Diagnosing pancreatic cancer: the role of percutaneous biopsy and CT

The Natural Product Parthenolide Inhibits Both Angiogenesis and Invasiveness and Improves Gemcitabine Resistance by Suppressing Nuclear Factor κB Activation in Pancreatic Cancer Cell Lines

We previously established pancreatic cancer (PaCa) cell lines resistant to gemcitabine and found that the activity of nuclear factor κB (NF-κB) was enhanced upon the acquisition of gemcitabine resistance. Parthenolide, the main active ingredient in feverfew, has been reported to exhibit antitumor activity by suppressing the NF-κB signaling pathway in several types of cancers. However, the antitumor effect of parthenolide on gemcitabine-resistant PaCa has not been elucidated. Here, we confirmed that parthenolide significantly inhibits the proliferation of both gemcitabine-resistant and normal PaCa cells at concentrations of 10 µM and higher, and that the NF-κB activity is significantly inhibited, even by 1 µM parthenolide. In Matrigel invasion assays and angiogenesis assays, the invasive and angiogenic potentials were higher in gemcitabine-resistant than normal PaCa cells and were inhibited by a low concentration of parthenolide. Furthermore, Western blotting showed suppressed MRP1 expression in gemcitabine-resistant PaCa treated with a low parthenolide concentration. In a colony formation assay, the addition of 1 µM parthenolide improved the sensitivity of gemcitabine-resistant PaCa cell lines to gemcitabine. These results suggest that parthenolide may be used as a novel therapeutic agent for the treatment of gemcitabine-resistant PaCa.

Impact of Biopsy Attempts, Race, and Access on Time to Initiation of Treatment for Pancreatic Cancer

BACKGROUND

Biopsy of suspected pancreatic cancer (PDAC) in surgical candidates is informative however not always necessary. Biopsies impact treatment options as histological diagnosis are presently required for neo-adjuvant therapy, but not surgical resection. We explored the impact of pursuing tissue diagnosis by endoscopic ultrasound (EUS) biopsy on time to treatment in patients with resectable and borderline resectable PDAC.

METHODS

A retrospective review of surgical patients with ultimately proven PDAC was performed (2011-2021). Milestone dates (cancer suspected, biopsy(ies), surgical or neo-adjuvant treatment) were collected. Mann-Whitney-Wilcoxon tests, Pearson's chi-squared tests, Fisher's exact tests, linear regressions, and Cox proportional hazard models were used for data analysis.

RESULTS

Among 131 resectable and 58 borderline resectable patients, the borderline resectable group underwent more biopsies (1.2 vs 0.7, p < 0.0001), were more likely to undergo biopsy at tertiary care centers (67.2% vs 30.5%, p < 0.0001), and trended toward longer time to treatment (49 vs 44 days, p = 0.070). Significant increases in days to treatment were seen in patients with Black race (29 days, p = 0.0002) and Medicare insurance (22 days, p = 0.038) and no biopsies at a tertiary care center (10 days, p = 0.039). After adjusting for covariates, additional biopsies significantly delayed treatment (1 biopsy: 21 days, p = 0.0001; 2 biopsies: 44 days, p < 0.0001; 3 biopsies: 68 days, p < 0.0001).

CONCLUSIONS

EUS biopsy significantly impacts time between suspicion and treatment of PDAC. This may be exacerbated by clinical practices increasingly favoring neo-adjuvant therapy that necessitates biopsy-proven disease. Time to treatment may also be impacted by access to tertiary centers and racial disparities.

Ethical Considerations of Biopsies in Early-Stage Pancreatic Cancer

PURPOSE

The standard of care in resectable and borderline resectable pancreatic ductal adenocarcinoma (PDAC) has evolved to include neoadjuvant treatment before surgical resection. Current guidelines call for obtaining histologic tissue diagnosis via endoscopic ultrasound fine-needle aspiration before administration of neoadjuvant therapy, which differ from guidelines discouraging delay in surgical resection for a biopsy.

MATERIALS AND METHODS

Whether to proceed with treatment before a biopsy confirms that malignancy is a nuanced decision and includes considerations of physical and psychological risks entailed in both pursuing and forgoing a biopsy.

RESULTS

Accuracy of imaging and biopsy results, the presence of contributing clinical signs/symptoms, and the existing precedents of considering biopsies as waivable such as in scenarios with high clinical suspicion and primary surgical resection.

CONCLUSION

When considering the aspects of ethical medical practice including beneficence (doing good), nonmaleficence (avoiding harm), autonomy (allowing patients to make decisions about their care), and utilitarianism (doing the most good for the most people), analysis of whether guidelines guiding biopsies should continue to differ between resection and neoadjuvant treatments in PDAC is prudent.

Approach to Pancreatic Head Mass in the Background of Chronic Pancreatitis

Chronic pancreatitis (CP) is a known risk factor for pancreatic cancer. CP may present with an inflammatory mass, and differentiation from pancreatic cancer is often difficult. Clinical suspicion of malignancy dictates a need for further evaluation for underlying pancreatic cancer. Imaging modalities remain the mainstay of evaluation for a mass in background CP; however, they have their shortcomings. Endoscopic ultrasound (EUS) has become the go-to investigation. Adjunct modalities such as contrast-harmonic EUS and EUS elastography, as well as EUS-guided sampling using newer-generation needles are useful in differentiating inflammatory from malignant masses in the pancreas. Paraduodenal pancreatitis and autoimmune pancreatitis often masquerade as pancreatic cancer. In this narrative review, we discuss the various modalities used to differentiate inflammatory from malignant masses of the pancreas.

Pancreatic Cancer Biopsy Modalities: Comparing Insurance Status, Length of Stay, and Hospital Complications Based on Percutaneous, Endoscopic, and Surgical Biopsy Methods

BACKGROUND

Pancreatic cancer is diagnosed histologically through percutaneous biopsy (PB), endoscopic biopsy (EB), or surgical biopsy (SB). Factors and outcomes associated with method type are not clearly understood. We aimed to evaluate the relationship between insurance status, length of hospital stay (LOS), complications, and different pancreatic biopsy modalities.

STUDY

The 2001-2013 database from the National (Nationwide) Inpatient Sample (NIS) was queried for those with pancreatic cancer who underwent biopsies using International Classification of Diseases, Ninth Revision (ICD-9) codes. Data regarding insurance status, hospital stay, demographics, and complications were analyzed using chi-square and multivariate analysis with α < 0.001.

RESULTS

A total of 824,162 patients with pancreatic cancer were identified. Uninsured and Medicaid patients were more likely to get PB compared to SB. Patients were more likely to have acute renal failure (ARF) with an EB compared to SB. Patients were more likely to have a urinary tract infection (UTI) with EB or PB compared to SB. All biopsy types were less likely to have pneumonia; pancreatitis was more prevalent in EB compared to PB and SB.

CONCLUSIONS

Uninsured and Medicaid patients were most likely to have a PB compared to EB despite unclear indications which may represent an underlying discrepancy in healthcare utilization. EB patients had the shortest LOS while SB patients stayed three more days; those who underwent a combination of biopsies had the greatest LOS. Patients with EB were more likely to develop ARF, UTI, and pancreatitis than SB, possibly attributed to the advanced nature of endoscopic ultrasound. It is important to establish appropriate algorithm contributors to guide decision-making.

10Z‑Hymenialdisine inhibits angiogenesis by suppressing NF‑κB activation in pancreatic cancer cell lines

10Z-Hymenialdisine is a natural product derived from the marine sponge Axinella carteri. 10Z-Hymenialdisine has anti-inflammatory effects exerted through NF-κB; however, it is unclear whether 10Z-Hymenialdisine has anti-angiogenic effects in cancer cells. In the present study, both the anti-angiogenic and antimetastatic effects of this compound in pancreatic cancer were investigated. It was initially confirmed that 10Z-Hymenialdisine significantly inhibited the proliferation of pancreatic cancer cells. Next, using both reverse transcription-quantitative PCR and ELISA, it was demonstrated that 10Z-Hymenialdisine significantly suppressed the expression of VEGF and IL-8 mRNAs and proteins in pancreatic cancer. Immunohistochemical analysis revealed that 10Z-Hymenialdisine inhibited NF-κB activity in pancreatic cancer cell lines. It was also identified that 10Z-Hymenialdisine inhibited tube formation in EA.hy926 cells. In vivo, 10Z-Hymenialdisine significantly inhibited the growth of BxPC-3 pancreatic cancer cells that were subcutaneously injected into model mice. In conclusion, the present study demonstrated that 10Z-Hymenialdisine exerted anti-angiogenic effects by suppressing NF-κB activity and angiogenic factors, such as VEGF and IL-8, in pancreatic cancer cell lines. 10Z-Hymenialdisine has potential applications as a novel therapeutic agent for the treatment of pancreatic cancer.

Pentraxin 3 is a stromally-derived biomarker for detection of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC), characterized by dense desmoplastic stroma laid down by pancreatic stellate cells (PSC), has no reliable diagnostic biomarkers for timely detection. A multi-center cohort of PDAC patients and controls (chronic pancreatitis, intra-ductal papillary neoplasms, gallstones and otherwise healthy) donated serum in an ethically approved manner. Serum PTX3 above 4.34 ng/mL has a higher sensitivity (86%, 95% confidence interval (CI): 65-97%) and specificity (86%, 95% CI: 79-91%), positive predictive value (97%) and likelihood ratio (6.05), and is superior when compared to serum CA19-9 and CEA for detection of PDAC. In vitro and ex vivo analyses of PTX3, in human PDAC samples, PSCs, cell lines and transgenic mouse model for PDAC, suggest that PTX3 originates from stromal cells, mainly PSC. In activated PSC, PTX3 secretion could be downregulated by rendering PSC quiescent using all-trans-retinoic acid (ATRA). PTX3 organizes hyaluronan in conjunction with tumor necrosis factor-stimulated gene 6 (TSG-6) and facilitates stellate and cancer cell invasion. In SCALOP clinical trial (ISRCTN96169987) testing chemo-radiotherapy without stromal targeting, PTX3 had no prognostic or predictive role. However, in STARPAC clinical trial (NCT03307148), stromal modulation by ATRA even at first dose is accompanied with serum PTX3 response in patients who later go on to demonstrate disease control but not those in whom the disease progresses. PTX3 is a putative stromally-derived biomarker for PDAC which warrants further testing in prospective, larger, multi-center cohorts and within clinical trials targeting stroma.

Escin inhibits angiogenesis by suppressing interleukin‑8 and vascular endothelial growth factor production by blocking nuclear factor‑κB activation in pancreatic cancer cell lines

Pancreatic cancer (PaCa) is one of the most aggressive types of cancer. Thus, the development of new and more effective therapies is urgently required. Escin, a pentacyclic triterpenoid from the horse chestnut, has been reported to exhibit antitumor potential by reducing cell proliferation and blocking the nuclear factor-κB (NF-κB) signaling pathway in several types of cancer. Our previous study reported that NF-κB enhanced the secretion of interleukin (IL)-8 and vascular endothelial growth factor (VEGF), thereby inducing angiogenesis in PaCa cell lines. In the present study, it was examined whether escin inhibited angiogenesis by blocking NF-κB activation in PaCa. It was initially confirmed that escin, at concentrations >10 µM, significantly inhibited the proliferation of several PaCa cell lines. Next, using immunocytochemical staining, it was found that escin inhibited the nuclear translocation of NF-κB. Furthermore, ELISA confirmed that NF-κB activity in the escin-treated PaCa cells was significantly inhibited and reverse transcription-quantitative PCR showed that the mRNA expression levels of tumor necrosis factor-α-induced IL-8 and VEGF were significantly suppressed following escin treatment in the PaCa cell lines. ELISA also showed that escin decreased the secretion of IL-8 and VEGF from the PaCa cells. Furthermore, tube formation in immortalized human endothelial cells was inhibited following incubation with the supernatants from escin-treated PaCa cells. These results indicated that escin inhibited angiogenesis by reducing the secretion of IL-8 and VEGF by blocking NF-κB activity in PaCa. In conclusion, escin could be used as a novel molecular therapy for PaCa.

Calcified peripancreatic lymph nodes in pancreatic and hepatic tuberculosis mimicking pancreatic malignancy: A case report and review of literature

RATIONALE

Tuberculosis remains a serious menace to the health of people. Isolated hepatic tuberculosis is rare and pancreatic tuberculosis is extremely rare. The preoperative diagnosis of pancreatic tuberculosis remains a great challenge.

PATIENT CONCERNS

A 58-year-old Asian woman was referred to our hospital for evaluation of low back pain for 4 years and abdominal pain for 1 month.

DIAGNOSES

Computed tomography (CT) of the abdomen showed a hypodense mass in the pancreatic head and neck with abundant calcifications, a hypodense lesion in the liver without calcification, peripancreatic lymphadenopathy, calcifications in some lymph nodes. CT-guided fine needle aspiration biopsy of the hepatic lesion was carried out and the cytological examination revealed hepatic tuberculosis.

INTERVENTIONS

The patient was treated with antituberculous therapy for 1 year.

OUTCOMES

Low back pain and abdominal pain disappeared 3 months after initial treatment and after 2 year of follow-up, the patient was asymptomatic.

LESSONS

Our data hint that calcifications in both pancreatic lesions and peripancreatic lymph nodes may suggest pancreatic tuberculosis rather than pancreatic malignancy.

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

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

1.0T MR-guided percutaneous coaxial cutting needle biopsy in pancreatic lesion diagnosis

BACKGROUND

Pancreatic carcinoma is a common cause of cancer deaths worldwide. Biopsy is often required for the initial diagnosis of pancreatic masses. Biopsy can be performed endoscopically or percutaneously with computed tomography (CT) and ultrasound (US) guidance. MRI offers many inherent advantages over CT and US.

PURPOSE/HYPOTHESIS

To prospectively evaluate the feasibility, accuracy, and safety of MRI-guided percutaneous coaxial cutting needle biopsy of pancreatic lesions using an open 1.0T high-field MR scanner.

STUDY TYPE

Prospective.

POPULATION

Thirty-one patients with 31 pancreatic lesions underwent MR-guided percutaneous coaxial cutting needle biopsy.

FIELD STRENGTH/SEQUENCE

1.0T T₂ WI-TSE PDW-aTSE T₁ WI-TFE.

ASSESSMENT

Final diagnosis was confirmed by surgery and clinical follow-up for at least 12 months. The accuracy, sensitivity, and specificity were calculated. Complications were recorded.

STATISTICAL TESTS

There was no statistical analysis in this study.

RESULTS

The procedure was technically successful and final biopsy samples were adequate for histopathological examination in all patients. Biopsy pathology revealed malignant pancreatic tumor in 25 patients (25/31, 80.6%), and benign pancreatic lesions were present in six patients (6/31, 19.4%). The final diagnosis was pancreatic malignancy in 27 patients and benign disease in four patients, which was confirmed by surgery and clinical follow-up. Two biopsy results were false-negative. The diagnostic accuracy in biopsies was 93.5% (29 of 31). The sensitivity to detect a malignant disease was 92.6% (25 of 27), and the specificity was 100%. All patients tolerated the procedure well; minor peripancreatic hemorrhage was found in two patients after the procedure, and none had major complications either during or after the procedure.

DATA CONCLUSION

MRI-guided percutaneous biopsy of pancreatic lesions using an open 1.0T high-field scanner has high diagnostic accuracy, which is feasible and safe for use in clinical practice.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2018;48:382-388.

Percutaneous CT fluoroscopy-guided core biopsy of pancreatic lesions: technical and clinical outcome of 104 procedures during a 10-year period

Background In unclear pancreatic lesions, a tissue sample can confirm or exclude the suspected diagnosis and help to provide an optimal treatment strategy to each patient. To date only one small study reported on the outcome of computed tomography (CT) fluoroscopy-guided biopsies of the pancreas. Purpose To evaluate technical success and diagnostic rate of all CT fluoroscopy-guided core biopsies of the pancreas performed in a single university center during a 10-year period. Material and Methods In this retrospective study we included all patients who underwent a CT fluoroscopy-guided biopsy of a pancreatic mass at our comprehensive cancer center between 2005 and 2014. All interventions were performed under local anesthesia on a 16-row or 128-row CT scanner. Technical success and diagnostic rates as well as complications and effective patient radiation dose were analyzed. Results One hundred and one patients (54 women; mean age, 63.9 ± 12.6 years) underwent a total of 104 CT fluoroscopy-guided biopsies of the pancreas. Ninety-eight of 104 interventions (94.2%) could be performed with technical success and at least one tissue sample could be obtained. In 88 of these 98 samples, a definitive pathological diagnosis, consistent with clinical success could be achieved (89.8%). Overall 19 minor and three major complications occurred during the intra- or 30-day post-interventional period and all other interventions could be performed without complications; there was no death attributable to the intervention. Conclusion CT fluoroscopy-guided biopsy of pancreatic lesions is an effective procedure characterized by a low major complication and a high diagnostic rate.

Imaging modalities for characterising focal pancreatic lesions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Percutaneous ultrasound-guided core needle biopsy of solid pancreatic masses: Results in 250 patients

BACKGROUND

To determine the diagnostic accuracy and complications of percutaneous sonographic (US)-guided core needle-needle biopsy in the diagnosis of solid pancreatic masses.

METHODS

Cases of US-guided percutaneous core needle biopsy of solid pancreatic masses performed in our department between July 2009 and June 2015 were analyzed retrospectively. The demographic data, lesions' size and location, pathology results, accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and complications of the biopsies were determined.

RESULTS

A total of 250 patients (150 males, 100 females; age range, 16-88 years; mean age, 64.3 ± 12.1 years) were included in the study. The overall diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of all 250 biopsies were 94.8%, 94.3%, 97.2%, 99.5%, and 75%, respectively, and changed to 98.4%, 99%, 94.7%, 99%, and 94.7%, respectively, after the biopsy was repeated in 12 patients. Four (1.6%) major complications, including a pseudoaneurysm of the gastroduodenal artery, and three cases of acute pancreatitis, and one (0.4%) minor complication (a vaso-vagal syncope), were observed. There was no biopsy-related death.

CONCLUSIONS

US-guided percutaneous core needle biopsy is a safe and highly effective method with acceptable complication rates in the diagnosis of solid pancreatic masses. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:470-473, 2016.

CT-guided percutaneous core-needle biopsy of pancreatic masses: comparison of the standard mesenteric/retroperitoneal versus the trans-organ approaches

AIM

To compare the safety and efficacy of percutaneous computed tomography (CT)-guided core-needle biopsy (CNB) of pancreatic masses traversing the gastrointestinal tract or solid viscera versus trans-mesenteric and retroperitoneal approaches.

MATERIALS AND METHODS

CT-guided CNB of pancreatic lesions performed between May 2004 and December 2014 were retrospectively analysed at a single centre. Biopsies were performed using 18- or 20-G needles with a coaxial system. CT images, histopathology reports, medical records, and procedural details for all patients were reviewed to evaluate the biopsy route, complications, and diagnostic accuracy. According to the routes, biopsies were divided into trans-mesenteric, retroperitoneal and trans-organ approaches for comparison.

RESULTS

A total of 85 patients, who had undergone 89 CNBs for pancreatic masses were reviewed. The overall sensitivity, specificity, and accuracy of CNB for detecting malignancy via various routes were 88.8%, 100%, and 89.9%, respectively, with a complication rate of 20.2%. Trans-organ biopsies of pancreatic masses (n=22) were performed safely via a direct pathway traversing the stomach (n=14), colon (n=3), small bowel (n=2), liver (n=2), and spleen (n=1). The sensitivity, specificity, and accuracy were 90.5%, 100%, and 90.9%, respectively. In the trans-organ biopsy group, three biopsies (13.6%) resulted in minor haematomas, but no major complications occurred. There were no statistically significant differences in the diagnostic efficacy or complication rate among the different biopsy routes.

CONCLUSION

Percutaneous CT-guided CNB using a trans-organ approach is a feasible technique for diagnosing pancreatic malignancy; however, as this series was small, more data is required.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

The Plasma Membrane Calcium Pump in Pancreatic Cancer Cells Exhibiting the Warburg Effect Relies on Glycolytic ATP

Evidence suggests that the plasma membrane Ca²⁺-ATPase (PMCA), which is critical for maintaining a low intracellular Ca²⁺ concentration ([Ca²⁺]_i), utilizes glycolytically derived ATP in pancreatic ductal adenocarcinoma (PDAC) and that inhibition of glycolysis in PDAC cell lines results in ATP depletion, PMCA inhibition, and an irreversible [Ca²⁺]_i overload. We explored whether this is a specific weakness of highly glycolytic PDAC by shifting PDAC cell (MIA PaCa-2 and PANC-1) metabolism from a highly glycolytic phenotype toward mitochondrial metabolism and assessing the effects of mitochondrial versus glycolytic inhibitors on ATP depletion, PMCA inhibition, and [Ca²⁺]_i overload. The highly glycolytic phenotype of these cells was first reversed by depriving MIA PaCa-2 and PANC-1 cells of glucose and supplementing with α-ketoisocaproate or galactose. These culture conditions resulted in a significant decrease in both glycolytic flux and proliferation rate, and conferred resistance to ATP depletion by glycolytic inhibition while sensitizing cells to mitochondrial inhibition. Moreover, in direct contrast to cells exhibiting a high glycolytic rate, glycolytic inhibition had no effect on PMCA activity and resting [Ca²⁺]_i in α-ketoisocaproate- and galactose-cultured cells, suggesting that the glycolytic dependence of the PMCA is a specific vulnerability of PDAC cells exhibiting the Warburg phenotype.

Differential diagnosis of pancreatic cancer from other solid tumours arising from the periampullary area on MDCT

PURPOSE

To investigate CT features and differential diagnosis of pancreatic adenocarcinoma compared to other solid tumours arising in the periampullary area.

MATERIALS AND METHODS

One hundred and ninety-five patients with pathologically proven, solid periampullary tumours, including pancreatic adenocarcinoma (n = 98), neuroendocrine tumours (n = 52), gastrointestinal stromal tumours (n = 31), and solid pseudopapillary neoplasms (n = 14), underwent preoperative CT. Two radiologists reviewed CT features and rated the possibility of pancreatic adenocarcinoma.

RESULTS

Statistically common findings for pancreatic adenocarcinoma included: patient age >50 years; ill-defined margin; completely solid mass; homogeneous enhancement; hypoenhancement on arterial and venous phases; atrophy; and duct dilatation. Statistically common findings for GIST included: heterogeneous enhancement; hyperenhancement on arterial and venous phases; rim enhancement; and prominent feeding arteries. The hyperenhancement on arterial and venous phases is statistically common in NET, and heterogeneous enhancement, hypoenhancement on the arterial and venous phases are statistically common in SPN. Diagnostic performance of CT for differentiating pancreatic adenocarcinomas from other solid periampullary tumours was 0.962 and 0.977 with excellent interobserver agreement (κ = 0.824).

CONCLUSION

CT is useful not only for differentiating pancreatic adenocarcinoma form other solid tumours but also for differentiating between other solid tumours, including NET, SPN, and GIST, arising in the periampullary area.

KEY POINTS

• Periampullary tumours arise within 2 cm of major duodenal papilla. • Many mass-forming periampullary tumours can be completely removed by minimal surgery. • Accurate differentiation of pancreatic adenocarcinoma from other solid tumours is important. • CT is useful for differentiating pancreatic adenocarcinoma from other solid tumours. • CT is useful for characterization of periampullary tumours other than adenocarcinomas.

Computed tomography-guided percutaneous core needle biopsy in pancreatic tumor diagnosis

AIM: To evaluate the techniques, results, and complications related to computed tomography (CT)-guided percutaneous core needle biopsies of solid pancreatic lesions.

METHODS: CT-guided percutaneous biopsies of solid pancreatic lesions performed at a cancer reference center between January 2012 and September 2013 were retrospectively analyzed. Biopsy material was collected with a 16-20 G Tru-Core needle (10-15 cm; Angiotech, Vancouver, CA) using a coaxial system and automatic biopsy gun. When direct access to the lesion was not possible, indirect (transgastric or transhepatic) access or hydrodissection and/or pneumodissection maneuvers were used. Characteristics of the patients, lesions, procedures, and histologic results were recorded using a standardized form.

RESULTS: A total of 103 procedures included in the study were performed on patients with a mean age of 64.8 year (range: 39-94 year). The mean size of the pancreatic lesions was 45.5 mm (range: 15-195 mm). Most (75/103, 72.8%) procedures were performed via direct access, though hydrodissection and/or pneumodissection were used in 22.2% (23/103) of cases and indirect transhepatic or transgastric access was used in 4.8% (5/103) of cases. Histologic analysis was performed on all biopsies, and diagnoses were conclusive in 98.1% (101/103) of cases, confirming 3.9% (4/103) of tumors were benign and 94.2% (97/103) were malignant; results were atypical in 1.9% (2/103) of cases, requiring a repeat biopsy to diagnose a neuroendocrine tumor, and surgical resection to confirm a primary adenocarcinoma. Only mild/moderate complications were observed in 9/103 patients (8.7%), and they were more commonly associated with biopsies of lesions located in the head/uncinate process (n = 8), than of those located in the body/tail (n = 1) of the pancreas, but this difference was not significant.

CONCLUSION: CT-guided biopsy of a pancreatic lesion is a safe procedure with a high success rate, and is an excellent option for minimally invasive diagnosis.

CT and MRI Findings of Autoimmune Polymorph Bifocal Pancreatitis Mimicking Pancreatic Adenocarcinoma: A Case Report and Review of the Literature

Autoimmune pancreatitis is a rare type of chronic pancreatitis. It is supposed to be a pancreatic manifestation of an immune-complex modulated systemic disorder. In contrast, pancreatic adenocarcinoma is the most frequent malignant neoplasm of the pancreas. Within the rare type of focal autoimmune pancreatitis, only few presentations with multifocal pancreatic lesions have been described. Herein we report a case of a 58-year-old patient with autoimmune pancreatitis presenting with bifocal manifestations of the pancreatic head and tail, mimicking pancreatic adenocarcinoma clinically, on computed tomography and magnetic resonance imaging. Typical imaging findings of autoimmune pancreatitis are compared with typical findings in pancreatic carcinoma. The diagnostic dilemma of differentiating between both entities is discussed. A review of the present literature regarding multifocal presence of autoimmune pancreatitis is performed.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Glycolytic ATP fuels the plasma membrane calcium pump critical for pancreatic cancer cell survival

Pancreatic cancer is an aggressive cancer with poor prognosis and limited treatment options. Cancer cells rapidly proliferate and are resistant to cell death due, in part, to a shift from mitochondrial metabolism to glycolysis. We hypothesized that this shift is important in regulating cytosolic Ca²⁺ ([Ca²⁺]_i), as the ATP-dependent plasma membrane Ca²⁺ ATPase (PMCA) is critical for maintaining low [Ca²⁺]_i and thus cell survival. The present study aimed to determine the relative contribution of mitochondrial versus glycolytic ATP in fuelling the PMCA in human pancreatic cancer cells. We report that glycolytic inhibition induced profound ATP depletion, PMCA inhibition, [Ca²⁺]_i overload, and cell death in PANC1 and MIA PaCa-2 cells. Conversely, inhibition of mitochondrial metabolism had no effect, suggesting that glycolytic ATP is critical for [Ca²⁺]_i homeostasis and thus survival. Targeting the glycolytic regulation of the PMCA may, therefore, be an effective strategy for selectively killing pancreatic cancer while sparing healthy cells.

Fine needle aspirating and cutting is superior to Tru-cut core needle in liver biopsy

BACKGROUND

Liver biopsy is the "gold standard" for evaluating liver disorders, but controversies over the potential risk of complications and patient discomfort still exist. Using a 21G fine needle, we developed a new biopsy procedure, fine needle aspirating and cutting (FNAC). Our procedure obtains enough tissue for pathological examination and meanwhile, reduces the risk of biopsy complications. The present study was to determine the safety and efficiency of 21G FNAC compared with 18G Tru-cut core needle (TCN) in liver tumor biopsies.

METHODS

Ninety-four patients with unresectable malignant tumors were included in this study. Patients were divided into 2 groups: 18G TCN and 21G FNAC. The total positive rate (TPR) and safety of both groups were compared.

RESULTS

TPR was not different between the two groups. Liver puncture track subcapsular hemorrhage and arteriovenous shunt were reported with 18G TCN but not with 21G FNAC. The incidence of pain caused by biopsy was higher for the 18G TCN group compared to the 21G FNAC group (P<0.05). About 82.6% of the patients in the 18G TCN group had a sample length >0.5 cm, but 52.1% in the 21G FNAC group (P<0.05). More than 50% of patients in both groups had sufficient tissue for immunohistochemical examination.

CONCLUSIONS

TPR is not different between the 21G FNAC and 18G TCN biopsy procedures, but the safety of 21G FNAC is superior to that of 18G TCN. Tissues obtained by either of these two procedures are sufficient for a pathological diagnosis.

Imaging of pancreatic cancer: An overview

Pancreatic cancer (PaCa) is the fourth leading cause of cancer-related death in the United States. The median size of pancreatic adenocarcinoma at the time of diagnosis is about 31 mm and has not changed significantly in last three decades despite major advances in imaging technology that can help diagnose increasingly smaller tumors. This is largely because patients are asymptomatic till late in course of pancreatic cancer or have nonspecific symptoms. Increased awareness of pancreatic cancer amongst the clinicians and knowledge of the available imaging modalities and their optimal use in evaluation of patients suspected to have pancreatic cancer can potentially help in diagnosing more early stage tumors. Another major challenge in the management of patients with pancreatic cancer involves reliable determination of resectability. Only about 10% of pancreatic adenocarcinomas are resectable at the time of diagnosis and would potentially benefit from a R0 surgical resection. The final determination of resectability cannot be made until late during surgical resection. Failure to identify unresectable tumor pre-operatively can result in considerable morbidity and mortality due to an unnecessary surgery. In this review, we review the relative advantages and shortcomings of imaging modalities available for evaluation of patients with suspected pancreatic cancer and for preoperative determination of resectability.

Incidence rates of exocrine and endocrine pancreatic cancers in the United States

Descriptive studies of pancreatic cancer incidence have been sparse particularly in terms of tumor histology and stage. The purpose of this study was to examine the incidence rate trends of exocrine and endocrine pancreatic cancers by demographic and tumor characteristics using data from the Surveillance, Epidemiology, and End Results (SEER) program from 1977 to 2005. During this period, the incidence of exocrine pancreatic cancer generally decreased whereas the incidence of endocrine pancreatic cancer increased. This difference in trends by histology was evident across age, gender, and racial groups. It was also evident among different racial/ethnic groups using data from 1992 to 2005. Variation in trends was observed by stage. The incidence of exocrine cancers declined for all stages except regional. Endocrine cancer incidence increased for all tumor stages, and the increase was most prominent for localized tumors. When exocrine tumors were stratified by tumor subsite, the incidence of cancers in the tail and body regions increased while the incidence in other regions decreased. While better detection and classification of tumors through improved diagnostic procedures may be related to these changing trends, etiologic factors warrant study.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative tissue diagnosis for tumours of the pancreas

BACKGROUND

Preoperative biopsy of pancreatic lesions suspected of malignancy is controversial.

METHODS

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

RESULTS

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

CONCLUSIONS

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

The use of immunoglobulin g4 immunostaining in diagnosing pancreatic and extrapancreatic involvement in autoimmune pancreatitis

BACKGROUND & AIMS

Autoimmune pancreatitis (AIP) is recognized increasingly as a multisystem disorder. We evaluated the use of immunoglobulin (Ig)G4 immunostaining of pancreatic and extrapancreatic biopsy specimens to make a definitive diagnosis of AIP.

METHODS

Seventeen biopsy specimens and 3 gallbladder resections were assessed from 11 patients with clinical and radiologic features of AIP. Biopsy specimens from pancreas, liver, colon, stomach, duodenum, bone marrow, salivary gland, and kidney were analyzed morphologically, immunostained for IgG4-positive plasma cells, and compared with controls.

RESULTS

Positive IgG4 immunostaining enabled a definitive diagnosis in 10 of 11 (91%) AIP patients. In both pancreatic and extrapancreatic tissues, high levels of IgG4 immunostaining (>10 IgG4-positive plasma cells/high-power field) were found in 17 of 20 (85%) specimens from AIP patients compared with 1 of 175 (0.6%) specimens from controls (P < .05). Positive extrapancreatic IgG4 immunostaining was found in 8 of 11 (73%) patients, including all those with diagnostic features in the pancreas. Increased tissue IgG4 was found irrespective of serum IgG4 level.

CONCLUSIONS

The finding of IgG4 immunostaining within a range of clinically involved tissues supports the hypothesis that AIP is a multisystem disease. Positive IgG4 immunostaining in extrapancreatic tissues may allow a definitive diagnosis of AIP to be made in those with evidence of pancreatic disease, without the necessity of pancreatic biopsy or surgical exploration. Immunostaining of involved tissue for IgG4 may be particularly useful when AIP is suspected clinically but the serum IgG4 level is normal.