Aspiration Of Cyst Fluid Research Articles

EUS-FNA of Cystic Pancreatic Tumors

Due to limitations with diagnostic imaging alone, endoscopic ultrasound (EUS)-guided fine needle aspiration (EUS-FNA) of pancreatic cyst fluid provides additional information to help characterize these lesions as inflammatory, benign, premalignant, or malignant. When greater than 2 mL of cyst fluid is obtained from EUS-FNA, the following should be examined: cytology, carcinoembryonic antigen (CEA), and amylase. Pseudocyst fluid generally has thin viscosity, is yellow to brown in color, and has low CEA and elevated amylase levels. Fluid from serous cystic neoplasms is thin, colorless with a low CEA (<200 ng/mL), and low amylase levels. Aspirates from mucinous cystic neoplasms (including intraductal papillary tumors [IPMTs]) are generally viscous with an elevated CEA (>200 ng/mL) but variable amylase levels. Complications following EUS-FNA of these lesions occur in 1% to 2% of patients and may be minimized by performing only one pass, completely aspirating the punctured cyst, and administration of antibiotics.

Cyst Fluid Cea Concentration, Age and a Diagnosis of Malignancy Are Associated with Increased Mortality: An Update From the Cooperative Pancreatic Cyst (CPS) Study

The natural history of mucinous cystic lesions is unknown. Mucinous cystic neoplasms (MCN) and intraductal papillary mucinous neoplasms (IPMN) are pre-malignant or malignant lesions that may be associated with a greater mortality rate compared to non-mucinous lesions. We have monitored the outcome of patients in the CPC study to identify risk factors for mortality. Methods: Clinical testing results and patient outcome were prospectively collected in the CPC Study from May 1, 1999 to November 19, 2004. We hypothesized that mortality rate would be determined by type of cystic lesion, presence of malignancy, and cyst fluid CEA concentration (conc). Results: There were 699 EUS-guided aspirations in 625 consecutive patients with a cystic lesion on cross sectional imaging. 209 patients had a diagnosis established by surgical pathology or cytology. The median follow-up period was 1124d (37.5 mo). 125 mucinous lesions (71 IPMN and 54 MCN), 11 serous cystadenomas, 45 inflammatory cysts, 6 neuroendocrine tumors and 20 other cystic lesions were analyzed. Among the mucinous lesions, 46 were benign, 21 had borderline histology and 59 were malignant (carcinoma-in-situ or invasive). During the study period, there were 45 deaths. 30/45 (67%) of these patients had malignant mucinous lesions (8 malignant MCN, 22 malignant IPMN). The mortality rate for patients with malignant mucinous lesions was 51% (30/59) vs. 3% (2/67) for those with benign mucinous lesions (p < 0.001), and 0% for those with serous cystadenomas (p < 0.01). The mortality rate for malignant MCN was 53% (8/15) and 50% (22/44) for malignant IPMN. The mortality rate of patients with a mucinous lesion and who were >70 y old was 38% compared to 15% for <70y old (p < 0.01). The relative risk (RR) of mortality in patients with a malignant mucinous lesion was 34 (95% confidence interval [CI] 4.8-242.2). Age > 70y had a RR of mortality of 2.45 (95% CI 1.29-4.66). Cyst fluid CEA conc. > 500ng/ml was found in 80% of deaths v. 49% in surviving patients (p < 0.01) and had a RR of mortality of 2.95 (95% CI 1.31-6.66). Conclusions: Patients with a malignant mucinous cystic lesion have a significantly higher mortality rate (51%) than those with a benign mucinous cystic lesion (3%). Risk factors for death include increased age and cyst fluid CEA conc >500 ng/ml. The results of cyst fluid aspiration offer prognostic information in the management of patients with a cystic lesion.

Management of Ovarian Cysts with Aspiration and Methotrexate Injection

To evaluate prospectively ultrasonography (US)-guided cyst aspiration and methotrexate injection in the management of simple and endometriotic ovarian cysts in selected patients. Authors obtained informed patient consent and approval from hospital ethics committee. Study included 162 female patients (aged 15-77 years) with simple or endometriotic ovarian cysts (3.0-10.6 cm) at a tertiary hospital. Criteria for inclusion in the study were (a) persistence of the cyst for at least 6 months, (b) benign appearance of the cyst at US, and (c) normal serum CA-125 level measurement before the procedure. Authors performed transabdominal aspiration of the cysts with direct US guidance and injection of methotrexate (30 mg). Cytologic examination was performed in all cases. Follow-up US was performed at 1, 3, and 6 months. If the cyst persisted, the procedure could be repeated. Main outcome measure was resolution or persistence of cysts. chi(2) Test or Mantel-Haentszel chi(2) tests for univariate analysis and multiple logistic regression were used for multivariate statistical analysis. Of 162 patients, 148 were available for follow-up. Malignant cells were not found in any of the cases at cytologic examination. At follow-up US, cysts had disappeared in 124 patients (83.8%) and persisted in 24 (16.2%). Cyst diameter proved to be a significant prognostic factor for cyst resolution (P = .01). No major complications were observed. Patients received neither analgesia nor antibiotics. US-guided transabdominal aspiration of cyst fluid and subsequent methotrexate injection appears to be an alternative treatment for both simple and endometriotic ovarian cysts in selected cases.

Late cyst formation following gamma knife surgery of arteriovenous malformations

The authors present data concerning the development of cysts following gamma knife surgery (GKS) in 1203 consecutive patients with arteriovenous malformations (AVMs) treated by the senior author (L.S.). The cyst was defined as a fluid-filled cavity at the site of a treated AVM. Cases involving regions corresponding to previous hematoma cavities were excluded. The incidence of cyst formation was assessed using magnetic resonance imaging studies performed in 196 cases with more than 10 years of follow up, in 332 cases with 5 to 10 years of follow up, and in 675 cases with less than 5 years of follow up. One hundred five cases were lost to follow-up study. The Cox regression method was used to analyze the factors related to cyst formation. The incidence of cyst formation in the entire patient population was 1.6 and 3.6% in those undergoing follow-up examination for more than 5 years. Ten of 20 cysts developed between 10 to 23 years, nine between 5 to 10 years, and one in less than 5 years following the treatment. Cyst fluid aspiration, cystoperitoneal shunt placement, or craniotomy were used in three symptomatic cases. Analysis of age, sex, and treatment parameters yielded no significant relationship with cyst formation; however, radiation-induced tissue change following GKS (p = 0.027) and prior embolization (p = 0.011) were related to cyst formation. Overall, the incidence of cyst formation in patients who underwent GKS for AVM was 1.6%. The development of the cyst was related to the duration of the follow-up period. When cysts are symptomatic, surgical intervention should be performed.

Late cyst formation following gamma knife surgery of arteriovenous malformations

Object. The authors present data concerning the development of cysts following gamma knife surgery (GKS) in 1203 consecutive patients with arteriovenous malformations (AVMs) treated by the senior author (L.S.). The cyst was defined as a fluid-filled cavity at the site of a treated AVM. Cases involving regions corresponding to previous hematoma cavities were excluded. The incidence of cyst formation was assessed using magnetic resonance imaging studies performed in 196 cases with more than 10 years of follow up, in 332 cases with 5 to 10 years of follow up, and in 675 cases with less than 5 years of follow up. One hundred five cases were lost to follow-up study. The Cox regression method was used to analyze the factors related to cyst formation. Methods. The incidence of cyst formation in the entire patient population was 1.6 and 3.6% in those undergoing follow-up examination for more than 5 years. Ten of 20 cysts developed between 10 to 23 years, nine between 5 to 10 years, and one in less than 5 years following the treatment. Cyst fluid aspiration, cystoperitoneal shunt placement, or craniotomy were used in three symptomatic cases. Analysis of age, sex, and treatment parameters yielded no significant relationship with cyst formation; however, radiation-induced tissue change following GKS (p = 0.027) and prior embolization (p = 0.011) were related to cyst formation. Conclusions. Overall, the incidence of cyst formation in patients who underwent GKS for AVM was 1.6%. The development of the cyst was related to the duration of the follow-up period. When cysts are symptomatic, surgical intervention should be performed.

Mutational Allelotyping of Aspirated Free-Floating DNA Predicts the Biological Behavior of Cystic Pancreatic Neoplasms

Background: Imaging, cytological examination and tumor marker analysis of cyst aspirates remain inadequate in assessing the underlying malignant potential of pancreatic cystic lesions. We propose that analysis of free floating DNA in cyst aspirates will predict the underlying biological behavior. Methods: From 11/02 to 12/03, 75 patients underwent EUS guided pancreatic cyst aspiration. Fluid was sent for cytological and biochemical analysis and mutational allelotyping. 21 cases with pathologic confirmation (6 malignant cysts, 6 premalignant cysts, 7 benign cysts {5 pseudocysts, 1 lymphoepithelial cyst, 1 VHL associated cyst}) and 2 clinically diagnosed pseudocysts (based on PD disruption) are presented. Cyst fluid aspirates underwent PCR amplification and were subjected to a broad panel of 15 microsatellite allele loss markers situated at 1p, 3p, 5q, 9p, 10q & 17q. Microdissection-based genotyping (MBG) was undertaken of select corresponding serially sectioned surgical specimens. LOH analysis utilized fluorescent capillary electrophoresis for quantitative determination of allelic imbalance. In addition k-ras-2 point’ mutation analysis was performed. Results: Cytological exam yielded an accurate diagnosis in 4/6 malignant and 1/6 premalignant cysts. CEA levels did not differ significantly between the malignant and premalignant cysts, but were higher in each than in the benign cyst group (p<0.03). All patients with malignant cysts had multiple LOH (3.8 allelic losses/cyst) at critical sites associated with k-ras mutations compared to the premalignant cysts (p<0.007) and benign cysts (p<0.001). Significantly more allelic losses were seen in the premalignant cysts (1.3 losses/cyst) compared to benign cysts (0.1 loss/cyst) (p<0.03). Allelic loss seen in cyst fluid aspirates correlated with the mutational profile of the corresponding surgical specimens. Conclusions: Mutational allelotyping of free floating DNA in pancreatic cyst aspirates reflect their genetic make-up. This mutational map should serve as an ancillary tool to the conventional workup of pancreatic cysts and provides meaningful prognostic information regarding the inherent malignant potential.

Vascular endothelial growth factor in adnexal masses

Objectives: To determine cyst fluid and serum vascular endothelial growth factor (VEGF) concentrations in patients with ovarian masses and to investigate the efficiency of this modulator in the clinical management of cystic pelvic masses. Methods: Needle puncture for cyst fluid aspiration were performed on 88 cystic ovarian masses intraoperatively. Forty-five patients with benign and 43 patients with malignant ovarian pathology were analyzed for cyst fluid and serum VEGF concentrations. Both cystic fluid and serum VEGF concentration were determined by enzyme-linked immunosorbent assay (ELISA). Results: Cyst fluid VEGF levels of malignant cysts (40.65±17.69 ng/ml) were significantly higher than those of benign cysts (12.53±6.13 ng/ml; P<0.001). Similarly, higher serum VEGF concentrations were found in patients with malignant disease (0.72±0.17 ng/ml) compared with benign cysts (0.33±0.11 ng/ml; P<0.001). A statistically significant correlation was observed between cyst fluid and serum VEGF levels in both malignant and benign cysts. For serum VEGF, at a cut-off value of 0.41 ng/ml; sensitivity, specificity, PPV, and NPV were 95%, 78%, 80% and 95%, respectively. No significant correlation between cyst fluid VEGF concentration and tumor stage or grade could be found. Conclusions: Significantly higher concentrations of VEGF are present in cyst fluid and serum of patients with malignant ovarian cysts compared with benign ovarian ones. There is no relation between VEGF and tumor stage or grade.

Renal Cysts: Can Percutaneous Ethanol Injections Be Considered an Alternative to Surgery?

Aim: To evaluate the efficacy of a new sclerotization technique with pure ethanol in the treatment of symptomatic renal cysts. Patients and Methods: Fourteen patients having renal cysts with a meant diameter of 10 (range 5–15) cm were treated. Our technique includes: ultrasound-guided percutaneous puncture with an 18-gauge needle, positioning of a 5-Fr catheter, complete cyst fluid aspiration, injection of pure alcohol equal to 15% of the initial cyst volume, and alcohol aspiration after 90 min. The procedure was repeated eight times within 5 days. The patients were followed up by ultrasound and/or CT scan for 1 year. Results: All patients became symptom free. Follow-up showed a progressive reduction of the cyst diameter in all cases. Three cysts only (in 2 patients; cyst diameter <2 cm) persisted after 12 months. No significant complications were observed. Conclusions: In our experience, injections of pure ethanol in renal cysts, repeated after some days, were effective in eliminating recurrences and related symptoms. The procedure was not associated with significant complications. Our findings suggest that it be considered the first-choice procedure in the treatment of renal cysts, due to the good results and the low cost of ethanol.

Risk for laparoscopic fenestration of liver cysts.

Laparoscopic fenestration is considered the best treatment for symptomatic simple liver cysts. Conversely, the laparoscopic approach for the management of hydatid simple liver cysts is not widely accepted because of the risk for severe complications. Despite improvement in imaging techniques, the probability of preoperatively mistaking a hydatid liver cyst for a simple liver cyst remains about 5%. Therefore, laparoscopic fenestration, planned for a liver cyst could be performed unintentionally for an undiagnosed hydatid liver cyst. From January 2000 to January 2001, 15 patients with a diagnosis of liver cyst underwent laparoscopy for fenestration. In all cases preoperative serologic and imaging assessment had excluded hydatid liver cyst. To further exclude hydatid liver cyst, preliminary aspiration of the cyst with assessment of cystic fluid characteristics was performed. In two patients with presumedly simple liver cyst, hydatid liver cyst was diagnosed instead at laparoscopy by aspiration of cystic fluid. The procedure was converted to laparotomy with subtotal pericystectomy. The risk of misdiagnosing a hydatid liver cyst for a simple liver cyst, especially in the presence of a solitary cyst, should be considered before laparoscopic fenestration is performed. Intraoperative aspiration of cyst fluid before fenestration can minimize this risk, thus avoiding severe intraoperative and late complications.

Immunochemical characterization of alkaline phosphatase from the fluid of sterile and fertile Echinococcus granulosus cysts.

Alkaline phosphatase (ALP) from hydatid cyst fluid (HCF) was purified and characterized for comparison between fertile and sterile HCF. Samples were obtained from slaughtered sheep and then sterile and fertile cysts were separated. ALP was purified from aspirated cyst fluid and biochemical parameters were determined. Sera from patients with hydatid disease (15 samples) and patients with other parasitic diseases including fascioliasis (2 samples), taeniasis ( Taenia saginata, 5 samples) and also sera from uninfected controls (15 samples), were collected and used in immunoblotting experiments with ALP from sterile and fertile HCF as antigen. Our results showed that ALP activity in fertile HCF [10.75+/-3.78 (SD) U/ml) was significantly more than in sterile HCF (6.25+/-2.43 U/ml). There were also some differences between the kinetic parameters and biochemical characteristics of ALP in fertile and sterile HCF. Immunoreactive bands were clearly observed when sera from hydatid infected patients were tested with ALP from fertile HCF as the antigen. However, this method revealed no cross-reaction between purified ALP from sterile HCF and sheep liver tissue. These findings suggest that there is some variation in the immunochemical characteristics of ALP from fertile and sterile HCF.

Off-pump technique for the treatment of ventricular myocardial echinococcosis

Background This study was planned to investigate the off-pump operability of ventricular myocardial Echinococcosis, which has no close relation with the cardiac chambers. Methods Twenty patients with cardiac echinococcosis, and 2 patients with isolated pericardial echinococcosis were operated on. Hydatid cysts were located in the ventricular wall in 17 patients and 10 of these 17 patients were operated without cardiopulmonary bypass. We present these 10 patients in this report. We used transesophageal echocardiography (TEE) and peroperative surface echocardiography (PSE) to determine the relation of cysts with cardiac chambers. The cysts were aspirated for diagnosis and to facilitate the dissection. Cyst cavities were left open in all cases. Results We did not observe any early complication and in long-term follow-up only one patient underwent reoperation 68 months after her first operation due to reoccurrence. Conclusions Ventricular myocardial echinococcosis without relation with the cardiac chambers can be operated without using cardiopulmonary bypass with the aid of TEE, PSE, and controlled cyst fluid aspiration.

Diagnosis and Treatment of Intracystic Breast Carcinomas

Cystic breast masses are very common in female patients attending breast clinics. Most of them are benign and managed by simple aspiration. We reviewed histology records for the last 12 years to find patients with cystic breast carcinomas and to evaluate special clinical signs that may help to identify patients with this rare entity. Eighteen patients with cystic breast carcinomas were found among 1510 new breast cancer patients (1.19%) who were seen at our Breast Unit during this period. Ten had intracystic papillary carcinoma (0.66% of all breast cancers), seven had cystic degeneration of ductal carcinoma, and one had a mucinous carcinoma. The diagnosis of intracystic papillary carcinoma was based on cyst fluid cytology and breast imaging in most patients and on open breast biopsy in two cases only. The prognosis of our cystic breast carcinoma patients was excellent regardless of the specific histologic type of the tumor. We conclude that cysts in postmenopausal women should be viewed with suspicion. Bloodstained aspirated cyst fluid should be sent for cytology and breast imaging should be carried out in all these cases. Residual mass after cyst aspiration is also an indication for open biopsy.

Fetal ovarian cysts: prenatal diagnosis, management and postnatal outcome.

In female fetuses ovarian cysts represent the most important differential diagnosis for intra-abdominal masses. Analyzing our own patient population we investigated whether there was a connection between sonographic parameters and postnatal course, especially with regard to the need for surgical intervention. This was a retrospective analysis of cases from the years 1986-1999. The pre- and postnatal data of 64 fetuses who were suspected prenatally to have an ovarian cyst were analyzed. The postnatal outcome was known for all the children. The diagnosis was made in all cases in the third trimester (median, 35; range, 26-40 weeks' gestation). In 34 of the 64 (53%) cases, resolution of the cyst occurred either prenatally (n = 18, 53%) or postnatally (n = 16, 47%). The cystic structure in the cases with resolution was isolated, smooth-walled (n = 29) or heterogeneous (n = 5). Postnatal surgery was performed in 30 of the 64 (47%) children. In 18 of the 30 children a fenestration of the ovary was performed (60%). In this group there were 13 children with an isolated, smooth-walled ovarian cyst and five children with a heterogeneous cyst. Twelve of the 30 (40%) children underwent an ovariectomy. Among these 12 children there were eight cases with a heterogeneous cystic structure and four cases with an isolated, smooth-walled cystic structure. Of the 30 cases that underwent surgery, 29 had a follicular cyst and one had an ovarian teratoma (with a heterogeneous internal structure). In three fetuses aspiration of cyst fluid was undertaken and subsequent resolution occurred in one case. The other two cases had to undergo postnatal fenestration. When an ovarian cyst is suspected prenatally, serial ultrasound monitoring should follow and delivery should take place in a perinatal center. The prenatal findings should also be checked postnatally by ultrasound. Prenatal aspiration of the cyst seems to be of no advantage and should be carried out only in special individual cases.

Cytology of Endolymphatic Sac Tumor

A 77-year-old man presented with decreased mental status and an enhancing partially cystic tumor along the left tentorium on magnetic resonance imaging after mastoidectomy and petrosectomy for an “auditory canal tumor.” Smears of the aspirated cyst fluid revealed rare epithelial cell clusters, some with papillary features, foamy macrophages, and blood. The cells were orderly, with fairly bland nuclei and well-defined cell borders. The cell block contained similar epithelium, with cells containing eosinophilic and focally vacuolated cytoplasm, some with pigmented granules resembling hemosiderin. Numerous foam cells were also present. Review of the patient's previous and concurrent resection material showed an endolymphatic sac tumor, a rare neoplasm that arises in the endolymphatic sac in the temporal bone. The previously undescribed cytologic features of this rare neoplasm are discussed.

Long-term results after percutaneous minimally invasive procedure treatment of symptomatic simple renal cysts.

To assess the effectiveness and long-term results of two repeated ethanol injections in the treatment of symptomatic renal cysts. Sixty-eight patients 47 to 75 years old with 77 large (6.3-14.8 cm; mean 8.62 cm) symptomatic cysts were included in this study. Of the 68 patients, in 4 cases there were renal cysts associated with renal calculi. An 8FR Pigtail catheter was inserted into the cyst under ultrasound guidance followed by aspiration of cystic fluid. Two repeated ethanol 95% injections were performed every 24 hours. Patients were followed-up by ultrasonography for a period of 12-48 months (mean 30). In two patients the cyst puncture was not feasible because of poor visualization of puncture site while in one patient there was communication of cystic cavity with the pelvocaliceal system. In these patients surgical resection of cysts was performed. Complete and partial regression rates were 57/68 (83.82%) and 8/68 (11.76%) respectively. In four patients with renal stones and renal cysts, extracorporeal shock wave lithotripsy (ESWL) was successfully executed I month after sclerotherapy. Our results suggest that percutaneous aspiration followed by two repeated ethanol injections is highly effective on reducing recurrence of simple renal cysts.

4698 Endoscopic intracystic treatment of pancreatic pseudocysts: a possible innovative technique in their management?

Introduction: Endoscopic transmural drainage is a treatment modality of pancreatic pseudocysts when visible extrinsic compression of the gastric or duodenal wall and close apposition to the lumen are present. We describe a new technique based upon introduction of the endoscope into the pseudocyst in order to treat complications of drainage. Case 1: A 52-year-old man with chronic pancreatitis presented with a mature symptomatic pseudocyst located in the pancreatic head and bulging into the duodenum. Endoscopic transduodenal drainage was complicated by stent migration into the pseudocyst. A nasocystic catheter was inserted. Three days later the cystostomy tract was dilated with a 12 mm balloon until we were able to advance the endoscope into the pseudocyst. The stent was removed with a snare and cyst fluid was aspirated before endoscope withdrawal. Since ERCP revealed pseudocyst communication with the pancreatic duct, a transpapillary drainage was performed. The pseudocyst resolved with no recurrence after 3 months of follow-up. Case 2:Seven months following an episode of acute pancreatitis, a 54-year-old man presented with a mature symptomatic pseudocyst located in the pancreatic head, bulging into the duodenum and not communicating with the pancreatic duct. Uneventful endoscopic transduodenal drainage was performed. Two days later stent migration into the gut and pseudocyst infection were noticed. Antibiotics were started. After 12 mm balloon dilation of the cystostomy tract, the endoscope was advanced into the pseudocyst followed by aspiration or extraction of cyst fluid and debris. A nasocystic catheter was inserted. The catheter was irrigated twice under endoscopic view with saline passing together with cyst debris through the cystostomy into the duodenum, until only clear fluid was returning. Two weeks later an intracystic bleeding due to rupture of a pseudoaneurysm was treated by angiographic embolization. Further follow-up was uneventful with pseudocyst resolution after 3 months. Conclusion: Balloon dilation of a cystostomy tract followed by advancement of an endoscope into a pseudocyst can be safely performed in a mature pancreatic pseudocyst adjacent to the upper GI-tract. This new technique enabled us to treat complications of endoscopic transmural pseudocyst drainage for which surgery is usually carried out. It offers new perspectives in the endoscopic treatment of well-defined pseudocysts but needs further validation before it can be promoted as such.

GCDFP-15 blood levels for stratification of risk of breast cancer development in women with active breast gross cystic disease

The risk of developing breast cancer has been shown to be elevated in women with breast gross cystic disease (GCD) confirmed by aspiration of breast cyst fluid. The GCDFP-15 protein is a major component protein of breast GCD fluid. The protein is secreted by apocrine metaplastic cells lining micro and gross cysts of the breast. It is also a constituent protein secreted by normal apocrine glandular systems, and it is present in approximately 50% of breast carcinomas. Blood levels of GCDFP-15 are measurable in the low ng/ml range in normal individuals. A proportion of patients with metastatic breast cancer have high circulating blood levels up to 70 000 ng/ml. This study evaluated the relationship between blood levels of GCDFP-15 in women with active breast gross cystic disease, demonstrated by breast cyst aspiration, and the risk of breast cancer development. A group of 135 patients who had active breast gross cystic disease demonstrated by cyst aspiration, also had a concomitant blood level of GCDFP-15 determined. The patients have been subsequently followed for an average of 10.1 years and assessed for risk of breast cancer development. Twelve of these women have developed breast carcinoma and two have died of unrelated causes. For the 72 women who clinically developed fewer than 10 aspirated cysts, the relative risk of breast cancer was 1.8 if their highest GCDFP-15 plasma level was in a normal range (less than 40 ng/ml) versus a relative risk of 4.2 if the GCDFP-15 plasma level was elevated. This difference was more pronounced for the 63 women in this study with 10 or more total aspirated cysts, where the relative risk for breast cancer development was 2.0 for women with normal range GCDFP-15 plasma levels versus 7.1 for those with elevated plasma levels. Our data indicate that GCDFP-15 blood levels may be useful in identifying groups of women with active breast gross cystic disease who are at increased risk of developing breast cancer.

Clinical assessment compared with cyst fluid analysis in the differential diagnosis of cystic lesions in the pancreas

In adults 80% to 90% of cystic lesions in the pancreas are pseudocysts and the remainder are mostly neoplastic cysts. To choose optimal treatment for an individual patient, exact nonoperative diagnosis would be preferable. This study was done to assess the value of cyst fluid analysis, compared with clinical and radiologic findings, in the differential diagnosis of pancreatic cystic lesions. Twenty-two patients with a cystic lesion in the pancreas underwent operation, cyst wall biopsy, and aspiration of cyst fluid. Carcinoembryonic antigen (CEA), CA 19-9, pancreatitis-associated protein (PAP), and total protein concentration, amylase activity, and cytologic findings were studied. Final diagnosis was pseudocyst in 14 patients, serous cystadenoma in two, mucinous cystadenoma in two, and mucinous cystadenocarcinoma in four patients. Clinical and radiologic judgment correctly differentiated pseudocysts and neoplastic cysts. Cyst fluid aspiration did not succeed in two patients with mucinous cystadenocarcinomas because of the high fluid viscosity. Cyst fluid amylase activity was high (greater than 16,000 IU/ml) in all but one pseudocyst and low (less than 83 IU/ml) in all but one neoplastic cyst. CEA level was lower in pseudocysts than in neoplastic cysts, but with an overlapping value between the groups. Mean CA 19-9 concentration was higher in pseudocysts than in neoplastic cysts, but with wide overlap between the groups. Pancreatitis-associated protein and total protein concentration and cystic fluid cytologic findings did not differ between various types of cysts. Clinical judgment including careful history and radiologic studies seems to be the most reliable method of differentiating neoplastic pancreatic cysts from pseudocysts. Amylase and CEA levels give suggestive information, but cyst fluid analysis may be misleading in an individual patient.

Proliferation tissue polypeptide antigen distinguishes malignant mucinous cystadenocarcinomas from benign cystic tumors and pseudocysts

Cystic lesions of the pancreas include inflammatory pseudocysts, serous cystadenomas, and mucinous cystic tumors, some of which are malignant. Previous studies have shown that malignant mucinous tumors differ from benign pancreatic cysts in proliferative activity, secretion of tumor markers, and expression of growth factor receptors. Analysis of aspirated cyst fluid for tumor markers, viscosity, and cytologic examination has been proposed as an aid to preoperative differential diagnosis. Tissue polypeptide antigen (TPA) is a soluble proliferation antigen produced by rapidly dividing tissues, including conventional ductal pancreatic carcinoma. TPA levels in pancreatic cyst fluids have not been reported. Tissue polypeptide antigen levels were determined in 46 pancreatic cyst fluids using a commercial immunoassay technique. Mucinous cystadenocarcinomas exhibited significantly higher levels of cyst fluid TPA than benign cystic lesions, including pseudocysts, serous cystadenomas, and benign mucinous cystadenomas (mean 910,672 U/mL, median 300,900 U/mL, range 16,600 to 4,210,000 U/mL for malignant mucinous cystadenocarcinomas; versus mean 16,082 U/mL, median 2,455 U/mL, range 0 to 155,000 U/mL for benign cystic lesions considered as a group; P < 0.0002). In 75% of the malignant cysts, the TPA values were in excess of 100,000 U/mL. Pseudocysts exhibited the lowest TPA levels (mean 2,108 U/mL, median 604 U/mL, range 0 to 20,240 U/mL) and were significantly lower than the values observed in cystic tumors (P < 0.0005). Serous and benign mucinous tumors had intermediate levels of TPA. Elevated levels of the proliferation antigen TPA in malignant pancreatic cysts correlate with earlier observations of increased proliferative activity and overexpression of growth factor receptors in these tumors. The TPA measurement may be a useful addition to previously reported cyst fluid markers to aid in preoperative differential diagnosis. Markedly elevated or very low values indicate a malignant or benign cyst, respectively.

Aspiration and tetracycline sclerotherapy for management of simple ovarian cysts.

To evaluate the procedure of aspiration and tetracycline sclerotherapy in the management of simple ovarian cysts. Twenty-five cases of simple ovarian cysts were subjected to cyst fluid aspiration and 5% tetracycline injection under ultrasound guidance. Cytological examination of the aspirated fluid was carried out in 24 cases and the patients were followed for 6-36 months. Cytology revealed a cellular sediment in 18 cases (simple cysts), follicular cells in four cases (follicular cysts), and blood and hemosiderin-laden macrophages in two cases (endometriosis); subsequent surgery was required in only one case (endometriosis). The procedure of aspiration and tetracycline sclerotherapy was easy, safe and acceptable, with no recurrences. It appears to be a valid alternative to cyst aspiration in the management of simple ovarian cysts.