1. Solid Pseudopapillary Tumor

2. Malignant Tumor

3. The Role of Biopsy in pancreas cancer
Unresectable lesion
Usually required before chemoradiation therapy of unresectable pancreatic tumors or neoadjuvant treatment of resectable tumors
Resectable lesion
a positive biopsy merely confirms the decision for resection and a negative biopsy is inconclusive
most surgeons would not recommend routine preoperative biopsy for confirmation of the diagnosis
5% to 10% of patients undergoing resection for suspected cancer will be found to have benign lesions

4. Characterization of Cyst Fluid
EUS-guided cyst aspiration is well tolerated and safe in the hands of an experienced operator, with a complication rate of less than 1% of bleeding, perforation, or infection.
Aspirated fluid has been evaluated by cytology and chemical measurements of amylase and tumor markers.
Characterization of cyst fluid is best used to differentiate those with malignant potential, mucinous cysts, from serous and nonneoplastic pseudocysts.

5. Cyst Fluid Analysis Tumor glycoproteins Amylase CEA, CA 19-9, CA 72-4
A number of glycoproteins are present in the epithelium of mucinous cystic neoplasm
Differentiate between mucinous and non-mucinous lesion
The higher the CEA, the higher the diagnostic confidence of a mucinous lesion
Amylase
Indicator of cyst communication with ductal system
Amylase rich fluid; Pseudocyst, IPMN

6. Cyst Fluid Analysis

7. Cyst Fluid Analysis

8. Cytologic Feature

9. Management Approach

10. Risk Stratification

11. Conclusion
The approach to the patient with a pancreatic cystic lesion begins with a detailed history, and consideration of the major diagnostic aspects.
In general, all symptomatic lesions and all mucinous lesions should proceed to appropriate surgical resection.
If preoperative characterization of the lesion will change management, EUS-FNA for cytology and fluid analysis may provide information of diagnostic value and support the approach of watchful waiting.

12. References
Scheiman JM. Cystic lesion of the pancreas. Gastroenterology Feb;128(2):463-9.
Van der Waaij LA et al. Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions:a pooled analysis. Gastrointest Endosc Sep;62(3):383-9.
Brugge WR. Should all pancreatic cystic lesions be resected? Cyst-fluid analysis in the differential diagnosis of pancreatic cystic lesions: a meta-analysis. Gastrointest Endosc Sep;62(3):390-1.
Sahani DV et al. Cystic pancreatic lesions: a simple imaging-based classification system for guiding management. Radiographics Nov-Dec;25(6):
Brugge WR et al. Cystic neoplasms of the pancreas. N Engl J Med Sep 16;351(12):