Diagnostic des lésions kystiques du pancréas par l'aspiration à l'aiguille fine guidée sous échoendoscopie digestive Quel prélèvement et pourquoi? Utilité de la microbiopsie sur la paroi du kyste et de l'analyse du liquide en technique monocouche

Impact of cytopathologist expert on diagnosis and treatment of pancreatic lesions in current clinical practice. A series of 106 endoscopic ultrasound-guided fine needle aspirations

OBJECTIVES

To evaluate the role of a cytopathologist expert in interpreting difficult pancreatic endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in terms of impact on diagnostic yield and therapy in current clinical practice.

METHODS

Retrospective study of 106 EUS-FNA performed between January 2002 and September 2004. Forty-seven cases of difficult interpretation by the local cytopathologist were mailed to an expert cytopathologist. The final diagnosis was established by histology obtained by either surgery (n=30), non-equivocal FNA (n=40) or core (n=8) biopsies, or by a mean follow-up of 14 months (n=28).

RESULTS

EUS-FNA involved 68 solid lesions (SL). Specimens collected were adequate in 63%. The overall sensitivity of EUS-FNA for the diagnosis of malignancy of SL was 88% versus 72% for local cytopathologist and 89% for expert. EUS-FNA with the reevaluation by expert of 39 SL gave a therapeutic impact in 47% of SL. Thirty-eight cystic lesions (CL) were evaluated. Specimens collected were adequate for cytology in 84% of cases and for biochemistry in 79%. The sensitivity of imaging+EUS-FNA+/-biochemistry for the diagnosis of a surgical CL was 58% with a therapeutic impact in 39.5%.

CONCLUSION

Pancreatic EUS-FNA is an easy technique for experienced endosonographers, which can be safely performed on an outpatient basis. The possibility of mailing difficult cases to an expert cytopathologist increases the diagnostic yield. In these circumstances, EUS-FNA has a therapeutic impact in current practice in nearly one out of two pancreatic lesions.

Cytopathology in France

In France, organization of the cytopathology seems to be quite different from that specifically regulated in the USA and in some other European countries. The aim of this article is to underline these specificities and to describe the solutions we advocate concerning new technologies, teaching, quality assurance, national guidelines em leader, to make our current practice compatible with the international recommendations. Moreover, we highlight the peculiar status of French cytotechnologists' and comment on the recent dramatic decrease of the medical demography in France, the consequence of which may promote a controlled transfer of competence.

Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions

OBJECTIVE

Preoperative diagnosis of cystic lesions of the pancreas remains difficult despite improvement in imaging modalities and cystic fluid analysis. The aim of our study was to assess the performance of endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration (FNA) in the diagnosis of pancreatic cystic lesions.

METHODS

Data from a series of 127 consecutive patients with pancreatic cystic lesions were prospectively studied. EUS and EUS-guided FNA were performed in all patients, and cystic material was used for cytological and histological analysis as well as for biochemical and tumor markers analysis. Performance of EUS diagnosis, biochemical and tumor markers, and FNA diagnosis were compared with the final histological diagnosis obtained at surgery or postmortem examination. Sixty-seven patients underwent surgery and therefore constituted our study group.

RESULTS

EUS provided a tentative diagnosis in 113 cases (89%). Cytohistological FNA provided a diagnosis in 98 cases (77%). When the results of EUS and EUS-guided FNA were compared with the final diagnosis (67 cases), EUS correctly identified 49 cases (73%), whereas FNA correctly identified 65 cases (97%). Sensitivity, specificity, positive predictive value, and negative predictive value of EUS and EUS-guided FNA to indicate whether a lesion needed further surgery were 71% and 97%, 30% and 100%, 49% and 100%, and 40% and 95%, respectively. Carbohydrate antigen 19-9 > 50,000 U/ml had a 15% sensitivity and a 81% specificity to distinguish mucinous cysts from other cystic lesions, whereas it had a 86% sensitivity and a 85% specificity to distinguish cystadenocarcinoma from other cystic lesions.

CONCLUSIONS

EUS-guided FNA is a valuable tool in the preoperative diagnostic assessment of pancreatic cystic lesions.

[Unilocular macrocystic serous cystadenoma of the pancreas: a morphologic variant to be considered]

Serous cystadenoma of the pancreas is a benign cystic tumor, which radiological diagnosis is easy in its typical microcystic variant. The macrocystic variant is uncommon and raises diagnostic problems with other macrocystic lesions of the pancreas such as pseudocysts and mucinous cystadenomas. We report the case of a young woman with a unilocular macrocystic serous cystadenoma of the pancreas which was identified on pathologic examination of the surgical specimen, after unconclusive abdominal ultrasound and CT-scan. This case describes an unusual clinical presentation of this cystic tumor and emphasizes that the diagnosis of such an entity is still based on pathological examination after cyst removal.