Pancreatic Cyst Fluid Cytology and Carcinoembryonic Antigen (CEA) Level Obtained by Endoscopic Ultrasound Guided- Fine Needle Aspiration: Which Is Better at Identifying High Grade Dysplasia/Invasion in Intraductal Papillary Mucinous Neoplasms?
Jarret House, Jason Klapman, Marino Leon, Mokenge Malafa, Jill Weber, Barbara A Centeno. University of South Florida, Tampa, FL; Moffitt Cancer Center, Tampa, FL
Background: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is routinely used at the Moffitt Cancer Center to sample suspected pancreatic intraductal papillary mucinous neoplasms (IPMNs) in order to guide surgical management. Previously, we demonstrated that cyst fluid CEA level is not a reliable predictor of IPMN grade of dysplasia. Here, we evaluated the EUS-FNA cytological diagnoses in the same population to determine if cytology is more effective at identifying malignant IPMN.
Design: Using an IRB-approved comprehensive IPMN cancer database we selected all patients who had previously undergone EUS-FNA of the cystic mass with cyst fluid CEA measurement and cytology. IPMNs were classified into low grade dysplasia (LG), moderate dysplasia (MD), high grade dysplasia (HG) or invasive carcinoma (INV). The cytology reports were prospectively reviewed, and each cytology specimen characterized as malignant (HG or INV) or nonmalignant (LG or MD). One-way ANOVA was performed to examine the difference in CEA levels among pathologic groups. The cytology results were correlated with the histology to calculate sensitivity, specificity, and positive (PPV) and negative predictive values (NPV).
Results: We identified 50 patients (22 males, 28 females). There were 9 LG, 19 MD, 15 HG and 7 INV. The fluid CEA levels and corresponding histological diagnoses are summarized in Table 1. No statistically significant difference was found in CEA levels among diagnoses (p=0.62). Cytology identified 6 of 7 INV as malignant (3 INV and 3 HG), and 3 of 15 HG as malignant (3 HG). 1 INV had indeterminate results. None of the 28 IPMN with LG or MD were classified as malignant. Using this two-tiered system, the sensitivity, specificity, PPV and NPV for the cytological detection of malignant IPMN were 45.5%, 100%, 100% and 70%, respectively. The sensitivity for the detection of INV alone was 85.7%.
Conclusions: Cyst fluid cytology more accurately predicts malignant IPMN than CEA level and has high specificity. Our data demonstrate that a pre-operative cytological diagnosis of malignant IPMN (HG or INV) reliably correlates with the final histological diagnosis.
|Histological Diagnosis||CEA ranges (ng/ml||Mean CEA, ng /ml||Median CEA, ng/ml|
|MD (N=19)||7.6- 90,100||6433.6||201|
|HG (N=15)||47.2- 136,441||12264||373.9|
|INV (N=7)||140- 1866||462.57||200|