The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma

Current concept of endoscopic ultrasound-guided fine needle aspiration for pancreatic cancer

Endoscopic ultrasound (EUS) provides detailed, high-resolution images of the pancreas. However, whether a lesion is malignant or benign cannot be diagnosed solely from its imaging features on EUS. The introduction of EUS-guided fine needle aspiration (EUS-FNA) offers the possibility to obtain a cytological or histological diagnosis of pancreatic lesions with a high sensitivity and specificity. Although the clinical utility of EUS-FNA for pancreatic diseases is widely accepted, the indication for preoperative tissue diagnosis of pancreatic lesions suspected to be malignant is still controversial. This review highlights the diagnostic potential of EUS-FNA, as well as its current indications and contraindications, complications, and techniques.

Recurrent acute pancreatitis and persistent hyperamylasemia as a presentation of pancreatic osteoclastic giant cell tumor: an unusual presentation of a rare tumor

Giant cell tumors of the pancreas are rare neoplasms divided into three forms: osteoclastic, pleomorphic, and mixed. We report an unusual case of a 62-year-old male presenting with recurrent acute pancreatitis and found to have a mass in the head of the pancreas on routine imaging. Endoscopic retrograde cholangiopancreatography showed a main pancreatic duct stricture, with brush cytology revealing the diagnosis of osteoclastic giant cell tumor of the pancreas. Whipple's procedure was successfully performed for resection of this tumor. and IAP.

Citrobacter freundii infection after acute necrotizing pancreatitis in a patient with a pancreatic pseudocyst: a case report

Introduction

Infections are the most frequent and severe complications of acute necrotizing pancreatitis with a mortality rate of up to 80 percent. Although experimental and clinical studies suggest that the microbiologic source of pancreatic infection could be enteric, information in this regard is controversial.

Case presentation

We describe a Citrobacter freundii isolation by endoscopy ultrasound fine needle aspiration in a 80-year-old Caucasian man with pancreatic pseudocyst after acute necrotizing pancreatitis.

Conclusion

Our case report confirms that this organism can be recovered in patients with a pancreatic pseudocyst. On-site cytology feedback was crucial to the successful outcome of this case as immediate interpretation of the fine needle aspiration sample directed the appropriate cultures and, ultimately, the curative therapy. To the best of our knowledge, this is the first reported case of isolated pancreatic C. freundii diagnosed by endoscopy ultrasound fine needle aspiration.

Estimation of malignant potential of GI stromal tumors by contrast-enhanced harmonic EUS (with videos)

BACKGROUND

Contrast-enhanced harmonic EUS (CEH-EUS) is a new sonographic technique that uses US contrast agents and depicts intratumoral vessels in real time.

OBJECTIVE

To evaluate whether assessment of tumor vascularity by CEH-EUS can predict the preoperative malignancy risk of GI stromal tumors (GISTs).

DESIGN

Prospective study to observe GIST vascularity.

SETTING

Kinki University School of Medicine.

PATIENTS

Between June 2007 and September 2009, 76 consecutive patients suspected of having subepithelial lesions underwent CEH-EUS.

INTERVENTION

CEH-EUS was performed by using a prototype echoendoscope in an extended pure harmonic detection mode.

MAIN OUTCOME MEASUREMENTS

Resected GIST specimens in 29 patients who underwent surgical resection were divided into high-grade (n=16) and low-grade (n=13) malignancy groups based on mitotic activity. The abilities of EUS-guided FNA and CEH-EUS to diagnose the malignant potential were compared. The sensitivities with which contrast-enhanced multidetector CT, power-Doppler EUS, and CEH-EUS detected intratumoral vessels in high-grade malignancy GISTs also were compared.

RESULTS

CEH-EUS identified irregular vessels and thereby predicted GIST malignancies with a sensitivity, specificity, and accuracy of 100%, 63%, and 83%, respectively. Diagnosis of high-grade malignancy GISTs by EUS-guided FNA had a sensitivity, specificity, and accuracy of 63%, 92%, and 81%, respectively. Contrast-enhanced multidetector CT, power-Doppler EUS, and CEH-EUS detected intratumoral vessels in high-grade malignancy GISTs with sensitivities of 31%, 63%, and 100%, respectively (P<.05).

LIMITATIONS

A single center was involved in this study.

CONCLUSIONS

CEH-EUS successfully visualized intratumoral vessels and may play an important role in predicting the malignancy risk of GISTs.

The impact of prior biliary stenting on the accuracy and complication rate of endoscopic ultrasound fine-needle aspiration for diagnosing pancreatic adenocarcinoma

OBJECTIVES

Our aim was to determine whether the presence of a biliary stent during endoscopic ultrasound fine-needle aspiration (EUS-FNA) affects diagnosis and complication rates.

METHODS

Retrospective analysis was performed of 268 patients with pancreatic head or neck adenocarcinoma who underwent EUS-FNA at our academic medical center between 2000 and 2009. Endoscopic ultrasound fine-needle aspiration and endoscopic retrograde cholangiopancreatography reports, cytology results, and physicians' notes were reviewed.

RESULTS

A total of 170 patients without stents, 87 patients with stents placed more than 1 day before EUS, and 11 patients with stents placed less than 1 day before EUS were identified. In patients without stents, the tissue diagnosis rate via EUS-FNA was 92.4% compared with a rate of 88.5% for those with stents placed more than 1 day before EUS-FNA (P=0.36). However, the patients with stents placed immediately before EUS-FNA were more likely to have indeterminate results from the EUS-FNA than the other patients were (P=0.008). Complication rates were the same among the groups.

CONCLUSIONS

Pre-EUS stenting of biliary obstruction due to pancreatic adenocarcinoma does not influence the rate of tissue diagnosis if performed more than 1 day before EUS-FNA. Lack of immediate EUS access should not preclude stent placement in appropriate patients with malignant biliary obstruction who will undergo EUS-FNA.

Contrast-enhanced and 3-dimensional endoscopic ultrasonography

Recent progress of the data processing applied to ultrasonographic (US) examination has made it possible to develop new software. The US workstation of the last generation thus incorporated in their center a computer allowing a precise treatment of the US image. This advancement has made it possible to work out new images such as 3-dimensional (3D) US, contrast harmonic US associated with the intravenous injection of contrast agents, and even more recently, elastography. These techniques, quite elaborate in percutaneous US at present, are to be adapted and evaluated with endoscopic US (EUS). The contribution of contrast agents of US to pancreatic EUS and then 3D EUS are successively approached in this article.

Staining for p53 and Ki-67 increases the sensitivity of EUS-FNA to detect pancreatic malignancy

AIM: To investigate whether tumor marker staining can improve the sensitivity of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to diagnose pancreatic malignancy.

METHODS: Patients who underwent EUS-FNA were retrospectively identified. Each EUS-FNA specimen was evaluated by routine cytology and stained for tumor markers p53, Ki-67, carcinoembryonic antigen (CEA) and CA19-9. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (PLR and NLR) were calculated in order to evaluate the performance of each test to detect malignancy.

RESULTS: Sixty-one specimens had complete sets of stains, yielding 49 and 12 specimens from pancreatic adenocarcinomas and benign pancreatic lesions due to pancreatitis, respectively. Cytology alone had sensitivity and specificity of 41% and 100% to detect malignancy, respectively. In 46% of the specimens, routine cytology alone was deemed indeterminate. The addition of either p53 or Ki-67 increased the sensitivity to 51% and 53%, respectively, with perfect specificity, PPV and PLR (100%, 100% and infinite). Both stains in combination increased the sensitivity to 57%. While additional staining with CEA and CA19-9 further increased the sensitivity to 86%, the specificity, PPV and PLR were significantly reduced (at minimum 42%, 84% and 1, respectively). Markers in all combinations performed poorly as a negative test (NPV 26% to 47%, and NLR 0.27 and 0.70).

CONCLUSION: Immunohistochemical staining for p53 and Ki-67 can improve the sensitivity of EUS-FNA to diagnose pancreatic adenocarcinoma.

Endoscopic ultrasound-guided paracentesis of ascitic fluid: a morphologic study with ultrasonographic correlation

BACKGROUND

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) has been widely used for the diagnosis of primary and metastatic gastrointestinal (GI) and non-GI malignancies. Few studies have been published to evaluate the accuracy and the cytologic features of EUS-guided paracentesis in the diagnosis and staging of malignant neoplasms.

METHODS

All EUS-guided paracenteses of ascitic fluid performed at the University of California Irvine Medical Center (UCIMC) from January 2003 to February 2006 were retrospectively retrieved. Corresponding EUS findings, cytology and histology slides, and follow-up information were reviewed.

RESULTS

One hundred one (101) cases were found. Two smears were submitted in 11 cases because of the scanty amount of fluid aspirated. In the remaining cases, 5 mL or less of fluid were aspirated in 56 patients, and, of 9 who had prior computed tomography (CT), ascitic fluid was not seen in 6. The cytologic diagnoses were as follows: 17 were positive for adenocarcinoma, 1 positive for metastatic small-cell carcinoma of the lung, 1 positive for diffuse large-cell lymphoma, 3 suspicious for adenocarcinoma, 1 suspicious for plasmacytoma, 4 atypical epithelial cells, and 74 negative. Cell block was available in 80 cases and immunohistochemical stains were performed in 71 cases to confirm the diagnosis. Six patients had peritoneal biopsy. The sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were 80%, 100%, 100%, 95%, and 96%, respectively.

CONCLUSIONS

EUS-guided paracentesis is a valuable aid in the cytologic diagnosis of malignant ascites. It is particularly useful when no abnormality is identified by CT.

Quantitative endoscopic ultrasound elastography: an accurate method for the differentiation of solid pancreatic masses

BACKGROUND & AIMS

Qualitative endoscopic ultrasound (EUS) elastography is an accurate but subjective tool for the differential diagnosis of solid pancreatic masses. Second-generation EUS elastography allows quantitative analysis of tissue stiffness. We evaluated the accuracy of quantitative, second-generation EUS elastography in the differential diagnosis of solid pancreatic masses.

METHODS

The study included 86 consecutive patients who underwent EUS for the evaluation of solid pancreatic masses. EUS elastography was performed with the linear Pentax EUS and the Hitachi EUB900. Representative areas from the mass (A) and soft reference areas (B) were analyzed. The result of the elastographic evaluation was defined by the quotient B/A (strain ratio). Final diagnosis was based on histology of surgical specimens and cytology of EUS-fine-needle aspiration samples. The diagnostic accuracy of EUS elastography in detecting malignancy was calculated using receiver operating curve analysis.

RESULTS

The mean size of the pancreatic masses was 31.4 ± 12.3 mm. The final diagnoses were pancreatic adenocarcinoma (n = 49), inflammatory mass (n = 27), malignant neuroendocrine tumor (n = 6), metastatic oat-cell lung cancer (n = 2), pancreatic lymphoma (n = 1), and pancreatic solid pseudopapillary tumor (n = 1). The strain ratio was significantly higher among patients with pancreatic malignant tumors compared with those with inflammatory masses. The sensitivity and specificity of strain ratio for detecting pancreatic malignancies were 100% and 92.9%, respectively (area under the receiver operating curve, 0.983).

CONCLUSIONS

Quantitative, second-generation EUS elastography is useful for differential diagnosis of solid pancreatic masses. It allows for a quantitative and objective evaluation of tissue stiffness, which indicates the malignant or benign nature of the pancreatic lesion.

Familial pancreatic cancer in Italy. Risk assessment, screening programs and clinical approach: a position paper from the Italian Registry

In Italy, pancreatic cancer is the fifth leading cause of tumor related death with about 7000 new cases per year and a mortality rate of 95%. In a recent prospective epidemiological study on the Italian population, a family history was found in about 10% of patients suffering from a ductal adenocarcinoma of the pancreas (PDAC). A position paper from the Italian Registry for Familial Pancreatic Cancer was made to manage these high-risk individuals. Even though in the majority of high-risk individuals a genetic test to identify familial predisposition is not available, a screening protocol seems to be reasonable for subjects who have a >10-fold greater risk for the development of PDAC. However this kind of screening should be included in clinical trials, performed in centers with high expertise in pancreatic disease, using the least aggressive diagnostic modalities.

Diagnostic efficacy of the cell block method in comparison with smear cytology of tissue samples obtained by endoscopic ultrasound-guided fine-needle aspiration

BACKGROUND

The diagnostic efficacy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology may vary greatly depending on the treatment of the samples obtained and the level of proficiency of the cytopathologist or cytoscreener.

METHODS

We prospectively evaluated the diagnostic efficacy of the cell block (CB) method and that of smear cytology using tissue samples obtained in the same needle pass at EUS-FNA in 33 patients with pancreatic tumors, abdominal tumors or swollen lymph nodes. An average of 3.1 passes were applied during the procedure without affirmation by rapid cytology. About half of the material obtained by each single pass was subjected to smear cytology, while the other half was evaluated by the CB method. Four to 12 glass slides were prepared for both Papanicolaou stain and Giemsa stain. The CB sections were prepared using the sodium alginate method and subjected to HE, PAS-AB and immunohistochemical stains. Two pathologists independently made cytological and histological diagnoses. The final diagnosis was based on integration of cytohistological findings, diagnostic imaging, and clinical course.

RESULTS

The diagnostic accuracy of the CB method and that of smear cytology were 93.9 and 60.6%, respectively (p = 0.003), and their respective sensitivities were 92.0 and 60.0% (p = 0.02). It was easier to make a definite diagnosis of not only malignancies but also benign conditions by the CB method than by the smear method.

CONCLUSION

The CB method with immunostaining showed a higher diagnostic yield than smear cytology in patients who had undergone EUS-FNA without rapid on-site cytology.

Role of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of solid pancreatic and peripancreatic lesions: is onsite cytopathology necessary?

OBJECTIVES

The reported median diagnostic yield from endoscopic ultrasound (EUS) fine-needle aspiration (FNA) cytology is 78% (range 39-93%). The aim of this study is to describe a single-centre experience in the diagnostic work-up of solid pancreatic and peripancreatic masses without the benefit of an onsite cytopathologist.

METHODS

In a consecutive series of 429 EUS examinations performed over a 12-month period by a single operator, 108 were on non-cystic pancreatic or biliary lesions. Data were collected prospectively and the accuracy of FNA was assessed retrospectively using either surgery or repeat imaging as the benchmark in the presence or absence of malignancy.

RESULTS

Of the 108 FNAs, 102 (94%) were diagnostic, four were falsely negative (FN) and two were atypical and considered equivocal. There were 78 pancreatic lesions, of which 65 were true positives (TP), 11 true negatives (TN) and two FN, giving an overall accuracy of 97% (76/78). Of nine periampullary lesions, two were TP, six were TN and one was FN, giving an overall accuracy of 89% (8/9). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of EUS-FNA for pancreatic and periampullary lesions combined were 96%, 100%, 100% [95% confidence interval (CI) 95-100%], 85% (95% CI 62-97%) and 97%, respectively. There were 21 bile duct lesions, of which 10 were TP, eight TN, two atypical and one FN, giving an overall accuracy of 86% (18/21). The sensitivity, specificity, PPV, NPV and accuracy of EUS-FNA for biliary lesions were 91%, 100%, 100% (95% CI 69-100%), 91% (95% CI 59-100%) and 95%, respectively.

CONCLUSIONS

The diagnostic accuracy of EUS-FNA for pancreatic lesions in our series was 97% and the PPV for the three subgroups of lesion type was 100%; these figures are comparable with the best rates reported in the literature, despite the absence of onsite cytopathology. These rates are potentially a direct result of high-volume practice, dedicated endosonography and cytopathology. These results show that it is possible to achieve high rates of accuracy in places where logistical issues make it impossible to maintain a cytopathologist in the endoscopy suite. In addition, our results contribute to the limited, collective global experience on the effectiveness of EUS-FNA in periampullary and biliary lesions.

Contrast enhanced endoscopic ultrasound: More than just a fancy Doppler

Contrast enhanced endoscopic ultrasound (CEUS) is a new modality that takes advantage of vascular structure and blood flow to distinguish different clinical entities. Contrast agents are microbubbles that oscillate when exposed to ultrasonographic waves resulting in characteristic acoustic signals that are then converted to colour images. This permits exquisite imaging of macro- and microvasculature, providing information to help delineate malignant from non-malignant processes. The use of CEUS may significantly increase the sensitivity and specificity over conventional endoscopic ultrasound. Currently available contrast agents are safe, with infrequent adverse effects. This review summarizes the theory and technique behind CEUS and the current and future clinical applications.

Pancreatic endoscopic ultrasound-guided fine needle aspiration: complication rate and clinical course in a single centre

BACKGROUND

Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-FNA) is effective for obtaining biopsy specimens from pancreatic lesions.

AIM

To determine the frequency and severity of complications after EUS-FNA of solid and cystic pancreatic lesions in a single centre large series of patients.

PATIENTS AND METHODS

From January 2005 to December 2008, information on all patients referred to our unit for pancreatic EUS was systematically entered in a computer database including clinical and morphologic data. Records were reviewed to evaluate whether complications such as haemorrhage, acute pancreatitis, intestinal perforation, or others occurred after EUS-FNA of the pancreas.

RESULTS

A total of 3296 pancreatic EUS were done in four years. In the 1034 pancreatic EUS-FNA, we observed 10 (0.96%) haemorrhages (7 intracystic, 2 in the pancreatic duct, and 1 in a small carcinoma), 2 (0.19%) acute severe pancreatitis and 1 (0.09%) duodenal perforation followed by complicated post-surgical hospitalization and death. The haemorrhages were all self-limiting. Overall, major complications (pancreatitis and perforation) arose in 0.29% of these examinations.

CONCLUSIONS

EUS-FNA is safe, with a low risk of severe haemorrhage. Although rare, acute pancreatitis is generally mild or severe, requiring prolonged hospitalization. One fatal complication occurred after duodenal perforation in a patient with duodenal neuroendocrine tumour and pancreatic infiltration.

The place of endoscopic ultrasound in bilio-pancreatic pathology

The place of endoscopic ultrasound (EUS) in malignant pathology of the pancreas is two-fold: (1) EUS is the best examination for the diagnosis of small tumours (<3cm in diameter). Its sensitivity is greater than that of CT scan, percutaneous ultrasound or magnetic resonance imaging (MRI) and is equal to that of endoscopic retrograde cholangiopancreatography (ERCP) without sharing its invasive character; (2) EUS is also indicated in the assessment of locoregional extension of tumours judged resectable by tomodensitometric (TDM) (scanner) data. The performance of EUS seems to be greater than other imaging techniques for the diagnosis of vascular and lymph node invasion although recent studies report less good results than those of studies in 1992 to 1994, particularly for vascular involvement. Nevertheless, EUS cannot affirm the malignant or benign character of these pancreatic masses. The development over the last 20 years of linear sector-based EUS has enabled us to perform guided biopsies of such lesions. EUS-guided biopsy is today the best technique for obtaining the histology of a pancreatic mass, with a sensitivity of 85 to 87%. Furthermore, it also has a non-negligible impact on the deciding the treatment particularly in the case of adenocarcinomas (ADKP) not visible to TDM (scanners). This is currently of importance because trials are being developed of preoperative radio-chemotherapy for resectable lesions. probably in the next future, contrast-enhanced EUS (CE-EUS) and elastography will improve the results of EUS and will be necessary for a precise local staging before treatment.

Prospective cytological assessment of gastrointestinal luminal fluid acquired during EUS: a potential source of false-positive FNA and needle tract seeding

OBJECTIVES

Endoscopic ultrasound (EUS) fine needle aspiration (FNA) can result in false-positive cytology and can also cause needle tract seeding. Our goal was to evaluate a potential cause, namely, the presence of malignant cells within gastrointestinal (GI) luminal fluid, either as a result of tumor sloughing from luminal cancers or secondary to FNA of extraluminal sites.

METHODS

During EUS, luminal fluid that is usually aspirated through the echoendoscope suction channel and discarded was instead submitted for cytological analysis among patients with cancer and benign disease. Pre- and post-FNA luminal fluid samples were collected to discern the role of FNA in inducing a positive cytology. When not performing FNA, one sample was collected for the entire examination. The final diagnosis was based on strict clinicopathological criteria and >or=2-year follow-up. This study was conducted in a tertiary referral center.

RESULTS

We assessed the prevalence of luminal fluid-positive cytology among patients with luminal (e.g., esophageal), extraluminal (e.g., pancreatic), and benign disease. Among the 140 patients prospectively enrolled with sufficient sampling and follow-up, an examination of luminal fluid cytology showed positive results for malignancy in luminal and extraluminal cancer patients, 48 and 10%, respectively. This included 8 out of 23 esophageal, 4 of 5 gastric, and 9 of 15 rectal cancers. The positive luminal fluid cytology rate with luminal cancers was not affected by performing FNA. Post-FNA luminal fluid cytology was positive in 3 out of 26 with pancreatic cancers. Cytological examination of luminal fluid aspirates did not demonstrate malignant cells in any patient with nonmalignant disease.

CONCLUSIONS

Malignant cells are commonly present in the GI luminal fluid of patients with luminal cancers and can also be found in patients with pancreatic cancer after EUS FNA. Further study is needed to determine the impact of these findings on cytological interpretation, staging, risk of needle tract seeding, and patient care and outcomes.

Progression from on-site to point-of-care fine needle aspiration service: Opportunities and challenges

Background

Standard-of-care requires the availability of an efficient, economical and accurate on-site fine needle aspiration (FNA) service. Presence of a trained individual during the procedure ensures an improved patient care. Appropriate selection of the equipment, interaction with the clinicians and compliance with the various regulations during the procedure is essential. This is often done by an on-site FNA service. Organization and implementation of such a system in a large academic center is challenging.

Method

we reviewed the ambulatory care needs in the new Perelman Center for Advanced Medicine (PeCAM). Multiple (9) FNA sites have been established keeping in view the patient's convenience, clinic demands, various regulatory requirements and laboratory staff. Each location has dedicated FNA station with microscopes and supplies. In addition, state- ofthe -art technologies including a mobile FNA cart (Penn-A- Cart), remote specimen evaluation (TeleCyP) have been incorporated.

Results

The new set up is extremely efficient and much valued by the patients and the clinicians. It has improved patient care.

Conclusion

With necessary investments and resources a point-of-care FNA service has been created which has improved patient care. This, albeit with certain modifications may serve as a model for FNA service.

PET and PET/CT for pancreatic malignancies

FDG PET imaging is useful for preoperative diagnosis of pancreatic carcinoma in patients with suspected pancreatic cancer in whom CT fails to identify a discrete tumor mass or in whom FNAs are nondiagnostic. FDG PET imaging is useful for M staging and restaging by detecting CT occult metastatic disease, allowing noncurative resection to be avoided in this group of patients. FDG PET can differentiate post-therapy changes from recurrence and holds promise for monitoring neoadjuvant chemoradiation therapy. The technique is less useful in periampullary carcinoma and marginally helpful in staging except for M staging. As with other malignancies, FDG PET is complementary to morphologic imaging with CT, therefore, integrated PET/CT imaging provides optimal images for interpretation and thus more optimal patient care.

Tumors of the Pancreatic Body and Tail

Tumors of the pancreatic body and tail are uncommon. They have a propensity to present late and often attain a large size with local invasion before they produce any clinical symptoms. The current review aims at comprehensively analysing these tumors with respect to their pathology, presentation, the investigation of these tumors, and finally the latest trends in their surgical and medical management.

The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer

Accurate staging of pancreatico-biliary cancer is essential for surgical planning and for identification of locally advanced and metastatic disease that is incurable by surgery. The complex regional anatomy of the pancreatico-biliary system makes histologic diagnosis of malignancy at this region difficult. The ability to position the endoscopic ultrasound transducer at endoscopy in direct proximity to the pancreas and the bile duct, combined with the use of fine-needle aspiration, enables accurate preoperative staging of cancer, especially cancer too small to be characterized by CT or MRI. Endoscopic ultrasonography (EUS) identifies patients unlikely to be cured by surgery due to vascular invasion or regional nodal metastasis, thereby limiting procedure-related morbidity and mortality. This article focuses on the utility and recent advances of EUS in the evaluation of pancreatico-biliary cancer.

Absence of a dilated duct predicts benign disease in suspected pancreas cancer: a simple clinical rule

BACKGROUND

Pancreatic cancer can be difficult to diagnose. Fine-needle aspiration (FNA) biopsies may be negative even when malignancy is present.

AIMS

To identify endosonographic features predictive of malignancy that will separate patients into high- and low-risk groups, in whom a negative FNA effectively rules out malignancy.

METHODS

Patients presenting for endoscopic ultrasound (EUS) evaluation for suspected pancreatic mass were prospectively enrolled. If a mass or abnormal lymph nodes were present, sampling via fine-needle aspiration (FNA) was performed. The characteristics of patients with cancer were compared to the characteristics of patients without cancer using Chi-square testing and t-tests.

RESULTS

Seventy-three patients were enrolled. Thirty-three patients had cancer and 40 had benign disease. On multivariate analysis, only vascular or organ invasion and dilation of the pancreatic duct (PD) were significantly associated with cancer. PD dilation was examined as a stand-alone feature. The presence of a dilated PD placed patients into a group with a 65% prevalence of malignancy. In the non-dilated PD group, the prevalence of malignancy was only 17%, and in this group, the negative predictive value of FNA was 100%, compared to an NPV of 73% in the entire cohort.

CONCLUSIONS

The most significant negative predictive endosonographic finding in patients with suspected pancreatic cancer is a non-dilated PD. If a patient with suspected pancreatic cancer does not have a dilated PD and the FNA is negative for malignancy, the likelihood of cancer is low.

Types of pancreatic cancer in EUS-FNA and chemotherapy

To determine the variety of chemotherapy drugs administrable for malignant pancreatic neoplasm as a result of typification with endoscopic ultrasonography-fine needle aspiration (EUS-FNA). A retrospective assessment, in one center, over a period of 1 year. Only malignant pancreatic neoplasm diagnosed by EUS-FNA was recorded. Benign (serous cystic neoplasm) and potentially malignant lesions (mucinous cystic neoplasm and intraductal papillary-mucinous neoplasm) were excluded. Medical data were recorded and Oncological Pharmacy records were studied. Ductal adenocarcinoma were detected in 17 patients (N = 17/22), 2 of them with adenocarcinoma in signet ring and 1 with mucinous adenocarcinoma. The primary therapies used were as follows: Whipple pancreaticoduodenectomy (3), biliary stent by endoscopic retrograde cholangiopancreatography (3), radiological transhepatic percutaneous stent (2), intestinal bypass (2), and a gastric stent (1). The adjuvant drugs used were gemcitabine (10), erlotinib (3), and cetuximab (1), and also radiotherapy was used (1). An unresectable squamous cell carcinoma (N = 1) of the tail was detected, and gemcitabine + vinorelbine + fluorouracil + cisplatin used. Nonfunctioning neuroendocrine tumors were seen in 3 (N = 3) cases and long-acting somatostatin analogues were used (1); the remaining 2 patients showed resectable tumors and were resected accordingly. A metastasis to the pancreatic head in a hepatocellular carcinoma was found in 1 patient (N = 1), allowing specific treatment with sorafenib. Histopathologic analysis with EUS-FNA implies a variety of different treatments. Optimal management was achieved as a result of improved diagnosis, with the advent of new molecular genetic diagnostic methods facilitating the design of specific new therapy and neoadjuvant targeting strategies.

EUS elastography for the characterization of solid pancreatic masses

BACKGROUND

Differential diagnosis of solid pancreatic masses remains a challenge. EUS elastography, by analyzing tissue stiffness of the mass, may be of help in this setting.

OBJECTIVE

To evaluate the different elastographic patterns of solid pancreatic masses and the diagnostic accuracy of EUS elastography for malignancy.

DESIGN

Prospective, consecutive, descriptive study with a second blind evaluation of elastographic patterns for concordance analysis and use of a well-defined reference method for calculation of diagnostic accuracy.

PATIENTS

This study involved 130 consecutive patients with solid pancreatic masses and 20 controls with normal pancreases.

INTERVENTION

EUS elastography was performed by using a linear Pentax echoendoscope and Hitachi EUB-8500 US.

MAIN OUTCOME MEASUREMENTS

Elastographic patterns of solid pancreatic masses and accuracy of the technique for malignancy.

RESULTS

Mean (SD) size of the masses was 30.9 (12.5) mm. The final diagnosis was malignant tumor in 78 patients, inflammatory mass in 42 patients, and neuroendocrine tumor in 10 patients. Four elastographic patterns were described, with a high concordance among 2 blinded investigators. A green-predominant pattern, either homogeneous or heterogeneous, excluded malignancy with a high accuracy. On the contrary, a blue-predominant pattern, either homogeneous or heterogeneous, supported the diagnosis of malignant tumor. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of EUS elastography for diagnosis of malignancy were 100%, 85.5%, 90.7%, 100%, and 94.0%, respectively.

LIMITATION

Single-center study.

CONCLUSION

EUS elastography is a useful tool for differential diagnosis of solid pancreatic masses. It provides specific patterns supporting the benign or malignant nature of the disease.

A prospective comparison of EUS-guided FNA using 25-gauge and 22-gauge needles

BACKGROUND AND AIMS

There are limited data on the differences in diagnostic yield between 25-gauge and 22-gauge EUS-FNA needles. This prospective study compared the difference in diagnostic yield between a 22-gauge and a 25-gauge needle when performing EUS-FNA.

METHODS

Forty-three patients with intraluminal or extraluminal mass lesions and/or lymphadenopathy were enrolled prospectively. EUS-FNA was performed for each mass lesion using both 25- and 22-gauge needles. The differences in accuracy rate, scoring of needle visibility, ease of puncture and quantity of obtained specimen were evaluated.

RESULTS

The overall accuracy of 22- and 25-gauge needle was similar at 81% and 76% respectively (N.S). Likewise the visibility scores of both needles were also similar. Overall the quantity of specimen obtained higher with the 22-gauge needle (score: 1.64 vs. P < .001). However the 25-gauge needle was significantly superior to the 22-gauge needle in terms of ease of puncture (score: 1.9 vs. 1.29, P < .001) and in the quantity of specimen in the context of pancreatic mass EUS-FNA (score: 1.8 vs. 1.58, P < .05).

CONCLUSION

The 22-gauge and 25-gauge needles have similar overall diagnostic yield. The 25-gauge needle appeared superior in the subset of patients with hard lesions and pancreatic masses.

Pancreatic tuberculosis mimicking pancreatic carcinoma: series of three cases

Tuberculosis (TB) is a worldwide pandemic, and is seeing a resurgence because of the AIDS epidemic. Pancreatic involvement is rare in the world, and when it is isolated around the pancreas, it is often mistaken for pancreatic carcinoma. We report three cases of pancreatic TB that masqueraded as malignancy in a 50-year-old female, a 34-year-old male and a 39-year-old male with a previous history of abdominal TB. All had computed tomographic scans suspicious of possible pancreatic malignancy. Endoscopic ultrasound was performed in two patients. Two patients underwent laparotomy but did not undergo the intended pancreaticoduodenectomy, whereas the third patient was diagnosed after computed tomographic-guided percutaneous biopsy of the pancreatic mass. In conclusion, pancreatic TB should always be considered as a differential diagnosis to pancreatic malignancy.

Contrast-enhanced endoscopic ultrasound and elastosonoendoscopy

Until recently, there was no contrast harmonic imaging technique available for EUS examination. Second-generation US contrast agents produce harmonic signals at lower acoustic powers and, therefore, are suitable for EUS imaging at low acoustic powers. CE-EUS could provide a contribution to the differential diagnosis between a primary pancreatic carcinoma, chronic pancreatitis and a pancreatic metastasis, and therefore can have a decisive influence on the selection of appropriate therapeutic strategies (follow-up, chemotherapy or surgery, for example). However, histology remains the standard in the differential diagnosis of pancreatic tumours. Regarding lymph nodes, CE-EUS cannot replace EUS-guided fine-needle aspiration. Elastography examines the elastic properties of tissues by applying a slight compression to the tissue and comparing an image obtained before and after this compression. EUS elastography is a new application in the field of endosonography and seems to be able to differentiate fibrous and benign tissue from malignant lesions. While our results are very encouraging, further research will be needed to further define the place of this new technique and should be aimed at further defining criteria for accurate elastography as well as subsequently assessing the technique using multiple operators in a blinded setting. EUS-guided sonoelastography has the potential for further guiding the diagnosis and therapy of gastrointestinal-related tumours.

Endosonography in the management of biliopancreatic disorders

Over the past two decades, endoscopic endosonography (EUS) has evolved into an indispensible diagnostic and therapeutic utility in the diagnosis and treatment of patients with pancreatobiliary disease. In this article, we summarise its current potential and provide an update of the latest literature.

Usefulness of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for undiagnosed intra-abdominal lymphadenopathy

BACKGROUND

The differentiation between benign and malignant abdominal lymph nodes is difficult, especially if no primary site is evident or if cancer resection was remote in time. The aim of this study was to evaluate the yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in patients with undiagnosed intra-abdominal lymphadenopathy.

METHODS

Fifty-seven consecutive patients with undiagnosed abdominal lymphadenopathy who were registered in our EUS-FNA database from January 1997 to December 2007 were reviewed. EUS-FNA was carried out using a 22-G needle. The final pathological diagnosis was based on the cytopathological, histological, and immunohistochemical (IHC) findings.

RESULTS

Adequate specimens were obtained in 93% cases. The final diagnoses included local recurrence of malignancy after resection (n = 16), lymphoma (n = 12), and benign/reactive changes (n = 17). The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of EUS-FNA were 94, 100, 100, 90 and 96%, respectively. In addition, it was also possible to classify lymphoma subtypes in 83% of cases. No complications occurred during the procedures.

CONCLUSIONS

EUS-FNA is clinically very useful for establishing the diagnosis of abdominal lymphadenopathy of unknown cause and can provide sufficient tissue for IHC and subtyping of lymphomas.

Diagnostic value of EUS-FNA in patients suspected of having pancreatic cancer with a focal lesion on CT scan/MRI but without obstructive jaundice

OBJECTIVE

Patients frequently present with suspected pancreatic neoplasm based on a focal pancreatic lesion on computed tomographic (CT) scan/magnetic resonance image (MRI) but without obstructive jaundice. We evaluated the performance characteristics of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in this patient subset.

METHODS

This is a retrospective analysis of a prospective database and included patients who underwent EUS-FNA at a university hospital for a focal pancreatic lesion noted on CT/MRI. Patients were excluded if (1) they had obstructive jaundice or (2) the lesion appear (seem)ed cystic on CT/MRI. The main outcome measurements were (1) prevalence of pancreatic cancer and (2) performance characteristics of EUS-FNA for identifying malignancy.

RESULTS

In the 213 study patients, a focal pancreatic lesion was identified in 173 patients by EUS. The final diagnosis included adenocarcinoma (n=89), neuroendocrine tumor (n=14), mucinous cystadenocarcinoma (n=1), solid pseudopapillary tumor (n=2), metastases (n=4), benign cyst (n=19), pseudocyst (n=9), abscess (n=4), chronic pancreatitis (n=32), and normal pancreas (n=39). Endoscopic ultrasound-guided FNA had an accuracy of 97.6% for diagnosing malignant neoplasm, with 96.6% sensitivity, 99.0% specificity, 96.2% negative predictive value, and 99.1% positive predictive value.

CONCLUSIONS

Endoscopic ultrasound-guided FNA is highly accurate for diagnosing malignancy in patients with a focal pancreatic lesion on CT scan/MRI but without obstructive jaundice. Endoscopic ultrasound-guided FNA can potentially be used as a definitive diagnostic test in the management of these patients.

Small cell carcinoma of the pancreas: role of EUS-FNA and subsequent effective chemotherapy using carboplatin and etoposide

BACKGROUND

Small cell carcinoma (SCC) of the pancreas is a rare entity, with only a few cases reported in the literature. The aim of this study was to evaluate the effectiveness of combination chemotherapy with carboplatin and etoposide (CE) in SCC of the pancreas.

METHODS

We performed a retrospective analysis of four patients diagnosed with SCC among 279 patients with malignant pancreatic tumors treated between 2000 and 2007. All patients were treated with combination chemotherapy using a schedule consisting of intravenous (IV) carboplatin (150 mg/m(2)) on day 1 and IV etoposide (80 mg/m(2)) on days 1, 2, and 3 every 28 days.

RESULTS

Pathological diagnosis was confirmed by endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) in all patients. Three patients treated with the combination chemotherapy achieved remission, two with a complete response and one with a partial response. The remaining one patient showed no change. One of the two patients with a complete response survived for 56 months following the diagnosis.

CONCLUSIONS

Combination chemotherapy with CE may be effective for the treatment of SCC of the pancreas; EUS-FNA plays an important role in distinguishing SCC from other pancreatic malignancies, leading to the appropriate treatment being given.

EUS-guided FNA of solid pancreatic masses: high yield of 2 passes with combined histologic-cytologic analysis

BACKGROUND

EUS-guided FNA (EUS-FNA) is an established tissue-acquisition technique, with most studies concentrating on cytologic analyses of specimens, with only few data existing on histologic assessment.

OBJECTIVE

To assess the sensitivity of a combined analysis of histologic followed by cytologic tissue diagnosis.

DESIGN

A retrospective 3-center study.

METHODS

In consecutive patients undergoing FNA of solid pancreatic masses, core specimens were harvested for histology; residual tissue was examined cytologically. Only unequivocally positive results were regarded as malignant. Criterion standards were positive results from EUS-FNA or other histologic findings, or, if negative, clinical follow-up data (minimum 12 months).

RESULTS

Among 192 patients (110 men; mean age 63 years) with mostly pancreatic-head masses (72.4%), overall, adequate tissue was obtained in 98.9% of all cases, with a mean of 1.88 needle passes and an overall sensitivity of 82.9% (95% CI, 76.0%-88.5%). Histology and subsequent cytology provided adequate tissue and sensitivities of 86.5% and 60%, and 92.7% and 68.1%, respectively. Excluding cases with inadequate specimens, sensitivities rose by 4% to 10%. Histology showed a trend for superiority over cytology only in characterizing nonadenocarcinoma tumor types. No differences in sensitivity were found between the centers involved.

LIMITATIONS

Retrospective design, different processing of cytologic specimens.

CONCLUSIONS

At EUS-FNA in pancreatic masses, combined histologic-cytologic analysis achieved a sensitivity of more than 80%, despite a low number of needle passes and may thus save time. Histology alone did not reach higher sensitivity than cytology. In particular situations, eg, rare tumors, histology may still be required.

Endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic masses with rapid on-site cytological evaluation by endosonographers without attendance of cytopathologists

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with rapid on-site evaluation (ROSE) has been reported to provide a more accurate diagnosis than EUS-FNA without such evaluation. However, even endosonographers can evaluate ROSE regarding sample adequacy. The aim of this study was to evaluate the diagnostic accuracy of EUS-FNA with ROSE by endosonographers compared to ROSE by cytopathologists in patients with solid pancreatic masses.

METHODS

Between September 2001 and October 2005, of the 73 EUS-FNA procedures with the final diagnoses, 38 procedures after the introduction of ROSE by endosonographers (September 2001-September 2003, period 1), and 35 procedures after the introduction of ROSE by cytopathologists (October 2003-October 2005, period 2) were included. The specimens were stained with Diff-Quik stain and assessed. When the on-site assessors (endosonographers or cytopathologists) indicated that the amounts of cell samples were adequate, the procedure was stopped.

RESULTS

Results are presented with 95% confidence limits. The average numbers of needle passes were 4.0 +/- 1.6 and 3.4 +/- 1.5 in periods 1 and 2, respectively (P = 0.06). The specimen collection rates were 97.4 and 97.1% in periods 1 and 2, respectively (P = 0.51). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for malignancy and benign were 92.9, 100, 100, 83.3, and 94.7%, respectively, in period 1, and 93.1, 100, 100, 75.0, and 94.3%, respectively, in period 2 (P = 0.97, P = 1.0, P = 1.0, P = 0.65, P = 0.93, respectively). No complications were seen.

CONCLUSIONS

For accurate diagnosis, ROSE should be performed during EUS-FNA by the endosonographer, if no cytopathologist is available.

Diagnosis of small pancreatic cancer by endoscopic balloon-catheter spot pancreatography: an analysis of 29 patients

OBJECTIVES

The diagnosis of small pancreatic cancer remains difficult. The present study describes the diagnostic value of endoscopic balloon-catheter spot pancreatography for small pancreatic cancer.

METHODS

Since April 1984, balloon spot pancreatography has been used to detect small-sized pancreatic cancer in patients having possible symptoms or findings of obstructive pancreatitis.

RESULTS

A resection was performed on 175 of 416 patients with conditions diagnosed as pancreatic cancer. Of the 175 patients, 23 (13%) had invasive carcinoma 2 cm or smaller based on histological measurements, 3 intraductal papillotubular adenocarcinoma, and 3 carcinoma in situ (CIS). Regarding invasive carcinoma, balloon pancreatography displayed duct abnormalities diagnosed as carcinoma in 20 of 22 patients, whereas carcinoma was suggested in 2. A definite diagnosis was obtained based on the findings of main duct stenosis or obstruction with marked stricture of the branch ducts (n = 18) and a filling defect in the main duct (n = 2). Moreover, this pancreatogram demonstrated an intraductal filling defect in 2 of 3 with intraductal carcinoma and dead twiglike findings in the branch ducts in 1 of 3 with CIS.

CONCLUSIONS

Balloon spot pancreatography is an essential tool for the diagnosis of small ductal pancreatic cancer, and it also makes it possible to locate CIS lesions of the branch ducts.

Rare pancreatic neoplasms: the utility of endoscopic ultrasound-guided fine-needle aspiration-a large single center study

BACKGROUND

Tumors other than ductal adenocarcinomas constitute 10%-15% of all pancreatic tumors. We describe the performance and pitfalls of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosis of these rare pancreatic tumors and their characteristic cytopathological features.

METHODS

The records of 455 pancreatic fine-needle aspiration procedures done between March 1997 and August 2006 at Aichi Cancer Center, Nagoya, Japan, were reviewed. Besides cytology, aspirated material was routinely submitted in formalin for cell-block analysis. The reference standard for final diagnosis was surgical pathology from resected specimens.

RESULTS

Twenty-eight rare (nonductal adenocarcinomas) pancreatic tumors were identified. Overall, EUS-FNA with the results of cytology, cell-block processing, and immunohistochemistry could correctly diagnose the type of neoplasm in 19 (67.9%) cases. EUS-FNA could distinguish benign from malignant rare tumors with a sensitivity of 69.2%, a specificity of 100%, positive predictive value of 100%, negative predictive value of 79.0%, and accuracy of 85.7%. None of three malignant pancreatic endocrine neoplasms could be diagnosed as malignant. An adequate core tissue sample could be obtained in 21 cases (75.0%) and provide a histopathological diagnosis in 19 (67.9%) cases. EUS-FNA could change the presumptive diagnosis in 11 (39.3%) cases. Specific immunochemical studies were useful adjuncts to the diagnosis. No major or minor complication was noted in any patient.

CONCLUSIONS

Pancreatic neoplasms other than ductal adenocarcinomas have diverse imaging and histopathological features. EUS-FNA is accurate and safe for their identification.

Yield of EUS-guided FNA on the diagnosis of pancreatic/peripancreatic tuberculosis

BACKGROUND

Pancreatic/peripancreatic tuberculosis (TB) is a very rare clinical entity, even in countries with high incidences of TB. The diagnosis of pancreatic/peripancreatic TB with EUS-guided FNA (EUS-FNA) remains a diagnostic challenge because of limitations of the endoscopists' expertise on this condition.

OBJECTIVE

This study evaluated the yield and usefulness of EUS-FNA in patients with pancreatic/peripancreatic TB.

DESIGN

A retrospective analysis was performed.

SETTING

A tertiary teaching hospital in Seoul, Korea.

PATIENTS

Baseline demographic and clinical features were evaluated in 21 consecutive patients with pancreatic/peripancreatic TB who underwent EUS-FNA between September 2003 and April 2007.

RESULTS

The mean lesion diameter was 31.3 +/- 14.6 mm. Thirteen patients (61.9%) showed granulomatous inflammation on histopathologic examination, and 10 of 15 patients (66.7%) were positive on a TB polymerase chain reaction assay. Ziehl-Neelsen staining was positive in 4 of 15 patients (26.7%), and 3 of 8 patients (37.5%) had cultures positive for Mycobacterium tuberculosis. EUS-FNA correctly diagnosed pancreatic/peripancreatic TB in 16 patients (76.2%). Therefore, unnecessary surgery was avoided for these patients.

LIMITATION

A retrospective study.

CONCLUSIONS

EUS-FNA is a safe and promising method for the diagnosis of pancreatic/peripancreatic TB. Use of this method may help us to avoid the use of surgery and provide timely and accurate diagnosis.

Prospective comparative study of the EUS guided 25-gauge FNA needle with the 19-gauge Trucut needle and 22-gauge FNA needle in patients with solid pancreatic masses

BACKGROUND AND STUDY AIMS

The aim of this prospective study was to compare fine-needle aspiration guided by endoscopic ultrasonography (EUS-FNA) using 25-gauge and 22-gauge needles with the EUS-guided 19-gauge Trucut needle biopsy (EUS-TNB) in patients with solid pancreatic mass.

PATIENTS AND METHODS

Twenty-four consecutive patients with pancreatic mass underwent biopsies by both EUS-FNA and EUS-TNB. Three needles were compared with respect to technical success rate, tissue size obtained, overall diagnostic accuracy and accuracy for histological and cytological diagnosis.

RESULTS

The 25-gauge EUS-FNA was technically easier and obtained superior overall diagnostic accuracy than the 22-gauge and Trucut needles, especially in lesions of the pancreas head and uncinate process. Overall accuracy for the 25-gauge, 22-gauge and Trucut needle was 91.7%, 79.7% and 54.1%, respectively. Accuracy for cytological diagnosis irrespective the site of lesions with 25-gauge, 22-gauge and Trucut needles was 91.7%, 75.0%, and 45.8%, respectively. For uncinate masses, it was 100%, 33.3%, and 0.0%, respectively. These differences were significant. Among technically successful patients, the accuracy for histological diagnosis using the 25-gauge was significantly inferior (P < 0.05) to 22-gauge and Trucut needles and the rates were 45.8%, 78.9% and 83.3%.

CONCLUSIONS

The 25-gauge FNA needle was significantly superior in terms of technical success rate and overall diagnostic accuracy, especially for the head and uncinate lesions, compared to the 22-gauge and Trucut needles and could be considered 'the best choice needle for cytological diagnosis' of solid pancreatic lesions. If histological diagnosis is required, the 22-gauge FNA needle and Trucut needle may be advantageous for use in head/uncinate and body/tail lesions, respectively.

Experimental endoscopy: objective evaluation of EUS needles

BACKGROUND

In the clinical setting, endosonographers acknowledge that not only the size and characteristics of EUS-guided FNA needles but also several conditions affect the acquisition of adequate samples.

OBJECTIVE

To compare the characteristics of the 19-gauge Tru-cut, 19-gauge aspiration, 22-gauge aspiration, and 25-gauge aspiration EUS needles under several conditions by using a bench simulator designed to provide standardized, reproducible, comparative performance data in combination with evaluation by 3 endosonographers of needle-insertion resistance.

DESIGN

Laboratory simulations that compare resistance to needle advancement under several conditions (straight and angulated endoscope position, endoscopic tip angulation, and the use of the elevator) by using both diagnostic and therapeutic EUS scopes. These varied conditions cause a range of resistance to the advancement of the needle through the endoscope.

SETTING

Research laboratory.

MAIN OUTCOME MEASUREMENT

The mean (SD) for advancement resistance (N) to each EUS needle. Needle resistance was evaluated individually by endosonographers and divided into 5 levels (0 [no resistance] to 5 [impossible for needle to be advanced]).

RESULTS

Endosonographers concluded that the needle-advancement resistance was moderate with a pressure resistance to the needle of 5 N or more and high at 8 N or more, and that it was impossible to advance the needle when the resistance to it was 11 N or more. Instrumentational evaluation showed that, with the 25-gauge and 22-gauge needles, needle resistance was approximately less than 2 N and 3 N, respectively. In the straight endoscope position, the 19-gauge aspiration or Tru-cut needle resistance when using upward angulation of the endoscope or the elevator was more than 8 N and 10 N, respectively. In the angulated endoscope position, the resistance to the 19-gauge aspiration or Tru-cut needle when using upward angulation was more than 10 N and 20 N, respectively.

LIMITATIONS

All data were collected ex vivo, and clinical validity remains to be determined.

CONCLUSIONS

The 22-gauge or 25-gauge EUS-guided FNA needles are suitable for insertion into the target regions if tight angulation is necessary.

Preoperative tissue diagnosis for tumours of the pancreas

BACKGROUND

Preoperative biopsy of pancreatic lesions suspected of malignancy is controversial.

METHODS

A systematic Medline literature search was carried out. Diagnostic studies reporting quantitative preoperative pancreatic biopsy data were evaluated.

RESULTS

The analysis included 53 studies, mostly of a retrospective nature. Despite acceptable rates for sensitivity and specificity, the negative predictive value of percutaneous and endoscopic ultrasonography-guided biopsies was 60-70 per cent. Biopsy results were considered to be essential for directing non-surgical therapy in advanced disease. However, they were of limited value in planning the treatment of resectable solid or cystic tumours, or focal lesions in the setting of chronic pancreatitis.

CONCLUSIONS

Biopsy of suspected pancreatic malignancies with systemic spread or local irresectability is indicated for planning palliative or neoadjuvant therapy. Preoperative biopsy of potentially resectable pancreatic tumours is not generally advisable, as malignancy cannot be ruled out with adequate reliability.

Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer

Early diagnosis of pancreatic cancer remains a difficult task, and multiple imaging tests have been proposed over the years. The aim of this review is to describe the current role of endoscopic ultrasound (EUS) for the diagnosis and staging of patients with pancreatic cancer. A detailed search of MEDLINE between 1980 and 2007 was performed using the following keywords: pancreatic cancer, endoscopic ultrasound, diagnosis, and staging. References of the selected articles were also browsed and consulted. Despite progress made with other imaging methods, EUS is still considered to be superior for the detection of clinically suspected lesions, especially if the results of other cross-sectional imaging modalities are equivocal. The major advantage of EUS is the high negative predictive value that approaches 100%, indicating that the absence of a focal mass reliably excludes pancreatic cancer. The introduction of EUS-guided fine needle aspiration allows a preoperative diagnosis in patients with resectable cancer, as well as a confirmation of diagnosis before chemoradiotherapy for those that are not. This comprehensive review highlighted the diagnostic capabilities of EUS including the newest refinements such as contrast-enhanced EUS, EUS elastography, and 3-dimensional EUS. The place of EUS-guided biopsy is also emphasized, including the addition of molecular marker techniques.

Cytology from pancreatic cysts has marginal utility in surgical decision-making

BACKGROUND

Preoperative diagnosis of pancreatic cystic neoplasms is problematic. We evaluated our experience with endoscopic ultrasound (EUS) to determine the utility of fine-needle aspiration cytology (FNAC) in surgical decision-making.

METHODS

Patients evaluated for pancreatic cysts with EUS fine-needle aspiration (FNA) from 3/1996-10/2003 were included. Patients undergoing both preoperative EUS-FNA and pancreatic resection were identified. FNAC read as a mucinous cystic neoplasm (MCN), suspicious for neoplasia, or mucinous epithelial/atypical cells were classified as "concerning." Cytology with no malignant cells was negative. FNAC read as indeterminate, atypical cells of undetermined significance, or possible contamination was nondiagnostic.

RESULTS

Of 95 patients evaluated with EUS FNAC, 29 underwent resection. On final pathology, 7/29 lesions (24%) were malignant [two neuroendocrine tumors, three adenocarcinomas, one invasive intraductal papillary mucinous neoplasm (IPMN), and one metastatic uterine tumor], 4/29 (14%) were benign (three serous cystadenomas and one chronic pancreatitis), and 18/29 (62%) were premalignant (ten MCNs and eight IPMNs). Seven patients had concerning FNAC. All seven harbored malignant or premalignant lesions. Nine patients had negative FNAC: three (33%) with benign lesions and six (67%) with premalignant lesions. Thirteen of the 29 patients (45%) had nondiagnostic FNAC with 12/13 (92%) harboring a malignant or premalignant lesion. Sensitivity, specificity, positive predictive value, and negative predictive value were 28%, 100%, 100%, and 18%, respectively.

CONCLUSION

The decision to proceed with nonoperative management should not be based on a negative or nondiagnostic FNAC alone, as 67% of negative and 92% of nondiagnostic specimens were associated with malignant or premalignant pathology.

Analysis of microRNAs in pancreatic fine-needle aspirates can classify benign and malignant tissues

BACKGROUND

MicroRNAs (miRNAs) are RNA molecules that are involved in the regulation of many cellular processes, including those related to human cancers. The aim of this study was to determine, as a proof of principle, whether specific candidate miRNAs could be detected in fine-needle aspirate (FNA) biopsies of pancreatic ductal adenocarcinoma (PDAC) and could accurately differentiate malignant from benign pancreatic tissues.

METHODS

We used TaqMan(R) assays to quantify miRNA levels in FNA samples collected in RNARetain (n = 16) and compared the results with a training set consisting of frozen macrodissected pancreatic samples (n = 20).

RESULTS

Quantitative reverse-transcription PCR analysis confirmed that miRNA levels are affected in PDAC FNAs and correlate well with the changes observed in the training set of frozen pancreatic samples. Analysis of the amounts produced for a few specific miRNAs enabled identification of PDAC samples. The combination of miR-196a and miR-217 biomarkers further improved the ability to distinguish between healthy tissue, PDAC, and chronic pancreatitis in the training set (P = 8.2 x 10(-10)), as well as segregate PDAC FNA samples from other FNA samples (P = 1.1 x 10(-5)). Furthermore, we showed that miR-196a production is likely specific to PDAC cells and that its incidence paralleled the progression of PDAC.

CONCLUSIONS

To the best of our knowledge, this study is the first to evaluate the diagnostic potential of miRNAs in a clinical setting and has shown that miRNA analysis of pancreatic FNA biopsy samples can aid in the pathologic evaluation of suspicious cases and may provide a new strategy for improving the diagnosis of pancreatic diseases.

Endoscopic ultrasound-guided ethanol injection in the pancreas in a porcine model: a preliminary study

BACKGROUND AND AIM

Despite aggressive multimodal treatments, survival rates for patients with pancreatic cancer remain disappointing. Local progression is problematic, and minimally invasive procedures allowing locoregional control are needed. In this study, we attempted endoscopic ultrasound (EUS)-guided injection of ethanol into the pancreas.

METHODS

Under EUS guidance, pure ethanol (2 mL) was injected into normal tissue of the pancreatic body in two anesthetized domestic pigs. Serum concentrations of amylase, aspartame aminotransferase, alanine aminotransferase, alkaline phosphatase, and lactate dehydrogenase were measured before treatment and at 2 h, 48 h and 2 weeks after injection. Body weight and clinical signs were also observed. After the animals were euthanized, the pancreases were analyzed histologically.

RESULTS

EUS imaging allows real-time surveillance of the injection procedure. Mild diarrhea was noted in one animal, but no other adverse effects were observed. No marked changes in laboratory tests were noted. Histologically, parenchymal necrosis extending over a wide area was seen without severe inflammation.

CONCLUSION

EUS-guided ethanol injection in the pancreas seems to be technically simple. More detailed assessments of the safety and dose-effect relationship issues associated with this procedure are required.

[Endoscopic ultrasound-guided biopsy for the evaluation of pancreatic tumors]

In the classical approach to pancreatic lesions, the key used to be to exclude malignancy and evaluate tumor resectability and the patient's suitability for surgery. Pancreatic biopsy was rejected because a negative result does not exclude malignancy, the risk of seeding, which could make curative surgery impossible, the low surgical risk of morbidity and mortality, and the high diagnostic efficacy of imaging techniques. In this context, pancreatic biopsy was limited to irresectable tumors, and cases with suspicion of tuberculosis, lymphoma, neuroendocrine tumors or cystic tumors. Currently, pancreatic biopsy is becoming essential for the correct management of all types of pancreatic lesions, improving therapeutic management. Endoscopic ultrasound-guided biopsy has been proven to be safe, with a low complications rate, and with higher diagnostic efficacy than that of other procedures and is probably the technique of choice for the study of pancreatic lesions.

Improved differentiation of pancreatic tumors using contrast-enhanced endoscopic ultrasound

BACKGROUND & AIMS

Endoscopic ultrasound is a widely accepted imaging method for staging of ductal adenocarcinoma and the localization of neuroendocrine tumors of the pancreas. We prospectively evaluated conventional color Doppler imaging and contrast-enhanced endoscopic Doppler ultrasound (CE-EDUS) as a new imaging technique for further characterization and differentiation of solid pancreatic tumors.

METHODS

From 300 patients with pancreatic lesions investigated using contrast-enhanced endoscopic ultrasound we could finally include 93 patients with an undetermined, solitary, predominantly solid, lesion 40 mm or less, and a definite histologically proven diagnosis. After bolus injection of the contrast agent SHU 508A 4 g (400 mg/dL) the vascular pattern of the lesion during the arterial phase was compared with the vascularity of the residual pancreatic parenchyma.

RESULTS

Color Doppler imaging did not reveal vascularity of the pancreatic parenchyma in any of the patients, and therefore tumor hypovascularity could not be determined in contrast to all CE-EDUS-examined patients revealing at least some degree of parenchymal vascularity. Fifty-seven of 62 patients with ductal adenocarcinoma of the pancreas showed a hypovascularity of the tumor using CE-EDUS. All other pancreatic lesions revealed an isovascular or hypervascular pattern using contrast-enhanced endoscopic ultrasound (20 neuroendocrine tumors, 10 serous microcystic adenomas, and 1 teratoma). Hypovascularity as a sign of malignancy in contrast-enhanced endoscopic ultrasound obtained 92% (82%-97%) sensitivity and 100% specificity (89%-100%).

CONCLUSIONS

Contrast-enhanced endoscopic ultrasound is effective in differentiating small solid pancreatic tumors of different origin in most cases. Hypovascularity indicates malignancy of pancreatic tumors.