Cytological and Cyst Fluid Analysis of Small (≤3 cm) Branch Duct Intraductal Papillary Mucinous Neoplasms Adds Value to Patient Management Decisions

Yaeger

Brugge

et al. 2012

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BACKGROUND: Pancreatic cysts are aspirated to assess whether a cyst is mucinous on one hand and malignant on the other. The authors' retrospective data have indicated that high-grade atypical epithelial cells (AECs) identified on cytology are a high-risk feature and a better threshold than ''positive'' for detecting malignancy. The objective of the current study was to assess the accuracy of AECs in predicting malignancy in pancreatic cysts.

Section: Introductionmentioning

confidence: 99%

Prospective analysis of atypical epithelial cells as a high‐risk cytologic feature for malignancy in pancreatic cysts

Yaeger

Brugge

et al. 2012

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“…Studies have shown that concentrations of around 110 to 200 ng/mL are approximately 80% accurate in determining a cyst to be mucinous. 13,[21][22][23][24][25] Raising the cutoff level improves the specificity of the test but at the expense of sensitivity. 24 Not all mucinous cysts will have such an elevated CEA concentration, and some mucinous cysts have very low concentrations of CEA.…”

Section: Commentary 362mentioning

confidence: 99%

“…Most importantly, some asymptomatic patients with carcinoma or high-grade dysplasia but with no high-risk imaging features were being followed conservatively. 12,13 In 2010, a new international, multidisciplinary group of physicians (the 8 members of the original group plus 6 new physicians from various specialties) met in Fukuoka, Japan to revisit the Sendai guidelines and to discuss advances in the understanding of the biology, imaging, preoperative testing, and surgical management of patients with mucinous cysts, with the goal of providing a revised management algorithm.…”

mentioning

confidence: 99%

Revised international consensus guidelines for the management of patients with mucinous cysts

2012

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The management of patients with pancreatic cysts is a significant issue in the health care community. We know from over 30 years of study that mucinous cysts account for a significant percentage of pancreatic cysts, and that mucinous cysts are precursors of pancreatic carcinoma. Based on autopsy studies, approximately 2.6% of the adult population and nearly 8% of elderly patients have a pancreatic cyst.1 How many of these cysts are mucinous and, of those that are mucinous, how many are malignant or sufficiently highgrade to prompt surgical management is a conundrum physicians are facing on an increasingly common basis. 2,3 The detection of mucinous cysts before the development of invasive carcinoma is the goal of management given that invasion is the single most important factor determining patient prognosis. 4Understanding the clinicopathological features of pancreatic cysts is critical in answering the important question of whether surgical management is warranted, and this requires a multidisciplinary approach. 5,6In 2005, an international and multidisciplinary group of physicians met in Sendai, Japan and developed a consensus document to guide physicians in the diagnosis and management of patients with pancreatic mucinous cysts (also known as the ''Sendai guidelines''). 7 In brief, these guidelines called for the conservative management of asymptomatic patients with pancreatic mucinous cysts that were small (< 3 cm), not associated with a dilated main pancreatic duct (MPD) ( 6 mm) or mural nodule by imaging, and without ''positive cytology.'' Since their publication in 2006, studies have shown the Sendai guidelines to be highly sensitive (approximately 97%), but very nonspecific (approximately 29%) for the detection of a malignant mucinous cyst. [8][9][10] Cyst size and nonspecific patient symptoms have proven to be poor predictors of malignancy. 11,12 Although the majority of patients with cancer were detected, many patients already had invasive cancers at the time of surgical resection. In addition, many elderly patients with significant comorbid conditions and mucinous cysts with low-to intermediate-grade (moderate) dysplasia were also undergoing surgical resection, which is riskier than conservative follow-up because the progression to carcinoma would likely take longer than the expected life expectancy of the patient. Most importantly, some asymptomatic patients with carcinoma or high-grade dysplasia but with no high-risk imaging features were being followed conservatively. 12,13In 2010, a new international, multidisciplinary group of physicians (the 8 members of the original group plus 6 new physicians from various specialties) met in Fukuoka, Japan to revisit the Sendai guidelines and to discuss advances in the understanding of the biology, imaging, preoperative testing, and surgical management of patients with mucinous cysts, with the goal of providing a revised management algorithm.14 Because the levels

“…8,34 For patients with suspected branch duct IPMNs or MCNs, recent international consensus guidelines recommend surgical resection for patients with mucinous cysts either >3 cm or smaller cysts with high-risk features such as symptoms, positive cytology, or a mural nodule. 14 We and others have shown, however, that not all asymptomatic cysts <3 cm 12,31,35 or those with less than positive cytology are benign, 11,24,28,31 and therefore have proposed aspiration and analysis of fluid from most pancreatic cysts, especially those suspected of being mucinous cysts. 20 The specific mode of analysis depends on the fluid volume available.…”

Section: Clinical Managementmentioning

confidence: 99%

“…12,21,[74][75][76][77][78][79][80][81] Cytology may underestimate the final histologic grade of neoplastic mucinous cyst, given that the cyst lining is quite heterogeneous, and the degree of epithelial atypia may not be representative of the highest degree of atypia of the cyst on histology. 12,79,82 Aside from the clinical suspicion of a neoplastic mucinous cyst, the presence of a mucinous cyst is often confirmed at the time of aspiration when thick, viscous mucus is grossly appreciated by the aspirator. Direct smears of this thick and viscous cyst fluid are reflected on the slide as thick sheets of colloid-like mucin that covers much of the slide (Fig.…”

Section: Pseudocystmentioning

confidence: 99%

Pancreatic cysts

Lewandrowski

Shen

et al. 2010

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125

Preoperative diagnosis of pancreatic cysts benefits from integrating the clinical, radiological, and cytological features. As patient management algorithms evolve to increasingly nonsurgical options, accuracy in distinguishing mucinous from nonmucinous and benign from malignant mucinous cysts is important. This review focuses on pseudocysts, serous cystadenomas, intraductal papillary mucinous neoplasms (IPMNs), and mucinous cystic neoplasms. Patients with pseudocysts almost always present with pancreatitis and are usually medically managed. Radiological studies reveal a unilocular cyst mostly in the pancreatic tail. Cyst fluid is thin, with high amylase but low carcinoembryonic antigen (CEA) levels. DNA mutations are absent. Serous cystadenomas are benign and do not require resection. Patients are usually asymptomatic and have microcystic or macrocystic masses anywhere in the pancreas. Cytology is frequently nondiagnostic. CEA and amylase levels are low. DNA analysis may reveal loss of heterozygosity (LOH) at 3p if associated with Von Hippel-Lindau disease. Neoplastic mucinous cysts are highly variable in their presentation. Most are resected. Mucinous cystic neoplasms typically arise in the body or tail of the pancreas of middle-aged women and demonstrate a septated cyst without dilatation of the main pancreatic duct. Branch duct IPMNs are more common in the pancreatic head of elderly men. Main duct dilatation correlates with main duct or combined type IPMN. Both types of mucinous cysts produce variable amounts of mucin. Cytologically nonmalignant but atypical epithelial cells, even when scant, are an indication of a high risk for malignancy. High CEA level supports a mucinous cyst, as do KRAS mutation and good quality DNA levels. KRAS mutation and multiple LOH support malignancy.