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• W4256348711 abstract "Very few would argue that a symptomatic cystic tumor in the pancreas should not be resected, nor would a (large) cystic tumor found in the pancreatic tail of a young and otherwise healthy person be left untreated. These are not the patients in whom we would need more certainty about the diagnosis before we proceed with a surgical resection. This is why we, as many others, have stated in our report that “most pancreatic cystic tumours should be resected without the need for cyst fluid analysis” (Gastrointest Endosc 2005;62:383–389). However, an increasing number of pancreatic cystic lesions is detected coincidentally and are asymptomatic. Furthermore, many patients are old (Gastroenterology 2004;126:1330–1336, Ann Surg 1999;230:152–161) and may have an increased surgical risk. Not infrequently, lesions are located in the head of the pancreas (Ann Surg 1999;230:152–161) and thus require a pancreatoduodenectomy, with associated morbidity and mortality, for complete resection. For these patients it is important to distinguish (pre)malignant tumors, such as mucinous cystadenomas and mucinous cystadenocarcinomas from benign tumors, such as pseudocysts and serous cystadenomas. Our pooled analysis has shown that the results of cytology and tumor markers may help to establish a diagnosis in these patients. However, as we have clearly stated in our paper, a low CEA (<5 ng/mL), for example, does not completely exclude a mucinous cystadenoma or adenocarcinoma (5% of these tumors has a CEA< 5 ng/mL) and, therefore, these patients should be included in a follow-up program with US or CT.Unfortunately, Pelaez-Luna and Chari do not give a correct summary of our article. An amylase <250 U/L virtually excludes a pseudocyst (44% sensitivity and 98% specificity), but an amylase >250 U/L has no value in making the diagnosis pseudocyst.We disagree with the rather negative conclusion by Pelaez-Luna and Chari that “cyst fluid analysis is not a sensitive and specific test to differentiate among the myriad of different pancreatic cystic lesions.” Most of the cut off values of the markers have a specificity of 95%–99% and a sensitivity of about 50% for the discrimination of (pre)malignant from benign cystic lesions, and for excluding a pseudocyst. This high specificity makes these markers valuable in clinical decision making. Combining markers and cytology will probably result in a higher sensitivity. Unfortunately, the nature of our study did not allow us to perform an analysis of various combinations of tumor markers in individual patients. Nevertheless, we assume, and this is also our personal experience, that cyst fluid analysis will be nondiagnostic in only a minority of the patients.We conclude that cyst fluid analysis may be helpful in many patients to reduce the diagnostic uncertainty and to guide the optimal therapeutic strategy. We agree with Pelaez-Luna and Chari that the current imaging techniques, as well as diagnostic fluid analyses to differentiate the major classes of cystic neoplasms, are still not perfect. Therefore, we should continue to search for a more accurate diagnostic test, particularly in the field of molecular genetics. Very few would argue that a symptomatic cystic tumor in the pancreas should not be resected, nor would a (large) cystic tumor found in the pancreatic tail of a young and otherwise healthy person be left untreated. These are not the patients in whom we would need more certainty about the diagnosis before we proceed with a surgical resection. This is why we, as many others, have stated in our report that “most pancreatic cystic tumours should be resected without the need for cyst fluid analysis” (Gastrointest Endosc 2005;62:383–389). However, an increasing number of pancreatic cystic lesions is detected coincidentally and are asymptomatic. Furthermore, many patients are old (Gastroenterology 2004;126:1330–1336, Ann Surg 1999;230:152–161) and may have an increased surgical risk. Not infrequently, lesions are located in the head of the pancreas (Ann Surg 1999;230:152–161) and thus require a pancreatoduodenectomy, with associated morbidity and mortality, for complete resection. For these patients it is important to distinguish (pre)malignant tumors, such as mucinous cystadenomas and mucinous cystadenocarcinomas from benign tumors, such as pseudocysts and serous cystadenomas. Our pooled analysis has shown that the results of cytology and tumor markers may help to establish a diagnosis in these patients. However, as we have clearly stated in our paper, a low CEA (<5 ng/mL), for example, does not completely exclude a mucinous cystadenoma or adenocarcinoma (5% of these tumors has a CEA< 5 ng/mL) and, therefore, these patients should be included in a follow-up program with US or CT. Unfortunately, Pelaez-Luna and Chari do not give a correct summary of our article. An amylase <250 U/L virtually excludes a pseudocyst (44% sensitivity and 98% specificity), but an amylase >250 U/L has no value in making the diagnosis pseudocyst. We disagree with the rather negative conclusion by Pelaez-Luna and Chari that “cyst fluid analysis is not a sensitive and specific test to differentiate among the myriad of different pancreatic cystic lesions.” Most of the cut off values of the markers have a specificity of 95%–99% and a sensitivity of about 50% for the discrimination of (pre)malignant from benign cystic lesions, and for excluding a pseudocyst. This high specificity makes these markers valuable in clinical decision making. Combining markers and cytology will probably result in a higher sensitivity. Unfortunately, the nature of our study did not allow us to perform an analysis of various combinations of tumor markers in individual patients. Nevertheless, we assume, and this is also our personal experience, that cyst fluid analysis will be nondiagnostic in only a minority of the patients. We conclude that cyst fluid analysis may be helpful in many patients to reduce the diagnostic uncertainty and to guide the optimal therapeutic strategy. We agree with Pelaez-Luna and Chari that the current imaging techniques, as well as diagnostic fluid analyses to differentiate the major classes of cystic neoplasms, are still not perfect. Therefore, we should continue to search for a more accurate diagnostic test, particularly in the field of molecular genetics. Cyst fluid analysis to diagnose pancreatic cystic lesions: An as yet unfulfilled promiseGastroenterologyVol. 130Issue 3Previewvan der Waaij LA, van Dullemen HM, Porte RJ (Groningen University Medical Center, Groningen, The Netherlands). Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointest Endosc 2005;62:383–389. Full-Text PDF" @default.
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