Diagnosis Of Pancreatic Cystic Lesions Research Articles

Differential diagnosis of pancreatic cysts: A prospective study on the role of intra-cystic glucose concentration

BackgroundThe accuracy and costs of current diagnostic methods in the differential diagnosis of pancreatic cystic lesions still has ample room for improvement. AimsThe aim of the study was to confirm the diagnostic yield of intracystic glucose in the diagnosis of pancreatic cyst subtypes. MethodsWe prospectively recruited all patients who underwent Endoscopic Ultrasound with Fine Needle Aspiration of pancreatic cyst at our Institution. ResultsFifty-six patients were included in the study. We found that intracystic glucose concentration < 50 mg/dL was significantly more sensitive than a concentration of Carcinoembryonic Antigen > 192 ng/mL (93.6% vs 54.8%; p = 0.003) for the diagnosis of mucinous cysts. In terms of specificity, the two markers were not different (96% vs 100%; p = 1). Regarding the diagnosis of non-mucinous cysts, intracystic glucose concentration ≥ 50 mg/mL showed higher sensitivity than Carcinoembryonic Antigen level < 5 ng/mL (96% vs 72%) although a statistical significance could not be reached (p = 0.07). The two markers were not statistically different in terms of specificity (93.6% vs 87.1%; p = 0.62). ConclusionGiven its diagnostic performance and ease of measurement, intracystic glucose may replace Carcinoembryonic Antigen in the differential diagnosis of mucinous versus non-mucinous pancreatic cysts.

Sa1411 DIAGNOSTIC ACCURACY OF INTRACYSTIC GLUCOSE VS. CEA FOR THE DIAGNOSIS OF MUCINOUS PANCREATIC CYSTIC LESIONS: A META-ANALYSIS

The differential diagnosis between mucinous(M) and non-mucinous (NM) pancreatic cystic lesions (PCLs) is often difficult and both false positive and negative results can lead to clinically relevant overtreatment and undertreatment. Dosage of intracystic Carcinoembryonic antigen (CEA) with a cut-off>192 ng/ml suggests the diagnosis of M-PCL, but its sensitivity is limited. Recently, it has been reported that low levels of intracystic glucose diagnose M-PCLs with high accuracy, but data are limited and heterogeneous. We aimed to perform a meta-analysis to gather data on sensitivity, specificity and accuracy of intracystic glucose as compared with CEA for the diagnosis of M-PCLs. A computerized bibliographic search was performed on Pubmed. Pooled effects were calculated using a random-effects model and expressed in terms of pooled sensitivity and specificity and OR (95% CI) for accuracy for the diagnosis of M-PCLs. Heterogeneity was evaluated by I2 and publication bias by Begg-Mazumdar test and funnel plot visual inspection. Overall, 4 cohort studies were included (3 conducted in the US, 1 in Portugal), for a total of 319 patients (207 M, 112 NM). The cut-off employed for glucose were 50 in 3 studies and 66 mg/dl in one, while all studies employed the CEA cut-off of 192 ng/ml. The employed gold-standard for diagnosis in the 4 studies was a composite of surgical pathology and cytology. Dosage of glucose showed a higher pooled sensitivity and lower heterogeneity (92%; I2= 0%) compared to CEA (69.4%; I2=64%), while specificity was higher for CEA (75.6% glucose vs 92% CEA) with lower heterogeneity (I2=89% glucose vs 69% CEA). Dosage of glucose was very close to be significantly superior in terms of pooled accuracy (OR 1.96; 95% CI 0.97-3.94; p=0.057; I2=53%). There was no publication bias at Begg-Mazumdar test and funnel plot. Our meta-analysis suggests that intracystic dosage of glucose is more sensitive, but CEA more specific for the diagnosis of mucinous PCLs, with an overall better accuracy of glucose. Given the heterogeneity of the results and the relative low number of investigated patients considering the high prevalence of PCLs, more studies are needed to define if combined use of both markers with different cut-offs is needed to increase accuracy significantly.

Epidermoid Cyst within an Intrapancreatic Accessory Spleen Mimicking a Pancreatic Cystic Neoplasm

Although intra-abdominal accessory spleens are commonly found in 10-30% of the general population, epidermoid cyst within an intrapancreatic accessory spleen (ECIPAS) is an extremely rare entity and is often misdiagnosed preoperatively as a cystic malignancy. We present the case of a 51-year-old man who was referred to our clinic because of an incidentally found pancreatic tail cystic mass. Due to CA 19-9 level over 2000 and high suspicion of malignancy, the patient underwent distal pancreatectomy with splenectomy. Histopathological analysis revealed a squamous epithelial lining with splenic parenchyma within the cyst wall, which was consistent with ECIPAS. The patient was discharged on postoperative day 4 without any complication. As this disease may mimic malignancy with no characteristic features in preoperative imaging, it should be considered in the differential diagnosis of pancreatic cystic lesions.

Diagnostic yield of endoscopic ultrasound with fine-needle aspiration in pancreatic cystic lesions

Abstract Introduction Despite advances in imaging techniques, in many cases they are insufficient to establish the diagnosis of pancreatic cystic lesions (PCL). There are few publications in our setting that evaluate the combination of several methods obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The aim of the study was to evaluate the overall utility of EUS-FNA in the diagnosis of PCL. Material and methods Retrospective study based on a database updated prospectively of a cohort of patients referred for EUS-FNA due to PCL detected in an imaging test. The sensitivity, specificity and diagnostic yield of carcinoembryonic antigen (CEA), cytology and viscosity were studied to detect mucinous lesions. Results From November 2013 to April 2018, 122 EUS were performed for PCL. EUS-FNA was performed in 94/122 (77%) and 21/122 (17.2%) patients were operated on. We included 33/122 patients who had diagnostic confirmation by histology, imaging (serous cyst with typical pattern) or clinical evolution. The study of the ROC curve determined the cutoff point ≥419 ng/ml to differentiate mucinous/non-mucinous cystic lesions. The diagnostic yield of CEA was 87.5% (21/24), cytology 81.8% (27/33) and viscosity 84.4% (27/32). The three parameters in combination obtained the best result (30/33, 90.9%). Conclusion The combination of CEA analysis, cytology and viscosity of pancreatic fluid obtained by EUS-FNA increases the performance in the diagnosis of mucinous pancreatic cystic lesions, with it being greater than 90%.

Genetic markers and confocal endomicroscopy as diagnostic approaches for pancreatic cystic lesion

Background: Preoperative diagnosis of cystic lesions of the pancreas, which can be inflammatory or proliferative, continue to present clinicians with significant clinical challenges due to the heterogeneity of the pathological processes involved. Although malignant transformation in these lesions is unusual, the opportunity for curative surgery makes identification of suitable patients essential. This requires diagnostic approaches that are up to date and evidence based. Improved diagnostic accuracy will also ensure that unnecessary surgical procedures and the associated morbidity are avoided. Methods: In this abstract we present the Results of a review of recent diagnostic approaches for pancreatic cystic lesions (PCLs). Results: Genetic sequencing allows specific mutations to be identified including the genetic profiles associated with common PCLs. This provides a potential opportunity to determine changes that indicate the progression to malignant lesions. In this respect there is increasing interest in novel cyst fluid biomarkers and their potential to differentiate between mucinous and non-mucinous PCLs. A number of mutations have been found to be associated with the main types of PCLs and these are shown in Table 1. Confocal laser endomicroscopy (CLE) is another novel diagnostic technique which allows in vivo, real time microscopy during endoscopic procedures. CLE allows for the evaluation of histology with high resolution imaging and obviates the need for a biopsy. Conclusion: There is a need to identify diagnostic Methods or combinations of Methods that will allow us to more accurately identify PCLs at risk of malignant transformation or those where it has already occurred but patients may still benefit from potentially curative surgery. There is clearly a need for a comprehensive, standardised algorithm for the diagnosis and management of PCLs utilising all the currently available diagnostic modalities.

Rendimiento diagnóstico de la punción mediante ultrasonografía endoscópica de las lesiones quísticas del páncreas

IntroductionDespite advances in imaging techniques, in many cases they are insufficient to establish the diagnosis of pancreatic cystic lesions (PCL). There are few publications in our setting that evaluate the combination of several methods obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The aim of the study was to evaluate the overall utility of EUS-FNA in the diagnosis of PCL. Material and methodsRetrospective study based on a database updated prospectively of a cohort of patients referred for EUS-FNA due to PCL detected in an imaging test. The sensitivity, specificity and diagnostic yield of carcinoembryonic antigen (CEA), cytology and viscosity were studied to detect mucinous lesions. ResultsFrom November 2013 to April 2018, 122 EUS were performed for PCL. EUS-FNA was performed in 94/122 (77%) and 21/122 (17.2%) patients were operated on. We included 33/122 patients who had diagnostic confirmation by histology, imaging (serous cyst with typical pattern) or clinical evolution. The study of the ROC curve determined the cutoff point ≥419 ng/ml to differentiate mucinous/non-mucinous cystic lesions. The diagnostic yield of CEA was 87.5% (21/24), cytology 81.8% (27/33) and viscosity 84.4% (27/32). The three parameters in combination obtained the best result (30/33, 90.9%). ConclusionThe combination of CEA analysis, cytology and viscosity of pancreatic fluid obtained by EUS-FNA increases the performance in the diagnosis of mucinous pancreatic cystic lesions, with it being greater than 90%.

Endoscopic ultrasound-through-the-needle biopsy in pancreatic cystic lesions: A large single center experience.

BACKGROUNDEstablishing a diagnosis of pancreatic cystic lesions (PCLs) preoperatively still remains challenging. Recently, endoscopic ultrasound (EUS)-through-the-needle biopsy (EUS-TTNB) using microforceps in PCLs has been made available.AIMTo assess the efficacy and safety of EUS-TTNB in the diagnosis of PCLs.METHODSWe retrospectively collected data of patients with PCLs who underwent both EUS-fine-needle aspiration (FNA) for cytology and EUS-TTNB at our institution since 2016. EUS-FNA for cytology was followed by EUS-TTNB in the same session. Evaluation of the cyst location, primary diagnosis, adverse events, and comparison between the cytologic fluid analyses and histopathology was performed. Technical success of EUS-TTNB was defined as visible tissue present after biopsy. Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis.RESULTSA total of 56 patients (mean age 66.9 ± 11.7, 53.6% females) with PCLs were enrolled over the study period. The mean cyst size was 28.8 mm (12-85 mm). The EUS-TTNB procedure was technically successful in all patients (100%). The clinical success rate using EUS-TTNB was much higher than standard EUS-FNA, respectively 80.4% (45/56) vs 25% (14/56). Adverse events occurred in 2 patients (3.6%) who developed mild pancreatitis that resolved with medical therapy. Using TTNB specimens, 23 of 32 cases (71.9%) with intraductal papillary mucinous neoplasm were further differentiated into gastric type (19 patients) and pancreaticobiliary type (4 patients) based on immunochemical staining.CONCLUSIONEUS-TTNB for PCLs was technically feasible and had a favorable safety profile. Furthermore, the diagnostic yield for PCLs was much higher with EUS-TTNB than standard EUS-FNA cytology and fluid carcinoembryonic antigen. EUS-TTNB should be considered as an adjunct to EUS-FNA and cytologic analysis in the diagnosis and management of PCLs.

Giant Cystic Pancreatic Lymphangioma with Mediastinal Extension: A Case Report and Review of the Literature

Lymphangioma is an infrequent benign tumour that is formed usually from a congenital malformation of the lymphatic ducts causing lymphangiectasis. The abdominal location represents 1-5%, with dominance in the mesentery and retroperitoneum, however, the pancreatic location is very rare having described less than 100 cases published worldwide. The clinical symptoms of the lymphangiomas are non-specific and depend of the tumour’s size and location. Here we present a clinical case of a pancreatic lymphangioma with mediastinal extension who was treated with a complete resection and this case shows that the diagnosis of cystic pancreatic lymphangioma must be taken as a differential diagnosis of pancreatic cystic lesions.

Sequential molecular and cytologic analyses provides a complementary approach to the diagnosis of pancreatic cystic lesions: a decade of clinical practice

Many pancreatic cystic lesions (PCL) are of neoplastic nature with potential to progress to pancreatic adenocarcinoma. Early stratification of patients to either clinical observation or surgical intervention can considerably increase the survival rate. Recent studies have shown the value of molecular analysis to current diagnostic modalities.The aim of this study is to evaluate the diagnostic improvement by utilizing multiple sequential cytologic and molecular cyst fluid analyses. We prospectively evaluated 58 patients for whom multiple endoscopic ultrasound-guided fine-needle aspiration of cyst fluid specimens were available. Specimens were subjected to next generation sequencing to identify any recurrent gene mutations commonly found in PCL. The molecular findings were compared with cytologic and final diagnoses. Cytologic diagnoses were classified into 3 groups: non-diagnostic (first visit: 33.9%, cumulative: 15.8%, P = 0.03), negative (1st visit: 53.6%, cumulative: 56.1%, P = 0.85) and atypical/suspicious/positive (first visit: 12.5%, cumulative: 28.1%, P = 0.06). The mutational analyses were clustered into indeterminate/failure (first visit: 1.7%, cumulative: 0%), KRAS/GNAS/VHL group (first visit: 50.0%, cumulative: 53.4%) and any mutation (first visit: 50.0%, cumulative: 53.4%). Mutational analysis identifies up to 72% and 71% whereas cytologic analysis classified up to 46% and 63% of lesions correctly in first and multiple visits, respectively. The cytology and molecular analyses provide a complementary approach to patients with PCL. Power of molecular analysis in detection of a neoplastic lesion is significantly higher in one visit (P = 0.01) with comparable detection rates (P = 0.43) for both cytologic and molecular analyses after multiple visits.

The Value of Contrast-Enhanced Ultrasound Classification in Diagnosis of Pancreatic Cystic Lesions.

Objective To compare the consistency of contrast-enhanced ultrasound (CEUS) classification results with magnetic resonance imaging (MRI) and to investigate the diagnostic value of CEUS classification in pancreatic cystic lesions. Methods 84 cases of pancreatic cystic lesions were enrolled in this study. According to the CEUS classification methods of previous study in our center, all the lesions were classified into four types: type I, unilocular cysts; type II, microcystic lesions; type III, macrocystic lesions; and type IV, cystic lesions with enhanced solid components. The consistency of CEUS and MRI typing results was analysed. Among the 84 cases, 45 cases had pathological results. The CEUS results were compared with the pathological results, and the diagnostic value of CEUS classification in diagnosing pancreatic cystic lesions was explored. Results Among the 84 cases, CEUS diagnosed 8 cases of type I, 24 of type II, 8 of type III, and 45 of type IV. MRI diagnosed 10 cases of type I, 25 of type II, 7 of type III, and 43 of type IV. The classification typing results of CEUS were highly consistent with that of enhanced MRI (kappa value: 0.852). Among the 45 cases with pathological results, the diagnostic accuracy of each type was 91.1%, 95.6%, 93.3%, and 88.9%. The accuracy of CEUS and MRI in diagnosing pancreatic cystic lesions was 75.56% (34/45) and 80% (36/45), respectively. The diagnostic accuracy of CEUS had no significant difference from that of MRI (P=0.687). Conclusion The classification results by CEUS and MRI are in excellent agreement. The classification of pancreatic cystic lesions by CEUS is significantly helpful for clinical diagnosis.

Endoscopic ultrasonography for the evaluation of pancreatic cystic neoplasms.

Endoscopic ultrasonography (EUS) is a modality with high spatial resolution that enables comprehensive observation of the entire pancreas and plays an important role in the diagnosis of pancreatic lesions. Recent advances in diagnostic imaging methods such as ultrasound, computed tomography, and magnetic resonance imaging have increased the incidental detection of pancreatic cystic lesions (PCLs). EUS has been recognized as an essential diagnostic method for the detection and evaluation of PCLs. EUS has two important roles: as a detailed (high-resolution) imaging diagnostic method and as an approach for collecting cyst fluid content by EUS-guided fine needle aspiration for pathological diagnosis or biomarker evaluation. Furthermore, in recent years, the usefulness of contrast-enhanced EUS for the differential diagnosis of PCLs or evaluation of grade of malignancy, and a novel imaging technique called needle-based confocal laser endomicroscopy to observe intraductal structures through a needle, has been reported. An understanding of the morphological characteristics of PCLs depicted by ultrasound imaging and of the benefits and limitations of EUS diagnosis in daily practice is needed.

80 Long-Term Follow-Up of Patients With Pancreatic Cystic Lesions Who Had No Significant Changes in the First 5 Years of Diagnosis

INTRODUCTION: Discontinuation of surveillance after 5 years for pancreatic cystic lesions (PCL) without significant changes remains controversial. Long-term outcomes of patients with PCL with no significant changes in the first 5 years were evaluated. METHODS: We performed a retrospective analysis of patients with PCL diagnosis from 2005 to 2011 with follow-up until 2017. Significant changes were defined as the history of pancreatic cancer, pancreatectomy, high risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). Details of HRS, WF, WEUS in Table 1. RESULTS: Of 1551 patients with the diagnosis of PCL, 984 had no significant changes in the first 5 years. Range of follow-up was 5–13 years (190 patients &gt;10 years). Median (Q1–Q3) cyst size at initial imaging was 12 (9–17) mm; maximum cyst size in first 5 years and post 5 years were 13 (9–18) mm and 15 (10–22) mm, respectively. 4 patients developed pancreatic cancer (0.41%; at 80, 97, 70, and 103 months). 7 (0.71%), 99 (10%), 5 (0.51%) patients developed HRS, WF, WEUS, respectively. Median (Q1–Q3) time to cancer, HRS, WF, and WEUS were 88.7 (75.3–100), 97.2 (66–109.6), 78.2 (72.5–97.9), 77 (68–104) months, respectively. Patients with CSO/clinically significant outcomes (defined as pancreatic cancer, HRS, WF, WEUS) post 5 years had larger maximum cyst size in the first 5 years compared to those without CSO [median (Q1–Q3) 16 (12–23) vs 12 (9–17) mm, P = 0.0001] (Figure 1). 152 patients died post 5 years (3 due to pancreatic cancer). The incidence of pancreatic cancer and CSO at 7 years post 5-year period (12 years from PCL diagnosis) in patients with no significant changes were 0.7% and 12.5%, respectively. The mortality due to pancreatic cancer was 0.45%; mortality due to all causes was 31.7%. Median (range) of Charlson Comorbidity Index (CCI) was 2 (0–16) at 5 years post PCL diagnosis. The mortality rate at 7 years post 5-year period for ACCI (age-adjusted CCI) of ≤3, 4–6, and ≥7 were 3.5%, 28% and 58% (P &lt; 0.0001), respectively (Figure 2). CONCLUSION: The incidence of pancreatic cancer in patients with PCL with no significant changes in the first 5 years of diagnosis remains low at 0.7%. The incidence of clinically significant outcomes (CSO) was higher at 12.5%. Maximum cyst size of ≥15 mm in the first 5 years had higher cumulative incidence of CSO in long-term follow-up. These risks should be weighed against patients' overall mortality (based on scoring systems such as CCI) when making surveillance decision of PCL beyond 5 years.

Cystic Lesions of the Pancreas: Differential Diagnosis and Cytologic-Histologic Correlation.

Pancreatic cystic lesions (PCLs) are very common, and their detection is increasing with the advances in imaging techniques. Because of the major implications for management, distinguishing between neoplastic and nonneoplastic PCLs is critical. Neoplastic cysts with potential to progress into cancer include mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasms) and nonmucinous cysts (solid pseudopapillary tumors, serous cystic neoplasms, and neuroendocrine tumors with cystic degeneration). Nonneoplastic cysts with no risk of malignant transformation include pseudocysts, retention cysts, lymphoepithelial cysts, cystic pancreatic lymphangioma, and duplication cyst/ciliated foregut cysts. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology with cyst fluid analysis in the diagnosis of PCLs has evolved during the last decade; however, a definitive diagnosis on cytologic specimens is hampered by the sparse cellularity and can be challenging. EUS-FNA can play an important role to differentiate low-risk from high-risk pancreatic cysts and to distinguish between patients with cysts who need clinical follow-up versus those who require surgery. To provide an integrative approach to diagnose pancreatic cystic lesions using EUS-FNA cytology and cyst fluid analysis, along with clinical, radiologic, histologic, genetic, and molecular characteristics. The review and analysis of the latest literature describing pancreatic cystic lesions. Accurate diagnosis of PCLs requires a multidisciplinary and multimodal team approach, including the integration of clinical findings, imaging, cytology, cyst fluid analysis, and molecular testing.

Role of transabdominal ultrasonography in the diagnosis of pancreatic cystic lesions.

Pancreatic cystic lesions (PCLs) are incidental findings that are being increasingly identified because of recent advancements in abdominal imaging technologies. PCLs include different entities, with each of them having a peculiar biological behavior, and they range from benign to premalignant or malignant neoplasms. Therefore, accurate diagnosis is important to determine the best treatment strategy. As transabdominal ultrasonography (US) is noninvasive, inexpensive, and widely available, it is considered to be the most appropriate imaging modality for the initial evaluation of abdominal diseases, including PCLs, and for follow-up assessment. We present a review of the possibilities and limits of US in the diagnosis of PCLs, the technical development of US, and the ultrasonographic characteristics of PCLs.

Pancreatic Cysts: Diagnostic Role of EUS-Guided Microforceps Biopsy and Confocal Laser Endomicroscopy.

Frequent use of high-quality cross-sectional imaging has led to a significant rise in diagnosis of pancreatic cystic lesions (PCLs). Despite the fact that enormous effort has been put into the research of PCLs within the last two decades and multiple guidelines have been developed, our clinical decision-making especially in regard to mucinous lesions remains limited. Currently, clinical assessment, cross-sectional imaging and EUS with fluid analysis (if appropriate) belong to the standard care in patients with PCLs. For differentiation of mucinous from nonmucinous cysts, the sensitivity of cytological investigation and CEA in the cyst fluid is 42% and 52-79%, respectively. Due to the limited accuracy, further diagnostic tools are warranted. Two EUS-guided approaches have been introduced recently. Through-the-(19-gauge EUS) needle Moray microforceps have been developed, and several studies have acknowledged their contribution to the correct diagnosis as they help to overcome limited cellularity of the EUS-guided cyst fluid aspiration and traditional cytology. Confocal laser endomicroscopy offers real-time images and seems to be a promising method for the diagnosis and differential diagnosis of pancreatic PCLs. Example images of the needle-based confocal laser endomicroscopy criteria for the diagnosis of PCLs have been suggested recently. Before both, Moray microforceps and confocal laser endomicroscopy can be widely accepted, further studies are necessary to determine the real diagnostic yield and the clinical efficacy.

Tu1407 EUS-THROUGH-THE-NEEDLE BIOPSY (EUS-TTNB) IN PANCREATIC CYSTIC LESIONS - A LARGE SINGLE CENTER EXPERIENCE

Establishing a diagnosis of pancreatic cystic lesions (PCLs) preoperatively still remains challenging. Recently, EUS-through-the-needle biopsy (EUS-TTNB) using microforceps (MorayTM microforceps, US Endoscopy, Ohio, USA) in PCLs has been made available. There still remains limited data regarding the efficacy and its safety profile. The aim of this study is to evaluate EUS-TTNB in terms of efficacy, diagnostic yield, and safety in the diagnosis of PCLs. A secondary aim is to evaluate the additive value in diagnostic yield over standard EUS-FNA.

Endoscopic ultrasound-guided fine needle aspiration in diagnosis of cystic pancreatic lesions

Background and study aimspancreatic cysts are commonly found lesions and proper diagnosis is very important for planning further management. The study aims to evaluate the role of cyst fluid amylase and tumour markers as cancer antigen (CA 19-9) and carcinoembryonic antigen (CEA) in addition to mucin stain in diagnosing pancreatic cysts and differentiating malignant from benign lesions. Patients and methodsThis prospective study was conducted on 184 patients diagnosed to have pancreatic cystic lesions from January 2013 to January 2018. Fluid analysis for CA 19-9, CEA, amylase, mucin stain and cytopathology were done. We compared these data with the final diagnosis based on histopathology after surgical resection, positive cytopathology and long period of follow up of the patients for at least 18 months. ResultsThe highest AUC was that of cystic CEA with cut-off value of 160 ng/ml; it had a sensitivity of 60.4% and a specificity of 85%. The best cut-off value for cystic CA 19-9 was 1318 U/ml with a sensitivity of 64.1% and a specificity of 68.1%. The cut-off value of cyst amylase level was 5500 U/L, with 84.2% sensitivity and 37.1% specificity. The sensitivity of mucin stain in detecting mucinous cystic neoplasm was 85.45%, specificity was 86.05% with accuracy 85.87%. ConclusionCyst fluid analysis by investigating amylase, mucin, CA 19-9, CEA and EUS examination improves the diagnosis of different pancreatic cysts.

Endoscopic Ultrasound-guided Needle-based Confocal Laser Endomicroscopy: Appraisal Concerning In-vivo Imaging of Intraductal Papillary Mucinous Neoplasm

Differential diagnosis between benign and potentially malignant cystic pancreatic lesions may be difficult. Previously we have compared cyst fluid serine protease inhibitor Kazal type I (SPINK1) with some traditionally used tumour markers (amylase, CEA, Ca19-9) and found that it may be a new promising maker in the differential diagnosis of cystic pancreatic lesions. In the present study, we focused on cyst fluid SPINK1 levels in benign and potentially malignant cystic pancreatic lesions.Sixty-one patients operated on for cystic pancreatic lesion in Tampere University Hospital, Finland and in Verona University Hospital, Italy, were included. Cyst fluid was aspirated during surgery, stored at −70 °C, and analysed with immunofluorometric assay for SPINK1. The final diagnosis was acute pancreatitis with fluid collection (Acute FC) in 4 patients, chronic pseudocyst (PS) in 17 patients, serous cystadenoma (SCA) in 7 patients, mucinous cystadenoma (MCA) in 21 patients and intraductal papillary-mucinous neoplasm (IPMN) in 12 patients (9 main/mixed duct type and 3 branch duct type).The acute FC patients had high SPINK1 levels. Among chronic cysts, SPINK1 levels were significantly higher in patients with potentially malignant cysts (main/mixed duct IPMN and MCA) than with benign cysts (side branch IPMN and SCA), (median and range, [480 (13–3602) vs. 18 (0.1–278) μg/L]; p < 0.0001). In the subcohort of 24 patients with <3 cm chronic cyst, cyst fluid SPINK 1 levels were significantly lower in SCA or side branch IPMN (3 [2–116] μg/L) than in main duct IPMN or MCA (638 [66–3602] μg/L; p = 0.018). The best sensitivity and specificity to differentiate any size MCA or main/mixed type IPMN from SCA or side branch IPMN were 85% and 84% (AUC 0.94; cut-off value 118 μg/L). The best sensitivity and specificity to differentiate <3 cm MCA or main duct IPMN from SCA or side branch IPMN were 93% and 89% (AUC 0.98; cut-off value 146 μg/L).Cyst fluid SPINK1 may be a possible marker in the differential diagnosis of benign and potentially malignant cystic pancreatic lesions.

The role of endoscopic ultrasound-guided through-the-needle microforceps biopsy in the diagnosis of pancreatic cystic lesions

The role of endoscopic ultrasound-guided through-the-needle microforceps biopsy in the diagnosis of pancreatic cystic lesions

Diagnostic ability of artificial intelligence using deep learning analysis of cyst fluid in differentiating malignant from benign pancreatic cystic lesions

The diagnosis of pancreatic cystic lesions remains challenging. This study aimed to investigate the diagnostic ability of carcinoembryonic antigen (CEA), cytology, and artificial intelligence (AI) by deep learning using cyst fluid in differentiating malignant from benign cystic lesions. We retrospectively reviewed 85 patients who underwent pancreatic cyst fluid analysis of surgical specimens or endoscopic ultrasound-guided fine-needle aspiration specimens. AI using deep learning was used to construct a diagnostic algorithm. CEA, carbohydrate antigen 19-9, carbohydrate antigen 125, amylase in the cyst fluid, sex, cyst location, connection of the pancreatic duct and cyst, type of cyst, and cytology were keyed into the AI algorithm, and the malignant predictive value of the output was calculated. Area under receiver-operating characteristics curves for the diagnostic ability of malignant cystic lesions were 0.719 (CEA), 0.739 (cytology), and 0.966 (AI). In the diagnostic ability of malignant cystic lesions, sensitivity, specificity, and accuracy of AI were 95.7%, 91.9%, and 92.9%, respectively. AI sensitivity was higher than that of CEA (60.9%, p = 0.021) and cytology (47.8%, p = 0.001). AI accuracy was also higher than CEA (71.8%, p < 0.001) and cytology (85.9%, p = 0.210). AI may improve the diagnostic ability in differentiating malignant from benign pancreatic cystic lesions.