胰腺导管内乳头状黏液性肿瘤：胰腺液分析对阳性诊断及恶性肿瘤预测的作用

Intraductal papillary mucinous neoplasms of the pancreas: performance of pancreatic fluid analysis for positive diagnosis and the prediction of malignancy.

作者信息

Maire Frédérique, Voitot Hélène, Aubert Alain, Palazzo Laurent, O'Toole Dermot, Couvelard Anne, Levy Philippe, Vidaud Michel, Sauvanet Alain, Ruszniewski Philippe, Hammel Pascal

机构信息

Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hôpital Beaujon, AP-HP, Clichy, France.

出版信息

Am J Gastroenterol. 2008 Nov;103(11):2871-7. doi: 10.1111/j.1572-0241.2008.02114.x. Epub 2008 Sep 4.

DOI:10.1111/j.1572-0241.2008.02114.x

PMID:18775021

Abstract

INTRODUCTION

The preoperative diagnosis of intraductal papillary mucinous neoplasms (IPMN) of the pancreas must be as reliable as possible because large or even total pancreatectomy may be necessary. Early diagnosis of malignant forms is important to improve prognosis. The diagnostic accuracy of fluid analysis using endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been confirmed in cystic lesions of the pancreas. It is not known if these results can be applied to IPMN.

AIMS

To determine the levels of biochemical and tumor markers in fluid from EUS-FNA in patients with IPMN and to assess the impact on the diagnosis of IPMN.

PATIENTS AND METHODS

In total, 41 patients (14 men, median age 64 yr) underwent EUS-FNA before surgical resection of IPMN in our center. Levels of amylase, lipase, carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19.9, and CA 72.4 were measured in the cyst fluid. The performance of the markers was retrospectively evaluated for: (a) a positive diagnosis of IPMN, using cutoffs validated in the literature for mucinous pancreatic lesions and (b) an assessment of malignancy (i.e., high-grade dysplasia or invasive carcinoma) compared with the final pathological examination of the surgical specimen.

RESULTS

EUS-FNA was performed in dilated branch ducts (BD) in 39 cases and in the main pancreatic duct in 2 cases. No serious complications occurred. The median fluid levels of amylase, lipase, CEA, CA 19.9, and CA 72.4 were 20,155 U/mL, 59,500 U/mL, 173 ng/mL, 6,400 U/mL, and 11.5 U/mL, respectively. A CEA level >200 ng/mL and a CA 72.4 >40 U/mL had a 44% and a 39% sensitivity, respectively, for the diagnosis of IPMN. The levels of CEA, CA 19.9, and CA 72.4 were significantly different between benign and malignant IPMN. The sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) of a CEA level >200 ng/mL for the diagnosis of malignant IPMN were 90%, 71%, 50%, and 96%, respectively. The sensitivity, specificity, PPV, and NPV of a CA 72.4 level >40 U/mL for this purpose were 87.5%, 73%, 47%, and 96%, respectively.

CONCLUSION

CEA and CA 72.4 in pancreatic cyst fluid have excellent NPVs in the preoperative differential diagnosis of benign versus malignant IPMN, and might reinforce the decision of not to operate on patients with BD-type without predictive factors of malignancy.

摘要

引言

胰腺导管内乳头状黏液性肿瘤（IPMN）的术前诊断必须尽可能可靠，因为可能需要进行大范围甚至全胰腺切除术。恶性形式的早期诊断对于改善预后很重要。使用内镜超声引导下细针穿刺（EUS-FNA）进行液体分析的诊断准确性已在胰腺囊性病变中得到证实。目前尚不清楚这些结果是否可应用于IPMN。

目的

确定IPMN患者EUS-FNA所取液体中的生化和肿瘤标志物水平，并评估其对IPMN诊断的影响。

患者与方法

本中心共有41例患者（14例男性，中位年龄64岁）在IPMN手术切除前接受了EUS-FNA。检测了囊液中的淀粉酶、脂肪酶、癌胚抗原（CEA）、糖类抗原（CA）19.9和CA 72.4水平。回顾性评估这些标志物的性能：（a）使用文献中针对黏液性胰腺病变验证的临界值对IPMN进行阳性诊断，以及（b）与手术标本的最终病理检查相比，评估恶性程度（即高级别异型增生或浸润性癌）。

结果

39例在扩张的分支导管（BD）中进行了EUS-FNA，2例在主胰管中进行。未发生严重并发症。淀粉酶、脂肪酶、CEA、CA 19.9和CA 72.4的中位液体水平分别为20,155 U/mL、59,500 U/mL、173 ng/mL、6,400 U/mL和11.5 U/mL。CEA水平>200 ng/mL和CA 72.4>40 U/mL对IPMN诊断的敏感性分别为44%和39%。良性和恶性IPMN之间CEA、CA 19.9和CA 72.4的水平有显著差异。CEA水平>200 ng/mL对恶性IPMN诊断的敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV）分别为90%、71%、50%和96%。CA 72.4水平>40 U/mL用于此目的的敏感性、特异性、PPV和NPV分别为87.5%、73%、47%和96%。