Pancreatic Cysts. Pancreatic Cysts. Multidisciplinary and Multimodal Approach To the Pre-Operative Diagnosis of Pancreatic Cysts

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1 Multidisciplinary and Multimodal Approach To the Pre-Operative Diagnosis of Pancreatic Cysts Martha Bishop Pitman, M.D. Director of Cytopathology Massachusetts General Hospital Professor of Pathology Harvard Medical School Boston, MA Pancreatic Cysts 1.2% of the general population 7-8% of the elderly 10% of pancreatic neoplasms Benign, premalignant and malignant Most patients are asymptomatic Management conundrum Accurate diagnosis requires a multidisciplinary and multimodal team approach Differential Diagnosis Pseudocyst Lymphoepithelial cyst Serous cyst Mucinous cyst (MCN and IPMN) Cystic degeneration of typically solid tumors PanNET SPN other Other more rare cysts Pancreatic Cysts radiologyassistant.nl 1

2 Management Options Surgical Distal pancreatectomy Middle pancreatectomy Pancreatoduodenectomy (Whipple) Medical Drain Ablate Observation Surgical procedures Whipple Middle pancreatectomy Distal pancreatectomy Other Frequency, (%) 368, (43.2%) 63, (7.4%) 373, (43.8%) 47, (5.5%) Complications (%) 40% 49.2% 36.4% 32.4% Pancreatic fistula 12.5% 35.5% 18.2% 8.8% Delayed gastric emptying Other major complication Median length of stay, days 6.5% 0% 0.3% 0% 12.9% 12.7% 12.6% 11.8% 8 days 6 days 6 days 8 days Operative mortality, n Outcomes MCN MD BD IPMN IPMN SCA CNET SPN n Malignant (%) 10.3% 33.7% 13.7% 0.0% 10.7% 0.0% Outcome 3-year survival (%) 94.0% 83.0% 88.0% 97.0% 98.0% 100.0% 5-year survival (%) 90.0% 78.0% 80.0% 90.0% 98.0% 100.0% 2

3 International Consensus Guidelines for Management of IPMN and MCN (Tanaka, et.al. Pancreatology. 2006; 6:17) The International Consensus Guidelines 2012 for the Management of IPMN and MCN of the Pancreas Tanaka M, Fernandez del-castillo C, Adsay V, Chari S, Falconi M, Jang J-Y, Levy P, Pitman MB, Schmidt MC, Shimizu M, Wolfgang CL, Yamaguchi K, Yamao K. Pancreatology, 2012 May-Jun;12(3): High Risk Stigmata Surgery if clinically feasible Obstructive jaundice in a patient with a cyst in the pancreatic head Enhancing solid component of the cyst Main pancreatic duct dilatation 10mm Worrisome Features EUS-FNA Cyst 3cm Thickened/enhancing cyst walls Main duct 5-9mm Non-enhancing mural nodule Abrupt change in MPD size with distal pancreatic atrophy EUS-FNA Susp/Pos cytology Surgery Current Recommendations Surgery-recommended MCN, all grades IPMN-HGD IPMN-invasive Cystic PanNET SPN Cystic Acinar Cell Ca. Cystic PDAC Surgery-optional PCT LEC SCA IPMN-LGD IPMN-IGD??. Cytology is a critical test in cyst classification for management. Decision to operate is based on surgical risk versus malignancy risk. 3

4 Pancreatic Cysts: CT unilocular Simple cysts PCT Benign imaging BD-IPMN w/ LGD MCN w/ LGD multilocular complex SCA BD-IPMN w/ LGD Benign to Worrisome imaging Small or non-enhancing MN: IPMN with HGD MCN w/ inv. Ca. IPMN w/ inv. Ca. SPN Worrisome to High-risk imaging cpannet Challenges in Cyst Characterization: Morphologic Overlap MCN Pseudocyst IPMN Cohen-Scali F et al. Radiolgy 2003 Khurana B et al. AJR 2003 Kim S et al. AJR 2006 Worrisome Imaging Cyst > 3cm Thickened/enhanced cyst walls MPD 5-9 mm Nonenhancing mural nodule Abrupt change in caliber of MPD with distal atrophy EUS Recommended (2012 guidelines) 4

5 Nonspecific EUS Imaging Broad differential diagnosis: Mucinous BD-IPMN MCN Nonmucinous Macrocystic SCA Lymphangioma Benign Malignant ( HGD) Small Cysts with Benign Imaging are not all low-grade Fritz S, Klauss M, Bergmann F, et al. Small (Sendai negative) branch-duct IPMNs: not harmless. Ann Surg. Aug 2012;256(2): Wong J, Weber J, B AC, et al. High-Grade Dysplasia and Adenocarcinoma Are Frequent in Side-Branch Intraductal Papillary Mucinous Neoplasm Measuring Less than 3 cm on Endoscopic Ultrasound. J Gastrointest Surg. Jan 2013;17(1): Pelaez-Luna M, Chari ST, Smyrk TC, et al. Do consensus indications for resection in branch duct intraductal papillary mucinous neoplasm predict malignancy? A study of 147 patients. Am J Gastroenterol. Aug 2007;102(8): Pitman, M. B., P. J. Michaels, et al. (2008). "Cytological and cyst fluid analysis of small 3 cm) branch duct intraductal papillary mucinous neoplasms adds value to patient management decisions." Pancreatology 8(3): Tang RS, Weinberg B, Dawson DW, et al. Evaluation of the guidelines for management of pancreatic branch-duct intraductal papillary mucinous neoplasm. Clin Gastroenterol Hepatol. Jul 2008;6(7): ; quiz 719. Woo SM, Ryu JK, Lee SH, Yoon WJ, Kim YT, Yoon YB. Branch duct intraductal papillary mucinous neoplasms in a retrospective series of 190 patients. Br J Surg. Apr 2009;96(4): EUS-guided FNA Technique of choice Controversial Not used in Japan and much of Korea Requires significant experience for quality aspiration and interpretation 5

6 FNA Only way to look inside the cyst Procures cyst fluid for analysis May produce sufficient cells for CB Requires training for both the endoscopist performing the FNA and the pathologist interpreting the sample EUS-FNA is safe Peritoneal Seeding in Intraductal Papillary Mucinous Neoplasm of the Pancreas Patients Who Underwent Endoscopic Ultrasound-Guided Fine- Needle Aspiration: The PIPE Study Yoon WJ, Dagilar ES, Fernandez-del Castillo C, Pitman MB, Brugge WR. Peritoneal Seeding in Intraductal Papillary Mucinous Neoplasm of the Pancreas Patients WHO Underwent Endoscopic Ultrasound-Guided Fine-Needle Aspiration; Results of the PIPE Study. Endoscopy. 2014;46(5):382-7 Table 1. Characteristics of patients with IPMN with pre-operative EUS-FNA (EUS-FNA Group) and patients with no pre-operative tissue sampling (No Sampling Group) EUS-FNA Group No Sampling Group p value Number of patients Sex (male : female) 32 : : * Age at surgery, y 68 (39 83) 66 (37 89) Follow-up period after 66.7 ( ) 58.6 ( ) surgery, mo Pancreatic head 38 (62.3) 41 (60.3) 0.816* involvement, no. (%) Main duct involvement, 28 (45.9) 37 (54.4) 0.334* no. (%) Invasive IPMN, no. (%) 11 (18.0) 19 (27.9) 0.184* Peritoneal seeding, no. 1 (1.6) 3 (4.4) (%) Quality FNA Quality specimen Specimen representative of the lesion Proper tissue triage and preparation Quality interpretation Knowledge of pancreatic pathology Experience of interpreter Team approach to diagnosis 6

7 Two basic questions for Cyst analysis 1) Is the cyst mucinous or non-mucinous? 2) Is the cyst low-grade or high-grade? Mucinous HGA IPMN with LGD GI duplication cyst Non-neoplastic Mucinous cyst IPMN/MCN with HGD IPMN/MCN with Invasive carcinoma Cystic PDAC Cystic PanNET Cystic Acinar Cell carcinoma SPN IPMN with IGD PCT LEC SCA MCN with LGD Surgery No-ROSE Cysts Direct smears If fluid thick enough Fresh undiluted cyst fluid CEA; Amylase Molecular Cytology Cytospin Cellblock Cytological Preparations 7

8 Pancreatic Cyst Fluid Triage CEA by cyst fluid analysis ng/ml 10 1 Serous Inflammatory Mucinous Borderline Malignant athology CFA cut-off levels lab and study dependent (van der Waaij, et. al. Cystfluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointes Endosc. 2005; 62:383) CEA >800ng/ml CEA <5ng/ml Amylase <250 U/L Neoplastic mucinous cysts Serous cystadenoma Pseudocyst Not a pseudocyst 8

9 CEA and Amylase: Key Points Elevated CEA ( 192 ng/ml) supports a mucinous cyst Does not distinguish IPMN from MCN Level does not correlate with malignancy Rare FP: PCT, GI duplication cyst, LEC Amylase levels Elevated in the 1000 s for most PCT Low amylase level tends to exclude a PCT Level does not distinguish IPMN from MCN Molecular Tests KRAS Mutation(s) support a neoplastic mucinous cyst Does not distinguish IPMN and MCN Does not correlate with grade GNAS Mutation supports IPMN over MCN Does not correlate with grade RNF43 Mutation supports a mucinous cyst Does not distinguish IPMN and MCN 3p deletions 3p25, VHL gene, supports SCA Other 3p deletions also noted in SCA CTNNB1 (beta-catenin) deletion Mutation(s) support SPN TP53, CDKN2A loss SMAD4 loss support a HR cyst Impact of Next-Generation Sequencing on the Clinical Impression of Pancreatic Cysts Martin Jones, MBBS 1*, Zongli Zheng, MD, PhD 1*, Jessica Wang, MD 1, Emily Albanese 1, Abdurrahman Kadayifci, MD 2, Dora Dias- Santagata, PhD 1, Long Le, MD 1, William R. Brugge, MD 2, Carlos Fernandez-del Castillo, MD 3, Mari Mino-Kenudson 1, MD, A. John Iafrate, MD, PhD 1^, and Martha Pitman, MD 1^ States *Co-first authors ^Co-senior authors Gastrointest Endosc Jan; 83(1): Massachusetts General Hospital, Department of Pathology, Boston, MA, United States 2 Massachusetts General Hospital, Department of Medicine, Boston, MA, United States 3 Massachusetts General Hospital, Department of Surgery, Boston, MA, United NGS supported the imaging impression in 78% but changed it in 12% NGS defined a cyst as mucinous in 48% of cysts with a non-elevated CEA KRAS and/or GNAS mutations supported a diagnosis of IPMN in 71% of cases without an elevated CEA KRAS mutation reclassified 19% of cysts nonneoplastic by imaging and with low CEA 9

10 Cytology Interpretation Multimodal Approach Clinical Information Patient age and gender Symptoms Past medical history Radiological Information Location of mass in the pancreas (and thus organ traversed for EUS) Mass characteristics Solid or cystic» Size, contours, invasion» Cyst structure: uni- or multilocular; thick/thin wall, Ca++, nodule/mass in the wall» Gross cyst contents: thick, viscous, thin, water, clear, brown Ancillary tests: CEA, amylase, molecular analysis Communication within the Care Team is Critical to Success EUS-FNA Requisition Form 10

11 Recommended Standardized Reporting Terminology Nondiagnostic Negative AP, CP, AIP, LEC, PCT, Splenule Atypical Suspicious Neoplastic Benign: SCA Other: MCN, IPMN, PanNET SPN Positive/Malignant PDAC, ACC, PBL, lymphomas, metastases Pitman MB, Centeno BA. Ali SZ, Genevay M, Stelow E, Mino-Kenudson M, Fernandez-del Castillo C, Schmidt CM, Brugge WR, and Layfield L. Standardized Terminology and Nomenclature for Pancreatobiliary Cytology: The Papanicolaou Society of Cytopathology Guidelines for Pancreatobiliary Cytology. Diagn Cytopathol, 2014.; 42(4): Complex Cysts (solid and cystic) High-Risk Imaging Secondarily Cystic Solid Neoplasms: SPN Clinical Rare but may represent up to 6% of all pancreatic neoplasms and 24% of resected cysts 89% in young women, mean age ~ 28 years 1/3 in head, 1/3 in body and 1/3 in tail Radiology shows large solid and cystic neoplasm Image: AFIP Pancreas fascicle

12 Classic Cytology SPN Papillary branching Myxoid stroma Clinging cells and single cells Euchromatin Oval, indented, grooved nuclei Perinuclear vacuoles/globules Cytohistology: CB SPN Beta-catenin Secondarily Cystic Solid Neoplasms: cpannet 12

13 Cystic PanNETs ~10% of PanNETS Half are completely cystic and half are solid and cystic Most are nonfunctioning If clinically suspected, serum chromogranin A (CgA) levels may support the diagnosis when elevated (sensitivity ~70%) False positive CgA levels have been reported in patients taking proton pump inhibitors, renal or liver failure and untreated hypertension. Elevated serum pancreatic polypeptide increases sensitivity to 93% Imaging Features Thick cyst wall is a clue Pseudocysts also have a thick wall, but almost all of these patients have a history of pancreatitis MCN have a thick wall, but these cysts are septated and almost all are in women SPN are solid and cystic, but these tumors are almost always in young women IPMNs and MCNs can be solid and cystic when malignant Cystic Pancreatic Neuroendocrine Tumors: The Value of Cytology in Pre-Operative Diagnosis Vicente Morales-Oyarvide MD, Won Jae Yoon, MD2, Thun Ingkakul MD, David G Forcione MD, Brenna Casey, MD, William R Brugge MD, Carlos Fernández-del Castillo MD, and Martha B Pitman MD Cancer Cytopathology. 2014; 122: TABLE 2. Accuracy of Cytology and EUS for the Diagnosis of Cystic Pancreatic Neuroendocrine T N Diagnostic Suspicious HR Benign or indeterminate Cytology 35 71% 77% 86% 5% EUS 34 38% 47% 56% 15% Key: EUS, endoscopic ultrasound; HR, high-risk 13

14 Cystic pancreatic neuroendocrine tumors: endoscopic ultrasound and fine-needle aspiration characteristics. Yoon WJ, Daglilar ES, Pitman MB, Brugge WR. Endoscopy. 2013;45(3): Table 3. Comparison of CPanNet patients and mucinous cyst patients CPanNet (n=15) * Mucinous cyst (n=15) P value Sex (male : female) 9 : 6 9 : Age, y, median (range) 57 (34 80) 57 (33 79) Cyst diameter, mm, 29 (16 70) 23 (8 90) median (range) Wall thickness (thick : 10 : 5 2 : thin) Septation (yes :no) 6 : 9 9 : Associated mass lesions 8 : 7 4 : (yes : no) Cyst fluid CEA level, 1.1 ( ) 400 ( ) <0.001 ng/ml, median (range) Diagnostic cytology 11 (73.3) # 3 (20.0) ** (n, %) Imaging Nonspecific Thick cyst wall Solid and cystic Cytology is THE diagnostic test CEA low Amylase low KRAS/GNAS negative Cells usually diagnostic when present Cystic Pancreatic Neuroendocrine Tumors: The Value of Cytology in Pre-Operative Diagnosis Vicente Morales-Oyarvide MD 1, Won Jae Yoon, MD 2, Thun Ingkakul MD 1, David G Forcione MD 3, Brenna Casey, MD 3, William R Brugge MD 3, Carlos Fernández-del Castillo MD 1, Martha B Pitman MD 4 Cancer Cytopathology, 2014; 122: Cystic PanNETS PanNET Cytohistology: CB cpannet Synaptophysin 14

15 Grading GEP NETs (WHO, ENETS) GRADE MITOSES KI-67 1 < 2 AND <3% OR 3-20% 3 >20 OR >20% Tumor Tumor Carcinoma Korean Journal of Pathology 2013; 47(3): Multilocular Cyst Serous Cystadenoma Clinical Benign, slow growing neoplasm women>>men, mean age 7 th decade Associated with VHL with deletion of 3p25 in most cases Often asymptomatic, but can hemorrhage and cause pain Radiology circumscribed, multi-lobulated Microcystic with fibrous septae, central scar, calcifications in ~30-40% Histology glycogen-rich dpas+ cuboidal epithelium 15

16 Serous Cystadenoma: Variants Unilocular and Macrocystic SCA Cuboidal non-mucinous epithelial cells Hemosiderin-laden macrophages in a clean or bloody, nonpseudocyst like background CEA and amylase low NO KRAS/GNAS 3p deletions support diagnosis Serous Cystadenoma 16

17 Cytohistology: CB SCA PAS/D Neoplastic Mucinous Cysts MCN IPMN Non-Complex Cyst 17

18 Clinical Associated with pancreatitis, trauma, surgery (almost always) Radiology Unilocular, nonseptated Thick walled No mural nodule Histology Cyst lining of histiocytes and inflammatory cells Pancreatic Pseudocyst Pancreatic Pseudocyst cytology cytospin smear cyst debris with blood, proteinaceous material and yellow hematoidin-like pigment variable inflammation NO cyst lining epithelium (beware of contamination, mucin and epithelium) CEA low; amylase usually in the 1000 s; no KRAS or GNAS Mucinous Cystic Neoplasm Clinical F:M=20:1 Most are benign Prognosis excellent for noninvasive completely resected tumors Resection recommended despite grade Radiology body and tail (90%) do not communicate with the pancreatic ductal system thick walled (Ca++ in 20%) thin or thick septa 18

19 Mucinous Cystic Neoplasm Not associated with the pancreatic ducts Lined by mucinous, generally non-papillary epithelium Subepithelial ovarian-like stroma required Atypia may be very heterogeneous; invasion may be very focal, so the entire cyst should be submitted for histology Mucinous Cystic Neoplasm is not an Aggressive Entity (Crippa, et.al. Annals of Surgery 2008; 247: Collaborative study between MGH and University of Verona 163 patients with MCN, strictly defined Non-invasive Invasive Mucinous Cystic Neoplasm LGD Difficult to distinguish from IPMN on cytology alone Ovarian-type stroma typically not seen Cyst lining denudation produces cyst aspirate resembling PCT CEA Amylase KRAS +/GNAS- INV 19

20 Intraductal Papillary Mucinuos Neoplasm Intra-ductal Branch duct IPMN Combined disease IPMN Main duct type Diagnosed clinically Dilated main pancreatic duct (definition varies, but >5mm) Pancreatic head mostly, but occur all through the pancreas Intestinal type lining most common 60% have HGD 45% have invasive carcinoma Symptoms common but 25% asymptomatic Treatment-resection AFIP 4 th Series Fascicle Branch Duct Type Most often in head/uncinate 1/3 with multiple cysts Supports clinical dx Most patients asymptomatic Imaging: bunch of grapes ; single cyst may not be diagnostic for BD-IPMN unless visualized connection to the MPD Most lined by gastric type epithelium Most low grade Treatment-depends. IPMN AFIP 4 th Series Fascicle 20

21 IPMN Variously papillary mucinous epithelium of variable cell type and heterogenous atypia No association with ovarian-like stroma under the epithelium AFIP 4 th Series Fascicle Gastric (null) Type Cells: Most BD-IPMN MUC 5AC+, MUC 6+, MUC1-, MUC2-, Usually LGD CDX2- AFIP 4 th Series Fascicle Intestinal Type Cells: Most Main Duct-IPMN MUC 5AC+, MUC 6 weak, MUC1-, Moderate/Intermediate-grade dysplasia MUC2+, CDX2+ AFIP 4 th Series Fascicle 21

22 Pancreatobiliary Type: Less common type High grade dysplasia MUC 5AC+, MUC 6 focal, MUC1+, MUC2-, CDX2- Shi and Hruban. Human Pathol 2011.epub 20 July 2011 Oncocytic Type: Uncommon type High grade dysplasia MUC 5AC goblet cells+, MUC1-, MUC2 goblet cells+, MUC 6 +, CDX2- AFIP 4 th Series Fascicle Intraductal Papillary Mucinous Neoplasm of the Pancreas: Cytologic Analysis and Correlation with Histologic Grade PJ Michaels, EF Brachtel, BC Bounds, WR Brugge, and MB Pitman (Cancer Cytopathol 2006; 108: ) Low grade dysplasia Moderate dysplasia HGD/Carcinoma 22

23 Two basic questions for Cyst analysis 1) Is the cyst mucinous or non-mucinous? 1) Gross examination 2) CEA (best test) 3) Cytology 4) Molecular mutations 2) Is the cyst low-grade or high-grade? 1) Cytology!! Gross Cyst Fluid Mucinous cyst fluid Non-mucinous cyst fluid Acellular thick, colloid-like mucin is NOT non-diagnostic! 23

24 Mucin with LBC processing Mucinous Epithelium Ancillary Tests for Mucinous Etiology CEA 192 ng/ml Genetic mutations KRAS (IPMN or MCN) GNAS (IPMN) 24

25 Two basic questions for Cyst analysis 1) Is the cyst mucinous or non-mucinous? 1) Gross examination 2) CEA (best test) 3) Cytology 2) Is the cyst low-grade or high-grade? 1) Cytology!! Diagnostic Morphology of Carcinoma Already invasive- prognosis decreases ~50% Ideal World- Recognize HGD with accuracy 25

26 Atypical Epithelial Cells Morphological Overlap with AEC Histologically Confirmed LGD-IGD Grading Epithelial Atypia in EUS-FNA of Intraductal Papillary Mucinous Neoplasms: An international interobserver concordance study Martha B Pitman MD 1, Barbara A Centeno MD 2, Muriel Genevay MD 3, Ricardo Fonseca, MD 4 and Mari Mino-Kenudson MD 1. Cancer Cytopathology 2013;121(12): Table 3. Kappa Coefficient for Two-Tiered Cytological Grading of Branch-Duct IPMN Cyst Fluids Grade Four Reviewers Randolph's Multirater Kappa Two Reviewers* Cohen's Kappa 0-2, % % , % % 0.71 * Two most experienced reviewers 26

27 1. de Jong K et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol. 2010;8: de Oliveira PB et al. Prevalence of incidental pancreatic cysts on 3 tesla magnetic resonance. PLoS One. 2015;10:e Ketwaroo GA, Mortele KJ, Sawhney MS. Pancreatic Cystic Neoplasms: An Update. Gastroenterol Clin North Am. 2016;45: Cytological Criteria of High-Grade Epithelial Atypia in the Cyst Fluid of Pancreatic Intraductal Papillary Mucinous Neoplasms Martha B. Pitman, MD, Barbara A. Centeno, MD, Ebubekir S. Daglilar, MD, William R. Brugge, MD, and Mari Mino-Kenudson, MD Cancer Cytopathology 2014;122(1): Reference duodenal enterocyte Low-grade High-grade HGA is most accurately identified in mucinous cyst fluids by: 1. an increased N/C ratio, 2. an abnormal chromatin pattern 3. background necrosis Risk of Malignancy in Pancreatic Cysts with High-Grade Atypical Cytology Raza S Hoda 1, Ronald Arpin 1, Matthew W Rosenbaum 1 and Martha B Pitman 1 1 Department of Pathology, Massachusetts General Hospital, Boston, MA, United States BACKGROUND The incidence of pancreatic cysts is rising, with the increasing use of high-resolution imaging techniques. Reported incidences on imaging studies of asymptomatic patients range from <1% to 24%. 1-3 This group of cysts is comprised of a variety of entities, ranging from pseudocysts to invasive adenocarcinomas. Intraductal papillary mucinous neoplasms (IPMNs) may present as such and demonstrate a variable disease course, depending on its histologic appearance. Given the rising incidence of these lesions and varied natural histories, accurate diagnosis though endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of pancreatic cyst fluid (PCF) can help guide management. OBJECTIVES Cytologic criteria for highgrade atypia (HGA) of IPMNs were recently reported by the Papanicolaou Society of Cytopathology (see Table 1). Our aims include: Evaluation of the risk of malignancy in PCF cytology with HGA Evaluation of the overall ability of PCF cytology to predict high-risk or malignant cysts Table 1. Cytologic criteria for HGA for IPMN 4 Abnormal chromatin pattern Increased nuclear:cytoplasmic ratio Background cellular necrosis Nuclear membrane irregularities Small cell size compared to 12µ enterocyte METHODS All patients who underwent EUS-FNA for a pancreatic cyst at Massachusetts General Hospital from June 2015 to July 2016 were evaluated. Clinical data, cytologic diagnoses and surgical outcomes were documented. High-risk imaging characteristics included an enhanced solid component, main pancreatic duct dilatation 1cm, and a cystic lesion in the head of the pancreas in a patient with obstructive jaundice. Worrisome imaging features were cysts 3cm in size, main pancreatic duct size of 5-9mm, abrupt change in the main pancreatic duct caliber with distal pancreatic atrophy, enhanced, thickened cyst wall, non-enhanced mural nodule, and lymphadenopathy. High-risk cytologic findings included an IPMN with HGA, neuroendocrine tumors (NET), and adenocarcinoma. Malignant histologic features included mucinous cysts with high-grade dysplasia (HGD), NET, and adenocarcinoma. The risk of malignancy was determined by the histologic outcomes. Figure 1. Radiologic and cytologic findings of high-grade atypia. RESULTS 90 PCFs from 80 patients were evaluated. Our patients were 54% women and ranged from 20 to 91 years old (mean = 66). 14 patients had follow-up histology (see Table 2). 10 PCFs (11%) had high-risk cytology, of which 9 had followup histology. The absence of HGA or worse was noted in 80 PCF samples from 70 patients, of which 5 had followup histology, all with no malignant features. One patient was thought to have a low-risk cyst by radiology, which was later found to be harboring adenocarcinoma. High-risk cytology was 100% sensitive and 83% specific for malignancy. All cysts with HGA were resected with one falsepositive of an IPMN with intermediategrade dysplasia (IGD). The risk of malignancy with HGA cytology was 89%. Table 2. Pancreatic Cysts with Histologic Followup. Imaging Cytologic Histologic Diagnosis Classification Diagnosis High Risk Adenocarcinoma Adenocarcinoma Worrisome Adenocarcinoma Adenocarcinoma Worrisome Adenocarcinoma Adenocarcinoma Worrisome MC with HGA Adenocarcinoma Low Risk IPMN with HGA Adenocarcinoma Worrisome NET NET High Risk IPMN with HGA IPMN with HGD High Risk IPMN with HGA IPMN with HGD Worrisome MC with HGA IPMN with IGD Worrisome MC without HGA IPMN with IGD Worrisome MC without HGA IPMN with LGD Worrisome Non-mucinous cyst MCN, denuded Worrisome Serous cystadenoma Serous cystadenoma Worrisome Non-mucinous cyst Endometriotic cyst Abbreviations: HGD, high-grade dysplasia; IGD, intermediate-grade dysplasia; LGD, low-grade dysplasia; MC, mucinous cyst; MCN, mucinous cystic neoplasm CONCLUSIONS High-risk cytology is both sensitive and specific for identifying malignant pancreatic cysts High grade atypia on PCF cytology is associated with a high risk of malignancy (89%) REFERENCES Benign/Low Grade Glandular Epithelium High-Grade Atypical Epithelial Cells in Pancreatic Mucinous Cysts are a More Accurate Predictor of Malignancy than Positive Cytology Martha Bishop Pitman M.D, et.al. (Cancer Cytopath 2010) 27

28 High Grade Atypical Glandular Epithelium High-Grade Atypical Epithelial Cells in Pancreatic Mucinous Cysts are a More Accurate Predictor of Malignancy than Positive Cytology Martha Bishop Pitman M.D, et.al. ( Cancer Cytopath 2010) Cytohistology: CB IPMN-HGA IPMN-LGA Ancillary Tests: IPMN/MCN IHC insufficiently specific to be diagnostic of grade in premalignant cysts SMAD4 may be helpful for dx of PDACloss of nuclear staining 28

29 Moray Micro-forceps biopsy Platform Presentation Moray TM Micro Forceps Biopsy Improves the Diagnosis of Specific Pancreatic Cysts M. Lisa Zhang, Ronald N. Arpin, William R. Brugge, David Forcione, Osman Yuksel, Omer Basar, Martha B. Pitman MGH, Harvard Medical School [in press, Cancer Cytopathology] 19 gauge needle Comparison of Pancreatic Cyst Fluid Analysis and Moray TM Micro Forceps Biopsy for the Diagnosis of Mucinous Cysts PCF (%) MFB (%) P Diagnostic Yield 35 (72.9) 36 (75.0) Mucinous Diagnosis 29 (61.8) 28 (58.8) High-risk Detection 3 (6.3) 2 (4.2) Specific Diagnosis 9 (18.8) 24 (50.0) <0.001 Cytology 26 (89.7) Extracellular mucin 13 (44.8) Mucinous epithelium 20 (69.0) Both 8 (27.6) CEA > 192 ng/ml 13 (44.8) Molecular 19 (65.5) (KRAS/GNAS) Mucinous Nonmucinous P 29

30 Specific Cysts Diagnosed by Pancreatic Cyst Fluid Analysis and Moray TM Micro Forceps Biopsy # Cases (%) PCF IPMN with low-grade atypia 6 (12.5) 1 (LGA) Adenocarcinoma 1 (2.1) 2 Serous cystadenoma 2 (4.2) 3 MFB IPMN with low-grade dysplasia 18 (37.5) (LGD) Mucinous cystic neoplasm 1 (2.1) Adenocarcinoma 1 (2.1) Serous cystadenoma 3 (6.3) Acinar cell cystadenoma 1 (2.1) 1 All cases diagnosed by GNAS mutation (IPMN) and cytology (LGA). 2 Diagnosed by cytology alone. 3 One case diagnosed by cytology alone and one case diagnosed by 3p25 mutation. IPMN-LGD MCN-LGD SCA IPMN-invasive carcinoma Nonmucinous epithelial cells with prominent nucleoli in acinar cell cystadenoma, Pap stain, 60x Chen AL et al. Diagn Cytopathol Acinar cell cystadenoma, H&E, 40x Acinar cell cystadenoma, Trypsin, 40x 30

31 PCF Analysis and Histology discordance SCA by PCF Fibrous tissue only by MFB NGS 3p25 deletion HGA by PCF Low-grade mucinous epithelium in CF patient-? Neoplasia vs. obstruction NGS KRAS and GNAS mutation Example Case 65 year old female with incidental pancreatic cyst Low-risk Sendai negative High-grade epithelial atypia CEA 357 ng/ml Amylase 11,203 U/L NGS pending Neoplastic:Other Mucinous cyst with HGA consistent with BD-IPMN with at least HGD Histology follow-up IPMN with HGD 31

32 Acknowledgements Dr. Carlos Fernandez-del Castillo Dr. Dushyant Sahani Dr. Bill Brugge Dr. Mari Mino-Kenudson Dr. Ralph Hruban Dr. David Klimstra Dr. Lester Layfield 32