Cytology from Pancreatic Cysts Has Marginal Utility in Surgical Decision-Making

• Published in: Annals of surgical oncology 2008-11, Vol.15 (11), p.3187-3192
• Main Authors: Maker, Ajay V., Lee, Linda S., Raut, Chandrajit P., Clancy, Thomas E., Swanson, Richard S.
• Format: Article
• Language: English
• Subjects: Adenocarcinoma, Mucinous - diagnosis; Adenocarcinoma, Mucinous - surgery; Adenocarcinoma, Papillary - diagnosis; Adenocarcinoma, Papillary - surgery; Adult; Aged; Biopsy, Fine-Needle - methods; Carcinoma, Neuroendocrine - diagnosis; Carcinoma, Neuroendocrine - surgery; Cystadenoma, Mucinous - diagnosis; Cystadenoma, Mucinous - surgery; Cystadenoma, Papillary - diagnosis; Cystadenoma, Papillary - surgery; Decision Making; Diagnosis, Differential; Endosonography; Female; Hepatic and Pancreatic Tumors; Humans; Male; Medicine; Medicine & Public Health; Middle Aged; Neoplasm Staging; Oncology; Pancreatic Cyst - diagnostic imaging; Pancreatic Cyst - pathology; Pancreatic Cyst - surgery; Pancreatic Neoplasms - diagnosis; Pancreatic Neoplasms - surgery; Prognosis; Retrospective Studies; Sensitivity and Specificity; Surgery; Surgical Oncology
• ISSN: 1068-9265; 1534-4681
• DOI: 10.1245/s10434-008-0110-0

Background Preoperative diagnosis of pancreatic cystic neoplasms is problematic. We evaluated our experience with endoscopic ultrasound (EUS) to determine the utility of fine-needle aspiration cytology (FNAC) in surgical decision-making. Methods Patients evaluated for pancreatic cysts with EUS fine-needle aspiration (FNA) from 3/1996–10/2003 were included. Patients undergoing both preoperative EUS-FNA and pancreatic resection were identified. FNAC read as a mucinous cystic neoplasm (MCN), suspicious for neoplasia, or mucinous epithelial/atypical cells were classified as “concerning.” Cytology with no malignant cells was negative. FNAC read as indeterminate, atypical cells of undetermined significance, or possible contamination was nondiagnostic. Results Of 95 patients evaluated with EUS FNAC, 29 underwent resection. On final pathology, 7/29 lesions (24%) were malignant [two neuroendocrine tumors, three adenocarcinomas, one invasive intraductal papillary mucinous neoplasm (IPMN), and one metastatic uterine tumor], 4/29 (14%) were benign (three serous cystadenomas and one chronic pancreatitis), and 18/29 (62%) were premalignant (ten MCNs and eight IPMNs). Seven patients had concerning FNAC. All seven harbored malignant or premalignant lesions. Nine patients had negative FNAC: three (33%) with benign lesions and six (67%) with premalignant lesions. Thirteen of the 29 patients (45%) had nondiagnostic FNAC with 12/13 (92%) harboring a malignant or premalignant lesion. Sensitivity, specificity, positive predictive value, and negative predictive value were 28%, 100%, 100%, and 18%, respectively. Conclusion The decision to proceed with nonoperative management should not be based on a negative or nondiagnostic FNAC alone, as 67% of negative and 92% of nondiagnostic specimens were associated with malignant or premalignant pathology.