Brugge et al. reported that cyst fluid CEA with a cut-off of 192 ng/mL accurately differentiated mucinous from non-mucinous cystic lesions. The accuracy of cyst fluid CEA was significantly greater than the accuracy of EUS morphology or cytology for the differentiation of mucinous from non-mucinous cystic lesions.43 Another study using pooled analysis showed that when CEA were > 800 ng/mL, the specificity for mucinous cysts was 98%.53 Guidelines state that cytodiagnosis and examination

of tumor markers are useful to distinguish mucinous cysts from other cystic lesions.54,55 Genetic analysis of cystic fluid by EUS-FNA might also be performed. Similar to pancreatic cancer, the development of malignancy in pancreatic cysts occurs through progressive accumulation of molecular alterations, including K-ras mutations.56 Positive K-ras mutation of cystic check details fluid enabled mucinous cysts to be distinguished from other cystic lesions (sensitivity 45%, specificity 62%), and when combined with CEA, the sensitivity could be increased to 84%.57 In summary, although cytological confirmation of pancreatic cyst could avoid misdiagnosis of mucinous versus non-mucinous cysts, and benign versus malignant

cysts, the low diagnostic yield of cyst fluid cytology and the potential risk for mucinous material leakage into the peritoneum leading to pseudomyxoma peritonei16 detract against the widespread use of EUS-FNA for

the diagnosis of pancreatic cystic lesions in some Asian countries, such as Japan. In light of this, further studies on the precise Palbociclib purchase medchemexpress role of EUS-FNA in the diagnosis and management of some or all pancreatic cysts in Asia need to be undertaken. EUS-FNA of pancreatic cysts is safer than previously thought as shown in several recent large series. Earlier studies, which included both solid and cystic lesions, consistently showed higher complication rates of 14% for cystic lesions, mainly pancreatic cysts.58 The image quality was poor with old processors. Subsequent change from radial scanners to linear scanners, which provide real-time imaging of the needle track during procedure, has led to improvement.59 Recent studies have shown significantly lower complication rates. However, the lack of consensus in the definition, classification, and grading of complications is the main limitation in comparing study outcomes. Hemorrhage and infectious complications are the most common and can result in serious adverse outcomes, as reported in the earlier studies. Hemorrhage can be intracystic or retroperitoneal. Intracystic hemorrhage occurs with variable frequency.60 Factors that might account for variable frequency include operator experience, differences among patients, use of color Doppler, and possible use of medication, such as non-steroidal anti-inflammatory drugs, before procedure.