Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study

Gastrointest Endosc. 2009 May;69(6):1095-102. doi: 10.1016/j.gie.2008.07.033. Epub 2009 Jan 18.


Background: The role of pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts remains unclear.

Objective: Our purpose was to evaluate the utility of a detailed DNA analysis of pancreatic cyst fluid to diagnose mucinous and malignant cysts.

Design: Prospective, multicenter study.

Patients: Patients with pancreatic cysts presenting for EUS evaluation.

Intervention: EUS-guided pancreatic cyst aspirates cytology evaluation, carcinoembryonic antigen (CEA) level determination, and a detailed DNA analysis; incorporating DNA quantification, k-ras mutation and multiple allelic loss analysis, mutational amplitude, and sequence determination.

Main outcome measurements: Cyst fluid analysis compared with surgical pathologic or malignant cytologic examination.

Results: The study cohort consisted of 113 patients with 40 malignant, 48 premalignant, and 25 benign cysts. Cyst fluid k-ras mutation was helpful in the diagnosis of mucinous cysts (odds ratio 20.9, specificity 96%), whereas receiver-operator characteristic curve analysis indicated optimal cutoff points for allelic loss amplitude (area under the curve [AUC] 0.79; optimal value > 65%) and CEA (AUC 0.74; optimal value >148 ng/mL). Components of DNA analysis detecting malignant cysts included allelic loss amplitude over 82% (AUC 0.9) and high DNA amount (optical density ratio >10, AUC 0.79). The criteria of a high amplitude k-ras mutation followed by allelic loss showed maximum specificity (96%) for malignancy. All malignant cysts with negative cytologic evaluation (10/40) could be diagnosed as malignant by using DNA analysis.

Limitations: Limited follow-up, selection bias.

Conclusions: Elevated amounts of pancreatic cyst fluid DNA, high-amplitude mutations, and specific mutation acquisition sequences are indicators of malignancy. The presence of a k-ras mutation is also indicative of a mucinous cyst. DNA analysis should be considered when cyst cytologic examination is negative for malignancy.

Publication types

  • Multicenter Study

MeSH terms

  • Adenocarcinoma, Mucinous / genetics
  • Adenocarcinoma, Mucinous / pathology
  • Adenocarcinoma, Mucinous / surgery
  • Adenocarcinoma, Papillary / genetics
  • Adenocarcinoma, Papillary / pathology
  • Adenocarcinoma, Papillary / surgery
  • Aged
  • Biomarkers, Tumor / blood
  • Carcinoembryonic Antigen / blood
  • Carcinoma, Pancreatic Ductal / genetics
  • Carcinoma, Pancreatic Ductal / pathology
  • Carcinoma, Pancreatic Ductal / surgery
  • Cell Transformation, Neoplastic / genetics
  • Cell Transformation, Neoplastic / pathology
  • Cyst Fluid / metabolism
  • Cystadenocarcinoma, Mucinous / genetics
  • Cystadenocarcinoma, Mucinous / pathology
  • Cystadenocarcinoma, Mucinous / surgery
  • Cystadenoma, Mucinous / genetics
  • Cystadenoma, Mucinous / pathology
  • Cystadenoma, Mucinous / surgery
  • DNA, Neoplasm / genetics*
  • Diagnosis, Differential
  • Female
  • Humans
  • Loss of Heterozygosity / genetics*
  • Male
  • Middle Aged
  • Pancreas / pathology
  • Pancreatic Cyst / genetics*
  • Pancreatic Cyst / pathology
  • Pancreatic Cyst / surgery
  • Pancreatic Neoplasms / genetics*
  • Pancreatic Neoplasms / pathology
  • Pancreatic Neoplasms / surgery
  • Precancerous Conditions / genetics*
  • Precancerous Conditions / pathology
  • Precancerous Conditions / surgery
  • Prognosis
  • Prospective Studies
  • Proto-Oncogene Proteins / genetics
  • Proto-Oncogene Proteins p21(ras)
  • ras Proteins / genetics


  • Biomarkers, Tumor
  • Carcinoembryonic Antigen
  • DNA, Neoplasm
  • KRAS protein, human
  • Proto-Oncogene Proteins
  • Proto-Oncogene Proteins p21(ras)
  • ras Proteins