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Kalsi H, Jue TL, Pannala R. Arterial Pseudoaneurysm Mimicking a Mural Nodule Within a Pancreatic Cyst. ACG Case Rep J 2023; 10:e01080. [PMID: 37389193 PMCID: PMC10306426 DOI: 10.14309/crj.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 05/24/2023] [Indexed: 07/01/2023] Open
Abstract
Pancreatic cysts with high-risk characteristics are at increased risk of harboring high-grade dysplasia or pancreatic cancer. Endoscopic ultrasound may clarify the nature of the cystic lesion and its malignant potential. A mural nodule found through endoscopic ultrasound within a cyst may represent malignancy and require fine-needle aspiration. Pancreatic pseudocysts are benign walled-off fluid collections that form in the setting of pancreatitis and may be difficult to differentiate from neoplastic cysts. Pseudoaneurysms form when pancreatitis inflammation damages vessel walls and can cause fatal hemorrhage. We present a pancreatic pseudocyst with pseudoaneurysm mimicking a neoplastic cyst with a mural nodule.
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Affiliation(s)
| | - Terry L. Jue
- Department of Gastroenterology & Hepatology, Mayo Clinic, AZ
| | - Rahul Pannala
- Department of Gastroenterology & Hepatology, Mayo Clinic, AZ
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EUS Morphology Is Reliable in Selecting Patients with Mucinous Pancreatic Cyst(s) Most Likely to Benefit from Surgical Resection. Gastroenterol Res Pract 2017; 2017:9863952. [PMID: 29081794 PMCID: PMC5610869 DOI: 10.1155/2017/9863952] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/28/2017] [Indexed: 12/25/2022] Open
Abstract
Background and Study Aims Endoscopic ultrasound (EUS) surveillance of patients with mucinous pancreatic cysts relies on the assessment of morphologic features suggestive of malignant transformation. These criteria were derived from the evaluation of surgical pathology in patients with pancreatic cysts who underwent surgery. Reliability of these criteria when evaluated by EUS in identifying lesions which require surgery has still not been established. Patients and Methods This retrospective cohort study included seventy-eight patients who underwent surgical resection of pancreatic cysts based on EUS-FNA (fine-needle aspiration) findings suggestive of mucinous pancreatic cysts with concern for malignancy. Results Final surgical pathology diagnoses of patients were the following: adenocarcinoma (19), intraductal papillary mucinous neoplasm (IPMN) (39), mucinous cystic neoplasm (MCN) (13), serous cystadenoma (2), pseudocyst (3), mucinous solid-cystic lesion of indeterminate type (1), and mesenteric cyst (1). Cysts with focal wall thickening ≥ 3 mm (p = 0.0008), dilation of pancreatic duct (PD) (p = 0.0067), and cyst size ≥ 3 cm (p = 0.016) had significantly higher risk of adenocarcinoma. None of the patients without any of these morphologic features had cancer. Conclusions In patients with mucinous pancreatic cyst(s), focal wall thickening, cyst size ≥ 3 cm, and PD dilation as assessed by EUS can help identify advanced mucinous cysts which require surgery and should routinely be evaluated during EUS surveillance.
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Zhang W, Linghu E, Chai N, Li H. New criteria to differentiate between mucinous cystic neoplasm and serous cystic neoplasm in pancreas by endoscopic ultrasound: A preliminarily confirmed outcome of 41 patients. Endosc Ultrasound 2017; 6:116-122. [PMID: 28440237 PMCID: PMC5418964 DOI: 10.4103/eus.eus_8_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Objectives: The ability to distinguish between mucinous cystic neoplasm (MCN) and serous cystic neoplasm (SCN) in the pancreas preoperatively by endoscopic ultrasound (EUS) remains a clinical challenge. To address this problem, we have developed new criteria using EUS findings and cyst fluid carcinoembryonic antigen (CEA) in the clinic. In this study, the validity and reliability of these criteria were assessed. Materials and Methods: Between April of 2015 and May of 2016, a total of 59 patients with pancreatic cystic neoplasms underwent EUS and ultimately received surgery in our hospital. Of the 59 patients, 21 were pathologically verified to have MCN while 20 were verified to have SCN in the pancreas. For these 41 patients with MCN or SCN, EUS findings and cyst fluid CEA were reviewed. Results: For the 41 patients reviewed, the new criteria were found to identify MCN with 85.71% sensitivity (95% confidence interval [CI], 64%–97%), 80.00% specificity (CI, 56%-94%), and 82.93% accuracy (CI, 68%–93%). Conclusion: These new criteria were preliminarily found to produce excellent results, with 82.93% accuracy determined for the differential diagnosis between MCN and SCN by EUS. However, a further prospective study with a larger population must be carried out to fully assess these new criteria.
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Affiliation(s)
- Wengang Zhang
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ningli Chai
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China
| | - Huikai Li
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China
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D'Souza SL, Holub JL, Pavic BT, Rodriguez SA. Multicenter evaluation of the utilization of endoscopic ultrasound. Dig Endosc 2016; 28:738-743. [PMID: 27010598 DOI: 10.1111/den.12659] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/15/2016] [Accepted: 03/17/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM There are currently no data regarding the number and type of endoscopic ultrasound (EUS) procedures being carried out in the USA. The aims of the present study are to: (i) estimate the annual number of EUS procedures being carried out in a nationwide database; (ii) describe the indications and types of EUS carried out; and (iii) examine short-term trends in volume. METHODS Retrospective analysis from the Clinical Outcomes Research Initiative (CORI) of EUS procedures carried out on patients >18 years of age from 1 January 2010 through 31 December 2013. RESULTS EUS cases (n = 7614) were carried out by 68 endoscopists at 18 sites over the study period, representing 1.7% of the total number of endoscopic procedures. The most common indications were evaluation of a pancreatic mass (14.7%), diagnostic sampling with fine-needle aspiration (14.1%), and evaluation of a pancreatic cyst (14.0%). The number of EUS examinations and cases undergoing same-day endoscopic retrograde cholangiopancreatography (ERCP) increased over the study period (P < 0.0001). Use of general anesthesia or deep sedation increased markedly from 37.8% to 82.8% of procedures (P < 0.0001). CONCLUSIONS This is the largest survey of EUS practice in the USA. Evaluation of the pancreas accounts for approximately 40% of the indications for EUS. Use of EUS increased over the study period, and the proportion carried out with deep sedation or general anesthesia also increased. These data may have implications regarding the number of endosonographers who should be trained, as well as cost issues pertaining to increasing use of anesthesia providers and same-day ERCP.
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Affiliation(s)
- Sharlene L D'Souza
- Department of Gastroenterology & Hepatology, Portland VA Medical Center, Oregon Health & Science University, Portland, USA. .,Department of Gastroenterology, Oregon Health & Science University, Legacy Meridian Park Medical Center, Portland, USA.
| | - Jennifer L Holub
- Department of Gastroenterology, Oregon Health & Science University, Legacy Meridian Park Medical Center, Portland, USA
| | - Brian T Pavic
- Department of Internal Medicine, Legacy Meridian Park Medical Center, Portland, USA
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Alkaade S, Chahla E, Levy M. Role of endoscopic ultrasound-guided fine-needle aspiration cytology, viscosity, and carcinoembryonic antigen in pancreatic cyst fluid. Endosc Ultrasound 2015; 4:299-303. [PMID: 26643697 PMCID: PMC4672587 DOI: 10.4103/2303-9027.170417] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Due to the advances and increased utility of abdominal cross-sectional imaging, the diagnosis of pancreatic cysts continues to increase. Many endosonographers, pancreatologists, and surgeons consider endoscopic ultrasound (EUS) to be an essential tool in the management of pancreatic cystic lesions (PCLs). EUS can help distinguish between mucinous and nonmucinous lesions and may identify the specific cyst type. EUS achieves these goals by delineating the cyst morphology, identifying high risk stigmata and worrisome features, and through image-guided fine-needle aspiration (FNA) and cyst fluid analysis. However, recent consensus statements have called to question the utility and diminished the role of EUS in this setting. The aim of this review is to assess the role and advances of EUS-FNA in pancreatic cyst fluid analysis, specifically in terms of fluid cytology, viscosity, and carcinoembryonic antigen (CEA) analysis.
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Affiliation(s)
- Samer Alkaade
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148:824-48.e22. [PMID: 25805376 DOI: 10.1053/j.gastro.2015.01.014] [Citation(s) in RCA: 255] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James M Scheiman
- Department of Internal Medicine and Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joo Ha Hwang
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Paul Moayyedi
- Division of Gastroenterology, Hamilton Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University Hamilton, Ontario, Canada
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Lami G, Biagini MR, Galli A. Endoscopic ultrasonography for surveillance of individuals at high risk for pancreatic cancer. World J Gastrointest Endosc 2014; 6:272-85. [PMID: 25031786 PMCID: PMC4094985 DOI: 10.4253/wjge.v6.i7.272] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 06/10/2014] [Accepted: 06/20/2014] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cancer is a highly lethal disease with a genetic susceptibility and familial aggregation found in 3%-16% of patients. Early diagnosis remains the only hope for curative treatment and improvement of prognosis. This can be reached by the implementation of an intensive screening program, actually recommended for individuals at high-risk for pancreatic cancer development. The aim of this strategy is to identify pre-malignant precursors or asymptomatic pancreatic cancer lesions, curable by surgery. Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) seems to be the most promising technique for early detection of pancreatic cancer. It has been described as a highly sensitive and accurate tool, especially for small and cystic lesions. Pancreatic intraepithelial neoplasia, a precursor lesion which is highly represented in high-risk individuals, seems to have characteristics chronic pancreatitis-like changes well detected by EUS. Many screening protocols have demonstrated high diagnostic yields for pancreatic pre-malignant lesions, allowing prophylactic pancreatectomies. However, it shows a high interobserver variety even among experienced endosonographers and a low sensitivity in case of chronic pancreatitis. Some new techniques such as contrast-enhanced harmonic EUS, computer-aided diagnostic techniques, confocal laser endomicroscopy miniprobe and the detection of DNA abnormalities or protein markers by FNA, promise improvement of the diagnostic yield of EUS. As the resolution of imaging improves and as our knowledge of precursor lesions grows, we believe that EUS could become the most suitable method to detect curable pancreatic neoplasms in correctly identified asymptomatic at-risk patients.
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Cho HW, Choi JY, Kim MJ, Park MS, Lim JS, Chung YE, Kim KW. Pancreatic tumors: emphasis on CT findings and pathologic classification. Korean J Radiol 2011; 12:731-9. [PMID: 22043156 PMCID: PMC3194778 DOI: 10.3348/kjr.2011.12.6.731] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 07/11/2011] [Indexed: 12/13/2022] Open
Abstract
Pancreatic tumors can be classified by their morphologic features on CT. The subtypes include solid tumors, mixed cystic and solid lesions, unilocular cysts, multilocular cystic lesions, and microcystic lesions. Endoscopic US and MRI can provide detailed information for classifying pancreatic lesions. Each subtype has different kinds of tumors and malignant potential, thus the classification can be useful for a better differential diagnosis and treatment planning. For this purpose, we suggest an appropriate modified classification system by using the imaging features of pancreatic tumors with an emphasis on CT findings and illustrate various findings of typical and atypical manifestations.
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Affiliation(s)
- Hee-Woo Cho
- Department of Radiology and the Research Institute of Radiological Sciences, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
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Abstract
A high-quality pancreatic protocol computed tomography (CT) is the primary imaging modality for diagnosing and staging pancreatic malignancy. The main limitation of CT is the lack of sensitivity for early pancreatic lesions. Endoscopic ultrasound (EUS) provides an excellent complement to CT for both diagnosis and staging of pancreatic cancer, and allows easy access for needle aspiration and tissue diagnosis. Magnetic resonance (MR) can be helpful for evaluating small hepatic nodules or cystic lesions of the pancreas, but in general, the role of MR and positron emission tomography remains limited to special situations when the results of CT and EUS are equivocal.
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10
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Long-term follow-up of patients with incidentally discovered pancreatic cystic neoplasms evaluated by endoscopic ultrasound. Surgery 2010; 147:13-20. [DOI: 10.1016/j.surg.2009.05.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 05/17/2009] [Indexed: 01/29/2023]
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Zhang S, Defrias DVS, Alasadi R, Nayar R. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA): experience of an academic centre in the USA. Cytopathology 2009; 21:35-43. [PMID: 19843142 DOI: 10.1111/j.1365-2303.2009.00664.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has become widely accepted as an effective modality for obtaining tissue for primary diagnosis and staging. We have been using EUS-FNA since July 2001 and herein we summarize our experience over a 5-year period. METHODS A computer-based search for in-house EUS-FNA was performed in the pathology database from July 2001 to October 2006. To calculate the sensitivity, specificity and accuracy of EUS-FNA, the cytology diagnosis was compared with the surgical follow-up. RESULTS A total of 951 EUS-FNAs were performed during the study period and included 279 pancreatic solid lesions, 186 pancreatic cyst lesions, 249 lymph node aspirations, 111 gastrointestinal (GI) tract submucosal lesions, and 126 miscellaneous lesions. EUS-FNA had a very high sensitivity and accuracy for solid pancreatic lesions (94.7 and 97.7%, respectively), low sensitivity and accuracy but high specificity (47, 64.8 and 95%, respectively) for cystic lesions. Cyst fluid carcinoembryonic (CEA) levels were significantly higher in mucinous neoplasms than non-neoplastic cysts. EUS-FNA also had very high sensitivity and specificity for detecting metastatic carcinoma in lymph nodes (95 and 100%, respectively). GI submucosal spindle cell tumours were further classified with immunohistochemical stains performed either on a cell block or a core biopsy obtained via EUS guidance. CONCLUSIONS EUS-FNA has a very high sensitivity and accuracy for pancreatic solid lesions, but the sensitivity for cystic lesions is generally low. Cyst fluid chemical analysis for CEA is helpful, but the overlap between mucinous neoplasm and non-neoplastic cysts is significant. Recognizing GI contamination is important and immunohistochemical stains are useful for GI submucosal spindle cell lesions.
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Affiliation(s)
- S Zhang
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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13
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Abstract
Pancreatic cystic lesions are being detected more frequently given increased use of cross-sectional imaging modalities. The most common cysts encountered are mucinous cysts, which have malignant potential. As many of these lesions are incidental findings, it is important to further evaluate them with endoscopic ultrasound-guided fine needle aspiration for diagnostic purposes and risk stratification. These cysts either require surgical resection or surveillance given the malignant risk. Mucinous cystic neoplasms should be resected. Intraductal papillary mucinous neoplasia (IPMN) has consensus-guideline indications for resection. These include main duct diameter > or = 10 mm, a branch duct size > or = 3 cm, presence of a mural nodule, or cytology suspicious for malignancy. Additionally, all symptomatic cysts, regardless of etiology, should undergo resection. Branch duct IPMN is less aggressive that the main duct variety, and may be conservatively followed. However, the development of an established indication for resection should prompt surgery. Despite generalized guidelines, decisions regarding management of pancreatic cysts should be individualized, accounting for the malignant risk of the lesion and the surgical risk of the patient.
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Affiliation(s)
- Kenneth E Fasanella
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Das A, Wells CD, Nguyen CC. Incidental cystic neoplasms of pancreas: what is the optimal interval of imaging surveillance? Am J Gastroenterol 2008; 103:1657-62. [PMID: 18564119 DOI: 10.1111/j.1572-0241.2008.01893.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The optimal interval of imaging studies for surveillance of incidental pancreatic cystic neoplasms is not known. OBJECTIVE A retrospective analysis of longitudinal medical records of patients with pancreatic cystic neoplasms was performed to examine the natural history of incidentally detected cystic pancreatic neoplasms with respect to the development of significant growth and to identify predictors of such growth. RESULTS After excluding patients with small (<10 mm) cysts (N = 144) and inadequate clinical follow-up of less than 6 months (N = 79) and those with a clinical diagnosis of pancreatic pseudocysts, serous cystadenoma, main duct intraductal papillary mucinous neoplasm (N = 29), and neuroendocrine tumor (N = 3), in total, 166 cysts in 150 patients were available for analysis. The working diagnoses on these cysts (based on clinical, radiological features, aspiration cytology, cyst fluid analysis, and surgical pathology data when available) were mucinous cystic neoplasm in 117 and branch-type intraductal papillary mucinous neoplasm in 49. The mean standard error (SE) initial size of these cysts was 2 (0.1) cm. Over a median period of follow-up of 32 (IQR [inter-quartile range] 19-48) months, 89% of all the cysts did not show significant growth during the follow-up. In a multivariate Cox proportional hazards model, the initial size of the cystic lesion was an independent predictor of significant growth during follow-up (relative risk 1.28, 95% confidence interval [CI] 1.08-1.61, P= 0.01); the only other significant variable was the presence of intracystic or mural nodule (relative risk 38.6, 95% CI 2.3-654, P= 0.01). CONCLUSION Most incidentally detected cystic neoplasms of the pancreas did not have significant growth during follow-up. Such growth is unlikely to occur before 2 yr of the baseline evaluation, and we suggest that the optimal imaging interval during follow-up of these patients should be at 2 yr from the baseline evaluation, particularly in cystic lesions 3.0 cm or less in size and without intracystic or mural nodules.
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Affiliation(s)
- Ananya Das
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona 85259, USA
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15
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Abstract
Pancreatic cystic lesions are being increasingly identified. Clinical decision making is driven by the differential diagnosis of the cyst and, for the asymptomatic patient, its likelihood of causing harm. The fundamental issue is whether the cyst is neoplastic, and, if so, what is its risk for malignant degeneration. High-resolution computed tomography provides detailed information about cyst structure and may facilitate differentiation from mucin-secreting tumors of the pancreas. Magnetic resonance imaging has the potential added advantage of determining communication between the cyst and pancreatic duct. Endoscopic ultrasound (EUS) imaging provides additional characterization of the lesion. While EUS morphology alone has limitations regarding definitive diagnosis, aspiration, and characterization of cyst, fluid contents may provide incremental information. Aspiration is well tolerated and safe, with a complication rate of less than 1%. In the absence of a history of pancreatitis, pseudocyst is quite unlikely, and the concern of a cystic neoplasm is paramount. In general, all symptomatic lesions should proceed to appropriate surgical resection. If preoperative characterization of the lesion will change management, EUS+FNA for cytology and fluid analysis (CEA) may characterize the lesion as mucinous, although cytology alone is rarely definitive. For those patients with benign-appearing lesions, such as classic appearance of a serous cystadenoma, observation alone seems appropriate. In some circumstances, EUS+FNA confirmation of a negative cytology and low fluid CEA can further provide evidence to support a monitoring approach and deferral of surgical intervention.
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Affiliation(s)
- James M Scheiman
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, 3912 Taubman Center/0362, Ann Arbor, MI, USA.
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Abstract
More than 95% of malignant tumours of the pancreas are exocrine carcinomas. The exocrine carcinomas have to be distinguished from benign serous cystadenomas and tumours, the latter including mucinous cystic neoplasms, serous cysts, and solid pseudopapillary neoplasms. Cystic lesions have to be separated from pseudocysts, which are the most common cysts. Pseudocysts are due to extensive confluent autodigestive tissue necrosis caused by alcoholic, biliary, or traumatic acute pancreatitis. This review focuses on the classification of the different types of solid and cystic lesions based on histological criteria. The various imaging procedures are also discussed, along with their strengths and limitations.
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Affiliation(s)
- Lukas Degen
- Department of Gastroenterology and Hepatology, University Hospital, Basel, Switzerland
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Katz DS, Friedel DM, Kho D, Georgiou N, Hines JJ. Relative Accuracy of CT and MRI for Characterization of Cystic Pancreatic Masses. AJR Am J Roentgenol 2007; 189:657-61. [PMID: 17715114 DOI: 10.2214/ajr.07.2772] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Douglas S Katz
- Department of Radiology, Winthrop-University Hospital, Mineola, NY 11501, USA
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18
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Jhala NC, Eltoum IA, Eloubeidi MA, Meara R, Chhieng DC, Crowe DR, Jhala D. Providing on-site diagnosis of malignancy on endoscopic-ultrasound-guided fine-needle aspirates: should it be done? Ann Diagn Pathol 2007; 11:176-81. [PMID: 17498591 DOI: 10.1016/j.anndiagpath.2006.03.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rapid and accurate tissue diagnosis for a deep-seated malignancy would allow treating physicians to provide disease-specific interventions and help patients make early informed management decisions. Providing on-site tissue diagnosis for fine-needle aspirate samples obtained with endosonography would help develop such efficient patient management issues. Here we report our experience of prospectively providing on-site diagnosis on 485 endoscopic ultrasound fine-needle aspirate samples. METHODS Four hundred eighty-five endoscopic ultrasound fine-needle aspirates from the pancreas (n= 305), lymph nodes (n = 91), biliary tree (n = 47), liver (n = 15), gastrointestinal tract (n = 19), and adrenal gland (n = 8) were reviewed. For all aspirates, the cytologic diagnoses, both preliminary and final, were categorized into the following: positive for malignancy, positive for neoplastic process, suspicious for malignancy, atypical cells, reactive process, and nondiagnostic. RESULTS Of the 485 cases, 163 (33.6%) were diagnosed as benign, 43 (8.8%) as atypical, 21 (4.3%) as suspicious, 18 (3.7%) as positive for neoplasm, and 230 (47.4%) as malignant after final cytologic interpretation. A significantly (P < .001) higher degree of concordance was noted for unequivocal diagnosis of malignancy (196/198, 98.9%) vs nonmalignancy (200/250, 67.2%) between on-site and final cytologic diagnosis. Of the 52 discordant cases, 12 (2.6%) diagnoses were downgraded and 40 (8.9%) were upgraded from preliminary on-site diagnosis. Our overall sensitivity (87 vs 92), specificity (95% vs 100%), and accuracy (90% vs 94%) improved for final cytologic diagnosis. CONCLUSION On-site diagnosis of malignancy could be used to initiate informed patient management decisions. Cases where a diagnosis of malignancy is not rendered at on-site interpretation need further cytologic evaluation.
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Affiliation(s)
- Nirag C Jhala
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35249, USA.
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Shami VM, Sundaram V, Stelow EB, Conaway M, Moskaluk CA, White GE, Adams RB, Yeaton P, Kahaleh M. The level of carcinoembryonic antigen and the presence of mucin as predictors of cystic pancreatic mucinous neoplasia. Pancreas 2007; 34:466-9. [PMID: 17446847 DOI: 10.1097/mpa.0b013e318033fa12] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Characterization of pancreatic cysts using endoscopic ultrasound-guided fine-needle aspiration includes cytological interpretation and chemical analysis. We prospectively analyzed the contribution of carcinoembryonic antigen (CEA) and cytological identification of extracellular mucin as predictors of mucinous neoplasia and malignancy. METHODS From January 2003 to October 2005, all patients referred to the University of Virginia with cystic lesions of the pancreas underwent endoscopic ultrasound-guided fine-needle aspiration with cytological evaluation and CEA level analysis. Data were collected prospectively and confirmed by resection or tissue biopsy. Univariate and multivariate analyses were performed on the following variables with regard to their ability to predict mucinous neoplasia: age (<55 or >55 years), sex, CEA level (<300 or >300 ng/mL), and cytological appreciation of extracellular mucin (positive or negative). P values less than 0.05 were considered significant. RESULTS A total of 43 patients were included in this study. There were 19 men and 24 women with a mean age of 63 +/- 14 years. The only complication was pancreatitis secondary to cyst leak in one patient. Multivariate analysis confirmed CEA level greater than 300 ng/mL (P= 0.007) and the identification of mucin (P < 0.001) as significant predictors. CONCLUSIONS With pancreatic cyst fluid analysis, the strongest predictor of mucinous neoplasia is the presence of identifiable mucin, followed by a CEA level greater than 300 ng/mL. The workup of cystic lesions of the pancreas should include chemical analysis for the CEA level and cytological examination with particular attention to extracellular mucin.
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Affiliation(s)
- Vanessa M Shami
- Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA 22908-0708, USA
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Abstract
BACKGROUND Pancreatic cancer is a lethal disease, with near uniform 5-year mortality rates. The key to improving survival of pancreatic cancer rests upon early detection of this neoplasm at a resectable, and hence potentially curable, stage. METHODS We review the current state of the literature vis-à-vis the three common precursor lesions of pancreatic adenocarcinoma: pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm. We also discuss two clinical scenarios of emerging importance, namely asymptomatic pancreatic cysts ('pancreatic incidentalomas') and the significance of precursor lesions in familial pancreatic cancer kindreds. RESULTS Pancreatic intraepithelial neoplasias are the microscopic precursor lesions of pancreatic adenocarcinomas, while intraductal papillary mucinous neoplasms and mucinous cystic neoplasms are macroscopic, cystic precursor lesions. All three noninvasive entities demonstrate a multistep morphologic and genetic progression that culminates in frank invasive adenocarcinoma. Despite these commonalities, each precursor lesion harbors a unique repertoire of clinicopathologic and genetic characteristics that has an impact on natural history and prognosis of these lesions. Due to improvements in radiological techniques, asymptomatic pancreatic cysts are being increasingly discovered in the general population; intraductal papillary mucinous neoplasms and mucinous cystic neoplasms are the most common underlying histology in resected incidentalomas of the pancreas. Pancreatic asymptomatic cysts present an enormous challenge in terms of accurate diagnosis and management stratification. Incorporating molecular signatures of cystic precursor lesions into the diagnostic algorithm will likely become a standard of care for asymptomatic pancreatic cysts. High-risk individuals from familial pancreatic cancer kindreds are another group of individuals where knowledge of precursor lesions has had a therapeutic impact; sensitive imaging technologies have enabled the identification and subsequent resection of pancreatic cancer precursors in these high-risk individuals, preventing the progression to invasive cancer. CONCLUSIONS Precursor lesions of pancreatic adenocarcinomas represent a unique opportunity for diagnosis and intervention for a malignancy with near uniform lethality. Further studies on these precursors will enable the development of rational early detection and therapeutic strategies in order to ameliorate pancreatic cancer survival.
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Affiliation(s)
- Mansher Singh
- Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
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Lazure T, Drak Alsibai K, Fabre M. [Endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic neoplasms: utility and limitations]. Ann Pathol 2007; 26:352-60. [PMID: 17255923 DOI: 10.1016/s0242-6498(06)70740-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Endoscopic ultrasound-guided fine-needle aspiration has become an important method for the diagnosis of pancreatic cystic lesions. The collection, endoscopic handling and lab processing of the material must be optimally performed to avoid diagnostic pitfalls. The wide cytological spectrum of cystic pancreatic neoplasms is described especially for the diagnosis of serous cystadenoma and mucinous neoplasms in order to distinguish them from gastrointestinal contaminants. Knowledge of the clinical history, sonographic findings and even the aspirated fluid gross appearance are essential in helping the cytopathologist reach an accurate diagnosis.
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Affiliation(s)
- Thierry Lazure
- Service d'Anatomie et de Cytologie Pathologiques, Université Paris-Sud 11, Faculté de Médecine Paris-Sud et Hôpital de Bicêtre, Assistance Publique Hôpitaux de Paris, 94270 Le Kremlin-Bicêtre
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22
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Pungpapong S, Noh KW, Wallace MB. Endoscopic ultrasonography in the diagnosis and management of cancer. Expert Rev Mol Diagn 2007; 5:585-97. [PMID: 16013976 DOI: 10.1586/14737159.5.4.585] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Since its development and introduction to clinical practice, endoscopic ultrasonography (EUS) has progressed rapidly from being a purely imaging modality with limited use in the detection of small pancreatic cancers to one that can provide a tissue diagnosis by fine-needle aspiration (FNA) and deliver therapy. EUS has now firmly established a place as the investigation of choice in the diagnosis, locoregional staging and management of a wide range of gastrointestinal cancers. With the increasing use of FNA, the accuracy of EUS has substantially improved and may become a stand-alone investigation in some situations. However, it is recommended that a combination of information obtained from other imaging modalities and EUS is needed to maximize the accuracy, in particular to complete staging beyond locoregional stage. In addition to well-established indications, newer applications of EUS are emerging and are no longer limited to the gastrointestinal system. In lung cancer, EUS combined with endobronchial ultrasonography is emerging as an accurate, minimally invasive, nonsurgical alternative to staging of the mediastinum. Furthermore, the ability of EUS to acquire tissue safely and conveniently results in a potential role of the molecular diagnostics to enhance the performance of EUS-guided FNA. Besides a diagnostic role of EUS, there continues to be technological advances in the field of interventional EUS, with many potential applications under investigation. This review focuses on the current and future roles of EUS in the diagnosis and management of cancers.
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Affiliation(s)
- Surakit Pungpapong
- Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Horvath K, Brody F, Davis B, Vitale G, Burtin P, Waschke KA, Callery M. Minimally invasive management of pancreatic disease: SAGES and SSAT pancreas symposium, Ft. Lauderdale, Florida, April 2005. Surg Endosc 2006; 21:367-72. [PMID: 17103282 DOI: 10.1007/s00464-006-9023-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 06/09/2006] [Accepted: 07/05/2006] [Indexed: 12/17/2022]
Affiliation(s)
- K Horvath
- Department of Surgery, University of Washington, Seattle, WA, USA
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24
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Genevay M, Rubbia-Brandt L. Diagnostic cytologique préopératoire des lésions kystiques du pancréas. Ann Pathol 2006. [DOI: 10.1016/s0242-6498(06)78387-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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25
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Abstract
A practical approach to the management of chronic abdominal pain is needed, given the high prevalence and impact of this problem. This article describes an approach that has evolved based on clinical experience and review of the literature: identifying predominant bloaters and abdominal wall pain; exclusion of organic disease, including consideration of laparoscopy for diagnosis; consideration of chronic functional abdominal pain and the first and second line pharmacotherapies; and seeking specialist care in a pain clinic, psychiatry, or behavioural therapy.
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Affiliation(s)
- M Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Program, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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26
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Bardales RH, Stelow EB, Mallery S, Lai R, Stanley MW. Review of endoscopic ultrasound-guided fine-needle aspiration cytology. Diagn Cytopathol 2006; 34:140-75. [PMID: 16511852 DOI: 10.1002/dc.20300] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This review, based on the Hennepin County Medical Center experience and review of the literature, vastly covers the up-to-date role of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (FNA) in evaluating tumorous lesions of the gastrointestinal tract and adjacent organs. Emphasis is given to the tumoral and nodal staging of esophageal, pulmonary, and pancreatic cancer. This review also discusses technical, pathological, and gastroenterologic aspects and the role of the pathologist and endosonographer in the evaluation of these lesions, as well as the corresponding FNA cytology and differential diagnosis.
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Affiliation(s)
- Ricardo H Bardales
- Department of Pathology, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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27
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Noh KW, Woodward TA, Wallace MB. Emerging endoscopic techniques in oncology. Gastrointest Endosc Clin N Am 2005; 15:615-29, x-xi. [PMID: 15990059 DOI: 10.1016/j.giec.2005.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
New techniques have expanded the role of endoscopy in the diagnosis, staging, therapy, and palliation of malignancies. Three major areas of emerging technologies--endoscopic ultrasound (EUS), luminal stent technology, and photodynamic therapy (PDT)--are discussed in this article. Although EUS and PDT have been used for more than two decades, they have only recently emerged as established integral methods in the armamentarium of the gastrointestinal endoscopist.
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Affiliation(s)
- Kyung W Noh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, USA
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28
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Abstract
Pancreatic biopsy is an invasive diagnostic method that is only performed when all other diagnostic measures for establishing the diagnosis of a tumorous lesion of the pancreas have failed. Because of the advances in modern imaging techniques, fine needle biopsy of the pancreas guided by ultrasonography, computer tomography or endosonography has become a reliable method that allows the diagnosis of ductal adenocarcinoma or any of the other, rarer pancreatic tumors with high sensitivity and specificity. Complications are rare, particularly with the endosonographically guided biopsy. A new biopsy indication is the demonstration of certain markers or gene mutations that are needed for the initiation of special treatments, e.g. EGFR-Cetuximab.
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Affiliation(s)
- J-M Löhr
- II. Medizinische Universitätsklinik Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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29
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Affiliation(s)
- James M Scheiman
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
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