Endoscopic ultrasonographic diagnosis of pancreatic cancer complicating chronic pancreatitis

Endoscopic Ultrasound in Cancer Staging

The authors review the role of endoscopic ultrasound (EUS) in the staging of cancers throughout the gastrointestinal tract. EUS offers an advantage over cross-sectional imaging in locoregional tumor staging but is less sensitive in identifying distant metastasis. The addition of FNA increases diagnostic accuracy and provides a tissue diagnosis. EUS combined with cross-sectional imaging is important in accurately staging GI tumors and thereby reducing unnecessary procedures and health care costs.

Pancreatic Cancer in Chronic Pancreatitis: Pathogenesis and Diagnostic Approach

Chronic pancreatitis is one of the main risk factors for pancreatic cancer, but it is a rare event. Inflammation and oncogenes work hand in hand as key promoters of this disease. Tobacco is another co-factor. During alcoholic chronic pancreatitis, the cumulative risk of cancer is estimated at 4% after 15 to 20 years. This cumulative risk is higher in hereditary pancreatitis: 19 and 12% in the case of PRSS1 and SPINK1 mutations, respectively, at an age of 60 years. The diagnosis is difficult due to: (i) clinical symptoms of cancer shared with those of chronic pancreatitis; (ii) the parenchymal and ductal remodeling of chronic pancreatitis rendering imaging analysis difficult; and (iii) differential diagnoses, such as pseudo-tumorous chronic pancreatitis and paraduodenal pancreatitis. Nevertheless, the occurrence of cancer during chronic pancreatitis must be suspected in the case of back pain, weight loss, unbalanced diabetes, and jaundice, despite alcohol withdrawal. Imaging must be systematically reviewed. Endoscopic ultrasound-guided fine-needle biopsy can contribute by targeting suspicious tissue areas with the help of molecular biology (search for KRAS, TP53, CDKN2A, DPC4 mutations). Short-term follow-up of patients is necessary at the clinical and paraclinical levels to try to diagnose cancer at a surgically curable stage. Pancreatic surgery is sometimes necessary if there is any doubt.

Atypical and uncommon CT and MR imaging presentations of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinomas (PDACs) occasionally have atypical and uncommon imaging presentations that can present a diagnostic dilemma and result in false interpretation. This article aimed to illustrate these CT and MR imaging findings, including isoattenuating PDAC, coexisting acute pancreatitis, PDAC with a cystic feature, groove PDAC, diffuse PDAC, hypointensity on diffusion-weighted imaging (DWI), multifocal PDAC, intratumoral calcification, and extrapancreatic invasion with a barely discernable mass. A subset of PDACs with atypical features are occasionally encountered during routine clinical practice. Knowledge of and attention to these atypical and uncommon variable imaging features may allow radiologists to avoid misinterpretation and a delayed diagnosis.

International consensus guidelines on surveillance for pancreatic cancer in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club

BACKGROUND

Patients with chronic pancreatitis (CP) have an increased risk of pancreatic cancer. We present the international consensus guidelines for surveillance of pancreatic cancer in CP.

METHODS

The international group evaluated 10 statements generated from evidence on 5 questions relating to pancreatic cancer in CP. The GRADE approach was used to evaluate the level of evidence available per statement. The working group voted on each statement for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient.

RESULTS

In the following domains there was strong consensus: (1) the risk of pancreatic cancer in affected individuals with hereditary pancreatitis due to inherited PRSS1 mutations is high enough to justify surveillance; (2) the risk of pancreatic cancer in patients with CP associated with SPINK1 p. N34S is not high enough to justify surveillance; (3) surveillance should be undertaken in pancreatic specialist centers; (4) surveillance should only be introduced after the age of 40 years and stopped when the patient would no longer be suitable for surgical intervention. All patients with CP should be advised to lead a healthy lifestyle aimed at avoiding risk factors for progression of CP and pancreatic cancer. There was only moderate or weak agreement on the best methods of screening and surveillance in other types of environmental, familial and genetic forms of CP.

CONCLUSIONS

Patients with inherited PRSS1 mutations should undergo surveillance for pancreatic cancer, but the best methods for cancer detection need further investigation.

Imaging of Tropical Chronic Pancreatitis—A Unique Clinico-Radiological Entity

Tropical chronic pancreatitis (TCP) is a unique juvenile nonalcoholic form of chronic pancreatitis prevalent in tropical developing countries. TCP is characterized by the younger age of onset, rapid progression, higher prevalence of diabetes and pancreatic calculi, and greater propensity to develop pancreatic malignancy. Identifying the distinct imaging features is critical for the diagnosis of TCP. Awareness of this condition will not only enable the radiologist to recognize it early but also help in better management. In this article, we review the etiopathogenesis, distinct imaging features, and complications of TCP.

Discriminating chronic pancreatitis from pancreatic cancer: Contrast-enhanced EUS and multidetector computed tomography in direct comparison

BACKGROUND AND OBJECTIVES

To compare the ability of multidetector computed tomography (MDCT) and contrast-enhanced EUS to discriminate chronic pancreatitis (CP) from pancreatic ductal adenocarcinoma (PDAC).

SUBJECTS AND METHODS

A total of 215 patients (age: 62 ± 15 years, sex: f/m 80/135) were included in this retrospective study. All patients were examined by conventional endoscopic B-mode and contrast-enhanced high mechanical index EUS (CEHMI-EUS). CELMI-EUS was performed in 159 patients and endoscopic sonoelastography (ESE) in 210 patients. MDCT was carried out in 131 patients as part of their clinical work-up. Radiological reports were retrospectively analyzed. Final diagnosis was achieved by biopsy and evaluation of cytological specimens collected was performed by EUS-FNA, surgery, or follow-up of 12 months or more in patients with benign findings. In a subgroup of 100 patients, all diagnostic five methods were performed, and head-to-head analysis was performed.

RESULTS

Sensitivity and specificity for MDCT were 89% and 70% and for CEHMI-EUS were 96% and 91%, respectively. Sensitivities and specificities for EUS were 92% and 63% for B-Mode EUS, 96% and 38% for ESE, and 82% and 76% for CELMI-EUS, respectively. In the head-to-head analysis, each modality had shown lower numbers for specificity than shown in the overall group analysis because of high drop-out rate. EUS-FNA for PDAC had a sensitivity of 96% and a specificity of 100%.

CONCLUSIONS

Contrast-enhanced EUS is a reliable tool in discriminating PDAC from CP.

Endoscopic ultrasound of pancreatic tumors

Computed tomography (CT) and endoscopic ultrasound (EUS) are the two most effective techniques for the assessment of pancreatic cancers. CT has revolutionized the field of tumor imaging in pancreatic cancer and is now a well-established imaging technique for diagnosis and staging. However, EUS still plays an important role in several situations, especially when the diagnosis is uncertain or when histopathological confirmation of the lesion is needed. Similarly, regarding cystic lesions, magnetic resonance imaging and CT have very good performances but are often inadequate because the diagnosis can be difficult to establish, while the consequences for the patient are major. New biopsy needles, the use of elastography and ultrasonographic contrast agents, and confocal laser endomicroscopy can also provide additional and essential information to improve diagnosis confidence of pancreatic lesions with EUS.

Role of endoscopic ultrasound in the diagnosis of pancreatic cancer

Endoscopic ultrasonography (EUS) with or without fine needle aspiration has become the main technique for evaluating pancreatobiliary disorders and has proved to have a higher diagnostic yield than positron emission tomography, computed tomography (CT) and transabdominal ultrasound for recognising early pancreatic tumors. As a diagnostic modality for pancreatic cancer, EUS has proved rates higher than 90%, especially for lesions less than 2-3 cm in size in which it reaches a sensitivity rate of 99% vs 55% for CT. Besides, EUS has a very high negative predictive value and thus EUS can reliably exclude pancreatic cancer. The complication rate of EUS is as low as 1.1%-3.0%. New technical developments such as elastography and the use of contrast agents have recently been applied to EUS, improving its diagnostic capability. EUS has been found to be superior to the recent multidetector CT for T staging with less risk of overstaying in comparison to both CT and magnetic resonance imaging, so that patients are not being ruled out of a potentially beneficial resection. The accuracy for N staging with EUS is 64%-82%. In unresectable cancers, EUS also plays a therapeutic role by means of treating oncological pain through celiac plexus block, biliary drainage in obstructive jaundice in patients where endoscopic retrograde cholangiopancreatography is not affordable and aiding radiotherapy and chemotherapy.

Follow-up of patients with pseudotumoral chronic pancreatitis: Outcome and surveillance

AIM: To follow up patients with pseudotumoral chronic pancreatitis (PCP) to assess their outcome and identify an optimal surveillance interval.

METHODS: Data obtained prospectively were analyzed in a retrospective manner. Patients with clinical evidence of chronic pancreatitis (abdominal pain in the epigastrium, steatorrhea, and diabetes mellitus), endoscopic ultrasound (EUS) criteria > 4, and EUS-fine needle aspiration (FNA) were included. A pseudotumor was defined as a non-neoplastic space-occupying lesion, a cause of chronic pancreatitis that may mimic changes typical of pancreatic cancer on CT or endoscopic ultrasound but without histological evidence. A real tumor was defined as a neoplastic space-occupying lesion because of pancreatic cancer confirmed by histology.

RESULTS: Thirty-five patients with chronic pancreatitis were included, 26 (74.2%) of whom were men. Nine (25.7%) patients were diagnosed with pseudotumoral chronic pancreatitis and two (2/35; 5.7%) patients with pseudotumoral chronic pancreatitis were diagnosed with pancreatic cancer on follow-up. The time between the diagnosis of pseudotumoral chronic pancreatitis and pancreatic adenocarcinoma was 35 and 30 d in the two patients. Definitive diagnosis of pancreatic adenocarcinoma was made by surgery. In the remaining six patients with pseudotumoral chronic pancreatitis, the median of follow-up was 11 mo (range 1-22 mo) and they showed no evidence of malignancy on surveillance. In the follow-up of patients without pseudotumoral chronic pancreatitis but with chronic pancreatitis, none were diagnosed with pancreatic cancer. According to our data, older patients with chronic pancreatitis are at risk of pseudotumoral chronic pancreatitis.

CONCLUSION: According to characteristics of patient, detection of PCP should lead a surveillance program for pancreatic cancer with EUS-FNA in < 1 mo or directly to surgical resection.

Endoscopic ultrasonography for pancreatic cancer: current and future perspectives

A suspected pancreatic lesion can be a difficult challenge for the clinician. In the last years we have witnessed tumultuous technological improvements of the radiological and nuclear medicine imaging. Taking this into account, we will try to delineate the new role of endoscopic ultrasound (EUS) in pancreatic imaging and to place it in a shareable diagnostic and staging algorithm of pancreatic cancer (PC). To date the most accurate imaging techniques for the PC remain contrast-enhanced computed tomography (CT) and EUS. The latter has the highest accuracy in detecting small lesions, in assessing tumor size and lymph nodes involvement, but helical CT or an up-to-date magnetic resonance imaging (MRI) must be the first choice in patients with a suspected pancreatic lesion. After this first step there is place for EUS as a second diagnostic level in several cases: negative results on CT/MRI scans and persistent strong clinical suspicion of PC, doubtful results on CT/MRI scans or need for cyto-histological confirmation. In the near future there will be great opportunities for the development of diagnostic and therapeutic EUS and pancreatic pathology could be the best testing bench.

Novel quantitative perfusion analysis with contrast-enhanced harmonic EUS for differentiation of autoimmune pancreatitis from pancreatic carcinoma

OBJECTIVE

Autoimmune pancreatitis (AIP) is often misdiagnosed as pancreatic carcinoma (PC) despite recent advances in imaging tests. The aim of the study was to evaluate whether the quantitative perfusion analysis using software "Time intensity curve" with contrast-enhanced harmonic EUS (CH-EUS) facilitate the differentiation of AIP from PC.

METHODS

Consecutive patients with focal AIP and pancreatic carcinoma who underwent CH-EUS from January 2009 to September 2010 were analyzed. CH-EUS was performed with intravenous administration of an ultrasonographic contrast (Sonazoid) and electronic radial echoendoscope. The graph of time intensity curve (TIC) for pancreatic mass was generated to depict the changes in signal intensity over time within the region of interest (ROI). ROI was placed to cover an area with a pancreatic mass lesion. Based on the analysis of TIC, base intensity before injection (BI), peak intensity (PI), time to peak, and maximum intensity gain (MIG: PI-BI) were calculated.

RESULTS

Eight patients with focal AIP and twenty-two patients with PC were evaluated by TIC. PI and MIG of mass lesion of AIP were significantly higher than that of PC (21.4 dB vs. 9.6 dB, 17.5 vs. 6.6). Receiver operating characteristics analysis yielded an optimal MIG cutoff value of 12.5 with high sensitivity and specificity.

CONCLUSION

Pancreatic mass lesions of AIP and PC exhibited markedly different patterns with the TIC. This novel diagnostic modality using TIC generated by CH-EUS might offer an opportunity to improve accuracy in the differential diagnosis between pancreatic mass lesion of AIP and PC.

Endoscopic ultrasound in chronic pancreatitis: Where are we now?

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be fulfilled, but for diagnosis of severe CP at least six criteria are necessary. The Rosemont classification, more restrictive, aims to standardize the criteria and assigns different values to different features, but requires further validation. EUS-fine needle aspiration (EUS-FNA) is less advisable for diagnosis of diffuse CP due to its potential side effects. Elastography and contrast-enhanced EUS are orientation in differentiating a focal pancreatic mass in a parenchyma with features of CP, but they cannot replace EUS-FNA. The usefulness of EUS-guided celiac block for painful CP is still being debated with regard to the best technique and the indications. EUS-guided drainage of pseudocysts is preferred in non-bulging pseudocysts or in the presence of portal hypertension. EUS-guided drainage of the main pancreatic duct should be reserved for cases in which endoscopic retrograde cholangiopancreatography has failed owing to difficult cannulation of the papilla or difficult endotherapy. It should be performed only by highly skilled endoscopists, due to the high rate of complications.

Novel blood biomarkers of pancreatic cancer-associated diabetes mellitus identified by peripheral blood-based gene expression profiles

OBJECTIVES

The prognosis of pancreatic cancer is still very poor, and the ability to detect pancreatic cancer in high-risk groups at an early stage is therefore essential for improving its long-term survival. The purpose of this study was to explore specific biomarkers that can differentiate pancreatic cancer-associated diabetes from type 2 diabetes, for the early detection of pancreatic cancer.

METHODS

From January 2006 to July 2008, 102 peripheral blood samples were collected from 25 patients diagnosed with pancreatic cancer and diabetes, 27 patients with pancreatic cancer without diabetes, 25 patients with diabetes mellitus >5 years, and 25 healthy controls. Thirty-two samples were used in microarray experiments to find differentially expressed genes specific for pancreatic cancer-associated diabetes. The results were further validated by quantitative real-time PCR for 101 blood samples. Protein expression of selected genes in serum and tissues was also detected.

RESULTS

Using microarray analysis, we found 58 genes to be unique in patients with pancreatic cancer-associated diabetes, including 23 upregulated genes and 35 downregulated genes. Eleven upregulated genes were further validated by RT-PCR, and two of these genes-vanin-1 (VNN1) and matrix metalloproteinase 9 (MMP9)-were selected for logistic regression analysis. The combination of VNN1 and MMP9 showed the best discrimination of pancreatic cancer-associated diabetes from type 2 diabetes. The protein expression of MMP9 and VNN1 was in accordance with the gene expression.

CONCLUSIONS

Our results indicate that the combination of VNN1 and MMP9 may be used as a novel blood biomarker panel for the discrimination of pancreatic cancer-associated diabetes from type 2 diabetes.

Incidence and characteristics of chronic and lymphoplasmacytic sclerosing pancreatitis in patients scheduled to undergo a pancreatoduodenectomy

BACKGROUND

The determination of the exact nature of a pancreatic head mass in a patient scheduled to undergo a pancreatoduodenectomy can be very difficult. This is important as patients who suffer from benign disease such as pancreatitis do not always require surgery. The aim of the present study was to analyse the incidence of pancreatitis and the signs and symptoms associated with these tumours mistaken for pancreatic cancer and the diagnostic procedures performed.

METHODS

A consecutive group of patients who underwent a pancreatoduodenectomy between 1992 and 2005 with histopathologically proven pancreatic adenocarcinoma (PCA) and pancreatitis were analysed.

RESULTS

The incidence of pancreatitis after pancreatoduodenectomy is 63 out of 639 patients who underwent a pancreaticoduodenectomy (9.9%). Of these patients, 24 patients (38%) had lymphoplasmacytic sclerosing pancreatitis (LPSP) and 31 patients (49%) had focal chronic pancreatitis. Eight patients (13%) had an intermediate form with characteristics of both. Pancreatic adenocarcinoma occurred in 227 patients (36%). The presence of pancreatitis without a discrete mass on endoscopic ultrasonography (EUS) seemed to have clinical relevance with a positive likelihood ratio of 5.1. Mortality after resection was nil in both groups.

CONCLUSION

The incidence of pancreatitis is 9.9% for patients scheduled to undergo a pancreatoduodenectomy. Of these patients, 38% had LPSP, 13% had a intermediate form and 49% had focal chronic pancreatitis. The determination of the exact nature of a pancreatic head mass remains difficult.

Usefulness of 18F-FDG PET, combined FDG-PET/CT and EUS in diagnosing primary pancreatic carcinoma: a meta-analysis

The aim was to evaluate the diagnostic value of (18)F-fluorodeoxyglucose-positron emission tomography ((18)F-FDG PET), combined (18)F-fluorodeoxyglucose-positron emission tomography/computed tomography ((18)F-FDG PET/CT) and endoscopic ultrasonography (EUS) in diagnosing patients with pancreatic carcinoma. MEDLINE, EMBASE, Cochrane library and some other databases, from January 1966 to April 2009, were searched for initial studies. All the studies published in English or Chinese relating to the diagnostic value of (18)F-FDG PET, PET/CT and EUS for patients with pancreatic cancer were collected. Methodological quality was assessed. The statistic software called "Meta-Disc 1.4" was used for data analysis.

RESULTS

51 studies were included in this meta-analysis. The pooled sensitivity estimate for combined PET/CT (90.1%) was significantly higher than PET (88.4%) and EUS (81.2%). The pooled specificity estimate for EUS (93.2%) was significantly higher than PET (83.1%) and PET/CT (80.1%). The pooled DOR estimate for EUS (49.774) was significantly higher than PET (32.778) and PET/CT (27.105). SROC curves for PET/CT and EUS showed a little better diagnostic accuracy than PET alone. For PET alone, when interpreted the results with knowledge of other imaging tests, its sensitivity (89.4%) and specificity (80.1%) were closer to PET/CT. For EUS, its diagnostic value decreased in differentiating pancreatic cancer for patients with chronic pancreatitis. In conclusion, PET/CT was a high sensitive and EUS was a high specific modality in diagnosing patients with pancreatic cancer. PET/CT and EUS could play different roles during different conditions in diagnosing pancreatic carcinoma.

EUS-guided FNA of solid pancreatic masses: high yield of 2 passes with combined histologic-cytologic analysis

BACKGROUND

EUS-guided FNA (EUS-FNA) is an established tissue-acquisition technique, with most studies concentrating on cytologic analyses of specimens, with only few data existing on histologic assessment.

OBJECTIVE

To assess the sensitivity of a combined analysis of histologic followed by cytologic tissue diagnosis.

DESIGN

A retrospective 3-center study.

METHODS

In consecutive patients undergoing FNA of solid pancreatic masses, core specimens were harvested for histology; residual tissue was examined cytologically. Only unequivocally positive results were regarded as malignant. Criterion standards were positive results from EUS-FNA or other histologic findings, or, if negative, clinical follow-up data (minimum 12 months).

RESULTS

Among 192 patients (110 men; mean age 63 years) with mostly pancreatic-head masses (72.4%), overall, adequate tissue was obtained in 98.9% of all cases, with a mean of 1.88 needle passes and an overall sensitivity of 82.9% (95% CI, 76.0%-88.5%). Histology and subsequent cytology provided adequate tissue and sensitivities of 86.5% and 60%, and 92.7% and 68.1%, respectively. Excluding cases with inadequate specimens, sensitivities rose by 4% to 10%. Histology showed a trend for superiority over cytology only in characterizing nonadenocarcinoma tumor types. No differences in sensitivity were found between the centers involved.

LIMITATIONS

Retrospective design, different processing of cytologic specimens.

CONCLUSIONS

At EUS-FNA in pancreatic masses, combined histologic-cytologic analysis achieved a sensitivity of more than 80%, despite a low number of needle passes and may thus save time. Histology alone did not reach higher sensitivity than cytology. In particular situations, eg, rare tumors, histology may still be required.

Screening of high-risk families for pancreatic cancer

PURPOSE OF REVIEW

To discuss how to recognise and manage high-risk individuals.

RECENT FINDINGS

Publication of initial results of screening for pancreatic cancer from US centres. Several masses and premalignant lesions have been detected, but the detection of the first pancreatic cancer through an organised study of screening has yet to be published. There has been progress in risk stratification; the role of diabetes in predisposing for cancer has been characterised and molecular modalities have been published which could be used in conjunction with imaging in a screening programme. A mutation in the palladin gene was found to segregate with the disease in a family with a clear predisposition for pancreatic cancer, though this has yet to be found in other such kindreds.

SUMMARY

Significant challenges remain to be solved in screening for early pancreatic cancer. Risk stratification needs to be improved and high-risk patients included in research-based screening programmes. It will be impossible to confirm that screening can detect cancers early enough for curative treatment until the results of these prospective studies become available.

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.

Efficacy of endoscopic ultrasound in characterizing mass lesions in chronic pancreatitis

BACKGROUND AND GOALS

The aim of this study is to determine the influence of endoscopic ultrasound (EUS) in the detection of chronic pancreatitis and identification of pancreatic masses suspected by other radiographic imaging modalities in such a clinical background.

METHODS

Retrospective analysis was performed on 105 consecutive pancreatic EUS examinations in an 18-month period at a single tertiary care referral center. Analysis included 75 patients with a suspected pancreatic mass by computerized axial tomography, magnetic resonance imaging, ultrasound, or endoscopic retrograde cholangiopancreotography. All patients underwent EUS examination and if a mass was visualized, fine-needle aspiration biopsy was performed. Patients underwent either surgical exploration or clinical and radiographic follow-up for 6 months to confirm EUS findings.

RESULTS

Chronic pancreatitis was suspected in 53 individuals by clinical or radiographic methods. Using standard EUS parenchymal and ductal criteria, chronic pancreatitis was confirmed in 41 (77%) of patients. In 33 patients with chronic pancreatitis detected by EUS, initial referral was for pancreatic mass. Twenty-eight (85%) patients had an actual mass and the remainder were false-positive clinical findings. Thirty-two percent of pancreatic masses in chronic pancreatitis were found to be malignant adenocarcinoma and the rest were inflammatory in nature. Subset analysis showed EUS-fine-needle aspiration of solid lesions to have a sensitivity and specificity of 87.9% and 100%, respectively. Detection of cystic lesions had a sensitivity and specificity of 88.5% and 100%, respectively.

CONCLUSIONS

EUS is superior to other radiographic modalities in the determination of chronic pancreatitis and detection of mass lesions.

A clinical and economic evaluation of endoscopic ultrasound for patients at risk for familial pancreatic adenocarcinoma

BACKGROUND AND AIMS

Approximately 10% of pancreatic adenocarcinoma is familial. Approximately 50% of 1st-degree relatives (FDRs) have endoscopic ultrasound (EUS) findings of chronic pancreatitis. We modeled the natural history of these patients to compare 4 management strategies.

METHODS

We performed a systematic review, and created a Markov model for 45-year-old male FDRs, with findings of chronic pancreatitis on screening EUS. We compared 4 strategies: doing nothing, prophylactic total pancreatectomy (PTP), annual surveillance by EUS, and annual surveillance with EUS and fine needle aspiration (EUS/FNA). Outcomes incorporated mortality, quality of life, procedural complications, and costs.

RESULTS

In the Do Nothing strategy, the lifetime risk of cancer was 20%. Doing nothing provided the greatest remaining years of life, the lowest cost, and the greatest remaining quality-adjusted life years (QALYs). PTP provided the fewest remaining years of life, and the fewest remaining QALYs. Screening with EUS provided nearly identical results to PTP, and screening with EUS/FNA provided intermediate results between PTP and doing nothing. PTP provided the longest life expectancy if the lifetime risk of pancreatic cancer was at least 46%, and provided the most QALYs if the risk was at least 68%.

CONCLUSIONS

FDRs from familial pancreatic cancer kindreds, who have EUS findings of chronic pancreatitis, have increased risk for cancer, but their precise risk is unknown. Without the ability to further quantify that risk, the most effective strategy is to do nothing.

Evidence-based diagnosis and staging of pancreatic cancer

Only 20% of patients who present with pancreatic cancer will be amenable to potentially curative resection. Therefore, it is necessary to reliably identify patients who might benefit from major surgical intervention by employing the appropriate staging methods. In this review, the pros and cons of each imaging technique are discussed and an algorithm for single and combined use of the different imaging modalities is proposed. To date, contrast-enhanced multi-detector row helical CT (MDR-CT) together with endoscopic ultrasound (EUS) remain the first staging methods of choice. MDR-CT has a high sensitivity for identifying vascular invasion and EUS is able to detect lesions as small as 2-3 mm. ERCP is performed mainly in patients with biliary obstruction with the option for therapeutic intervention during the same session. MRI with MR-angiography, MRCP, PET/CT and staging laparoscopy are additional modalities which might give further information in cases of equivocal findings by MDR-CT and EUS. The role of tumour markers such as CA 19-9 and CEA is reserved for monitoring and diagnosing post-surgery recurrence. Cytological or histological confirmation should usually be performed in patients that are not eligible for surgery prior to the commencement of palliative radio- or chemotherapy. In the routine clinical setting, MDR-CT and EUS play the predominant roles by providing the most cost-effective and accurate means for diagnosing and staging most cases of pancreatic cancer.

Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis

BACKGROUND

Evaluation of a focal pancreatic mass in the setting of chronic pancreatitis (CP) is a diagnostic challenge. The objectives of the study were to compare the diagnostic yield and accuracy of EUS-guided FNA (EUS-FNA) in the evaluation of pancreatic-mass lesions in the presence or the absence of CP and to identify predictors of CP before EUS-FNA of pancreatic-mass lesions.

METHODS

The study design was analysis of data collected prospectively on all patients with solid pancreatic-mass lesions who underwent EUS-FNA at a tertiary referral center. A total of 282 consecutive patients underwent 300 EUS-FNA procedures of pancreatic-mass lesions over a 3-year period. The diagnostic yield and the accuracy of EUS-FNA was compared between patients with and without CP. CP was defined by the presence of more than 4 EUS criteria.

RESULTS

Final diagnosis was adenocarcinoma in 210 (70%), benign disease in 64 (21%), other pathology in 19 (6%), and indeterminate in 4 (2%); 3 patients (1%) were lost to follow-up. CP was noted in 75/300 (25%) patients. A lower sensitivity for EUS-FNA was observed in patients with CP than in those without CP (73.9% vs. 91.3%; p = 0.02). While patients with CP had a higher negative predictive value (88.9% vs. 45.5%; p < 0.001), no significant differences were observed for specificity (100% vs. 93.8%), positive predictive value (100% vs. 99.5%), and accuracy (91.5% vs. 91.4%) between those with and without CP. False-negative cytology was encountered in 24 cases: 6/71 (8%) with CP vs. 18/222 (8%) without CP. Patients with CP required more EUS-FNA passes to establish a diagnosis vs. those without CP (median, 5 vs. 2; p < 0.001). On multivariable analysis, age < 50 years (p < 0.001), male gender (p < 0.001), black race (p = 0.001), and the absence of jaundice (p = 0.005) were significantly associated with CP. The impact of EUS-FNA on long-term clinical management was not analyzed. The impact of individual EUS features of CP on sensitivity of EUS-FNA was not evaluated. By protocol, mass lesions that were benign required more passes to definitively exclude malignancy.

CONCLUSIONS

EUS-FNA has a low sensitivity for pancreatic-mass lesions in the setting of CP. This decreased sensitivity can be overcome by performing more numbers of passes at FNA, which improves diagnostic accuracy. Demographic features and clinical presentation are predictive of underlying CP in patients with pancreatic-mass lesions.

Pancreatic cancer after surgery for chronic pancreatitis

BACKGROUND

Chronic pancreatitis is known to be a risk factor for pancreatic cancer.

AIMS

To identify patients who were diagnosed with pancreatic cancer after undergoing surgery for histologically documented chronic pancreatitis.

PATIENTS/METHODS

Records of 484 consecutive patients who underwent surgery for chronic pancreatitis from 1976 to 1997 were reviewed.

RESULTS

Pancreatic cancer was diagnosed after a mean of 3.4 years (range: 2 months-1 years) in 14 patients (2.9%). In four patients, pancreatic cancer became evident within 12 months of surgery for chronic pancreatitis, suggesting cancer was present at the original surgery. Cancer presented with recurrent or persistent pain, jaundice, and/or weight loss. Pancreatic resection was possible in eight patients, but in the others, the cancer was inoperable. There was one long-term survivor (alive 14 years postoperatively), but for theothers mean survival was 10 months (16 months after resection vs. 4 months for inoperable cancer).

CONCLUSION

Pancreatic malignancy should be suspected in patients who have had surgery for chronic pancreatitis when symptoms (such as recurrent pain, jaundice, weight loss, or anorexia) recur. Attempts at curative pancreatic resection are indicated and can offer palliation and the potential for a cure.

Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis

OBJECTIVES

The clinical value of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic lesions is uncertain in patients with normal parenchyma and chronic pancreatitis. The aim of this study was to analyze the diagnostic yield and influence of EUS-FNA on the clinical management of patients with pancreatic lesions, in the presence (CP) or absence (NP) of chronic pancreatitis.

METHODS

A total of 207 consecutive patients with NP (n = 133) and CP (n = 74) were examined using linear array echo endoscopes for the procedure and 22-gauge needles.

RESULTS

Adequate specimens were obtained from 200 lesions. A correct final diagnosis was established at histology (n = 108), bacteriology (n = 9), and clinical follow-up (n = 83). Cytology gave 17 false-negative EUS-FNA results (overall sensitivity: 85%). In patients with NP, 60 solid adenocarcinomas were detected, 32 other malignancies, and 38 benign lesions, with 11 false-negative results (sensitivity: 89%). In patients with CP, only seven of 13 malignancies (all solid adenocarcinomas) were identified using FNA (sensitivity: 54%). Overall, malignancy was identified in 116 patients, 32 of whom (27%) had lesions other than primary solid adenocarcinomas. Management was altered in 25 of these patients, which changed the surgical approach in 21%. EUS-FNA influenced the therapeutic approach in 44% of the total patient group.

CONCLUSIONS

EUS-FNA was especially useful in patients with a focal pancreatic lesion with normal parenchyma. Its sensitivity in patients with CP was unacceptably low, and resection of the tumor using standard surgical techniques was still usually required to confirm the correct diagnosis. Diagnostic EUS-FNA influenced clinical management in nearly half of patients.

Early detection of pancreatic cancer in patients with chronic pancreatitis: diagnostic utility of a K-ras point mutation in the pancreatic juice

OBJECTIVE

Point mutations of the K-ras oncogene at codon 12 have been described several months before the onset of pancreatic cancer in isolated cases of chronic pancreatitis (CP). The aim of this study was to evaluate the interest of a prospective follow-up of patients with CP and K-ras mutations at codon 12 in the detection of early pancreatic cancer.

METHODS

From February 1996 to March 1998, 36 patients (mean age 52.6 yr, 31 men, five women) with CP (alcoholic: 61.1%, pancreas divisum: 5.6%, autoimmune: 5.6%, unknown origin: 27.7%) were included and then prospectively monitored (median duration of 22 months) for detection of pancreatic carcinoma. K-ras point mutations were examined by two-step polymerase chain reaction combined with restriction enzyme digestion in pancreatic juice collected during endoscopic retrograde pancreatography.

RESULTS

Ten patients (27.8%) were positive for K-ras mutation. Patients with and without the mutation were not different with respect to age and sex ratio. K-ras mutations were homogeneously distributed according to the etiology (alcoholic vs nonalcoholic) and morphological characteristics (ductal stricture or mass vs none) of CP. A pancreatic carcinoma was discovered at an invasive stage in two patients, respectively at 7 and 17 months after disclosure of a K-ras mutation, versus none in patients without the mutation (p < 0.02).

CONCLUSIONS

Presence of a K-ras gene mutation is not rare in patients with CP and represents an increased risk of developing pancreatic cancer. However, its utility for the detection of early pancreatic cancer remains doubtful in clinical practice.

EUS to detect evidence of pancreatic disease in patients with persistent or nonspecific dyspepsia

BACKGROUND

Mild chronic pancreatitis is difficult to diagnose and the diagnosis is therefore not sought routinely in patients with dyspepsia. The aim of our study was to compare the prevalence of endosonographic pancreatic abnormalities in patients with dyspepsia and control subjects.

METHODS

The number of endosonographic abnormalities was compared prospectively in patients with dyspepsia and control patients. Patients in whom there was any suspicion of pancreatic disease were analyzed separately.

RESULTS

Between November 1998 and January 1999, 156 patients with dyspepsia were compared with 27 control patients. The groups were similar except that control patients were significantly older and more likely to be men. The mean number of endosonographic abnormalities was higher in dyspeptic patients than in control patients (mean number of abnormalities 3.3: 95% CI [2.9, 3.6] vs. 1.9: 95% CI [0.3, 1.7]). The strongest independent predictors of severe endosonographic abnormalities (defined as 5 or more abnormalities) were the presence of suspected pancreatic disease (odds ratio 7.29: 95% CI [2.03, 26. 14]) and dyspepsia (odds ratio 7.21: 95% CI [1.99, 26.26]). In the dyspepsia group, no clinical variables were significant predictors of severe abnormalities. However, most patients had nonspecific-type dyspepsia or persistent symptoms after therapeutic trials of acid suppression.

CONCLUSIONS

Dyspepsia may be an atypical presentation of pancreatic disease in patients with persistent or nonspecific symptoms. Endosonography may be useful to screen for pancreatic disease in patients with persistent dyspepsia.

Screening for early pancreatic ductal adenocarcinoma in hereditary pancreatitis

Patients with hereditary pancreatitis have a 40% lifetime risk of developing pancreatic ductal adenocarcinoma. Existing methods of diagnosing pancreatic cancer such as tumor markers, endoscopy, and radiological imaging lack the sensitivity and specificity for early diagnosis, particularly in a background of chronic pancreatitis. Molecular based strategies offer new avenues of screening for pancreatic ductal adenocarcinoma in these high-risk patients, which may allow the development of highly sensitive and specific diagnostic tests for the early detection of cancer.

Factors predicting the number of EUS-guided fine-needle passes for diagnosis of pancreatic malignancies

BACKGROUND

The factors that affect the number of needle passes needed to diagnose pancreatic malignancies using endoscopic ultrasound (EUS) -guided fine-needle aspiration are unknown.

METHODS

Patient and endosonographic data were prospectively recorded on 121 consecutive patients with pancreatic malignancy. Of these, 110 underwent EUS-guided fine-needle aspiration. A cytopathologist was in attendance for all aspiration procedures.

RESULTS

Initial EUS detected a pancreatic mass in 96% of cases; 23% of these were not seen by computed tomography. EUS-guided fine-needle aspiration was performed in 109 of 110 (99%) patients, including 95 masses, 7 lymph nodes, and 7 hepatic metastases. EUS-guided fine-needle aspiration provided a cytologic diagnosis of malignancy in 104 of 110 (95%). Only tumor differentiation and the site of aspiration affected the number of passes.

CONCLUSIONS

With the participation of a cytopathologist, EUS-guided fine-needle aspiration can diagnose pancreatic malignancies with a high degree of accuracy. Only the aspiration site (mass versus node/liver metastasis) can be used to direct the number of passes if a cytopathologist is not present. Without a cytopathologist in attendance, 5 to 6 passes should be made for pancreatic masses and 2 to 3 for liver metastases or lymph nodes; however, this approach will be associated with a 10% to 15% reduction in definitive cytologic diagnoses, extra procedure time, increased risk and additional needles.

The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer

Endoscopy plays an important role in the diagnosis and treatment of acute and chronic pancreatitis as well as pancreatic cancer. Sphincterotomy and stone removal in biliary pancreatitis, stone extraction and drainage in chronic pancreatitis, and stent implantation in pancreatic cancer are the predominant procedures. With endoscopy, minimal invasive techniques are at hand to solve urgent and long term problems.

Pancreatic cancer in patients with chronic pancreatitis: a challenge from a surgical perspective

Chronic pancreatitis (CP) is generally considered as a risk factor for pancreatic adenocarcinoma (PAC). However, the cumulative risk differs among the epidemiological studies. In the individual patient, the differential diagnosis between PAC and CP cannot be always resolved preoperatively and even intraoperatively. In those cases, the uncertainty can only be answered with histological studies of the resected specimen after a radical resection, provided that this type of surgery can be performed with a reasonable risk in a surgically fit patient. The type of resection depends on the location of the suspicious mass. For masses in the tail of the pancreas, a distal pancreatectomy is the procedure of choice. For suspicious lesions in the head of the pancreas, a pancreatoduodenectomy (PD) should be performed. The surgeon and the patient should also acknowledge that a radical resection will occasionally be performed for a suspected malignancy only to find that another etiology (i.e. CP) accounts for the suspicious pancreatic mass. In the presence of a strong suspicion for an underlying malignancy in a patient with head dominant CP, PD should probably be preferred over the newer organ-preserving Beger and Frey procedures, since it is an adequate procedure for both CP and PAC.

Differentiation of benign from malignant pancreatic masses by endoscopic ultrasound

BACKGROUND

It is often difficult to determine whether a mass in the pancreas is benign or malignant. The goal was to evaluate whether endoscopic ultrasound (EUS) can reliably establish whether a mass is benign or malignant.

METHODS

One hundred five patients with possible pancreatic tumors were referred for EUS. Those who were found to have a lesion suspicious for carcinoma and did not have a known malignancy also underwent EUS-guided FNA.

RESULTS

A mass suspicious for cancer was identified in 73 patients, whereas inflammatory changes or a normal pancreas was noted in 32 patients. Four of the latter 32 patients were subsequently found to have cancer. EUS-guided FNA was performed on 47 of the 73 patients with a suspicious mass and was read as cancer in 27 patients, atypia in 10 patients, and benign in 10 patients. All 10 patients with atypia were subsequently confirmed to have cancer, and 6 of the 10 patients with a benign FNA were proved to have a tumor at surgery. EUS could differentiate the lesion as malignant with a sensitivity of 95%, specificity 88%, positive predictive value 95%, and negative predictive value 88%.

CONCLUSIONS

Radial array EUS is helpful in supporting or refuting a diagnosis of cancer in a patient with a pancreatic mass. Although EUS-guided FNA can confirm the diagnosis, a negative FNA should not preclude exploration when clinically indicated.