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Background: Differentiation between the various pathologies presenting as a cystic pancreatic lesion is clinically important but often challenging. We have previously advocated the performance of endoscopic ultrasound (EUS) with aspiration and determination of mucin and carcinoembryonic antigen (CEA) content. We sought to report the results of this ongoing protocol and determine the relative importance of cyst fluid mucin and CEA for the diagnostic process., Methods: The institutions prospectively maintained pancreatic cyst database was accessed to identify patients who had undergone pancreatic EUS and cyst aspiration as part of their evaluation. Only those patients who had subsequently undergone resection were selected, with histopathology being the gold standard for comparison., Results: From January 2000 to July 2009, 174 patients with pancreatic cystic disease underwent surgery, 121 of whom had an EUS with aspiration attempted at our institution with specimens sent for mucin and CEA. Based on histopathology, 86 mucinous lesions were identified, including 44 cystadenomas, 34 intraductal papillary mucinous neoplasms, 7 mucinous adenocarcinomas, and 1 intraductal oncocytic papillary neoplasm; 42 were nonmucinous lesions. The median cyst CEA levels were significantly higher in the mucinous lesions group at 850 versus 2 ng/mL (P = .001). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive diagnostic likelihood ratio, and negative diagnostic likelihood ratio (NDLR) were calculated respectively for mucin alone (0.80, 0.40, 0.61, 0.63, 1.33, 0.68); CEA alone (0.93, 0.43, 0.51, 0.91, 1.63, 0.16); cytology alone (0.38, 0.9, 0.92, 0.31, 3.67, 0.69); mucin or CEA (0.83, 0.65, 0.87, 0.57, 2.51, 0.26); mucin or CEA or cytology (0.92, 0.52, 0.86, 0.68, 1.91, 0.15); mucin plus CEA (0.96, 0.34, 0.25, 0.97, 1.45, 0.12); mucin plus cytology (0.25, 0.97, 0.96, 0.29,7.25, 0.78); CEA plus cytology (0.12, 1.00, 1.00, 0.26, ∞, 0.88); and mucin plus CEA plus cytology (0.08, 1.00, 1.00, 0.25, ∞, 0.92)., Conclusion: Assessment of cyst mucin and CEA are complementary, with the best profile obtained when both markers are determined along with cytology. This combination provides a good sensitivity, PPV, and NDLR, as well as reasonable PPV and PDNR., (Copyright © 2010 Mosby, Inc. All rights reserved.)

Background: The management of incidental pancreatic cysts is not well established because of lack of information on their natural history. International Consensus Guidelines advocate observation of asymptomatic patients with small lesions, despite limited data to support this approach., Methods: To characterize clinical outcomes in a cohort of asymptomatic patients with incidental pancreatic cysts who underwent endoscopic ultrasound (EUS) evaluation+/-fine needle aspiration (FNA)., Results: Overall, 317 patients underwent EUS for evaluation of pancreatic cysts from 1995 to 2005. A total of 97/317 (31%) had asymptomatic, incidentally discovered pancreatic cysts; of 97 asymptomatic patients, 93 were contacted. Of these patients, 71/93 (76%) had lesions<3 cm and benign EUS features. All were followed without operative therapy. The mean follow-up was 44 months (range, 6-123). A total of 69/71 (97%) were alive and free of symptoms of pancreatic disease; 2 patients died of unrelated causes. Among these 71 patients with lesions<3 cm, FNA was performed in 33 patients and cytology was negative for malignant cells in all. Overall, 45/71 patients had either follow-up cross-sectional imaging or EUS. All of them had stable lesions. Surveillance studies were performed with a mean follow-up of 28 months (range, 4-120). The 22 patients with lesions >3 cm and/or concerning EUS features underwent resection. Pathologic analysis revealed that 2/22 patients had adenocarcinoma and that 60% had premalignant lesions., Conclusion: Endoscopic ultrasound is helpful in evaluation of patients with small incidental pancreatic cystic lesions. Asymptomatic cysts with benign radiographic and/or endosonographic features may safely be followed clinically and with serial imaging., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Background: The optimal treatment for incidental asymptomatic pancreatic cysts is not known. The purpose of this study was to determine whether nonmucinous cysts by cyst-aspiration analysis can be observed safely., Methods: A prospective protocol was initiated in September of 1999 for all suspected cystic neoplasms. Asymptomatic patients with negative cyst aspirates (no extracellular mucin, and concentration of carcinoembryonic antigen in the cyst fluid <200 ng/mL) were followed-up clinically and radiographically., Results: Through December 2004, 221 patients have been evaluated, and 80 (36%) initially were operated. There were 141 (64%) patients with indeterminate cysts, 98 have been followed-up for more than 12 months. Compared with resected patients, observed patients were older (62 vs 56 y, P < .006), and had smaller cysts (2.4 vs 4.0, P = .001). At a mean follow-up period of 24 months, 4 patients (4%) were resected. The indication, time to resection, and pathology were as follows: 2 patients for symptoms (abdominal pain and obstructive jaundice) at 24 and 72 months, respectively: mucinous and serous cystadenomas; 1 patient for an increase in size (6.6 to 7.8 cm) at 18 months: lymphoepithelial cyst; and 1 patient for abdominal pain and increase in size (2.0 to 3.7 cm) at 41 months: pseudocyst. The only patient resected for a mucinous neoplasm had a cyst fluid carcinoembryonic antigen level of 896 ng/mL. In the remaining observed patients, 20 (23%) showed a decrease in cyst size, and 16 (19%) showed an increase in size (mean diameter change, 21%)., Conclusions: Initial follow-up evaluation indicates that asymptomatic patients without evidence of a mucinous neoplasm by cyst aspiration can be followed clinically and with interval imaging.