Pancreas

United European Gastroenterol J. 2023;11(7):601–11

Levink IJM, Jaarsma SC, Koopmann BDM, van Riet PA, Overbeek KA, Meziani J, Sprij MLJA, Casadei R, Ingaldi C, Polkowski M, Engels MML, van der Waaij LA, Carrara S, Pando E, Vornhülz M, Honkoop P, Schoon EJ, Laukkarinen J, Bergmann JF, Rossi G, van Vilsteren FGI, van Berkel AM, Tabone T, Schwartz MP, Tan ACITL, van Hooft JE, Quispel R, van Soest E, Czacko L, Bruno MJ, Cahen DL; PACYFIC-registry work group

The additive value of CA19.9 monitoring in a pancreatic cyst surveillance program

Background: Surveillance of pancreatic cysts focuses on the detection of (mostly morphologic) features warranting surgery. European guidelines consider elevated CA19.9 as a relative indication for surgery. The authors aimed to evaluate the role of CA19.9 monitoring for early detection and management in a cyst surveillance population.
Methods: The PACYFIC-registry is a prospective collaboration that investigates the yield of pancreatic cyst surveillance performed at the discretion of the treating physician. Participants for whom at least 1 serum CA19.9 value was determined by a minimum follow-up of 12 months were included.
Results: Of 1865 PACYFIC participants, 685 met the inclusion criteria for this study (mean age, 67 years [standard deviation 10]; 61% female). During a median follow-up of 25 months (interquartile range [IQR], 24, 1966 visits), 29 participants developed high-grade dysplasia (HGD) or pancreatic cancer. At baseline, CA19.9 ranged from 1 to 591 kU/l (median 10 kU/l [IQR, 14]), and was elevated (≥ 37 kU/l) in 64 participants (9%). During 191 of 1966 visits (10%), an elevated CA19.9 was detected, and these visits more often led to an intensified follow-up (42%) than those without an elevated CA19.9 (27%; p < 0.001). An elevated CA19.9 was the sole reason for surgery in 5 participants with benign disease (10%). The baseline CA19.9 value was (as continuous or dichotomous variable at the 37 kU/l threshold) not independently associated with HGD or pancreatic cancer development, whilst a CA19.9 of ≥ 133 kU/l was (hazard ratio = 3.8, 95% confidence interval: 1.1–13, p = 0.03).

Conclusions: In this pancreatic cyst surveillance cohort, CA19.9 monitoring caused substantial harm by shortening surveillance intervals (and performance of unnecessary surgery). The current CA19.9 cut-off was not predictive of high-grade dysplasia and pancreatic cancer, whereas a higher cut-off may decrease false-positive values. The role of CA19.9 monitoring should be critically appraised prior to implementation in surveillance programs and guidelines.

DOI: 10.1002/ueg2.12422