Original article
Clinical endoscopy
Performance characteristics of molecular (DNA) analysis for the diagnosis of mucinous pancreatic cysts

https://doi.org/10.1016/j.gie.2013.05.026Get rights and content

Background

Diagnosis of mucinous pancreatic cysts (MPCs) is challenging due to the poor sensitivity of cytology provided by EUS-guided-FNA (EUS-FNA).

Objective

To quantify the test characteristics of molecular (DNA) analysis in suspected low-risk MPCs.

Design

A prospective cohort study performed in between 2008 and 2011.

Setting

Academic referral center.

Patients

Consecutive patients who underwent EUS-FNA of suspected MPCs.

Intervention

EUS-FNA and molecular (DNA) analysis of cyst fluid.

Main Outcome Measurements

The sensitivity and specificity of molecular analysis in the diagnosis of MPCs using the criterion standard of surgical pathology in resected cysts.

Results

Patients with suspected MPCs underwent EUS-FNA and cyst fluid DNA analysis. Surgical resection was performed in 48 patients (17%), confirming a mucinous pathology in 38 (79%). In this group, molecular analysis had a sensitivity of 50% and a specificity of 80% in identifying MPCs (accuracy of 56.3%). The combination of molecular analysis with cyst fluid carcinoembryonic antigen (CEA) and cytology resulted in higher MPC diagnostic performance than either one of its individual components, with a sensitivity, specificity, and accuracy of 73.7%, 70%, and 72.9%, respectively. There was no significant difference in accuracy between molecular analysis and CEA/cytology in this group.

Limitations

Single-center experience.

Conclusion

Molecular analysis aids in the diagnosis of MPCs when cytology is nondiagnostic or cyst fluid is insufficient for CEA or its level is indeterminate. Our results do not support the routine use of molecular analysis, which should be used selectively after review of imaging findings and cyst fluid studies. Further studies are needed to assess DNA's performance in malignant cysts.

Section snippets

Methods

This prospective cohort study was approved by the Indiana University Health Institutional Review Board. All authors had access to the study data and had reviewed and approved the final manuscript. Consecutive patients referred for EUS-FNA of pancreatic cysts were enrolled.

EUS-FNA

The following EUS findings were documented: the location of pancreatic cysts and the number, size, morphology (septations, mural nodules, associated mass), and main pancreatic duct features. EUS-FNA was performed by using a 19-, 22-, or 25-gauge needle (Echotip; Cook Medical, Winston-Salem, NC). Cysts were aspirated until collapse whenever possible. Intravenous antibiotics were given after EUS followed by a 3- to 5-day course of oral antibiotics. Cyst fluid was sent for cytologic examination,

Results

Between April 2008 and October 2011, 453 consecutive patients referred to our institution for EUS-FNA of pancreatic cysts evident on cross-sectional imaging were prospectively enrolled. There were 167 excluded after informed consent was obtained (Fig. 1). Our study population comprised 286 patients (190 females, 67%) with mean age of 64.1 years (±13.9). The baseline demographic, clinical, and imaging characteristics of patients included in the study are shown in Table 1. Surgical pathology was

Discussion

Accurate identification of MPCs is important because of their malignant potential and the need to consider surgery in high malignancy risk cysts or periodic imaging surveillance in low-risk ones. The consensus statement for the management of IPMNs initially published in 2006 and updated recently identified select groups of patients with high-risk features associated with malignant progression.15, 17 These guidelines advocated resection of all IPMNs with main duct involvement, in addition to

Acknowledgments

The authors acknowledge the efforts of Dr Ihab El Hajj in data collection.

References (30)

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DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: Dr DeWitt receives research support from RedPath Integrated Pathology; Dr Schmidt is a speaker and consultant for RedPath Integrated Pathology. All other authors disclosed no financial relationships relevant to this publication. Dr Al-Haddad (PI, 2008-2010)is the recipient of an American Society for Gastrointestinal Endoscopy (ASGE) Career Development Award.

If you would like to chat with an author of this article, you may contact Dr Al-Haddad at [email protected].

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