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Xu YC, Fu DL, Yang F. Unraveling the enigma: A comprehensive review of solid pseudopapillary tumor of the pancreas. World J Gastrointest Oncol 2024; 16:614-629. [PMID: 38577449 PMCID: PMC10989376 DOI: 10.4251/wjgo.v16.i3.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/28/2023] [Accepted: 01/16/2024] [Indexed: 03/12/2024] Open
Abstract
Solid pseudopapillary tumor of the pancreas (SPTP) is a rare neoplasm predominantly observed in young females. Pathologically, CTNNB1 mutations, β-catenin nuclear accumulation, and subsequent Wnt-signaling pathway activation are the leading molecular features. Accurate preoperative diagnosis often relies on imaging techniques and endoscopic biopsies. Surgical resection remains the mainstay treatment. Risk models, such as the Fudan Prognostic Index, show promise as predictive tools for assessing the prognosis of SPTP. Establishing three types of metachronous liver metastasis can be beneficial in tailoring individualized treatment and follow-up strategies. Despite advancements, challenges persist in understanding its etiology, establishing standardized treatments for unresectable or metastatic diseases, and developing a widely recognized grading system. This comprehensive review aims to elucidate the enigma by consolidating current knowledge on the epidemiology, clinical presentation, pathology, molecular characteristics, diagnostic methods, treatment options, and prognostic factors.
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Affiliation(s)
- Ye-Cheng Xu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - De-Liang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Fudan University, Shanghai 200040, China
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Meliti A, Al-Maghrabi J. Solid Pseudopapillary Neoplasm of the Pancreas: A Clinicopathological Study of 12 Cases With Emphasis on Diagnostic Pitfalls. Cureus 2023; 15:e49858. [PMID: 38169685 PMCID: PMC10758586 DOI: 10.7759/cureus.49858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Solid pseudopapillary neoplasm of the pancreas (SPNP) is a rare primary neoplasm with distinct clinicopathological features. The tumor most commonly occurs in younger (premenopausal) women and is typified by low malignant potential and an excellent overall prognosis. METHODS A retrospective search over 20 years at two referral tertiary care institutions (King Faisal Hospital and Research Center and King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia) revealed 12 female patients diagnosed with SPNPs. The reslts of ancillary studies performed at the time of diagnosis were also reviewed and placed in the context of current recommendations. RESULTS The clinical and pathological findings were reviewed. All patients were females, aged 18 to 30 years. Eight patients presented with abdominal pain, of which two experienced significant weight loss, and four presented with abdominal mass/discomfort. The tumor size ranged from 1.5 and 15 cm. Two cases were initially diagnosed as neuroendocrine tumors (NETs). One of the cases presented as a multifocal disease. All patients were treated surgically with a follow-up period between one and 11 years. Only one patient presented with peritoneal metastasis after seven years of follow-up, but generally, all are doing well. CONCLUSIONS We have analyzed 12 SPNP cases in our population over 20 years (2001-2021) in this study. In brief, SPNP is a low-grade malignant potential tumor. Even though SPNP is a recognized entity, diagnostic challenges can arise particularly in the setting of limited sampling. Pathologists must be aware of the classic morphological features of SPNP and the characteristic profile of immunohistochemistry and be able to differentiate SPNP from other mimickers, especially well-differentiated NETs of the pancreas, and ultimately to avoid misdiagnosis and unnecessary oncologic treatment. Adequate surgical resection with negative margins is associated with an excellent outcome.
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Affiliation(s)
- Abdelrazak Meliti
- Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
- Pathology, Alfaisal University College of Medicine, Riyadh, SAU
| | - Jaudah Al-Maghrabi
- Department of Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
- Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
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Park S, Park MG, Roh YH, Kim DK. Solid Pseudopapillary Neoplasm of the Pancreas with Lymph Node Metastasis in a Young Male Patient. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:77-82. [PMID: 35232923 DOI: 10.4166/kjg.2021.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 11/03/2022]
Abstract
Solid pseudopapillary pancreatic neoplasms are rare. The male-to-female ratio is 1:9, and metastasis occurs only in a few cases. A 39-year-old male with a solid pseudopapillary neoplasm (SPN) with lymph node metastasis underwent ultrasonography, CT, and MRI, which revealed a mass (8 cm) in the pancreatic head. Fluorodeoxyglucose (FDG)-PET showed a hypermetabolic lymph node in the root area of the superior mesenteric artery (SMA). The patient underwent pylorus-preserving pancreaticoduodenectomy, which confirmed a peripancreatic lymph node metastasis. The lymph node of the SMA root area remained because of the encasing of the superior mesenteric artery. After 14 months of follow-up (with no adjuvant therapy initiated), the residual metastatic lymph nodes showed no change and no recurrence. In conclusion, surgery of the primary tumor for patients with SPN is recommended, even in cases with metastatic lymph nodes remaining.
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Affiliation(s)
- Seyeon Park
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Min Gyoung Park
- Department of Pathology, Dong-A University College of Medicine, Busan, Korea
| | - Young Hoon Roh
- Department of Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Dong Kyun Kim
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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Funari MP, Ribeiro IB, Lera Dos Santos ME, Matuguma SE, de Moura EGH. Managing adverse events after endoscopic ultrasound-guided drainage of the biliary tract and pancreatic fluid collections: Narrative review (with video). Dig Endosc 2022; 34:359-366. [PMID: 34245627 DOI: 10.1111/den.14080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 02/08/2023]
Abstract
Endoscopic ultrasound (EUS)-guided therapeutic procedures have become increasingly common in clinical practice. The development of EUS-guided fine needle aspiration cytology led to the concept of interventional EUS. However, it carries a considerable risk of adverse events (AEs), which occur in approximately 23% of the procedures performed for the drainage of pancreatic fluid collections and 2.5-37.0% of those performed for drainage of the biliary tract. Although the vast majority of AEs occurring after EUS-guided drainage are mild, a deep understanding of such events is necessary for their appropriate management. Because EUS-guided drainage is a novel procedure, there have been few studies of the topic. To our knowledge, this is the first narrative review that focuses on the management and resolution of AEs occurring after EUS-guided drainage of pancreatic fluid collections or the biliary tract. We also include an explanatory video.
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Affiliation(s)
- Mateus Pereira Funari
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Igor Braga Ribeiro
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcos Eduardo Lera Dos Santos
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sergio Eiji Matuguma
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Nakashima S, Sato Y, Imamura T, Hattori D, Tamura T, Koyama R, Sato J, Kobayashi Y, Hashimoto M. Solid pseudopapillary neoplasm of the pancreas in a young male with main pancreatic duct dilatation: A case report. World J Clin Cases 2021; 9:11382-11391. [PMID: 35071569 PMCID: PMC8717495 DOI: 10.12998/wjcc.v9.i36.11382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/22/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Solid pseudopapillary neoplasms (SPNs) are rare tumors of the pancreas. Typically, they occur in young females, often have characteristic imaging features, such as cystic components and calcification, and have few effects on the pancreatic duct.
CASE SUMMARY A 31-year-old man was admitted to our hospital with the chief complaint of epigastric pain. There was only mild tenderness in his upper abdomen, and blood tests showed only a slight increase in alkaline phosphatase. Contrast-enhanced computed tomography showed a 40-mm-diameter, hypovascular mass in the head of the pancreas, and the main pancreatic duct upstream of the mass was severely dilated. Magnetic resonance imaging showed low intensity on T1-weighted images, with high intensity on T2-weighted image in some parts. Pancreatic ductal adenocarcinoma was the primary differential diagnosis. Portal vein infiltration could not be ruled out, so this case was a candidate for neoadjuvant chemotherapy. Subsequently, endoscopic ultrasound-guided fine needle aspiration was performed, and pathological evaluation and immunostaining suggested a diagnosis of SPN. Thus, pancreatoduodenectomy was performed. One year after the operation, the patient is alive with no recurrence.
CONCLUSION Main pancreatic duct dilatation is usually a finding of suspected pancreatic cancer. However, pancreatic duct dilatation can occur in SPN depending on the location and growth speed. Therefore, SPN should be considered in the differential diagnosis of tumors with pancreatic duct dilatation, and pathological evaluation by endoscopic ultrasound-guided fine needle aspiration should be actively performed.
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Affiliation(s)
- Saki Nakashima
- Department of Neurology, The University of Tokyo Hospital, Bunkyo-ku 113-8655, Tokyo, Japan
| | - Yoshiki Sato
- Department of Gastroenterology, Toranomon Hospital, Tokyo 105-0001, Japan
| | - Tsunao Imamura
- Department of Gastroenterology, Toranomon Hospital, Tokyo 105-0001, Japan
| | - Daisuke Hattori
- Department of Gastroenterology, Toranomon Hospital, Tokyo 105-0001, Japan
| | - Tetsuo Tamura
- Department of Gastroenterology, Toranomon Hospital, Tokyo 105-0001, Japan
| | - Rikako Koyama
- Department of Gastroenterology, Toranomon Hospital, Tokyo 105-0001, Japan
| | - Junichiro Sato
- Department of Pathology, Toranomon Hospital, Tokyo 105-0001, Japan
| | - Yuta Kobayashi
- Department of Gastrointestinal Surgery, Toranomon Hospital, Tokyo 105-0001, Japan
| | - Masaji Hashimoto
- Department of Gastrointestinal Surgery, Toranomon Hospital, Tokyo 105-0001, Japan
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Guimaraes N, Vila Nova C, Oliveira Dias R, Fonseca Pinho J, Valente Cecílio J. Distal Pancreatectomy for Solid Pseudopapillary Tumor of the Pancreas: A Case Report. Cureus 2021; 13:e19880. [PMID: 34858768 PMCID: PMC8614182 DOI: 10.7759/cureus.19880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 11/05/2022] Open
Abstract
Solid pseudopapillary tumor (SPT) of the pancreas is a rare tumor, sometimes asymptomatic, mainly affecting young females. It has a low malignant potential, and its complete surgical resection with free margins is the treatment of choice, offering an excellent prognosis. We present the case of a 43-year-old healthy female who was referred to the surgery department for a large abdominal mass found in the abdominal ultrasound. In the course of the study of this mass, an abdominal CT with fine needle aspiration (FNA) was performed, revealing a solid pseudopapillary tumor of the tail of the pancreas. A laparotomic distal pancreatectomy with total splenectomy was performed. A grade B pancreatic fistula occurred on the third postoperative day, and she was released on postoperative day 11. Histopathology study revealed a 10 cm solid pseudopapillary tumor of the pancreas, with cavities filled with hematic content and limited by a partially calcified capsule. SPT is a rare and indolent tumor. Prognosis is highly favorable after an adequate surgical resection, hence the importance of a precise preoperative diagnosis. Therefore, it is important to choose the most appropriate surgical strategy for each patient.
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Affiliation(s)
- Narcisa Guimaraes
- General Surgery, Hospital Distrital da Figueira da Foz, Figueira da Foz, PRT
| | - Carlos Vila Nova
- General Surgery, Hospital Distrital da Figueira da Foz, Figueira da Foz, PRT
| | | | - Joao Fonseca Pinho
- General Surgery, Hospital Distrital da Figueira da Foz, Figueira da Foz, PRT
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Eric D, Milosavljevic V, Gonzalez-Urquijo M, Tadic B, Veselinovic M, Grubor N, Jelic D, Bjelovic M. Laparoscopic enucleation of Frantz's tumor of the pancreas: Case report and literature review. Ann Med Surg (Lond) 2021; 64:102221. [PMID: 33796288 PMCID: PMC7995482 DOI: 10.1016/j.amsu.2021.102221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/09/2021] [Accepted: 03/09/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction Frantz's tumor of the pancreas is a rare phenomenon, and it accounts for 1-3% of all neoplasms of the pancreas. Its percentage is much higher in younger persons, especially in younger women, as compared to the rest of the population. Presentation of case The present study describes a 32-year-old female patient in whom a preoperative imaging diagnosis confirmed a mass in the junction of the pancreas' body and tail. Based on the anamnesis, the preoperative diagnosis, and the patient's general status, the decision was made to performed laparoscopic enucleation of the pancreatic tumor. The operation and postoperative recovery passed without complications. Definitive histopathological and immunohistochemical findings confirmed a solid pseudopapillary neoplasm of the pancreas. Discussion Depending on the localization and the size of the tumor, surgical options range from typical and atypical resections of the pancreas to minimally invasive surgical procedures, such as local excision and enucleation. Laparoscopic procedures have a comparative advantage in cases of enucleation and resection of the pancreas. The low frequency of recidivation and a favorable prognosis, even after repeated surgery, are additional reasons for favoring the laparoscopic approach over the classical surgical approach. Conclusion A minimally invasive surgical approach should be applied whenever the dimensions and the localization of the tumor permit it, bearing in mind all the benefits and advantages that this surgical technique offers.
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Affiliation(s)
| | | | - Mauricio Gonzalez-Urquijo
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Ignacio Morones Prieto O 3000, Monterrey, 64710, Mexico
- Corresponding author. Dr. Ignacio Morones Prieto O 3000, Monterrey, 64710, Mexico.
| | - Boris Tadic
- Clinical Center of Serbia, University Hospital for Digestive Surgery, Department for Minimally Invasive Upper Digestive Surgery, Belgrade, Serbia
| | - Milan Veselinovic
- Clinical Center of Serbia, University Hospital for Digestive Surgery, Department for Minimally Invasive Upper Digestive Surgery, Belgrade, Serbia
| | - Nikola Grubor
- Clinical Center of Serbia, University Hospital for Digestive Surgery, Department for Minimally Invasive Upper Digestive Surgery, Belgrade, Serbia
| | - Djordje Jelic
- University of Kragujevac, Faculty of Medicine, Kragujevac, Serbia
| | - Miloš Bjelovic
- Clinical Center of Serbia, University Hospital for Digestive Surgery, Department for Minimally Invasive Upper Digestive Surgery, Belgrade, Serbia
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Song H, Dong M. The Prognostic Factors of Preoperative Prognostic Nutritional Index and Radiological Findings of Solid Pseudopapillary Tumors of Pancreas: A Single-Center Experience of 14 Years. Cancer Manag Res 2020; 12:5689-5699. [PMID: 32765072 PMCID: PMC7367723 DOI: 10.2147/cmar.s256650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/28/2020] [Indexed: 01/17/2023] Open
Abstract
Introduction Solid pseudopapillary tumors of pancreas (SPTP) is an indolent rare tumor with malignant potential. The prediction of malignancy is an enigma. The aim of this study is to explore the relationship between operative measurements and malignancy prognosis of SPTP patients. Methods A cohort of consecutive 102 patients were enrolled in this study. Preoperative measurements and clinical outcomes were analyzed. Results Eighteen patients (17.6%) were confirmed as malignant. The malignant SPTP of the optimal cut-off value was 47.9 (p=0.012) for prognostic nutritional index (PNI). The value of PNI≤47.9 and incomplete capsule were significantly correlated with malignancy. Univariate analysis showed that the PNI≤47.9 (p=0.013) and incomplete capsule (p<0.001) were predictors of disease-specific survival (DSS). Multivariate analysis identified the PNI≤47.9 (p=0.036) and incomplete capsule (p=0.023) as the independent prognostic factors of DSS. The new score of 0,1,2 based on PNI and capsule presence stratified the patients into 3 groups. The patients with low PNI and incomplete capsule achieved the worst prognosis. Conclusion The combination test of operative PNI and capsule presence would be a reliable indicator of the aggressive natural history of SPTP.
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Affiliation(s)
- He Song
- Department of Gastrointestinal Surgery of the First Hospital of China Medical University, Shenyang 110001, People's Republic of China
| | - Ming Dong
- Department of Gastrointestinal Surgery of the First Hospital of China Medical University, Shenyang 110001, People's Republic of China
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EUS-guided fine-needle biopsy sampling versus FNA in the diagnosis of subepithelial lesions: a large multicenter study. Gastrointest Endosc 2020; 92:108-119.e3. [PMID: 32105712 PMCID: PMC7340004 DOI: 10.1016/j.gie.2020.02.021] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 02/10/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although conventional EUS-guided FNA (EUS-FNA) has previously been considered first-line for sampling subepithelial lesions (SELs), variable accuracy has resulted in increased use of fine-needle biopsy (FNB) sampling to improve diagnostic yield. The primary aim of this study was to compare FNA versus FNB sampling for the diagnosis of SELs. METHODS This was a multicenter, retrospective study to evaluate the outcomes of EUS-FNA and EUS-guided FNB sampling (EUS-FNB) of SELs over a 3-year period. Demographics, lesion characteristics, sensitivity, specificity, accuracy, number of needle passes, diagnostic adequacy of rapid on-site evaluation (ROSE), cell block accuracy, and adverse events were analyzed. Subgroup analyses were performed comparing FNA versus FNB sampling by location and diagnostic yield with or without ROSE. Multivariable logistic regression was also performed. RESULTS Two hundred twenty-nine patients with SELs (115 FNA and 114 FNB sampling) underwent EUS-guided sampling. Mean patient age was 60.86 ± 12.84 years. Most lesions were gastric in location (75.55%) and from the fourth layer (71.18%). Cell block for FNB sampling required fewer passes to achieve conclusive diagnosis (2.94 ± 1.09 vs 3.55 ± 1.55; P = .003). The number of passes was not different for ROSE adequacy (P = .167). Immunohistochemistry was more able to be successfully performed in more FNB sampling samples (69.30% vs 40.00%; P < .001). Overall, sensitivity and accuracy were superior for FNB sampling versus FNA (79.41% vs 51.92% [P = .001] and 88.03% vs 77.19% [P = .030], respectively). On subgroup analysis, sensitivity and accuracy of FNB sampling alone was superior to FNA + ROSE (79.03% vs 46.67% [P = .001] and 87.25% vs 68.00% [P = .024], respectively). There was no significant difference in diagnostic yield of FNB sampling alone versus FNB sampling + ROSE (P > .05). Multivariate analysis showed no predictors associated with accuracy. One minor adverse event was reported in the FNA group. CONCLUSIONS EUS-FNB was superior to EUS-FNA in the diagnosis of SELs. EUS-FNB was also superior to EUS-FNA alone and EUS-FNA + ROSE. These results suggest EUS-FNB should be considered a first-line modality and may suggest a reduced role for ROSE in the diagnosis of SELs. However, a large randomized controlled trial is required to confirm our findings.
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de Moura DT, McCarty TR, Jirapinyo P, Ribeiro IB, Hathorn KE, Madruga-Neto AC, Lee LS, Thompson CC. Evaluation of endoscopic ultrasound fine-needle aspiration versus fine-needle biopsy and impact of rapid on-site evaluation for pancreatic masses. Endosc Int Open 2020; 8:E738-E747. [PMID: 32490158 PMCID: PMC7247894 DOI: 10.1055/a-1122-8674] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/06/2020] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is traditionally considered a first-line strategy for diagnosing pancreatic lesions; however, given less than ideal accuracy rates, fine-needle biopsy (FNB) has been recently developed to yield histological tissue. The aim of this study was to compare diagnostic yield and safety between EUS-FNA and EUS-FNB in sampling of pancreatic masses. Patients and methods This was a multicenter retrospective study to evaluate efficacy and safety of EUS-FNA and EUS-FNB for pancreatic lesions. Baseline characteristics including sensitivity, specificity, and accuracy, were evaluated. Rapid on-site evaluation (ROSE) diagnostic adequacy, cell-block accuracy, and adverse events were analyzed. Subgroup analyses comparing FNA versus FNB route of tissue acquisition and comparison between methods with or without ROSE were performed. Multivariable logistic regression was also performed. Results A total of 574 patients (n = 194 FNA, n = 380 FNB) were included. Overall sensitivity, specificity, and accuracy of FNB versus FNA were similar [(89.09 % versus 85.62 %; P = 0.229), (98.04 % versus 96.88 %; P = 0.387), and 90.29 % versus 87.50 %; P = 0.307)]. Number of passes for ROSE adequacy and cell-block accuracy were comparable for FNA versus FNB [(3.06 ± 1.62 versus 3.04 ± 1.88; P = 0.11) and (3.08 ± 1.63 versus 3.35 ± 2.02; P = 0.137)]. FNA + ROSE was superior to FNA alone regarding sensitivity and accuracy [91.96 % versus 70.83 %; P < 0.001) and (91.80 % versus 80.28 %; P = 0.020)]. Sensitivity of FNB + ROSE and FNB alone were superior to FNA alone [(92.17 % versus 70.83 %; P < 0.001) and (87.44 % versus 70.83 %; P < 0.001)]. There was no difference in sensitivity though improved accuracy between FNA + ROSE versus FNB alone [(91.96 % versus 87.44 %; P = 0.193) and (91.80 % versus 80.72 %; P = 0.006)]. FNB + ROSE was more accurate than FNA + ROSE (93.13 % versus 91.80 % ; P = 0.001). Multivariate analysis showed ROSE was a significant predictor of accuracy [OR 2.60 (95 % CI, 1.41-4.79)]. One adverse event occurred after FNB resulting in patient death. Conclusion EUS-FNB allowed for more consistent cell-block evaluation as compared to EUS-FNA. EUS-FNA + ROSE was found to have a similar sensitivity to EUS-FNB alone suggesting a reduced need for ROSE as part of the standard algorithm of pancreatic sampling. While FNB alone produced similar diagnostic findings to EUS-FNA + ROSE, FNB + ROSE still was noted to increase diagnostic yield. This finding may favor a unique role for FNB + ROSE, suggesting it may be useful in cases when previous EUS-guided sampling may have been indeterminate.
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Affiliation(s)
- Diogo T.H. de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States,Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil
| | - Thomas R. McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
| | - Igor B. Ribeiro
- Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil
| | - Kelly E. Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
| | - Antonio Coutinho Madruga-Neto
- Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil
| | - Linda S. Lee
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
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Efficacy of digital single-operator cholangioscopy in the visual interpretation of indeterminate biliary strictures: a systematic review and meta-analysis. Surg Endosc 2020; 34:3321-3329. [PMID: 32342216 DOI: 10.1007/s00464-020-07583-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/18/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Indeterminate biliary strictures remain a significant diagnostic challenge. Digital single-operator cholangioscopy (D-SOC) incorporates digital imaging which enables higher resolution for better visualization and diagnosis of biliary pathology. We aimed to conduct a systematic review and meta-analysis of available literature in an attempt to determine the efficacy of D-SOC in the visual interpretation of indeterminate biliary strictures. MATERIAL AND METHODS Electronic searches were performed using Medline (PubMed), EMBASE, and Cochrane Library. All D-SOC studies that reported the diagnostic performance in visual interpretation of indeterminate biliary strictures and biliary malignancies were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 was used to evaluate the quality of the included studies. All data were extracted and pooled to construct a 2 × 2 table. The visual interpretation of D-SOC was compared to resected surgical specimens or clinical follow-up in the included patients. Pooled sensitivity, specificity, positive predictive value, negative predictive value, prevalence, positive likelihood ratio (+LR), negative likelihood ratio (-LR), and diagnostic odds ratio (OR) were calculated. The summarized receiver operating characteristic (SROC) curve corresponding with the area under the curve (AUC) was also analyzed. RESULTS The search yielded 465 citations. Of these, only six studies with a total of 283 procedures met inclusion criteria and were included in the meta-analysis. The overall pooled sensitivity and specificity of D-SOC in the visual interpretation of biliary malignancies was 94% (95% CI 89-97) and 95% (95%CI 90-98), respectively, while +LR, -LR, diagnostic OR, and AUC were 15.20 (95%CI 5.21-44.33), 0.08 (95%CI 0.04-0.14), 308.83 (95%CI 106.46-872.82), and 0.983, respectively. The heterogeneity among 6 included studies was moderate for specificity (I2 = 0.51) and low for sensitivity (I2 = 0.17) and diagnostic OR (I2 = 0.00). CONCLUSION D-SOC is associated with high sensitivity and specificity in the visual interpretation of indeterminate biliary strictures and malignancies. D-SOC should be considered routinely in the diagnostic workup of indeterminate biliary lesions.
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Delgado AADA, de Moura DTH, Ribeiro IB, Bazarbashi AN, dos Santos MEL, Bernardo WM, de Moura EGH. Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis. World J Gastrointest Endosc 2019; 11:573-588. [PMID: 31839876 PMCID: PMC6885729 DOI: 10.4253/wjge.v11.i12.573] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/17/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Propofol is commonly used for sedation during endoscopic procedures. Data suggests its superiority to traditional sedatives used in endoscopy including benzodiazepines and opioids with more rapid onset of action and improved post-procedure recovery times for patients. However, Propofol requires administration by trained healthcare providers, has a narrow therapeutic index, lacks an antidote and increases risks of cardio-pulmonary complications.
AIM To compare, through a systematic review of the literature and meta-analysis, sedation with propofol to traditional sedatives with or without propofol during endoscopic procedures.
METHODS A literature search was performed using MEDLINE, Scopus, EMBASE, the Cochrane Library, Scopus, LILACS, BVS, Cochrane Central Register of Controlled Trials, and The Cumulative Index to Nursing and Allied Health Literature databases. The last search in the literature was performed on March, 2019 with no restriction regarding the idiom or the year of publication. Only randomized clinical trials with full texts published were included. We divided sedation therapies to the following groups: (1) Propofol versus benzodiazepines and/or opiate sedatives; (2) Propofol versus Propofol with benzodiazepine and/or opioids; and (3) Propofol with adjunctive benzodiazepine and opioid versus benzodiazepine and opioid. The following outcomes were addressed: Adverse events, patient satisfaction with type of sedation, endoscopists satisfaction with sedation administered, dose of propofol administered and time to recovery post procedure. Meta-analysis was performed using RevMan5 software version 5.39.
RESULTS A total of 23 clinical trials were included (n = 3854) from the initial search of 6410 articles. For Group I (Propofol vs benzodiazepine and/or opioids): The incidence of bradycardia was not statistically different between both sedation arms (RD: -0.01, 95%CI: −0.03–+0.01, I2: 22%). In 10 studies, the incidence of hypotension was not statistically difference between sedation arms (RD: 0.01, 95%CI: −0.02–+0.04, I2: 0%). Oxygen desaturation was higher in the propofol group but not statistically different between groups (RD: −0.03, 95%CI: −0.06–+0.00, I2: 25%). Patients were more satisfied with their sedation in the benzodiazepine + opioid group compared to those with monotherapy propofol sedation (MD: +0.89, 95%CI: +0.62–+1.17, I2: 39%). The recovery time after the procedure showed high heterogeneity even after outlier withdrawal, there was no statistical difference between both arms (MD: -15.15, 95%CI: −31.85–+1.56, I2: 99%). For Group II (Propofol vs propofol with benzodiazepine and/or opioids): Bradycardia had a tendency to occur in the Propofol group with benzodiazepine and/or opioid-associated (RD: -0.08, 95%CI: −0.13–−0.02, I2: 59%). There was no statistical difference in the incidence of bradycardia (RD: -0.00, 95%CI: −0.08–+0.08, I2: 85%), desaturation (RD: −0.00, 95%CI: −0.03–+0.02, I2: 44%) or recovery time (MD: -2.04, 95%CI: −6.96–+2.88, I2: 97%) between sedation arms. The total dose of propofol was higher in the propofol group with benzodiazepine and/or opiates but with high heterogeneity. (MD: 70.36, 95%CI: +53.11–+87.60, I2: 61%). For Group III (Propofol with benzodiazepine and opioid vs benzodiazepine and opioid): Bradycardia and hypotension was not statistically significant between groups (RD: -0.00, 95%CI: −0.002–+0.02, I2: 3%; RD: 0.04, 95%CI: −0.05–+0.13, I2: 77%). Desaturation was evaluated in two articles and was higher in the propofol + benzodiazepine + opioid group, but with high heterogeneity (RD: 0.15, 95%CI: 0.08–+0.22, I2: 95%).
CONCLUSION This meta-analysis suggests that the use of propofol alone or in combination with traditional adjunctive sedatives is safe and does not result in an increase in negative outcomes in patients undergoing endoscopic procedures.
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Affiliation(s)
- Aureo Augusto de Almeida Delgado
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403000, Brazil
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de Moura DTH, McCarty TR, Jirapinyo P, Ribeiro IB, Farias GFA, Ryou M, Lee LS, Thompson CC. Endoscopic Ultrasound Fine-Needle Aspiration versus Fine-Needle Biopsy for Lymph Node Diagnosis: A Large Multicenter Comparative Analysis. Clin Endosc 2019; 53:600-610. [PMID: 31794654 PMCID: PMC7548151 DOI: 10.5946/ce.2019.170] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/26/2019] [Indexed: 02/06/2023] Open
Abstract
Background/Aims Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is preferred for sampling of lymph nodes (LNs) adjacent to the gastrointestinal wall; however, fine-needle biopsy (FNB) may provide improved diagnostic outcomes. This study aimed to evaluate the comparative efficacy and safety of FNA versus FNB for LN sampling.
Methods This was a multicenter retrospective study of prospectively collected data to evaluate outcomes of EUS-FNA and EUS-FNB for LN sampling. Characteristics analyzed included sensitivity, specificity, accuracy, the number of needle passes, diagnostic adequacy of rapid on-site evaluation (ROSE), cell-block analysis, and adverse events.
Results A total of 209 patients underwent EUS-guided LN sampling. The mean lesion size was 16.22±8.03 mm, with similar sensitivity and accuracy between FNA and FNB ([67.21% vs. 75.00%, respectively, p=0.216] and [78.80% vs. 83.17%, respectively, p=0.423]). The specificity of FNB was better than that of FNA (100.00% vs. 93.62%, p=0.01). The number of passes required for diagnosis was not different. Abdominal and peri-hepatic LN location demonstrated FNB to have a higher sensitivity (81.08% vs. 64.71%, p=0.031 and 80.95% vs. 58.33%, p=0.023) and accuracy (88.14% vs. 75.29%, p=0.053 and 88.89% vs. 70.49%, p=0.038), respectively. ROSE was a significant predictor for accuracy (odds ratio, 5.16; 95% confidence interval, 1.15–23.08; p=0.032). No adverse events were reported in either cohort.
Conclusions Both EUS-FNA and EUS-FNB are safe for the diagnosis of LNs. EUS-FNB is preferred for abdominal LN sampling. EUS-FNA+ ROSE was similar to EUS-FNB alone, showing better diagnosis for EUS-FNB than traditional FNA. While ROSE remained a significant predictor for accuracy, due to its poor availability in most centers, its use may be limited to cases with previous inconclusive diagnoses.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Igor Braga Ribeiro
- Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Galileu Ferreira Ayala Farias
- Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Linda S Lee
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
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de Moura DTH, Ryou M, de Moura EGH, Ribeiro IB, Bernardo WM, Thompson CC. Endoscopic Ultrasound-Guided Fine Needle Aspiration and Endoscopic Retrograde Cholangiopancreatography-Based Tissue Sampling in Suspected Malignant Biliary Strictures: A Meta-Analysis of Same-Session Procedures. Clin Endosc 2019; 53:417-428. [PMID: 31684700 PMCID: PMC7403009 DOI: 10.5946/ce.2019.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/25/2019] [Indexed: 12/11/2022] Open
Abstract
Background/Aims: The diagnosis of biliary strictures can be challenging. There are no systematic reviews studying same-session endoscopic retrograde cholangiopancreatography (ERCP)-based tissue sampling and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the diagnosis of biliary strictures.
Methods: A systematic review was conducted on studies analyzing same-session EUS and ERCP for tissue diagnosis of suspected malignant biliary strictures. The primary outcome was the accuracy of each method individually compared to the two methods combined. The secondary outcome was the accuracy of each method in pancreatic and biliary etiologies. In the meta-analysis, we used Forest plots, summary receiver operating characteristic curves, and estimates of the area under the curve for intention-to-treat analysis.
Results: Of the 12,132 articles identified, six were included, resulting in a total of 497 patients analyzed. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and accuracy of the association between the two methods were: 86%, 98%, 12.50, 0.17, and 96.5%, respectively. For the individual analysis, the sensitivity, specificity and accuracy of EUS-FNA were 76%, 100%, and 94.5%, respectively; for ERCP-based tissue sampling, the sensitivity, specificity, and accuracy were 58%, 98%, and 78.1%, respectively. For pancreatic lesions, EUS-FNA was superior to ERCP-based tissue sampling. However, for biliary lesions, both methods had similar sensitivities.
Conclusions: Same-session EUS-FNA and ERCP-based tissue sampling is superior to either method alone in the diagnosis of suspected malignant biliary strictures. Considering these results, combination sampling should be performed when possible.
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Affiliation(s)
- Diogo Turiani Hourneax de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Igor Braga Ribeiro
- Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Wanderlei Marques Bernardo
- Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Xu X, Chen D, Cao L, Feng X, Tong R, Zheng S, Wu J. Spontaneous rupture of solid pseudopapillary tumor of pancreas: A case report and review of literature. Medicine (Baltimore) 2019; 98:e17554. [PMID: 31689759 PMCID: PMC6946308 DOI: 10.1097/md.0000000000017554] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Solid pseudopapillary tumors (SPT) account for 1% to 3% of all pancreatic tumors. They have low malignant potential with a favorable prognosis, and predominantly occur in young women. The pathogenesis and clinical behavior of SPT are still uncertain. In addition, most ruptures of SPT were associated with blunt abdominal trauma, while spontaneous ruptures seemed to be quite rare. Up to now, there have been only 3 spontaneous ruptured SPT cases reported worldwide. PATIENT CONCERNS Here, we reported a 22-year-old female patient with left lower abdominal pain. Computed tomography (CT) showed that a hemorrhagic complex solid cystic mass located in the lesser omentum sac. DIAGNOSIS According to pathological findings of tumor specimen, the diagnosis of solid pseudopapillary tumor (SPT) of the pancreas was made. INTERVENTIONS Distal pancreatectomy and splenectomy was carried out. OUTCOMES The patient recovered to normal status within 10 days after surgery. CONCLUSION Besides, we reviewed about 50 cases in literatures to find out the clinical characteristics and differential diagnostic strategies of SPT.
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Affiliation(s)
- Xiaofeng Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University,
| | - Diyu Chen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University,
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health,
| | - Linping Cao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University,
| | - Xiaode Feng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University,
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health,
| | - Rongliang Tong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University,
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health,
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University,
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health,
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Jian Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University,
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health,
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
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McHugh KE, Stelow EB, Harrison GP, Policarpio‐Nicolas MLC. The usefulness of lymphoid enhancer‐binding factor 1 and androgen receptor in diagnosing solid pseudopapillary neoplasm of the pancreas on cytopathology. Cancer Cytopathol 2019; 127:700-707. [DOI: 10.1002/cncy.22186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Kelsey E. McHugh
- Department of Laboratory Medicine Cleveland Clinic Cleveland Ohio
| | - Edward B. Stelow
- Department of Pathology University of Virginia School of Medicine Charlottesville Virginia
| | - Grant P. Harrison
- Department of Pathology University of Virginia School of Medicine Charlottesville Virginia
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