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Background: More accurate diagnosis of mucinous cysts will reduce the risk of unnecessary pancreatic surgery. Carcinoembryonic antigen (CEA) and glucose in pancreatic cyst fluid (PCF) can differentiate mucinous from non-mucinous pancreatic cystic neoplasms (PCN). The current study assessed the value of combined CEA and glucose testing in PCF., Methods: Cross-sectional validation study including prospectively collected PCF from patients undergoing endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) and pancreatic surgery. We performed laboratory measurements for CEA and glucose and measured glucose levels by a hand glucometer. Primary outcome was diagnostic accuracy evaluated by receiver operator curves (ROC), sensitivity, specificity, positive, and negative predictive value (PPV, NPV)., Results: Overall, PCF was collected from 63 patients, including 33 (52%) with mucinous and 30 (48%) with non-mucinous PCN. Histopathology (n = 36; 57%), cytopathology (n = 2; 3%), or clinical and/or radiological diagnosis (n = 25; 40%) was used as reference standard. Combined CEA (cut-off ≥ 192 ng/ml) and laboratory glucose testing (cut-off ≤ 50 mg/dL) reached 92% specificity and 48% sensitivity, whereas either positive CEA (cut-off ≥ 20 ng/ml) or glucose testing (cut-off ≤ 50 mg/dL) showed 97% sensitivity and 50% specificity. Sensitivity and specificity were 80% and 68% for CEA ≥ 20 ng/mL versus 50% and 93% for CEA ≥ 192 ng/mL (the conventional cut-off level). Laboratory and glucometer glucose both reached 100% sensitivity and 60% and 45% specificity, respectively. None of the biomarkers and cut-offs reached a PPV exceeding 90%, whereas both glucose measurements had a NPV of 100% (i.e., high glucose excludes a mucinous cyst)., Conclusion: Combined CEA and glucose testing in PCF reached high specificity and sensitivity for differentiating mucinous from non-mucinous PCN. Glucose testing, whether alone or combined with the new CEA cut-off (≥ 20 ng/mL), reached > 95% sensitivity for mucinous cysts, whereas only glucose reached a NPV > 95%., (© 2023. The Author(s).)

Background: Although cyst fluid carcinoembryonic antigen (CEA; > 192 ng/ml) is the preferred test for identifying mucinous pancreatic cysts, the data are more robust for mucinous cystic neoplasms (MCN) than for intraductal papillary mucinous neoplasms (IPMN). The role of cyst fluid CEA as a marker for either malignancy or malignant progression is uncertain., Methods: All patients with pancreatic cysts who had undergone endoscopic ultrasound with cyst fluid CEA measurement between 2001 and 2009 were identified. Patient outcomes and pathology from operative resections were recorded., Results: Two hundred sixty-seven patients were identified; pathological diagnosis was obtained in 97. Mucinous cysts were identified in 66 of 97 (68%): benign IPMN, n = 42; malignant IPMN, n = 10; benign MCN, n = 12; malignant MCN, n = 2. CEA > 192 ng/mL had a sensitivity and specificity of 73% and 65% for identifying mucinous cysts; cyst fluid CEA was not associated with malignancy (p = 0.85). One hundred seventy-eight patients were managed with an initial non-operative strategy. Eight (4%) developed radiographic changes necessitating surgery; pathology demonstrated seven benign mucinous cysts and one retention cyst. CEA was not associated with radiographic progression (p = 0.37)., Conclusions: Cyst fluid CEA is a useful test for identifying mucinous cysts, including MCN and IPMN. In mucinous cysts, cyst fluid CEA is not associated with malignancy or radiographic progression.

Background: Among pancreatic cysts, mucinous cystadenoma, and intraductal papillary mucinous neoplasms have the potential for malignant transformation. Differentiation between benign and potentially malignant/malignant (PMM) cysts remains difficult. The purpose of this study was to: (1) identify the diagnostic value of endoscopic ultrasound findings, serum, and cyst fluid tumor markers (CA19-9 and CEA), (2) determine the rate of subsequent surgical resection in patients initially managed conservatively, and (3) determine the role of cyst fluid viscosity "string sign" in differentiating pancreatic cysts., Methods: Patients with cytologic or pathologic diagnosis for pancreatic cystic neoplasms were analyzed., Results: The study included 79 patients. Cyst fluid CEA had a median of 1.0 ng/mL in benign cysts and 471.1 ng/mL in PMM cysts (P < .0001). Cyst fluid CA 19-9 was not statistically significant (P = .22). Neither serum CA 19-9 nor CEA was useful (P = .68 and P = .31). Increased cyst fluid viscosity was associated with PMM cysts (P < .0001). Median string sign was 0 mm in benign cysts and 3.5 mm in PMM cysts. The presence of thick walls (5 of 5, 100%) or intracystic growth (6 of 6, 100%) were associated with PMM cysts. Of the 50 patients with PMM cysts, 19 were treated conservatively. In those patients followed for more than 6 months, 2 of 12 (16.7%) had surgical resection after a median of 29.5 months for worrisome changes on imaging., Conclusions: The presence of a thick cyst wall or intracystic growth, elevated cyst fluid CEA, and a long "string sign" were associated with PMM cysts. 16.7% of patients with a PMM cyst managed conservatively ultimately required surgical resection.

In clinical practice it is important to differentiate pseudocysts from cystic pancreatic tumors, especially potentially malignant mucinous cystic tumors. We investigated three new markers-tumor-associated trypsin inhibitor (TATI) and the free alpha and beta subunits of human choriogonadotropin (hCGalpha and hCGbeta, respectively)-in the cyst fluid of patients with cystic pancreatic lesions and compared the concentrations of these markers to those of carcinoembryonic antigen (CEA), CA 19-9, CA 242, CA 125, CA 15-3, alpha-fetoprotein, and tissue polypeptide antigen in order to distinguish benign cysts from malignant cysts. Between 1995 and 2001, a total of 34 patients operated on for cystic pancreatic lesions at Tampere University Hospital were included. Cyst fluid was aspirated at operation and stored at -70 C. The histologic diagnosis was pseudocyst in 23 patients, serous cystadenoma (SCA) in four patients, benign mucinous cystadenoma (MCA) in four patients, cystic papillary neoplasm (CPN) in one patient, glucagonoma in one patient, and malignant endocrine islet cell carcinoma (EC) in one patient. Significantly higher concentrations of TATI were found in patients with MCA and EC (2239 +/- 149 microg/L [mean +/- SEM]) than in patients with pseudocyst (55 +/- 29 microg/L; P=0.001) and in patients with SCA (36 +/- 23 microg/L; P=0.01). The patient with CPN and the patient with glucagonoma had relatively low levels of TATI (30.7 and 46.5 microg/L). Mean CEA was higher in patients with MCA compared to those with pseudocysts (19,993 +/- 9418 vs. 53 +/- 20 microg/L, P=0.002) and SCA (0.4 +/- 0.1 microg/L; P=0.02), but in the patient with malignant EC, the patient with CPN, and the patient with glucagonoma, CEA was normal. HCGalpha, hCGbeta, CA 19-9, CA 242, CA 125, CA 15-3, alpha fetoprotein, and tissue polypeptide antigen could not distinguish between MCA vs. pseudocyst or SCA, because both normal and elevated values were seen in all groups. To our knowledge, this is the first time that TATI has been quantitated in the cyst fluid of patients with cystic pancreatic lesions. It appears to be a potential marker in the differential diagnosis of benign from malignant cystic pancreatic lesions.