patients developed mild pancreatitis after the EUS-FNA that resolved within 3 days.

The patient characteristics are presented in Table 1. Patients were predominantly female (63%, P < 0.001). Most of the cysts examined (n = 207, 61%) were greater than 2 cm in diameter, and most were located in the head of the

Discussion

Cystic mucinous neoplasms of the pancreas are composed of a group of cystic tumors that are lined by mucinous, columnar epithelium. The diagnosis of this type of cystic lesion is very important because of the presence of malignancy in some lesions at the time of presentation and the tendency to develop malignancy over time. This feature is highlighted in our highly selected patients by the presence of malignancy or borderline malignancy in 40 of 68 patients with a mucinous cystic lesion. Other

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  • Cited by (0)

    Supported by the American Society of Gastrointestinal Endoscopy (ASGE) and a career development award from the ASGE (to W.R.B.).

    None of the investigators have a financial conflict of interest with the corporations referred to in this study.

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