Cystic Neoplasms of the Pancreas Cyst fluid analysis

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Cystic Neoplasms of the PancreasCyst fluid
analysis
2006.2.10Biliary Conference Review
Oh Heung Kwon M.D.
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Background

• Increasing frequency
• Increased use of cross sectional imaging
• Incidental finding on the screening test
• Fundamental issue
• Neoplastic or not
• Malignant degeneration or not
• All lesion should be resected or not
• Clinical decision making is driven by an
  understanding of the differential diagnosis and
  natural history

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Classification
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Characteristics
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Morphologic types
Microcystic
Unilocular
PCIPMN
SC
Cyst with solid portion
MCIPMNMalignancy
Macrocystic
MCIPMN
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Pseudocyst
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IPMN
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Serous Cysadenoma
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Mucinous Cystadenoma
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Solid Pseudopapillary Tumor
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Malignant Tumor
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The Role of Biopsy in pancreas cancer

• Unresectable lesion
• Usually required before chemoradiation therapy of
  unresectable pancreatic tumors or neoadjuvant
  treatment of resectable tumors
• Resectable lesion
• a positive biopsy merely confirms the decision
  for resection and a negative biopsy is
  inconclusive
• most surgeons would not recommend routine
  preoperative biopsy for confirmation of the
  diagnosis
• 5 to 10 of patients undergoing resection for
  suspected cancer will be found to have benign
  lesions

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Characterization of Cyst Fluid

• EUS-guided cyst aspiration is well tolerated and
  safe in the hands of an experienced operator,
  with a complication rate of less than 1 of
  bleeding, perforation, or infection.
• Aspirated fluid has been evaluated by cytology
  and chemical measurements of amylase and tumor
  markers.
• Characterization of cyst fluid is best used to
  differentiate those with malignant potential,
  mucinous cysts, from serous and nonneoplastic
  pseudocysts.

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Cyst Fluid Analysis

• Tumor glycoproteins
• CEA, CA 19-9, CA 72-4
• A number of glycoproteins are present in the
  epithelium of mucinous cystic neoplasm
• Differentiate between mucinous and non-mucinous
  lesion
• The higher the CEA, the higher the diagnostic
  confidence of a mucinous lesion
• Amylase
• Indicator of cyst communication with ductal
  system
• Amylase rich fluid Pseudocyst, IPMN

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Cyst Fluid Analysis
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Cyst Fluid Analysis
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Cytologic Feature
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Management Approach
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Risk Stratification
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Conclusion

• The approach to the patient with a pancreatic
  cystic lesion begins with a detailed history, and
  consideration of the major diagnostic aspects.
• In general, all symptomatic lesions and all
  mucinous lesions should proceed to appropriate
  surgical resection.
• If preoperative characterization of the lesion
  will change management, EUS-FNA for cytology and
  fluid analysis may provide information of
  diagnostic value and support the approach of
  watchful waiting.

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References

• Scheiman JM. Cystic lesion of the pancreas.
  Gastroenterology. 2005 Feb128(2)463-9.
• Van der Waaij LA et al. Cyst fluid analysis in
  the differential diagnosis of pancreatic cystic
  lesionsa pooled analysis. Gastrointest Endosc.
  2005 Sep62(3)383-9.
• Brugge WR. Should all pancreatic cystic lesions
  be resected? Cyst-fluid analysis in the
  differential diagnosis of pancreatic cystic
  lesions a meta-analysis. Gastrointest Endosc.
  2005 Sep62(3)390-1.
• Sahani DV et al. Cystic pancreatic lesions a
  simple imaging-based classification system for
  guiding management. Radiographics. 2005
  Nov-Dec25(6)1471-84.
• Brugge WR et al. Cystic neoplasms of the
  pancreas. N Engl J Med. 2004 Sep
  16351(12)1218-26.

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Thank you for your attentions