Video Microscopy Tutorial 19 EUS FNA of Pancreatic Cysts Martha Pitman, MD There are no disclosures necessary.
EUS-FNA of Pancreatic Cysts Martha Bishop Pitman, M.D. Massachusetts General Hospital Harvard Medical School
Course Objectives Define the subclassification of the cystic lesions of the pancreas. Recognize the pitfalls to diagnosis introduced by the EUS-guided biopsy technique. Identify the cytological criteria for the diagnosis of most cystic lesions of the pancreas. Understand the benefits and limitations of ancillary tests such as mucin stains, cyst fluid analysis and molecular analysis in the cytological evaluation of pancreatic cysts.
Cystic Mass lesions of the Pancreas (WHO Classification 2010) Pseudocyst Serous cystadenoma Lymphoepithelial cyst Premalignant Lesions PanIN-3 Intraductal papillary mucinous neoplasm with low to intermediate grade dysplasia Intraductal papillary mucinous neoplasm with high grade dysplasia Mucinous cystic neoplasm with low to intermediate grade dysplasia Mucinous cystic neoplasm with high grade dysplasia Malignant Intraductal papillary mucinous neoplasm with invasive carcinoma Mucinous cystic neoplasm with invasive carcinoma
Normal Pancreas Ductal Cells
Gastrointestinal Contamination Duodenum Stomach
Multimodal Approach required for diagnosis of pancreatic cysts Clinical presentation EUS features Gross appearance of cyst fluid Cytology Special stains for mucin Cyst fluid analysis Molecular analysis
Multimodal Approach required for diagnosis of pancreatic cysts Clinical presentation Patient age and gender Alcoholism Pancreatitis Trauma Jaundice Asymptomatic
Multimodal Approach required for diagnosis of pancreatic cysts EUS features Location Number and size of cysts Main duct dilatation Connectivity to the main duct Septations Cyst wall thickness Mural nodule Invasion of peripancreatic structures
Multimodal Approach required for diagnosis of pancreatic cysts Gross appearance of cyst fluid Cyst volume aspirated Watery Clear or colored Bloody Mucoid-thick and viscous or thin
Multimodal Approach required for diagnosis of pancreatic cysts Cytology Extracellular mucin-quality and quantity Epithelial cells Uniform and cuboidal; finely vacuolated Columnar and glandular Mucinous Atypical GI contamination Background elements (other than mucin) Inflammation and histiocytes Cellular necrosis
Pancreas Cyst Fluid Triage Protocol Sept. 1, 2011 All, fresh to molecular lab Warren 5 by endoscopist ~0.3cc KRAS (fresh) <0.5cc or EUS Requisition form with detailed information and all requests marked CEA (fresh) ~0.3cc ~0.3cc All, fresh to cytology lab Warren 113 0.5 cc supernatant ~0.3cc ~volumes required vortex &/or Centrifuge residual 0.3cc ~0.3cc cells Warren 5 KRAS (clinical) Warren 5 1. CEA 2. Amylase 3. Molecular (research) Cytospin Core lab Gray 5 Core lab Gray 5 Warren 5 Cytologist 11
Two basic questions for Cyst analysis 1) Is the cyst mucinous or non mucinous? 2) Is the cyst benign or malignant? MASSACHUSETTS GENERAL PHYSICIANS ORGANIZATION HARVARD 12 MEDICAL SCHOOL
Pancreatic Cyst Fluid Analysis Biochemical CEA Amylase Molecular KRAS, GNAS Cytological MASSACHUSETTS GENERAL PHYSICIANS ORGANIZATION HARVARD 13 MEDICAL SCHOOL
Cytological Analysis of Cyst Fluid Challenges Scant fluid Low to no cellularity GI contamination Lack of experience with these types of specimens
GI contamination in EUS FNAB Duodenum Stomach
Mucin Stains Alcian Blue Mucicarmine
Atypical Epithelial Cells Significant
Amylase Levels High levels should be seen in Pseudocysts Low levels should be seen in Serous cysts LEC Variable levels in IPMN MCN
CEA by cyst fluid analysis 1000000 100000 10000 1000 100 >~200 ng/ml 10 1 Serous Inflammatory Mucinous Borderline Malignant thology 200ng/ml 19
Molecular Analysis Controversial for accurate diagnosis of cyst type and grade Studies have looked at KRAS and LOH mutations as well as DNA quality and quantity in cyst fluid to Differentiate non-mucinous from mucinous Benign from malignant
Molecular Tests KRAS Mutations support mucinous etiology GNAS Mutations present in ~60% IPMN but not MCN Sci Transl Med 20 July 2011 ** KRAS and GNAS mutations do not predict malignancy
Case 1 A 42 year old alcoholic male with abdominal pain is found to have a 3cm pancreatic cyst. An FNA is performed and 3 cc's of thin brown fluid is sent fresh to the lab where 4 cytospins are made: 2 for Papanicolaou stain and 2 for mucins stains (Alcian blue ph 2.5 and mucicarmine). 1 cc of fresh aspirate is sent to the chemistry lab for amylase and CEA analysis.
Case 1: EUS Report EUS shows a unilocular thin walled cyst in the pancreatic head without septations. No mural mass is noted.
Case 1
Case 1
Case 1: Cyst Fluid Analysis Amylase = 153,000 U/L CEA = 0.5 ng/ml.
Case 1 Cytology Diagnosis: Cyst debris consistent with pseudocyst Histology Diagnosis: Pseudocyst
Case 2 A 59 year old alcoholic male with a history of pancreatitis presents with abdominal pain and is found to have a 3cm cyst in the pancreatic tail. Aspiration is productive of 1cc of thick fluid; a direct smear is made and the remaining fluid submitted for cyst fluid analysis.
Case 2: EUS Report A 3cm thin walled unilocular cyst in the pancreatic tail is seen. No mural mass is noted. The main pancreatic duct is normal. The cyst is collapsed by aspiration.
Case 2
Case 2
Cyst Fluid Analysis Amylase = 105,000 U/L CEA = 10 ng/ml.
Case 2 Cytology Diagnosis: Mucoid cyst fluid with high amylase and low CEA suggestive of a pseudocyst. A mucinous cyst cannot entirely be excluded. Short term clinical follow-up recommended. Follow-up: Cyst resolved at 3 months
Pancreatic Pseudocyst Clinical Most common cystic lesion in the pancreas (75-90%) Associated with pancreatitis, trauma, surgery Radiology Thin to thick walled, unilocular, no septations 65% in the tail Fluid aspirated is often dark, hemorrhagic, oily and not mucoid
Pseudocysts: Ancillary tests Cytospins for mucin stains are negative(mucicarmine and or alcian blue) Cyst fluid analysis Consistently elevated amylase (thousand U/L) due to connectivity of the cyst to the duct Undetectable or very low CEA
Case 3 A 76 year old asymptomatic man was found to have a mass in the pancreatic tail. Approximately 1cc of slightly cloudy thin fluid was removed. One direct smear was made from a drop of fluid and the remaining fluid sent for cyst fluid analysis.
Case 3: EUS Report A 4 cm well defined microcystic mass was noted in the pancreatic tail. There was no evidence of invasion of surrounding structures.
Case 3
Case 3
Case 3
Case 3: Cyst Fluid Analysis Amylase = 20 U/L CEA = 0.5 ng/ml.
Case 3 Cytology Diagnosis: Serous cystadenoma Histology Diagnosis: Serous cystadenoma
Case 4 A 63 year old woman with epigastric pain was found to have a large mass in the pancreatic head. Approximately 5cc of thin straw colored fluid was removed. A ThinPrep was made of an aliquot of fluid; cytospins were made for mucin stains and 1 cc of fluid was sent for cyst fluid analysis.
Case 4: EUS Report An 11 x 7x 6 cm well defined multicystic thinwalled cyst was noted in the pancreatic head. No solid component was noted. There was no evidence of invasion of surrounding structures.
Case 4
Case 4
Case 4: Cyst Fluid Analysis Amylase = 83 U/L CEA = 3.0 ng/ml.
Case 4 Cytology Diagnosis: Nonmucinous cyst fluid with low CEA and amylase levels consistent with serous cystadenoma Histology Diagnosis: Oligocystic Serous cystadenoma
Serous Cystadenoma benign neoplasm in the head and tail of elderly men and women star-burst calcifications within a central scar diagnostic on imaging when present, but this is rarely present most tumors are microcystic with multiple, <2cm cysts, but can be unilocular due to specific variant or due to hemorrhagic degeneration, causing problems with imaging diagnosis
Serous Cystadenoma grossly large (10-12 cm), well circumscribed, multilobulated masses with fibrous septae histology: small cysts lined by glycogen-rich cuboidal epithelial cells
Serous Cystadenoma scant, watery, non-mucinous fluid scant cellularity clean, proteinaceous or bloody background monolayered sheets or small, flat clusters bland, uniform, round nuclei scant but visible non-mucinous cytoplasm
Surrogate Marker for SCA
Case 5 A 53-year-old female with diabetes mellitus since the age of 39, developed some right-sided abdominal pain, which prompted a CT scan that demonstrated a mass in the pancreatic tail that showed growth on repeat CT scan and FNA was recommended.
Case 5: EUS Report A round mass was identified in the pancreatic tail. The mass was hypoechoic and markedly heterogenous. The mass measured 34 mm by 22 mm in maximal crosssectional diameter. The endosonographic borders were well-defined. The remainder of the pancreas appeared normal. The mass had the appearance of a pancreatic Solid-pseudopapillary tumor vs neuroendocrine tumor.
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Lymphoepithelial Cyst Lymphoepithelial cysts are rare benign cysts lined by squamous epithelium with subepithelial non-neoplastic lymphoid tissue. Much more common in men with a male to female ratio of 4:1. It is a cyst of older adults with a mean age of 56 years. Are benign with no reported cases of malignant transformation. Are unilocular or multilocular and generally have thick appearing walls with internal debris that corresponds to keratinous debris that can make the cysts appear as a heterogeneous mass occur anywhere in the pancreas, and may even appear extra-pancreatic
Lymphoepithelial Cyst The differential diagnosis is with other squamous lined cysts: dermoid cyst of the pancreas splenic epidermoid cyst pseudocyst (due to the necrotic appearance of the keratinous debris)
Case 6 A 45 year old male is found to have a cyst in the head of the pancreas on work-up of elevated LFT's from an insurance exam.
Case 6: EUS Report A hypoechoic lesion suggestive of a cyst/pseudocyst was identified in the pancreatic head. The lesion measured 30 mm by 30 mm in maximal cross-sectional diameter. There was a single compartment without septae. The outer wall of the lesion was thin. There was no associated mass. There was no internal debris within the fluid-filled cavity. A transduodenal FNA was performed. The amount of fluid collected was 1 cc. The fluid was clear, white and very thick. Direct smears were made; no fluid sent for cyst fluid analysis. The pancreatic duct was diffusely dilated to 8mm, thought to be due to obstruction. An aspirate of the duct was also performed and 3cc of clear, white and thin fluid was obtained.
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Case 6 Cytology Diagnosis: Thick, viscous mucin consistent with neoplastic mucinous cyst. See note. Note: The quantity and quality of the mucin is consistent with the contents of a neoplastic mucinous cyst- IPMN or MCN. No high-grade atypia is identified. Acute inflammation and necrosis are also absent..
Case 6 Histology: Intraductal papillary mucinous neoplasm with moderate dysplasia, branch duct type.
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Case 7 An 84 year old female was found to have a cyst in the body/tail of the pancreas during evaluation of her Barrett s esophagus. An FNA was performed with cytospins and cyst fluid analysis.
Case 7: EUS Report A 20 mm anechoic cystic lesion was noted n the body-tail of the pancreas. There were no septations and the wall was thin. There was no associated mass lesion. FNA was performed for cytology with a 22 g needle. 2 ml of clear, mildly viscous fluid was aspirated. The CBD and pancreatic ducts were normal caliber.
Case 7: Cyst Fluid Analysis Amylase = 111,153 U/L CEA = 1361 ng/ml.
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Case 7: Cytology Diagnosis Extracellular mucin and few benign low-grade appearing glandular cells consistent with the clinical and radiological impression of a branch duct intraductal papillary mucinous neoplasm. (See note). Note: An alcian blue confirms the gross appearance of the 2cc of clear, mildly viscous aspirated fluid as mucinous. A few bland appearing glandular cells with clear cytoplasm are also present. The elevated CEA also supports a mucinous cyst. No background inflammation or necrosis is present, and no high-grade atypical epithelial cells are noted.
Case 7: Follow-up Repeat EUS at one year shows a stable cyst without significant growth. FNA is negative. The patient is enrolled in an ethanol ablation study and no pancreatectomy is performed.
Case 8 A 74 year old male was found to have a pancreatic cyst in the body following resolution of a bout of pancreatitis that brought him to the ER. An FNA was done with cytospins made, cyst fluid analysis and molecular analysis performed.
Case 8: EUS Report The lesion measured 25 mm There was a single compartment without septae. The outer wall of the lesion was thick. There was internal debris within the fluid-filled cavity. There was a possible mural nodule. Transgastric FNA produced 5 cc of very viscous fluid.
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Case 8: Cyst Fluid Analysis Amylase = 409 U/L CEA = 5165 ng/ml.
Case 8: Molecular Analysis KRAS mutation present
Case 8: Cytology Diagnosis Mucinous cyst with high-grade atypia suspicious for carcinoma consistent with IPMN. See note. Note: Several papillary fragments of atypical epithelial cells are present associated with extracellular mucin (confirmed with mucicarmine and alcian blue stains). Molecular analysis demonstrates a KRAS mutation. CEA is markedly elevated at >5000 ng/ml and amylase is 409 U/L. These findings from a cyst in the pancreatic body from a male support the above interpretation.
Case 8: Histology IPMN with high-grade dysplasia, branch duct type.
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Case 9 A 62 year old female is worked up for acute onset of abdominal pain. Ultrasound shows a markedly dilated pancreatic duct with sharp tapering in the pancreatic head where a 2 cm round cystic mass is identified. EUS with FNA is recommended.
Case 9: EUS Report A round mass is identified in the pancreatic head. The mass is hypoechoic, calcified and cystic. The mass measures 16 mm by 20 mm in maximal cross-sectional diameter. The endosonographic borders are well-defined. An intact interface is seen between the mass at the adjacent structures suggesting a lack of invasion. Diagnostic needle aspiration for fluid is performed into the cystic component of the mass and into the mass itself. The amount of fluid collected is 4 ml. The fluid is brown-yellow. The fluid is sent for molecular analysis. The pancreatic parenchyma in the body and tail is diffusely hypoechoic and lobular likely secondary to ductal obstruction. The pancreatic duct measures 2.3 mm. No lymphadenopathy is detected.
Case 9: Molecular Analysis KRAS mutation present
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Case 9: Cytology Diagnosis Adenocarcinoma consistent with invasive IPMN.
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Case 8: Histology Intraductal papillary mucinous neoplasm, branch duct type, with invasive tubular carcinoma
Case 10 A 64 year old woman being worked up for esophageal stricture is noted to have cysts in her pancreas along with a cystic mass in the uncinate. An EUS-FNA is scheduled.
Case 10: EUS Report The body and tail of the pancreas is very atrophic. In midbody, there is a 3 compartment cyst measuring about 8 mm in diameter. The pancreatic duct is not clearly seen in the body. In the head, CBD measures between 3-6 mm in diameter. The pancreatic duct is about 3.7 mm in diameter. In the uncinate process, there is a fairly well circumscribed heterogenous mass measuring about 30 X 20 mm rounded. At one edge there is some cystic component but it appears mostly solid. Aspirates are productive of bloody tissue, no cyst fluid. Direct smears are made. Slides are sent to me in consultation.
Case 10: Cytology Diagnosis Cystic pancreatic neuroendocrine tumor
Mucinous Cysts of the Premalignant Lesions PanIN-3 Pancreas WHO Classification 2010 Intraductal papillary mucinous neoplasm with low to intermediate grade dysplasia Intraductal papillary mucinous neoplasm with high grade dysplasia Mucinous cystic neoplasm with low to intermediate grade dysplasia Mucinous cystic neoplasm with high grade dysplasia Malignant Intraductal papillary mucinous neoplasm with invasive carcinoma Mucinous cystic neoplasm with invasive carcinoma
Changes in Nomenclature Adenoma (WHO 2000) Low grade dysplasia (AFIP and WHO 2010) Borderline carcinoma (WHO 2000) Moderate dysplasia (AFIP) Intermediate grade dysplasia (WHO 2010) Carcinoma in-situ (WHO 2000) High grade dysplasia/cis (AFIP) High Grade dysplasia/premalignant (WHO 2010) Mucinous Cystadenocarcinoma (WHO 2000) MCN with invasive carcinoma (AFIP and WHO 2010) IPMN carcinoma (WHO 2000) IPMN with invasive carcinoma (AFIP and WHO 2010)
Helpful Features to Distinguish Mucinous Cystic Neoplasms from Intraductal Papillary Mucinous Neoplasms Relationship to larger pancreatic ducts MCN None IPMN Arise within larger ducts Cellular stoma Present Absent Cystic configuration Single multilocular Multiple separate Sex ration (M:F) 1 : 20 1.5 : 1 Mean Age 45 63 Location Tail Head > Tail Papilla formation Focal Extensive Papilla types Gastric foveolar, pancreatobiliary Gastric foveolar intestinal, pancreatobiliary Peripheral Capsule Present Absent 4 th Series Fascicle on Tumors of the Pancreas.
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. 2012 May-Jun;12(3):183-97. Epub 2012 Apr 16. 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 Cyst 3cm Thickened/enhancing cyst walls Main duct 5-9mm Non-enhancing mural nodule EUS-FNA Abrupt change in MPD size with distal pancreatic atrophy EUS-FNA Susp/Pos cytology Surgery
Mucinous Cystic Neoplasm Predominantly in middle aged females (F:M=20:1) Mostly in the pancreatic body and tail (90%) Cysts do not communicate with the pancreatic ductal system; thick walled, thin or thick septa 20% have a rim of peripheral calcification on CT
Mucinous Cystic Neoplasm Lined by mucinous, generally non-papillary epithelium, but can be focally papillary Associated with a subepithelial ovarian-like stroma (not seen on cytology) Atypia may be very heterogeneous
MCN with invasive carcinoma Invasive component can be very focal Diagnosis cannot be made from FNA of cyst alone Invasion suggested by combination of cytology and EUS features
Intraductal Papillary Mucinous Neoplasm (IPMN) Main duct IPMN Branch duct IPMN Combined IPMN
Intraductal Papillary Mucinous Neoplasm (IPMN) Arise in older patients, M>F Generally in the pancreatic head, although can extend into the tail; single or multiple cysts Cysts do communicate with the pancreatic ductal system, but this may not be visible on EUS
Intraductal Papillary Mucinous Neoplasm Mostly papillary mucinous epithelium with variable and heterogenous atypia No association with ovarian-like stroma under the epithelium
Epithelium of Neoplastic Mucinous Cysts (MCN or IPMN) LGD (adenoma) Intermediate/Moderate dysplasia (Borderline carcinoma) HGD (CIS)
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. (in press, Cancer Cytopath)
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. (in press, Cancer Cytopath)
Take Home Points Thick colloid-like mucin even if acellular is sufficient to diagnose a neoplastic mucinous cyst Cytology may under-estimate the final histology of mucinous cysts Mural nodule and dilated MPD are high-risk imaging features Cyst fluid without a high amylase is very unlikely to be a pseudocyst CEA > 200 ng/ml supports mucinous cyst High amylase should be present in a pseudocyst, low in SCA and LEC and does not distinguish IPMN and MCN. Mucin stains help to highlight thin background mucin KRAS mutations support a mucinous cyst but not necessarily malignancy. Typically solid masses, especially PanNETs, can undergo cystic degeneration and mimic a primary pancreatic cyst
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