Ultrasound-guided fine needle biopsy of pancreatic masses: results of a multicenter study

Biomarkers to diagnose metastatic breast carcinoma to the pancreas: A case report and update

The patient is a 72-year-old female who presents with new onset jaundice. The patient has a past medical history significant for right-sided estrogen receptor (ER)-positive and left-sided ER-negative breast cancers in 2005 and 2009, respectively, and recent 1-year history of ER-positive right-sided breast cancer with bone and brain metastases. CT scan and endoscopic ultrasound (EUS) revealed a new 2 cm mass in the head of the pancreas, leading to EUS-guided fine-needle aspiration of the lesion. Pathologic workup revealed adenocarcinoma with signet-ring cells, representing either metastatic breast or primary pancreatic cancer. Immunohistochemistry and molecular diagnostic workup identified positive GATA-binding protein 3 (GATA3) immunoreactivity and a mutation in Erb-B2 receptor tyrosine kinase 2 (ERBB2), also known as human epidermal growth factor receptor 2 (HER2). Here, we review the diagnostic markers commonly used to differentiate metastatic breast vs primary pancreatic adenocarcinoma, and discuss the challenges of utilizing GATA3 immunoreactivity and ERBB2 mutations for diagnosis.

Ultrasound-guided percutaneous procedures in pancreatic diseases: new techniques and applications

Ultrasound (US) is not only an important diagnostic tool for the evaluation of the pancreas, but is also a fundamental imaging technique to guide percutaneous interventions for several pancreatic diseases (fluid aspiration and drainage; invasive diagnosis by means fine-needle aspiration and core-needle biopsy; tumour ablation by radiofrequency, microwaves, irreversible electroporation, cryoablation, and high-intensity focused US). Technical improvements, such as contrast media and fusion imaging, have recently increased precision and safety and reduced procedure-related complications. New treatment US techniques for the ablation of pancreatic tumours, such as contrast-enhanced US and multimodality fusion imaging, have been recently developed and have elicited a growing interest worldwide. The purpose of this article was to review the most up-to-date role of US in percutaneous procedures for pancreatic diseases.

Ultrasound-Guided Percutaneous Core Needle Biopsy for the Diagnosis of Pancreatic Disease

Few studies have evaluated the performance of percutaneous core needle biopsies of the pancreas. This article is an overview of the advantages, disadvantages, predictive power and complications associated with percutaneous ultrasound-guided core needle biopsies of pancreatic lesions. A comprehensive literature search of Medline (using PubMed as the search engine) and EMBASE was done to identify suitable studies up to March 2017. A study of quantitative pre-operative pancreatic biopsy data was reported. Lesion location, mean or median number of passes, inadequate tissue or technical failures and complications were assessed for all cases by reviewing clinical notes and post-procedural imaging. The analysis included 13 studies, mostly of a retrospective nature. The sensitivity (mean: 94.42%, range: 90%-100%) and specificity (mean: 97.94%, range: 94.7%-100%) of the procedure were high, and the mean accuracy of diagnosis was 95.76 (range: 91-100). Furthermore, the procedure had a high negative predictive value of approximately 76.26%. Of the 13 reported studies, 7.3% were inadequate or technical failure cases. The mean rate of complications was 2.08%, which seemed similar to the lower limit of this rate for endoscopic ultrasound-guided fine-needle aspirations. The risk of tumor seeding with ultrasound-guided core needle biopsies was not reported in the included articles. With the development of technology, ultrasound-guided percutaneous core needle biopsy for pancreatic lesions is increasingly available and has optimal diagnostic power in pancreatic neoplasms.

Diagnostic potency of EUS-guided FNA for the evaluation of pancreatic mass lesions

Background and Objectives:

Diagnosis of pancreatic lesions remains a clinical challenge. This study aimed to evaluate the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pancreatic mass lesions.

Patients and Methods:

Clinical data, laboratory tests, and cytopathological and imaging reports were collected from 185 pancreatic EUS cases performed from March 2010 to January 2014. The final diagnosis was based on surgical findings, EUS-FNA or computed tomography (CT)-guided biopsy.

Results:

A total of 100 pancreatic FNAs were obtained by EUS. Most positive diagnoses of malignancy were pancreatic adenocarcinomas (n = 61). The site of pancreatic adenocarcinoma was the head in 50 (82.0%), body in seven (11.5%), and tail in four (6.5%). The sensitivity, specificity, and positive and negative predictive values of EUS-FNA for diagnosing adenocarcinoma were 80.3%, 92.3%, 94.2%, and 75.0%, respectively.

Discussion:

We concluded that EUS-FNA of pancreatic lesion accurately diagnoses pancreatic adenocarcinoma and should be considered for the standard management of pancreatic adenocarcinoma.

Evidence-based clinical practice guidelines for chronic pancreatitis 2015

Chronic pancreatitis is considered to be an irreversible progressive chronic inflammatory disease. The etiology and pathology of chronic pancreatitis are complex; therefore, it is important to correctly understand the stage and pathology and provide appropriate treatment accordingly. The newly revised Clinical Practice Guidelines of Chronic Pancreatitis 2015 consist of four chapters, i.e., diagnosis, staging, treatment, and prognosis, and includes a total of 65 clinical questions. These guidelines have aimed at providing certain directions and clinically practical contents for the management of chronic pancreatitis, preferentially adopting clinically useful articles. These revised guidelines also refer to early chronic pancreatitis based on the Criteria for the Diagnosis of Chronic Pancreatitis 2009. They include such items as health insurance coverage of high-titer lipase preparations and extracorporeal shock wave lithotripsy, new antidiabetic drugs, and the definition of and treatment approach to pancreatic pseudocyst. The accuracy of these guidelines has been improved by examining and adopting new evidence obtained after the publication of the first edition.

Pretest prediction and diagnosis of metastatic lesions to the pancreas by endoscopic ultrasound-guided fine needle aspiration

BACKGROUND AND AIM

Early diagnosis of solid pancreatic lesions (SPLs) enables prompt treatment. The study aims to identify factors differentiating metastatic lesion to the pancreas (PMET) from pancreatic ductal adenocarcinoma (PDAC) and pancreatic neuroendocrine tumors (PNETs).

METHODS

This is a retrospective study at a tertiary cancer center. Consecutive patients referred for endoscopic ultrasound (EUS) of SPLs from 2004 to 2011 were reviewed. The main outcomes were pre-EUS-FNA (endoscopic ultrasound-guided fine needle aspiration) predictors and diagnostic accuracy of EUS-FNA for PMETs.

RESULTS

Among a total of 1108 EUS-FNAs for pancreatic lesions, 672 patients had neoplastic SPLs (PMETs = 53; PDACs = 528, PNETs = 91). The sensitivity, specificity, positive predictive value, and accuracy of EUS-FNA for diagnosis of PMETs were 84.9%, 100%, 100%, and 98.8%, respectively. The mean number of EUS-FNA passes for diagnosis of PMET was 3.1 per patient. For each endosonographer, preceding 3-year EUS volume (mean/year) significantly correlated with fewer needle passes (rs [-0.30], P = 0.03). The most common PMET was renal cell carcinoma. Stratified multivariate analyses were performed. Compared with patients with PDACs, PMETs were more common in men (odds ratio [OR] = 2.0; 95% confidence interval [CI] = 1.0-4.0); located in the pancreatic tail (OR = 2.4; 95%CI = 1.1-5.2); and were less likely with increasing age (OR = 0.95; 95%CI = 0.92-0.99), presence of major symptoms (abdomen pain/diarrhea/weight loss; OR = 0.2; 95%CI = 0.1-0.4), elevated bilirubin (OR = 0.3; 95%CI = 0.13-0.69), and imaging evidence of arterial invasion (OR = 0.15; 95%CI = 0.03-0.67). Compared with PNETs, PMETs were more common with increase age (OR = 1.05; 95%CI = 1.02-1.08) and increasing lesion size (OR = 1.03; 95%CI = 1.0-1.1), and were less likely in patients with diabetes (OR = 0.34; 95%CI = 0.11-0.99).

CONCLUSION

Among the largest numbers of neoplastic SPLs evaluated at a single center, pre-test features reliably characterize, and EUS-FNA provides a highly specific diagnosis of PMETs.

Ultrasound-guided percutaneous fine-needle aspiration of solid pancreatic neoplasms: 10-year experience with more than 2,000 cases and a review of the literature

OBJECTIVES

To evaluate the diagnostic accuracy and complication rate of percutaneous ultrasound-guided fine-needle aspiration (US-FNA) of solid pancreatic neoplasms through the analysis of 10-year experiences of two centres.

METHODS

Clinical, radiological and pathologic data of 2,024 patients with solid pancreatic masses who underwent US-FNAs were retrospectively evaluated. Indications for aspiration were: unresectable lesions before neo-adjuvant therapy; doubtful imaging findings; and suspicion of uncommon neoplasms with prognostic or therapeutic implications such as metastases or lymphoma. US-FNAs were performed using aspiration needles with a cytopathologist present in centre 1. In centre 2, cytologic samples were collected with Chiba needles and separately evaluated by a cytopathologist.

RESULTS

US-FNA had a diagnostic sample rate of 92.2 % (centre 1: 95.9 %; centre 2: 87.2 %). US-FNA repetition after non-diagnostic samples provided a diagnosis in 86.3 % of cases. Sensitivity, specificity, positive and negative predictive values, and accuracy were 98.7 %, 100 %, 100 %, 75.5 %, and 98.7 %, respectively. The complication rate was 0.8 %.

CONCLUSIONS

Percutaneous US-FNA is a sensitive, accurate and safe method for the invasive diagnosis of solid pancreatic neoplasms. The use of aspiration needles and the on-site presence of a cytopathologist may lead to a high rate of diagnostic samples, thus reducing the need for US-FNA repetition.

KEY POINTS

• Percutaneous ultrasound-guided fine-needle aspiration of pancreatic neoplasms is sensitive and accurate. • The short-term complication rate of percutaneous ultrasound-guided fine-needle aspiration is low. • Technical aspects may influence the rate of diagnostic samples.

Trans-organ versus trans-mesenteric computed tomography-guided percutaneous fine-needle aspiration biopsy of pancreatic masses: feasibility and safety

AIM

To evaluate the safety and efficacy of computed tomography (CT)-guided percutaneous fine-needle aspiration biopsy (FNAB) of pancreatic masses that traverses the gastrointestinal tract or solid viscera.

MATERIALS AND METHODS

From January 2002 to December 2012, 144 patients underwent 165 CT-guided biopsies of pancreatic masses. Biopsies were performed using a 21 or 22 G needle. Cytology reports, medical records, and procedure details for all patients were retrospectively reviewed to evaluate the biopsy route, complications, and diagnostic accuracy.

RESULTS

Trans-organ biopsies of pancreatic masses were safely performed via a direct pathway traversing the stomach (n = 45), colon (n = 14), jejunum (n = 4), or liver (n = 5). There were five self-limiting mesenteric haematomas along the biopsy route on immediate post-procedure CT and all patients remained asymptomatic. All haematomas occurred after a trans-mesenteric approach rather than passage through abdominal organs. Three patients had acute pancreatitis. There was no significant difference in complications and diagnostic yields between the groups. The sensitivity, specificity, positive predictive value, and negative predictive value of final FNAB cytology for malignancy were 98.3%, 100%, 100% and 71.4%, respectively. The overall accuracy was 98.4%.

CONCLUSION

Percutaneous FNAB using the trans-organ approach is a safe and effective technique to diagnose pancreatic malignancy.

Role of Fine-Needle Aspiration in the Surgical Management of Pancreatic Neuroendocrine Tumors: Utility and Limitations in Light of the New World Health Organization Classification

Context.—Pancreatic neuroendocrine tumors (Panc-NETs) are rare and tend to get overshadowed by their more prevalent and aggressive ductal adenocarcinoma counterparts. The biological behavior of PancNETs is unpredictable, and thus management is controversial. However, the new World Health Organization classification has significantly contributed to the prognostic stratification of these patients. Concurrently, there have been advances in surgical techniques for benign or low-grade pancreatic tumors. These procedures include minimally invasive and parenchyma-sparing operations such as laparoscopy and enucleation.

Objective.—To report on the utility and limitations of fine-needle aspiration in the preoperative evaluation and management of PancNETs.

Design.—This was a retrospective review of our institutional tumor database from 2002 to 2012. There were 25 cases of PancNETs that were localized and staged by medical imaging and diagnosed by fine-needle aspiration.

Results.—Fourteen patients underwent laparotomy, with some requiring only limited surgery; 4 had laparoscopic resections; 4 were serially observed without surgical intervention; and another 3 were inoperable. After a mean follow-up of 37 months, more than half of the patients had no evidence of disease, including most of those who underwent minimally invasive surgery.

Conclusions.—Fine-needle aspiration is a useful diagnostic adjunct to medical imaging in the preoperative evaluation and management of PancNETs. However, there are limitations with regard to grading PancNETs using this technique.

Evaluation of percutaneous ultrasound-guided biopsies of solid mass lesions of the pancreas: a center's 10-year experience

OBJECTIVE

To assess the efficacy and complication rates of percutaneous ultrasound (US)-guided pancreatic mass biopsy and to determine if location of the mass or method of biopsy affects efficacy.

METHODS

Imaging, pathology, and clinical records of all patients undergoing percutaneous US-guided pancreatic mass sampling from January 2001 until November 2011 were reviewed. Of 88 pancreatic masses, 13 underwent fine needle aspiration (FNA) only, 60 underwent core needle biopsy only, and 15 underwent both. Diagnostic rate, sensitivity, specificity, accuracy, and positive predictive value and negative predictive value (NPV) based on location of the mass (head/neck vs. body/tail) and method of biopsy (core vs. FNA vs. combined) were determined. The final diagnosis was determined on the basis of follow-up imaging, clinical course, and/or surgical pathology. Complications were assessed by reviewing clinical notes and postprocedural imaging.

RESULTS

The overall diagnostic rate, sensitivity, accuracy, and NPV of all 88 biopsies were 94%, 93%, 93%, and 57%, respectively. Five samples were nondiagnostic and considered false negatives. There were no false-positive biopsy results. No significant difference was observed in the diagnostic rate, sensitivity, accuracy, and NPV between core biopsies, FNAs, and combined core and FNA biopsies. Furthermore, no significant difference was found between head/neck and body/tail samplings. In 96.7% (85/88) of the cases, the procedure was uneventful. There were no major complications.

CONCLUSIONS

Percutaneous US-guided sampling of pancreatic mass is safe and effective irrespective of location of the mass and method of biopsy.

Secondary tumors of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration: a 10-year experience

Determining whether a pancreatic mass is a primary or secondary neoplasm is necessary for appropriate treatment. We reviewed our experience using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for diagnosis of pancreatic tumors to identify clinical and cytopathologic characteristics of metastatic disease. We reviewed all cases of tumors metastatic to the pancreas evaluated at The University of Texas MD Anderson Cancer Center and The Methodist Hospital in Houston, Texas during the period from 2002 to 2012. The review included cytologic specimens, clinical history, radiologic findings, primary tumor type, and clinical follow-up. We identified 66 patients with disease metastatic to the pancreas for which cytologic material was available: 38 (58%) men and 28 (42%) women, with an average age of 63 years (range, 40-89 years). Most metastases (98%) were single lesions, and nearly half were located in the head of the pancreas (30/66). The most common site of origin for these metastases was kidney (27 [41%] cases). Follow-up information was available for 65 (98%) patients, and duration of follow-up ranged from <1 to 10 years (mean, 2.3 years). Thirty-three patients (50%) were alive at the time of the most recent follow-up contact. Of the 25 patients with metastatic renal cell carcinoma, clear cell type, 19 (76%) were alive at the time of the most recent follow-up. It was concluded that metastases may mimic primary pancreatic carcinomas both clinically and cytologically. Ancillary studies in conjunction with clinical history are necessary for the accurate diagnosis of FNAs of secondary pancreatic tumors.

Pancreatic fine-needle aspiration cytology in patients < 35-years of age: a retrospective review of 174 cases spanning a 17-year period

Pancreatic lesions in young patients are relatively rare and, to our knowledge, the clinical value of pancreatic fine needle aspiration (FNA) in patients < 35 years of age has not been previously established by any other large retrospective studies. All pancreatic endoscopic ultrasound-guided FNA (EUS-FNA) cases performed on patients < 35 years of age were identified for a 17-year period (1994-2010). All FNAs and all available correlating surgical pathology reports were reviewed. There were a total of 174 cases of pancreatic FNA performed on 109 females and 65 males under the age of 35 (range: 8-34, mean: 27 years). The FNA diagnoses included 37 malignant, 114 negative, nine atypia/suspicious, and 14 cases that were nondiagnostic. Of the 37 malignant FNA cases, the diagnoses included 18 pancreatic neuroendocrine tumors (PanNeT), 11 solid pseudopapillary neoplasms (SPN), five adenocarcinomas and three metastatic neoplasms. Histologic follow-up was available in 22 of the 37 malignant cases diagnosed by FNA, and the diagnosis was confirmed in 21 cases. One pancreatoblastoma was misclassified as SPN on EUS-FNA. False negative diagnoses were noted in three cases of low-grade mucinous cystic neoplasm and one case of PanNeT. The most common type of neoplasms diagnosed by EUS-FNA in patients < 35-year old is PanNeT, followed by SPN with both tumors accounting for 75% of all the neoplasms encountered in this age group. The sensitivity and specificity for positive cytology in EUS-FNA of the pancreas to identify malignancy and mucinous neoplasms were 90% and 100%, respectively. Diagn. Cytopathol. 2014;42:297-301. © 2013 Wiley Periodicals, Inc.

Pancreatic Cancer: Current Options for Diagnosis, Staging and Therapeutic Management

BACKGROUND

Pancreatic cancer is characterized by frequently delayed diagnosis and aggressive tumor growth which hampers most of the current treatment modalities. This review aims to summarize the available evidence about the diagnostic and therapeutic aspects of resectable and non-resectable pancreatic cancer therapy.

SUMMARY

Embedded in the concept of multimodal therapy, surgery plays the central role in the treatment of pancreatic cancer. With advantageous tumor characteristics and complete tumor resection as the most relevant positive prognostic factors, the detection of premalignant or early invasive lesions combined with safe and oncologic adequate surgery is the major therapeutic aim. Most pancreatic adenocarcinomas are locally advanced or metastatic when diagnosed and need to be treated by the combination of surgery and (radio)chemotherapy or by palliative chemotherapy.

Aspiration cytopathology of peripancreatic space: a clinicoradiologic and cytopathologic analyses of 42 cases

Background

The pancreas is surrounded by soft tissue known as the peripancreatic space (PPS). Pathologic lesions of the PPS are infrequent and have only rarely been reported in the cytopathology literature.

Methods

A retrospective review of cytopathology files at two large institutions revealed 42 cases of PPS lesions obtained by transabdominal fine needle aspiration (FNA) or endoscopic ultrasound-guided FNA over a 16-year period. Clinicoradiologic findings and follow-up information were also reviewed.

Results

Patients ranged in age from 23-83 years (mean, 60 years) with an equal gender distribution. The major clinical presentations included pain, jaundice, nausea/vomiting, and abnormal liver enzymes. Radiographic characteristics included lymphadenopathy and cystic/solid soft tissue masses with a size range of 1.5 to 8 cm. Cytologically, 4 (9.5%) cases were nondiagnostic, 9 (21.5%) were diagnosed as benign, 4 (9.5%) were atypical or suspicious for cancer, and 25 (59.5%) were malignant. Six of 25 (24%) patients had metastasis of a prior known malignancy.

Conclusions

FNA of PPS masses is a rare occurrence. The majority of lesions are metastatic carcinomas from a variety of primary sites. Flow cytometry and immunoperoxidase studies are useful adjuncts to determine the tumor origin. The sensitivity of PPS aspiration for a malignant diagnosis is 90% with a positive predictive value of 100%.

Endoscopic ultrasonography for pancreatic cancer: current and future perspectives

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

Sonographically guided puncture of the pancreas: incidence of complications, and risk factors

PURPOSE

Data yielded by transabdominal ultrasound-guided puncture techniques are valuable for determining the malignancy of inoperable mass lesions of the pancreas. In this study we analyzed the incidence of complications and the risk factors.

METHODS

A total of 430 punctures of the pancreas were performed for 281 patients. Risk factors were prospectively assessed and complications were recorded. All punctures were sonographically guided.

RESULTS

The 281 patients underwent a total of 351 puncture procedures including 430 punctures and 901 passes. The maximum diameter of the pancreatic mass lesion was documented; the mean diameter was 48.3 ± 29.1 mm. 75.8 % of punctures were performed with a needle diameter of 0.7-0.95 mm, and 23.0 % of punctures were performed as cutting biopsies producing a tissue sample 1.2 or 1.6 mm in diameter. In 77.8 % of punctures, one puncture was performed, and in 21.9 %, two punctures were performed. Three punctures were performed for one patient (0.3 %) only. The incidence of major complications was 0.3 %. None of the assessed risk factors was associated with an elevated incidence of complications.

CONCLUSION

Our findings demonstrate the safety of transabdominal percutaneous puncture of the pancreas but do not enable conclusions to be drawn with regard to individual risk factors.

A Case of a Metastatic Disease to the Pancreas from a Small-Cell Lung Carcinoma Documented by a CT-Scan-Guided Trucut Biopsy: The Diagnostic Role of Cytomorphology and Immunohistochemistry

Unlike primary pancreatic carcinoma, metastatic lesions of the pancreas are uncommon and account for approximately 2% of pancreatic malignancies. Small-cell lung carcinoma (SCLC) represents a group of highly malignant tumors giving rise to early and widespread metastasis at the time of diagnosis. However, the pancreas is a relatively infrequent site of metastasis by this neoplasm, and reports on metastatic small-cell carcinoma (SCC) in the pancreas, either of pulmonary or extrapulmonary origin, to be diagnosed by CT-scan-guided trucut biopsy (CT-TCB) are very rare. A 56-year-old man presented with a laterocervical lymphadenopathy associated to a mixed-density lung mass and a mass in the pancreatic body. CT-TCB slides from the pancreatic mass contained small, round tumor cells with extensive nuclear molding. The cytomorphological and histological diagnosis was metastatic SCC. Immunocytochemical staining showed that a variable number of neoplastic cells were positive for cytokeratin 7, TTF1, chromogranin A, and synaptophysin but negative for leukocyte common antigen and cytokeratin 20 with a very high expression of KI67. The transbronchial needle biopsy confirmed the diagnosis of an SCC. This case represents a rare metastatic lesion in the pancreas from SCLC, diagnosed by CT-TCB histological and immunohistochemical studies.

Preliminary study analyzing the methylated genes in the plasma of patients with pancreatic cancer

BACKGROUND AND AIMS

CpG islands of the promoter region of some genes are methylated in pancreatic cancer tissue and the detection of this methylation has been suggested to be useful in the diagnosis of various cancers. The aim of this study was to investigate whether the detection of methylated CpG islands in plasma can be used in the diagnosis of pancreatic cancer.

MATERIAL AND METHODS

Plasma DNA was collected from patients with pancreatic cancer, chronic pancreatitis, and healthy controls. The methylation status of six genes, UCHL1, NPTX2, SARP2, ppENK, p16, and RASSF1A, was checked by methylation-specific PCR and was subsequently confirmed by direct sequencing after bisulfite treatment.

RESULTS

CpG island methylation was detectable in 13 of 16 patients (81.3%) with pancreatic cancer, 1 of 29 healthy controls (3.5%), and 8 of 13 patients with chronic pancreatitis (61.5%). The mean number of genes with CpG island methylation was 1.6±1.2 in pancreatic cancer, 0.04±0.19 in healthy controls, and 1.2±1.1 in chronic pancreatitis. Among six genes, p16 was more specifically methylated in pancreatic cancer compared with chronic pancreatitis (p=0.016). The methylation status was not correlated with smoking history, tumor size, or cancer stage.

CONCLUSIONS

The detection of methylated genes in the plasma may have a role in differentiating between pancreatic cancers and healthy controls but not between pancreatic cancer and chronic pancreatitis.

Cytology of the Pancreas: A Practical Review for Cytopathologists

Pancreatic cytopathology plays a critical role in the management of patients with cystic and solid pancreatic masses. The frequency of pancreatic fine-needle aspiration continues to increase and general surgical pathologists and cytopathologists need to be aware of the most commonly encountered entities as well as the pitfalls associated with gastrointestinal tract contaminants in endoscopic ultrasound-guided fine-needle aspiration. This article focuses on the most commonly encountered pancreatic lesions and the importance of correlation of cytologic features with clinical, radiologic, and ancillary studies for accurate diagnosis.

Endoscopic ultrasound for non-gastroenterologists: what you need to know

Endoscopic ultrasound (EUS) combines the use of flexible fiberoptic endoscopes with high-resolution ultrasound technology. It is increasingly used for the evaluation, staging, and diagnosis of many luminal and extraluminal gastrointestinal (GI) cancers, as well as non-GI tract ailments, including the staging of lung cancer. In the past decade, EUS has become available on a wide scale, with an increasing number of indications. The technology has been shown to be comparable with and often more sensitive than computed tomography scan and magnetic resonance imaging in staging many malignancies. The use of fine-needle aspiration and ultrasound-guided injection also allows for accurate tissue diagnosis and therapy of GI ailments. Despite increasing availability and indications for EUS over the past decade, general internists may not be aware of EUS technology, when to order an EUS, and how to integrate the results of an EUS into their management decisions. This article will review the general indications for EUS referral, limitations, and role of EUS in the practice of general medicine.

Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review

BACKGROUND

EUS-guided FNA (EUS-FNA) permits both morphologic and cytologic analysis of lesions within or adjacent to the GI tract. Although previous studies have evaluated the accuracy of EUS-FNA, little is known about the complications of EUS-FNA. Moreover, the frequency and severity of complications may vary from center to center and may be related to differences in individual experience.

OBJECTIVE

To systematically review the morbidity and mortality associated with EUS-FNA.

DESIGN

MEDLINE and EMBASE were searched to identify relevant English-language articles.

MAIN OUTCOME MEASUREMENTS

EUS-FNA-specific morbidity and mortality rates.

RESULTS

We identified 51 articles with a total of 10,941 patients who met our inclusion and exclusion criteria; the overall rate of EUS-FNA-specific morbidity was 0.98% (107/10,941). In the small proportion of patients with complications of any kind, the rates of pancreatitis (36/8246; 0.44%) and postprocedure pain (37/10,941; 0.34%) were 33.64% (36/107) and 34.58% (37/107), respectively. The mortality rate attributable to EUS-FNA-specific morbidity was 0.02% (2/10,941). Subgroup analysis showed that the morbidity rate was 2.44% in prospective studies compared with 0.35% in retrospective studies for pancreatic mass lesions (P=.000), whereas it was 2.33% versus 5.07% for pancreatic cysts (P=.036).

LIMITATIONS

Few articles reported well-designed, prospective studies and few focused on overall complications after EUS-FNA.

CONCLUSIONS

EUS-FNA-related morbidity and mortality rates are relatively low, and most associated events are mild to moderate in severity.

Ultrasound-guided percutaneous fine-needle aspiration of 545 focal pancreatic lesions

OBJECTIVE

The purpose of this study was to assess the accuracy and short-term complication rate of ultrasound-guided fine-needle aspiration cytologic sampling of focal pancreatic lesions.

MATERIALS AND METHODS

We reviewed 545 consecutive ultrasound-guided fine-needle aspiration cytologic sampling procedures for focal pancreatic lesions from January 2004 through June 2008. The procedures were performed with a 20- or 21-gauge needle. The onsite cytopathologist evaluated the appropriateness of the sample and made a diagnosis. We reviewed the final diagnosis and the radiologic and medical records of all patients for onset of complications during or within 7 days of the procedure.

RESULTS

The study sample included 262 women and 283 men (mean age, 62 years; range, 25-86 years). The head or uncinate process of the pancreas was the location of 63.0% of the lesions, and 35.2% of the lesions were located in the body or tail of the pancreas. The site of 10 lesions (1.8%) was not specified. Sampling was diagnostic in 509 of the 545 cases (93.4%). Excluding the 36 nondiagnostic samples, ultrasound-guided fine-needle aspiration cytologic sampling had 99.4% sensitivity, 100% specificity, and 99.4% accuracy. In 537 of the 545 cases (98.5%), the procedure was uneventful. In two cases, abdominal fluid was found after the procedure that was not present before the procedure. Six patients experienced postprocedural pain without abnormal findings at subsequent imaging. No major complications occurred.

CONCLUSION

Ultrasound-guided cytologic sampling is safe and accurate for the diagnosis and planning of management of focal pancreatic lesions. With a cytologist on site, the rate of acquisition of samples adequate for diagnosis is high, reducing the need for patient recall.

Preoperative tissue diagnosis for tumours of the pancreas

BACKGROUND

Preoperative biopsy of pancreatic lesions suspected of malignancy is controversial.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ultrasound-guided percutaneous pancreatic tumor biopsy in pancreatic cancer: a comparison with metastatic liver tumor biopsy, including sensitivity, specificity, and complications

BACKGROUND

The aims of this study were to investigate the diagnostic value and safety of ultrasound-guided percutaneous pancreatic tumor biopsy (pancreatic biopsy) in patients with suspected unresectable pancreatic cancer, and to compare the data with those obtained by metastatic liver tumor biopsy (liver metastases biopsy).

METHODS

Data were collected retrospectively from 388 patients (398 procedures) for whom a final diagnosis was available and who underwent ultrasound-guided pancreatic or liver metastases biopsy with a 21-gauge needle (core biopsy) or a 22-gauge needle (fine-needle aspiration biopsy: FNAB). The sensitivity, specificity, and accuracy of pancreatic and liver metastases biopsies were evaluated. Biopsy-related complications were collected and analyzed.

RESULTS

Data from 271 pancreatic and 112 liver metastases biopsy procedures were available. For pancreatic core biopsy and FNAB, the sensitivity, specificity, and accuracy were 93%, 100%, and 93%, and 86%, 100%, and 86%, respectively, all of which were comparable to those of liver metastases biopsy. The complication rate in pancreatic biopsy was 21.4%, including a 4.4% incidence of post-biopsy ephemeral fever. The complication rate in liver metastases biopsy was 38.7%, including an 8.0% incidence of ephemeral fever. Fever and infection occurred more frequently among patients who underwent liver metastases biopsy (4.4% vs. 11%: P = 0.038). In pancreatic biopsy cases, a prebiopsy high serum total bilirubin level was a statistically significant predictor of ephemeral fever.

CONCLUSIONS

Ultrasound-guided percutaneous pancreatic biopsy is an effective and safe modality for confirming the pathologic diagnosis in patients with unresectable pancreatic cancer.

Ultrasound-guided biopsies in the abdomen and pelvis

Ultrasound-guided biopsies in the abdomen and pelvis are generally more effective, safer, faster, and cheaper than those performed under computed tomography guidance. This manuscript will discuss multiple aspects of sonographic biopsies performed between the diaphragm and the symphysis pubis. We begin with systems issues, patient preparation (including bleeding profile and anticoagulant use), pain management, and infection precautions. The procedure itself is then analyzed, including needle guidance, the role of the sonographer, image optimization, patient positioning, core- versus fine-needle aspiration, coaxial versus individual pass, needle technique, and postprocedure management. Issues specific to different sites are then discussed: liver, spleen, pancreas, kidney, adrenal, bowel, retroperitoneum and mesentery, and the pelvis. We finish with a discussion of complications, future trends, and a brief summary.

CT-guided core needle biopsy in the diagnosis of pancreatic diseases with an automated biopsy gun

PURPOSE

To evaluate the safety and diagnostic accuracy of computed tomographic (CT)-guided core needle biopsy (CNB) in the diagnosis of pancreatic diseases by using an automated biopsy gun with a cutting-type needle.

MATERIALS AND METHODS

From January 2000 to January 2006, CT-guided CNB was performed in 80 patients suspected of having pancreatic diseases in the absence of liver metastasis. Biopsies were performed with an 18-20-gauge cutting needle driven by a spring-loaded biopsy gun. Histologic reports and medical records of all patients were retrospectively reviewed. An institutional review board exemption was obtained to perform this retrospective study.

RESULTS

All patients tolerated the biopsies well, with no serious complications. Three patients had mild abdominal pain after the procedure, and a limited abdominal CT scan did not reveal any marked abnormality. Two patients had an elevated serum amylase level, which returned to normal within 2 weeks. A definitive diagnosis and accurate histologic diagnosis were obtained for 69 patients, for a successful diagnosis rate of 86%. Surgical sampling was performed in 11 patients with neoplasms and nondiagnostic core-needle biopsies. Only 50% of patients with well-differentiated adenocarcinomas were definitely diagnosed with CT-guided CNB.

CONCLUSIONS

CT-guided CNB with an automated biopsy gun is a safe and effective method for obtaining tissue for the histologic evaluation of pancreatic diseases. However, CT-guided CNB requires further development for the accurate diagnosis of well-differentiated adenocarcinomas.

Pancreatic metastasis from renal cell carcinoma with intraportal tumor thrombus

A 68-year-old woman with a history of renal cell carcinoma (RCC) resected curatively 12 years previously was admitted to our department for scrutiny of pancreatic tumors. Various imaging studies demonstrated heterogeneously well-enhanced masses in the head and tail of the pancreas. The well-enhanced mass in the head of the pancreas was connected with the tumor thrombus in the portal vein. To differentially diagnose the multiple pancreatic lesions, we performed endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB). Histopathologic findings of the EUS-FNAB specimens were similar to those of the renal clear cell carcinoma previously resected. The patient underwent a surgical operation with segmental resection of the portal vein with the preoperative diagnosis of RCC metastasis to the pancreas with intraportal growth. Histopathological examination of the resected specimen revealed that the masses in the pancreas were multiple pancreatic metastases with intraportal tumor thrombus of RCC. The pancreas is a rare target for metastasis. This is a rare case of pancreatic metastasis from RCC with intraportal extension, and is the first preoperatively definitely diagnosed case using EUS-FNAB.

Quantitative analysis of NPTX2 hypermethylation is a promising molecular diagnostic marker for pancreatic cancer

OBJECTIVES

Percutaneous fine-needle aspiration cytology or biopsy has been used for pathological confirmation in pancreatic cancer. Sometimes, it is difficult to approach the mass because of surrounding major vessels, and there is a risk of seeding. Although endoscopic retrograde cholangiopancreatography (ERCP)-guided pancreatic duct brush cytology is less invasive, its reliability is very low. Recently, aberrantly methylated genes were reported in pancreatic cancer tissue. This study was to develop a novel molecular diagnostic approach based on epigenetic characteristics.

METHODS

We enrolled pathologically proven 33 pancreatic cancer patients and 22 benign pancreaticobiliary disease patients. The ERCP-guided pancreatic duct brush cytology samples were obtained. Genomic DNA was extracted, and NPTX2 CpG island hypermethylation was examined quantitatively by real-time polymerase chain reaction amplification after chemical modification.

RESULTS

Pancreatic cancer cytology samples had statistically significant higher levels of NPTX2 methylation compared with benign diseases, and the optimal cutoff value of NPTX2 methylation was 1.2%. The sensitivity was 87%, and specificity was 80%, whereas pathological examination by ERCP-guided pancreatic duct brush cytology had a sensitivity of 38%.

CONCLUSIONS

The quantitative analysis of NPTX2 hypermethylation may play a role in making highly sensitive and less invasive diagnosis of pancreatic cancer. Therefore, NPTX2 hypermethylation could be a promising molecular diagnostic marker.

Endoscopic ultrasound-guided fine needle aspiration cytology of the pancreas: a morphological and multimodal approach to the diagnosis of solid and cystic mass lesions

Cytological evaluation of pancreatic masses and cysts is the preferred pre-operative diagnostic modality and is increasingly being performed by endoscopic ultrasound. This review focuses on the multimodal approach at the Massachusetts General Hospital that utilizes clinical, cytological, radiological and ancillary studies in rendering a final cytological diagnosis.

Assessment of pancreatic neoplasms: review of biopsy techniques

Pancreatic cancer is the 4th leading cause of cancer death annually. Recent technological advances in imaging have led to non-uniformity in the evaluation of pancreatic neoplasms. The following article describes the history behind various biopsy techniques and the rationale for obtaining a biopsy of a pancreatic neoplasm and discusses the benefits and disadvantages of the various pancreatic biopsy techniques, including fine needle aspiration biopsy, Tru-cut needle biopsy, endoscopic brushings/cytology, and endoscopic ultrasound guided biopsies. A treatment algorithm for pancreatic neoplasms is then presented.

EUS with CT improves efficiency and structure identification over conventional EUS

BACKGROUND

EUS is complicated because of the subtleties of US interpretation, small fields of observation, and uncertainty of probe position and orientation.

OBJECTIVE

Improved EUS performance is sought by providing contextual information to support US probe positioning and identification of features in US images. Our aims were to demonstrate the feasibility of the image registered gastroscopic US (IRGUS) system in a porcine model and to compare the effectiveness and the efficiency of IRGUS with traditional EUS.

DESIGN

Animal feasibility study.

INTERVENTIONS

The IRGUS system uses preprocedure CT and miniature US probe trackers to create real-time synthetic displays of the position of the probe tip and a matched slice of CT data for comparison with the US image. Participants used EUS and IRGUS systems in a porcine model to evaluate the speed and accuracy of structure identification.

MAIN OUTCOME MEASUREMENTS

The performance and utility of IRGUS were determined by the number of correctly identified structures in a timed trial, kinematic variables, and a structured survey.

RESULTS

IRGUS was twice as effective as EUS in localizing and identifying individual structures. In timed trials, IRGUS users identified over 25% more structures than EUS users. Improvement in examination efficiency and accuracy of feature identification was statistically significant, and 90% of the users preferred IRGUS to EUS for these tasks.

CONCLUSIONS

IRGUS appears feasible and may be superior to conventional EUS in efficiency and accuracy of probe positioning and in image interpretation. IRGUS has the potential to shorten the EUS learning curve and to broaden the adoption of EUS techniques by gastroenterologists.

Diagnosing pancreatic cancer: the role of percutaneous biopsy and CT

AIMS

To determine the sensitivity and complications of percutaneous biopsy of pancreatic masses, and whether typical computed tomography (CT) features of adenocarcinoma can reliably predict this diagnosis.

MATERIALS AND METHODS

A 5 year retrospective analysis of percutaneous core biopsies of pancreatic masses and their CT features was undertaken. Data were retrieved from surgical/pathology databases; medical records and CT reports and images.

RESULTS

Three hundred and three patients underwent 372 biopsies; 56 of 87 patients had repeat biopsies. Malignancy was diagnosed in 276 patients, with ductal adenocarcinoma in 259 (85%). Final sensitivity of percutaneous biopsy for diagnosing pancreatic neoplasms was 90%; for repeat biopsy it was 87%. Complications occurred in 17 (4.6%) patients, in three of whom the complications were major (1%): one abscess, one duodenal perforation, one large retroperitoneal bleed. CT features typical of ductal adenocarcinoma were: hypovascular pancreatic mass with bile and/or pancreatic duct dilatation. Atypical CT features were: isodense or hypervascular mass, calcification, non-dilated ducts, cystic change, and extensive lymphadenopathy. Defining typical CT features of adenocarcinoma as true-positives, CT had a sensitivity of 68%, specificity of 95%, positive predictive value (PPV) of 98%, and negative predictive value of 41% for diagnosing pancreatic adenocarcinoma.

CONCLUSION

Final sensitivity of percutaneous biopsy for establishing the diagnosis was 90%. CT features typical of pancreatic adenocarcinoma had high specificity and PPV. On some occasions, especially in frail patients with co-morbidity, it might be reasonable to assume a diagnosis of pancreatic cancer if CT features are typical, and biopsy only if CT shows atypical features.

Evaluation of imaging-guided core biopsy of pancreatic masses

OBJECTIVE

The purpose of this study was to determine the sensitivity and accuracy of imaging-guided core biopsy in the diagnosis of pancreatic masses.

CONCLUSION

Imaging-guided core biopsy is sensitive, safe, and accurate in the diagnosis of malignant lesions of the pancreas. Benign biopsy findings cannot be used to exclude the presence of a neoplasm, and repetition of a biopsy should be considered if there is high clinical suspicion of malignancy.

Primary pancreatic lymphoma: Report of six cases

AIM: To heighten recognition of primary pancreatic lymphoma (PPL) in clinical practice.

METHODS: A retrospective review of the clinical presentation, imaging characteristics and pathological features of PPL patients were presented, as well as their diagnosis and treatment, in combination with literature review.

RESULTS: Histological diagnosis was made in four patients by surgery and in two patients by EUS-FNA. The six PPL patients (5 males and 1 female; age range, 16-65 years; mean age, 46 years) had the duration of symptoms for two weeks to three months. The primary presenting symptoms, though not characteristic, were abdominal pain, abdominal masses, weight loss, jaundice, nausea and vomiting. One of the patients developed acute pancreatitis. In one patient, the level of serum CA19-9 was 76.3 μg/L. Abdominal CT scan showed that three of the six tumors were located in the head of pancreas, two in the body and tail, and one throughout the pancreas. Diameter of the tumors in the pancreas in four cases was more than 6 cm, with homogeneous density and unclear borders. Enhanced CT scan showed that only the tumor edges were slightly enhanced. The pancreatic duct was irregularly narrowed in two cases whose tumors were located in the pancreatic head and body, in which endoscopic retrograde cholangiopancreatography (ERCP) showed that the proximal segment was slightly dilated. Two patients underwent Whipple operation, one patient underwent pancreatectomy, and another patient underwent operative biliary decompression. PPL was in stageIE in 2 patients and in stage II E in 4 patients according to the Ann Arbor classification system. The diagnosis of B-cell non-Hodgkin’s lymphoma was made in all patients histopathologically. All six patients underwent systemic chemotherapy, one of whom was also treated with gamma radiometry. One patient died two weeks after diagnosis, two patients lost follow-up, two patients who received chemotherapy survived 49 and 37 mo, and the remaining patient is still alive 21 mo, after diagnosis and treatment.

CONCLUSION: PPL is a rare form of extranodal lymphoma originating from the pancreatic parenchyma. Clinical and imaging findings are otherwise not specific in the differentiation of pancreatic lymphoma and pancreatic cancer, which deserves attention. EUS-guided fine-needle aspiration (EUS-FNA) of the pancreas requires experienced cytopathologists as well as advanced immunohistochemical assays to obtain a final diagnosis on a small amount of tissue. Surgery and adjuvant chemotherapy or radiotherapy can produce fairly good outcomes.

Ultrasonography of the pancreas. 5. Interventional procedures

Interventional ultrasonography (US) is often used for the diagnosis and therapy of pancreatic pathologies, and its diffusion has definitely modified the diagnostic and therapeutic management of some diseases. US is particularly suitable for targeting percutaneous pancreatic interventional procedures and important technical features contribute to this result. First of all, US is dynamic, and thus the ongoing procedure can be continually monitored. Then, the high spatial resolution achieved by US imaging in recent years, its speed and availability and the low-cost of the technique, together with the technical features, have led to an ever-increasing use of US in pancreatic interventional procedures. This article will review the application of US as guide of diagnostic and interventional procedures in the different pancreatic pathologies.

A randomized comparison of EUS-guided FNA versus CT or US-guided FNA for the evaluation of pancreatic mass lesions

BACKGROUND

Diagnosing pancreatic cancer by EUS-FNA is a potentially appealing alternative to percutaneous biopsy.

AIM

To compare EUS-FNA with CT or US-guided FNA for diagnosing pancreatic cancer.

DESIGN

Single center, prospective, randomized, cross-over.

SETTING

Duke University Medical Center.

POPULATION

Eighty-four patients referred with suspicious solid pancreatic mass lesions randomized to CT/US-FNA (n = 43) or EUS-FNA (n = 41).

INTERVENTION

Patients underwent an imaging procedure/FNA. If cytology was nondiagnostic, cross over to the other modality was offered. Final outcome was determined by clinical follow-up every 6 months for 2 years and/or surgical pathology for patients with negative FNA.

MAIN OUTCOME MEASUREMENTS

Sensitivity and accuracy of EUS-FNA versus CT/US-FNA for pancreatic cancer.

RESULTS

There were 16 true positive (TP) by CT/US-FNA and 21 TP by EUS-FNA. Sixteen of the 20 CT/US-FNA negative patients crossed over to EUS-FNA; 12 underwent FNA, 4 had no mass at EUS. Seven of the 12 had positive EUS-FNA. Eight EUS-FNA negative crossed over to CT/US; 4 had no mass at CT/US, 3 remained true negative throughout follow-up, 1 had chronic pancreatitis at surgery. The sensitivity of CT/US-FNA and EUS-FNA for detecting malignancy was 62% and 84%, respectively. A comparison of the accuracy for CT/US-FNA and EUS-FNA was not statistically significant (P = .074, chi(2)).

LIMITATIONS

Failure to meet target enrollment resulted in an inability to demonstrate a statistically significant difference between the 2 modalities.

CONCLUSIONS

EUS-FNA is numerically (though not quite statistically) superior to CT/US-FNA for the diagnosis of pancreatic malignancy.

My approach to pancreatic fine needle aspiration

Pancreatic fine needle aspiration cytopathology has earned a reputation as a rapid, safe, accurate and cost-beneficial modality of investigation of pancreatic mass lesion. Optimal results can be expected only if these procedures are undertaken regularly in gastroenterology departments processing large numbers of patients; occasional aspirators cannot exploit the technique to full potential. Professional teams following a dedicated approach to patient selection and management develop requisite expertise over time. Cytodiagnosis rests as much on morphological examination as on the milieu in which is it practised, and as much on sample quality as on cellular criteria. This article focuses attention on specimen handling, with particular reference to rapid on-site evaluation. The significance of particular cytodiagnoses in patient care is evaluated, and tumour types that may be encountered are enumerated and illustrated.

Pancreatic FNA in 1000 cases: a comparison of imaging modalities

BACKGROUND

Image-guided FNA is a popular method for evaluating pancreatic lesions, but few large studies on pancreatic FNA exist.

METHODS

Cytologic material, imaging reports, and clinical follow-up information were reviewed from pancreatic FNA cases performed over a 5-year period.

RESULTS

A total of 1050 pancreatic FNAs were obtained by EUS (n = 843), US (n = 140), and CT (n = 67). On-site assessment was performed in 89.2% (n = 937) of cases. Findings were as follows: positive for neoplasm 48.9% (n = 503), negative 29.1% (n = 306), descriptive 10% (n = 105), suspicious 5.9% (n = 62), atypical/inconclusive 4.6% (n = 48), and nondiagnostic/inadequate 1.5% (n = 26). Follow-up in the form of histology or at least 6 months of clinical observation was available for 61.2% (n = 643). There was an overall false-positive rate of 0.3% and a false-negative rate of 14.3%. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were as follows: 79.4, 99.0, 99.4, 67.9, 84.5 for the total series, respectively; 79.9, 98.8, 99.2, 72.5, 86.5 for EUS, respectively; 77.9, 100, 100, 48.6, 81.7 for US, respectively; and 78.6, 100, 100, 47.1, 82.0 for CT, respectively. In general, accuracy was not influenced by lesion size or site, number of FNA passes, or number of procedures per patient. After controlling for lesion size, EUS resulted in greater accuracy than US or CT when evaluating lesions <3 cm ( p = 0.015).

CONCLUSIONS

All imaging modalities showed moderate to high sensitivity, specificity, and accuracy. Logistic regression analysis showed that for lesions <3 cm, the EUS method had higher accuracy than US or CT. No statistically significant difference was seen for larger lesions or for the number of FNA passes.

Diagnosis of nonprimary pancreatic neoplasms by endoscopic ultrasound-guided fine-needle aspiration

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a proven modality for the diagnosis of primary pancreatic neoplasms. We describe our experience in diagnosing nonprimary pancreatic tumors by EUS-FNA. Cytology files were searched for all EUS-FNA of the pancreas for the period 2000-2002. All cases diagnosed as neoplasms were selected and those diagnosed as nonprimary pancreatic tumors were reviewed and analyzed. One hundred ninety-one of 468 cases were diagnosed as neoplasms. Eleven of these cases were diagnosed as nonprimary pancreatic tumors (2.4% of all diagnoses and 5.7% of all neoplasms). The diagnoses were supported by clinical history (n = 7), cytological findings (n = 11), cell block histology (n = 11), cell block immunohistochemistry (n = 6), and flow cytometry (n = 1). EUS-FNA is a safe and minimally invasive method for the diagnosis of nonprimary pancreatic neoplasms. Evaluation of clinical history, cytomorphology, and ancillary techniques, especially those applied to cell block material, are essential for accurate diagnoses.

Metastases in the pancreas from nonhematologic neoplasms: report of 20 cases evaluated by fine-needle aspiration

We reviewed fine-needle aspiration (FNA) samples of metastatic tumor in the pancreas from nonhematologic neoplasms over a 5-year period. In 1,050 total procedures, 20 metastases were diagnosed: 9 renal-cell carcinomas (RCCs), 3 melanomas, 2 pulmonary small-cell carcinomas, 2 breast carcinomas, 1 prostate carcinoma, 1 colon adenocarcinoma, 1 pulmonary squamous-cell carcinoma, and 1 gastrointestinal stromal tumor. A wide range of latency from primary diagnosis was noted; the longest was RCC at 12.6 years (range, 5-28). Sites of involvement were: 13 heads, 4 bodies, and 3 tails. Eighteen cases presented as a solitary mass. The average size was 4.7 cm (range, 1.5-9.8), and a case of RCC (9.8 cm) was the largest. In seven cases, the clinical and radiographic impression was of a pancreatic primary. We conclude that metastases to the pancreas are rarely diagnosed by FNA and may clinically mimic a pancreatic primary.

Pancreatic metastases: a multicentric study of 22 patients

AIMS OF THE STUDY

To evaluate the diagnosis, treatment and outcome of patients with pancreatic metastases.

PATIENTS AND METHODS

We retrospectively reviewed the records of patients with pancreatic metastasis managed in the Paris area between 1990 and 2000.

RESULTS

The series analyzed included 22 patients, 10 men and 12 women, mean age 61 years (range: 35-76). The primary tumors were renal-cell carcinoma (N=10), colorectal cancer (N=4), lung cancer (N=4), breast cancer (N=2), cutaneous melanoma (N=1) and ileal carcinoid (N=1). The mean interval between primary treatment and presentation was 73.5 months (range: 2-151). Diagnosis was established because of clinical symptoms (N=15) or during surveillance (N=7). Computed tomography (N=19) and endoscopic ultrasound (EUS) (N=18) mainly showed solitary and hypodense/or hypoechoic masses. Histological diagnosis was obtained before surgery by EUS-guided fine needle aspiration (N=6), ultrasound-guided biopsy (N=3) or duodenoscopy (N=3). Among 10 patients with primary renal-cell carcinoma, 7 were treated by surgery. Median global survival was 33 months. Median survival was 61 months in the event of surgical treatment and 20 months in the other patients (ns). Mean survival depended on the type of primary tumor, 61 months for renal-cell carcinoma and 33 for colorectal cancer (P=0.06).

CONCLUSIONS

Most pancreatic metastases develop from renal-cell carcinoma and can occur several years after nephrectomy. Histological diagnosis is often obtained before surgery. Surgical resection must be discussed as it can allow long-term survival.