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Background: The objective was to evaluate cyst fluid carcinoembryonic antigen (CEA) as a putative marker of malignant potential in cystic pancreatic lesions (CPLs). Methods: Prospective observational cohort study from October 2008 to September 2013. A total of 190 patients with CPL were in- cluded after signed informed consent. Endoscopic ultrasound and fine needle aspiration (EUS-FNA) of cyst fluid for analysis of CEA was performed as part of the multimodal preoperative workup. The diagnostic performance of cyst fluid CEA value for the selection of the right patients for surgery was evaluated by histological diagnosis as endpoint in operated patients. Diagnostic accuracy of cyst fluid CEA was assessed by receiver operating characteristics (ROC) analysis. Results: Surgical resection was performed in 65 patients (34.2%) after evaluation by the multidisciplinary team (MDT). Lesions with malignant potential or invasive carcinomas were found in 46 (70.8%) of resected cases. Area under the ROC curve (AUC) for cyst fluid CEA was 0.71 (95% CI 0.61 - 0.81). The optimal cut-off value was 36.3 ng/mL (sensitivity 74%, specificity 62%, PPV 51%, NPV 81%, accuracy 66%). A total of 125 patients (65.8%) were never operated, 15 because of unresectable carcinoma. None of the 110 patients undergoing conservative management developed malignancy at a median follow-up of 46.5 months (range 4 - 86 months). Conclusion: There is a significant diagnostic yield of cyst fluid CEA determination, when the indication for surgical exploration is focused.

The different risk of malignancy in various cystic pancreatic neoplasms has been well known for more than two decades, and thera- peutic management has been improved accordingly. Numerous guidelines have directed the progress, based on the technological development in health care within imaging, endoscopy and surgery. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and minimally invasive/laparoscopic techniques are relevant examples. [...]