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

1. 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

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 areasymptomatic • Lesion with malignant potential – 42% • Ca in situ / invasive cancer – 17% Fernandez Del Castillo et al. Arch Surg 2003

4. Classification • Non neoplastic (pseudocysts) • Neoplastic • Non Mucinous • Serous cystadenoma • Cystic endocrine tumors • Others • Mucinous • Mucinous cystadenoma • Malignant mucinous cystic tumors • Intraductal papillary mucinous neoplasms - IPMN

5. 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

6. Methods

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

8. 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)

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

10. Results

12. Results 101 women, 54 men Mean age – 64.3±14 years

13. Results

14. Results

15. 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.

16. 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)

17. BoxPlot Ln(CEA) Non-mucinous Mucinous

18. ROC of CEA classification of Mucinous vs. Serous A Threshold of CEA=58 ng/ml yields 86.4% and 87.5% sensitivity and specificity respectively sensitivity 1-specificity AUC=0.902 (CI=(0.79-1.0))

19. 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

20. Thank You

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

22. 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

23. Treatment • Serous cyst - follow up only • Mucinous cyst – surgery • Diagnosis indeterminate - surgery