Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration in patients with presumed pancreatic cancer

Pancreaticobiliary Cytology Practice in 2021: Results of a College of American Pathologists Survey

CONTEXT.—

The College of American Pathologists (CAP) surveys provide national benchmarks of pathology practice.

OBJECTIVE.—

To investigate pancreaticobiliary cytology practice in domestic and international laboratories in 2021.

DESIGN.—

We analyzed data from the CAP Pancreaticobiliary Cytology Practice Supplemental Questionnaire that was distributed to laboratories participating in the 2021 CAP Nongynecologic Cytopathology Education Program.

RESULTS.—

Ninety-three percent (567 of 612) of respondent laboratories routinely evaluated pancreaticobiliary cytology specimens. Biliary brushing (85%) was the most common pancreaticobiliary cytology specimen evaluated, followed by pancreatic fine-needle aspiration (79%). The most used sampling methods reported by 235 laboratories were 22-gauge needle for fine-needle aspiration (62%) and SharkCore needle for fine-needle biopsy (27%). Cell block was the most used slide preparation method (76%), followed by liquid-based cytology (59%) for pancreatic cystic lesions. Up to 95% (303 of 320) of laboratories performed rapid on-site evaluation (ROSE) on pancreatic solid lesions, while 56% (180 of 320) performed ROSE for cystic lesions. Thirty-six percent (193 of 530) of laboratories used the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology in 2021. Among all institution types, significant differences in specimen volume, specimen type, ROSE practice, and case sign-out were identified. Additionally, significant differences in specimen type, slide preparation, and ROSE practice were found.

CONCLUSIONS.—

This is the first survey from the CAP to investigate pancreaticobiliary cytology practice. The findings reveal significant differences among institution types and between domestic and international laboratories. These data provide a baseline for future studies in a variety of practice settings.

Basic Principles and Role of Endoscopic Ultrasound in Diagnosis and Differentiation of Pancreatic Cancer from Other Pancreatic Lesions: A Comprehensive Review of Endoscopic Ultrasound for Pancreatic Cancer

Pancreatic cancer is one of the leading causes of cancer-related deaths worldwide. Pancreatic lesions consist of both neoplastic and non-neoplastic lesions and often pose a diagnostic and therapeutic challenge due to similar clinical and radiological features. In recent years, pancreatic lesions have been discovered more frequently as incidental findings due to the increased utilization and widespread availability of abdominal cross-sectional imaging. Therefore, it becomes imperative to establish an early and appropriate diagnosis with meticulous differentiation in an attempt to balance unnecessary treatment of benign pancreatic lesions and missing the opportunity for early intervention in malignant lesions. Endoscopic ultrasound (EUS) has become an important diagnostic modality for the identification and risk stratification of pancreatic lesions due to its ability to provide detailed imaging and acquisition of tissue samples for analysis with the help of fine-needle aspiration/biopsy. The recent development of EUS-based technology, including contrast-enhanced endoscopic ultrasound, real-time elastography-endoscopic ultrasound, miniature probe ultrasound, confocal laser endomicroscopy, and the application of artificial intelligence has significantly augmented the diagnostic accuracy of EUS as it enables better evaluation of the number, location, dimension, wall thickness, and contents of these lesions. This article provides a comprehensive overview of the role of the different types of EUS available for the diagnosis and differentiation of pancreatic cancer from other pancreatic lesions while discussing their key strengths and important limitations.

Rapid on-site evaluation improves the sensitivity of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions irrespective of technique: A single-centre experience

OBJECTIVE

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the first-line technique for the sampling of pancreatic lesions. Many factors can influence the diagnostic performance of this procedure, including the use of rapid on-site evaluation (ROSE). The primary aim of this study was to compare the adequacy, diagnostic yield, accuracy, sensitivity and specificity of EUS-FNA for solid pancreatic lesions before and after the introduction of ROSE.

METHODS

This retrospective single-centre study evaluated all consecutive patients who underwent EUS-FNA for suspicious, solid pancreatic masses from April 2012 to March 2015. We compared the findings of EUS-FNA procedures performed during the first and second years following the adoption of ROSE ("ROSE1" and "ROSE2", respectively) to those performed the year before ROSE introduction (the "pre-ROSE" group).

RESULTS

Ninety-one consecutive patients with a total of 93 pancreatic lesions were enrolled. For the pre-ROSE, ROSE1 and ROSE2 groups, the adequacy rates were 96.2%, 96.6% and 100%, the diagnostic yield values were 76.9%, 89.7% and 92.1% and accuracy values were 69.2%, 86.2% and 89.5% (p = NS). Sensitivity for malignancy improved from 63.7% in the pre-ROSE group to 91.7% and 91.2% in the post-ROSE groups (p < 0.05). Specificity for malignancy was 100% in all groups.

CONCLUSIONS

ROSE can improve the diagnostic performance of EUS-FNA for solid pancreatic lesions, although only sensitivity reached statistical significance.

Advances in pre-treatment evaluation of pancreatic ductal adenocarcinoma: a narrative review

BACKGROUND AND OBJECTIVE

Despite advances in the multidisciplinary management of pancreatic cancer, overall prognosis remains poor, due to early progression of the disease. There is a need to also take action in staging, to make it increasingly accurate and complete, to define the setting of the therapeutic strategy. This review was planned to update the current status of pre-treatment evaluation for pancreatic cancer.

METHODS

We conducted an extensive review, including relevant articles dealing with traditional imaging, functional imaging and minimally invasive surgical procedures before treatment for pancreatic cancer. We searched articles written in English only. Data in the PubMed database, published in the period between January 2000 and January 2022, were retrieved. Prospective observational studies, retrospective analyses and meta-analyses were reviewed and analysed.

KEY CONTENT AND FINDINGS

Each imaging modality (endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, computed tomography, positron emission tomography/computed tomography, staging laparoscopy) has its own diagnostic advantages and limitations. The sensitivity, specificity and accuracy for each image set are reported. Data that support the increasing role of neoadjuvant therapy (radiotherapy and chemotherapy) and the meaning of a patient-tailored treatment selection, based on tumour staging, are also discussed.

CONCLUSIONS

A multimodal pre-treatment workup should be searched as it improves staging accuracy, orienting patients with resectable tumors towards surgery, optimizing patient selection with locally advanced tumors to neoadjuvant or definite therapy and avoiding surgical resection or curative radiotherapy in those with metastatic disease.

The value of concurrent endoscopic ultrasound‐guided fine needle aspirates and needle core biopsies in the diagnosis of pancreatic neoplasms

Background

Endoscopic ultrasound (EUS) fine needle aspiration (FNA) is highly sensitive and specific in the detection and diagnosis of pancreatic neoplasms. EUS‐guided needle core biopsy has been used alone or as an adjunct to maximize diagnostic yield. This study compared the use of FNA versus needle core biopsy in the diagnosis of pancreatic neoplasms.

Methods

From January 1, 2018 through December 21, 2020, the Cytopathology Laboratory processed 374 FNAs from solid pancreatic masses of which 332 (89%) had concurrent pancreatic biopsies and form the basis of this study.

Results

Of the 332 FNAs, 173 (52%) were positive/suspicious for pancreatic adenocarcinoma, 33 (10%) were positive for a neoplasm, 20 (6%) were atypical 19 (6%) were negative and 87 (26%) were non‐diagnostic. Biopsies were concordant in 248 (75%) cases and discordant in 84 (25%) cases. Of the 84 discordant cases, 29 (35%) had neoplastic cells on FNA of which 14 were atypical, 11 were negative and 4 were nondiagnostic on core biopsy. Of the 18 (21%) FNAs with atypical cells, 8 showed adenocarcinoma on core biopsy. Thirty‐seven nondiagnostic FNAs showed adenocarcinoma on 25 (70%) core biopsies. If nondiagnostic FNAs were included, FNA sensitivity was 89% and specificity; 100%, and both were 100%, if the nondiagnostic cases were excluded. The needle core biopsy sensitivity was 91% and specificity; 100%.

Conclusion

Both FNAs and core biopsies show high sensitivity and specificity in the detection of pancreatic neoplasms. However, combining the techniques enhances cellular yields and provides material for ancillary tests.

Accuracy and clinical outcomes of pancreatic EUS-guided fine-needle biopsy in a consecutive series of 852 specimens

Background and Objectives:

Pancreatic EUS-guided fine needle biopsy (EUS-FNB) is increasingly used. Accuracy of EUS-FNB, particularly for benign diseases, utility of additional EUS-FNB if malignancy is suspected but initial diagnosis is inconclusive, and complication rate are not fully elucidated. We evaluated operating characteristics of EUS-FNB overall and for different diagnostic categories, value of additional EUS-FNB if malignancy is suspected but initial diagnosis is inconclusive, and frequency and type of complications.

Methods:

A retrospective tertiary single-center study including 852 consecutive pancreatic SharkCore EUS-FNBs from 723 patients between 2015 and 2020. EUS-FNB diagnoses were applied according to Papanicolaou Society's system and each category was further subcategorized.

Results:

Sufficient tissue cylinders for a histologic diagnosis were obtained in 93.4% (796/852). Accuracy was overall, for malignant, and benign entities 85.6% (confidence interval [CI]: 83.2%–87.9%), 88.3% (CI: 85.9%–90.4%), and 94% (CI: 92.2%–95.5%). Sensitivity and accuracy of EUS-FNB for autoimmune pancreatitis (AIP) (n = 15) was 83.3% (CI: 58.6%–96.4%) and 99.2% (CI: 98.3%–99.7%). Of patients in whom malignancy was suspected but initial EUS-FNB diagnosis was inconclusive, 7.3% (53/723) underwent one or two additional EUS-FNBs, and in 54.7% (29/53) of these, a malignant diagnosis was established. The frequency of hospitalization following EUS-FNB was 4.7%, with 0.2% (n = 2) incidents needing active intervention.

Conclusions:

We found a high accuracy of pancreatic EUS-FNB across all diagnostic categories including rare entities, such as AIP. In patients with a clinical suspicion of malignancy, additional EUS-FNB resulted in a conclusive diagnosis in more than half of cases. Complications necessitate hospitalization in almost 5%, but the majority are self-limiting.

Efficacy of Contrast-Enhanced Endoscopic Ultrasonography for the Diagnosis of Pancreatic Tumors

Endoscopic ultrasound can be useful for obtaining detailed diagnostic images for pancreatic disease. Contrast-enhanced harmonic endoscopic ultrasound has allowed to demonstrate not only microvasculature but also real perfusion imaging using second-generation contrast agents. Furthermore, endoscopic ultrasound fine-needle aspiration cytology and histology have become more ubiquitous; however, the risk of dissemination caused by paracentesis has yet to be resolved, and the application of less invasive contrast-enhanced endoscopic ultrasound for the differential diagnosis of pancreatic tumors has been anticipated. Contrast-enhanced harmonic endoscopic ultrasound can contribute to the differential diagnosis of pancreatic tumors.

Endoscopic ultrasound (EUS) and the management of pancreatic cancer

Pancreatic cancer is one of the leading causes of cancer-related mortality in western countries. Early diagnosis of pancreatic cancers plays a key role in the management by identification of patients who are surgical candidates. The advancement in the radiological imaging and interventional endoscopy (including endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography and endoscopic enteral stenting techniques) has a significant impact in the diagnostic evaluation, staging and treatment of pancreatic cancer. The multidisciplinary involvement of radiology, gastroenterology, medical oncology and surgical oncology is central to the management of patients with pancreatic cancers. This review aims to highlight the diagnostic and therapeutic role of EUS in the management of patients with pancreatic malignancy, especially pancreatic ductal adenocarcinoma.

Long-term positive psychological outcomes in an Australian pancreatic cancer screening program

Screening for pancreatic cancer (PC) in high-risk groups aimed to detect early cancers is currently done only in the research setting, and data on psychological outcomes of screening in these populations is scarce. To determine the psychological impact of a national Australian pancreatic screening program, a prospective study was conducted using validated psychological measures: impact of events scale (IES), psychological consequences questionnaire (PCQ) and the cancer worry scale. Measures were administered at baseline, 1-month and at 1-year post-enrolment and correlations with abnormal endoscopic ultrasound (EUS) results were calculated. Over a 6-year period, 102 participants were recruited to the screening program. Thirty-nine patients (38.2%) had an abnormal endoscopic ultrasound, and two patients (2.0%) were diagnosed with PC and two with other malignancies. Those with a personal history of cancer or a positive BRCA2 mutation demonstrated significantly increased worry about developing other types of cancer at baseline (p < 0.01). Irrespective of EUS result, there was a significant decrease of total IES score at 1 year (Z = - 2.0, p = 0.041). In patients with abnormal EUS results, there was a decrease in the total IES score at 1 year (Z = - 2.5, p = 0.011). In participants deemed to be most distressed at baseline based on their negative PCQ score, there was a significant decrease of the total PCQ (Z = - 3.2, p = 0.001), emotional (Z = - 3.0, p = 0.001), social (Z = 3.0, p = 0.001) and physical (Z = - 2.8, p = 0.002) subscale at 1-year post-intervention. This study provides evidence of the long-term psychological benefits of PC screening in high-risk patients. There was no negative impact of screening in the short-term and the positive benefits appeared at 1-year post-intervention irrespective of screening result.

The Utility of EUS-FNA to Determine Surgical Candidacy in Patients with Pancreatic Cancer after Neoadjuvant Therapy

BACKGROUND

In patients with borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC) who undergo neoadjuvant therapy, CT imaging is the standard of care for restaging. However, differentiating residual tumor from post-treatment inflammation with CT is unreliable. The diagnosis of periarterial soft tissue cuffing (PSTC) near major vessels is key to guiding resectability. The goal of this study was to assess the utility of EUS-FNA in determining the etiology of PSTC in BRPC or LAPC after neoadjuvant treatment.

METHODS

We performed a retrospective analysis of patients referred for EUS-FNA of PSTC following downstaging therapy for LAPC or BRPC at our tertiary medical center. Negative EUS-FNA cytology results were compared with surgical pathology after resection. Patients with positive EUS-FNA cytology results were either followed clinically or results were compared to surgical pathology if surgery was attempted despite the positive cytology.

RESULTS

Fourteen patients were included in the study of whom four had positive cytology. Two of these patients had progression of disease, and two had attempted resection with positive surgical pathology (100% true positives). All ten patients with negative cytology underwent attempted surgical resection. Nine patients (90%) achieved negative margins, and one patient (10%) had a positive surgical margin. The sensitivity, specificity, and accuracy of EUS-FNA for determining resectability were 80%, 100%, and 92.9%, respectively.

CONCLUSIONS

In this series of patients with BRPC or LAPC and persistent PSTC after downstaging neoadjuvant treatment, EUS-FNA accurately determined surgical resectability and should be considered as part of the evaluation of such patients.

Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration: A Narrative Review

Considerable progress has been made recently in the use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to diagnose intra-luminal gastrointestinal lesions and extra-luminal lesions near the gastrointestinal tract. Numerous reports have indicated that EUS-FNA has high diagnostic performance and safety, which has led to the routine use of EUS-FNA and an increasing number of cases. Thus, while EUS-FNA has a low rate of complications, endoscopists may encounter these complications as the number of cases increases. Infrequent reports have also described life-threatening complications. Therefore, endoscopists should possess a comprehensive understanding of the complications of EUS-FNA, which include hemorrhage, perforation, infection, and acute pancreatitis, as well as their management. This review examines the available evidence regarding the complications associated with EUS-FNA, and the findings will be useful for ensuring that endoscopists perform EUS-FNA safely and appropriately.

Early Diagnosis of Pancreatic Cancer: The Key for Survival

Pancreatic cancer (PC) is one of the most aggressive forms of cancer. Negative prognosis is mainly due to the late diagnosis in advanced stages, when the disease is already therapeutically overcome. Studies in recent years have focused on identifying biomarkers that could play a role in early diagnosis, leading to the improvement of morbidity and mortality. Currently, the only biomarker widely used in the diagnosis of PC is carbohydrate antigen 19-9 (CA19.9), which has, however, more of a prognostic role in the follow-up of postoperative recurrence than a diagnostic role. Other biomarkers, recently identified as the methylation status of ADAMTS1 (A disintegrin and metalloproteinase with thrombospondin motifs 1) and BNC1 (zinc finger protein basonuclin-1) in cell-free deoxyribonucleic acid (DNA), may play a role in the early detection of PC. This review focuses on the diagnosis of PC in its early stages.

Factors affecting the accuracy of endoscopic ultrasound-guided fine needle aspiration for the diagnosis of small (≤20 mm) pancreatic lesions

To explore the diagnostic value of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for small, solid or semi-solid pancreatic lesions (≤20 mm) and the factors affecting its accuracy.

METHODS

Altogether 92 patients with small, solid or semi-solid pancreatic lesions who underwent EUS-FNA at the Nanjing Drum Tower Hospital from November 2009 to January 2019 were retrospectively analyzed. Univariate and multivariate analyses were used to determine the factors affecting the accuracy of EUS-FNA for detecting these lesions.

RESULTS

Among the 92 cases, 56 (60.9%) were diagnosed as having malignant lesions and 36 (39.1%) as benign lesions, respectively. The overall sensitivity, specificity and accuracy of EUS-FNA for the diagnosis of small, solid or semi-solid pancreatic lesions were 71.4%, 100% and 82.6%, respectively. When considering the impact of the presence of a tissue core on the diagnosis, the sensitivity, specificity, and accuracy of EUS-FNA with tissue core compared with those based on cytology alone were 77.3% vs 50.0%; 100% vs 100%; and 86.8% vs 62.5%, respectively. The multivariate analysis showed that larger tumor size (>15-20 mm) (odds ratio [OR] 4.200, 95% confidence interval [CI] 1.21-14.53, P = 0.023) and histologic diagnosis based on tissue core (OR 4.593, 95% CI 1.03-20.47, P = 0.046) were related to a higher accuracy of EUS-FNA. Adverse events were observed in three patients, all were treated conservatively and recovered within 3 days.

CONCLUSIONS

EUS-FNA is effective and safe for diagnosing small pancreatic lesions. Tumor size and presence of tissue core are related to higher accuracy of the EUS-FNA.

Complication incidence of EUS-guided pancreas biopsy: A systematic review and meta-analysis of 11 thousand population from 78 cohort studies

A systematic review and meta-analysis were performed to estimate the incidence of possible complications following EUS-guided pancreas biopsy. Pancreatic cancer has a very poor prognosis with a high fatality rate. Early diagnosis is important to improve the prognosis of pancreatic cancer. We searched Pubmed, Embase, Web of Science, and Scopus databases for studies published from inception to Augest, 2018. Meta-analysis were conducted with random-effect models and heterogeneity was calculated with the Q, I² and τ² statistics. We enrolled 78 studies from 71 articles in the meta-analysis, comprising 11,652 patients. Pooled data showed that the whole complication incidences were low 0.210 × 10^-4(95%CI -0.648 × 10^-4, 1.068 × 10^-4). And they were in bleeding 0.002 × 10^-4 (95%CI -0.092 × 10^-4, 0.097 × 10^-4), pancreatitis 0.002 (95%CI -0.082 × 10^-4, 0.086 × 10^-4), abdominal pain 0 (95%CI -0.037 × 10^-4, 0.038 × 10^-4), fever 0 (95%CI -0.032 × 10^-4, 0. 032 × 10^-4), infection 0 (95%CI -0.030 × 10^-4, 0.031 × 10^-4), duodenal perforation 0 (95%CI -0.033 × 10^-4, 0.034 × 10^-4), pancreatic fistula 0 (95%CI -0.029 × 10^-4, 0.029 × 10^-4), abscess 0 (95%CI -0.029 × 10^-4, 0.029 × 10^-4) and sepsis 0 (95%CI -0.029 × 10^-4, 0.030 × 10^-4). Subgroup analysis based on the tumor size, site, needle type and tumor style also showed robust results. The pooled data showed EUS-guided pancreas biopsy could be a safe approach for the diagnosis of pancreatic lesions. More large-scale studies will be necessary to confirm the findings across different population.

Safety and efficacy of endoscopic ultrasound-guided fine needle aspiration for pancreatic masses: A prospective multicenter study

OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions has high diagnostic yield. However, few prospective multicenter studies have been performed. We performed a prospective cohort study to evaluate the efficacy and safety of EUS-FNA for diagnosis of solid pancreatic lesions.

METHODS

This prospective cohort study involved five hospitals in Japan. The primary outcome was sensitivity of EUS-FNA for diagnosing malignant lesions. We also evaluated parameters of diagnostic sufficiency and the safety of EUS-FNA.

RESULTS

In total, 246 patients were enrolled. The absolute values of the parameters evaluated showed no significant differences; however, the percentage changes in the white blood cell counts and C-reactive protein levels after examination were significantly higher, and the percentage change in hemoglobin concentrations was significantly lower. The minor and major complication rates at the time of puncture, 24 h, 7 days and 28 days were 4.1%, 2.8%, 1.6%, and 0.0%, respectively. The true complication rate was 1.2%. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 97.2%, 88.0%, 96.2%, 100%, and 81.4%, respectively.

CONCLUSIONS

EUS-FNA for solid pancreatic lesions has high diagnostic yield and is safe, consistent with previously studies.

Endoscopic management of iatrogenic EUS-related duodenal perforations with over-the-scope clips

Background and study aims  Iatrogenic endoscopic ultrasound (EUS) perforations are life-threatening adverse event and to date, surgery has been the main treatment for them. The aim of this study was to assess feasibility and safety of conservative treatment with over-the-scope clips (OTSC). Patients and methods  We performed a retrospective study, including iatrogenic EUS duodenal perforation with conservative endoscopic management from 2011 to August 2018. Patients who initial had surgical management were excluded. Results  In 8504 EUS procedure occurred, 13 perforations occurred (0.15 %). Eleven patients were included in the study, all women. Mean patient age was 75 years (range 68 - 88). Eighth of 11 perforations (72.7 %) were due to a radial probe and three of 11 (27.3 %) were due to a curvilinear probe. Eleven procedures (100 %) were performed as diagnostic. Defect size ranged from 10 to 15 mm. All procedures were successful. Three of eleven patients (27 %) had a stay in intensive care unit for less than 72 hours and length of total hospital stay ranged from 3 to 22 days. Conclusion  Conservative endoscopic treatment of Iatrogenic EUS perforation, with OTSC is feasible, efficient and safe.

Endoscopic Ultrasound-Guided Tissue Acquisition Using Fork-Tip Needle Improves Histological Yield, Reduces Needle Passes, Without On-Site Cytopathological Evaluation

Background and Aim: Endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) and fine needle aspiration (FNA) are established methods in tissue acquisition. A new fork-tip FNB needle has been used to obtain core tissue samples. We compared the performance of the FNB using fork-tip needles with that of the FNA using conventional needles in patients who had solid neoplastic lesions within and around the upper gastrointestinal (GI) tract.

Methods: In this retrospective single-center study, patients who underwent EUS examinations for solid neoplastic lesions between October 2013 and February 2017 were included. The procedures were performed in the absence of an on-site cytologist. The main objectives were to compare the diagnostic yield and average number of passes of FNB using fork-tip needles versus those of FNA using conventional needles.

Results: EUS/FNA and EUS/FNB were performed on 181 solid neoplastic lesions primarily in the pancreas and GI tract walls. There was no significant difference in patient's age, gender, tumor location, or tumor size. The mean number of needle passes was significantly lower in the fork-tip needle group than in the conventional needle group (3.8 vs. 5.9; p < 0.0001). There was a trend toward higher sensitivity (89.9% vs. 81%) using the fork-tip needles than when using the conventional needles (p = 0.119). No significant difference in rates of adverse events between two groups was found.

Conclusions: Our study demonstrates that, compared with FNA using conventional needles, FNB using fork-tip needles required significantly fewer needle passes while achieving a relatively higher diagnostic yield due to its superior capacity in tissue acquisition from solid neoplastic lesions in and around GI tract walls without on-site cytological assessment.

Familial Pancreatic Cancer and the Future of Directed Screening

Pancreatic cancer (PC) is the third most common cause of cancer-related death in the United States and the 12th most common worldwide. Mortality is high, largely due to late stage of presentation and suboptimal treatment regimens. Approximately 10% of PC cases have a familial basis. The major genetic defect has yet to be identified but may be inherited by an autosomal dominant pattern with reduced penetrance. Several known hereditary syndromes or genes are associated with an increased risk of developing PC and account for approximately 2% of PCs. These syndromes include the hereditary breast-ovarian cancer syndrome, Peutz-Jeghers syndrome, familial atypical multiple mole melanoma, Lynch syndrome, familial polyposis, ataxia-telangiectasia, and hereditary pancreatitis. Appropriate screening using methods such as biomarkers or imaging, with endoscopic ultrasound and magnetic resonance imaging, may assist in the early detection of neoplastic lesions in the high-risk population. If these lesions are detected and treated before the development of invasive carcinoma, PC disease morbidity and mortality may be improved. This review will focus on familial PC and other hereditary syndromes implicated in the increased risk of PC; it will also highlight current screening methods and the future of new screening modalities.

Pancreatic cancer cell detection by targeted lipid microbubbles and multiphoton imaging

Surgical resection of pancreatic cancer represents the only chance of cure and long-term survival in this common disease. Unfortunately, determination of a cancer-free margin at surgery is based on one or two tiny frozen section biopsies, which is far from ideal. Not surprisingly, cancer is usually left behind and is responsible for metastatic disease. We demonstrate a method of receptor-targeted imaging using peptide ligands, lipid microbubbles, and multiphoton microscopy that could lead to a fast and accurate way of examining the entire cut surface during surgery. Using a plectin-targeted microbubble, we performed a blinded in-vitro study to demonstrate avid binding of targeted microbubbles to pancreatic cancer cells but not noncancerous cell lines. Further work should lead to a much-needed point-of-care diagnostic test for determining clean margins in oncologic surgery.

Comparison of the diagnostic performance of 2 core biopsy needles for EUS-guided tissue acquisition from solid pancreatic lesions

BACKGROUND AND AIMS

A new core biopsy needle with a novel tip, opposing bevel, and sheath design has recently been introduced for EUS-guided fine-needle biopsy (FNB). The diagnostic utility of this needle for differentiating solid pancreatic masses is currently unknown. The aim of this study was to compare the diagnostic performance and yield for tissue acquisition from solid pancreatic lesions of the opposing bevel needle with those of a reverse bevel EUS-FNB needle.

METHODS

Consecutive patients with solid pancreatic masses undergoing EUS-FNB using the opposing bevel (n = 101) and the reverse bevel (n = 100) core biopsy needles were included in the study. Final diagnosis was based on positive histology or at least 12 months of follow-up in cases with a negative biopsy. The primary outcome was the diagnostic performance of the 2 needles for malignant pancreatic masses. A secondary outcome was the diagnostic yield.

RESULTS

Compared with the reverse bevel needle, using strict criteria the opposing bevel needle provided significantly higher sensitivity (71.1% vs 90.1%; P = .0006) and overall accuracy (74% vs 92%; I = 0.0006) for discriminating malignant from benign solid pancreatic masses. The proportion of samples classified as adequate for histologic analysis was 87% for the reverse bevel needle versus 99% for the opposing bevel needle (p = 0.002) Multivariate analysis controlling the needle gauge and site did not show any significant difference in accuracy and sensitivity between the 2 groups. There were no adverse events in either group.

CONCLUSIONS

In this first, large, single-center preliminary cohort study, an EUS core biopsy needle with a novel tip, opposing bevel, and sheath design afforded substantially superior tissue yield and diagnostic performance compared with a reverse-bevel needle. If replicated by randomized controlled trials, our findings suggest that similarly designed needles could become the standard of care for EUS-guided tissue acquisition from solid pancreatic masses.

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.

The role of S100P and IMP3 in the cytologic diagnosis of pancreatic adenocarcinoma

PURPOSE

The aim of this study was to assess the role of the two markers, S100P and IMP3, in differentiating between pancreatic ductal adenocarcinoma (PDA) and non-neoplastic pancreatic tissue in (fine needle aspiration cytology) FNAC.

PATIENTS AND METHODS

This is a retrospective study that included 72 cases presented with pancreatic mass, where endoscopic guided FNAC was taken from pancreatic lesions. The final histopathologic diagnosis was considered the gold standard. Cell blocks were stained with anti S100P, and IMP3. Nuclear immunoreactivity with or without cytoplasmic staining for the first marker, and cytoplasmic staining for the second marker was considered specific. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and total accuracy of the two markers, as well as the combined accuracy of both markers were calculated.

RESULTS

S100P achieved 96.4% sensitivity, 93.3% specificity, 98.2% PPV, 87.5% NPV and 95.8% total accuracy, while IMP3 achieved 91.2% sensitivity, 86.7% specificity, 96.2% PPV, 72.2% NPV and 90.3% total accuracy for PDA. Both markers showed a total combined accuracy of 89%. S100P showed strong and diffuse staining pattern in most of cases, while the staining pattern for IMP3 was moderate and focal in most of cases.

CONCLUSION

Both markers were sensitive and specific for diagnosis of PDA. The staining pattern for S100P was easier to evaluate than IMP3.

Endoscopic ultrasound-guided techniques for diagnosing pancreatic mass lesions: Can we do better?

The diagnostic approach to a possible pancreatic mass lesion relies first upon various non-invasive imaging modalities, including computed tomography, ultrasound, and magnetic resonance imaging techniques. Once a suspect lesion has been identified, tissue acquisition for characterization of the lesion is often paramount in developing an individualized therapeutic approach. Given the high prevalence and mortality associated with pancreatic cancer, an ideal approach to diagnosing pancreatic mass lesions would be safe, highly sensitive, and reproducible across various practice settings. Tools, in addition to radiologic imaging, currently employed in the initial evaluation of a patient with a pancreatic mass lesion include serum tumor markers, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). EUS-FNA has grown to become the gold standard in tissue diagnosis of pancreatic lesions.

Endoscopic ultrasound-guided fine needle aspiration biopsy of pancreatic lesions. An 8-year analysis of single institution material focusing on efficacy and learning progress

OBJECTIVE

To evaluate the efficacy and the learning curve of the endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) diagnostics of pancreatic lesions over 8 years (2007-2014).

MATERIAL AND METHODS

EUS-FNAB using a Linear Echoendoscope Olympus was performed in 531 patients, mostly without rapid on-site evaluation (ROSE). Smears plus cytoblock sections were used routinely. Immunocytochemistry was utilised as indicated.

RESULTS

The average, satisfactory sampling rate increased from the 61.2% in the first 3-year period to 72.9% in the last 3-year period (P = 0.008). The availability of the material for cytoblocks increased from 36.4% in the first period to 75.3% in the last period (P = 0.017). The efficacy of cytoblocks increased from 39.6% to 46.2% (P = 0.086). Comparing the first and last 3-year periods, the indication for immunocytochemistry did not rise substantially (5.2% and 8.5% respectively), but the predictive value of immunocytochemistry rose from 56.3% to 100.0% (P = 0.001). The most frequent diagnostic result was malignancy confirmation - both primary (41.2%) and metastatic (2.1%). In cases with representative samples and follow-up information, the specificity, sensitivity, positive predictive value and accuracy were high from the beginning. The negative predictive value decreased slightly in the last 3-year period.

CONCLUSION

The pancreatic EUS-FNAB without ROSE represents a suboptimal arrangement conditioned with our staff/time/location reality. Nevertheless, within the last 3 years of our activity, nearly three-quarters of patients profit from the diagnostic contribution of this procedure.

Endoscopic ultrasonography with fine-needle aspiration for histological diagnosis of solid pancreatic masses: a meta-analysis of diagnostic accuracy studies

Background

Previous studies have demonstrated that endoscopic ultrasound-fine needle aspiration (EUS-FNA) is a reliable tool for diagnosing pancreatic lesions; however, the reported sensitivity and specificity vary greatly across studies. The aim of this study was to pool the existing literature and assess the overall performance of EUS-FNA in the diagnosis of solid pancreatic lesions.

Methods

A systematic search of MEDLINE, Cochrane Database for Systematic Reviews, and EMBASE was performed to identify original and review articles published between January 1995 and January 2014 that reported the accuracy of EUS-FNA in the diagnosis of pancreatic masses. Quality of the included studies was assessed using the quality assessment of diagnosis accuracy studies score tool. Meta-DiSc software was used to calculate the pooled sensitivity and specificity, positive and negative likelihood ratios, and to construct the summary receiver operating characteristics curve.

Results

Twenty studies involving a total of 2,761 patients were included in the study. The pooled sensitivity and specificity of EUS-FNA in the diagnosis of solid pancreatic lesions were 90.8 % [95 % confidence interval (CI), 89.4–92 %] and 96.5 % (95 % CI, 94.8–97.7 %), respectively. The positive and negative likelihood ratios were 14.8 (95 % CI, 8.0–27.3) and 0.12 (95 % CI, 0.09–0.16), respectively. The overall diagnostic accuracy was 91.0 %.

Conclusions

Our findings suggest that EUS-FNA has high sensitivity and specificity in the diagnosis of solid pancreatic lesions.

Prospective multicenter study on the usefulness of EUS-guided FNA biopsy for the diagnosis of autoimmune pancreatitis

BACKGROUND AND AIMS

In the International Consensus Diagnostic Criteria (ICDC), autoimmune pancreatitis (AIP) is classified into types 1 and 2, and its definite histopathology diagnosis can be made based only on surgical or core biopsy specimens. Although EUS-guided FNA (EUS-FNA) biopsy is a safe technique for the collection of pancreatic tissue, no consensus viewpoint has been reached with regard to the role of EUS-FNA biopsy in the diagnosis of AIP. This study investigated the utility of pancreatic tissue collected by EUS-FNA biopsy by using a standard 22-gauge aspiration needle in the diagnosis of AIP.

METHODS

Patients with suspected AIP were prospectively enrolled in Nagoya University Hospital and Nagoya University-affiliated institutions. Pancreatic tissue was collected from each by EUS-FNA biopsy with a standard 22-gauge aspiration needle.

RESULTS

Fifty patients were registered, including 45 with a final diagnosis of AIP. Lymphoplasmacytic infiltration and abundant immunoglobulin G4-positive plasmacyte infiltration (>10/high-power field) were detected in 36 (72%) and 27 (54%) patients, respectively. Obliterative phlebitis and storiform fibrosis were not detected in our study. Granulocytic epithelial lesions (GEL) were observed in 3 patients. The sensitivity, specificity, positive predictive value, and negative predictive value of EUS-FNA biopsy to definitively diagnose AIP were 7.9% (3/38), 100% (12/12), 100% (3/3), and 25.5% (12/47), respectively. Pathology evaluation of pancreatic tissue collected by EUS-FNA biopsy improved the diagnostic accuracy in 8 (16%) of the 50 patients.

CONCLUSIONS

In this study, EUS-FNA biopsy by using a standard 22-gauge aspiration needle is not an effective diagnostic method for most patients with AIP. The combination of level 2 histology diagnosis of AIP with other findings specified in the ICDC slightly improved the diagnostic accuracy, although it still remains insufficiently accurate for routine clinical use.(

CLINICAL TRIAL REGISTRATION NUMBER

000006297.).

Reliable Detection of Somatic Mutations in Fine Needle Aspirates of Pancreatic Cancer With Next-generation Sequencing: Implications for Surgical Management

OBJECTIVE

To determine the feasibility of genotyping pancreatic tumors via fine needle aspirates (FNAs).

BACKGROUND

FNA is a common method of diagnosis for pancreatic cancer, yet it has traditionally been considered inadequate for molecular studies due to the limited quantity of DNA derived from FNA specimens and tumor heterogeneity.

METHODS

In vitro mixing studies were performed to deduce the minimum cellularity needed for genetic analysis. DNA from both simulated FNAs and clinical FNAs was sequenced. Mutational concordance was determined between simulated FNAs and that of the resected specimen.

RESULTS

Limiting dilution studies indicated that mutations present at allele frequencies as low as 0.12% are detectable. Comparison of simulated FNAs and matched tumor tissue exhibited a concordance frequency of 100% for all driver genes present. In FNAs obtained from 17 patients with unresectable disease, we identified at least 1 driver gene mutation in all patients including actionable somatic mutations in ATM and MTOR. The constellation of mutations identified in these patients was different than that reported for resectable pancreatic cancers, implying a biologic basis for presentation with locally advanced pancreatic cancer.

CONCLUSIONS

FNA sequencing is feasible and subsets of patients may harbor actionable mutations that could potentially impact therapy. Moreover, preoperative FNA sequencing has the potential to influence the timing of surgery relative to systemic therapy. FNA sequencing opens the door to clinical trials in which patients undergo neoadjuvant or a surgery-first approach based on their tumor genetics with the goal of utilizing cancer genomics in the clinical management of pancreatic cancer.

Fluorescence cytology with 5-aminolevulinic acid in EUS-guided FNA as a method for differentiating between malignant and benign lesions (with video)

BACKGROUND

EUS-guided FNA (EUS-FNA) has been increasingly performed to obtain specimens for the pathological evaluation of patients with GI and pancreaticobiliary masses as well as lymphadenopathies of unknown origin. Photodynamic diagnosis by using 5-aminolebulinic acid (ALA) has been reported to be useful for enabling the visual differentiation between malignant and normal tissue in various cancers.

OBJECTIVE

To evaluate the diagnostic accuracy of fluorescence cytology with ALA in EUS-FNA.

DESIGN

A prospective study.

SETTING

A single center.

PATIENTS

A total of 28 consecutive patients who underwent EUS-FNA for the pathological diagnosis of a pancreaticobiliary mass lesion or intra-abdominal lymphadenopathy of unknown origin.

INTERVENTIONS

Patients were orally administered ALA 3 to 6 hours before EUS-FNA. The sample was obtained via EUS-FNA for fluorescence cytology and conventional cytology. A single gastroenterologist performed the fluorescence cytology by using fluorescence microscopy after the procedure, independently of the conventional cytology by pathologists.

MAIN OUTCOME MEASUREMENTS

The accuracy of fluorescence cytology with ALA in the differentiation between benign and malignant lesions by comparing the results of fluorescence cytology with the final diagnosis.

RESULTS

Of the 28 patients included in the study, 22 were considered as having malignant lesions and 6 patients as having benign lesions. Fluorescence cytology could correctly discriminate between benign and malignant lesions in all patients. Therefore, both the sensitivity and specificity of fluorescence cytology were 100% in our study.

LIMITATIONS

Fluorescence cytology was performed by only 1 gastroenterologist with a small number of patients.

CONCLUSION

Fluorescence cytology with ALA in EUS-FNA may be an effective and simple method for differentiating between benign and malignant lesions.

Pathologic Diagnosis of Pancreatic Adenocarcinoma in the United States: Its Status and Prognostic Value

Purpose: Even with the development of new biopsy methods, diagnosis of pancreatic cancer is sometimes without histological evidence. The aim of our study is to find out the status of pancreatic cancer patients who are diagnosed without pathologic confirm and the prognostic value of pathologic diagnosis.

Methods: We identified 52,759 pancreatic adenocarcinoma patients from the Surveillance, Epidemiology, and End Results (SEER) database. Logistic regression model was used to identify factors relating to no pathologic diagnosis. Multivariable Cox regression model identified potential prognostic factors. All statistical tests were two-sided.

Results: There were 6206 (11.76%) patients without pathologic diagnosis. Older age, reported from nursing/convalescent home/hospice or physician's office/private medical practitioner, early year of diagnosis, larger tumor size, pancreatic head cancer, unmarried patients, uninsured and stage I disease all contributed to no pathologic diagnosis. Median cause specific-survival for patients with and without pathologic diagnosis were 7.72 and 3.52 months, respectively. The HR for pathologic diagnosis was 0.92 (95% CI: 0.89-0.95), P<0.001.

Conclusions: Pathologic diagnosis was an independent prognostic factor for pancreatic adenocarcinoma patients. New diagnostic methods are needed to get the pathologic diagnosis.

Diagnostic potency of EUS-guided FNA for the evaluation of pancreatic mass lesions

Background and Objectives:

Diagnosis of pancreatic lesions remains a clinical challenge. This study aimed to evaluate the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pancreatic mass lesions.

Patients and Methods:

Clinical data, laboratory tests, and cytopathological and imaging reports were collected from 185 pancreatic EUS cases performed from March 2010 to January 2014. The final diagnosis was based on surgical findings, EUS-FNA or computed tomography (CT)-guided biopsy.

Results:

A total of 100 pancreatic FNAs were obtained by EUS. Most positive diagnoses of malignancy were pancreatic adenocarcinomas (n = 61). The site of pancreatic adenocarcinoma was the head in 50 (82.0%), body in seven (11.5%), and tail in four (6.5%). The sensitivity, specificity, and positive and negative predictive values of EUS-FNA for diagnosing adenocarcinoma were 80.3%, 92.3%, 94.2%, and 75.0%, respectively.

Discussion:

We concluded that EUS-FNA of pancreatic lesion accurately diagnoses pancreatic adenocarcinoma and should be considered for the standard management of pancreatic adenocarcinoma.

Endoscopic ultrasound-guided fine-needle aspiration diagnosis of secondary tumors involving the pancreas: An institution's experience

BACKGROUND

Pancreatic masses may seldom represent a metastasis or secondary involvement by lymphoproliferative disorders. Recognition of this uncommon occurrence may help render an accurate diagnosis and avoid diagnostic pitfalls during endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). In this study, we review our experience in diagnosing secondary tumors involving the pancreas.

MATERIALS AND METHODS

The electronic database of cytopathology archives was searched for cases of secondary tumors involving the pancreas at our institution and a total of 31 cases were identified. The corresponding clinical presentations, imaging study findings, cytological diagnoses, the results of ancillary studies, and surgical follow-up, if available, were reviewed.

RESULTS

Nineteen of the patients were male and 12 female, with a mean age of 66 years. Twenty-three patients (74%) had a prior history of malignancy, with the latency ranging from 6 months to 19 years. The secondary tumors involving the pancreas included metastatic carcinoma (24 cases), metastatic sarcoma (3 cases), diffuse large B-cell lymphoma (2 cases), and plasma cell neoplasm (2 cases). The most common metastatic tumors were renal cell carcinoma (8 cases) and lung carcinoma (7 cases). Correct diagnoses were rendered in 29 cases (94%). The remaining two cases were misclassified as primary pancreatic carcinoma. In both cases, the patients had no known history of malignancy, and no ancillary studies were performed.

CONCLUSIONS

Secondary tumors involving the pancreas can be accurately diagnosed by EUS-FNA. Recognizing uncommon cytomorphologic features, knowing prior history of malignancy, and performing ancillary studies are the keys to improve diagnostic performance and avoid diagnostic pitfalls.

Gastrointestinal Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy Specimens: Adequate Diagnostic Yield and Accuracy Can Be Achieved without On-Site Evaluation

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is the preferred method for biopsying the gastrointestinal tract, and rapid on-site cytological evaluation is considered standard practice. Our institution does not perform on-site evaluation; this study analyzes our overall diagnostic yield, accuracy, and incidence of nondiagnostic cases to determine the validity of this strategy.

DESIGN

Data encompassing clinical information, procedural records, and cytological assessment were analyzed for gastrointestinal EUS-FNA procedures (n = 85) performed at Vancouver General Hospital from January 2012 to January 2013. We compared our results with those of studies that had on-site evaluation and studies that did not have on-site evaluation.

RESULTS

Eighty-five biopsies were performed in 78 patients, from sites that included the pancreas, the stomach, the duodenum, lymph nodes, and retroperitoneal masses. Malignancies were diagnosed in 45 (53%) biopsies, while 24 (29%) encompassed benign entities. Suspicious and atypical results were recorded in 8 (9%) and 6 (7%) cases, respectively. Only 2 (2%) cases received a cytological diagnosis of 'nondiagnostic'. Our overall accuracy was 72%, our diagnostic yield was 98%, and our nondiagnostic rate was 2%. Our results did not significantly differ from those of studies that did have on-site evaluation.

CONCLUSION

Our study highlights that adequate diagnostic accuracy can be achieved without on-site evaluation.

PanGen-Fam: Spanish registry of hereditary pancreatic cancer

PURPOSE

To describe the organisation of the registry and the preliminary results in terms of characteristics of high-risk pancreatic ductal adenocarcinoma (PDAC) families recruited to date and findings of the screening programme. To compare early onset sporadic cases (⩽50 years), sporadic cases (>50 years) and cases with family history of cancer, for PDAC possible risk factors.

METHODS/PATIENTS

Families with hereditary cancer syndromes predisposing to PDAC were recruited from two main sources: Spanish hospitals participating in PanGenEU, a pan-European multicentre case-control study, and their genetic counseling unit. Individuals at high-risk of PDAC were enrolled into a screening programme, consisting of Endoscopic ultrasound, computerised tomography, magnetic resonance imaging. Genetic testing of candidate genes was offered according to each patient's risk.

RESULTS

Among 577 consecutive PDAC cases, recruited via PanGenEU, 36 (6%) had ⩾2 first-degree relative with PDAC: Familial pancreatic cancer (FPC). So far PanGen-Fam has recruited 42 high-risk PDAC families; 25 (60%) had FPC. Five index cases with cancer were positive for BRCA2 and one for BRCA1 germline mutations. In the second year of prospective PDAC screening, one neuroendocrine tumour and a high-grade dysplasia lesion suspicious of carcinoma were diagnosed among 41 high-risk individuals. Furthermore EUS detected chronic-pancreatitis-like parenchymal changes in 15 patients.

CONCLUDING STATEMENT

The identification and recruitment of PDAC high-risk families into the PanGen-Fam registry provides an opportunity to detect early onset cancer and precursor pancreatic cancer lesions at a potentially curative stage and to increase the knowledge of the natural history of the disease.

Borderline resectable pancreatic cancer

Borderline resectable pancreatic cancer (BRPC) is an evolving diagnostic entity that blurs the distinction between resectable and locally advanced pancreatic cancer (Varadhachary et al. Ann Surg Oncol 13:1035-1046, 2006). Until recently the management of this disease has been poorly defined; however, consensus guidelines have been developed regarding the proper management of this diagnostic entity. Recent studies have shown that if appropriately identified and treated, this subset of disease can have outcomes similar to pancreatic cancer that is defined as resectable (Laurence et al. J Gastrointest Surg 15:2059-2069, 2011). The aim of this review is to outline the current consensus on definitions, workup and management of BRPC, and also provide a summary of issues that require progress as defined by the International Study Group of Pancreatic Surgery (ISGPS).

Differentiation of pancreatic ductal adenocarcinoma from other neoplastic solid pancreatic lesions: a tertiary oncology center experience

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC), pancreatic neuroendocrine tumors (pNET), and metastatic lesions (pMET) are the most common neoplastic solid pancreatic lesions (SPLs). Early diagnosis enables prompt treatment.

OBJECTIVE

To identify factors differentiating PDAC from non-PDAC lesions and assess the accuracy of EUS-guided FNA.

DESIGN AND SETTING

Retrospective tertiary center.

PATIENTS AND INTERVENTION

Consecutive patients referred for EUS evaluation of SPLs from 2004 to 2011.

MAIN OUTCOME MEASUREMENTS

Pretest (preceding EUS-guided FNA [EUS-FNA]) predictors of PDAC among neoplastic SPLs and accuracy of EUS-FNA.

RESULTS

A total of 1333 EUS scans with 1108 EUS-FNAs were performed for pancreatic lesions. Of the 672 patients with neoplastic SPLs, 528 had PDAC and 144 non-PDAC. The sensitivity, specificity, positive predictive value, and accuracy of EUS-FNA for the diagnosis of PDAC were 97.3%, 99.3%, 99.8%, and 97.8%, respectively. Years of EUS experience significantly correlated with fewer needle passes (Rs = -0.18, P < .001). Controlling for all potential confounders, multivariable regression analysis demonstrated that patients with PDAC compared with pNETs and pMETs were older (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.1-9.5; P < .001), had weight loss (OR 3.0; 95% CI, 1.6-5.4; P < .001), hyperbilirubinemia (OR 3.7; 95% CI, 1.8-7.5; P < .001), elevated CA19-9 (OR 6.9; 95% CI, 2.4-20.3; P < .01), evidence of arterial invasion (OR 6.5; 95% CI, 2.7-15.4; P < .001), and PD dilation (OR 3.3; 95% CI, 1.8-5.9; P < .001).

LIMITATIONS

Retrospective design, single center.

CONCLUSIONS

When evaluating neoplastic SPLs, demographic, clinical, laboratory, and imaging characteristics can reliably discern and suggest PDAC. In addition, EUS-FNA is exceedingly sensitive and specific for PDAC.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Role of endoscopy in the diagnosis of autoimmune pancreatitis and immunoglobulin G4-related sclerosing cholangitis

Autoimmune pancreatitis (AIP) must be differentiated from pancreatic carcinoma, and immunoglobulin (Ig)G4-related sclerosing cholangitis (SC) from cholangiocarcinoma and primary sclerosing cholangitis (PSC). Pancreatographic findings such as a long narrowing of the main pancreatic duct, lack of upstream dilatation, skipped narrowed lesions, and side branches arising from the narrowed portion suggest AIP rather than pancreatic carcinoma. Cholangiographic findings for PSC, including band-like stricture, beaded or pruned-tree appearance, or diverticulum-like outpouching are rarely observed in IgG4-SC patients, whereas dilatation after a long stricture of the bile duct is common in IgG4-SC. Transpapillary biopsy for bile duct stricture is useful to rule out cholangiocarcinoma and to support the diagnosis of IgG4-SC with IgG4-immunostaining. IgG4-immunostaining of biopsy specimens from the major papilla advances a diagnosis of AIP. Contrast-enhanced endoscopic ultrasonography (EUS) and EUS elastography have the potential to predict the histological nature of the lesions. Intraductal ultrasonographic finding of wall thickening in the non-stenotic bile duct on cholangiography is useful for distinguishing IgG4-SC from cholangiocarcinoma. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is widely used to exclude pancreatic carcinoma. To obtain adequate tissue samples for the histological diagnosis of AIP, EUS-Tru-cut biopsy or EUS-FNA using a 19-gauge needle is recommended, but EUS-FNA with a 22-gauge needle can also provide sufficient histological samples with careful sample processing after collection and rapid motion of the FNA needles within the pancreas. Validation of endoscopic imaging criteria and new techniques or devices to increase the diagnostic yield of endoscopic tissue sampling should be developed.

Expression of KOC, S100P, mesothelin and MUC1 in pancreatico-biliary adenocarcinomas: development and utility of a potential diagnostic immunohistochemistry panel

BACKGROUND

Pancreatico-biliary adenocarcinomas (PBA) have a poor prognosis. Diagnosis is usually achieved by imaging and/or endoscopy with confirmatory cytology. Cytological interpretation can be difficult especially in the setting of chronic pancreatitis/cholangitis. Immunohistochemistry (IHC) biomarkers could act as an adjunct to cytology to improve the diagnosis. Thus, we performed a meta-analysis and selected KOC, S100P, mesothelin and MUC1 for further validation in PBA resection specimens.

METHODS

Tissue microarrays containing tumour and normal cores in a ratio of 3:2, from 99 surgically resected PBA patients, were used for IHC. IHC was performed on an automated platform using antibodies against KOC, S100P, mesothelin and MUC1. Tissue cores were scored for staining intensity and proportion of tissue stained using a Histoscore method (range, 0-300). Sensitivity and specificity for individual biomarkers, as well as biomarker panels, were determined with different cut-offs for positivity and compared by summary receiver operating characteristic (ROC) curve.

RESULTS

The expression of all four biomarkers was high in PBA versus normal ducts, with a mean Histoscore of 150 vs. 0.4 for KOC, 165 vs. 0.3 for S100P, 115 vs. 0.5 for mesothelin and 200 vs. 14 for MUC1 (p < .0001 for all comparisons). Five cut-offs were carefully chosen for sensitivity/specificity analysis. Four of these cut-offs, namely 5%, 10% or 20% positive cells and Histoscore 20 were identified using ROC curve analysis and the fifth cut-off was moderate-strong staining intensity. Using 20% positive cells as a cut-off achieved higher sensitivity/specificity values: KOC 84%/100%; S100P 83%/100%; mesothelin 88%/92%; and MUC1 89%/63%. Analysis of a panel of KOC, S100P and mesothelin achieved 100% sensitivity and 99% specificity if at least 2 biomarkers were positive for 10% cut-off; and 100% sensitivity and specificity for 20% cut-off.

CONCLUSION

A biomarker panel of KOC, S100P and mesothelin with at least 2 biomarkers positive was found to be an optimum panel with both 10% and 20% cut-offs in resection specimens from patients with PBA.

Endoscopic ultrasonography for surveillance of individuals at high risk for pancreatic cancer

Pancreatic cancer is a highly lethal disease with a genetic susceptibility and familial aggregation found in 3%-16% of patients. Early diagnosis remains the only hope for curative treatment and improvement of prognosis. This can be reached by the implementation of an intensive screening program, actually recommended for individuals at high-risk for pancreatic cancer development. The aim of this strategy is to identify pre-malignant precursors or asymptomatic pancreatic cancer lesions, curable by surgery. Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) seems to be the most promising technique for early detection of pancreatic cancer. It has been described as a highly sensitive and accurate tool, especially for small and cystic lesions. Pancreatic intraepithelial neoplasia, a precursor lesion which is highly represented in high-risk individuals, seems to have characteristics chronic pancreatitis-like changes well detected by EUS. Many screening protocols have demonstrated high diagnostic yields for pancreatic pre-malignant lesions, allowing prophylactic pancreatectomies. However, it shows a high interobserver variety even among experienced endosonographers and a low sensitivity in case of chronic pancreatitis. Some new techniques such as contrast-enhanced harmonic EUS, computer-aided diagnostic techniques, confocal laser endomicroscopy miniprobe and the detection of DNA abnormalities or protein markers by FNA, promise improvement of the diagnostic yield of EUS. As the resolution of imaging improves and as our knowledge of precursor lesions grows, we believe that EUS could become the most suitable method to detect curable pancreatic neoplasms in correctly identified asymptomatic at-risk patients.

Predictive value of intra-abdominal lymph nodes in pancreatic endoscopic ultrasonography-guided fine-needle aspiration biopsy

INTRODUCTION

Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) biopsy is a commonly used method for the evaluation of pancreatic lesions. EUS-guided FNA of the intra-abdominal lymph nodes (LNs) can provide critical diagnostic information that is important for clinical management and tumor staging. This study examines the predictive value of intra-abdominal LN EUS-guided FNA biopsy associated with pancreatic lesions.

MATERIALS AND METHODS

Over a 10-year period, the pathology database was searched for patients with concurrent pancreas and intra-abdominal LN EUS-guided FNA biopsy. The corresponding reports were reviewed, and clinical information and diagnostic results were recorded.

RESULTS

There were 252 cases where both a pancreas lesion and intra-abdominal LN were biopsied. Of this group, 182 LNs were classified as negative (72%), 47 as positive (19%), and 23 as atypical (9%). Within the negative LN cohort, the pancreas FNAs fell into the following diagnostic categories: benign (47%), malignant (30%), and atypical/suspicious (23%). Within the positive LN cohort, the pancreas lesion correlated with the following diagnostic categories: malignant (89%), atypical (4%), and suspicious (6%). A positive LN EUS-guided FNA biopsy had a 98% positive predictive value for malignancy. Within the atypical LN cohort, the pancreas correlated with the following diagnostic categories: malignant (57%), atypical/suspicious (26%), and benign (17%).

CONCLUSIONS

An atypical LN diagnostic category is strongly associated with a malignant pancreas lesion. A positive LN EUS-guided FNA biopsy has a 98% positive predictive value for pancreatic malignancy. A positive diagnostic category for an intra-abdominal LN can provide strong predictive evidence of a corresponding malignancy of the pancreas.

Basic techniques in endoscopic ultrasound-guided fine needle aspiration for solid lesions: Adverse events and avoiding them

Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is often the preferred technique for tissue acquisition in the diagnosis of suspected intrathoracic and intraabdominal pathology. Although EUS FNA is a safe and accurate procedure, it has been associated with a low risk of adverse events. The unique properties of the echoendoscope and its ability to acquire tissue outside of the gastrointestinal lumen impart risks that are not associated with routine endoscopic procedures. In this review, we discuss the risk of perforation related to the echoendoscope itself and adverse events related to FNA of solid masses including infections, bleeding, pancreatitis and pancreatic duct leak, bile duct leak and tumor seeding. We also provide tips on how to avoid the most common adverse events related to EUS-FNA.

Yield of Contrast-Enhanced Power Doppler Endoscopic Ultrasonography and Strain Ratio Obtained by EUS-Elastography in the Diagnosis of Focal Pancreatic Solid Lesions

OBJECTIVE

Although endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is the gold standard for diagnosing pancreatic lesions, its negative predictive value is suboptimal. Our aim was to evaluate the yield of contrast-enhanced EUS (CED-EUS) and of strain ratio EUS-elastography (SR-E-EUS) for differentiating pancreatic solid lesions.

METHODS

Forty-seven patients (27 men, 20 women, 70 ± 11 years) were consecutively involved in this single-center, prospective study. They were submitted to EUS, SR-E-EUS, CED-EUS with Sonovue(®), and EUS-FNA. The final diagnosis was based on the histological assessment of EUS-FNA and/or surgical specimens when available, and on follow-up of at least 6 months.

RESULTS

From the 47 focal pancreatic lesions included, 13 (28%) were benign and 34 (72%) malignant. Patients with malignancy were older (70 ± 11 vs. 61 ± 8, P = 0.003), and had larger lesions (34 ± 12 mm vs. 22 ± 11 mm, P = 0.03). Malignant lesions had higher SR-E-EUS (31 ± 32 vs. 8 ± 9, P = 0.001) and more hypovascular pattern (93% vs. 33%, P < 0.001). Logistic regression determined that only hypovascularity (OR = 2.6, 95%CI: 1.5-130, P = 0.02) was independently predictive of malignancy. ROC analysis for SR-E-EUS yielded an optimal cutoff of 8 (AUC 0.91, 95%CI: 0.74-0.98) for the best power distinction for malignancy. There was no significant difference concerning sensitivity (79%, 90%, 93%) and specificity rates (85%, 75%, 67%) of EUS-FNA, SR-E-EUS, and CED-EUS, respectively. By analysis of the inconclusive EUS-FNA subset (9 patients, 19%), SR-E-EUS > 8 and hypovascularity showed sensitivity of 80% and 100%, and specificity of 67% and 67%, respectively.

CONCLUSION

The clinical utility of CED-EUS and SR-E-EUS remains questionable. The accuracies of CED-EUS and SR-E-EUS are similar to EUS-FNA. Hypovascularity was independently predictive of malignancy. Patients with inconclusive EUS-FNA could benefit from CED-EUS due to the high sensitivity of hypovascularity for diagnosing malignancy.

Accuracy of endoscopic ultrasound in the evaluation of cystic pancreatic neoplasms: a community hospital experience

OBJECTIVES

Reports on the use of endoscopic ultrasound (EUS) in differentiating benign, premalignant, and malignant pancreatic lesions have been widely variable, particularly with cystic neoplasms. We evaluated the use of EUS for cystic pancreatic lesions in a community hospital setting.

METHODS

All patients who underwent EUS for cystic pancreatic neoplasms from 2007 to 2010 were reviewed. A final EUS diagnosis was determined based on the examiner's impression and fine-needle aspiration results if available. Lesions were stratified as benign, premalignant, or malignant. Patients underwent surgical resection, serial imaging studies, or medical oncology/palliative care consultation as indicated.

RESULTS

One hundred eighteen patients with cystic pancreatic lesions underwent EUS during the study period. Endoscopic ultrasound diagnoses included 75 benign (63.6%), 35 premalignant (29.7%), and 8 malignant (4.2%) lesions. Thirty-eight patients (32.2%) underwent surgery, 77 (65.3%) were monitored with imaging, and 3 (2.5%) had unresectable malignancies. Elevated carcinoembryonic antigen levels showed a trend toward predicting mucinous cysts (P = 0.062). Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for cystic lesions were 87.3%, 86.8%, 87.5%, 76.7%, and 93.3%, respectively.

CONCLUSIONS

Endoscopic ultrasound is a valuable diagnostic modality in the evaluation of cystic pancreatic neoplasms in a community hospital setting.

Impact of rapid on-site evaluation on the adequacy of endoscopic-ultrasound guided fine-needle aspiration of solid pancreatic lesions: a systematic review and meta-analysis

BACKGROUND

Rapid on-site evaluation (ROSE) has the potential to improve adequacy rates for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solid pancreatic lesions, but its impact is context-dependent. No studies exist that summarize the relationship between ROSE, number of needle passes, and resulting adequacy rates.

AIMS

To analyze data from previous studies to establish if ROSE is associated with improved adequacy rates; to evaluate the relationship between ROSE, number of needle passes, and the resulting adequacy rates of EUS-FNA for solid pancreatic lesions.

METHODS

Systematic review and meta-analysis of studies reporting the adequacy rates for EUS-FNA of solid pancreatic lesions.

RESULTS

The search produced 3822 original studies, of which 70 studies met our inclusion criteria. The overall average adequacy rate was 96.2% (95% confidence interval: 95.5, 96.9). ROSE was associated with a statistically significant improvement of up to 3.5% in adequacy rates. There was heterogeneity in adequacy rates across all subgroups. No association between the assessor type and adequacy rates was found. Studies with ROSE have high per-case adequacy and a relatively high number of needle passes in contrast to non-ROSE studies. ROSE is an effect modifier of the relationship between number of needle passes and adequacy.

CONCLUSIONS

ROSE is associated with up to 3.5% improvement in adequacy rates for EUS-FNA of solid pancreatic lesions. ROSE assessor type has no impact on adequacy rates. ROSE is an effect modifier on the relationship between needle passes and per-case adequacy for EUS-FNA of solid pancreatic lesions.

Significance of the diagnostic categories "atypical" and "suspicious for malignancy" in the cytologic diagnosis of solid pancreatic masses

Endoscopic ultrasound guided (EUS) fine-needle aspiration (FNA) investigation of solid pancreatic lesions has been shown to have good sensitivity and specificity. Many lesions can be definitely classified as benign or malignant but some can only be cytologically classified as "atypical" or "suspicious for malignancy". Risk for malignancy in these indeterminate categories has not been well categorized. The cytology records of four University Medical centers were searched for all EUS guided FNAs of solid pancreatic lesions. All cases with a diagnosis of "atypical", or "suspicious for malignancy" were selected for analysis when histologic biopsy or over 18 months clinical follow-up was available. Two hundred and ninety-two cases with a diagnosis of "atypical" or "suspicious for malignancy" and adequate follow-up were obtained from the combined data of the four institutions. The percentage malignant for the categories "atypical" and "suspicious for malignancy" were 79.2 and 96.3%, respectively. If the category "atypical" was classified as benign and "suspicious for malignancy" was classified as malignant, the resulting positive predictive value was 96.3 (95% CI: 92.6-98.5) and the negative predictive value 20.8 (95% CI: 13.4-30.0). The categories of "atypical" and "suspicious for malignancy" stratify risk for malignancy in a fashion, which may aid in patient counseling and selection of follow-up protocols. Classification of "suspicious for malignancy" as malignant optimizes diagnostic sensitivity and specificity.