Role of endoscopic ultrasound in diagnosis and therapy of pancreatic adenocarcinoma

Resectable pancreatic solid lesions: Time to move from surgical diagnosis?

Benign or malignant conditions can present as pancreatic solid lesions (PSLs), and a thorough diagnostic workup is necessary to differentiate them. The need to acquire a tissue sample to reach a definitive diagnosis should be stratified by the findings at multidetector computed tomography (MDCT) with a pancreatic protocol. Tissue biopsy is currently indicated in patients fit for chemotherapy in whom a metastatic tumor or a locally advanced unresectable lesion are discovered. For these patients, EUS-guided tissue acquisition, with fine-needle aspiration (FNA) or biopsy represents the gold standard to provide a definitive cyto- and/or histopathologic diagnosis, with a high rate of accuracy. For resectable PSLs with a nonhypoenhancing MDCT pattern, which is not disease specific, a tissue diagnosis to distinguish benign from malignant etiologies appears mandatory. On the other hand, for hypo-enhancing PSLs, the debate of whether to obtain a preoperative definitive diagnosis still favors direct surgery. However, availability of novel EUS-guided fine-needle biopsy needles, which can ameliorate the negative predictive value of EUS-FNA and allow performance of DNA and RNA whole-genome extraction and RNA sequencing, coupled with the increasing evidence that preoperative neoadjuvant chemotherapy can be of value for these patients may change completely the diagnostic and therapeutic approach to resectable PSLs. These recent breakthroughs suggest the need for a new multidisciplinary consensus meeting to integrate them into the decision-making process assessing the need for preoperative tissue diagnosis in resectable PSLs.

Rapid shrinkage of a pancreatic serous cystadenoma with cystic degeneration: report of a case

We report a rare case of pancreatic serous cystadenoma, which shrank remarkably from 6 to 1.5 cm in diameter, with cystic degeneration, over a period of only 3 weeks. A 29-year-old woman who presented with epigastric pain and jaundice underwent computed tomography, which showed a 6-cm monolocular cystic tumor in the pancreatic head. Endoscopic retrograde cholangiopancreatography showed stenosis and deviation of the inferior part of the extrahepatic bile duct. We performed surgery 3 weeks later for suspected mucinous cystadenoma or macroscopic serous cystadenoma of the pancreas. At laparotomy, the tumor in the pancreatic head was found to have shrunk remarkably. We excised the tumor completely by performing the Whipple procedure. Macroscopically, the mass was a 1.5-cm monolocular cyst. Microscopically, the cystic tumor was composed of a thick fibrous wall with granulation tissue and hemorrhage. Although epithelial cells were not found inside the cystic wall, numerous grossly invisible microcysts with glycogen-containing epithelial cells were seen at its periphery. Based on these findings, the tumor was diagnosed as a serous cystadenoma with cystic degeneration.

Staging accuracy of pancreatic cancer: comparison between non-contrast-enhanced and contrast-enhanced PET/CT

PURPOSE

Our aim was to clarify the diagnostic impact of contrast-enhanced (CE) (18)F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) for staging of pancreatic cancer compared to non-CE PET/CT.

METHOD AND MATERIALS

Between April 2006 and November 2009, a total of 95 patients (age range, 36-83 years [mean age, 67]) with primary pancreatic cancer underwent (18)F-FDG PET/CT examinations. Diagnostic accuracy was compared between non-CE PET/CT and CE PET/CT. Images were analyzed visually and quantitatively by two blinded reviewers. Reference standard was histological examination in 48 patients (51%) and/or confirmation of an obvious progression in number and/or size of the lesions on follow-up CT examinations in 47 patients (49%).

RESULTS

For T-staging, invasion of duodenum (n=20, 21%), mesentery (n=12, 13%), and retroperitoneum (n=13, 14%) was correctly diagnosed by both modalities. The ROC analyses revealed that the Az values of celiac artery (CA), common hepatic artery (CHA), splenic artery (SV), and superior mesenteric vein (SMV) invasion were significantly higher in the CE PET/CT group for both readers. Nodal metastasis was correctly diagnosed by CE PET/CT in 38 patients (88%) and by non-CE PET/CT in 45 patients (87%). Diagnostic accuracies of nodal metastasis in two modalities were similar. Using CE PET/CT, distant metastasis, scalene node metastasis, and peritoneal dissemination were correctly assigned in 39 patients (91%), while interpretation based on non-CE PET/CT revealed distant metastasis, scalene node metastasis, and peritoneal dissemination in 42 patients (81%). Diagnostic accuracy of distant metastasis, scalene node metastasis, and peritoneal dissemination with CE PET/CT was significantly higher than that of non-CE PET/CT (p<0.05).

CONCLUSION

CE PET/CT allows a more precise assessment of distant metastasis, scalene node metastasis, and peritoneal dissemination in patients with pancreatic cancer.

Cholangiopancreatoscopy and endoscopic ultrasound for indeterminate pancreaticobiliary pathology

BACKGROUND

Techniques to confirm suspected pancreaticobiliary (PB) malignancy when index sampling is non-diagnostic include cholangiopancreatoscopy (CP) and endoscopic ultrasound (EUS). However, comparative data are lacking.

AIM

The purpose of this study was to compare the yield of EUS and CP for the diagnosis of PB pathology.

METHODS

Consecutive patients with indeterminate PB pathology who underwent both CP and EUS within 3 months of each other were retrospectively identified. For CP, tissue sampling included biopsy under direct inspection (cholangioscopy-directed biopsy), biopsy following CP with fluoroscopic guidance (cholangioscopy-assisted biopsy), or brush cytology. For EUS-FNA, lesions included ductal strictures or hypoechoic masses. A comparison of operating characteristics between CP and EUS utilizing tissue confirmation or 12-month clinical course consistent with either benign or malignant disease was performed.

RESULTS

Between February 2000 and June 2007, 66 (33 males, 33 females, median age 64.5) patients with indeterminate PB pathology who had undergone both CP and EUS within 3 months of each other were included. Lesions amenable to sampling were noted in 59 CP and 50 EUS patients. On follow-up, 39 patients had neoplasia and 27 were benign. The sensitivity/specificity for the diagnosis of neoplasia for CP and EUS was 48.7/96.3 % and 33.3/96.3 %, respectively (comparison of sensitivities, P = 0.183). The combined (CP and EUS) sensitivity/specificity was 66.7/96.3 % (P = 0.0064 and P = 0.0001 comparing combined sensitivity vs. sensitivity of either CP alone or EUS alone, respectively).

CONCLUSIONS

In patients who undergo both EUS and CP for indeterminate PB pathology, the combined yield of EUS and CP to detect neoplasia appears to be higher than either examination alone.

Endoscopic ultrasound fine needle aspiration: Technique and applications in clinical practice

Since its initial report in 1992, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has now been incorporated into the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of adjacent organs. Its introduction constitutes a major breakthrough in the endoscopic field and has gradually transformed EUS from a pure imaging modality into a more interventional. In addition, the possibility of collecting samples, providing a definitive cytological and/or histological evidence of the presence of malignancy, has strongly contributed to changing EUS from a subjective, highly operator dependant procedure into a more objective one. This article will review the instrumentation, technique and the most important clinical applications of EUS-FNA.

Diagnostic management of pancreatic cancer

Pancreatic cancer is one of the most deadly solid tumors, with an overall 5-year survival rate of less than 5%. Due to a non-specific clinical presentation, it is often diagnosed at an advanced stage and is rarely amenable for curative treatment. Therefore early diagnosis and appropriate staging are still essential to define the best care and to improve patient survival. Several imaging modalities are currently available for the evaluation of pancreatic cancer. This review focuses on different techniques and discusses the diagnostic management of patients with pancreatic cancer. This review was conducted utilizing Pubmed and was limited to papers published within the last 5 years. The search key words pancreatic cancer, pancreatic adenocarcinoma, pancreatic tumors, diagnosis, radiology, imaging, nuclear imaging, endoscopy, endoscopic ultrasound and biochemical markers were used.

The impact of prior biliary stenting on the accuracy and complication rate of endoscopic ultrasound fine-needle aspiration for diagnosing pancreatic adenocarcinoma

OBJECTIVES

Our aim was to determine whether the presence of a biliary stent during endoscopic ultrasound fine-needle aspiration (EUS-FNA) affects diagnosis and complication rates.

METHODS

Retrospective analysis was performed of 268 patients with pancreatic head or neck adenocarcinoma who underwent EUS-FNA at our academic medical center between 2000 and 2009. Endoscopic ultrasound fine-needle aspiration and endoscopic retrograde cholangiopancreatography reports, cytology results, and physicians' notes were reviewed.

RESULTS

A total of 170 patients without stents, 87 patients with stents placed more than 1 day before EUS, and 11 patients with stents placed less than 1 day before EUS were identified. In patients without stents, the tissue diagnosis rate via EUS-FNA was 92.4% compared with a rate of 88.5% for those with stents placed more than 1 day before EUS-FNA (P=0.36). However, the patients with stents placed immediately before EUS-FNA were more likely to have indeterminate results from the EUS-FNA than the other patients were (P=0.008). Complication rates were the same among the groups.

CONCLUSIONS

Pre-EUS stenting of biliary obstruction due to pancreatic adenocarcinoma does not influence the rate of tissue diagnosis if performed more than 1 day before EUS-FNA. Lack of immediate EUS access should not preclude stent placement in appropriate patients with malignant biliary obstruction who will undergo EUS-FNA.

Endoscopic ultrasound in the evaluation of pancreaticobiliary disorders

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

A pilot study of urokinase-type plasminogen activator (uPA) overexpression in the brush cytology of patients with malignant pancreatic or biliary strictures

We have previously demonstrated that uPA is overexpressed in pancreatic tumors. In an attempt to diagnose these tumors earlier, we sought to determine whether uPA could be identified in endoscopic retrograde cholangiopancreatography obtained brushings in patients with malignant pancreatic and biliary strictures. Secondarily, uPA was measured in the serum of this patient population. uPA overexpression was identified in the cytologic tissue in 8 of 11 patients (72.7%). Serum analysis demonstrated a 2-fold higher concentration of uPA in the pancreaticobiliary cancer patients (1.27 versus 0.56 ng/mL; P = .0182). Also, uPA overexpression correlated with serum levels (P < .0001). This study confirms that uPA can be detected in the ERCP cytologically obtained tissue and is frequently present in a higher concentration in the serum of pancreaticobiliary cancer patients. A larger sample size will be required to address its value as a sensitive marker for the diagnosis of pancreatic or biliary cancers.

Diagnostic impact of 18F-FDG PET-CT evaluating solid pancreatic lesions versus endosonography, endoscopic retrograde cholangio-pancreatography with intraductal ultrasonography and abdominal ultrasound

PURPOSE

This prospective single-centre phase II trial assessed the diagnostic impact of (18)F-FDG PET-CT in the evaluation of solid pancreatic lesions (phi >or= 10 mm) compared to endosonography (EUS), endoscopic retrograde cholangio-pancreatography (ERCP) with intraductal ultrasound (IDUS), abdominal ultrasound (US) and histopathological reference.

METHODS

Forty-six patients (32 men/14 women, phi 61.7 years) with suspected pancreatic neoplasms underwent PET-CT with contrast-enhanced biphasic multi-detector CT of the upper abdomen followed by a diagnostic work-up with EUS, ERCP with IDUS and US within 3 weeks. PET-CT data sets were analysed by two expert readers in a consensus reading. Histology from surgery, biopsy/fine-needle aspiration and/or clinical follow-up >or=12 months served as standard of reference.

RESULTS

Twenty-seven pancreatic malignancies were histopathologically proven; 19 patients had benign diseases: 36/46 lesions (78%) were detected in the head of the pancreas, 7/46 and 3/46 in the body and tail region, respectively. Sensitivity and specificity of PET-CT were 89% and 74%, respectively; positive predictive value (PPV) and negative predictive value (NPV) were 83% and 82%, respectively. Sensitivity (81-89%), specificity (74-88%), PPV (83-90%) and NPV (77-82%) achieved by EUS, ERCP and US were not significantly different. PET analysis revealed significantly higher maximum mean standardised uptake values (SUV(max) 6.5+/-4.6) in patients with pancreatic malignancy (benign lesions: SUV(max) 4.2+/-1.5; p<0.05). PET-CT revealed cervical lymphonodal metastasis from occult bronchogenic carcinoma and a tubular colon adenoma with intermediate dysplasia on polypectomy, respectively.

CONCLUSIONS

(18)F-FDG PET-CT achieves a comparably high diagnostic impact evaluating small solid pancreatic lesions versus conventional reference imaging modalities. Additional clinical diagnoses are derived from concomitant whole-body PET-CT imaging.

Current medical treatment of pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (NETs) consist of a wide group of neoplasms, with different biological behaviors in terms of aggressiveness and hormone production. In the last two decades, significant progress has been observed in our understanding of their biology, diagnosis and treatment. Surgery remains to be the only curative approach, but unfortunately the diagnosis is often delayed due to the slow growth of these tumors and the difficulty in identifying the symptoms related to the tumor-released hormones. In addition to surgery, other approaches to control the disease are biological therapy consisting of somatostatin analogs and interferon (IFN), systemic chemotherapy, radioligand therapy and local therapy with chemoembolization. Several newer cytotoxic agents, including irinotecan, gemcitabine, taxanes, oxaliplatin, capecitabine and PS-341 have been studied in metastatic patients. Considering the high vascularity of these tumors, antiangiogenic agents like endostatin and thalidomide have also been evaluated in advanced NETs. Although these agents seem to have potential activity in NETs and may increase progression free survival, none of these currently available medical therapeutic options are curative. While more efficient novel strategies are to be developed, the rationale use of the current therapeutic options may improve quality of life, control the symptoms related to the hypersecretion of hormones and/or peptides, control tumor proliferation and prolong survival in patients suffering from NETs.