1. 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. 2 Introduction Significant increase in detection due Significant increase in detection due to widespread use of US,CT to widespread use of US,CT Most lesions detected incidentally Most lesions detected incidentally The prevalence of pancreatic cyst is … The prevalence of pancreatic cyst is … Cystic lesions constitute about 10 % of pancreatic tumors Cystic lesions constitute about 10 % of pancreatic tumors

3. 3 Clinical Presentation Most are asymptomatic Most are asymptomatic Lesion with malignant potential – 42% Lesion with malignant potential – 42% Ca in situ / invasive cancer – 17% Ca in situ / invasive cancer – 17% Fernandez Del Castillo et al. Arch Surg 2003

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

5. 5 Diagnosis EUS - highly sensitive EUS - highly sensitive FNA – fluid characteristics, tumor markers, cytology FNA – fluid characteristics, tumor markers, cytology CEA in fluid - most accurate marker CEA in fluid - most accurate marker

6. 6 AIM To describe a single center experience with EUS guided FNA in cystic pancreatic lesions 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 To determine the ability of EUS guided FNA to differentiate between serous and mucinous cystic tumors

7. 7 Methods

8. 8 Methods Retrospective study Retrospective study 170 patients between 1997-2006 170 patients between 1997-2006 155 patients,195 EUS exams 155 patients,195 EUS exams 40 patients – EUSx2 40 patients – EUSx2

9. 9 Methods Demographic data Demographic data Clinical presentation Clinical presentation Imaging – US, CT, EUS Imaging – US, CT, EUS FNA FNA Surgical findings Surgical findings Follow up on all patients ( office visits, data from family physicians, gastroenterologists, patient’s families) Follow up on all patients ( office visits, data from family physicians, gastroenterologists, patient’s families)

10. 10 Methods EUS Cyst location, size, morphology Cyst location, size, morphology FNA – fluid: FNA – fluid: - characteristics - cytology - tumor markers – CEA,CA19-9,CA72-4,MCA Cyst wall sampling (cell block) Cyst wall sampling (cell block)

11. 11 Results

12. 12

13. 13 Results Clinical Presentation No. % Incidental finding 103 103 69.3 69.3 Abdominal pain 29 29 19.6 19.6 Weight loss 2 1.4 1.4 Jaundice 2 Abdominal pain/weight loss 5 3.4 3.4 Dyspepsia 2 1.4 1.4 Diarrhea 2 Diarrhea/weight loss 3 2.0 2.0 101 women, 54 men Mean age – 64.3±14 years

14. 14 Results FNA HistologyNo.% Non neoplastic1216.0 Serous2733.8 Mucinous2531.3 Carcinoma1417.5 Neuroendocrine22.5

15. 15 Results Surgical PathologyNo.% Non neoplastic616.2 Serous410.8 Mucinous1335.1 Mucinous ca.1129.7 IPMN25.4 Neuroendocrine12.7

16. 16 –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. 59%80% –Sensitivity and specificity of FNA are 59% and 80% respectively. EUS-FNA vs. Surgical biopsy

17. 17 Results Mean of Ln(CEA) * levels were 2.6 and 5.8 for non mucinous and mucinous cases respectively (p<0.0001) 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 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) Rate of solid component in cyst – the difference was not statistically significant (p=0.14) No difference concerning cyst size or morphology No difference concerning cyst size or morphology *CEA is highly skewed distributed and therefore we transformed the CEA level to Ln(CEA)

18. 18 Mucinous Ln(CEA) BoxPlot Non-mucinous

19. 19 ROC of CEA classification of Mucinous vs. Serous 1-specificity sensitivity AUC=0.902 (CI=(0.79-1.0)) A Threshold of CEA=58 ng/ml yields 86.4% and 87.5% sensitivity and specificity respectively

20. 20Conclusions EUS is a useful tool but it can not alone distinguish between cystic lesions with variable malignant potential 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% 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 Combination of parameters – cytology and CEA levels can significantly increase the diagnostic yield

21. 21 Thank You

22. 22 Criteria used in our Institute for Dx of Serous cysts Criteria used in our Institute for Dx of Serous cysts - Clinical - Microcystic morphology - CEA level < 5 ng / ml - Histology- cuboidal, non secreting cells

23. 23 - Clinical - Morphology – unilocular, thick septa, solid component - High viscosity (mucinous) fluid - CEA - >140 ng/ml - Histology – columnar secreting epithelium Criteria used in our Institute for Dx of Mucinous cysts

24. 24 Treatment Serous cyst - Serous cyst - follow up only Mucinous cyst – surgery Diagnosis indeterminate - surgery