Do features point to benign disease?

Dina H. – 50 year old female patient

  • Married, working mother of 2 teenagers
  • Evaluation of a body/tail junction cyst
  • 1.8 cm x 1.6 cm
  • Consists of a single compartment without communication with the pancreatic ductal system
  • Outer wall thin
  • Mural nodule
  • No evidence of chronic pancreatitis
  • Fluid aspirated from cyst showed abundant extracellular mucin
  • Presence of macrophages
  • Debris and rare groups of benign-appearing ductal cells
  • No evidence of high-grade dysplasia or malignancy
  • Many features point to benign disease
  • Mural nodule creates significant concern that cancer may be present
  • CEA and cytology provide insufficient support to discriminate between benign vs aggressive disease
Fluid Chemistry
AccuCEA43 ng/mL
Amylase169,313 U/L
Molecular Results
DNA QuantityLow
DNA QualityPoor
Oncogene Point Mutations
KRAS Point MutationNo mutation detected
GNAS Point MutationNot ordered
Tumor Suppressor Genes (LOH)No amplification
BenignStatistically IndolentStatistically Higher RiskAggressive
This Patient

  • Molecular analysis indicates BENIGN biologic behavior
  • Surgery not performed
  • Patient has been followed for over 48 months without clinical evidence of progression

Surgery or surveillance?

Kelly G. – 86 year old female patient

  • Widow, lives alone, 6 grandchildren
  • Cystic lesion in head of the pancreas
  • Endoscopic ultrasound revealed a complex head cyst
  • 3.1 cm x 2.1 cm
  • Composed of tubular structures in continuity with the main pancreatic duct as well as a side branch
  • No solid component, no nodules, no masses
  • Aspirate fluid had thick, mucinous character
  • Cytology exam revealed markedly degenerated specimen with atypical ductal cells and focal extracellular mucin
  • Degeneration precludes definitive evaluation
  • Large size raises possibility of aggressive disease
  • Qualifies for surgical resection
  • Cytologic atypia adds to concern
  • Advanced age encourages a conservative approach
Fluid Chemistry
AccuCEA694 ng/mL
Amylase134 U/L
Molecular Results
DNA QuantityLow
DNA QualityGood
Oncogene Point Mutations
KRAS Point MutationNo mutation
GNAS Point MutationNot ordered
Tumor Suppressor Genes (LOH)No LOH detected
BenignStatistically IndolentStatistically Higher RiskAggressive
This Patient

  • Molecular analysis provides support for BENIGN biologic behavior
  • Surgery not performed
  • Patient has been followed for over 30 months without clinical evidence of progression

When do molecular alterations begin?

Jack Z. – 65 year old male patient

  • Married business owner, 3 children, 1 grandchild
  • Pancreatic cystic disease revealed during a workup for cirrhosis
  • Endoscopic ultrasound showed mildly prominent pancreatic duct in the neck region, 3.2 mm in diameter
  • Cyst found in pancreatic head region, 1.3 cm x 0.9 cm
  • No masses or lymphadenopathy
  • Clear fluid aspirated and submitted for testing
  • First-line testing shows changes of a mild-to-moderate nature
  • Cytology was inadequate for interpretation
Fluid Chemistry
AccuCEA13,800 ng/mL
Amylase24 U/L
Molecular Results
DNA QuantityModerate
DNA QualityGood
Oncogene Point Mutations
KRAS Point MutationHigh clonality mutation, codon 12 GGT to GAT
GNAS Point MutationNo mutation detect
Tumor Suppressor Genes (LOH)No LOH detected
BenignStatistically IndolentStatistically Higher RiskAggressive
This Patient

  • Molecular analysis supports STATISTICALLY INDOLENT disease
  • This patient exemplifies a common finding in pancreatic cyst lesions: molecular alterations occur early in the molecular pathogenesis of this disease, and thus are the most helpful when first-line testing shows changes of a mild-to-moderate nature
  • While mutational change is detected, the extent is still within the range seen with benign or non-progressive disease
  • Patient continues to do well under surveillance for 56 months

Is testing the solid component enough?

Larry T. – 76 year old male patient

  • Retired, divorced, recently moved to the area
  • 3.0 cm hypoechoic mass in mid-body of the pancreas adjacent to a 2.5 cm anechoic cystic mass
  • No adenopathy
  • Changes suggestive of chronic pancreatitis detected
  • Upstream dilation of the pancreatic duct
  • Multiple additional cysts present in the pancreas w/ thin walls and no mural nodules
  • Both the hypoechoic lesion and the anechoic cyst lesion were biopsied
  • After sampling the solid component, cytology failed to find evidence of malignancy
  • The hypoechoic mass showed a few ribbons of mucinous cells in a background of inflammation
  • The anechoic cyst fluid showed debris and a few inflammatory cells
Fluid Chemistry
AccuCEA259,850 ng/mL
Amylase
Molecular Results
DNA QuantityGreatly elevated
DNA QualityGood
Oncogene Point Mutations
KRAS Point MutationHigh clonality mutation, codon 12 GGT to GTT
GNAS Point MutationNot ordered
Tumor Suppressor Genes (LOH)Two high-clonality (9p, 17q)
BenignStatistically IndolentStatistically Higher RiskAggressive
This Patient

  • Molecular analysis provides full support for AGGRESSIVE disease
  • Cytology of the sampled solid component failed to identify atypia or malignancy
  • Surgery was performed, disclosing pancreatic adenocarcinoma occupying part of the cyst wall lining