What Is Your Guess?

Cyst, What Art Thou? Tanner Bartholow1 and Octavia M. Peck Palmer1,2*

CASE DESCRIPTION A 51-year-old woman, with a medical history of abnormal Pap smears, extended menstrual cycles, and Barrett’s esophagus, underwent an upper gastrointestinal endoscopic ultrasound for abnormal findings on a computed tomography scan. The ultrasound characterized a peripherally calcified, multicystic, and septated lesion that was close to both the pancreatic tail and the upper pole of the left kidney. It measured 42 by 37 mm. Biochemical analysis was conducted on the lesion’s contents (Table 1).

Table 1. Analysis of multicystic lesion fluid content.a Analyte

CEA, ng/mL Amylase, IU/L Cholesterol, mg/dL Cortisol, ␮g/dL

Laboratory value

0.8 26 117 ⬎62

a Sample was submitted as an adrenal cyst; no reference ranges available for the analytes.

QUESTIONS 1. If high concentrations of carcinoembryonic antigen (CEA) were detected in this sample, what primary pancreatic lesions might be responsible? 2. If low concentrations of amylase were detected in this sample, what primary pancreatic lesion might be ruled out? 3. Based on the laboratory evidence provided, what site might the clinicians favor for the origin of the lesion? The answers are below. ANSWERS Increased CEA concentrations may suggest pancreatic mucinous lesions, including mucinous cystic neoplasms and intraductal papillary mucinous neoplasms (79% accuracy at ⬎192 ng/mL) (1, 2). A low amylase concentration helps to exclude pancreatic pseudocysts (98% specificity for pancreatic non-pseudocyst lesions ⬍250 IU/L) (3). Conversely, increased cortisol and cholesterol concentrations can be present in benign adrenal cysts (4). The laboratory profile and cytologyfindings(macrophagesandbenignepithelioidcells) are consistent with an adrenal cyst.

1

University of Pittsburgh Medical Center, Pittsburgh, PA; 2 Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA. * Address correspondence to this author at: University of Pittsburgh School of Medicine, 3477 Euler Way, Room 3014, Pittsburgh, PA 15261. Fax: 412-6478567; e-mail [email protected]. Received March 12, 2014; accepted April 16, 2014. DOI: 10.1373/clinchem.2014.224584 © 2014 American Association for Clinical Chemistry

Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approval of the published article. Authors’ Disclosures or Potential Conflicts of Interest: No authors declared any potential conflicts of interest.

References 1. Shen J, Kindelberger DW. Pancreas and biliary tree. In: Cibas ES, Ductaman BS, eds. Cytology, 3rd Ed. Philadelphia: Elsevier Saunders 2009:385– 402. 2. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, Centeno BA, Szydlo T, Regan S, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004;126:1330 – 6. 3. van der Waaij LA, van Dullemen HM, Porte RJ. Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointest Endosc 2005;62:383–9. 4. Tung GA, Pfister RC, Papanicolaou N, Yoder IC. Adrenal cysts: imaging and percutaneous aspiration. Radiology 1989;173:107–10.

Clinical Chemistry 60:11 (2014) 1459

Cyst, what art thou?

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