Safety and efficacy of cytology brushings versus standard FNA in evaluating cystic lesions of the pancreas: a pilot study

Risk Models for Pancreatic Cyst Diagnosis

The overall prevalence of pancreatic cysts (PCs) is high in the general population. In clinical practice PCs are often incidentally discovered and are classified into benign, premalignant, and malignant lesions according to the World Health Organization. For this reason, in the absence of reliable biomarkers, to date clinical decision-making relies mostly on risk models based on morphological features. The aim of this narrative review is to present the current knowledge regarding PC's morphologic features with related estimated risk of malignancy and discuss available diagnostic tools to minimize clinically relevant diagnostic errors.

Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review

Pancreatic cystic lesions are being discovered as incidental lesions during cross-sectional imaging studies of the abdomen with increasing frequency. Endoscopic ultrasound is an important diagnostic modality for managing pancreatic cystic lesions. There are various types of pancreatic cystic lesions, from benign to malignant. Endoscopic ultrasound has a multifactorial role in delineating the morphology of pancreatic cystic lesions, ranging from fluid and tissue acquisition for analysis-fine needle aspiration and through-the-needle biopsy, respectively-to advanced imaging techniques, such as contrast-harmonic mode endoscopic ultrasound and EUS-guided needle-based confocal laser endomicroscopy. In this review, we will summarize and provide an update on the specific role of EUS in the management of pancreatic cystic lesions.

Cystic pancreatic lesions: MR imaging findings and management

Cystic pancreatic lesions (CPLs) are frequently casual findings in radiological examinations performed for other reasons in patients with unrelated symptoms. As they require different management according to their histological nature, differential diagnosis is essential. Radiologist plays a key role in the diagnosis and management of these lesions as imaging is able to correctly characterize most of them and thus address to a correct management. The first step for a correct characterization is to look for a communication between the CPLs and the main pancreatic duct, and then, it is essential to evaluate the morphology of the lesions. Age, sex and a history of previous pancreatic pathologies are important information to be used in the differential diagnosis. As some CPLs with different pathologic backgrounds can show the same morphological findings, differential diagnosis can be difficult, and thus, the final diagnosis can require other techniques, such as endoscopic ultrasound, endoscopic ultrasound-fine needle aspiration and endoscopic ultrasound-through the needle biopsy, and multidisciplinary management is important for a correct management.

Management of Incidental Pancreatic Cystic Lesions: Integrating Novel Diagnostic and Prognostic Factors With Current Clinical Guidelines

Owing to increased detection rates, the diagnosis and management of incidental pancreatic cysts has become a common predicament. Up to 13% of patients undergoing cross-sectional imaging studies for other indications are found to have pancreatic cystic lesions. Although most cystic lesions are benign, the malignant potential of several types of pancreatic cysts makes accurate classification vital to directing therapy. To this end, advances in the last decade led to better characterization of pancreatic cyst morphology and hence enhanced the ability to predict underlying histopathology, and biological behavior. Although accurate classification remains a challenge, the utilization of complementary diagnostic tools is the optimal approach to dictate management. The following review includes a description of pancreatic cysts, a critical review of current and emerging diagnostic techniques and a review of recent guidelines in the management of incidental pancreatic cysts.

Endoscopic ultrasound cytologic brushing vs endoscopic ultrasound - fine needle aspiration for cytological diagnosis of cystic pancreatic lesions. A multicenter, randomized open-label trial

INTRODUCTION

the incidence of cystic pancreatic lesions (CPL) in the asymptomatic population is increasing. Achieving a preoperative diagnosis of CPL still remains a challenge.

OBJECTIVES

to evaluate the diagnostic accuracy of the cytological diagnosis of CPL from samples obtained by cytology brush versus standard endoscopic ultrasound fine needle aspiration (EUS-FNA).

METHODS

a multicenter, randomized, open-label trial was performed of EUS-cytology brush (EUS-EB) versus EUS-FNA for the cytological diagnosis of CPL. Patients that underwent EUS-FNA with a CPL > 15 mm were included and randomized into two groups: group I, EUS-EB; group II, EUS-FNA. The final diagnosis was based on the histological evaluation of surgical specimens and clinical parameters, imaging and a five year follow-up in non-operated patients. The main outcome was the diagnostic accuracy of both methods. Secondary outcomes were the diagnostic adequacy of specimens and the rate of adverse events. Data were compared using the Chi-squared test. An intention to treat (ITT) and per-protocol (PP) analysis were performed.

RESULTS

sixty-five patients were included in the study, 31 in group I and 34 in group II. Three patients initially randomized to group I were changed to group II as it was impossible to obtain a sample using the brush. The mean size of the CPL was 28.2 mm (range 16-60 mm). The diagnostic accuracy of EUS-EB was not superior to EUS-FNA, neither in the ITT nor the PP analysis (44.8% vs 41.1%, p = 0.77 and 38.4% vs 45.9%, p = 0.55).

CONCLUSIONS

EUS-EB does not improve the diagnostic accuracy of CPL in comparison with EUS-FNA.

Pancreatic Cystic Lesions: New Endoscopic Trends in Diagnosis

The diagnosis of incidental pancreatic cystic lesions is increasing in the general population because of the routine use of cross-sectional imaging modalities. Not all cysts are neoplastic, and the majority of cystic neoplasms have a low overall likelihood of progression to malignancy. Current management is based on imaging and cyst fluid analysis, but we are not able to diagnose the specific type of cyst and its malignant potential in a significant number of patients. Better diagnostic tools are required to avoid unnecessary surgical resections that carry an important risk of morbidity and mortality. Herein we review current evidence concerning the use of new endoscopic modalities for the evaluation of pancreatic cystic lesions. We focus our discussion on the new cyst fluid markers, and the advancements on modalities such as confocal endomicroscopy, contrast-enhanced endoscopic ultrasound, and the use of Spyglass. We also discuss the use of new devices to improve the cellular yield from cyst fluid and to obtain cyst-wall tissue, namely the cytology brush, the fine needle biopsy, and forceps for cyst-wall biopsy.

Endoscopic Ultrasound Imaging for Diagnosing and Treating Pancreatic Cysts

Cystic pancreatic lesions are increasingly diagnosed owing to the abundant use of cross-sectional imaging. Given their malignant potential, true pancreatic cysts should be considered for resection or periodic follow-up. Cystic lesions of the pancreas (CLPs) require further evaluation and management. Therefore, it is important to establish a solid diagnosis at the time of detection. Endoscopic ultrasound examination is the imaging modality of choice. Fine needle aspiration provides fluid for cytologic, biochemical, and molecular assays to classify lesions and predict biological behavior. This review provides an overview of the diagnosis and management of various types of commonly encountered true CLPs.

Imaging modalities for characterising focal pancreatic lesions

BACKGROUND

Increasing numbers of incidental pancreatic lesions are being detected each year. Accurate characterisation of pancreatic lesions into benign, precancerous, and cancer masses is crucial in deciding whether to use treatment or surveillance. Distinguishing benign lesions from precancerous and cancerous lesions can prevent patients from undergoing unnecessary major surgery. Despite the importance of accurately classifying pancreatic lesions, there is no clear algorithm for management of focal pancreatic lesions.

OBJECTIVES

To determine and compare the diagnostic accuracy of various imaging modalities in detecting cancerous and precancerous lesions in people with focal pancreatic lesions.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, and Science Citation Index until 19 July 2016. We searched the references of included studies to identify further studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We planned to include studies reporting cross-sectional information on the index test (CT (computed tomography), MRI (magnetic resonance imaging), PET (positron emission tomography), EUS (endoscopic ultrasound), EUS elastography, and EUS-guided biopsy or FNA (fine-needle aspiration)) and reference standard (confirmation of the nature of the lesion was obtained by histopathological examination of the entire lesion by surgical excision, or histopathological examination for confirmation of precancer or cancer by biopsy and clinical follow-up of at least six months in people with negative index tests) in people with pancreatic lesions irrespective of language or publication status or whether the data were collected prospectively or retrospectively.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the references to identify relevant studies and extracted the data. We planned to use the bivariate analysis to calculate the summary sensitivity and specificity with their 95% confidence intervals and the hierarchical summary receiver operating characteristic (HSROC) to compare the tests and assess heterogeneity, but used simpler models (such as univariate random-effects model and univariate fixed-effect model) for combining studies when appropriate because of the sparse data. We were unable to compare the diagnostic performance of the tests using formal statistical methods because of sparse data.

MAIN RESULTS

We included 54 studies involving a total of 3,196 participants evaluating the diagnostic accuracy of various index tests. In these 54 studies, eight different target conditions were identified with different final diagnoses constituting benign, precancerous, and cancerous lesions. None of the studies was of high methodological quality. None of the comparisons in which single studies were included was of sufficiently high methodological quality to warrant highlighting of the results. For differentiation of cancerous lesions from benign or precancerous lesions, we identified only one study per index test. The second analysis, of studies differentiating cancerous versus benign lesions, provided three tests in which meta-analysis could be performed. The sensitivities and specificities for diagnosing cancer were: EUS-FNA: sensitivity 0.79 (95% confidence interval (CI) 0.07 to 1.00), specificity 1.00 (95% CI 0.91 to 1.00); EUS: sensitivity 0.95 (95% CI 0.84 to 0.99), specificity 0.53 (95% CI 0.31 to 0.74); PET: sensitivity 0.92 (95% CI 0.80 to 0.97), specificity 0.65 (95% CI 0.39 to 0.84). The third analysis, of studies differentiating precancerous or cancerous lesions from benign lesions, only provided one test (EUS-FNA) in which meta-analysis was performed. EUS-FNA had moderate sensitivity for diagnosing precancerous or cancerous lesions (sensitivity 0.73 (95% CI 0.01 to 1.00) and high specificity 0.94 (95% CI 0.15 to 1.00), the extremely wide confidence intervals reflecting the heterogeneity between the studies). The fourth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (dysplasia) provided three tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing invasive carcinoma were: CT: sensitivity 0.72 (95% CI 0.50 to 0.87), specificity 0.92 (95% CI 0.81 to 0.97); EUS: sensitivity 0.78 (95% CI 0.44 to 0.94), specificity 0.91 (95% CI 0.61 to 0.98); EUS-FNA: sensitivity 0.66 (95% CI 0.03 to 0.99), specificity 0.92 (95% CI 0.73 to 0.98). The fifth analysis, of studies differentiating cancerous (high-grade dysplasia or invasive carcinoma) versus precancerous (low- or intermediate-grade dysplasia) provided six tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing cancer (high-grade dysplasia or invasive carcinoma) were: CT: sensitivity 0.87 (95% CI 0.00 to 1.00), specificity 0.96 (95% CI 0.00 to 1.00); EUS: sensitivity 0.86 (95% CI 0.74 to 0.92), specificity 0.91 (95% CI 0.83 to 0.96); EUS-FNA: sensitivity 0.47 (95% CI 0.24 to 0.70), specificity 0.91 (95% CI 0.32 to 1.00); EUS-FNA carcinoembryonic antigen 200 ng/mL: sensitivity 0.58 (95% CI 0.28 to 0.83), specificity 0.51 (95% CI 0.19 to 0.81); MRI: sensitivity 0.69 (95% CI 0.44 to 0.86), specificity 0.93 (95% CI 0.43 to 1.00); PET: sensitivity 0.90 (95% CI 0.79 to 0.96), specificity 0.94 (95% CI 0.81 to 0.99). The sixth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (low-grade dysplasia) provided no tests in which meta-analysis was performed. The seventh analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) provided two tests in which meta-analysis was performed. The sensitivity and specificity for diagnosing cancer were: CT: sensitivity 0.83 (95% CI 0.68 to 0.92), specificity 0.83 (95% CI 0.64 to 0.93) and MRI: sensitivity 0.80 (95% CI 0.58 to 0.92), specificity 0.81 (95% CI 0.53 to 0.95), respectively. The eighth analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) or benign lesions provided no test in which meta-analysis was performed.There were no major alterations in the subgroup analysis of cystic pancreatic focal lesions (42 studies; 2086 participants). None of the included studies evaluated EUS elastography or sequential testing.

AUTHORS' CONCLUSIONS

We were unable to arrive at any firm conclusions because of the differences in the way that study authors classified focal pancreatic lesions into cancerous, precancerous, and benign lesions; the inclusion of few studies with wide confidence intervals for each comparison; poor methodological quality in the studies; and heterogeneity in the estimates within comparisons.

Endoscopic approach to the diagnosis of pancreatic cystic tumor

Because of the aging of the population, prevalence of medical checkups, and advances in imaging studies, the number of pancreatic cystic lesions detected has increased. Once these lesions are detected, neoplastic cysts should be differentiated from non-neoplastic cysts. Furthermore, because of the malignant potential of some neoplastic pancreatic cysts, further differentiation between benign and malignant cysts should be made regardless of their size. Although endoscopic ultrasound (EUS) has a very high diagnostic performance for pancreatic cystic lesions among the various imaging modalities, EUS findings alone are insufficient for the differentiation of pancreatic cysts and diagnosis of malignancy. In addition, cytology by EUS-guided fine-needle aspiration (FNA) has a high specificity but a low sensitivity for diagnosing malignancy in pancreatic cystic tumors. The levels of amylase, lipase, and tumor markers in pancreatic cystic fluid are considered auxiliary parameters for diagnosis of benign and malignant cysts, and a definitive diagnosis of malignancy using these parameters is difficult. Thus, in addition to EUS, cytology by EUS-FNA, and cystic fluid analysis, new techniques based on EUS-guided through-the-needle imaging, such as confocal laser endomicroscopy and cystoscopy, have been explored in recent years.

Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study

BACKGROUND AND AIMS

The exact cutoff value at which pancreatic cyst fluid carcinoembryonic antigen (CEA) level distinguishes pancreatic mucinous cystic neoplasms (MCNs) from pancreatic nonmucinous cystic neoplasms (NMCNs) is unclear. The aim of this multicenter retrospective study was to evaluate the diagnostic accuracy of cyst fluid CEA levels in differentiating between MCNs and NMCNs.

METHODS

Consecutive patients who underwent EUS with FNA at 3 tertiary care centers were identified. Patients with histologic confirmation of cyst type based on surgical specimens served as the criterion standard for this analysis. Demographic characteristics, EUS morphology, FNA fluid, and cytology results were recorded. Multivariate logistic regression analysis to identify predictors of MCNs was performed. Receiver-operating characteristic (ROC) curves were generated for CEA levels.

RESULTS

A total of 226 patients underwent surgery (mean age, 61 years, 96% white patients, 39% female patients) of whom 88% underwent Whipple's procedure or distal pancreatectomy. Based on surgical histopathology, there were 150 MCNs and 76 NMCNs cases. The median CEA level was 165 ng/mL. The area under the ROC curve for CEA levels in differentiating between MCNs and NMCNs was 0.77 (95% confidence interval, 0.71-0.84, P < .01) with a cutoff of 105 ng/mL, demonstrating a sensitivity and specificity of 70% and 63%, respectively. The cutoff value of 192 ng/mL yielded a sensitivity of 61% and a specificity of 77% and would misdiagnose 39% of MCN cases.

CONCLUSIONS

Cyst fluid CEA levels have a clinically suboptimal accuracy level in differentiating MCNs from NMCNs. Future studies should focus on novel cyst fluid markers to improve risk stratification of pancreatic cystic neoplasms.

Endoscopic diagnosis and treatment of pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (PNETs) are rare pancreatic neoplasms comprising only 1% to 2% of all pancreatic tumors. In recent years, the number of incidentally discovered PNETs has greatly increased given the widespread use of axial imaging. However, a significant proportion of PNETs may not be visualized on conventional imaging such as computed tomography, magnetic resonance imaging, and somatostatin receptor scintigraphy. Endoscopic ultrasound (EUS) has become an integral part of the diagnosis of PNETs because of its high sensitivity for detecting, localizing, and diagnosing PNETs. EUS-guided tissue acquisition provides histologic and immunologic confirmation, and may also allow prognostication about tumor behavior. In addition to preoperative assessment of these tumors, EUS has also been shown to have an important role in nonoperative management of small nonfunctional PNETs. Finally, recent developments suggest that interventional EUS may be used to aid intraoperative localization of PNETs and to deliver therapeutic agents for the treatment of PNETs. This review will discuss the endoscopic diagnosis and treatment of PNETs, with focus on recent advances in the utility of EUS in the clinical management of these tumors.

Endoscopic Ultrasound-Guided Treatment beyond Drainage: Hemostasis, Anastomosis, and Others

Since the introduction of endoscopic ultrasound (EUS) in the 1990s, it has evolved from a primarily diagnostic modality into an instrument that can be used in various therapeutic interventions. EUS-guided fine-needle injection was initially described for celiac plexus neurolysis. By using the fundamentals of this method, drainage techniques emerged for the biliary and pancreatic ducts, fluid collections, and abscesses. More recently, EUS has been used for ablative techniques and injection therapies for patients with for gastrointestinal malignancies. As the search for minimally invasive techniques continued, EUS-guided hemostasis methods have also been described. The technical advances in EUS-guided therapies may appear to be limitless; however, in many instances, these procedures have been described only in small case series. More data are required to determine the efficacy and safety of these techniques, and new accessories will be needed to facilitate their implementation into practice.

To fine needle aspiration or not? An endosonographer's approach to pancreatic cystic lesions

Endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) is an established diagnostic tool in the management of pancreatic cystic lesions (PCLs). Due to the proximity to the target lesion, the fine diagnostic needle travels through only minimal normal tissues. The risks of bleeding, pancreatitis and infection are small. Valuable diagnostic morphological information can be obtained by EUS before the use of FNA. The additional cytopathologic and cyst fluid analysis for the conventional markers such as amylase, carcinoembryonic antigen (CEA) and CA19.9 improves the diagnostic capability. Pancreatic cyst fluid CEA concentration of 192 ng/mL is generally the most agreed cutoff to differentiate mucinous from non-mucinous lesion. A fluid amylase level of <250 IU/L excludes the diagnosis of pseudocyst. Technical tips of EUS-FNA and the limitations of the procedure are discussed. Promising technique and FNA needle modifications have been described to improve the diagnostic yield at the cytopathologic analysis. The use of novel cyst fluid proteomics and deoxyribonucleic acid-based biomarkers of the PCLs are reviewed. Although it is considered a safe procedure, EUS-FNA is not a routine in every patient. Recommendations of the role of EUS-FNA at various common clinical scenarios are discussed.

Tips to overcome technical challenges in EUS-guided tissue acquisition

The diagnostic yield of EUS-FNA depends on several factors, such as the experience of the endosonographer, the characteristics of the lesion, the clinical status of the patient, the size and type of needles, the methods of specimen preparation, as well as cytopathologist expertise. The endosonographic technique can be improved when several tips and tricks useful to overcome challenges of FNA are known. Technical challenges of FNA are related to the characteristics of the lesion and its surroundings, sonographic imaging, and limitations related to the needle. Several tips and tricks necessary to overcome them are presented in this review.

A review of pancreatic cyst fluid analysis in the differential diagnosis of pancreatic cyst lesions

Diagnosis and management of pancreatic cyst lesions is challenging as there is currently no investigation that offers both high diagnostic sensitivity and high specificity for the identification of potentially malignant lesions. Accurate classification of these lesions is vital in order to avoid unnecessary treatment of benign lesions and missed opportunities for early treatment of lesions that are malignant/pre-malignant. Pancreatic cyst fluid analysis has an important role in diagnosis, although all currently available investigations based on fluid analysis have significant limitations. Cytological analysis can reveal features that are specific for a certain class of cyst, but offers limited sensitivity in detecting malignant/pre-malignant cysts. Measurement of tumour markers, particularly carcinoembryonic antigen can also be informative. Concentrations of cyst fluid carcinoembryonic antigen tend to be higher in malignant/pre-malignant cysts, although there is a wide overlap between the various classes of cyst. A number of studies have suggested that diagnostic carcinoembryonic antigen cut-offs can be chosen that provide a high degree of specificity but limited sensitivity. Studies of the analytical validity of tumour marker assays in pancreatic cyst fluid analysis have highlighted discrepancies in some fluid specimens, which require further investigation. DNA analysis also has a role. In particular, K-Ras-2 mutational analysis appears to provide high specificity for detection of malignant/pre-malignant lesions. A number of diagnostic algorithms have been published, integrating use of available investigations in order to achieve the optimum discrimination of benign and potentially malignant cysts. Research into new biochemical markers and optimal use of available pancreatic cyst fluid analyses is ongoing.

Endoscopic ultrasonography for pancreatic cancer: current and future perspectives

A suspected pancreatic lesion can be a difficult challenge for the clinician. In the last years we have witnessed tumultuous technological improvements of the radiological and nuclear medicine imaging. Taking this into account, we will try to delineate the new role of endoscopic ultrasound (EUS) in pancreatic imaging and to place it in a shareable diagnostic and staging algorithm of pancreatic cancer (PC). To date the most accurate imaging techniques for the PC remain contrast-enhanced computed tomography (CT) and EUS. The latter has the highest accuracy in detecting small lesions, in assessing tumor size and lymph nodes involvement, but helical CT or an up-to-date magnetic resonance imaging (MRI) must be the first choice in patients with a suspected pancreatic lesion. After this first step there is place for EUS as a second diagnostic level in several cases: negative results on CT/MRI scans and persistent strong clinical suspicion of PC, doubtful results on CT/MRI scans or need for cyto-histological confirmation. In the near future there will be great opportunities for the development of diagnostic and therapeutic EUS and pancreatic pathology could be the best testing bench.

Accuracy of endoscopic ultrasound-guided fine needle aspiration cytology on the differentiation of malignant and benign pancreatic cystic lesions: a single-center experience

OBJECTIVES

The aim was to compare the use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in cytology and the biochemical analysis of cyst fluid, together with the size of the lesion in the differentiation between benign and malignant pancreatic cystic lesions.

METHODS

Data of patients who underwent EUS-FNA for pancreatic cystic lesions in our center from January 2006 to October 2010 were retrospectively analyzed. The diagnostic accuracy of EUS-FNA was determined.

RESULTS

Of the 56 patients, 37 (66.1%) had evaluable cytology for diagnosis and sufficient cyst fluid was available for biochemical analysis in 58.9% (33/56) of the patients. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-FNA for detecting malignancy were 63%, 100%, 100% and 85%, respectively. EUS-FNA was the most accurate diagnostic method for differentiating malignant and benign pancreatic cystic lesions (88%). Cyst fluid carcinoembryonic antigen (CEA) > 365 ng/mL had a sensitivity of 100% for the detection of malignant cystic lesions.

CONCLUSIONS

Although the rate of insufficient cyst fluid aspiration is high, the combination of cytological evaluation and CEA analysis of cyst fluid obtained by EUS-FNA is accurate in differentiating malignant cystic lesions from benign ones. Safe techniques are essential to improve the yield of cyst fluid aspiration by EUS.

Endoscopy in the patient on antithrombotic therapy

PURPOSE OF REVIEW

The management of antithrombotics during the periendoscopic period is a common clinical problem. This review focuses on recent literature addressing this issue, primarily on articles published from 2009 to 2012.

RECENT FINDINGS

A large proportion of the studies retrieved focused on the effect of antithrombotics on bleeding risk following diagnostic endoscopy, polypectomy, endoscopic mucosal resection, and submucosal dissection, whereas studies involving other endoscopic procedures were scarce. Recent American and European guidelines direct the management of antithrombotic therapy in patients undergoing endoscopy according to the procedure's risk of bleeding and the patient's thromboembolic risk. The difficulty in determining a priori the need for endotherapy and hence appropriate classification of risk of bleeding prior to the procedure is a potential limitation of such classification. Moreover, most studies have primarily addressed the risk of immediate or early bleeding by proposing interruption of antithrombotic therapy prior to endotherapy, and few have focused on the risk of delayed bleeding and the optimal time for resumption of these agents following high-risk procedures.

SUMMARY

Management of patients on antithrombotics remains complex, especially in high-risk settings. Existing guidelines are valuable but should not be a substitute for a careful personalized risk assessment strategy involving patient and physician.

Endoscopic ultrasound-guided fine needle aspiration in cystic pancreatic lesions

Incidental pancreatic cysts are being increasingly recognized recently with incremented concern about health and frequent health check-up. Endoscopic ultrasound (EUS) has emerged as the principal modality for imaging pancreas for various pancreatic diseases including pancreatic cyst. But imaging alone cannot accurately identify the exact nature of the pancreatic cyst. EUS-guided fine needle aspiration is a useful adjunctive procedure to differentiate pancreatic cystic lesions. Cystic fluid analysis with cytologic evaluation is important to diagnose etiology of pancreatic cystic lesions, helping the clinician to more accurately assess the presence or potential for malignancy.

Targeted cyst wall puncture and aspiration during EUS-FNA increases the diagnostic yield of premalignant and malignant pancreatic cysts

BACKGROUND

Characterization of pancreatic cysts by using EUS-FNA includes chemical and cytologic analysis.

OBJECTIVE

To evaluate whether material obtained from FNA of the cyst wall increases diagnostic yield.

DESIGN

Prospective series.

SETTING

Tertiary referral center.

PATIENTS

Consecutive patients with pancreatic cysts referred for EUS-FNA between March 2010 and March 2011.

INTERVENTION

FNA was performed with aspiration of cyst fluid for carcinoembryonic antigen (CEA) and cytology, followed by cyst wall puncture (CWP). CWP is defined as puncturing the far wall of the cyst and moving the needle back and forth through the wall to sample the wall epithelium.

MAIN OUTCOME MEASUREMENTS

The diagnostic yield for mucinous cystic pancreatic neoplasms by CEA and cytology obtained from cyst fluid compared with cytology obtained from CWP. CEA ≥192 ng/mL was considered mucinous.

RESULTS

A total of 69 pancreatic cysts from 66 patients were included. Adequate amounts of fluid were aspirated for CEA, amylase, and cytology in 60 cysts (81%). Cellular material adequate for cytologic assessment from CWP was obtained in 56 cysts (81%). Ten (30%) of 33 cysts with CEA <192 ng/mL and negative results of cyst fluid cytology had a mucinous diagnosis from CWP; 6 of 9 (67%) cysts with an insufficient amount of fluid for CEA analysis and cyst fluid cytology had a mucinous diagnosis from CWP. Furthermore, 4 malignant cysts were independently diagnosed by CWP cytology. The incremental diagnostic yield of CWP for mucinous or malignant cysts was therefore 29% (20 of 69 cysts, P = .0001). An episode of pancreatitis (1.45%) occurred.

LIMITATION

Lack of surgical criterion standard.

CONCLUSIONS

CWP during EUS-FNA is a safe and effective technique for improving the diagnostic yield for premalignant and malignant pancreatic cysts.

Current status on the diagnosis and management of pancreatic cysts in the Asia-Pacific region: role of endoscopic ultrasound

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) play increasingly prominent roles in the diagnosis and management of pancreatic cysts. The Asian Consortium of Endoscopic Ultrasound was recently formed to conduct collaborative research in this area. This is a review of literature on true pancreatic cysts. Due to the lack of systematic studies, there are no robust data on the true incidence of pancreatic cystic lesions in Asia and any change in over the recent decades. Certain EUS morphological features have been used to predict particular types of pancreatic cysts. Pancreatic cyst fluid viscosity, cytology, pancreatic enzymes, and tumor markers, in particular carcinoembryonic antigen, can aid in the diagnosis of pancreatic cysts. Hemorrhage and infection are the most common complications of EUS-FNA of pancreatic cysts. Pancreatic cysts can either be observed or resected depending on the benign or malignant nature, or malignant potential of the lesions. Guidelines from an international consensus did not require positive cytological findings to be present in their recommendation for resection, which included all mucinous cystic neoplasms, all main-duct intraductal papillary mucinous neoplasms (IPMN), all mixed IPMN, symptomatic side-branch IPMN, and side-branch IPMN larger than 3 cm. In patients with poor surgical risks, EUS-guided cyst ablation of mucinous pancreatic cysts is an alternative. As long-term prospective data on pancreatic cysts are still not available in Asia, management strategies are largely based on risk stratification by surgical risk and malignant potential. Gene expression profiling of pancreatic cyst fluid and confocal laser endomicroscopic examination of pancreatic cysts are novel techniques currently being studied.

Epidemiology, diagnosis, and management of cystic lesions of the pancreas

Although little is known on the true prevalence of pancreatic cysts, physicians are currently more frequently confronted with pancreatic cysts because of the increasing use of sophisticated cross-sectional abdominal imaging. Cystic lesions of the pancreas comprise of a heterogeneous group of diagnostic entities, some of which are benign such as inflammatory pseudocysts or serous cystadenomas and do not require resection when asymptomatic. Others like mucinous cysts or intraductal papillary mucinous neoplasms (IPMN) have a malignant potential and in these cases surgical resection is often indicated. For this reason an adequate distinction between the various cysts is crucial to optimize management strategy. Different diagnostic methods that could be of value in the differentiation include radiologic imaging techniques such as CT, MR, and endosonography. In addition, fluid aspiration for cytopathology, tumormarkers or molecular analysis is widely used. Different guidelines are available but so far no optimal diagnostic algorithm exists. We summarize the epidemiology, classification, clinical presentation, diagnostics, management, and future perspectives.

Diagnosis and treatment of cystic pancreatic tumors

Cystic pancreatic tumors (CPTs) have more frequently been identified in the last decade because of increased use of cross-sectional abdominal imaging. Although serous CPTs follow an indolent course and do not necessarily require surgical resection or long-term follow-up, mucinous CPTs (mucinous cystic neoplasms and intraductal papillary mucinous neoplasms) have a greater risk for malignancy. Although most CPTs are initially detected with imaging modalities such as computed tomography or magnetic resonance imaging, these tests alone rarely permit an accurate clinical diagnosis. Endoscopic ultrasound and endoscopic ultrasound-guided, fine-needle aspiration allow real-time examination and biopsy analysis of CPTs, which increases diagnostic accuracy because cytopathology features and tumor markers in cyst fluid can be analyzed. Management of patients with mucinous CPTs by surgery or imaging surveillance is controversial, partially because of limited information about disease progression and the complexities of surgical resection. We review approaches to diagnosis and management of common CPTs.

Cystic pancreatic lesions: current evidence for diagnosis and treatment

Pancreatic cystic neoplasms are detected at an increasing frequency due to an increased use and quality of abdominal imaging. There are well known differential diagnostic difficulties concerning these lesions. The aim is to review current literature on the diagnostic options and the following treatment for cystic lesions in the pancreas focusing on serous cystadenomas, primary mucinous neoplasm of the pancreas and mucinous cystadenocarcinomas, as well as intraductal papillary mucinous neoplasms, starting with excluding pseudocysts. A conservative approach is feasible in patients with a clinical presentation suggestive of an asymptomatic serous cystadenoma. Surgical management, as well as follow-up, is discussed for each of the types of neoplastic lesions, including an uncharacterized cyst, based on patient data, symptoms, serum analysis, cyst fluid analysis and morphological features. Aspects for future diagnostics and management of these neoplasia are commented upon.

Metastatic Kaposi's Sarcoma with Perirectal Involvement Diagnosed with Endoscopic Ultrasound-Guided EchoBrush Cytology Sampling

AIDS-related Kaposi's sarcoma (KS) is a low-grade vascular tumor that occurs in association with human herpesvirus 8 infection. Here we report the case of a 21-year-old male with recently diagnosed cutaneous KS who presented with rectal bleeding and anal pruritus. Initial endoscopic evaluation was nondiagnostic. CT imaging showed diffuse lymphadenopathy including perirectal involvement which was suspicious for metastatic KS. Echoendoscopy with needle biopsies and EchoBrush sampling of the lymph nodes revealed spindle cells confirming metastatic KS. Treatment was initiated with liposomal doxorubicin resulting in rapid improvement of the skin lesions. After treatment completion, repeat CT imaging showed improved lymphadenopathy. No further rectal bleeding or perianal pruritus was reported. Although the EchoBrush has previously been used to aid in the diagnosis of pancreatic lesions, this report describes a novel use of EchoBrush to diagnose KS from perirectal lymph nodes.

EchoBrush may be superior to standard EUS-guided FNA in the evaluation of cystic lesions of the pancreas: preliminary experience

BACKGROUND

Cystic lesions of the pancreas are being detected with increasing frequency. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is one of the most precise methods of diagnosis but still has limited accuracy. A new, through-the-needle cytologic brush system (EchoBrush; Cook Medical, Bloomington, Ind) has been approved for use during EUS evaluation of cystic pancreatic lesions.

METHODS

Data from 127 EUS-FNAs of pancreatic cystic lesions were analyzed to compare the cytologic yield of EchoBrush with conventional EUS-FNA. An attending cytopathologist was present on site to assess specimen adequacy in all the cases. Diagnostic yields of both procedures, as well as related adverse events, were recorded. Statistical analysis was performed with the SPSS 15.0 version software (SPSS, Chicago, Ill).

RESULTS

A total of 127 cystic lesions of the pancreas from 120 patients (42 men and 78 women, mean age of 62.17 ± 12.17 years) were included in the study. Mean size of lesions was 23.58 ± 21.69 mm. Adequacy of the samples and diagnostic yield were higher using EchoBrush. In 80 (63 %) cases, conventional EUS-FNA was performed, whereas in 47 (37%), we used EchoBrush. Diagnostic material was obtained in 85.1% (40 of 47) of cases using EchoBrush and in 66.3% (53 of 80) with conventional EUS-FNA. (P < .05). There were very few clinically relevant complications related to EUS-FNA and EUS-EchoBrush techniques.

CONCLUSIONS

This study suggests that cytological specimens from pancreatic cystic lesions obtained using EchoBrush at the time of EUS are superior to conventional EUS-FNA mainly because of the higher yield of epithelial cells. Larger studies are needed to compare both methods.

Endoscopic ultrasonography-guided brushing increases cellular diagnosis of pancreatic cysts: A prospective study

BACKGROUND

The diagnosis of pancreatic cystic lesions is still a challenge.

AIM

To prospectively investigate the usefulness and safety of EUS-guided cytology brushing (EUS BR) in the cellular diagnosis of pancreatic cysts.

METHODS

Cysts >15mm were sampled with a 19G needle. The fluid was aspirated and processed for cytology. The brush was introduced to scrub the cystic wall and processed as standard brushings. Antibiotic prophylaxis was administered. Complications were assessed in the first 24h and 7 days after the procedure.

RESULTS

30 patients were included. In 8 patients the technique failed for technical reasons. EUS BR provided with a cellular diagnosis in 20/22 cases (91%). The EUS BR was superior to the aspirated fluid for detecting diagnostic cells (73% vs. 36%, p=0.08) and mucinous cells (50% vs. 18%, p=0.016). In the 8 patients operated on, the specimen was consistent with EUS BR diagnosis. Three patients (10%) had complications, one of them a subacute retroperitoneal haemorrhage in a patient on anticoagulation therapy who died for complications 1 month later.

CONCLUSIONS

EUS BR increases cellular diagnosis of pancreatic cystic lesions as compared with fluid analysis, mainly in mucinous lesions. Its use is not recommended in patients under anticoagulation therapy.

Lymphoepithelial cyst of the pancreas: a rare case report and review of literature

Lymphoepithelial cysts are rare pancreatic lesions of undetermined pathogenesis. The literature on this entity is limited to case reports or small series. We describe a case of 66 year male, incidentally diagnosed as lymphoepithelial cyst of pancreas that was managed by enucleation. This is the first case report of lymphoepithelial cyst from India. An extensive Medline search was carried out for lymphoepithelial cyst of pancreas. Till date less than 100 cases were identified in available literature. All these cases (including our case) were analyzed. This entity has uniform and distinctive clinicopathological features. About half of the reported cases were asymptomatic with most of the lesions diagnosed incidentally. Majority of patients presents with non-specific symptoms making preoperative diagnosis difficult. Lymphoepithelial cyst of the pancreas is a rare benign lesion, which is difficult to diagnose preoperatively. High index of suspicion and preoperative fine needle aspiration cytology may help in making diagnosis and avoiding surgery in asymptomatic patients.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi:10.1007/s12262-010-0152-y) contains supplementary material, which is available to authorized users.

Endoscopic ultrasound in the evaluation of pancreaticobiliary disorders

The close proximity of the endoscopic ultrasound probe to the pancreas coupled with the ability to perform fine needle aspiration has made endoscopic ultrasound an extremely important technique for the evaluation of both benign and malignant pancreaticobiliary disorders. In parallel to the widespread importance of diagnostic endoscopic ultrasound, the therapeutic and interventional applications of this procedure are expanding and may become a major breakthrough in the management of pancreaticobiliary diseases. This article focuses on the utility and recent advances of endoscopic ultrasound in the diagnostic evaluation pancreaticobiliary disorders and analyses the data of well established interventional procedures such as celiac plexus neurolysis and pseudocyst drainage. Moreover, the more innovative procedures, such endoscopic ultrasound-guided biliary and pancreatic ducts access and drainage and the experimental use of direct endoscopic ultrasound-guided therapy of both solid and cystic pancreatic lesions will also be reviewed.

Preliminary experience with a new cytology brush in EUS-guided FNA

BACKGROUND

Despite the high diagnostic yield of EUS-guided FNA, room for technical improvements remains. Recently, the EchoBrush (Cook Endoscopy, Winston-Salem, NC), a disposable cytologic brush, was introduced to the market. To date, only 1 study, limited to 10 pancreatic cyst cases, using this device has been published.

OBJECTIVE

To assess the diagnostic yield of the EchoBrush in a cohort of consecutive patients, irrespective of the target lesion.

DESIGN

Case series.

SETTING

Tertiary care university hospital (Molinette Hospital, Turin, Italy).

PATIENTS

Thirty-nine consecutive patients (12 with solid pancreatic masses, 12 with pancreatic cysts, 7 with enlarged lymph nodes, and 8 with submucosal masses) were enrolled.

INTERVENTIONS

The material collected with the EchoBrush and with a standard FNA needle was double-blind evaluated by 2 cytopathologists.

MAIN OUTCOME MEASUREMENTS

Adequacy of the sample and sensitivity and specificity of the EchoBrush method.

RESULTS

Adequate material for cytologic analysis was collected in 17 of 39 patients (43.6%) with a single pass of the EchoBrush. Results were better for pancreatic lesions (for solid and cystic lesions, the adequacy was 58.3% and 50%, respectively); adequacy was low (28.6% and 25%, respectively) for lymph nodes and submucosal masses. The overall sensitivity and specificity were 57.9% and 31.2%, respectively. There were no adverse events with the procedure.

LIMITATION

Preliminary study.

CONCLUSIONS

This report suggests that the EchoBrush may provide adequate cellularity to diagnose solid and cystic pancreatic lesions. More extensive studies are needed to compare the EchoBrush and standard needles.

Interventional endoscopic ultrasound: Therapeutic capability and potential

The linear echoendoscope, introduced in the 1990s, opened the era of interventional endoscopic ultrasound (IEUS). The linear echoendoscope enabled EUS guided Fine Needle Aspiration (EUS-FNA) allowing the path of the needle to be traced during the puncture process. After EUS-FNA, other interventional procedures were introduced in clinical practice. Tissue acquisition was the first EUS-guided interventional procedure and its higher diagnostic quality has undoubtedly been established. After EUS-FNA, Celiac plexus neurolysis (CPN) and block (CPB), pancreatic pseudocyst drainage, abdominal and mediastinal collections/abscesses drainage, and in selected cases, pancreatic and biliary ductal system drainage, were introduced in clinical practice. EUS-guided fine needle injection with local delivery of antitumor agents is considered a promising modality. We have reviewed published data on EUS guided interventional procedures with the object of summarizing the diagnostic capability of endoscopic ultrasound and elaborates in detail its therapeutic capability and potential.

Endoscopic ultrasound-guided fine-needle aspiration biopsy and trucut biopsy in gastroenterology - An overview

Endoscopic ultrasound (EUS)-guided biopsies are reliable, safe and effective techniques in obtaining samples for cytological or histological examinations either as a primary procedure or in cases where other biopsy techniques have failed. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA), as well as endoscopic ultrasound-guided trucut biopsy (EUS-TCB), has proven to be of significant value in the diagnostic evaluation of benign and malignant diseases, as well as in staging of the malignant tumours of the gastrointestinal tract and of adjacent organs. The diagnostic yield of EUS-guided biopsies depends on site, size and characteristics of target tissues as well as technical and procedural factors (type of needle, biopsy technique and material processing). Other weighting factors include expertise, training and interaction between the endosonographer and cytopathologist. Rapid on-site cytological evaluation has proven to be successful in optimising the diagnostic efficiency of EUS-FNA. A sensible alternative is to collect specimens for histological and immunohistochemical investigations in addition to the cytological smears. EUS-FNA using a 22-gauge needle is successful in harvesting core biopsies in approximately three out of four cases. Therefore, the use of 19-gauge needles for EUS-FNA or EUS-TCB may only be necessary in selected cases. The reproducibility of cytopathological diagnosis among pathologists with special experience in assessing material obtained by EUS-guided biopsies is very high. False-positive diagnosis of malignancy in EUS-guided biopsy is rare. False-negative diagnosis appears with variable frequency depending on the target tissue, technical factors and expertise of the endosonographer and cytopathologist. There are numerous challenges and pitfalls in the differential diagnostic classification of benign and malignant lesions. These problems are related to the characteristics of samples obtained by EUS-guided biopsy, as well as to the multiple diagnoses with similar or overlapping cytological or histological characteristics. The high prognostic and therapeutic relevance of the cytopathological diagnoses resulting from EUS-guided biopsy calls for a shared responsibility of an endosonographer and a cytopathologist.

Septated cystic tumors of the pancreas: is it possible to treat them by endoscopic ultrasonography-guided intervention?

OBJECTIVES

Endoscopic ultrasonography (EUS)-guided intervention has recently been tried in the treatment of cystic tumors of the pancreas. Factors that can influence the treatment response include cyst wall thickness and the presence of septation and mural nodules. This study aimed to evaluate the effectiveness of EUS-guided ethanol lavage with paclitaxel injection (EUS-EP) in the treatment of septated cystic tumors of the pancreas.

METHODS

Ten patients with oligolocular septated cystic tumors underwent EUS-EP and the treatment response was analyzed by measuring cyst volume before and more than 6 months after treatment.

RESULTS

The 10 patients comprised 7 women and 3 men, of mean age 38.4 years (range 22-54 years). Median tumor diameter was 29.5 mm (range 20-68 mm), while median tumor volume was 5.07 ml (range 1.51-68.74 ml). Median carcinoembryonic antigen and amylase concentrations in the cyst fluid were 39.2 ng/ml (range 1-8,190 ng/ml) and 115.5 U/L (range 5-75,633 U/L), respectively. Three tumors were diagnosed as mucinous cystic neoplasms, four as serous cystadenomas, and three as indeterminate cysts. Median tumor volume had decreased to 0.54 ml (range 0.00-12.42 ml). Complete resolution was achieved in six patients and partial resolution in two, whereas two patients had persistent cysts. Two patients with persistent cysts underwent surgical resection, and focal remnant neoplastic epithelial lining was observed on the resected specimens.

CONCLUSIONS

EUS-EP resulted in complete resolution in 6 of 10 patients with septated cystic tumors. Careful patient selection and tailored intervention are required to maximize the therapeutic efficacy of this procedure.

Pancreatic cytopathology: a practical approach and review

CONTEXT

Pancreatic cytopathology plays an important role in the diagnosis and management of patients with solid and cystic lesions of the pancreas.

OBJECTIVE

To serve as a practical guide to pancreatic cytopathology for the practicing pathologist. Data Sources.-A comprehensive assessment of the medical literature was performed.

CONCLUSIONS

We review pancreatic cytopathology, with specific discussions of its role in patient management, specimen types and specimen processing, specific diagnostic criteria, and the use of ancillary testing and advanced techniques.

Neuroendocrine tumors of the pancreas: endoscopic diagnosis

PURPOSE OF REVIEW

Endoscopic ultrasound (EUS) is a valuable tool in the diagnosis and management of pancreatic neuroendocrine tumors. This review highlights advances over the last year in EUS in the evaluation of pancreatic neuroendocrine tumors.

RECENT FINDINGS

We will focus on recent findings regarding the accuracy of EUS, EUS-guided fine needle aspiration (EUS-fine needle aspiration), emerging cytologic markers obtained from fine needle aspiration samples, and the role of EUS screening for patients with multiple endocrine neoplasia type 1 syndrome. Additionally, we will introduce potential therapeutic EUS interventions in the treatment of pancreatic neuroendocrine tumors.

SUMMARY

The present review highlights recent advances in the utility of EUS in the clinical management of pancreatic neuroendocrine tumors. Key studies from the last year demonstrate the important role of EUS in the diagnosis, prognosis, and treatment of pancreatic neuroendocrine tumors.