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Iwashita T, Uemura S, Shimizu M. Endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: a comprehensive review. J Med Ultrason (2001) 2024; 51:219-226. [PMID: 38051460 DOI: 10.1007/s10396-023-01389-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/09/2023] [Indexed: 12/07/2023]
Abstract
Advancements in diagnostic radiology have amplified the incorporation of these techniques into routine clinical practice. Concurrently, the frequency of incidentally identifying pancreatic cystic lesions (PCLs) has surged. PCLs encompass diverse categories contingent upon their origin. Among them, branch duct-intraductal papillary mucinous neoplasms (BD-IPMN) and mucinous cystic neoplasms (MCN) are categorized as mucinous cystic lesions that have malignant potential. Even solid neoplasms occasionally show cystic degeneration. Therefore, precise differential PCL diagnosis is crucial to optimize clinical management strategies and detect malignant transformations. Endoscopic ultrasound (EUS) affords comprehensive visualization of the pancreas with high-resolution ultrasound, complemented by fine-needle aspiration (FNA) under real-time EUS guidance, which is a minimally invasive procedure for obtaining pathological samples. This synergy has established EUS and EUS-FNA as vital procedures in the management of PCLs, enabling differentiation of PCLs. Cyst fluid analysis has played a pivotal role in deciding the optimal management strategy. The efficacy of cytological analysis is limited by scant cytologic material. The "string sign" test evaluates fluid viscosity, and its simplicity warrants initial consideration. Amylase and tumor markers, such as CEA, have been studied, but they yield varied sensitivity and specificity. Glucose and genetic mutations (KRAS, GNAS) exhibit promise, while comprehensive genomic profiling underscores genetic insights. Through-the-needle biopsy and needle-based confocal laser endomicroscopy also show high diagnostic yield. EUS-FNA, however, entails risks like infection and needle tract seeding, emphasizing the need for proper utilization. Pancreatic cyst fluid analysis augments diagnostic accuracy and informs clinical decisions, making it a valuable adjunct to imaging.
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Affiliation(s)
- Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 502-0061, Japan.
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 502-0061, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 502-0061, Japan
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2
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Gardner TB, Park WG, Allen PJ. Diagnosis and Management of Pancreatic Cysts. Gastroenterology 2024:S0016-5085(24)00248-8. [PMID: 38442782 DOI: 10.1053/j.gastro.2024.02.041] [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: 10/09/2023] [Revised: 01/01/2024] [Accepted: 02/18/2024] [Indexed: 03/07/2024]
Abstract
As pancreatic cyst incidence rises, likely due to the ubiquitous increase in cross-sectional imaging, their management presents multiple challenges for both the practitioner and patient. It is critical that all pancreatic cysts are appropriately characterized, as treatment decisions depend on an accurate diagnosis. Diagnostic modalities such as cytology, biopsy, and cyst fluid biomarkers allow for definitive diagnosis of virtually all lesions. Some cysts, such as intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, and cystic pancreatic endocrine neoplasms, have malignant potential and must be surveyed. Other cysts, such as serous cystadenomas and pancreatic fluid collections, do not have malignant potential. Surveillance strategies vary widely depending on cyst type and size and while multiple medical societies advocate surveillance, their published surveillance guidelines are heterogenous. Cysts with high-risk stigmata or worrisome features are usually resected, depending on the patient's surgical fitness. In patients unfit for resection, newer endoscopic ablative techniques are advocated. Controversial aspects regarding cyst management include whether surveillance can be stopped, how surveillance should be performed, and the extensive financial burden cyst management places on the health care system. Further study into the natural history of cystic lesions, including definitive determination of the rate of malignant transformation for each cyst type, is essential.
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Affiliation(s)
- Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Walter G Park
- Section of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California
| | - Peter J Allen
- Division of Surgical Oncology, Duke University Medical Center, Durham, North Carolina
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3
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AbiMansour JP, Law R. Histologic analysis of pancreatic cystic lesions: Is tissue the issue? Endosc Int Open 2024; 12:E341-E343. [PMID: 38464980 PMCID: PMC10919997 DOI: 10.1055/a-2241-8038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 03/12/2024] Open
Affiliation(s)
- Jad P AbiMansour
- Division of Gastroenterology, Mayo Clinic, Rochester, United States
| | - Ryan Law
- Division of Gastroenterology, Mayo Clinic, Rochester, United States
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4
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Al-Taee AM, Taylor JR. Endoscopic Imaging of Pancreatic Cysts. Gastrointest Endosc Clin N Am 2023; 33:583-598. [PMID: 37245937 DOI: 10.1016/j.giec.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pancreatic cystic lesions (PCLs) have been diagnosed with increasing frequency likely due to the widespread use of cross-sectional imaging. A precise diagnosis of the PCL is important because it helps identify patients in need of surgical resection and those who can undergo surveillance imaging. A combination of clinical and imaging findings as well as cyst fluid markers can help classify PCLs and guide management. This review focuses on endoscopic imaging of PCLs including endoscopic and endosonographic features and fine needle aspiration. We then review the role of adjunct techniques, such as microforceps, contrast-enhanced endoscopic ultrasound, pancreatoscopy, and confocal laser endomicroscopy.
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Affiliation(s)
- Ahmad M Al-Taee
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Digestive Health Institute, 611 West Park Street, Urbana, IL 61801, USA.
| | - Jason R Taylor
- St Luke's Hospital, 224 South Woods Mill Road, Suite 410, Chesterfield, MO 63017, USA
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Singh RR, Gopakumar H, Sharma NR. Diagnosis and Management of Pancreatic Cysts: A Comprehensive Review of the Literature. Diagnostics (Basel) 2023; 13:diagnostics13030550. [PMID: 36766654 PMCID: PMC9914101 DOI: 10.3390/diagnostics13030550] [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] [Received: 12/23/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
The prevalence of pancreatic cysts has been rising due to the widespread use of cross-sectional imaging (CT scan and MRI) of the abdomen. While most pancreatic cysts are benign and do not require treatment or surveillance, a significant minority are premalignant and rarely malignant. The risk stratification of these lesions is not straightforward, and individual risk assessment, cyst size, distribution, and alarming morphologic features (when present) can guide the next steps in management. Neoplastic pancreatic cysts are mucinous or non-mucinous. Endoscopic ultrasound with fine-needle aspiration is often required to classify pancreatic cysts into mucinous and non-mucinous cysts and to assess the malignant potential. Advances in endoscopic techniques (confocal laser endomicroscopy, microforceps biopsy) can provide a definitive diagnosis of pancreatic cysts in some cases; however, the use of these techniques involves a higher risk of adverse events.
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Affiliation(s)
- Ritu R. Singh
- Parkview Cancer Institute (PCI), Parkview Regional Medical Center, Fort Wayne, IN 46845, USA
- Department of Medicine, Indiana University School of Medicine, Fort Wayne, IN 46805, USA
| | - Harishankar Gopakumar
- Division of Gastroenterology and Hepatology, University of Illinois College of Medicine, Peoria, IL 61656, USA
| | - Neil R. Sharma
- Parkview Cancer Institute (PCI), Parkview Regional Medical Center, Fort Wayne, IN 46845, USA
- Department of Medicine, Indiana University School of Medicine, Fort Wayne, IN 46805, USA
- Correspondence:
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Comparative Performance of Endoscopic Ultrasound-Based Techniques in Patients With Pancreatic Cystic Lesions: A Network Meta-Analysis. Am J Gastroenterol 2023; 118:243-255. [PMID: 36563321 DOI: 10.14309/ajg.0000000000002088] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/02/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Evidence on the comparative diagnostic performance of endoscopic ultrasound (EUS)-based techniques for pancreatic cystic lesions (PCLs) is limited. This network meta-analysis comprehensively compared EUS-based techniques for PCL diagnosis. METHODS A comprehensive literature search was performed for all comparative studies assessing the accuracy of 2 or more modalities for PCL diagnosis. The primary outcome was the diagnostic efficacy for mucinous PCLs. Secondary outcomes were the diagnostic efficacy for malignant PCLs, diagnostic success rate, and adverse event rate. A network meta-analysis was conducted using the ANOVA model to assess the diagnostic accuracy of each index. RESULTS Forty studies comprising 3,641 patients were identified. The network ranking of the superiority index for EUS-guided needle-based confocal laser endomicroscopy (EUS-nCLE) and EUS-guided through-the-needle biopsy (EUS-TTNB) were significantly higher than other techniques for differentiating mucinous PCLs; besides, EUS-TTNB was also the optimal technique in identifying malignant PCLs. The evidence was inadequate for EUS-nCLE diagnosing malignant PCLs and contrast-enhanced harmonic EUS diagnosing both mucinous and malignant PCLs. Glucose showed a high sensitivity but low specificity, and molecular analysis (KRAS, GNAS, and KRAS + GNAS mutations) showed a high specificity but low sensitivity for diagnosing mucinous PCLs. Satisfactory results were not obtained during the evaluation of the efficiency of pancreatic cyst fluid (PCF) biomarkers in detecting malignant PCLs. DISCUSSION For centers with relevant expertise and facilities, EUS-TTNB and EUS-nCLE were better choices for the diagnosis of PCLs. Further studies are urgently required for further improving PCF biomarkers and validating the diagnostic performance of the index techniques.
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Oyedeji O, Rodgers S, Wrubel A, Shah R, Husain S. Pancreatic lymphoepithelial cyst with concurrent HIV infection: A case report and review of the literature. SAGE Open Med Case Rep 2022; 10:2050313X221131166. [PMID: 36274859 PMCID: PMC9580076 DOI: 10.1177/2050313x221131166] [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] [Received: 06/24/2022] [Accepted: 09/19/2022] [Indexed: 11/15/2022] Open
Abstract
Pancreatic lymphoepithelial cysts are rare, benign, non-neoplastic unilocular or multilocular cystic lesions. These circumscribed pancreatic lesions are filled with keratinous material grossly and exhibit distinct microscopic features. Pancreatic lymphoepithelial cysts are like the more common lymphoepithelial cysts of the parotid glands, which have been associated with the diffuse infiltrative lymphocytosis syndrome often seen in patients with HIV infection. However, pancreatic lymphoepithelial cysts are rare and their association with HIV infection has not been established. The presence of secondary changes in non-neoplastic cysts such as goblet cell metaplasia that was present in our case is an important feature to be included in the differential diagnosis and not to be interpreted as a mucinous neoplasm, particularly on fine-needle aspiration specimen microscopic evaluation that would impact further management. Here we describe the diagnosis and treatment of lymphoepithelial cysts in a patient who was on highly active antiretroviral therapy for HIV infection and we provide a brief literature review. Defining the clinical characteristics of lymphoepithelial cysts in patients with HIV and determining accurate preoperative diagnostic procedures will be critical for establishing effective surgical and medical approaches to treating these cysts, which differ substantially from other more serious pancreatic cystic lesions.
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Affiliation(s)
- Oluwayomi Oyedeji
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA,Oluwayomi Oyedeji, Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI 48202, USA.
| | - Shannon Rodgers
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Allen Wrubel
- Department of Diagnostic Radiology, Henry Ford Hospital, Detroit, MI, USA
| | - Rupen Shah
- Division of Surgical Oncology, Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Sanam Husain
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA
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Abstract
Andrew Canakis.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Linda S Lee
- Division of Gastroenterology Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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9
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Intracystic Glucose and Carcinoembryonic Antigen in Differentiating Histologically Confirmed Pancreatic Mucinous Neoplastic Cysts. Am J Gastroenterol 2022; 117:478-485. [PMID: 35034045 DOI: 10.14309/ajg.0000000000001623] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/29/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Differentiating mucinous neoplastic pancreatic cysts (MNPC) from cysts without malignant potential can be challenging. Guidelines recommend using fluid carcinoembryonic antigen (CEA) to differentiate MNPC; however, its sensitivity and specificity vary widely. Intracystic glucose concentration has shown promise in differentiating MNPC, but data are limited to frozen specimens and cohorts of patients without histologic diagnoses. This study aimed to compare glucose and CEA concentrations in differentiating MNPC using fresh fluid obtained from cysts with confirmatory histologic diagnoses. METHODS This multicenter cohort study consisted of patients undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic cysts during January 2013-May 2020. Patients were included if the cyst exhibited a histologic diagnosis and if both CEA and glucose were analyzed from fresh fluid. Receiver operating curve (ROC) characteristics were analyzed, and various diagnostic parameters were compared. RESULTS Ninety-three patients, of whom 59 presented with MNPC, met the eligibility criteria. The area under the receiver operating curve (AUROC) was 0.96 for glucose and 0.81 for CEA (difference 0.145, P = 0.003). A CEA concentration of ≥192 ng/mL had sensitivity of 62.7% and specificity of 88.2% in differentiating MNPC, whereas glucose concentration of ≤25 mg/dL had sensitivity and specificity of 88.1% and 91.2%, respectively. DISCUSSION Intracystic glucose is superior to CEA concentration for differentiating MNPC when analyzed from freshly obtained fluid of cysts with histologic diagnoses. The advantage of glucose is augmented by its low cost and ease of implementation, and therefore, its widespread adoption should come without barriers. Glucose has supplanted CEA as the best fluid biomarker in differentiating MNPC.
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Ardeshna DR, Cao T, Rodgers B, Onongaya C, Jones D, Chen W, Koay EJ, Krishna SG. Recent advances in the diagnostic evaluation of pancreatic cystic lesions. World J Gastroenterol 2022; 28:624-634. [PMID: 35317424 PMCID: PMC8900547 DOI: 10.3748/wjg.v28.i6.624] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/30/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cystic lesions (PCLs) are becoming more prevalent due to more frequent abdominal imaging and the increasing age of the general population. It has become crucial to identify these PCLs and subsequently risk stratify them to guide management. Given the high morbidity associated with pancreatic surgery, only those PCLs at high risk for malignancy should undergo such treatment. However, current diagnostic testing is suboptimal at accurately diagnosing and risk stratifying PCLs. Therefore, research has focused on developing new techniques for differentiating mucinous from non-mucinous PCLs and identifying high risk lesions for malignancy. Cross sectional imaging radiomics can potentially improve the predictive accuracy of primary risk stratification of PCLs at the time of detection to guide invasive testing. While cyst fluid glucose has reemerged as a potential biomarker, cyst fluid molecular markers have improved accuracy for identifying specific types of PCLs. Endoscopic ultrasound guided approaches such as confocal laser endomicroscopy and through the needle microforceps biopsy have shown a good correlation with histopathological findings and are evolving techniques for identifying and risk stratifying PCLs. While most of these recent diagnostics are only practiced at selective tertiary care centers, they hold a promise that management of PCLs will only get better in the future.
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Affiliation(s)
- Devarshi R Ardeshna
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Troy Cao
- College of Medicine, Ohio State University, Columbus, OH 43210, United States
| | - Brandon Rodgers
- College of Medicine, Ohio State University, Columbus, OH 43210, United States
| | - Chidiebere Onongaya
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Dan Jones
- James Molecular Laboratory, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Wei Chen
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Eugene J Koay
- Department of GI Radiation Oncology, The University of Texas MD Anderson, Houston, TX77030, United States
| | - Somashekar G Krishna
- Division of Gastroenterology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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Lisotti A, Napoleon B, Facciorusso A, Cominardi A, Crinò SF, Brighi N, Gincul R, Kitano M, Yamashita Y, Marchegiani G, Fusaroli P. Contrast-enhanced EUS for the characterization of mural nodules within pancreatic cystic neoplasms: systematic review and meta-analysis. Gastrointest Endosc 2021; 94:881-889.e5. [PMID: 34217751 DOI: 10.1016/j.gie.2021.06.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Pancreatic cystic neoplasms (PCNs) carry a considerable malignancy risk. Along with main duct dilation, the presence of enhanced mural nodules represents a significant risk factor for malignancy. Several articles assessed the role of contrast-enhanced EUS (CE-EUS) for the identification of malignant features in mural nodules. We evaluate the pooled diagnostic performance of CE-EUS for the identification of high-grade dysplasia or invasive carcinoma among mural nodules in PCNs. METHODS A systematic review (Medline, PubMed, EMBASE) and meta-analysis were conducted. Subgroup analysis was used to assess the usefulness of a dedicated contrast-harmonic (CH-EUS). The primary outcome was pooled sensitivity for identification of high-grade dysplasia or invasive carcinoma. RESULTS Ten studies (532 patients) were included. Pooled sensitivity of CE-EUS was 88.2% (95% confidence interval [CI], 82.7%-92.5%), specificity 79.1% (95% CI, 74.5%-83.3%), and diagnostic accuracy 89.6% (95% CI, 83.4%-95.8%). Eight studies (320 patients) were conducted using CH-EUS: pooled sensitivity increased to 97.0% (95% CI, 92.5%-99.2%), specificity to 90.4% (95% CI, 85.2%-94.2%), and diagnostic accuracy to 95.6% (95% CI, 92.6%-98.7%). At 42% disease prevalence (pretest probability), a positive CH-EUS increased the disease probability to 88%, whereas a negative test decreased the disease probability to 2%. The number needed to diagnose was 1.5 (95% CI, 1.7-1.3) for CE-EUS and just 1.2 (95% CI, 1.3-1.1) for CH-EUS. CONCLUSIONS This study provided robust evidence on CE-EUS value for the characterization of mural nodules within PCNs. A dedicated contrast-harmonic mode, namely CH-EUS, provided an increased diagnostic yield in the identification and characterization of malignant mural nodules.
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Affiliation(s)
- Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy; Endoscopy Unit, Hôpital privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Bertrand Napoleon
- Endoscopy Unit, Hôpital privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Antonio Facciorusso
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per Lo Studio Dei Tumori (IRST) "Dino Amadori," Meldola, Itally
| | - Anna Cominardi
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Nicole Brighi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Rodica Gincul
- Endoscopy Unit, Hôpital privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | | | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
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12
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Barutcuoglu B, Oruc N, Ak G, Kucukokudan S, Aydın A, Nart D, Harman M. Co-analysis of pancreatic cyst fluid carcinoembryonic antigen and glucose with novel cut-off levels better distinguishes between mucinous and non-mucinous neoplastic pancreatic cystic lesions. Ann Clin Biochem 2021; 59:125-133. [PMID: 34719238 DOI: 10.1177/00045632211053998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cyst fluid analysis plays an important role in distinguishing between mucinous and non-mucinous cyst lesions. We aimed to compare the diagnostic performances of cyst fluid carcinoembryonic antigen (CEA), CA 19-9, and glucose in differentiating mucinous from non-mucinous neoplastic pancreatic cystic lesions (PCLs) and determine the best cut-off levels. METHODS Patients' data were evaluated retrospectively. 102 patients' PCLs were grouped as non-neoplastic (n = 25), non-mucinous neoplastic (n = 20), mucinous neoplastic (n = 47) and pancreatic adenocarcinomas with cystic degeneration (n = 10); and CEA, CA 19-9, and glucose levels were compared. Receiver-operating characteristic analysis was performed, and the ideal cut-off values were determined. RESULTS Cyst fluid CEA and CA 19-9, levels were significantly higher (P < 0.001, P < 0.001, respectively) and glucose levels were significantly lower (P = 0.001) in mucinous than in non-mucinous neoplastic PCLs. Area under curve with 95% confidence interval of CEA, glucose and CEA and glucose test combination was 0.939 (95% CI = 0.885-0.993, P = 0.001), 0.809 (95% CI = 0.695-0.924, P < 0.001) and 0.937 (95% CI = 0.879-0.995), respectively. CEA cut-offs to rule-in and rule-out mucinous neoplastic were 135.1 ng/mL (sensitivity = 62%, specificity = 94.7%) and 6.12 ng/mL (sensitivity = 94.1%, specificity = 80.4%), respectively. Glucose cut-off of 2.8 mmol/L was chosen both to rule-in and rule-out mucinous neoplastic PCLs (sensitivity = 78%, specificity = 80%). Co-analysis of CEA and glucose to distinguish mucinous from non-mucinous neoplastic PCLs had sensitivity = 87.8%, specificity = 93.3%, and diagnostic accuracy = 89.3%. CONCLUSIONS We concluded that co-analysis of cyst fluid CEA (cut-off = 135.1 ng/mL) and glucose (cut-off = 2.8 mmol/L) at novel cut-offs had the best testing performance to rule-in mucinous neoplastic PCLs. To rule-out mucinous PCLs co-analysis of CEA (cut-off = 6.12 ng/mL) and glucose (cut-off = 2.8 mmol/L) added value to prediction.
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Affiliation(s)
- Burcu Barutcuoglu
- Department of Clinical Biochemistry, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Nevin Oruc
- Department of Gastroenterology, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Güneş Ak
- Department of Clinical Biochemistry, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Serdar Kucukokudan
- Department of Medical Biochemistry, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Ahmet Aydın
- Department of Gastroenterology, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Deniz Nart
- Department of Pathology, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Mustafa Harman
- Department of Radiology, 60521Ege University, Faculty of Medicine, Izmir, Turkey
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13
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From bench to bedside: Is it time to incorporate molecular testing for diagnostic and management algorithms for pancreatic cystic lesions? Gastrointest Endosc 2021; 93:1034-1037. [PMID: 33875142 DOI: 10.1016/j.gie.2021.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/29/2021] [Indexed: 02/08/2023]
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14
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Geisler D, Khader SN. Educational Case: Pancreatic Cystic Disease: A Multimodal Diagnostic Approach to Determine Clinical Management. Acad Pathol 2021; 8:2374289521998031. [PMID: 35155743 PMCID: PMC8819742 DOI: 10.1177/2374289521998031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/30/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040 . 1
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Affiliation(s)
- Daniel Geisler
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Samer N. Khader
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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15
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Schmitz D, Kazdal D, Allgäuer M, Trunk M, Vornhusen S, Nahm AM, Doll M, Weingärtner S, Endris V, Penzel R, Kirchner M, Brandt R, Neumann O, Sültmann H, Budczies J, Kienle P, Magdeburg R, Hetjens S, Schirmacher P, Bergmann F, Rudi J, Stenzinger A, Volckmar AL. KRAS/GNAS-testing by highly sensitive deep targeted next generation sequencing improves the endoscopic ultrasound-guided workup of suspected mucinous neoplasms of the pancreas. Genes Chromosomes Cancer 2021; 60:489-497. [PMID: 33686791 DOI: 10.1002/gcc.22946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/28/2022] Open
Abstract
Pancreatic cysts or dilated pancreatic ducts are often found by cross-sectional imaging, but only mucinous lesions can become malignant. Therefore, distinction between mucinous and non-mucinous lesions is crucial for adequate patient management. We performed a prospective study including targeted next generation sequencing (NGS) of cell-free DNA in the diagnostic endoscopic ultrasound (EUS)-guided workup. Pancreatic cyst(s) or main duct fluid obtained by EUS-guided FNA was analysed by carcinoembryonic antigen (CEA), cytology and deep targeted NGS of 14 known gastrointestinal cancer genes (AKT1, BRAF, CTNNB1, EGFR, ERBB2, FBXW7, GNAS, KRAS, MAP2K1, NRAS, PIK3CA, SMAD4, TP53, APC) with a limit of detection down to variant allele frequency of 0.01%. Results were correlated to histopathology and clinical follow-up. One hundred and thirteen patients with pancreatic cyst(s) and/or a dilated pancreatic main duct (≥5 mm) were screened. Sixty-six patients had to be excluded, mainly due to inoperability or small cyst size (≤10 mm). Forty-seven patients were enrolled for further analysis. A final diagnosis was available in 27 cases including 8 negative controls. In 43/47 (91.5%) of patients a KRAS- and/or GNAS-mutation was diagnosed by NGS. 27.0% of the KRAS-mutated and 10.0% of the GNAS-mutated lesions harbored multiple mutations. KRAS/GNAS-testing by NGS, cytology, and CEA had a sensitivity and specificity of 94.7/100%, 38.1/100%, and 42.1/75.0%, respectively. KRAS/GNAS-testing was significantly superior to CEA (P = .0209) and cytology (P = .0016). In conclusion, KRAS/GNAS-testing by deep targeted NGS is a suitable method to distinguish mucinous from non-mucinous pancreatic lesions, suggesting its usage as a single diagnostic test. Results must be confirmed in a larger cohort.
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MESH Headings
- Aged
- Aged, 80 and over
- Chromogranins/genetics
- Endoscopic Ultrasound-Guided Fine Needle Aspiration/methods
- Endoscopic Ultrasound-Guided Fine Needle Aspiration/standards
- Female
- GTP-Binding Protein alpha Subunits, Gs/genetics
- Genetic Testing/methods
- Genetic Testing/standards
- High-Throughput Nucleotide Sequencing/methods
- High-Throughput Nucleotide Sequencing/standards
- Humans
- Male
- Middle Aged
- Neoplasms, Cystic, Mucinous, and Serous/diagnostic imaging
- Neoplasms, Cystic, Mucinous, and Serous/genetics
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Pancreatic Cyst/diagnostic imaging
- Pancreatic Cyst/genetics
- Pancreatic Cyst/pathology
- Pancreatic Neoplasms/diagnostic imaging
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/pathology
- Proto-Oncogene Proteins p21(ras)/genetics
- Sensitivity and Specificity
- Sequence Analysis, DNA/methods
- Sequence Analysis, DNA/standards
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Affiliation(s)
- Daniel Schmitz
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Daniel Kazdal
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Michael Allgäuer
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Marcus Trunk
- Institute of Pathology, SYNLAB GmbH Mannheim, Mannheim, Germany
| | - Sylke Vornhusen
- Institute of Pathology, SYNLAB GmbH Mannheim, Mannheim, Germany
| | - Anna-Maria Nahm
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Matthias Doll
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Simon Weingärtner
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Volker Endris
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Roland Penzel
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Martina Kirchner
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Regine Brandt
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Olaf Neumann
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Holger Sültmann
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jan Budczies
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Peter Kienle
- Department of General and Visceral Surgery, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Mannheim, Germany
| | - Richard Magdeburg
- Department of General and Visceral Surgery, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Medical Statistics, Biomathematics and Information Processing of Mannheim University Hospital, University Hospital of Heidelberg, Mannheim, Germany
| | - Peter Schirmacher
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Jochen Rudi
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anna-Lena Volckmar
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
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16
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Hakim S, Coronel E, González GMN, Ge PS, Chari ST, Thosani N, Ramireddy S, Badillo R, DaVee T, Catalano MF, Sealock RJ, Parupudi S, Hernandez LV, Joshi V, Irisawa A, Rana S, Lakhtakia S, Vilmann P, Saftoiu A, Sun S, Giovannini M, Katz MH, Kim MP, Bhutani MS. An international study of interobserver variability of "string sign" of pancreatic cysts among experienced endosonographers. Endosc Ultrasound 2021; 10:39-50. [PMID: 33473044 PMCID: PMC7980687 DOI: 10.4103/eus.eus_73_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and Objectives: No single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the “string sign” test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied. Methods: An experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: “Is the string sign positive?” and “If the string sign is positive, what is the length of the formed string?” Also asked “What is the cutoff length for string sign to be considered positive?” Interobserver variability was assessed using the kappa statistic (κ). Results: A total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive. Conclusion: String sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.
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Affiliation(s)
- Seifeldin Hakim
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA
| | - Emmanuel Coronel
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Philip S Ge
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Suresh T Chari
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nirav Thosani
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA
| | - Srinivas Ramireddy
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA
| | - Ricardo Badillo
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA
| | - Tomas DaVee
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA
| | - Marc F Catalano
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA
| | - Robert J Sealock
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Sreeram Parupudi
- Division of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Lyndon V Hernandez
- Department of Gastroenterology, Ascension Hospital, Racine, Wisconsin, USA
| | - Virendra Joshi
- Department of Medicine, LSU Health Sciences Center, New Orleans, LA, USA
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
| | - Surinder Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyberabad, Telangana, India
| | - Peter Vilmann
- Division of Endoscopy, Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Adrian Saftoiu
- Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy, Craiova; Department of Gastroenterology, Ponderas Academic Hospital Bucharest, Romania
| | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Marc Giovannini
- Department of Endoscopy, Institute Paoli-Calmettes, Marseille, France
| | - Matthew H Katz
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P Kim
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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17
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Tacelli M, Celsa C, Magro B, Barchiesi M, Barresi L, Capurso G, Arcidiacono PG, Cammà C, Crinò SF. Diagnostic performance of endoscopic ultrasound through-the-needle microforceps biopsy of pancreatic cystic lesions: Systematic review with meta-analysis. Dig Endosc 2020; 32:1018-1030. [PMID: 31912580 DOI: 10.1111/den.13626] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/24/2019] [Accepted: 01/06/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Endoscopic ultrasound through-the-needle biopsy (EUS-TTNB) is a useful tool for differential diagnosis among pancreatic cystic lesions (PCLs). Cystic fluid cytology (CFC) is recommended by guidelines, but its diagnostic accuracy is about 50%. The aim of this meta-analysis is to assess the clinical impact of EUS-TTNB in terms of technical success (TS), histological accuracy (HA) and diagnostic yield (DY). METHODS Original studies in English language on EUS-TTNB were searched in MEDLINE and EMBASE until October 2019. Diagnostic accuracy of EUS-TTNB for identification of mucinous PCLs was calculated using individual diagnostic data of patients who underwent CFC and surgery. RESULTS Nine studies, including 454 patients who underwent EUS-TTNB, met the inclusion criteria for the meta-analysis. TS and HA of EUS-TTNB were, respectively, 98.5% (95% Confidence Interval [CI] 97.3%-99.6%) and 86.7% (95%CI 80.1-93.4). DY was 69.5% (95%CI 59.2-79.7) for EUS-TTNB and 28.7% (95%CI 15.7-41.6) for CFC. Heterogeneity persisted significantly high in most of subgroup analyses. In the multivariate meta-regression, cyst size was independently associated with higher DY. Sensitivity and specificity for mucinous PCLs were 88.6 and 94.7% for EUS-TTNB, and 40 and 100% for CFC. Adverse events rate was 8.6% (95%CI 4.0-13.1). CONCLUSIONS This meta-analysis shows that EUS-TTNB is a feasible technique that allows a high rate of adequate specimens to be obtained for histology; in about two-thirds of patients a specific histotype diagnosis could be assessed. The number of adverse events is slightly higher respect to standard EUS-FNA, but complications are very rarely severe.
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Affiliation(s)
- Matteo Tacelli
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Bianca Magro
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Marco Barchiesi
- Department of Internal Medicine, ASST FBF-Sacco, Milan, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Gabriele Capurso
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Calogero Cammà
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
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18
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Ribaldone DG, Bruno M, Gaia S, Cantamessa A, Bragoni A, Caropreso P, Sacco M, Fagoonee S, Saracco GM, De Angelis C. Differential diagnosis of pancreatic cysts: A prospective study on the role of intra-cystic glucose concentration. Dig Liver Dis 2020; 52:1026-1032. [PMID: 32675041 DOI: 10.1016/j.dld.2020.06.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 06/20/2020] [Accepted: 06/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The accuracy and costs of current diagnostic methods in the differential diagnosis of pancreatic cystic lesions still has ample room for improvement. AIMS The aim of the study was to confirm the diagnostic yield of intracystic glucose in the diagnosis of pancreatic cyst subtypes. METHODS We prospectively recruited all patients who underwent Endoscopic Ultrasound with Fine Needle Aspiration of pancreatic cyst at our Institution. RESULTS Fifty-six patients were included in the study. We found that intracystic glucose concentration < 50 mg/dL was significantly more sensitive than a concentration of Carcinoembryonic Antigen > 192 ng/mL (93.6% vs 54.8%; p = 0.003) for the diagnosis of mucinous cysts. In terms of specificity, the two markers were not different (96% vs 100%; p = 1). Regarding the diagnosis of non-mucinous cysts, intracystic glucose concentration ≥ 50 mg/mL showed higher sensitivity than Carcinoembryonic Antigen level < 5 ng/mL (96% vs 72%) although a statistical significance could not be reached (p = 0.07). The two markers were not statistically different in terms of specificity (93.6% vs 87.1%; p = 0.62). CONCLUSION Given its diagnostic performance and ease of measurement, intracystic glucose may replace Carcinoembryonic Antigen in the differential diagnosis of mucinous versus non-mucinous pancreatic cysts.
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Affiliation(s)
| | - Mauro Bruno
- Department of General and Specialist Medicine, Gastroenterologia-U, Città della Salute e della Scienza di Torino, C.so Bramante 88, 10126 Turin, Italy
| | - Silvia Gaia
- Department of General and Specialist Medicine, Gastroenterologia-U, Città della Salute e della Scienza di Torino, C.so Bramante 88, 10126 Turin, Italy
| | - Alessandro Cantamessa
- Department of General and Specialist Medicine, Gastroenterologia-U, Città della Salute e della Scienza di Torino, C.so Bramante 88, 10126 Turin, Italy
| | - Alberto Bragoni
- Department of Laboratory Medicine, Città della Salute e della Scienza di Torino, C.so Bramante 88, 10126 Turin, Italy
| | - Paola Caropreso
- Department of Laboratory Medicine, Città della Salute e della Scienza di Torino, C.so Bramante 88, 10126 Turin, Italy
| | - Marco Sacco
- Department of Medical Sciences, Division of Gastroenterology, University of Torino, Torino, Italy; Department of General and Specialist Medicine, Gastroenterologia-U, Città della Salute e della Scienza di Torino, C.so Bramante 88, 10126 Turin, Italy
| | - Sharmila Fagoonee
- Institute of Biostructure and Bioimaging, CNR c/o Molecular Biotechnology Centre, 10126 Turin, Italy
| | - Giorgio Maria Saracco
- Department of Medical Sciences, Division of Gastroenterology, University of Torino, Torino, Italy
| | - Claudio De Angelis
- Department of General and Specialist Medicine, Gastroenterologia-U, Città della Salute e della Scienza di Torino, C.so Bramante 88, 10126 Turin, Italy.
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19
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Kanani T, Isherwood J, Chung WY, Dennison A. Diagnostic approaches for pancreatic cystic lesions. ANZ J Surg 2020; 90:2211-2218. [PMID: 32815222 DOI: 10.1111/ans.16251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cystic lesions of the pancreas (PCLs) may be inflammatory or proliferative and making an accurate and timely pre-operative diagnosis remains a significant clinical challenge. This is principally due to the heterogeneity of the pathological processes involved. PCLs constitute an entity with diverse histology and although infrequent, the possible potential for malignant transformation of these lesions and the opportunity for curative surgery mandates that our diagnostic approaches are up to date and evidence based. In addition, improved diagnostic accuracy is crucial to prevent unnecessary surgical procedures with the inevitable associated morbidity. METHODS This narrative review examines the current diagnostic benchmarks and identifies novel diagnostic techniques that warrant further consideration, a number of which are beginning to be included in routine clinical practice when these PCLs are being investigated. A computerized search was made of MEDLINE, EMBASE and PubMed using the search words 'diagnostic approaches to pancreatic cystic lesions'. All relevant articles in English language or with an English abstract were retrieved and additionally cross referenced. CONCLUSION The increasing accuracy of available imaging techniques together with the wider availability of endoluminal ultrasound and the development of additional novel methods to assess PCLs presents an opportunity to significantly improve the pre-operative diagnosis rate. This is essential to classify the type of PCL and hence guide the management particularly with lesions where there is a likelihood of progression to more serious pathology. We have highlighted the need for a comprehensive and standardized algorithm for the diagnosis and management of PCLs.
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Affiliation(s)
- Trisha Kanani
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK
| | - John Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK
| | - Wen Yuan Chung
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK
| | - Ashley Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University of Leicester, Leicester, UK
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20
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The Utility of Endoscopic Ultrasound Fine Needle Aspiration in Pancreatic Cystic Lesions Diagnosis. Diagnostics (Basel) 2020; 10:diagnostics10080507. [PMID: 32707780 PMCID: PMC7460058 DOI: 10.3390/diagnostics10080507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/14/2020] [Accepted: 07/21/2020] [Indexed: 12/28/2022] Open
Abstract
The yield of biochemical analysis of pancreatic cysts fluid obtained via fine needle aspiration (FNA) is limited. We aimed to assess whether biochemical cyst analysis correlates with the endoscopic ultra-sonographic (EUS) diagnosis. A retrospective study including patients who underwent EUS-FNA was performed. Agreement level between EUS diagnosis and biochemical analysis was reported. One-hundred-and-eleven patients were included. For cyst CEA level, 42.4% of patients with endoscopic diagnosis of pancreatic mucinous cystic neoplasm (intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasms (MCN)) had CEA level >192 ng/mL vs. 15.8% of patients who had another endoscopic diagnosis (chi square = 0.03) with poor agreement level (Kappa = 0.130). For the serous cystadenoma (SCA), the levels of amylase and CEA were defined as <250 unit/L and <5 ng/mL, respectively. Eight patients (57.1%) had amylase of <250 unit/L, while 42.9% had >250 unit/L (chi square = 0.007). The agreement level between EUS diagnosis of SCA and amylase level was poor (Kappa = 0.231). For cyst CEA level, 71.4% had CEA level <5 ng/mL vs. 28.6% who had CEA >5 ng/mL (chi square < 0.001) with fair agreement level (Kappa = 0.495). EUS-FNA for pancreatic cystic lesions poorly correlated with the EUS diagnosis. FNA should be considered in the setting of EUS worrisome findings.
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21
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Molecular markers contribute to the clinical diagnosis for pancreatic cystic neoplasms. Chin Med J (Engl) 2020; 133:847-852. [PMID: 32106125 PMCID: PMC7147649 DOI: 10.1097/cm9.0000000000000716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
A pancreatic cystic neoplasm (PCN) is a rare pancreatic disease. Malignant PCNs are usually identified incidentally while evaluating other lesions. However, PCNs are being identified more frequently owing to the increased use of abdominal imaging. Malignant PCNs have complicated and diverse biological behaviors, including various malignant risk factors, diverse molecular features, natural history, and complex pathological classifications. Although many diagnostic methods, such as cross-sectional imaging and endoscopic evaluation, have been developed, malignant PCNs are still difficult to differentiate from benign tumors. On searching for related articles in the recent decade, we found that some molecular biomarkers such as carcinoembryonic antigen could be useful for discriminating between malignant tumors and benign tumors. However, cytopathologic evaluation is the most useful method for differentiating between benign and malignant lesions. Although cytopathologic evaluation has a specificity of 100% for identifying malignancies, its accuracy is often hampered by the low cellularity of PCN cells in the cystic fluid. Herein, we review the progress in the use of cellular and molecular markers for the accurate identification of PCNs.
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22
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Endoscopic ultrasonography for the evaluation of pancreatic cystic neoplasms. J Med Ultrason (2001) 2019; 47:401-411. [PMID: 31605262 DOI: 10.1007/s10396-019-00980-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/11/2019] [Indexed: 12/12/2022]
Abstract
Endoscopic ultrasonography (EUS) is a modality with high spatial resolution that enables comprehensive observation of the entire pancreas and plays an important role in the diagnosis of pancreatic lesions. Recent advances in diagnostic imaging methods such as ultrasound, computed tomography, and magnetic resonance imaging have increased the incidental detection of pancreatic cystic lesions (PCLs). EUS has been recognized as an essential diagnostic method for the detection and evaluation of PCLs. EUS has two important roles: as a detailed (high-resolution) imaging diagnostic method and as an approach for collecting cyst fluid content by EUS-guided fine needle aspiration for pathological diagnosis or biomarker evaluation. Furthermore, in recent years, the usefulness of contrast-enhanced EUS for the differential diagnosis of PCLs or evaluation of grade of malignancy, and a novel imaging technique called needle-based confocal laser endomicroscopy to observe intraductal structures through a needle, has been reported. An understanding of the morphological characteristics of PCLs depicted by ultrasound imaging and of the benefits and limitations of EUS diagnosis in daily practice is needed.
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23
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Nigam N, Rastogi A, Bhatia V, Sureka B, Jain P, Bihari C. EUS-guided FNA in Diagnosing Pancreatic Lesions: Strength and Cytological Spectrum. J Cytol 2019; 36:189-195. [PMID: 31741576 PMCID: PMC6844018 DOI: 10.4103/joc.joc_5_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 12/09/2018] [Accepted: 01/14/2019] [Indexed: 12/12/2022] Open
Abstract
Introduction: Early and accurate diagnosis is paramount for improving the therapeutic efficacy of pancreatic cancers. Endoscopic ultrasonography–fine needle aspiration (EUS-FNA) cytology has come up with the advantage of an early and accurate diagnosis of pancreatic cancers. This study was conducted to analyze the spectrum of pancreatic lesions cytology, and appraise the diagnostic accuracy of EUS-FNA cytology for pancreatic solid and cystic lesions. Materials and Methods: This retrospective study includes 288 EUS-guided pancreatic FNA cases. Clinical data, laboratory tests, cytopathology, histopathology, and imaging reports were retrieved. The final diagnosis was based on EUS-FNA cell block and/or pathology in surgical specimens, with immunohistochemistry support. The results of EUS-guided FNA were compared with the final diagnoses to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: Among 288 EUS-guided pancreatic FNA cases, 175 (62.0%) were malignant. The mean age was 57.8 ± 13.5 years and 50.1 ± 13.7 years, and the mean size of the lesion was 4.1 ± 1.8 cm and 2.2 ± 1.1 cm in malignant and benign groups, respectively. Sensitivity, specificity, PPV, and NPV of EUS-FNA cytology for solid malignant lesions were 98.3%, 95.1%, 98.3%, and 95.1%, and those for cystic lesions were 88%, 92.3%, 100%, and 100%. Diagnostic accuracy of EUS-FNA cytology for solid and cystic pancreatic lesions is 97.4% and 95.0%, respectively. In conclusion of the above; diagnosis of pancreatic solid and cystic malignancy can be assigned from a composite of the EUS-FNA cytology, cell block preparation and immunohistochemistry Diagnosis of pancreatic solid and cystic malignancy can be assigned from a composite of the EUS-FNA cytology, cell block preparation, and immunohistochemistry.
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Affiliation(s)
- Neha Nigam
- Department of Pathology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Vikram Bhatia
- Department of Hepatology, I.L.B.S., New Delhi, India
| | - Binit Sureka
- Department of Radiology, A.I.I.M.S., Jodhpur, Rajasthan, India
| | - Priyanka Jain
- Department of Biostatistics, I.L.B.S., New Delhi, India
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Faias S, Pereira L, Luís Â, Chaves P, Cravo M. Genetic testing vs microforceps biopsy in pancreatic cysts: Systematic review and meta-analysis. World J Gastroenterol 2019; 25:3450-3467. [PMID: 31341368 PMCID: PMC6639554 DOI: 10.3748/wjg.v25.i26.3450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/17/2019] [Accepted: 05/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Carcinoembryonic antigen (CEA) and cytology in pancreatic cystic fluid are suboptimal for evaluation of pancreatic cystic neoplasms. Genetic testing and microforceps biopsy are promising tools for pre-operative diagnostic improvement but comparative performance of both methods is unknown.
AIM To compare the accuracy of genetic testing and microforceps biopsy in pancreatic cysts referred for surgery.
METHODS We performed a literature search in Medline, Scopus, and Web of Science for studies evaluating genetic testing of cystic fluid and microforceps biopsy of pancreatic cysts, with endoscopic ultrasound with fine-needle aspiration (EUS-FNA) prior to surgery and surgical pathology as reference standard for diagnosis. We evaluated the diagnostic accuracy for: 1- benign cysts; 2- mucinous low-risk cysts; 3- high-risk cysts, and the diagnostic yield and rate of correctly identified cysts with microforceps biopsy and molecular analysis. We also assessed publication bias, heterogeneity, and study quality.
RESULTS Eight studies, including 1206 patients, of which 203 (17%) referred for surgery who met the inclusion criteria were analyzed in the systematic review, and seven studies were included in the meta-analysis. Genetic testing and microforceps biopsies were identical for diagnosis of benign cysts. Molecular analysis was superior for diagnosis of both low and high-risk mucinous cysts, with sensitivities of 0.89 (95%CI: 0.79-0.95) and 0.57 (95%CI: 0.42-0.71), specificities of 0.88 (95%CI: 0.75-0.95) and 0.88 (95%CI: 0.80-0.93) and AUC of 0.9555 and 0.92, respectively. The diagnostic yield was higher in microforceps biopsies than in genetic analysis (0.73 vs 0.54, respectively) but the rates of correctly identified cysts were identical (0.73 with 95%CI: 0.62-0.82 vs 0.71 with 95%CI: 0.49-0.86, respectively).
CONCLUSION Genetic testing and microforceps biopsies are useful second tests, with identical results in benign pancreatic cysts. Genetic analysis performs better for low- and high-risk cysts but has lower diagnostic yield.
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Affiliation(s)
- Sandra Faias
- Department of Gastroenterology, Instituto Português de Oncologia de Lisboa de Francisco Gentil, EPE, Lisboa 1099-023, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã 6200-506, Portugal
- GRUBI-Grupo de Revisões Sistemáticas, Universidade da Beira Interior, Covilhã 6200-506, Portugal
| | - Luisa Pereira
- GRUBI-Grupo de Revisões Sistemáticas, Universidade da Beira Interior, Covilhã 6200-506, Portugal
- Centro de Matemática e Aplicações (CMA-UBI), Universidade da Beira Interior, Covilhã 6200-506, Portugal
| | - Ângelo Luís
- GRUBI-Grupo de Revisões Sistemáticas, Universidade da Beira Interior, Covilhã 6200-506, Portugal
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã 6200-506, Portugal
| | - Paula Chaves
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã 6200-506, Portugal
- Department of Pathology, Instituto Português de Oncologia de Lisboa de Francisco Gentil, EPE, Lisboa 1099-023, Portugal
| | - Marília Cravo
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures 2674-514, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisboa 1099-023, Portugal
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KRAS in Cyst Fluid Obtained by Endoscopic Ultrasound-Fine-Needle Aspiration in Pancreatic Cystic Lesions: A Systematic Review and Meta-analysis. Pancreas 2019; 48:749-758. [PMID: 31206466 DOI: 10.1097/mpa.0000000000001325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
To evaluate the diagnostic accuracy of KRAS mutation in pancreatic cystic fluid and compare it with carcinoembryonic antigen and cytology, we identified studies with cyst fluid obtained by endoscopic ultrasound prior to surgery. We classified cysts as malignant, premalignant, and benign. A random-effects model was used for quantitative meta-analysis. Pooled sensitivities, specificities, and summary receiver operating characteristic curve analysis were conducted. We analyzed 16 studies, with 3429 patients, including 731 referred for surgery. Carcinoembryonic antigen was better for clinically significant cysts (premalignant and malignant) with sensitivity = 0.58 (95% confidence interval [CI], 0.53-0.65), specificity = 0.9 (95% CI, 0.76-0.97), and area under the curve (AUC) = 0.69. Cytology performed better in malignant cysts, with sensitivity = 0.37 (95% CI, 0.27-0.48), specificity = 0.96 (95% CI, 0.93-0.98), and AUC = 0.78. Isolated, KRAS mutation failed the diagnosis of malignant and significant cysts, with sensitivities = 0.43 (95% CI, 0.34-0.43) and 0.46 (95% CI, 0.42-0.51), specificities = 0.62 (95% CI, 0.56-0.68) and 0.97 (95% CI, 0.92-0.99), and AUCs = 0.56 and 0.53, respectively. Carcinoembryonic antigen and cytology are more accurate than KRAS. Additional studies are lacking to recommend KRAS as a single diagnostic test.
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Şahin D, Çiçek B, Akpolat İ, Şişman G, Tekkeşin N. Should pancreas cyst fluids be divided into two for cytological diagnosis and biochemical tests? TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:903-909. [PMID: 31231069 DOI: 10.5152/tjg.2019.19006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS The aim of the present study was to investigate whether pancreas cyst fluids should be divided into two for cytological diagnosis and biochemical tests. MATERIALS AND METHODS The present study was conducted with fluids aspirated from 12 pancreas cysts. The fluids were divided into two and sent to the cytopathology (fluid 1) and biochemistry (fluid 2) laboratories. Fluid 1 was centrifuged at the cytopathology laboratory. Cytology slides were prepared from the deposit, and the supernatant was sent to the biochemistry laboratory. Fluid 2 was centrifuged at the biochemistry laboratory, and amylase, carcinoembryonic antigen, and cancer antigen 19.9 levels were determined in the supernatant. These procedures were repeated for fluid 1 from the cytopathology laboratory. The remaining fluid 2 was sent to the cytopathology laboratory. Fluid 1-like slides were prepared from fluid 2 in the cytopathology laboratory. Cytological diagnoses of fluid 1 and fluid 2 were compared, and the Pearson correlation coefficient for biochemical test results was identified. RESULTS 92% of fluid 1 and 50% of fluid 2 were diagnostic. Biochemical test results of fluid 1 and fluid 2 were similar, and the Pearson correlation coefficient was high. CONCLUSION Our results showed that pancreatic cyst fluids did not need to be divided into two for cytological diagnosis and biochemical tests. Following centrifugation of the whole fluid at the cytopathology laboratory, the deposit and the supernatant can be used for cytological diagnosis and for biochemical tests, respectively. With this protocol, the sensitivity of cytological diagnoses and biochemical tests of pancreatic cyst fluids may increase.
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Affiliation(s)
- Davut Şahin
- Department of Pathology-Cytopathology, Acıbadem Health Group, İstanbul, Turkey
| | - Bahattin Çiçek
- Department of Gastroenterology, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey
| | - İlkser Akpolat
- Department of Pathology, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey
| | - Gürhan Şişman
- Department of Gastroenterology, Acıbadem Mehmet Ali Aydınlar University Atakent Hospital, İstanbul, Turkey
| | - Nilgün Tekkeşin
- Department of Biochemistry, Memorial Şişli Hospital, İstanbul, Turkey
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Barresi L, Tacelli M, Ligresti D, Traina M, Tarantino I. Tissue acquisition in pancreatic cystic lesions. Dig Liver Dis 2019; 51:286-292. [PMID: 30166219 DOI: 10.1016/j.dld.2018.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 02/06/2023]
Abstract
Despite the progress achieved by scientific research in recent years, pancreatic cystic lesions (PCLs) remain a challenging clinical problem. A significant percentage of benign PCLs are still wrongly sent to surgery, with all the related risks of a high number of surgery-related complications and mortality. Diagnosis of the type of PCL, and risk stratification for malignancy are essential for a correct management of these lesions. Several guidelines have identified some clinical and morphological aspects suggesting the need for more accurate exams. Endoscopic ultrasound fine needle aspiration (EUS-FNA) of cystic fluid for cytology is the advised method of tissue acquisition in several guidelines, and the most used technique around the world. However sensitivity and adequacy of this technique are limited by the low amount of cells dispersed in cystic fluid. Alternative techniques have been tested to target the cystic walls in an attempt to obtain microhistologic specimens in order to augment the probability of obtaining an adequate diagnostic sample. The aim of this review is to offer a critical overview of the existing literature on tissue acquisition in PCLs, and emphasize advantages and disadvantages of each technique, and unclear areas that need to be investigated with future research.
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Affiliation(s)
- Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy.
| | - Matteo Tacelli
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
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Levink I, Bruno MJ, Cahen DL. Management of Intraductal Papillary Mucinous Neoplasms: Controversies in Guidelines and Future Perspectives. ACTA ACUST UNITED AC 2018; 16:316-332. [PMID: 30196428 PMCID: PMC6153570 DOI: 10.1007/s11938-018-0190-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management. Recent findings The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk. Summary International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).
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Affiliation(s)
- Ijm Levink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Abstract
PURPOSE OF REVIEW The goal of this review is to critically analyze the current literature regarding the management of incidental pancreatic cysts. Given their increased rates of detection due to the frequent use of cross-sectional imaging, correctly identifying the subset of high risk lesions that are appropriate for surgical resection is critical. However, the existing consensus and societal guidelines discussed in this review lack high quality data to create evidence-based recommendations, making achieving this important aim challenging. RECENT FINDINGS Several recent studies have focused on the natural history of pancreatic cysts and defining the role of endoscopic ultrasound, which remains unclear. EUS-guided diagnostic tools include molecular analysis of obtained fluid; EUS-guided FNA, FNB, and intracystic forceps biopsy of the cyst wall; and confocal endomicroscopy. While their precise role in diagnosing pancreatic cystic neoplasms remains to be defined, they represent promising innovations that may play a future role in cyst assessment and management. Large, long-term, prospective studies of incidentally identified pancreatic cysts are essential to fully understand their natural history and potential for neoplastic progression. Given the absence of such data at present, an individualized patient approach is recommended.
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Affiliation(s)
- Jennifer Phan
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Suite 330-37, Los Angeles, CA, 90095, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Suite 330-37, Los Angeles, CA, 90095, USA.
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Lévy P, Rebours V. The Role of Endoscopic Ultrasound in the Diagnosis of Cystic Lesions of the Pancreas. Visc Med 2018; 34:192-196. [PMID: 30140684 DOI: 10.1159/000489242] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A precise diagnosis of the nature of pancreatic cystic neoplasm (PCN) is crucial since it determines the patients in need of rapid surgical resection as well as those who can be followed up, and, accordingly, the frequency and modalities of surveillance. Endoscopic ultrasound (EUS) and especially fine needle aspiration (FNA) are invasive methods, with specific adverse events occurring in 2.7-5%. Thus, they should only be used as a third-line tool in the absence of characteristic radiographic features on computed tomography (CT) scan and magnetic resonance imaging (MRI). The most difficult aspects of differential diagnosis are: intraductal papillary mucinous neoplasm (IPMN) versus chronic pancreatitis; unifocal IPMN versus serous cystic neoplasm (SCN); macrocystic SCN versus mucinous cystic neoplasm (MCN); cystic neuroendocrine tumors versus MCN; solid serous cystadenoma versus neuroendocrine tumors versus small solid pseudopapillary tumors; pseudocyst versus MCN; low-grade, high-grade, or invasive IPMN. When classical radiological and EUS features are not conclusive, EUS-FNA may be helpful by analyzing cytological, chemical, and/or molecular data. The addition of EUS-FNA to CT scan and MRI increased the overall accuracy for diagnosing PCN by 36 and 54%, respectively. Analysis of molecular markers in pancreatic cyst fluid might increase the limited accuracy of EUS-FNA by using cytology and chemical and/or tumor marker analysis alone. Current evidence suggests that contrast-enhanced EUS (CH-EUS) is highly accurate for distinguishing non-neoplastic cysts from neoplastic cysts. CH-EUS might also be useful for distinguishing mural epithelial nodules from mucinous clots. Needle-based confocal laser endomicroscopy (nCLE) images a target tissue at a subcellular level of resolution, providing real-time in-vivo optical biopsy. nCLE is feasible during EUS-FNA and allows in-vivo diagnosis of PCN with high accuracy. In conclusion, EUS is a third-line tool in the diagnosis of PCN. Clinical context as well as careful evaluation of CT scan and magnetic resonance cholangiopancreatography images by specialized radiologists are crucial in the diagnosis process. Nowadays it is inconceivable to skip these steps.
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Affiliation(s)
- Philippe Lévy
- Department of Gastroenterology and Pancreatology, Pôle des Maladies de l'Appareil Digestif, DHU Unity, Hôpital Beaujon, Faculté Denis Diderot, AP-HP, Clichy, France.,Centre de référence des maladies rares du pancréas (PAncreatic RAre DISeases), Hôpital Beaujon, Clichy, France.,Centre de référence européen des tumeurs neuroendocrines digestives et pancréatiques, Hôpital Beaujon, Clichy, France
| | - Vinciane Rebours
- Department of Gastroenterology and Pancreatology, Pôle des Maladies de l'Appareil Digestif, DHU Unity, Hôpital Beaujon, Faculté Denis Diderot, AP-HP, Clichy, France.,Centre de référence des maladies rares du pancréas (PAncreatic RAre DISeases), Hôpital Beaujon, Clichy, France.,Centre de référence européen des tumeurs neuroendocrines digestives et pancréatiques, Hôpital Beaujon, Clichy, France
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Anaplastic carcinoma of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration: a case report and review of the literature. J Med Case Rep 2018; 12:152. [PMID: 29848384 PMCID: PMC5977485 DOI: 10.1186/s13256-018-1615-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 02/12/2018] [Indexed: 12/30/2022] Open
Abstract
Background Anaplastic carcinoma of the pancreas is a rare pancreatic neoplasm with a poor prognosis. It is classified as a variant of ductal adenocarcinoma, but the clinical features and treatment of it remain unknown because of its rarity and aggressiveness. Endoscopic ultrasonography and endoscopic ultrasound-guided fine-needle aspiration are useful techniques for the diagnosis of pancreatic tumors with high sensitivity and specificity. Case presentation A 72-year-old Japanese woman presented with a diagnosis of acute pancreatitis, and a cystic lesion with slightly high density area was observed by computed tomography in her pancreatic head. In addition, endoscopic ultrasound revealed a heterogeneous lesion. Endoscopic ultrasound-guided fine-needle aspiration showed pleomorphic atypical cells. We diagnosed anaplastic carcinoma of the pancreas. We resected the lesion, and she has shown no sign of recurrence for > 6 months. There are few reports of anaplastic carcinoma of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration and treated by surgery. Our analysis indicates that anaplastic carcinoma of the pancreas is more likely than typical ductal carcinomas to have cystic lesions with the tumor. Conclusions We report a case of anaplastic carcinoma of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration and subsequently resected with a clear margin. We speculate that anaplastic carcinoma of the pancreas is more likely to have cystic changes than pancreatic ductal adenocarcinoma. When we diagnose pancreas tumor as having cystic changes, anaplastic carcinoma of the pancreas should be considered one of the differential diagnoses.
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Cazacu IM, Luzuriaga Chavez AA, Saftoiu A, Vilmann P, Bhutani MS. A quarter century of EUS-FNA: Progress, milestones, and future directions. Endosc Ultrasound 2018; 7:141-160. [PMID: 29941723 PMCID: PMC6032705 DOI: 10.4103/eus.eus_19_18] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/21/2018] [Indexed: 12/11/2022] Open
Abstract
Tissue acquisition using EUS has considerably evolved since the first EUS-FNA was reported 25 years ago. Its introduction was an important breakthrough in the endoscopic field. EUS-FNA has now become a part of the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of the organs in its proximity, including lung diseases. This review aims to present the history of EUS-FNA development and to provide a perspective on the recent developments in procedural techniques and needle technologies that have significantly extended the role of EUS and its clinical applications. There is a bright future ahead for EUS-FNA in the years to come as extensive research is conducted in this field and various technologies are continuously implemented into clinical practice.
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Affiliation(s)
- Irina Mihaela Cazacu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas – MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Adrian Saftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
| | - Peter Vilmann
- Gastrounit, Division of Surgery, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas – MD Anderson Cancer Center, Houston, Texas, USA
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Elta GH, Enestvedt BK, Sauer BG, Lennon AM. ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol 2018; 113:464-479. [PMID: 29485131 DOI: 10.1038/ajg.2018.14] [Citation(s) in RCA: 349] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/05/2018] [Indexed: 02/07/2023]
Abstract
Pancreatic cysts are very common with the majority incidentally identified. There are several types of pancreatic cysts; some types can contain cancer or have malignant potential, whereas others are benign. However, even the types of cysts with malignant potential rarely progress to cancer. At the present time, the only viable treatment for pancreatic cysts is surgical excision, which is associated with a high morbidity and occasional mortality. The small risk of malignant transformation, the high risks of surgical treatment, and the lack of high-quality prospective studies have led to contradictory recommendations for their immediate management and for their surveillance. This guideline will provide a practical approach to pancreatic cyst management and recommendations for cyst surveillance for the general gastroenterologist.
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Affiliation(s)
- Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Brintha K Enestvedt
- Division of Gastroenterology, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Bryan G Sauer
- Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Anne Marie Lennon
- Division of Gastroenterology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Hoshi H, Zaheer A, El Abiad RG, Maxwell JE, Chu LC, Gerke H, Chan CH. Management of pancreatic intraductal papillary mucinous neoplasm. Curr Probl Surg 2018; 55:126-152. [DOI: 10.1067/j.cpsurg.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 12/16/2022]
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35
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Reviewing the Utility of EUS FNA to Advance Precision Medicine in Pancreatic Cancer. Cancers (Basel) 2018; 10:cancers10020035. [PMID: 29382047 PMCID: PMC5836067 DOI: 10.3390/cancers10020035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Advanced pancreatic cancer (PC) is an aggressive malignancy with few effective therapeutic options. While the evolution of precision medicine in recent decades has changed the treatment landscape in many cancers, at present no targeted therapies are used in the routine management of PC. Only a minority of patients with PC present with surgically resectable disease, and in the remainder obtaining high quality biopsy material for both diagnosis and molecular testing can prove challenging. Endoscopic ultrasound-guided fine needle aspiration (EUS FNA) is a widely used diagnostic procedure in PC, and allows tumour sampling in patients with both early and late stage disease. This review will provide an update on the role of EUS FNA as a diagnostic tool, as well as a source of genetic material which can be used both for molecular analysis and for the creation of valuable preclinical disease models. We will also consider relevant clinical applications of EUS FNA in the management of PC, and the path towards bringing precision medicine closer to the clinic in this challenging disease.
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36
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Barresi L, Tacelli M, Tarantino I, Cipolletta F, Granata A, Traina M. Improving the yield of EUS-guided histology. Endosc Ultrasound 2018; 7:301-305. [PMID: 30323157 PMCID: PMC6199905 DOI: 10.4103/eus.eus_45_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Matteo Tacelli
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Fabio Cipolletta
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
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Mukewar SS, Muthusamy VR. Future directions in endoscopic ultrasound-guided tissue acquisition. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Wright PK, Shelton DA, Holbrook MR, Thiryayi SA, Narine N, Slater D, Rana DN. Outcomes of endoscopic ultrasound-guided pancreatic FNAC diagnosis for solid and cystic lesions at Manchester Royal Infirmary based upon the Papanicolaou Society of Cytopathology pancreaticobiliary terminology classification scheme. Cytopathology 2017; 29:71-79. [DOI: 10.1111/cyt.12502] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 12/12/2022]
Affiliation(s)
- P. K. Wright
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - D. A. Shelton
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - M. R. Holbrook
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - S. A. Thiryayi
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - N. Narine
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - D. Slater
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - D. N. Rana
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
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Jabbar KS, Arike L, Verbeke CS, Sadik R, Hansson GC. Highly Accurate Identification of Cystic Precursor Lesions of Pancreatic Cancer Through Targeted Mass Spectrometry: A Phase IIc Diagnostic Study. J Clin Oncol 2017; 36:367-375. [PMID: 29166170 DOI: 10.1200/jco.2017.73.7288] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose Pancreatic cystic lesions are common incidental findings on imaging, but up to half may be forerunners of pancreatic cancer. Therefore, accurate differential diagnosis is crucial for correct patient management. Unfortunately, currently available diagnostic methods cannot robustly identify premalignant and malignant pancreatic cystic lesions. Methods Cyst fluid samples obtained by routine endoscopic ultrasound-guided aspiration were used for the analyses. In a cohort of 24 patients, eight biomarker candidates for malignant potential and high-grade dysplasia/cancer were identified by an explorative proteomic approach. Subsequently, a quantitative analysis, using 30 heavy-labeled peptides from the biomarkers and parallel reaction monitoring mass spectrometry, was devised, tested in a training cohort of 80, and prospectively evaluated in a validation cohort of 68 patients. End points were surgical pathology diagnosis/clinical follow-up. Diagnostic assessments were blinded to mass spectrometry results. Results The optimal set of markers for detecting malignant potential was a panel of peptides from mucin-5AC and mucin-2, which could discriminate premalignant/malignant lesions from benign with an accuracy of 97% (95% CI, 89% to 99%) in the validation cohort. This result compared favorably with the accuracy of standard analyses: cyst fluid carcinoembryonic antigen (61%; 95% CI, 46% to 74%; P < .001) and cytology (84%; 95% CI, 71% to 92%; P = .02). A combination of proteins mucin-5AC and prostate stem-cell antigen could identify high-grade dysplasia/cancer with an accuracy of 96% (95% CI, 90% to 99%), and detected 95% of malignant/severely dysplastic lesions, compared with 35% and 50% for carcinoembryonic antigen and cytology ( P < .001 and P = .003, respectively). Conclusion Targeted mass spectrometry analysis of just three cyst fluid biomarkers provides highly accurate identification and assessment of cystic precursors to pancreatic adenocarcinoma. Additional studies should determine whether the method can facilitate timely cancer diagnosis, successful intervention, and prevention.
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Affiliation(s)
- Karolina S Jabbar
- Karolina S. Jabbar, Liisa Arike, and Gunnar C. Hansson, University of Gothenburg; Karolina S. Jabbar and Riadh Sadik, Sahlgrenska University Hospital, Gothenburg, Sweden; and Caroline S. Verbeke, University of Oslo, Oslo, Norway
| | - Liisa Arike
- Karolina S. Jabbar, Liisa Arike, and Gunnar C. Hansson, University of Gothenburg; Karolina S. Jabbar and Riadh Sadik, Sahlgrenska University Hospital, Gothenburg, Sweden; and Caroline S. Verbeke, University of Oslo, Oslo, Norway
| | - Caroline S Verbeke
- Karolina S. Jabbar, Liisa Arike, and Gunnar C. Hansson, University of Gothenburg; Karolina S. Jabbar and Riadh Sadik, Sahlgrenska University Hospital, Gothenburg, Sweden; and Caroline S. Verbeke, University of Oslo, Oslo, Norway
| | - Riadh Sadik
- Karolina S. Jabbar, Liisa Arike, and Gunnar C. Hansson, University of Gothenburg; Karolina S. Jabbar and Riadh Sadik, Sahlgrenska University Hospital, Gothenburg, Sweden; and Caroline S. Verbeke, University of Oslo, Oslo, Norway
| | - Gunnar C Hansson
- Karolina S. Jabbar, Liisa Arike, and Gunnar C. Hansson, University of Gothenburg; Karolina S. Jabbar and Riadh Sadik, Sahlgrenska University Hospital, Gothenburg, Sweden; and Caroline S. Verbeke, University of Oslo, Oslo, Norway
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Park J, Han D, Do M, Woo J, Wang JI, Han Y, Kwon W, Kim SW, Jang JY, Kim Y. Proteome characterization of human pancreatic cyst fluid from intraductal papillary mucinous neoplasm by liquid chromatography/tandem mass spectrometry. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2017; 31:1761-1772. [PMID: 28815810 DOI: 10.1002/rcm.7959] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/12/2017] [Accepted: 08/11/2017] [Indexed: 06/07/2023]
Abstract
RATIONALE In recent years, the molecular components of pancreatic cyst fluid have been used for diagnosis and prognosis. Because the protein markers that are currently used in clinical tests are unreliable, proteomic studies to find new protein markers are being conducted. However, such researches have been limited due to the complexity of pancreatic cyst fluid and the immaturity of proteomic techniques. METHODS To overcome these limitations and provide a pancreatic cyst proteome dataset, we examined cyst fluid proteome with tandem mass spectrometry. The proteomic analysis was performed using a Orbitrap-based mass spectrometer (Q-Exactive) coupled with a 50-cm-long nano-liquid chromatography column. Protein mutations were identified using mutation sequence database search. RESULTS A total of 5850 protein groups were identified from microliters of cyst fluid. Among those, 3934 protein groups were reported for the first time in pancreatic cyst fluid. Although high-abundance proteins were not depleted in the experiment, our dataset detected almost all pancreatic tumor markers such as mucin family members, S100 proteins, and CEA-related proteins. In addition, 590 protein mutation marker candidates were discovered. CONCLUSIONS We provide a comprehensive cyst proteome dataset that includes cystic cellular proteins and mutated proteins. Our findings would serve as a rich resource for further IPMN studies and clinical applications. The MS data have been deposited in the ProteomeXchange with identifier PXD005671 (http://proteomecentral.proteomexchange.org/dataset/PXD005671).
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MESH Headings
- Amino Acid Sequence
- Biomarkers, Tumor/analysis
- Carcinoma, Pancreatic Ductal/chemistry
- Carcinoma, Pancreatic Ductal/pathology
- Chromatography, Liquid/methods
- Cyst Fluid/chemistry
- Humans
- Neoplasms, Cystic, Mucinous, and Serous/chemistry
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Pancreas/chemistry
- Pancreas/pathology
- Pancreatic Cyst/chemistry
- Pancreatic Cyst/pathology
- Pancreatic Neoplasms/chemistry
- Pancreatic Neoplasms/pathology
- Proteome/analysis
- Proteomics/methods
- Tandem Mass Spectrometry/methods
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Affiliation(s)
- Joonho Park
- Department of Biomedical Engineering, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
| | - Dohyun Han
- Biomedical Research Institute, Seoul National University Hospital, 101 Daehak-ro, Seoul, Korea
| | - Misol Do
- Department of Biomedical Sciences, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
| | - Jongmin Woo
- Department of Biomedical Sciences, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
| | - Joseph I Wang
- Department of Biomedical Engineering, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
| | - Youngmin Han
- Department of Surgery, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
| | - Youngsoo Kim
- Department of Biomedical Engineering, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Korea
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Kearns M, Ahmad NA. Diagnosis and Management of Pancreatic Cystic Neoplasms. ACTA ACUST UNITED AC 2017; 15:587-602. [DOI: 10.1007/s11938-017-0162-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Le Pen C, Palazzo L, Napoléon B. A health economic evaluation of needle-based confocal laser endomicroscopy for the diagnosis of pancreatic cysts. Endosc Int Open 2017; 5:E987-E995. [PMID: 29159273 PMCID: PMC5633408 DOI: 10.1055/s-0043-117947] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/04/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The low sensitivity of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), especially for the diagnosis of serous cystadenomas (SCAs), can be associated with diagnostic uncertainty that can regularly lead to unnecessary surgical procedures. Needle-based confocal laser endomicroscopy (nCLE) used with EUS-FNA improves diagnostic accuracy, helping to reduce unnecessary surgery and patient follow-up. This study was conducted to evaluate the economic benefit of EUS-FNA + nCLE. PATIENTS AND METHODS Probabilities used were derived from two studies representative of the two diagnostic strategies: a retrospective analysis of patients diagnosed by EUS-FNA alone and a prospective study of patients diagnosed by EUS-FNA + nCLE. Costs were based on French healthcare system rates; both private and public sector rates were included. A decision tree structure model used these probabilities and costs for two hypothetical cohorts of 1000 patients. RESULTS EUS-FNA + nCLE resulted in a reduction of 23 % in the total rate of surgical intervention, which translated to a reduction in clinical costs of 13 % (public sector) and 14 % (private sector). Additionally, the reduced rate of surgery would save the lives of 4 in 1000 patients. A stochastic sensitivity analysis using 100 simulations showed that in all cases the number of interventions was less for EUS-FNA + nCLE than for EUS-FNA. There was also a reduction in the incidence of false negatives using EUS-FNA + nCLE. CONCLUSIONS EUS-FNA + nCLE results in significant economic benefits by reducing the incidence of misdiagnosis through improved diagnostic accuracy.
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Affiliation(s)
- Claude Le Pen
- Université Paris-Dauphine, Paris, France,Corresponding author Claude Le Pen Laboratoire d’Économie et de Gestion des Organisations de Santé (LEGOS)Université Paris-DauphinePlace du Maréchal de Lattre de Tassigny75016 ParisFrance+33-1-44054949
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EUS Morphology Is Reliable in Selecting Patients with Mucinous Pancreatic Cyst(s) Most Likely to Benefit from Surgical Resection. Gastroenterol Res Pract 2017; 2017:9863952. [PMID: 29081794 PMCID: PMC5610869 DOI: 10.1155/2017/9863952] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/28/2017] [Indexed: 12/25/2022] Open
Abstract
Background and Study Aims Endoscopic ultrasound (EUS) surveillance of patients with mucinous pancreatic cysts relies on the assessment of morphologic features suggestive of malignant transformation. These criteria were derived from the evaluation of surgical pathology in patients with pancreatic cysts who underwent surgery. Reliability of these criteria when evaluated by EUS in identifying lesions which require surgery has still not been established. Patients and Methods This retrospective cohort study included seventy-eight patients who underwent surgical resection of pancreatic cysts based on EUS-FNA (fine-needle aspiration) findings suggestive of mucinous pancreatic cysts with concern for malignancy. Results Final surgical pathology diagnoses of patients were the following: adenocarcinoma (19), intraductal papillary mucinous neoplasm (IPMN) (39), mucinous cystic neoplasm (MCN) (13), serous cystadenoma (2), pseudocyst (3), mucinous solid-cystic lesion of indeterminate type (1), and mesenteric cyst (1). Cysts with focal wall thickening ≥ 3 mm (p = 0.0008), dilation of pancreatic duct (PD) (p = 0.0067), and cyst size ≥ 3 cm (p = 0.016) had significantly higher risk of adenocarcinoma. None of the patients without any of these morphologic features had cancer. Conclusions In patients with mucinous pancreatic cyst(s), focal wall thickening, cyst size ≥ 3 cm, and PD dilation as assessed by EUS can help identify advanced mucinous cysts which require surgery and should routinely be evaluated during EUS surveillance.
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Tumor Markers in Pancreatic Cystic Fluids for Diagnosis of Malignant Cysts. Int J Biol Markers 2017; 32:e291-e296. [DOI: 10.5301/jbm.5000257] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2017] [Indexed: 12/18/2022]
Abstract
Background and aim Early diagnosis of premalignant or malignant pancreatic cysts is essential to improve prognosis. Sampling of pancreatic cyst fluid by fine-needle aspiration during endoscopic ultrasonography (EUS) enables cytopathological examination combined with biochemical analysis. This study aimed to provide an aid based on biological markers for the preoperative management of patients with pancreatic cysts. Methods Pancreatic fluids obtained by EUS-guided fine-needle aspiration from 115 patients with cystic lesions were assayed for amylase, lipase, carcinoembryonic antigen (CEA), CA 19-9 and CA 72-4. In addition, chromogranin A (CgA) and neuron-specific enolase (NSE) were measured in 28 fluid samples. Results ROC curve analysis of the different markers for diagnosis of mucinous cysts showed that CEA had the highest area under the curve (0.93, 95% CI 0.87-0.97), with a sensitivity and specificity of 89% and 93%, respectively, at the cutoff value of 317 μg/L. The CgA and NSE concentrations in 5 NET cysts (median values of 210 [63-492] and 68.5 [9-496] μg/L, respectively) were higher than in 23 other cysts (median values of 8 [7-828] and 2.7 [0.5-35.8] μg/L, respectively) (p = 0.0015 and p = 0.0045, respectively). Conclusions CEA is the best marker for identifying a cyst as mucinous. In case of low levels of CEA, our results suggest that CgA and NSE measurements may be helpful in the diagnosis of a neuroendocrine tumor and therefore deserve further investigation.
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Abstract
With increased utilization and ongoing advancements in cross-sectional abdominal imaging, the identification of a pancreatic cyst has become a frequent finding. While many pancreatic cysts are associated with a benign clinical course, others may transform into pancreatic ductal adenocarcinoma. However, distinguishing a benign from a malignant pancreatic cyst or pancreatic cyst with malignant potential on the basis of standard clinical findings, imaging parameters and ancillary studies can be challenging. Hence, a significant interest within the past decade has been the identification of novel biomarkers to accurately classify and prognosticate a pancreatic cyst. Within this review, we discuss novel DNA, miRNA, protein and metabolite biomarkers, and their relevance in clinical practice. In addition, we focus on future areas of research that have the potential to change pancreatic cyst management.
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Surgery for pancreatic neoplasms: How accurate are our surgical indications? Surgery 2017; 162:112-119. [DOI: 10.1016/j.surg.2017.01.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/08/2017] [Accepted: 01/17/2017] [Indexed: 02/07/2023]
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Abstract
Management of pancreatic cystic lesions relies on patients' clinical presentation, imaging, and endoscopic ultrasound. Current research in basic science, radiology, and endoscopy is evolving and making progress in this condition which is relatively common in the general population. This review focuses on the recent endoscopic ultrasound approaches to the diagnosis of these pancreatic disorders.
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Affiliation(s)
- Michael J Bartel
- Department of Medicine, Section of Gastroenterology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Massimo Raimondo
- Department of Gastroenterology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Bhatia V, Varadarajulu S. Endoscopic ultrasonography-guided tissue acquisition: How to achieve excellence. Dig Endosc 2017; 29:417-430. [PMID: 28140485 DOI: 10.1111/den.12823] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/25/2017] [Indexed: 02/08/2023]
Abstract
Endoscopic ultrasound (EUS)-guided tissue acquisition is a basic forte of an endosonographer. The multiple skills required to accomplish successful results include not only the puncture itself, but also proper lesion identification, correct puncture sequence, collaboration with the pathologist onsite or remotely, proper handling of the specimens, choosing one or more of cytology, cell-block, and/or tissue core preparation and, last, deciding the immunohistochemistry (IHC) panels and ancillary tests which may be needed for the current case. Error in any of these decisions may lead to incomplete or inconclusive information from the procedure, even if the aspirate is 'adequate.' In the present review, we will describe the technical aspects of EUS-guided tissue acquisition, current needles available and how to choose between them, and how to appropriately handle the specimen. We will also discuss the optimal approach to common targets including lymph nodes, pancreatic masses, pancreatic cysts, and subepithelial lesions.
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Affiliation(s)
- Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India
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Kirtane T, Bhutani MS. Recent developments in endoscopic ultrasound-guided diagnosis and therapy of pancreatic cystic neoplasms. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Tejas Kirtane
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Soyer OM, Baran B, Ormeci AC, Sahin D, Gokturk S, Evirgen S, Basar R, Firat P, Akyuz F, Demir K, Besisik F, Kaymakoglu S, Karaca C. Role of biochemistry and cytological analysis of cyst fluid for the differential diagnosis of pancreatic cysts: A retrospective cohort study. Medicine (Baltimore) 2017; 96:e5513. [PMID: 28072692 PMCID: PMC5228652 DOI: 10.1097/md.0000000000005513] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Management of pancreatic cysts is based on neoplastic-nonneoplastic discrimination. Endoscopic ultrasound (EUS) enables to differentiate neoplastic-nonneoplastic lesions and also allows fine-needle aspiration (FNA). In this study, we aim to assess feasibility and clinical relevance of cytological and biochemical analysis in differential diagnosis of cystic pancreatic lesions in patients who had undergone endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) due to pancreatic cysts. METHODS Participants were 96 patients who had undergone EUS-FNA for differential diagnosis of pancreatic cysts. Pancreatic cysts were classified as benign-mucinous, nonmucinous, and malignant according to patient history, physical examination, EUS appearance, and cystic fluid assessment. Tumor markers (CEA, CA(cancer antigens) 72.4, CA 19-9) , amylase, lipase and cytological assesment were compared between 3 different groups. Receiver-operating characteristics (ROC) curves were constructed to identify appropriate cut-off values. RESULTS Fluid CEA and CA 72.4 levels for benign-mucinous and malignant cysts were significantly higher than for nonmucinous cysts (P ≤ 0.04). A cut-off CEA level of 207 ng/mL differentiated mucinous etiology with a sensitivity of 72.7%, specificity of 97.7%, and accuracy of 89.5%. The sensitivity, specificity, and accuracy of the CA 72.4 cut-off level of 3.32 ng/mL were 80%, 69.5%, and 73.6%, respectively. CONCLUSION Cyst fluid CEA and CA 72.4 levels have a high accuracy in discriminating mucinous from nonmucinous cysts. When combined with cytology their accuracy rate increases.
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Affiliation(s)
| | | | | | - Davut Sahin
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | | | | | - Pinar Firat
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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