Differential Diagnosis

Pancreatic pseudocysts comprise approx 75% of all cystic lesions within or adjacent to the pancreas. The remainder of pancreatic cysts consists of retention cysts (10%), congenital cysts (5%), and cystic neoplasm (20). It is essential to distinguish between a cystic neoplasm, and a pancreatic pseudocyst to determine the specific therapeutic intervention, more specifically, resection rather than a drainage procedure. Several guidelines based on clinical and radiologic criteria have been proposed to differentiate those with a greater risk of a cystic neoplasm. A cystic lesion is considered to be a probable neoplasm if: 1) there is no antecedent history of pancreatitis; 2) the pancreatogram is normal on ERCP; 3) there are multiple cysts or internal septae on CT scan; 4) it is a hypervascular tumor as demonstrated on angiography; 5) it is thin-walled, and not adherent to any surrounding tissue at the time of laparotomy; 6) serum amylase levels are normal; and 7) fluid amylase levels are equal to or lower than serum (21).

Some authors advocate percutaneous aspiration with fluid analysis for viscosity, CA-125, carcinoembryonic antigen (CEA) and cytology. CA-125 and CEA levels have been found to be elevated in neoplastic cysts, and lower in pseudocysts (22). Cytologic analysis has an accuracy of approx 88% for mucinous cysts and its diagnostic value in serous cystadenomas appears to be limited (23).

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