The role of endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration in distinguishing pancreatic cystic lesions

The Yield of String Sign in Differentiating Mucinous from Non-Mucinous Pancreatic Cysts: A Retrospective Cross-Sectional Study

Background and Objectives: The diagnosis of pancreatic cysts is mostly based on a combination of morphological appearance and fluid analysis of amylase and carcinoembryonic antigen (CEA). We aimed to assess the capability of the string sign in differentiating mucinous from non-mucinous pancreatic cysts. Materials and Methods: All patients who were referred for endoscopic ultrasound (EUS) for pancreatic cysts assessment from 2015 to 2020 were retrospectively analyzed. Results: Our cohort consisted of 112 patients. Of them, 92 patients (82.1%) had mucinous cystic neoplasms (group A) and 20 patients (17.9%) had non-mucinous cystic neoplasms (group B). The average age in groups A and B was 71.3 and 60.4 years, respectively. String sign was positive in 47 patients (51.1%) and negative in 21 patients (22.8%) in group A, while in group B, string sign was negative in 19 patients (95%). String sign showed significant correlation with the diagnosis of mucinous cystic neoplasms (OR 64.2, 95% CI 8.1-508.6, p = 0.0001). Cytology confirmed mucinous cystic neoplasms that included 32 patients; the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of string sign for mucinous cystic neoplasms were high, reaching 93.8%, 85.7%, 96.8%, and 75%, respectively, with an excellent accuracy rate of 92.3%. Conclusions: The string sign is highly accurate for predicting pancreatic mucinous cystic neoplasms, and should be used as an important aid for improving diagnostic accuracy.

Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration: A single-center analysis

Background: Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) has become an important modality for identification of intra-abdominal masses. This study analyzed the accuracy of EUS-FNAB in a single medical center and explored factors related to positive diagnosis. Materials and methods: In total, 77 patients with EUS-FNAB were retrospectively reviewed from July 2016 to February 2020. "Atypical (tends to be neoplasm/malignancy)," "suspicious (first consider neoplasm/malignancy)," and "malignant" were defined as positive cytology. The final diagnoses were based on histopathologic examination. The positive rate of EUS-FNAB for the diagnosis of neoplasm and its associations with age, sex, target puncture mass size, liver function, tumor markers, albumin, hypertension, and diabetes were examined. Results: Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of EUS-FNAB cytologic diagnoses in all patients were 77.9% (60/77), 76.1% (54/71), 100%, 100%, and 26.1% (6/23), respectively. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of EUS-FNAB cytologic diagnoses in the pancreas were 80.0% (48/60), 79.3% (46/58), 100%, 100%, and 14.3% (2/14), respectively. The results of EUS-FNAB in pancreatic masses showed that the level of CA19-9 was higher in the true positive group than in the false-negative group (p<0.05). There were no factors associated with the true positive cytologic diagnoses (p>0.05). Conclusions: Our single-medical center study showed that EUS-FNAB is an accurate diagnostic procedure for the evaluation of intra-abdominal masses. Further follow-up is required to explore factors associated with the true positive cytology.

Endoscopic diagnosis of cystic lesions of the pancreas

Endoscopic methods are increasingly used in the diagnosis of cystic lesions of the pancreas. The two major endoscopic approaches are endoscopic ultrasonography (EUS) and transpapillary diagnosis. EUS-guided fine-needle aspiration cytology and EUS-guided fine needle-based confocal laser endomicroscopy have been used in the differential diagnosis of mucinous and non-mucinous pancreatic cysts. EUS is the most sensitive modality for detecting mural nodules (MN) in intraductal papillary mucinous neoplasms (IPMN). Contrast-enhanced harmonic EUS (CH-EUS), as an add-on to EUS, is useful for identifying and characterizing MN. Recent studies show that CH-EUS has a sensitivity of 60-100% and a specificity of 75-92.9% for diagnosing malignant cysts. Intraductal ultrasonography and peroral pancreatoscopy are especially useful for detecting MN and IPMN. A recent meta-analysis showed that cytological assessment of pancreatic juice using a transpapillary approach had a pooled sensitivity, specificity, and accuracy of 35.1%, 97.2%, and 92.9%, respectively, for diagnosing malignant IPMN. Further studies are warranted to determine the indications for each of these novel techniques in assessing cystic lesions of the pancreas.

Endoscopic ultrasound cytologic brushing vs endoscopic ultrasound - fine needle aspiration for cytological diagnosis of cystic pancreatic lesions. A multicenter, randomized open-label trial

INTRODUCTION

the incidence of cystic pancreatic lesions (CPL) in the asymptomatic population is increasing. Achieving a preoperative diagnosis of CPL still remains a challenge.

OBJECTIVES

to evaluate the diagnostic accuracy of the cytological diagnosis of CPL from samples obtained by cytology brush versus standard endoscopic ultrasound fine needle aspiration (EUS-FNA).

METHODS

a multicenter, randomized, open-label trial was performed of EUS-cytology brush (EUS-EB) versus EUS-FNA for the cytological diagnosis of CPL. Patients that underwent EUS-FNA with a CPL > 15 mm were included and randomized into two groups: group I, EUS-EB; group II, EUS-FNA. The final diagnosis was based on the histological evaluation of surgical specimens and clinical parameters, imaging and a five year follow-up in non-operated patients. The main outcome was the diagnostic accuracy of both methods. Secondary outcomes were the diagnostic adequacy of specimens and the rate of adverse events. Data were compared using the Chi-squared test. An intention to treat (ITT) and per-protocol (PP) analysis were performed.

RESULTS

sixty-five patients were included in the study, 31 in group I and 34 in group II. Three patients initially randomized to group I were changed to group II as it was impossible to obtain a sample using the brush. The mean size of the CPL was 28.2 mm (range 16-60 mm). The diagnostic accuracy of EUS-EB was not superior to EUS-FNA, neither in the ITT nor the PP analysis (44.8% vs 41.1%, p = 0.77 and 38.4% vs 45.9%, p = 0.55).

CONCLUSIONS

EUS-EB does not improve the diagnostic accuracy of CPL in comparison with EUS-FNA.

Imaging modalities for characterising focal pancreatic lesions

BACKGROUND

Increasing numbers of incidental pancreatic lesions are being detected each year. Accurate characterisation of pancreatic lesions into benign, precancerous, and cancer masses is crucial in deciding whether to use treatment or surveillance. Distinguishing benign lesions from precancerous and cancerous lesions can prevent patients from undergoing unnecessary major surgery. Despite the importance of accurately classifying pancreatic lesions, there is no clear algorithm for management of focal pancreatic lesions.

OBJECTIVES

To determine and compare the diagnostic accuracy of various imaging modalities in detecting cancerous and precancerous lesions in people with focal pancreatic lesions.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, and Science Citation Index until 19 July 2016. We searched the references of included studies to identify further studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We planned to include studies reporting cross-sectional information on the index test (CT (computed tomography), MRI (magnetic resonance imaging), PET (positron emission tomography), EUS (endoscopic ultrasound), EUS elastography, and EUS-guided biopsy or FNA (fine-needle aspiration)) and reference standard (confirmation of the nature of the lesion was obtained by histopathological examination of the entire lesion by surgical excision, or histopathological examination for confirmation of precancer or cancer by biopsy and clinical follow-up of at least six months in people with negative index tests) in people with pancreatic lesions irrespective of language or publication status or whether the data were collected prospectively or retrospectively.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the references to identify relevant studies and extracted the data. We planned to use the bivariate analysis to calculate the summary sensitivity and specificity with their 95% confidence intervals and the hierarchical summary receiver operating characteristic (HSROC) to compare the tests and assess heterogeneity, but used simpler models (such as univariate random-effects model and univariate fixed-effect model) for combining studies when appropriate because of the sparse data. We were unable to compare the diagnostic performance of the tests using formal statistical methods because of sparse data.

MAIN RESULTS

We included 54 studies involving a total of 3,196 participants evaluating the diagnostic accuracy of various index tests. In these 54 studies, eight different target conditions were identified with different final diagnoses constituting benign, precancerous, and cancerous lesions. None of the studies was of high methodological quality. None of the comparisons in which single studies were included was of sufficiently high methodological quality to warrant highlighting of the results. For differentiation of cancerous lesions from benign or precancerous lesions, we identified only one study per index test. The second analysis, of studies differentiating cancerous versus benign lesions, provided three tests in which meta-analysis could be performed. The sensitivities and specificities for diagnosing cancer were: EUS-FNA: sensitivity 0.79 (95% confidence interval (CI) 0.07 to 1.00), specificity 1.00 (95% CI 0.91 to 1.00); EUS: sensitivity 0.95 (95% CI 0.84 to 0.99), specificity 0.53 (95% CI 0.31 to 0.74); PET: sensitivity 0.92 (95% CI 0.80 to 0.97), specificity 0.65 (95% CI 0.39 to 0.84). The third analysis, of studies differentiating precancerous or cancerous lesions from benign lesions, only provided one test (EUS-FNA) in which meta-analysis was performed. EUS-FNA had moderate sensitivity for diagnosing precancerous or cancerous lesions (sensitivity 0.73 (95% CI 0.01 to 1.00) and high specificity 0.94 (95% CI 0.15 to 1.00), the extremely wide confidence intervals reflecting the heterogeneity between the studies). The fourth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (dysplasia) provided three tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing invasive carcinoma were: CT: sensitivity 0.72 (95% CI 0.50 to 0.87), specificity 0.92 (95% CI 0.81 to 0.97); EUS: sensitivity 0.78 (95% CI 0.44 to 0.94), specificity 0.91 (95% CI 0.61 to 0.98); EUS-FNA: sensitivity 0.66 (95% CI 0.03 to 0.99), specificity 0.92 (95% CI 0.73 to 0.98). The fifth analysis, of studies differentiating cancerous (high-grade dysplasia or invasive carcinoma) versus precancerous (low- or intermediate-grade dysplasia) provided six tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing cancer (high-grade dysplasia or invasive carcinoma) were: CT: sensitivity 0.87 (95% CI 0.00 to 1.00), specificity 0.96 (95% CI 0.00 to 1.00); EUS: sensitivity 0.86 (95% CI 0.74 to 0.92), specificity 0.91 (95% CI 0.83 to 0.96); EUS-FNA: sensitivity 0.47 (95% CI 0.24 to 0.70), specificity 0.91 (95% CI 0.32 to 1.00); EUS-FNA carcinoembryonic antigen 200 ng/mL: sensitivity 0.58 (95% CI 0.28 to 0.83), specificity 0.51 (95% CI 0.19 to 0.81); MRI: sensitivity 0.69 (95% CI 0.44 to 0.86), specificity 0.93 (95% CI 0.43 to 1.00); PET: sensitivity 0.90 (95% CI 0.79 to 0.96), specificity 0.94 (95% CI 0.81 to 0.99). The sixth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (low-grade dysplasia) provided no tests in which meta-analysis was performed. The seventh analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) provided two tests in which meta-analysis was performed. The sensitivity and specificity for diagnosing cancer were: CT: sensitivity 0.83 (95% CI 0.68 to 0.92), specificity 0.83 (95% CI 0.64 to 0.93) and MRI: sensitivity 0.80 (95% CI 0.58 to 0.92), specificity 0.81 (95% CI 0.53 to 0.95), respectively. The eighth analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) or benign lesions provided no test in which meta-analysis was performed.There were no major alterations in the subgroup analysis of cystic pancreatic focal lesions (42 studies; 2086 participants). None of the included studies evaluated EUS elastography or sequential testing.

AUTHORS' CONCLUSIONS

We were unable to arrive at any firm conclusions because of the differences in the way that study authors classified focal pancreatic lesions into cancerous, precancerous, and benign lesions; the inclusion of few studies with wide confidence intervals for each comparison; poor methodological quality in the studies; and heterogeneity in the estimates within comparisons.

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of pancreatic cysts by combined cytopathology and cystic content analysis

Recent advances in imaging technology have resulted in an increase in incidental discoveries of pancreatic cystic lesions. Pancreatic cysts comprise a wide variety of lesions and include non-neoplastic cysts and neoplastic cysts. Because some pancreatic cysts have more of a malignant potential than others, it is absolutely essential that an accurate diagnosis is rendered so that effective care can be given to each patient. In many centers, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has emerged as the modality of choice that enables one to distinguish between mucinous and non-mucinous lesion, diagnose malignancy and collect cyst fluid for further diagnostic studies, such as pancreatic enzyme levels, molecular analysis and other tumor biomarkers. The current review will focus on EUS-guided FNA and the cytological diagnosis for pancreatic cysts.

Prevalence of extra-pancreatic cysts in patients with cystic pancreatic lesions detected by endoscopic ultrasound

Background and Objectives:

Extra-pancreatic cysts (EPCs) are incidentally found in patients with pancreatic cystic lesions (PCLs). The aim of this study is to find the prevalence of concurrent EPC in patients with PCLs, investigate associations with neoplastic lesions, and compare the prevalence of EPC to a control population.

Materials and Methods:

A retrospective study of patients who underwent endoscopic ultrasound (EUS) over a 3-year period. The study group consisted of patients with PCLs. The control group included equal number of matched (age and sex) patients who had undergone EUS for reasons other than evaluation of PCLs. All patients had undergone computed tomography (CT) that was reviewed for EPCs.

Results:

A total of 191 patients were found to have PCLs. One patient with Von Hippel-Lindau (VHL) disease was excluded. Majority of the patients were female (60%); most PCLs were solitary (68.9%), unilocular (56.8%), predominantly located in the head of the pancreas (37.4%); and mean PCL diameter was 28.12 ± 18.4mm. EUS-guided fine-needle aspiration (FNA) was performed in 171 (90%) patients with 73 (42.7%) PCLs demonstrating cysts with benign epithelial cells, 37 (21.6%) mucinous cysts, 18 (10.5%) mucinous adenocarcinomas, 11 (6.4%) neuroendocrine tumors, nine intraductal papillary mucinous cystic neoplasms (IPMNs), six pseudocysts, five serous cyst adenomas (SCAs), and five with inadequate sampling. An EPC was observed in 97 of 190 (51.18%) patients with PCLs and in 67 of 190 (35.3%) controls (P < 0.001). The distribution of EPCs in PCL patients and controls (n = 190) were 32.1% vs. 15.8% (P < 0.001) for liver cysts, 30.0% vs. 20.5% (P = 0.04) for renal cysts, and 3.7% vs. 1.6% (P = 0.34) for cysts in other organs. Mean liver cyst diameter (15.6 mm vs. 10.1 mm, P = 0.23) and renal cyst diameter (20.4 mm vs. 20.1 mm, P = 0.95) were not statistically different in PCL patients compared to controls. Multivariate analysis demonstrated that among patients with PCLs, EPCs increased with age (mean age 69.6 vs. 62.4 years, P ≤ 0.001, odds ratio (OR) 1.06, 95% confidence interval (CI) 1.03, 1.09), and male gender was associated with higher chance of finding renal cysts (OR 2.17, P = 0.021, 95% CI 1.13, 4.19). There was no association between FNA result and prevalence or type of EPC.

Conclusion:

The prevalence of EPCs in patients with PCLs was significantly higher than in a matched control group. Among patients with PCLs, a liver cyst is the most common EPC. Increasing age is associated with higher prevalence of EPCs.

Pancreatic cystic neoplasms: Review of current knowledge, diagnostic challenges, and management options

Pancreatic cystic lesions are being detected with increasing frequency, largely due to advances in cross-sectional imaging. The most common neoplasms include serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, solid pseudopapillary neoplasms, and cystic pancreatic endocrine neoplasms. Computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS) are currently used as imaging modalities. EUS-guided fine needle aspiration has proved to be a useful diagnostic tool, and enables an assessment of tumor markers, cytology, chemistries, and DNA analysis. Here, we review the current literature on pancreatic cystic neoplasms, including classification, diagnosis, treatment, and recommendations for surveillance. Data for this manuscript was acquired via searching the literature from inception to December 2014 on PubMed and Ovid MEDLINE.

Endoscopic Ultrasound-Guided Treatment beyond Drainage: Hemostasis, Anastomosis, and Others

Since the introduction of endoscopic ultrasound (EUS) in the 1990s, it has evolved from a primarily diagnostic modality into an instrument that can be used in various therapeutic interventions. EUS-guided fine-needle injection was initially described for celiac plexus neurolysis. By using the fundamentals of this method, drainage techniques emerged for the biliary and pancreatic ducts, fluid collections, and abscesses. More recently, EUS has been used for ablative techniques and injection therapies for patients with for gastrointestinal malignancies. As the search for minimally invasive techniques continued, EUS-guided hemostasis methods have also been described. The technical advances in EUS-guided therapies may appear to be limitless; however, in many instances, these procedures have been described only in small case series. More data are required to determine the efficacy and safety of these techniques, and new accessories will be needed to facilitate their implementation into practice.

Endoscopic ultrasound-guided fine-needle aspiration of the pancreas: a retrospective study of 1000 cases

INTRODUCTION

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has emerged as a superior method for the diagnosis of pancreatic tumors. Very few large studies have been published. We retrospectively examined 1000 cases to determine the sensitivity and specificity of EUS-guided FNA for solid and cystic lesions.

MATERIALS AND METHODS

EUS-guided FNA was performed in 1000 patients. Air-dried aspirates were reviewed immediately to ensure adequacy, and ethanol-fixed aspirates were reviewed the following day. The rendered diagnoses were placed into various categories and compared to subsequent histologic and clinical follow-up data.

RESULTS

Of the 1000 cases, 579 were solid lesions. The FNA diagnoses of the solid lesions were benign (B) 229 (39.5%), atypia (A) 22 (3.8%), suspicious (S) 27 (4.7%), malignant (M) 260 (44.9%), tumor (T) 1 (0.2%), and nondiagnostic (ND) 40 (6.9%). The sensitivity, specificity, positive predictive value, and negative predictive value for solid lesions were 97%, 97%, 99%, and 94%, respectively. There were 421 cystic lesions. The FNAs of the cystic lesions were classified as follows: B 342 (81.2%), A 5 (1.2%), S 4 (1%), M 7 (1.7%), T 46 (10.9%), and ND 17 (4.0%). The sensitivity, specificity, positive predictive value, and negative predictive value to identify mucinous tumors and malignancy for cystic lesions were 46%, 98%, 94%, and 87%, respectively.

CONCLUSIONS

At our institution, EUS-guided FNA of solid pancreatic lesions is both sensitive and specific for the diagnosis of both primary and metastatic tumors. For cystic lesions, FNA is not as sensitive, but its specificity remains high.

Differential diagnosis of pancreatic serous oligocystic adenoma and mucinous cystic neoplasm with spectral CT imaging: initial results

AIM

To investigate the imaging characteristics of pancreatic serous oligocystic adenoma (SOA) and mucinous cystic neoplasms (MCNs) using spectral computed tomography (CT) and to evaluate whether quantitative information derived from spectral imaging can improve the differential diagnosis of these diseases.

MATERIALS AND METHODS

From February 2010 to June 2013, 44 patients (24 SOAs and 20 MCNs) who underwent spectral CT imaging were included in the study. Conventional characteristics and quantitative parameters were compared between the two disease groups. Logistic regression was used for multiparametric analysis. The receiver-operating characteristic curve was used to evaluate the diagnostic performance of single parameter and multiparametric analysis. Two radiologists diagnosed the diseases blinded and independently, without and with the information of the statistical analysis.

RESULTS

Tumour location, contour, size, and monochromatic CT values at 40 keV to 70 keV, iodine concentration, and effective atomic number (effective-Z) in the late arterial phase were the independent factors correlated with category. Multiparametric analysis with logistic regression showed that tumour size, location, and contour were the most effective variations, and obtained an area under the ROC curve (AUC) of 0.934. With the knowledge of statistical analysis, the accuracy of the first reader increased from 70.5% to 86.4%, and the accuracy of the second reader increased from 81.8% to 90.9%.

CONCLUSIONS

Although CT spectral imaging provided additional information and multiparametric analysis obtained better performance than single-parameter analysis in differentiating MCNs from SOAs, multiparametric analysis with the combination of quantitative parameters derived from CT spectral imaging did not improve the diagnostic performance. Tumour size, location, and contour played an important role in differentiating MCNs from SOAs.

Post-brushing and fine-needle aspiration biopsy follow-up and treatment options for patients with pancreatobiliary lesions: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology (PSC) has developed a set of guidelines for pancreatobiliary cytology including indications for endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) biopsy, techniques of EUS-FNA, terminology and nomenclature for pancreatobiliary cytology, ancillary testing and post-procedure management. All documents are based on the expertise of the authors, a review of the literature and discussions of the draft document at several national and international meetings over an 18 month period and synthesis of online comments of the draft document on the PSC web site (www.papsociety.org). This document selectively presents the results of these discussions and focuses on the follow-up and treatment options for patients after procedures performed for obtaining cytology samples for the evaluation of biliary strictures and solid and cystic masses in the pancreas. These recommendations follow the six-tiered terminology and nomenclature scheme proposed by committee III.

Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms

This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.

False-negative rate of endoscopic ultrasound-guided fine-needle aspiration for pancreatic solid and cystic lesions with matched surgical resections as the gold standard: one institution's experience

BACKGROUND

The diagnosis of pancreatic tumors is often complicated because of sampling and interpretive challenges. The current study was performed to determine the rates, types, and causes of diagnostic discrepancies.

METHODS

The authors retrospectively reviewed cytology cases from 2004 to 2010 using matched surgical resection cases as the gold standard.

RESULTS

A total of 733 cases were divided into 3 categories: 1) positive or suspicious (290 cases); 2) negative or atypical (403 cases); and 3) unsatisfactory (40 cases). Of these cases, 101 fine-needle aspiration (FNA) cases had matched surgical resections including 58 positive diagnoses, 39 negative diagnoses, and 4 unsatisfactory diagnoses. All 19 discrepant cases represented false-negative diagnoses without any false-positive cases noted, which included 2 cases with interpretive errors (10%) and 17 cases with sampling errors (90%). All matched cytology cases were divided into 5 subgroups based on the type of lesion or type of error and were analyzed for sensitivity and specificity. The sampling error rate in cystic lesions (8 of 24; 33%) was significantly higher than that in solid lesions (9 of 73; 12%). The false-negative rate in the interpretive error group (3%) was significantly lower than that in the sampling error group (23%).

CONCLUSIONS

The results of the current study confirm that pancreatic endoscopic ultrasound-guided FNA diagnosis has a very low false-positive rate but a relatively high false-negative rate using matched surgical resections as the gold standard. The major cause of a false-negative cytology diagnosis is sampling error and the rate of sampling error in cystic lesions is significantly higher than that in solid lesions.

Accuracy of endoscopic ultrasound-guided fine needle aspiration cytology on the differentiation of malignant and benign pancreatic cystic lesions: a single-center experience

OBJECTIVES

The aim was to compare the use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in cytology and the biochemical analysis of cyst fluid, together with the size of the lesion in the differentiation between benign and malignant pancreatic cystic lesions.

METHODS

Data of patients who underwent EUS-FNA for pancreatic cystic lesions in our center from January 2006 to October 2010 were retrospectively analyzed. The diagnostic accuracy of EUS-FNA was determined.

RESULTS

Of the 56 patients, 37 (66.1%) had evaluable cytology for diagnosis and sufficient cyst fluid was available for biochemical analysis in 58.9% (33/56) of the patients. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-FNA for detecting malignancy were 63%, 100%, 100% and 85%, respectively. EUS-FNA was the most accurate diagnostic method for differentiating malignant and benign pancreatic cystic lesions (88%). Cyst fluid carcinoembryonic antigen (CEA) > 365 ng/mL had a sensitivity of 100% for the detection of malignant cystic lesions.

CONCLUSIONS

Although the rate of insufficient cyst fluid aspiration is high, the combination of cytological evaluation and CEA analysis of cyst fluid obtained by EUS-FNA is accurate in differentiating malignant cystic lesions from benign ones. Safe techniques are essential to improve the yield of cyst fluid aspiration by EUS.

Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer: a meta-analysis

BACKGROUND AND OBJECTIVE

EUS-FNA of pancreatic lesion has been put into clinical use widely in many centers. The present meta-analysis was conducted to study the diagnostic role of EUS-FNA in pancreatic cancer.

METHODS

A comprehensive review of study on the precision of EUS-FNA in the diagnosis of pancreatic cancer. A random effects model was used to pool the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR). A summary receiver-operating characteristic (SROC) was constructed to summarize the overall test performance.

RESULTS

Thirty-one articles were eligible for the meta-analysis. The pooled sensitivity, specificity, PLR, NLR and DOR of EUS-FNA in the diagnosis of pancreatic cancer were 0.89 (95% CI: 0.88-0.90), 0.96 (95% CI: 0.95-0.97), 16.88 (95% CI: 10.63-26.79), 0.13 (95%CI: 0.10-0.16) and 150.80 (95%CI: 95.94-237.03) respectively. In subgroup meta-analysis of the prospective studies, the pooled sensitivity, specificity, PLR, NLR and DOR were 0.91 (95% CI: 0.90-0.93), 0.94 (95% CI: 0.91-0.96), 11.19 (95% CI: 6.36-19.69), 0.10 (95% CI: 0.07-0.15) and 125.22 (62.37-251.41). The area under the curve (AUC) was 0.97, indicating a good performance of overall accuracy.

CONCLUSION

EUS-FNA has the high sensitivity and specificity in differentiating pancreatic cancer. Moreover, it is also a safe diagnostic modality with little complications.

Commercial molecular panels are of limited utility in the classification of pancreatic cystic lesions

The PathfinderTG biomarker panel is useful in the evaluation of pancreatic cysts that have clinical features suspicious for malignancy, but its utility in classifying fine-needle aspiration biopsies from small pancreatic cystic lesions is yet to be proven. We used morphology to classify 20 pancreatic cyst cytology aspirates, all of which met radiographic criteria for close observation. Cases were cytologically classified as consistent with pseudocyst, serous cystadenoma, or mucinous neoplasm with low-grade, intermediate-grade, or high-grade dysplasia and analyzed for carcinoembryonic antigen. Redpath Integrated Pathology Inc. rendered diagnoses of nonmucinous (reactive/indolent or serous) or mucinous (low-risk or at risk) cyst on the basis of results of the PathfinderTG panel (KRAS mutations, DNA content, and loss of heterozygosity at microsatellites linked to tumor suppressor genes). Cytologic and commercial laboratory diagnoses were concordant in only 7 (35%) cases. Seven cysts classified as mucinous with low-grade dysplasia by cytology were interpreted as nonmucinous on the basis of the PathfinderTG panel, 2 of which were resected mucinous cysts. Two pancreatitis-related pseudocysts were misdiagnosed as low-risk mucinous cysts; 1 mucinous cyst with low-grade dysplasia was considered at risk for neoplastic progression using the PathfinderTG panel. Only 1 cyst misclassified as pseudocyst by cytology, but low-risk mucinous cyst by molecular analysis, proved to be a mucinous cystic neoplasm with low-grade dysplasia after surgical resection. We conclude that the PathfinderTG panel may aid the classification of pancreatic lesions, but is often inaccurate and should not replace cytologic evaluation of these lesions.

Pancreatic cystic lesions: How endoscopic ultrasound morphology and endoscopic ultrasound fine needle aspiration help unlock the diagnostic puzzle

Cystic lesions of the pancreas are being diagnosed with increasing frequency, covering a vast spectrum from benign to malignant and invasive lesions. Numerous investigations can be done to discriminate between benign and non-evolutive lesions from those that require surgery. At the moment, there is no single test that will allow a correct diagnosis in all cases. Endoscopic ultrasound (EUS) morphology, cyst fluid analysis and cytohistology with EUS-guided fine needle aspiration can aid in this difficult diagnosis.

Current status on the diagnosis and management of pancreatic cysts in the Asia-Pacific region: role of endoscopic ultrasound

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) play increasingly prominent roles in the diagnosis and management of pancreatic cysts. The Asian Consortium of Endoscopic Ultrasound was recently formed to conduct collaborative research in this area. This is a review of literature on true pancreatic cysts. Due to the lack of systematic studies, there are no robust data on the true incidence of pancreatic cystic lesions in Asia and any change in over the recent decades. Certain EUS morphological features have been used to predict particular types of pancreatic cysts. Pancreatic cyst fluid viscosity, cytology, pancreatic enzymes, and tumor markers, in particular carcinoembryonic antigen, can aid in the diagnosis of pancreatic cysts. Hemorrhage and infection are the most common complications of EUS-FNA of pancreatic cysts. Pancreatic cysts can either be observed or resected depending on the benign or malignant nature, or malignant potential of the lesions. Guidelines from an international consensus did not require positive cytological findings to be present in their recommendation for resection, which included all mucinous cystic neoplasms, all main-duct intraductal papillary mucinous neoplasms (IPMN), all mixed IPMN, symptomatic side-branch IPMN, and side-branch IPMN larger than 3 cm. In patients with poor surgical risks, EUS-guided cyst ablation of mucinous pancreatic cysts is an alternative. As long-term prospective data on pancreatic cysts are still not available in Asia, management strategies are largely based on risk stratification by surgical risk and malignant potential. Gene expression profiling of pancreatic cyst fluid and confocal laser endomicroscopic examination of pancreatic cysts are novel techniques currently being studied.

First assessment of needle-based confocal laser endomicroscopy during EUS-FNA procedures of the pancreas (with videos)

BACKGROUND

Challenges in EUS-guided FNA (EUS-FNA) include sampling error, nondiagnostic cytology, and limited on-site cytological evaluation. A prototype needle-based confocal laser endomicroscopy (nCLE) probe is a submillimeter probe that provides real-time imaging at the microscopic level through the FNA needle.

OBJECTIVE

To evaluate the feasibility of nCLE during EUS-FNA of pancreatic lesions.

DESIGN

Feasibility study.

SETTING

Multicenter, tertiary care.

PATIENTS

Eighteen patients presenting for EUS-FNA.

INTERVENTIONS

Patients were injected with 2.5 mL of 10% fluorescein. The lesion was interrogated with the nCLE probe positioned at the tip of a 19-gauge FNA needle.

MAIN OUTCOME MEASUREMENTS

Device integrity, technical ease, safety, and image acquisition.

RESULTS

Cases included 16 cysts and 2 masses. There were no device malfunctions. Technical challenges were encountered in 6 of 18 attempts to image and reflected challenges with a postloading technique, the longer ferule tip, and a transduodenal approach. Technical feasibility to perform imaging with nCLE during a pancreatic EUS-FNA procedure was achieved in 17 of 18 cases. Ten cases had good to very good image quality. Two serious adverse events occurred; both were pancreatitis requiring hospitalization.

LIMITATIONS

Limited sample size, small number of patients with confirmed pathological diagnosis, lack of coregistered pathology and images.

CONCLUSIONS

nCLE in the pancreas is technically feasible via a 19-gauge needle under endosonographic guidance. Future studies will address identification of structures, diagnostic accuracy, and complication profiles. The rate of pancreatitis needs to be further clarified and mitigated.

Current role of imaging methods in the diagnosis of cystic solid pancreas neoplasms: part II

The authors address the value of endoscopic retrograde cholangiopancreatography, ultrasonography, computed tomography, magnetic resonance imaging and endoscopic ultrasound for the diagnosis of cystic and solid neoplasms of the pancreas, demonstrating that each of them is of great importance to undoubtedly increase the diagnostic accuracy of the biliopancreatic system diseases. The best method for each of several tumors is then determined.

Clinical features and natural history of serous cystic neoplasm of the pancreas

AIMS

To clarify the clinical features and the natural history of serous cystic neoplasm (SCN) of the pancreas.

METHODS

We retrospectively analyzed data from 30 patients affected by SCN. SCNs were classified as (1) microcystic type, (2) micro- and macrocystic type, and (3) macrocystic type according to the modified WHO classification. Eighteen patients who underwent serial radiographic imaging were identified, and tumor growth rate in these patients was evaluated.

RESULTS

The median age was 62 years, and the female:male ratio was 2:1. Twenty-five patients (83%) were asymptomatic and 5 (17%) were symptomatic. The median tumor size was 2.6 cm. Fifteen cases (50%) had the microcystic type, 7 (23%) the micro- and macrocystic type, and 8 (27%) the macrocystic type. Age, gender, symptoms, location or tumor size did not differ significantly among the three subtypes. Eighteen patients were followed up for a median of 58 months. Morphological changes were observed in 3 patients (17%) and enlargement of tumor size in 9 patients (50%) during the follow-up. The growth rate was 0.29 cm per year and doubling time was 3.5 years; these rates did not differ among morphological subtypes or size of tumors.

CONCLUSIONS

In asymptomatic patients with a clear imaging diagnosis of SCN, nonoperative management with a careful follow-up should be recommended. Surgery should be suggested in only symptomatic patients, those with giant tumors (>10 cm), rapid growing or when the presence of a potentially malignant tumor cannot be excluded. and IAP.

Pleomorphic giant cell carcinoma of the pancreas with hepatic metastases--initially presenting as a benign serous cystadenoma: a case report and review of the literature

INTRODUCTION

Pleomorphic giant cell pancreatic cancer is a very rare and aggressive pancreatic neoplasm. A case of pleomorphic giant cell pancreatic cancer presenting as a cystic lesion and in association with a serous cystadenoma presents a unique case which has not been described before.

CASE PRESENTATION

A 44-year-old alcoholic man presented with abdominal pain, vomiting, and weight loss. Initially, imaging suspected a pancreatic pseudocyst measuring 4.2 cm. Endoscopic ultrasound- (EUS-) guided fine-needle aspiration revealed a serous cystadenoma. With conservative intervention only (fluid resuscitation, analgesia, and antiemetics) the patient improved and was discharged under close observation. Follow-up scan at four months revealed minimal change. Three months later, he was admitted acutely. Repeat scans demonstrated mild cyst enlargement with new liver lesions. Laparoscopic biopsy revealed pleomorphic giant cell carcinoma with the organ of origin the pancreas.

CONCLUSION

This unusual case highlights the challenges in managing pancreatic cystic lesions and emphasizes the importance of considering less common forms of pancreatic cystic masses when the findings are atypical for the presentation. Surgical excision in these cases over conservative steps may be the most appropriate management.

Management of mucinous cystic neoplasms of the pancreas

The purpose of this study was to investigate the actual management of mucinous cystic neoplasm (MCN) of the pancreas. A systematic review was performed in December 2009 by consulting PubMed MEDLINE for publications and matching the key words “pancreatic mucinous cystic neoplasm”, “pancreatic mucinous cystic tumour”, “pancreatic mucinous cystic mass”, “pancreatic cyst”, and “pancreatic cystic neoplasm” to identify English language articles describing the diagnosis and treatment of the mucinous cystic neoplasm of the pancreas. In total, 16 322 references ranging from January 1969 to December 2009 were analysed and 77 articles were identified. No articles published before 1996 were selected because MCNs were not previously considered to be a completely autonomous disease. Definition, epidemiology, anatomopathological findings, clinical presentation, preoperative evaluation, treatment and prognosis were reviewed. MCNs are pancreatic mucin-producing cysts with a distinctive ovarian-type stroma localized in the body-tail of the gland and occurring in middle-aged females. The majority of MCNs are slow growing and asymptomatic. The prevalence of invasive carcinoma varies between 6% and 55%. Preoperative diagnosis depends on a combination of clinical features, tumor markers, computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound with cyst fluid analysis, and positron emission tomography-CT. Surgery is indicated for all MCNs.

Role of EUS-FNA-based cytology in the diagnosis of mucinous pancreatic cystic lesions: a systematic review and meta-analysis

BACKGROUND

Preoperative diagnosis of malignancy in pancreatic cystic lesions (PCLs) remains challenging. Most non-mucinous cystic lesions (NMCLs) are benign, but mucinous cystic lesions (MCLs) are more likely to be premalignant or malignant.

AIM

The aim of this study was to assess the sensitivity, specificity, and positive and negative likelihood ratios (LRs) of EUS-FNA-based cytology in differentiating MCLs from non-mucinous PCLs.

METHODS

We conducted a comprehensive search of MEDLINE, SCOPUS, Cochrane, and "CINAHL Plus" databases to identify studies, in which the results of EUS-FNA-based cytology of PCLs were compared with those of surgical biopsy or surgical excision histopathology. A DerSimonian-Laird random effect model was used to estimate the pooled sensitivity, specificity, and LRs, and a summary receiver-operating characteristic (SROC) curve was constructed.

RESULTS

We included 376 patients from 11 distinct studies who underwent EUS-FNA-based cytology and also had histopathological diagnosis. The pooled sensitivity and specificity in diagnosing MCLs were 0.63 (95% CI, 0.56-0.70) and 0.88 (95% CI, 0.83-0.93), respectively. The positive and negative LRs in diagnosing MCLs were 4.46 (95% CI, 1.21-16.43) and 0.46 (95% CI, 0.25-0.86), respectively. The area under the curve (AUC) was 0.89.

CONCLUSIONS

EUS-FNA-based cytology has overall low sensitivity but good specificity in differentiating MCLs from NMCLs. Further research is required to improve the overall sensitivity of EUS-FNA-based cytology to diagnose MCLs while evaluating PCL.

Cystic neoplasms of the pancreas

Cystic neoplasms of the pancreas are a heterogeneous group of pancreatic tumors that vary in pathophysiology, malignant potential, clinical course, and outcomes. Their management is heavily predicated on establishing an accurate diagnosis. This can be particularly challenging, but can often be achieved by a thorough history and physical examination combined with high-quality, thin-slice computed tomography, although additional diagnostic tools may be required. Once the diagnosis is established, treatment can range from simple observation to total pancreatectomy. This decision rests on a clear and complete understanding of each disease process in the context of the patient's age and comorbidities. This article reviews the most common cystic neoplasms of the pancreas, focusing on their diagnosis and management.

Interventional endoscopic ultrasound: Therapeutic capability and potential

The linear echoendoscope, introduced in the 1990s, opened the era of interventional endoscopic ultrasound (IEUS). The linear echoendoscope enabled EUS guided Fine Needle Aspiration (EUS-FNA) allowing the path of the needle to be traced during the puncture process. After EUS-FNA, other interventional procedures were introduced in clinical practice. Tissue acquisition was the first EUS-guided interventional procedure and its higher diagnostic quality has undoubtedly been established. After EUS-FNA, Celiac plexus neurolysis (CPN) and block (CPB), pancreatic pseudocyst drainage, abdominal and mediastinal collections/abscesses drainage, and in selected cases, pancreatic and biliary ductal system drainage, were introduced in clinical practice. EUS-guided fine needle injection with local delivery of antitumor agents is considered a promising modality. We have reviewed published data on EUS guided interventional procedures with the object of summarizing the diagnostic capability of endoscopic ultrasound and elaborates in detail its therapeutic capability and potential.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA): experience of an academic centre in the USA

OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has become widely accepted as an effective modality for obtaining tissue for primary diagnosis and staging. We have been using EUS-FNA since July 2001 and herein we summarize our experience over a 5-year period.

METHODS

A computer-based search for in-house EUS-FNA was performed in the pathology database from July 2001 to October 2006. To calculate the sensitivity, specificity and accuracy of EUS-FNA, the cytology diagnosis was compared with the surgical follow-up.

RESULTS

A total of 951 EUS-FNAs were performed during the study period and included 279 pancreatic solid lesions, 186 pancreatic cyst lesions, 249 lymph node aspirations, 111 gastrointestinal (GI) tract submucosal lesions, and 126 miscellaneous lesions. EUS-FNA had a very high sensitivity and accuracy for solid pancreatic lesions (94.7 and 97.7%, respectively), low sensitivity and accuracy but high specificity (47, 64.8 and 95%, respectively) for cystic lesions. Cyst fluid carcinoembryonic (CEA) levels were significantly higher in mucinous neoplasms than non-neoplastic cysts. EUS-FNA also had very high sensitivity and specificity for detecting metastatic carcinoma in lymph nodes (95 and 100%, respectively). GI submucosal spindle cell tumours were further classified with immunohistochemical stains performed either on a cell block or a core biopsy obtained via EUS guidance.

CONCLUSIONS

EUS-FNA has a very high sensitivity and accuracy for pancreatic solid lesions, but the sensitivity for cystic lesions is generally low. Cyst fluid chemical analysis for CEA is helpful, but the overlap between mucinous neoplasm and non-neoplastic cysts is significant. Recognizing GI contamination is important and immunohistochemical stains are useful for GI submucosal spindle cell lesions.

Comparative performance of MDCT and MRI with MR cholangiopancreatography in characterizing small pancreatic cysts

OBJECTIVE

The objective of our study was to compare MDCT with MRI-MR cholangiopancreatography (MRCP) in characterizing small pancreatic cysts (< or = 3 cm) and predicting aggressiveness.

MATERIALS AND METHODS

In a retrospective analysis, contrast-enhanced MDCT and MRI examinations of 30 patients with 38 pathologically confirmed small pancreatic cysts were reviewed. MDCT and MRCP studies were independently evaluated by two readers for cyst morphology, cyst characterization, and prediction of lesion aggressiveness, which included lesions with moderate-grade dysplasia, high-grade dysplasia (carcinoma in situ), and invasive carcinomas. The sensitivity of MDCT and MRI for the detection of each morphologic feature, accuracy for cyst characterization, and predictive values for aggressiveness were calculated.

RESULTS

Of 38 lesions, 14 were side-branch intraductal papillary mucinous neoplasms (IPMNs), 12 mixed IPMNs, six mucinous cystic neoplasms, and six nonneoplastic cysts. On histopathology, 26 lesions were nonaggressive (six nonneoplastic cysts, six benign mucinous cystic neoplasms, 14 low-grade dysplasias in IPMNs), whereas 12 lesions revealed aggressive biology (eight moderate-grade dysplasias, four high-grade dysplasias in IPMNs). The sensitivity of MRCP for the detection of morphologic features was better than that of MDCT, but the differences were not statistically significant (p = 0.25-1). Interreader agreement and MDCT-MRI agreement for morphologic features were good to perfect (kappa = 0.7-1). The accuracy of MDCT and MRI was higher in classifying cysts as mucinous or nonmucinous than in determining a specific diagnosis (71-84.2% vs 39.5-44.7%, respectively), whereas the accuracy of the two techniques in characterizing cysts into nonaggressive and aggressive categories was similar (MDCT vs MRI, 75-78% vs 78-86%, respectively; p > 0.05).

CONCLUSION

MRI enables more confident assessment of the morphology of small cysts than MDCT, but the accuracy of the two imaging techniques for cyst characterization is comparable. MDCT and MRI have high accuracy in classifying cysts into mucinous and nonmucinous categories and perform similarly in estimating histologic aggressiveness.

Cystic neoplasms of the pancreas: A diagnostic challenge

Cystic neoplasms of the pancreas are increasingly recognized due to the expanding use and improved sensitivity of cross-sectional abdominal imaging. Major advances in the last decade have led to an improved understanding of the various types of cystic lesions and their biologic behavior. Despite significant improvements in imaging technology and the advent of endoscopic-ultrasound (EUS)-guided fine-needle aspiration, the diagnosis and management of pancreatic cystic lesions remains a significant clinical challenge. The first diagnostic step is to differentiate between pancreatic pseudocyst and cystic neoplasm. If a pseudocyst has been effectively excluded, the cornerstone issue is then to determine the malignant potential of the pancreatic cystic neoplasm. In the majority of cases, the correct diagnosis and successful management is based not on a single test but on incorporating data from various sources including patient history, radiologic studies, endoscopic evaluation, and cyst fluid analysis. This review will focus on describing the various types of cystic neoplasms of the pancreas, their malignant potential, and will provide the clinician with a comprehensive diagnostic approach.

Endoscopic ultrasound in pancreatic disease--its influence on surgical decision-making. An update 2008

Endoscopic ultrasonography (EUS) was introduced about 25 years ago with the primary aim of better visualization of the pancreas as compared to transabdominal ultrasonography. This review discusses the current evidence in 2008 concerning the role of EUS in the clinical management of patients, with a special emphasis on its impact on surgical therapy. According to the literature, good indications are detection of common bile duct stones (e.g. in acute pancreatitis), the detection of small exo- and endocrine pancreatic tumors, the performance of fine-needle aspiration in pancreatic masses depending on therapeutic consequences. In other areas such as diagnosis of chronic pancreatitis and cystic pancreatic lesions, the contribution of EUS seems limited. Pancreatic cancer staging is discussed controversially due to conflicting evidence and certainly has lost grounds due to improvements in CT technology. Therapeutic EUS is, however, more widely accepted and may replace other techniques, e.g. in pancreatic cyst drainage and celiac plexus neurolysis; further techniques of interest are being developed.

Cystic lesions of the pancreas. A diagnostic and management dilemma

BACKGROUND/AIMS

Due to enhanced imaging modalities, pancreatic cysts are being increasingly detected, often as an incidental finding. They comprise a wide range of differing underlying pathologies from completely benign through premalignant to frankly malignant. The exact diagnostic and management pathway of these cysts remains problematic and this review attempts to provide an overview of the pathology underlying pancreatic cystic lesions and suggests appropriate methods of management.

METHODS

A search was undertaken with a Pubmed database to identify all English articles using the keywords 'pancreatic cysts', 'serous cystadenoma', 'intraductal papillary mucinous tumour', 'pseudocysts', 'mucinous cystic neoplasm' and 'solid pseudopapillary tumour'.

RESULTS

The mainstay of assessment of pancreatic cysts is cross-sectional imaging incorporating CT and MRI. Fine-needle aspiration (FNA) (often with endoscopic ultrasound) may provide valuable additional information but can lack sensitivity. Symptomatic cysts, increasing age and multilocular cysts (with a solid component and thick walls) are predictors of malignancy. A raised cyst aspirate CEA, CA 19-9 and mucin content (including abnormal cytology), if present, can accurately distinguish premalignant and malignant cysts from benign ones.

CONCLUSION

In summary, all patients with pancreatic cystic lesions, whether asymptomatic or symptomatic, must be thoroughly investigated to ascertain the underlying nature of the cyst. Small asymptomatic cysts (<3 cm) with no suspicious features on imaging or FNA may be safely followed up. Follow-up should continue for at least 4 years, with a repeat FNA if needed. An algorithm for the management of pancreatic cystic tumours is also suggested. and IAP.

Progress on molecular markers of pancreatic cancer

PURPOSE OF REVIEW

To describe advances in the development of biomarkers for pancreatic cancer over the past year.

RECENT FINDINGS

Several new approaches were taken in the search for biomarkers for pancreatic cancer. Studies of CA19-9 revealed new prognostic abilities of the already well known biomarker. New blood biomarkers were investigated and CEACAM1 and MIC-1 were found to be superior to CA19-9 at distinguishing cancer from normal but, unfortunately, not from chronic pancreatitis. MUC1 was reported to be superior to CA19-9 based on the use of a novel immunoassay. The superiority of the concept of a panel of biomarkers as opposed to single biomarkers was supported by several studies, but no such panel was identified. RNA levels in blood and DNA methylation in pancreatic juice yielded some promising findings. Advancements were also made in the area of tissue biomarkers, which can improve the diagnostic accuracy of fine-needle aspirations and provide prognostic information. A new source of potential biomarkers, microRNAs, also made its debut in the past year.

SUMMARY

The tools to identify pancreatic-cancer biomarkers and sources of samples needed in this search are expanding. The field has not yet achieved its aims, but several encouraging breakthroughs have been made.