Incidental Pancreatic Duct Dilation on Imagings3.gi.org/wp-content/uploads/2013/04/13ACG_Eastern... · · 2013-04-17Di th it d f th blDiscuss the magnitude of the problem. ... Future

Nadim G. Haddad, MD

Incidental Pancreatic Duct Incidental Pancreatic Duct Dilation on Imaging Dilation on Imaging

ByByNadim G. Haddad, M.D.Nadim G. Haddad, M.D.

Associate ProfessorAssociate ProfessorClinical Director Clinical Director

Division of Gastroenterology & Division of Gastroenterology & HepatologyHepatologyMGUHMGUH

DisclosuresDisclosures

Consultant Boston ScientificConsultant Boston Scientific

ACG Regional Postgraduate Course - Washington, DC Copyright 2013 American College of Gastroenterology

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Nadim G. Haddad, MD

ObjectivesObjectives

Di th it d f th blDi th it d f th bl Discuss the magnitude of the problem.Discuss the magnitude of the problem. Differential Diagnosis.Differential Diagnosis. Diagnostic testing. Diagnostic testing. Future developments.Future developments.

ll Conclusion.Conclusion.

Differential Diagnosis of Ductal Differential Diagnosis of Ductal DilationDilation

Chronic Pancreatitis.Chronic Pancreatitis. Tumor obstructing the main duct.Tumor obstructing the main duct. IPMN: MPD vs BD vs Mixed.IPMN: MPD vs BD vs Mixed. Pancreatic Cystic Neoplasm.Pancreatic Cystic Neoplasm. Dilation > 10 mm.Dilation > 10 mm.


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Nadim G. Haddad, MD

Abnormal MR PancreatogramAbnormal MR Pancreatogram““DuctectaticDuctectatic””PatternPattern

Chronic Pancreatitis

Side branch ectasia


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Nadim G. Haddad, MD

6mm Pancreatic Adenocarcinoma6mm Pancreatic Adenocarcinoma

Late phase enhancing

Complex cystic mass MCAdenoca


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Nadim G. Haddad, MD

Incidental Pancreatic Cystic Lesion

2 cm simple cyst-MCA

Pancreas Cysts: An Epidemic?Pancreas Cysts: An Epidemic? 2.4% of all individuals harbor a pancreas cyst by 2.4% of all individuals harbor a pancreas cyst by

screening MRIscreening MRIscreening MRIscreening MRI 20% of clinically indicated abdominal MRI studies 20% of clinically indicated abdominal MRI studies

demonstrate a cyst in the pancreasdemonstrate a cyst in the pancreas Prevalence is on the rise due to improved detection Prevalence is on the rise due to improved detection

with increasingly sophisticated imagingwith increasingly sophisticated imaging

37% of cysts referred for evaluation are discovered37% of cysts referred for evaluation are discovered 37% of cysts referred for evaluation are discovered 37% of cysts referred for evaluation are discovered incidentallyincidentally

De Jong et al. Clin Gastro Hep 2010; 8(9) 806-11Kimura wt al. Int J Pancreatol 1995; 18:197-206 Zhang et al. Radiology 2002, 223: 547-53Fernandez-del Castillo et al. Arch Surg 2003 138:427-34


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Nadim G. Haddad, MD

Pancreas Cysts…What Are They?Pancreas Cysts…What Are They?

NonNon--neoplastic cystsneoplastic cysts–– Congenital cystCongenital cyst

Cystic Cystic neoplasmsneoplasms–– Serous Serous CystadenomaCystadenomag yg y

–– Retention cystRetention cyst–– Inclusion cystInclusion cyst–– Endometriotic cystEndometriotic cyst–– Inflammatory cystsInflammatory cysts PseudocystPseudocyst

yy–– MucinousMucinous

CystadenomaCystadenoma–– IPMNIPMN–– LymphangiomaLymphangioma–– HemangiomaHemangioma–– LymphoepithelialLymphoepithelial cystcyst

Solid tumors containing cystic spacesSolid tumors containing cystic spaces–– DuctalDuctal adenocarcinomaadenocarcinoma–– SolidSolid--pseudopapillarypseudopapillary neoplasmneoplasm–– Cystic endocrine tumorCystic endocrine tumor

Pancreatic Cystic NeoplasiaPancreatic Cystic Neoplasia

Benign / Low RiskBenign / Low Risk–– Serous cystadenomaSerous cystadenomaSerous cystadenomaSerous cystadenoma–– Lymphoepithelial cyst/Endometriotic cystLymphoepithelial cyst/Endometriotic cyst–– Hemangioma/lymphangiomaHemangioma/lymphangioma

Malignant potential / High RiskMalignant potential / High Risk–– Mucinous cystadenomaMucinous cystadenomayy–– Intraductal papillary mucinous neoplasmIntraductal papillary mucinous neoplasm

Main ductMain duct Side branchSide branch

Early identification and intervention can prevent Early identification and intervention can prevent the development of cancer and/or metastasisthe development of cancer and/or metastasis


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Nadim G. Haddad, MD

Serous CystadenomaSerous Cystadenoma

30% of Pancreatic Cysts, Head/Body/Tail.30% of Pancreatic Cysts, Head/Body/Tail. Central Calcification in 30%.Central Calcification in 30%. Cuboidal Cells, glycogenCuboidal Cells, glycogen--rich rich (PAS+(PAS+).). Highly Vascular.Highly Vascular. Benign.Benign. Fluid analysis: CEA<5, low Fluid analysis: CEA<5, low amylase.amylase.

Tseng JF, Warshaw AL, Sahani DV, Lauwers GY, Rattner DW, Fernandez-del Castillo C.Ann Surg. 2005 Sep;242(3):413-9Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment.

Serous Cystadenoma

T2

T1 post contrastT1 post contrast


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Nadim G. Haddad, MD

MR Bright T2 SCA

Post contrast septal enhancement SCA


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Nadim G. Haddad, MD

Mucinous CystadenomaMucinous Cystadenoma

Most common pancreatic cystic neoplasm.Most common pancreatic cystic neoplasm. Female predominance (>75%).Female predominance (>75%). Mean age of diagnosis = 60Mean age of diagnosis = 60’’s.s. Macrocystic, often unilocular, eggshell Macrocystic, often unilocular, eggshell

calcification , mural nodule.calcification , mural nodule.d b d / l ( )d b d / l ( ) Located in body/tail (90%).Located in body/tail (90%).

Do not communicate with the pancreatic Do not communicate with the pancreatic duct.duct.–– Distinguishes from IPMNDistinguishes from IPMN

Scheiman J. Gastroenterology 2005:128:463-9Sarr et al. J Gastrointest Surg 2003:7:417-28



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Nadim G. Haddad, MD

Mucinous Cystadenocarcinoma with Liver Mets


HistologyHistologyColumnar mucin producingColumnar mucin producing–– Columnar mucin producing Columnar mucin producing epitheliumepithelium Variable degrees of cellular atypiaVariable degrees of cellular atypia

–– Unique ovarian stromaUnique ovarian stroma

WHO ClassificationWHO Classification–– BenignBenigne ge g–– LowLow--grade malignantgrade malignant–– MalignantMalignant–– Other classifications proposedOther classifications proposed

Reddy et al. Clin Gastro Hep 2(11); 1026-1031


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Nadim G. Haddad, MD

Mucinous Cystadenoma:Mucinous Cystadenoma:Fluid aspirateFluid aspirate

CEACEA–– ElevatedElevated

AmylaseAmylase AmylaseAmylase–– LowLow

Viscous fluidViscous fluid–– String signString sign

CytologyCytology–– MucinMucin producing epitheliumproducing epithelium–– AtypiaAtypia/dysplasia/carcinoma/dysplasia/carcinoma

Genetic dataGenetic dataHi h t f DNAHi h t f DNA

FINAL DIAGNOSIS:FINAL DIAGNOSIS:

PANCREAS, FINE NEEDLE ASPIRATE WITH PANCREAS, FINE NEEDLE ASPIRATE WITH QUICK EVALUATION:QUICK EVALUATION:

FRAGMENTS OF ATYPICAL GLANDULAR FRAGMENTS OF ATYPICAL GLANDULAR CELLS IN A MUCIN PRODUCINGCELLS IN A MUCIN PRODUCING–– High amount of DNAHigh amount of DNA

–– kk--rasras mutationmutation–– Loss of Loss of heterozygosityheterozygosity

CELLS IN A MUCIN PRODUCING CELLS IN A MUCIN PRODUCING EPITHELIUMEPITHELIUM

IPMN: Clinical PresentaionIPMN: Clinical Presentaion

Mean age of diagnosis = 60Mean age of diagnosis = 60--7070’’s.s. Male predominanceMale predominance Male predominance.Male predominance. Most commonly located in the pancreatic head.Most commonly located in the pancreatic head. Clinical presentationClinical presentation

–– AsymptomaticAsymptomatic–– Recurrent pancreatitisRecurrent pancreatitis–– Abdominal painAbdominal painAbdominal painAbdominal pain–– JaundiceJaundice

Commonly initially misdiagnosed as obstructive Commonly initially misdiagnosed as obstructive pancreatits.pancreatits.

Horwat et at. JOP 2004: 5(4):289-303


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Nadim G. Haddad, MD

IPMN: Main vs. Branch DuctIPMN: Main vs. Branch Duct

Main Duct IPMNMain Duct IPMN Branch Duct IPMNBranch Duct IPMN

–– Arises from the main ductArises from the main duct

–– Prevalent cancer risk 23Prevalent cancer risk 23--70%70%

–– 10 year risk of progression = 63%10 year risk of progression = 63%

–– Tends to be unifocal althoughTends to be unifocal although

–– Arises in a side branchArises in a side branch

–– Prevalent cancer risk 0Prevalent cancer risk 0--36%36%

–– 10 year risk of progression 15%10 year risk of progression 15%

–– Unifocal or multifocal (39Unifocal or multifocal (39--64%)64%)–– Tends to be unifocal although Tends to be unifocal although may extend along ductmay extend along duct

–– Unifocal or multifocal (39Unifocal or multifocal (39--64%)64%)

Levy et al. Clin Gastro Hep. 2006;4(4):460-468. Tanaka et al. Pancreatology 2006;6;17-32Pelaez-Luna M,Am J Gastro 2007;102:1759–1764Salvia R et al. Gut 2007;56:1086–1090.

IPMN: HistologyIPMN: Histology

Benign

Ban et al. Am J Surg Pathol 2006;30(12);1561-9

Borderline

Carcinoma in situ


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Nadim G. Haddad, MD

Side Branch IPMN: MRCPSide Branch IPMN: MRCP

MPD

Bile Duct

Cyst

Main Duct IPMNMain Duct IPMN


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Focal dilationFocal dilation


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Present in 25% of cases, is a diagnostic finding

Fernández-del Castillo C et al. Gastro 2010;139:708–713


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Nadim G. Haddad, MD

IPMN: Fluid aspirateIPMN: Fluid aspirate CEACEA

–– ElevatedElevatedA lA l AmylaseAmylase–– High High –– Due to communication with MPDDue to communication with MPD

CytologyCytology–– Mucin producing epitheliumMucin producing epithelium–– Atypia/dysplasia/carcinomaAtypia/dysplasia/carcinoma

Viscous fluidViscous fluid–– String signString signString signString sign

Genetic dataGenetic data–– High amount of DNAHigh amount of DNA–– KK--ras and p53 mutationsras and p53 mutations–– Loss of heterozygosityLoss of heterozygosity


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Nadim G. Haddad, MD

Pancreas Cyst Fluid AspiratePancreas Cyst Fluid AspirateIn a perfect world….In a perfect world….

A lA l CEACEA C t lC t lAmylaseAmylase CEACEA CytologyCytology

Serous Serous CystadenomaCystadenoma

LowLow LowLowCuboidal cellsCuboidal cells

PAS +PAS +

PseudocystPseudocyst HighHigh LowLow

DebrisDebris

NeutrophilsNeutrophils

Hemosiderin laden Hemosiderin laden macrophagesmacrophagesmacrophagesmacrophages

Mucinous Mucinous CystadenomaCystadenoma

LowLow HighHighMucin producing Mucin producing

columnar epithelium, columnar epithelium, ovarian stromaovarian stroma

IPMNIPMN HighHigh HighHigh Mucin producing Mucin producing columnar epitheliumcolumnar epithelium

Back to reality…..Back to reality….. FNA is performed through the stomach or duodenal wallFNA is performed through the stomach or duodenal wall

–– Contamination of sampleContamination of sample

Some IPMN (especially branch duct) harbor cells identical to Some IPMN (especially branch duct) harbor cells identical to gastric mucosagastric mucosa

Insufficient fluid for cytologyInsufficient fluid for cytology–– Who wins CEA? Molecular analysis?Who wins CEA? Molecular analysis?

CEA frequently nonCEA frequently non--diagnosticdiagnosticld lld l Mild elevationMild elevation

Elevated in benign processesElevated in benign processes Absent in preAbsent in pre--malignant/malignantmalignant/malignant

CEA cutoff levels vary among laboratoriesCEA cutoff levels vary among laboratories

20% of BD IPMN harbor main duct component20% of BD IPMN harbor main duct componentCorrea-Gallego et al. Pancreatology 2010;10:144-150


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Nadim G. Haddad, MD

CEA: How good is it?CEA: How good is it?

Cooperative Pancreas Cyst StudyCooperative Pancreas Cyst Study–– Optimal CEA cutoff to maximize AUC = 192Optimal CEA cutoff to maximize AUC = 192 Sensitivity 73%Sensitivity 73% Specificity 84%Specificity 84% Accuracy 79%Accuracy 79%

–– Median CEA for nonMedian CEA for non--mucinous lesions = 284mucinous lesions = 284–– Other studies with similar or worse resultsOther studies with similar or worse results

Brugge et al. Gastro 2004;126:1330–1336Khalid et al. Am J Gastro 2006; 101:2493-2500Park et al. Pancreas. 2010 Oct 13

Limitations of CEALimitations of CEA

Pooled analysis of 450 patients (no IPMN) from 12 studiesPooled analysis of 450 patients (no IPMN) from 12 studies–– CEA > 800 48% sensitivity 98% specific for mucinous CEA > 800 48% sensitivity 98% specific for mucinous

cystadenoma and cystadenocarcinomacystadenoma and cystadenocarcinoma

van derWaaij et al. 2005 Gastro Endoscopy 62:383-9


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Nadim G. Haddad, MD

CEA cutoff = 192 missed 25% (4/12) of malignant mucinous cysts

Nagula, et al. J Gastroint Surgery. 2010; 147: 13-20.

Cyst Fluid CytologyCyst Fluid Cytology

Sensitivity 35%Sensitivity 35%S ifi it 83%S ifi it 83%

• Acellular or non-diagnostic in 30 43% Specificity 83%Specificity 83%

Accuracy 59%Accuracy 59%

i i i %Combination Cytology + CEA

diagnostic in 30-43%

van derWaaij et al. 2005 Gastro Endoscopy 62:383-9Brugge et al. Gastro 2004;126:1330–1336Khalid et al. GastrintestEndosc 2009; 69(6) 1095-1102

• Sensitivity 82%• Specificity 71%• Accuracy 77%


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Nadim G. Haddad, MD

Strategies to Improve Diagnostic AccuracyStrategies to Improve Diagnostic Accuracy

Molecular analysisMolecular analysis Cyst wall tissue acquisitionCyst wall tissue acquisition Cyst wall tissue acquisitionCyst wall tissue acquisition

–– Brush cytologyBrush cytology–– Cyst wall puncture/biopsyCyst wall puncture/biopsy

Intracystic imagingIntracystic imaging–– Confocoal endomicroscopyConfocoal endomicroscopy–– Direct visualization (Spyglass)Direct visualization (Spyglass)

PET scanPET scan–– Sensitivity poor (57%)Sensitivity poor (57%)

Serial cross sectional imaging and/or EUS FNASerial cross sectional imaging and/or EUS FNA

Mansour et al. J GastrointestSurg 2006; 10:1354-60

Pancreatic Cyst Fluid DNA Pancreatic Cyst Fluid DNA AnalysisAnalysis

Genetic mutations occur early in theGenetic mutations occur early in the Genetic mutations occur early in the Genetic mutations occur early in the process of pancreatic carcinogenesisprocess of pancreatic carcinogenesis

The molecular process of pancreatic The molecular process of pancreatic carcinogenesis is being increasingly carcinogenesis is being increasingly elucidatedelucidated–– Similarity in some pathways with Similarity in some pathways with

heterogeneity in others heterogeneity in others


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Nadim G. Haddad, MD

Pancreatic CystDNA QUANTITY

DNA QUALITY

Integrated analysis of DNA/mutational change.

CEA

FREE DNA

DNA QUALITY

KRAS POINT MUTATION (ONCOGENE)

LOSS OF HETEROZYGOSITYHETEROZYGOSITY (LOH) MUTATION (TUMOR SUPPRESSOR GENE)

DETACHED LINING CELLS

Analysis of free DNA and protein can help assess sampling variation


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Nadim G. Haddad, MD

Commercially available DNA analysisCommercially available DNA analysis

Quantity of DNA Quantity of DNA –– optical densityoptical densityQ lit f DNAQ lit f DNA l th h ld ll th h ld l Quality of DNA Quality of DNA –– cycle threshold valuecycle threshold value

Degree of allelic imbalance Degree of allelic imbalance –– allelic loss allelic loss amplitude (ALA), loss of heterozygosityamplitude (ALA), loss of heterozygosity

kk--rasras--2 mutation2 mutation Number of mutationsNumber of mutations Sequence of mutationsSequence of mutations

–– kk--ras followed by allelic lossras followed by allelic loss

DIAGNOSTIC CATEGORIES

BENIGN: NON-MUCINOUS & MUCINOUS (LACKS AGGRESSIVE MOLECULAR FEATURES)

STATISTICALLY INDOLENT (SINGLE AGGRESSIVE MOLECULAR FEATURE)

STATISTICALLY INDOLENT SHOWING GREATER RISK FOR NEOPLASTIC PROGRESSION (SINGLE AGGRESSIVE FEATURES WITH CLINCIAL CORRELATIVE SUPPORT FOR AGGRESSIVE BIOLOGY)

AGGRESSIVE


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Nadim G. Haddad, MD

Incremental Value of Molecular Analysis for Pancreatic Cyst Management using

Endoscopic Ultrasound

Provides a separate source of multiparameter informationProvides a separate source of multiparameter information to diagnosis and better understand pancreatic cyst biology

Capable of identifying aggressive disease relatively early in development prior to other clinical evidence

Assist in the evaluation when conflicting data on bi l i l i i t ft fi t li t tibiological aggressiveness is present after first line testing

Possible to plot the trajectory of pancreatic cyst biology through serial integrated molecular/clinical analysis

Performance of Molecular Analysis for Performance of Molecular Analysis for Diagnosis of Mucinous CystsDiagnosis of Mucinous Cysts

Multicenter analysis of 113 patients undergoing EUS FNA for Multicenter analysis of 113 patients undergoing EUS FNA for evaluation of pancreas cysts with histologic confirmationevaluation of pancreas cysts with histologic confirmation–– 88 mucinous88 mucinous88 mucinous88 mucinous

Fluid cytology Fluid cytology –– Insufficient in 1/3 of cases Insufficient in 1/3 of cases –– Acellular/nonAcellular/non--diagnostic in 43%diagnostic in 43%

CEA @ 192 cutoff for mucinous cystsCEA @ 192 cutoff for mucinous cysts–– Sensitivity 64% Specificity 83%Sensitivity 64% Specificity 83%

CEA @ 192 + kCEA @ 192 + k--ras mutationras mutation CEA @ 192 + kCEA @ 192 + k--ras mutationras mutation–– Sensitivity 82%, Specificity 83%Sensitivity 82%, Specificity 83%

KK--ras alone specificity 96% for mucinous cystsras alone specificity 96% for mucinous cysts

Khalid et al. GastrintestEndosc 2009; 69(6) 1095-1102


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Nadim G. Haddad, MD

Incremental Value of Molecular Analysis Incremental Value of Molecular Analysis for the Diagnosis of Mucinous Cystsfor the Diagnosis of Mucinous Cysts

Single center of 100 patients with FNA of cystsSingle center of 100 patients with FNA of cysts Single center of 100 patients with FNA of cysts Single center of 100 patients with FNA of cysts (0.8(0.8--14cm)14cm)–– Quantity not sufficient for CEA = 16%Quantity not sufficient for CEA = 16%–– CEA > 192 in 33% of cysts, sensitivity 82%CEA > 192 in 33% of cysts, sensitivity 82%–– Molecular analysis consistent with mucinous cyst in Molecular analysis consistent with mucinous cyst in

49%, sensitivity 77%49%, sensitivity 77%, y, y–– CEA + molecular, sensitivity 100%, specificity 100%CEA + molecular, sensitivity 100%, specificity 100%

-- Histology proven cystsHistology proven cysts

Sawhnwey et al.Gastrointest Endosc 2009; 69(6) 1106-10

Small Cysts Small Cysts –– The real problemThe real problem

Single center cyst registry Single center cyst registry –– 69% of cysts 3cm or smaller69% of cysts 3cm or smaller–– Cytology, CEA, DNA analysisCytology, CEA, DNA analysis

Cytology CEA MolecularUnsatisfactory18 (28.6%) 16 (25.4%) 2 (3.2%)Benign/serous17 (27.0%) 31 (49.2%) 14 (22.2%)Mucinous 26 (41 3%) 16 (25 4%) 43 (68 3%)Mucinous 26 (41.3%) 16 (25.4%) 43 (68.3%)Malignant 2 (3.2%) N/A 4 (6.3%)

Toll et al. J Pancreas 2010: 211(6):582-586


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Nadim G. Haddad, MD

Incremental Value of Molecular Analysis in Incremental Value of Molecular Analysis in Cysts < 3cmCysts < 3cm

CEA & Molecular analysisCEA & Molecular analysisyy–– All cases with CEA > 192 had concordant molecular resultsAll cases with CEA > 192 had concordant molecular results

Includes cytology nonIncludes cytology non--diagnostic but CEA elevated (n=4) diagnostic but CEA elevated (n=4) 75% confirmed 75% confirmed histologicallyhistologically, and concordant, and concordant KK--rasras mutations only seen in mutations only seen in mucinousmucinous cystscysts

Additional value of molecular analysisAdditional value of molecular analysis–– 31% with non diagnostic cytology/CEA obtained a diagnosis 31% with non diagnostic cytology/CEA obtained a diagnosis

based on molecular analysis alonebased on molecular analysis aloneyy 84% agreed with clinical impression84% agreed with clinical impression

–– One patient with nonOne patient with non--mucinousmucinous histology/CEA and aggressive histology/CEA and aggressive molecular profile had repeat EUS FNA identified molecular profile had repeat EUS FNA identified adenocarcinomaadenocarcinoma

Toll et al. J Pancreas 2010: 211(6):582-586

Practical considerations of cyst fluid Practical considerations of cyst fluid analysis….analysis….

Cyst fluid mismanagementCyst fluid mismanagement–– Splitting of samples to more than one locationSplitting of samples to more than one location

–– CEA, amylaseCEA, amylase

Variability among institutions in determining optimal cutoffVariability among institutions in determining optimal cutoff

One test is not the answer, especially for small cystsOne test is not the answer, especially for small cysts–– Clinical + CEA + molecularClinical + CEA + molecular

–– Enhancing the knowledge baseEnhancing the knowledge base

CostCost–– CMS approved molecular analysis for patients with CMS approved molecular analysis for patients with pancreatic cysts where pancreatic cysts where ““traditionaltraditional”” fluid chemistry and/or fluid chemistry and/or cytology evaluations were inconclusive.cytology evaluations were inconclusive.


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Nadim G. Haddad, MD

Cyst Wall PunctureCyst Wall Puncture Hypothesis: Puncture of the cyst wall will Hypothesis: Puncture of the cyst wall will

provide greater cytologic yield than fluid aspirateprovide greater cytologic yield than fluid aspiratep g y g y pp g y g y p

Retrospective review 107 cystsRetrospective review 107 cysts–– Insufficient fluid for analysis = 30%Insufficient fluid for analysis = 30%

CWP diagnosis of mucinous cyst 47%CWP diagnosis of mucinous cyst 47%–– Cyst fluid CEA <192Cyst fluid CEA <192

CWP diagnosis of mucinous cyst = 31%CWP diagnosis of mucinous cyst = 31%–– Overall incremental diagnosis of mucinous cysts Overall incremental diagnosis of mucinous cysts

based on CWP = 37%based on CWP = 37%

Complications 2.8%Complications 2.8%

Rogart et al. J Clin Gastro 2010: in press

Incremental Yield of CWP for the Diagnosis of Incremental Yield of CWP for the Diagnosis of Mucinous CystsMucinous Cysts

60% Mucinous Cysts As Percent of Total

20%

30%

40%

50%

Total

QNS

-10%

0%

10%

Without CWP With CWP

Q

CEA<192

Rogart et al. J Clin Gastro 2010: in press


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Nadim G. Haddad, MD

Cyst Wall Puncture

Prospective collection of 39 cysts28% inadequate cyst fluid for cytologic analysis– 28% inadequate cyst fluid for cytologic analysis

– 20/39 had findings consistent with non-mucinous cyst (CEA < 192 & Non-mucinous cytology) 40% (8/20) CWP diagnosed mucinous cyst

– 7 cysts with insufficient fluid for cytology/CEA 5/7 mucinous by cyst wall puncture

– Incremental diagnostic yield of CWP = 33% 2 adenocarcinoma

– Pancreatitis n=1

SummarySummary

Accurate diagnosis of pancreas cysts is paramount to Accurate diagnosis of pancreas cysts is paramount to determine appropriate management strategydetermine appropriate management strategydetermine appropriate management strategydetermine appropriate management strategy

Combination of tests hold promise for the best Combination of tests hold promise for the best performance characteristicsperformance characteristics–– CEACEA–– Molecular DNA analysisMolecular DNA analysis–– Cyst wall punctureCyst wall puncture

Further insights into molecular carcinogenesis holdFurther insights into molecular carcinogenesis hold Further insights into molecular carcinogenesis hold Further insights into molecular carcinogenesis hold promise for future refinementspromise for future refinements


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Incidental Pancreatic Duct Dilation on Imagings3.gi.org/wp-content/uploads/2013/04/13ACG_Eastern... · · 2013-04-17Di th it d f th blDiscuss the magnitude of the problem. ... Future