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Sinha SR, Mondal S, Akhtar MJ, Singh RK, Prakash P. Evaluating Carcinoembryonic Antigen and Glucose Levels in Pancreatic Cyst Fluid for Mucinous Versus Non-mucinous Differentiation. Cureus 2024; 16:e62686. [PMID: 39036216 PMCID: PMC11259022 DOI: 10.7759/cureus.62686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND A more precise identification of mucinous cysts will lower the likelihood of needless pancreatic surgery. Pancreatic cyst fluid (PCF) contains glucose and carcinoembryonic antigen (CEA), which serve as biomarkers to differentiate mucinous from non-mucinous pancreatic cystic neoplasms (PCNs). OBJECTIVE To evaluate the diagnostic accuracy of combined CEA and glucose levels in PCF for distinguishing mucinous from non-mucinous PCNs preoperatively. METHODS After receiving approval from the Institutional Ethical Committee of Indira Gandhi Institute of Medical Sciences, Patna, a cross-sectional validation research was carried out. All patients ≥18 years of age who had undergone pancreatic surgery or endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for a pancreatic cystic lesion and for whom PCF was acquired were eligible for inclusion. Patients were excluded if there was no PCF available, if they had been diagnosed with an extrapancreatic illness (such as ampullary adenoma), or if they could not be excluded due to pancreatic cancer generated from PCN. Diagnoses were pathologically confirmed. We performed measurements for CEA and glucose in PCF. CEA and glucose were measured using an Architect i2000SR analyzer (Abbott, Lake County, IL) and AU 5800 Beckman Coulter (Brea, CA), respectively. Diagnostic accuracy was evaluated by receiver operator characteristic (ROC) curves. RESULTS PCF was obtained from 100 patients, of whom 54 (54%) had mucinous PCN and 46 (46%) had non-mucinous PCN. When CEA (cut-off ≥ 151 ng/ml) and glucose levels (cut-off ≤ 50 mg/dL) were combined, the results showed 46% sensitivity and 92% specificity. However, when CEA (cut-off ≥ 17 ng/ml) or glucose testing (cut-off ≤ 50 mg/dL) was used separately, the results showed 82% sensitivity and 73% specificity. CONCLUSION The combined CEA and glucose testing in PCF demonstrated high specificity and sensitivity for differentiating mucinous from non-mucinous PCNs, suggesting its potential utility in preoperative diagnosis.
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Affiliation(s)
- Seema R Sinha
- Biochemistry, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Saptarshi Mondal
- General Surgery, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Md Jawed Akhtar
- Anatomy, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Rakesh Kumar Singh
- Surgical Gastroenterology and Liver Transplant, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Prem Prakash
- General Surgery, Indira Gandhi Institute of Medical Sciences, Patna, IND
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2
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Machicado JD, Napoleon B, Akshintala V, Bazarbashi AN, Bilal M, Corral JE, Dugum M, Han S, Hussain FS, Johnson AM, Jovani M, Kolb JM, Leonor P, Lee PJ, Mulki R, Shah H, Singh H, Sánchez-Luna SA, Shah SL, Singla A, Vargas EJ, Tielleman T, Nikahd M, Fry M, Culp S, Krishna SG. Structured training program on confocal laser endomicroscopy for pancreatic cystic lesions: a multicenter prospective study among early-career endosonographers (with video). Gastrointest Endosc 2023; 98:953-964. [PMID: 37473969 PMCID: PMC10771632 DOI: 10.1016/j.gie.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/08/2023] [Accepted: 07/17/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND AND AIMS Data on how to teach endosonographers needle-based confocal laser endomicroscopy (nCLE)-guided histologic diagnosis of pancreatic cystic lesions (PCLs) are limited. Hence, we developed and tested a structured educational program to train early-career endosonographers in nCLE-guided diagnosis of PCLs. METHODS Twenty-one early-career nCLE-naïve endosonographers watched a teaching module outlining nCLE criteria for diagnosing PCLs. Participants then reviewed 80 high-yield nCLE videos, recorded diagnoses, and received expert feedback (phase 1). Observers were then randomized to a refresher feedback session or self-learning at 4 weeks. Eight weeks after training, participants independently assessed the same 80 nCLE videos without feedback and provided histologic predictions (phase 2). Diagnostic performance of nCLE to differentiate mucinous versus nonmucinous PCLs and to diagnose specific subtypes were analyzed using histopathology as the criterion standard. Learning curves were determined using cumulative sum analysis. RESULTS Accuracy and diagnostic confidence for differentiating mucinous versus nonmucinous PCLs improved as endosonographers progressed through nCLE videos in phase 1 (P < .001). Similar trends were observed with the diagnosis of PCL subtypes. Most participants achieved competency interpreting nCLE, requiring a median of 38 assessments (range, 9-67). During phase 2, participants independently differentiated PCLs with high accuracy (89%), high confidence (83%), and substantial interobserver agreement (κ = .63). Accuracy for nCLE-guided PCL subtype diagnoses ranged from 82% to 96%. The learned nCLE skills did not deteriorate at 8 weeks and were not impacted by a refresher session. CONCLUSIONS We developed a practical, effective, and durable educational intervention to train early-career endosonographers in nCLE-guided diagnosis of PCLs.
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Affiliation(s)
- Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Bertrand Napoleon
- Gastroenterology Department, Hopital Privé Jean Mermoz, Ramsay Generale de Sante, Lyon, France
| | - Venkata Akshintala
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | - Mohammad Bilal
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Juan E Corral
- Division of Gastroenterology and Hepatology, Presbyterian Hospital, Albuquerque, New Mexico, USA
| | | | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Alyson M Johnson
- Division of Gastroenterology, Duke University, Durham, North Carolina, USA
| | - Manol Jovani
- Division of Gastroenterology, Maimonides Medical Center, SUNY Downstate University, Brooklyn, New York, USA
| | - Jennifer M Kolb
- Division of Digestive Diseases, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Paul Leonor
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Peter J Lee
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ramzi Mulki
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology & Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Hamza Shah
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Harkirat Singh
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sergio A Sánchez-Luna
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology & Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Shawn L Shah
- Division of Digestive and Liver Diseases, Veterans Affairs North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Anand Singla
- Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas Tielleman
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Melica Nikahd
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Megan Fry
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stacey Culp
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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3
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Siddappa PK, Park WG. Pancreatic Cyst Fluid Analysis. Gastrointest Endosc Clin N Am 2023; 33:599-612. [PMID: 37245938 DOI: 10.1016/j.giec.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pancreatic cyst fluid analysis can help diagnose pancreatic cyst type and the risk of high-grade dysplasia and cancer. Recent evidence from molecular analysis of cyst fluid has revolutionized the field with multiple markers showing promise in accurate diagnosis and prognostication of pancreatic cysts. The availability of multi-analyte panels has great potential for more accurate prediction of cancer.
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Affiliation(s)
- Pradeep K Siddappa
- Division of Gastroenterology & Hepatology, Stanford University, Stanford, CA, USA
| | - Walter G Park
- Division of Gastroenterology & Hepatology, Stanford University, Stanford, CA, USA.
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4
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Søreide K. Burgeoning rise in intraductal papillary mucinous neoplasia (IPMN) - a blessing in disguise. Scand J Gastroenterol 2023; 58:1101-1104. [PMID: 37022179 DOI: 10.1080/00365521.2023.2197095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/07/2023]
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- SAFER Surgery, Surgical Research Group, Stavanger University Hospital, Stavanger, Norway
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5
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Chaves J, Fernandez Y Viesca M, Arvanitakis M. Using Endoscopy in the Diagnosis of Pancreato-Biliary Cancers. Cancers (Basel) 2023; 15:3385. [PMID: 37444495 DOI: 10.3390/cancers15133385] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Pancreatic cancer and cholangiocarcinoma are life threatening oncological conditions with poor prognosis and outcome. Pancreatic cystic lesions are considered precursors of pancreatic cancer as some of them have the potential to progress to malignancy. Therefore, accurate identification and classification of these lesions is important to prevent the development of invasive cancer. In the biliary tract, the accurate characterization of biliary strictures is essential for providing appropriate management and avoiding unnecessary surgery. Techniques have been developed to improve the diagnosis, risk stratification, and management of pancreato-biliary lesions. Endoscopic ultrasound (EUS) and associated techniques, such as elastography, contrasted-enhanced EUS, and EUS-guided needle confocal laser endomicroscopy, may improve diagnostic accuracy. In addition, intraductal techniques applied during endoscopic retrograde cholangiopancreatography (ERCP), such as new generation cholangioscopy and in vivo cellular evaluation through probe-based confocal laser endomicroscopy, can increase the diagnostic yield in characterizing indeterminate biliary strictures. Both EUS-guided and intraductal approaches can provide the possibility for tissue sampling with new tools, such as needles, biopsies forceps, and brushes. At the molecular level, novel biomarkers have been explored that provide new insights into diagnosis, risk stratification, and management of these lesions.
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Affiliation(s)
- Julia Chaves
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium
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6
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Triantopoulou C, Gourtsoyianni S, Karakaxas D, Delis S. Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Challenging Diagnosis. Diagnostics (Basel) 2023; 13:2015. [PMID: 37370909 DOI: 10.3390/diagnostics13122015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Intraductal papillary mucinous neoplasm of the pancreas (IPMN) was classified as a distinct entity from mucinous cystic neoplasm by the WHO in 1995. It represents a mucin-producing tumor that originates from the ductal epithelium and can evolve from slight dysplasia to invasive carcinoma. In addition, different aspects of tumor progression may be seen in the same lesion. Three types are recognized, the branch duct variant, the main duct variant, which shows a much higher prevalence for malignancy, and the mixed-type variant, which combines branch and main duct characteristics. Advances in cross-sectional imaging have led to an increased rate of IPMN detection. The main imaging characteristic of IPMN is the dilatation of the pancreatic duct without the presence of an obstructing lesion. The diagnosis of a branch duct IPMN is based on the proof of its communication with the main pancreatic duct on MRI-MRCP examination. Early identification by imaging of the so-called worrisome features or predictors for malignancy is an important and challenging task. In this review, we will present recent imaging advances in the diagnosis and characterization of different types of IPMNs, as well as imaging tools available for early recognition of worrisome features for malignancy. A critical appraisal of current IPMN management guidelines from both a radiologist's and surgeon's perspective will be made. Special mention is made of complications that might arise during the course of IPMNs as well as concomitant pancreatic neoplasms including pancreatic adenocarcinoma and pancreatic endocrine neoplasms. Finally, recent research on prognostic and predictive biomarkers including radiomics will be discussed.
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Affiliation(s)
| | - Sofia Gourtsoyianni
- 1st Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Areteion Hospital, 11528 Athens, Greece
| | - Dimitriοs Karakaxas
- Department of Surgery, Konstantopouleio General Hospital, 14233 Athens, Greece
| | - Spiros Delis
- Department of Surgery, Konstantopouleio General Hospital, 14233 Athens, Greece
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7
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Poiraud M, Gkolfakis P, Arvanitakis M. Recent Developments in the Field of Endoscopic Ultrasound for Diagnosis, Staging, and Treatment of Pancreatic Lesions. Cancers (Basel) 2023; 15:cancers15092547. [PMID: 37174012 PMCID: PMC10177103 DOI: 10.3390/cancers15092547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Endoscopic ultrasound (EUS) plays a crucial role in the diagnosis of both solid and cystic pancreatic lesions and in the staging of patients with pancreatic cancer through its use for tissue and fluid sampling. Additionally, in cases of precancerous lesions, EUS-guided therapy can also be provided. This review aims to describe the most recent developments regarding the role of EUS in the diagnosis and staging of pancreatic lesions. Moreover, complementary EUS imaging modalities, the role of artificial intelligence, new devices, and modalities for tissue acquisition, and techniques for EUS-guided treatment are discussed.
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Affiliation(s)
- Marie Poiraud
- Department of Gastroenterology, CUB Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, CUB Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, CUB Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium
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8
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Mohapatra S, Krishna SG, Pannala R. Pancreatic Cystic Neoplasms: Translating Guidelines into Clinical Practice. Diagnostics (Basel) 2023; 13:diagnostics13040749. [PMID: 36832238 PMCID: PMC9955807 DOI: 10.3390/diagnostics13040749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
A combination of several factors, including the increasing use of cross-sectional imaging and an aging population, has led to pancreatic cystic lesions (PCLs) becoming the most detected incidental pancreatic lesions. Accurate diagnosis and risk stratification of PCLs is challenging. In the last decade, several evidence-based guidelines have been published addressing the diagnosis and management of PCLs. However, these guidelines cover different subsets of patients with PCLs and offer varying recommendations regarding diagnostic assessment, surveillance, and surgical resection. Further, recent studies comparing the accuracy of various guidelines have reported significant variations in the rate of missed cancer versus unnecessary surgical resections. In clinical practice, it is challenging to decide which guideline to follow specifically. This article reviews the varying recommendations of the major guidelines and results of comparative studies, provides an overview of newer modalities not included in the guidelines, and offers perspectives on translating the guidelines into clinical practice.
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Affiliation(s)
- Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA
| | - Somashekar G. Krishna
- Department of Gastroenterology and Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA
- Correspondence: ; Tel.: +1-480-301-4755
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9
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Comparative Performance of Endoscopic Ultrasound-Based Techniques in Patients With Pancreatic Cystic Lesions: A Network Meta-Analysis. Am J Gastroenterol 2023; 118:243-255. [PMID: 36563321 DOI: 10.14309/ajg.0000000000002088] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/02/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Evidence on the comparative diagnostic performance of endoscopic ultrasound (EUS)-based techniques for pancreatic cystic lesions (PCLs) is limited. This network meta-analysis comprehensively compared EUS-based techniques for PCL diagnosis. METHODS A comprehensive literature search was performed for all comparative studies assessing the accuracy of 2 or more modalities for PCL diagnosis. The primary outcome was the diagnostic efficacy for mucinous PCLs. Secondary outcomes were the diagnostic efficacy for malignant PCLs, diagnostic success rate, and adverse event rate. A network meta-analysis was conducted using the ANOVA model to assess the diagnostic accuracy of each index. RESULTS Forty studies comprising 3,641 patients were identified. The network ranking of the superiority index for EUS-guided needle-based confocal laser endomicroscopy (EUS-nCLE) and EUS-guided through-the-needle biopsy (EUS-TTNB) were significantly higher than other techniques for differentiating mucinous PCLs; besides, EUS-TTNB was also the optimal technique in identifying malignant PCLs. The evidence was inadequate for EUS-nCLE diagnosing malignant PCLs and contrast-enhanced harmonic EUS diagnosing both mucinous and malignant PCLs. Glucose showed a high sensitivity but low specificity, and molecular analysis (KRAS, GNAS, and KRAS + GNAS mutations) showed a high specificity but low sensitivity for diagnosing mucinous PCLs. Satisfactory results were not obtained during the evaluation of the efficiency of pancreatic cyst fluid (PCF) biomarkers in detecting malignant PCLs. DISCUSSION For centers with relevant expertise and facilities, EUS-TTNB and EUS-nCLE were better choices for the diagnosis of PCLs. Further studies are urgently required for further improving PCF biomarkers and validating the diagnostic performance of the index techniques.
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10
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Gorris M, Dijk F, Farina A, Halfwerk JB, Hooijer GK, Lekkerkerker SJ, Voermans RP, Wielenga MC, Besselink MG, van Hooft JE. Validation of combined carcinoembryonic antigen and glucose testing in pancreatic cyst fluid to differentiate mucinous from non-mucinous cysts. Surg Endosc 2023; 37:3739-3746. [PMID: 36656409 PMCID: PMC10156886 DOI: 10.1007/s00464-022-09822-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/05/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND More accurate diagnosis of mucinous cysts will reduce the risk of unnecessary pancreatic surgery. Carcinoembryonic antigen (CEA) and glucose in pancreatic cyst fluid (PCF) can differentiate mucinous from non-mucinous pancreatic cystic neoplasms (PCN). The current study assessed the value of combined CEA and glucose testing in PCF. METHODS Cross-sectional validation study including prospectively collected PCF from patients undergoing endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) and pancreatic surgery. We performed laboratory measurements for CEA and glucose and measured glucose levels by a hand glucometer. Primary outcome was diagnostic accuracy evaluated by receiver operator curves (ROC), sensitivity, specificity, positive, and negative predictive value (PPV, NPV). RESULTS Overall, PCF was collected from 63 patients, including 33 (52%) with mucinous and 30 (48%) with non-mucinous PCN. Histopathology (n = 36; 57%), cytopathology (n = 2; 3%), or clinical and/or radiological diagnosis (n = 25; 40%) was used as reference standard. Combined CEA (cut-off ≥ 192 ng/ml) and laboratory glucose testing (cut-off ≤ 50 mg/dL) reached 92% specificity and 48% sensitivity, whereas either positive CEA (cut-off ≥ 20 ng/ml) or glucose testing (cut-off ≤ 50 mg/dL) showed 97% sensitivity and 50% specificity. Sensitivity and specificity were 80% and 68% for CEA ≥ 20 ng/mL versus 50% and 93% for CEA ≥ 192 ng/mL (the conventional cut-off level). Laboratory and glucometer glucose both reached 100% sensitivity and 60% and 45% specificity, respectively. None of the biomarkers and cut-offs reached a PPV exceeding 90%, whereas both glucose measurements had a NPV of 100% (i.e., high glucose excludes a mucinous cyst). CONCLUSION Combined CEA and glucose testing in PCF reached high specificity and sensitivity for differentiating mucinous from non-mucinous PCN. Glucose testing, whether alone or combined with the new CEA cut-off (≥ 20 ng/mL), reached > 95% sensitivity for mucinous cysts, whereas only glucose reached a NPV > 95%.
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Affiliation(s)
- Myrte Gorris
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Frederike Dijk
- Cancer Center Amsterdam, Amsterdam, The Netherlands. .,Department of Pathology, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Arantza Farina
- Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Pathology, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Johannes B Halfwerk
- Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Pathology, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Gerrit K Hooijer
- Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Pathology, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Selma J Lekkerkerker
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mattheus C Wielenga
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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11
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Molecular Analysis of Pancreatic Cyst Fluid for the Management of Intraductal Papillary Mucinous Neoplasms. Diagnostics (Basel) 2022; 12:diagnostics12112573. [PMID: 36359417 PMCID: PMC9689264 DOI: 10.3390/diagnostics12112573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 12/03/2022] Open
Abstract
Pancreatic cancer is one of the most lethal human cancers. Early detection and diagnosis of precursor lesions for pancreatic malignancy is essential to improve the morbidity and mortality associated with this diagnosis. Of the cystic precursor lesions, branch duct intraductal papillary mucinous neoplasm (IPMN) is the most frequently identified lesion and has a wide range of malignant potential. Currently, Carcinogenic embryonic antigen (CEA) levels in the cyst fluid and cytology are the two most often utilized tools to diagnose these lesions; however, their diagnostic and risk stratification capabilities are somewhat limited. Within the last decade, the use of endoscopic ultrasound-guided fine-needle aspiration has opened the door for molecular analysis of cystic fluid as an option to enhance both the diagnosis and risk stratification of these lesions. The first step is to differentiate branch duct IPMNs from other lesions. KRAS and GNAS alterations have been shown to be accurate markers for this purpose. Following cyst type identification, mutational analysis, telomere fusion, microRNAs, long non-coding RNA, and DNA methylation have been identified as potential targets for stratifying malignant potential using the cystic fluid. In this review, we will examine the various targets of cyst fluid molecular analysis and their utility in the diagnosis and risk stratification of branch duct IPMNs.
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12
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Pancreatic Incidentaloma. J Clin Med 2022; 11:jcm11164648. [PMID: 36012893 PMCID: PMC9409921 DOI: 10.3390/jcm11164648] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic incidentalomas (PIs) represent a clinical entity increasingly recognized due to advances in and easier access to imaging techniques. By definition, PIs should be detected during abdominal imaging performed for indications other than a pancreatic disease. They range from small cysts to invasive cancer. The incidental diagnosis of pancreatic cancer can contribute to early diagnosis and treatment. On the other hand, inadequate management of PIs may result in overtreatment and unneeded morbidity. Therefore, there is a strong need to evaluate the nature and clinical features of individual PIs. In this review, we summarize the major characteristics related to PIs and present suggestions for their management.
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13
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Sharma RK, Bush N, Rana SS, Srinivasan R, Nada R, Gupta R, Rana S, Singh T. Lower cyst fluid carcinoembryonic antigen cutoff is helpful in the differential diagnosis of mucinous versus non-mucinous pancreatic cysts. Indian J Gastroenterol 2022; 41:397-404. [PMID: 36057043 DOI: 10.1007/s12664-022-01269-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 06/02/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Pancreatic cystic lesions (PCLs) are being diagnosed with increased frequency and have varying neoplastic potential. We conducted this multimodal, prospective study to evaluate the role of tumor cytology and molecular markers to differentiate PCL subtypes. METHODS Consecutive undiagnosed patients with PCLs (n = 100, mean age: 50.37 years; 41% males) were prospectively studied. Cyst fluid carcinoembryonic antigen (CEA), CA19.9, CA125, CA72.4, and vascular endothelial growth factor-alpha (VEGF-α) levels were measured by quantitative enzyme-linked immunosorbent assay (ELISA) method. Mutational analysis of the KRAS gene (exon 2, Codon 12 and 13) and GNAS gene (Exon 8, Codon 201) were performed by Sanger's sequencing. RESULTS The mean cyst size was 4.32 ± 2.4 cm. Fluid cytology revealed definitive diagnosis in 21 (22.3%) patients. All malignant PCLs could be identified on cytology whereas 10/14 (71%) non-malignant mucinous PCLs could also be identified on cytology based on mucin staining. Among the tested tumor markers, cyst fluid CEA had the best diagnostic performance for differentiation between mucinous and non-mucinous PCLs (AUC 0.933 [95% CI 0.86-0.91]). At a cyst fluid CEA cutoff level of 45.0 ng/mL, the sensitivity, specificity, positive predictive value, and negative predictive value for differentiation between mucinous and non-mucinous cysts were 88.5%, 96.8%, 92.0%, and 95.3%, respectively (p < 0.05). KRAS and GNAS mutation had no significant diagnostic benefit in comparison to fluid cytology and CEA levels. CONCLUSIONS Fluid CEA at a lower cutoff of 45 ng/mL is the most accurate marker to differentiate between mucinous and non-mucinous PCL. The KRAS and GNAS mutational analysis does not improve upon the diagnostic performance of fluid cytology and tumor markers.
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Affiliation(s)
- Ravi Kumar Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Nikhil Bush
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
| | - Radhika Srinivasan
- Department of Cytology and Gynecology Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Satyavati Rana
- Department of Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Tarundeep Singh
- Department of Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
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14
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Suresh V, Byers K, Rajesh UC, Caiazza F, Zhu G, Craik CS, Kirkwood K, Davisson VJ, Sheik DA. Translation of a Protease Turnover Assay for Clinical Discrimination of Mucinous Pancreatic Cysts. Diagnostics (Basel) 2022; 12:diagnostics12061343. [PMID: 35741154 PMCID: PMC9222202 DOI: 10.3390/diagnostics12061343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022] Open
Abstract
The classification of pancreatic cyst fluids can provide a basis for the early detection of pancreatic cancer while eliminating unnecessary procedures. A candidate biomarker, gastricsin (pepsin C), was found to be present in potentially malignant mucinous pancreatic cyst fluids. A gastricsin activity assay using a magnetic bead-based platform has been developed using immobilized peptide substrates selective for gastricsin bearing a dimeric rhodamine dye. The unique dye structure allows quantitation of enzyme-cleaved product by both fluorescence and surface enhanced Raman spectroscopy (SERS). The performance of this assay was compared with ELISA assays of pepsinogen C and the standard of care, carcinoembryonic antigen (CEA), in the same clinical sample cohort. A retrospective cohort of mucinous (n = 40) and non-mucinous (n = 29) classes of pancreatic cyst fluid samples were analyzed using the new protease activity assay. For both assay detection modes, successful differentiation of mucinous and non-mucinous cyst fluid was achieved using 1 µL clinical samples. The activity-based assays in combination with CEA exhibit optimal sensitivity and specificity of 87% and 93%, respectively. The use of this gastricsin activity assay requires a minimal volume of clinical specimen, offers a rapid assay time, and shows improvements in the differentiation of mucinous and non-mucinous cysts using an accurate standardized readout of product formation, all without interfering with the clinical standard of care.
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Affiliation(s)
- Vallabh Suresh
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University College of Pharmacy, West Lafayette, IN 47907, USA; (V.S.); (V.J.D.)
| | - Kaleb Byers
- Amplified Sciences, Inc., West Lafayette, IN 47906, USA; (K.B.); (U.C.R.)
| | | | - Francesco Caiazza
- Alaunus Biosciences, Inc., San Francisco, CA 94107, USA;
- Department of Pharmaceutical Chemistry, University of California, San Francisco, CA 94143, USA;
| | - Gina Zhu
- Department of Surgery, University of California, San Francisco, CA 94143, USA; (G.Z.); (K.K.)
| | - Charles S. Craik
- Department of Pharmaceutical Chemistry, University of California, San Francisco, CA 94143, USA;
| | - Kimberly Kirkwood
- Department of Surgery, University of California, San Francisco, CA 94143, USA; (G.Z.); (K.K.)
| | - Vincent Jo Davisson
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University College of Pharmacy, West Lafayette, IN 47907, USA; (V.S.); (V.J.D.)
- Amplified Sciences, Inc., West Lafayette, IN 47906, USA; (K.B.); (U.C.R.)
| | - Daniel A. Sheik
- Amplified Sciences, Inc., West Lafayette, IN 47906, USA; (K.B.); (U.C.R.)
- Correspondence:
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15
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Abstract
Andrew Canakis.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Linda S Lee
- Division of Gastroenterology Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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16
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Sun T, Zuo T, Hui P, Cai G. Significance of KRAS mutation testing in biliary brushing cytology specimens: A 10-year retrospective review. Cancer Cytopathol 2022; 130:558-565. [PMID: 35417072 DOI: 10.1002/cncy.22579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Biliary strictures can be caused by benign and malignant conditions. A biliary duct brushing diagnosis can be challenging because of low cellularity and overlapping morphology among different entities, leading to a variable reported sensitivity. This study aimed to assess the value of KRAS mutation testing in adding cytological diagnosis of biliary duct brushings. METHODS With institutional review board approval, biliary duct brushing cytology specimens were collected from 269 patients with extrahepatic biliary stenosis between August 2011 and July 2021. The results of cytology and KRAS mutational analyses were evaluated in view of corresponding cytology examination and histopathological/clinical follow-up. RESULTS KRAS mutations were identified in 50 of 269 biliary stricture brushing cases (19%). Among the cases with available follow-up, 72% (34 of 47) of biliary brushings had confirmed malignancy when there were KRAS mutations. The overall specificity and sensitivity of KRAS mutation testing was 92% and 36%, respectively. KRAS mutation was significantly more enriched in pancreatic duct adenocarcinoma than in cholangiocarcinoma (66% vs 5%, P < .001). The absolute risk of malignancy was 3%, 28%, and 71%, respectively, in negative, atypical, and suspicious cytological diagnostic categories and the risks increased to 14%, 68%, and 95% in corresponding categories with KRAS mutation. CONCLUSIONS Our results suggested that KRAS mutational analysis can be considered supplementary to cytology diagnosis of biliary duct brushing for patients with extrahepatic biliary stenosis in clinical practice.
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Affiliation(s)
- Tong Sun
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Tao Zuo
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Pei Hui
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Guoping Cai
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.,Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
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17
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Ardeshna DR, Cao T, Rodgers B, Onongaya C, Jones D, Chen W, Koay EJ, Krishna SG. Recent advances in the diagnostic evaluation of pancreatic cystic lesions. World J Gastroenterol 2022; 28:624-634. [PMID: 35317424 PMCID: PMC8900547 DOI: 10.3748/wjg.v28.i6.624] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/30/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cystic lesions (PCLs) are becoming more prevalent due to more frequent abdominal imaging and the increasing age of the general population. It has become crucial to identify these PCLs and subsequently risk stratify them to guide management. Given the high morbidity associated with pancreatic surgery, only those PCLs at high risk for malignancy should undergo such treatment. However, current diagnostic testing is suboptimal at accurately diagnosing and risk stratifying PCLs. Therefore, research has focused on developing new techniques for differentiating mucinous from non-mucinous PCLs and identifying high risk lesions for malignancy. Cross sectional imaging radiomics can potentially improve the predictive accuracy of primary risk stratification of PCLs at the time of detection to guide invasive testing. While cyst fluid glucose has reemerged as a potential biomarker, cyst fluid molecular markers have improved accuracy for identifying specific types of PCLs. Endoscopic ultrasound guided approaches such as confocal laser endomicroscopy and through the needle microforceps biopsy have shown a good correlation with histopathological findings and are evolving techniques for identifying and risk stratifying PCLs. While most of these recent diagnostics are only practiced at selective tertiary care centers, they hold a promise that management of PCLs will only get better in the future.
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Affiliation(s)
- Devarshi R Ardeshna
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Troy Cao
- College of Medicine, Ohio State University, Columbus, OH 43210, United States
| | - Brandon Rodgers
- College of Medicine, Ohio State University, Columbus, OH 43210, United States
| | - Chidiebere Onongaya
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Dan Jones
- James Molecular Laboratory, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Wei Chen
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Eugene J Koay
- Department of GI Radiation Oncology, The University of Texas MD Anderson, Houston, TX77030, United States
| | - Somashekar G Krishna
- Division of Gastroenterology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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18
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Søreide K, Marchegiani G. Clinical Management of Pancreatic Premalignant Lesions. Gastroenterology 2022; 162:379-384. [PMID: 34678216 DOI: 10.1053/j.gastro.2021.09.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Hepato-Pancreato-Biliary Unit, Stavanger University Hospital, Stavanger, Norway and, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Verona, Italy
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19
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Gorris M, Janssen QP, Besselink MG, van den Broek BLJ, van Eijck CHJ, van Gils MJ, Koerkamp BG, Struik F, van Driel LMJW, van Hooft JE. Sensitivity of CT, MRI, and EUS-FNA/B in the preoperative workup of histologically proven left-sided pancreatic lesions. Pancreatology 2022; 22:136-141. [PMID: 34857486 DOI: 10.1016/j.pan.2021.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Left-sided pancreatic lesions are often treated surgically. Accurate diagnostic work-up is therefore essential to prevent futile major abdominal surgery. Large series focusing specifically on the preoperative work-up of left-sided pancreatic lesions are lacking. This surgical cohort analysis describes the sensitivity of CT, MRI, and EUS-FNA/B in the diagnostic work-up of left-sided pancreatic lesions. METHODS We performed a post-hoc analysis of patients who underwent surgery for a left-sided pancreatic lesion between April 2010 and August 2017 and participated in the randomized CPR trial. Primary outcome was the sensitivity of CT, MRI, and EUS-FNA/B. Sensitivity was determined as the most likely diagnosis of each modality compared with the postoperative histopathological diagnosis. Additionally, the change in sensitivity of EUS versus EUS-FNA/B (i.e., cyst fluid analysis, and/or tissue acquisition) was measured. RESULTS Overall, 181 patients were included (benign: 23%, premalignant: 27%, malignant: 50%). Most patients had solid lesions (65%). Preoperative imaging included CT (86%), MRI (41%), EUS (68%). Overall, CT and EUS-FNA/B reached a sensitivity of both 71%, compared with 66% for MRI. When EUS was combined with FNA/B, sensitivity rose from 64% to 71%. For solid lesions, CT reached the highest sensitivity (75%) when compared with MRI (70%) and EUS-FNA/B (69%). For cystic lesions, EUS-FNA/B reached the highest sensitivity (75%) when compared with CT and MRI (both 62%). CONCLUSIONS CT is the most sensitive diagnostic modality for solid and EUS-FNA/B for cystic left-sided pancreatic lesions. EUS-FNA/B was associated with an increased sensitivity when compared to EUS alone.
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Affiliation(s)
- Myrte Gorris
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | - Quisette P Janssen
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bram L J van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marjon J van Gils
- Department of Radiology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Femke Struik
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
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20
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Facciorusso A, Ramai D, Gkolfakis P, Shapiro A, Arvanitakis M, Lisotti A, Triantafyllou K, Fusaroli P, Papanikolaou IS, Crinò SF. Through-the-needle biopsy of pancreatic cystic lesions: current evidence and implications for clinical practice. Expert Rev Med Devices 2021; 18:1165-1174. [PMID: 34842023 DOI: 10.1080/17434440.2021.2012450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION There is increasing evidence to support the efficacy of endoscopic ultrasound (EUS)-guided through-the-needle biopsy (TTNB) technique as a means of sampling pancreatic cystic lesions (PCLs). Results provide evidence demonstrating the benefits of this procedure over standard EUS fine-needle aspiration (FNA), thus supporting a push for its widespread implementation in clinical practice. Though this technique has demonstrated advantages, achieving these advantages in clinical practice is contingent upon careful considerations to ensure safety and efficacy. AREAS COVERED The purpose of this review is to assess the level of evidence supporting the use of through-the-needle biopsy, revise its main technical and procedural characteristics, and to develop suggested guidelines outlining the safe assimilation of this device in clinical practice. EXPERT OPINION EUS-TTNB enables more definitive and accurate diagnosis of PCLs by providing higher-quality histological samples. However, EUS-TTNB is not appropriate for all PCLs. Selection of suitable patients as well as morphology and risk factors of the cystic lesion is a crucial component of achieving the described benefits of this procedure while minimizing risks of adverse effects. Subjects with weak or absent indications for this procedure are susceptible to a range of complications and may even result in fatality.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical and Surgical Sciences, Section of Gastroenterology, University of Foggia, Foggia, Italy.,Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT, USA
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cub Erasme Hospital, Université Libre de Bruxelles (Ulb), Brussels, Belgium
| | - Alexandra Shapiro
- Department of Medicine, St. George's University School of Medicine, True Blue, Grenada
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cub Erasme Hospital, Université Libre de Bruxelles (Ulb), Brussels, Belgium
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
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21
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Jabłońska B, Szmigiel P, Mrowiec S. Pancreatic intraductal papillary mucinous neoplasms: Current diagnosis and management. World J Gastrointest Oncol 2021; 13:1880-1895. [PMID: 35070031 PMCID: PMC8713311 DOI: 10.4251/wjgo.v13.i12.1880] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/17/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) represent approximately 1% of all pancreatic neoplasms and 25% of cystic neoplasms. They are divided into three types: main duct-IPMN (MD-IPPMN), branch duct-IPMN (BD-IPMN), and mixed type-IPMN. In this review, diagnostics, including clinical presentation and radiological investigations, were described. Magnetic resonance imaging is the most useful for most IPMNs. Management depends on the type and radiological features of IPMNs. Surgery is recommended for MD-IPMN. For BD-IPMN, management involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, the presence of symptoms (jaundice, new-onset diabetes, pancreatitis), and CA 19.9 serum level. The patient’s age and comorbidities should also be taken into consideration. Currently, there are different guidelines regarding the diagnosis and management of IPMNs. In this review, the following guidelines were presented: Sendai International Association of Pancreatology guidelines (2006), American Gastroenterological Association guidelines, revised international consensus Fukuoka guidelines (2012), revised international consensus Fukuoka guidelines (2017), and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas (2018). The Verona Evidence-Based Meeting 2020 was also presented and discussed.
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Affiliation(s)
- Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice 40-752, Poland
| | - Paweł Szmigiel
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice 40-752, Poland
| | - Sławomir Mrowiec
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice 40-752, Poland
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22
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Nista EC, Schepis T, Candelli M, Giuli L, Pignataro G, Franceschi F, Gasbarrini A, Ojetti V. Humoral Predictors of Malignancy in IPMN: A Review of the Literature. Int J Mol Sci 2021; 22:ijms222312839. [PMID: 34884643 PMCID: PMC8657857 DOI: 10.3390/ijms222312839] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cystic lesions are increasingly detected in cross-sectional imaging. Intraductal papillary mucinous neoplasm (IPMN) is a mucin-producing subtype of the pancreatic cyst lesions arising from the pancreatic duct system. IPMN is a potential precursor of pancreatic cancer. The transformation of IPMN in pancreatic cancer is progressive and requires the occurrence of low-grade dysplasia, high-grade dysplasia, and ultimately invasive cancer. Jaundice, enhancing mural nodule >5 mm, main pancreatic duct diameter >10 mm, and positive cytology for high-grade dysplasia are considered high-risk stigmata of malignancy. While increased levels of carbohydrate antigen 19-9 (CA 19-9) (>37 U/mL), main pancreatic duct diameter 5-9.9 mm, cyst diameter >40 mm, enhancing mural nodules <5 mm, IPMN-induced acute pancreatitis, new onset of diabetes, cyst grow-rate >5 mm/year are considered worrisome features of malignancy. However, cross-sectional imaging is often inadequate in the prediction of high-grade dysplasia and invasive cancer. Several studies evaluated the role of humoral and intra-cystic biomarkers in the prediction of malignancy in IPMN. Carcinoembryonic antigen (CEA), CA 19-9, intra-cystic CEA, intra-cystic glucose, and cystic fluid cytology are widely used in clinical practice to distinguish between mucinous and non-mucinous cysts and to predict the presence of invasive cancer. Other biomarkers such as cystic fluid DNA sequencing, microRNA (mi-RNA), circulating microvesicles, and liquid biopsy are the new options for the mini-invasive diagnosis of degenerated IPMN. The aim of this study is to review the literature to assess the role of humoral and intracystic biomarkers in the prediction of advanced IPMN with high-grade dysplasia or invasive carcinoma.
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Affiliation(s)
- Enrico C. Nista
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.C.N.); (T.S.); (L.G.); (A.G.)
| | - Tommaso Schepis
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.C.N.); (T.S.); (L.G.); (A.G.)
| | - Marcello Candelli
- Department of Emergency Medicine, Fondazione Policlinico Universitario, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.C.); (G.P.); (F.F.)
| | - Lucia Giuli
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.C.N.); (T.S.); (L.G.); (A.G.)
| | - Giulia Pignataro
- Department of Emergency Medicine, Fondazione Policlinico Universitario, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.C.); (G.P.); (F.F.)
| | - Francesco Franceschi
- Department of Emergency Medicine, Fondazione Policlinico Universitario, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.C.); (G.P.); (F.F.)
| | - Antonio Gasbarrini
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.C.N.); (T.S.); (L.G.); (A.G.)
| | - Veronica Ojetti
- Department of Emergency Medicine, Fondazione Policlinico Universitario, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.C.); (G.P.); (F.F.)
- Correspondence: ; Tel.: +39-063-0153-188
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23
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McCarty TR, Garg R, Rustagi T. Pancreatic cyst fluid glucose in differentiating mucinous from nonmucinous pancreatic cysts: a systematic review and meta-analysis. Gastrointest Endosc 2021; 94:698-712.e6. [PMID: 33964311 DOI: 10.1016/j.gie.2021.04.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Recently, low levels of intracystic glucose acquired with EUS-guided pancreatic cyst fluid sampling have been shown to help to differentiate mucinous from nonmucinous cystic neoplasms. The aim of this study was to perform a systematic review and meta-analysis to evaluate the diagnostic characteristics of pancreatic cyst fluid glucose compared with carcinoembryonic antigen (CEA) for pancreatic cystic lesions. METHODS Individualized searches were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines and meta-analysis analyzed according to Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute pooled sensitivity and specificity, likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristics curve for intracystic glucose or CEA alone or combination testing. RESULTS Eight studies (609 lesions; mean patient age, 63.56 ± 2.75 years; 60.36% women) were included. The pooled sensitivity for pancreatic cyst fluid glucose was significantly higher compared with CEA alone (91% [95% confidence interval {CI}, 88-94; I2 = .00] vs 56% [95% CI, 46-66; I2 = 537.14]; P < .001) with no difference in specificity (86% [95% CI, 81-90; I2 = 24.16] vs 96% [95% CI, 90-99; I2 = 38.06]; P > .05). Diagnostic accuracy was significantly higher for pancreatic cyst fluid glucose versus CEA alone (94% [95% CI, 91-96] vs 85% [95% CI, 82-88]; P < .001). Combination testing with pancreatic cyst fluid glucose and CEA did not improve the diagnostic accuracy compared with glucose alone (97% [95% CI, 95-98] vs 94% [95% CI, 91-96]; P > .05). CONCLUSIONS Low pancreatic cyst fluid glucose was associated with a high sensitivity and specificity with significantly improved diagnostic accuracy compared with CEA alone for the diagnosis of mucinous versus nonmucinous pancreatic cystic lesions.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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24
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Buerlein RCD, Shami VM. Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc 2021; 14:26317745211045769. [PMID: 34589706 PMCID: PMC8474323 DOI: 10.1177/26317745211045769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022] Open
Abstract
The prevalence of pancreatic cysts has increased significantly over the last
decade, partly secondary to increased quality and frequency of cross-sectional
imaging. While the majority never progress to cancer, a small number will and
need to be followed. The management of pancreatic cysts can be both confusing
and intimidating due to the multiple guidelines with varying recommendations.
Despite the differences in the specifics of the guidelines, they all agree on
several high-risk features that should get the attention of any clinician when
assessing a pancreatic cyst: presence of a mural nodule or solid component,
dilation of the main pancreatic duct (or presence of main duct intraductal
papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology
on pancreatic cyst fluid aspiration. Other important criteria to consider
include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9
levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related
to the cystic lesion.
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Affiliation(s)
| | - Vanessa M Shami
- University of Virginia Digestive Health, 1215 Lee Street, Charlottesville, VA 22903, USA
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25
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Lee LS. Updates in diagnosis and management of pancreatic cysts. World J Gastroenterol 2021; 27:5700-5714. [PMID: 34629795 PMCID: PMC8473602 DOI: 10.3748/wjg.v27.i34.5700] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/14/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
Incidental pancreatic cysts are commonly encountered with some cysts having malignant potential. The most common pancreatic cystic neoplasms include serous cystadenoma, mucinous cystic neoplasm and intraductal papillary mucinous neoplasm. Risk stratifying pancreatic cysts is important in deciding whether patients may benefit from endoscopic ultrasound (EUS) or surgical resection. Surgery should be reserved for patients with malignant cysts or cysts at high risk for developing malignancy as suggested by various risk features including solid mass, nodule and dilated main pancreatic duct. EUS may supplement magnetic resonance imaging findings for cysts that remain indeterminate or have concerning features on imaging. Various cyst fluid markers including carcinoembryonic antigen, glucose, amylase, cytology, and DNA markers help distinguish mucinous from nonmucinous cysts. This review will guide the practicing gastroenterologist in how to evaluate incidental pancreatic cysts and when to consider referral for EUS or surgery. For presumed low risk cysts, surveillance strategies will be discussed. Managing pancreatic cysts requires an individualized approach that is directed by the various guidelines.
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Affiliation(s)
- Linda S Lee
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
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26
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From bench to bedside: Is it time to incorporate molecular testing for diagnostic and management algorithms for pancreatic cystic lesions? Gastrointest Endosc 2021; 93:1034-1037. [PMID: 33875142 DOI: 10.1016/j.gie.2021.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/29/2021] [Indexed: 02/08/2023]
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