The string sign for diagnosis of mucinous pancreatic cysts

Benjamin L. Bick, Felicity T Enders, Michael J. Levy, Lizhi Zhang, Michael R. Henry, Barham K Abu Dayyeh, Suresh T Chari, Jonathan E. Clain, Michael B. Farnell, Ferga C. Gleeson, Michael L. Kendrick, Randall K. Pearson, Bret Thomas Petersen, Elizabeth Rajan, Santhi Swaroop Vege, Mark Topazian

Research output: Contribution to journalArticle

32 Citations (Scopus)

Abstract

Background and study aims: Pancreas cyst fluid analysis does not provide optimal discrimination between mucinous and nonmucinous cysts. The aim of this study was to assess the performance characteristics of the string sign-a test performed at the time of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), for the diagnosis of mucinous pancreatic cysts (branch duct intraductal papillary mucinous neoplasms [bIPMN] and mucinous cystic neoplasms). Patients and methods: Patients undergoing EUS-FNA of pancreatic cystic lesions at one referral center between 2003 and 2012 were included. The string sign was performed prospectively, and was considered positive if ≥1cm string formed in cyst fluid and lasted for ≥1 second. Performance characteristics of the string sign and a sequential cyst fluid test interpretation model were assessed. Results: For 98 histologically proven cases, the sensitivity, specificity, positive predictive value, and negative predictive value of the string sign for diagnosis of mucinous cysts were 58% (95% confidence interval [CI] 44%-70%), 95% (83%-99%), 94% (81%-99%), and 60% (46%-72%), respectively. When string sign results and carcinoembryonic antigen (CEA) concentration (≥200ng/mL) were combined, diagnostic accuracy improved from 74% and 83%, respectively, to 89% (P≤0.03). Among bIPMN, a positive string sign was associated with gastric and intestinal epithelial subtypes. The sequential cyst fluid test interpretation model (including cytology, mucin stain, CEA, and string sign) yielded an overall sensitivity for mucinous lesions of 96%, with a specificity of 90%. Conclusions: The string sign is highly specific for diagnosis of mucinous pancreatic cysts, and improves overall diagnostic accuracy of pancreatic cyst fluid analysis. Sequential cyst fluid test interpretation yields high diagnostic sensitivity and specificity for mucinous cysts.

Original languageEnglish (US)
Pages (from-to)626-631
Number of pages6
JournalEndoscopy
Volume47
Issue number7
DOIs
StatePublished - Jul 29 2015

Fingerprint

Pancreatic Cyst
Cyst Fluid
Endoscopic Ultrasound-Guided Fine Needle Aspiration
Cysts
Carcinoembryonic Antigen
Sensitivity and Specificity
Neoplasms
Mucins
Cell Biology
Pancreas
Stomach
Coloring Agents
Referral and Consultation
Confidence Intervals

ASJC Scopus subject areas

  • Gastroenterology

Cite this

The string sign for diagnosis of mucinous pancreatic cysts. / Bick, Benjamin L.; Enders, Felicity T; Levy, Michael J.; Zhang, Lizhi; Henry, Michael R.; Dayyeh, Barham K Abu; Chari, Suresh T; Clain, Jonathan E.; Farnell, Michael B.; Gleeson, Ferga C.; Kendrick, Michael L.; Pearson, Randall K.; Petersen, Bret Thomas; Rajan, Elizabeth; Vege, Santhi Swaroop; Topazian, Mark.

In: Endoscopy, Vol. 47, No. 7, 29.07.2015, p. 626-631.

Research output: Contribution to journalArticle

Bick, BL, Enders, FT, Levy, MJ, Zhang, L, Henry, MR, Dayyeh, BKA, Chari, ST, Clain, JE, Farnell, MB, Gleeson, FC, Kendrick, ML, Pearson, RK, Petersen, BT, Rajan, E, Vege, SS & Topazian, M 2015, 'The string sign for diagnosis of mucinous pancreatic cysts', Endoscopy, vol. 47, no. 7, pp. 626-631. https://doi.org/10.1055/s-0034-1391484
Bick, Benjamin L. ; Enders, Felicity T ; Levy, Michael J. ; Zhang, Lizhi ; Henry, Michael R. ; Dayyeh, Barham K Abu ; Chari, Suresh T ; Clain, Jonathan E. ; Farnell, Michael B. ; Gleeson, Ferga C. ; Kendrick, Michael L. ; Pearson, Randall K. ; Petersen, Bret Thomas ; Rajan, Elizabeth ; Vege, Santhi Swaroop ; Topazian, Mark. / The string sign for diagnosis of mucinous pancreatic cysts. In: Endoscopy. 2015 ; Vol. 47, No. 7. pp. 626-631.
@article{4990e594f7eb4b4ba5b054210ece9db1,
title = "The string sign for diagnosis of mucinous pancreatic cysts",
abstract = "Background and study aims: Pancreas cyst fluid analysis does not provide optimal discrimination between mucinous and nonmucinous cysts. The aim of this study was to assess the performance characteristics of the string sign-a test performed at the time of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), for the diagnosis of mucinous pancreatic cysts (branch duct intraductal papillary mucinous neoplasms [bIPMN] and mucinous cystic neoplasms). Patients and methods: Patients undergoing EUS-FNA of pancreatic cystic lesions at one referral center between 2003 and 2012 were included. The string sign was performed prospectively, and was considered positive if ≥1cm string formed in cyst fluid and lasted for ≥1 second. Performance characteristics of the string sign and a sequential cyst fluid test interpretation model were assessed. Results: For 98 histologically proven cases, the sensitivity, specificity, positive predictive value, and negative predictive value of the string sign for diagnosis of mucinous cysts were 58{\%} (95{\%} confidence interval [CI] 44{\%}-70{\%}), 95{\%} (83{\%}-99{\%}), 94{\%} (81{\%}-99{\%}), and 60{\%} (46{\%}-72{\%}), respectively. When string sign results and carcinoembryonic antigen (CEA) concentration (≥200ng/mL) were combined, diagnostic accuracy improved from 74{\%} and 83{\%}, respectively, to 89{\%} (P≤0.03). Among bIPMN, a positive string sign was associated with gastric and intestinal epithelial subtypes. The sequential cyst fluid test interpretation model (including cytology, mucin stain, CEA, and string sign) yielded an overall sensitivity for mucinous lesions of 96{\%}, with a specificity of 90{\%}. Conclusions: The string sign is highly specific for diagnosis of mucinous pancreatic cysts, and improves overall diagnostic accuracy of pancreatic cyst fluid analysis. Sequential cyst fluid test interpretation yields high diagnostic sensitivity and specificity for mucinous cysts.",
author = "Bick, {Benjamin L.} and Enders, {Felicity T} and Levy, {Michael J.} and Lizhi Zhang and Henry, {Michael R.} and Dayyeh, {Barham K Abu} and Chari, {Suresh T} and Clain, {Jonathan E.} and Farnell, {Michael B.} and Gleeson, {Ferga C.} and Kendrick, {Michael L.} and Pearson, {Randall K.} and Petersen, {Bret Thomas} and Elizabeth Rajan and Vege, {Santhi Swaroop} and Mark Topazian",
year = "2015",
month = "7",
day = "29",
doi = "10.1055/s-0034-1391484",
language = "English (US)",
volume = "47",
pages = "626--631",
journal = "Endoscopy",
issn = "0013-726X",
publisher = "Georg Thieme Verlag",
number = "7",

}

TY - JOUR

T1 - The string sign for diagnosis of mucinous pancreatic cysts

AU - Bick, Benjamin L.

AU - Enders, Felicity T

AU - Levy, Michael J.

AU - Zhang, Lizhi

AU - Henry, Michael R.

AU - Dayyeh, Barham K Abu

AU - Chari, Suresh T

AU - Clain, Jonathan E.

AU - Farnell, Michael B.

AU - Gleeson, Ferga C.

AU - Kendrick, Michael L.

AU - Pearson, Randall K.

AU - Petersen, Bret Thomas

AU - Rajan, Elizabeth

AU - Vege, Santhi Swaroop

AU - Topazian, Mark

PY - 2015/7/29

Y1 - 2015/7/29

N2 - Background and study aims: Pancreas cyst fluid analysis does not provide optimal discrimination between mucinous and nonmucinous cysts. The aim of this study was to assess the performance characteristics of the string sign-a test performed at the time of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), for the diagnosis of mucinous pancreatic cysts (branch duct intraductal papillary mucinous neoplasms [bIPMN] and mucinous cystic neoplasms). Patients and methods: Patients undergoing EUS-FNA of pancreatic cystic lesions at one referral center between 2003 and 2012 were included. The string sign was performed prospectively, and was considered positive if ≥1cm string formed in cyst fluid and lasted for ≥1 second. Performance characteristics of the string sign and a sequential cyst fluid test interpretation model were assessed. Results: For 98 histologically proven cases, the sensitivity, specificity, positive predictive value, and negative predictive value of the string sign for diagnosis of mucinous cysts were 58% (95% confidence interval [CI] 44%-70%), 95% (83%-99%), 94% (81%-99%), and 60% (46%-72%), respectively. When string sign results and carcinoembryonic antigen (CEA) concentration (≥200ng/mL) were combined, diagnostic accuracy improved from 74% and 83%, respectively, to 89% (P≤0.03). Among bIPMN, a positive string sign was associated with gastric and intestinal epithelial subtypes. The sequential cyst fluid test interpretation model (including cytology, mucin stain, CEA, and string sign) yielded an overall sensitivity for mucinous lesions of 96%, with a specificity of 90%. Conclusions: The string sign is highly specific for diagnosis of mucinous pancreatic cysts, and improves overall diagnostic accuracy of pancreatic cyst fluid analysis. Sequential cyst fluid test interpretation yields high diagnostic sensitivity and specificity for mucinous cysts.

AB - Background and study aims: Pancreas cyst fluid analysis does not provide optimal discrimination between mucinous and nonmucinous cysts. The aim of this study was to assess the performance characteristics of the string sign-a test performed at the time of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), for the diagnosis of mucinous pancreatic cysts (branch duct intraductal papillary mucinous neoplasms [bIPMN] and mucinous cystic neoplasms). Patients and methods: Patients undergoing EUS-FNA of pancreatic cystic lesions at one referral center between 2003 and 2012 were included. The string sign was performed prospectively, and was considered positive if ≥1cm string formed in cyst fluid and lasted for ≥1 second. Performance characteristics of the string sign and a sequential cyst fluid test interpretation model were assessed. Results: For 98 histologically proven cases, the sensitivity, specificity, positive predictive value, and negative predictive value of the string sign for diagnosis of mucinous cysts were 58% (95% confidence interval [CI] 44%-70%), 95% (83%-99%), 94% (81%-99%), and 60% (46%-72%), respectively. When string sign results and carcinoembryonic antigen (CEA) concentration (≥200ng/mL) were combined, diagnostic accuracy improved from 74% and 83%, respectively, to 89% (P≤0.03). Among bIPMN, a positive string sign was associated with gastric and intestinal epithelial subtypes. The sequential cyst fluid test interpretation model (including cytology, mucin stain, CEA, and string sign) yielded an overall sensitivity for mucinous lesions of 96%, with a specificity of 90%. Conclusions: The string sign is highly specific for diagnosis of mucinous pancreatic cysts, and improves overall diagnostic accuracy of pancreatic cyst fluid analysis. Sequential cyst fluid test interpretation yields high diagnostic sensitivity and specificity for mucinous cysts.

UR - http://www.scopus.com/inward/record.url?scp=84933278950&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84933278950&partnerID=8YFLogxK

U2 - 10.1055/s-0034-1391484

DO - 10.1055/s-0034-1391484

M3 - Article

C2 - 25730281

AN - SCOPUS:84933278950

VL - 47

SP - 626

EP - 631

JO - Endoscopy

JF - Endoscopy

SN - 0013-726X

IS - 7

ER -