Endosonography-guided, fine-needle aspiration cytology extending the indication for organ-preserving pancreatic surgery

Prospective study of EUS-guided tissue acquisition with a 20G core biopsy needle with a forward bevel for solid pancreatic mass

There is a growing need for tissue collection for immunostaining and genetic testing. Recently, several fine-needle biopsy needles are commercially available for endoscopic ultrasound-guided tissue acquisition.This prospective historical controlled study evaluates a 20G core biopsy needle with a forward bevel for solid pancreatic masses larger than 15 mm in diameter. The primary endpoint was the accuracy of histological diagnosis. The secondary endpoints included technical success rate, sample adequacy for histology, cytological diagnostic accuracy, and adverse events.Seventy consecutive patients were enrolled between January and October 2017. We achieved technical success in all cases regardless of the puncture sites or the endosonographer's experience. The final diagnoses were neoplasms in 67 patients (95.7%; pancreatic cancer in 65 patients, neuroendocrine neoplasm in 1, and malignant lymphoma in 1) and benign lesions in 3 patients (4.3%; autoimmune pancreatitis in 2 patients and mass-forming pancreatitis in 1). The obtained specimens were adequate for histological evaluation in all cases and the histological accuracy was 91.4% (95% confidence interval, 82.3-96.8%, P < .05) with the sensitivity and specificity of 91.0% and 100%, respectively. The cytological diagnostic accuracy was 95.7% and all patients were accurately diagnosed by combining cytological and histological examinations. As for adverse events, an asymptomatic needle fracture occurred in 1 case (1.4%).This 20G core biopsy needle with a forward bevel showed a high accuracy of histological diagnosis for solid pancreatic masses.

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 ultrasound-guided fine-needle aspiration vs fine-needle biopsy for the diagnosis of pancreatic neuroendocrine tumors

Background and study aims  Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as a method of obtaining preoperative diagnosis of pancreatic neuroendocrine tumors (PanNETs) has been reported in several series. Fine-needle biopsies (FNB) are increasingly employed to obtain core specimens during EUS. However, the differences in efficacy between these sampling methods in the diagnosis of PanNETs still needs to be defined. Patients and methods  Over a 13-year period, all patients who underwent EUS-guided tissue sampling of suspicious pancreatic lesions with clinical, endoscopic and pathologic details were entered into an electronic database. Lesions underwent EUS-FNA or FNB sampling, or a combination of the two. The accuracy and safety of different EUS-guided sampling methods for confirmed PanNETs were investigated. Results  A total of 91 patients (M/F: 42/49, median age: 57 years), who underwent 102 EUS procedures had a final diagnosis of PanNET. Both EUS-guided sampling modalities were used in 28 procedures, EUS-FNA alone was used in 61 cases, while EUS-FNB alone in 13 cases. Diagnostic yield of EUS-FNA and EUS-FNB alone, including the inadequate specimens, was 77.5 % (95 %CI: 68.9 - 86.2 %) and 85.4 % (95 %CI: 74.6 - 96.2 %), respectively. The combination of both sampling modalities established the diagnosis in 96.4 % of cases (27/28) (95 %CI: 89.6 - 100 %), significantly superior to EUS-FNA alone ( P  = 0.023). Diagnostic sensitivity among the adequate samples for EUS-FNA, EUS-FNB and for the combination of the two methods was 88.4 % (95 %CI: 80.9 - 96.0 %), 94.3 % (95 %CI: 86.6 - 100 %) and 100 % (95 %CI: 100 - 100 %). There was one reported complication, a post-FNA bleeding, treated conservatively. Conclusions  EUS-FNB improves diagnostic sensitivity and confers additional information to cytological assessment of PanNETs.

Imaging modalities for characterising focal pancreatic lesions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) in insulinomas: Indications and clinical relevance in a single investigator cohort of 47 patients

PURPOSE

This study was aimed to investigate the role and relevance of endoscopic ultrasound-guided fine-needle aspiration biopsy in the diagnostic work-up of insulinomas.

METHODS

We have analysed the frequency, clinical indications, success rate (obtaining diagnostic tissue), diagnostic accuracy (in comparison to the pathological diagnosis after surgery), complications, and tolerability of endoscopic ultrasound-guided fine-needle aspiration biopsy and the localization and size of the lesions in 47 consecutive patients (29 females, 18 males; 46 ± 15 years) who had surgery for insulinoma following fasting test and were explored by single investigator EUS 1994-2015.

RESULTS

Endoscopic ultrasound-guided fine-needle aspiration biopsy was performed in 21 % (10/47) of the patients. The clinical indications for endoscopic ultrasound-guided fine-needle aspiration biopsy were non-conclusive result of fasting test (n = 7), missing toxicology (n = 2), suspected malignancy at EUS (n = 1), suspicious extra-pancreatic localization of the lesion (n = 1). The diagnostic success rate of the procedure was 80 % (8/10 cases), the diagnostic accuracy of the fine-needle aspiration biopsy 70 % (7/10 cases). The lesions undergoing endoscopic ultrasound-guided fine-needle aspiration biopsy were localized in the cauda (n = 5), corpus (n = 2), caput/processus uncinatus (n = 3), the diameter of the tumors was 21 ± 18 (10-70) mm. Only one accidental vascular puncture without any clinical complication occurred and all patients tolerated the procedure well.

CONCLUSIONS

In the majority of cases, positive fasting test, negative toxicology, and detection of a typical pancreatic lesion at endoscopic ultrasound is sufficient for the diagnosis of insulinoma and the definition of the appropriate surgical strategy. Based on our data, we suggest including endoscopic ultrasound-guided fine-needle aspiration biopsy in the diagnostic work-up of organic hyperinsulinism in selected patients with inconclusive or uncertain diagnosis before surgery.

Customized Surgical Strategy in Chronic Pancreatitis

Despite major advances in the management of patients with chronic pancreatitis, yet the disease remains an enigmatic process of uncertain pathogenesis, unpredictable clinical course, and unclear treatment. In most of the cases intractable pain is the main indication for surgical intervention. Furthermore complications related to adjacent organs, endoscopically not permanently controlled pancreatic pseudocysts, ductal pathology, conservatively intractable internal pancreatic fistula or suspected malignancy also require surgery. The ideal surgical approach should address all these problems — tailoring the various therapeutic options to meet the individual patient's needs. In our opinion, the ideal procedure for chronic pancreatitis is the duodenum preserving pancreatic head resection in terms of an extended drainage procedure, were the extent of the pancreatic head resection may be tailored to the morphology of the pancreatic gland, thus allowing a tailored concept (to resect and/or drain as much as necessary but as little as possible). Looking at the present data, there is no need to transsect the pancreatic axis above the portal vein. If portal vein thrombosis is present, an extended drainage procedure is mandatory without transsection of the neck of the pancreas.

Incremental benefit of preoperative EUS for the detection of pancreatic neuroendocrine tumors: a meta-analysis

BACKGROUND

Current guidelines recommend CT scan or magnetic resonance imaging as the initial imaging modalities for the work-up of suspected pancreatic neuroendocrine tumors (PNETs).

OBJECTIVE

To determine the incremental benefit of preoperative EUS (IBEUS) for the detection of suspected PNETs after other investigative modalities have been attempted.

DESIGN

This systematic review searched MEDLINE, EMBASE, bibliographies of included articles, and conference proceedings for studies reporting original data regarding the preoperative detection of PNETs. Pooled IBEUS was calculated by using random effects models. Heterogeneity was explored by using stratified meta-analysis and meta-regression. Evidence of small-study effects was assessed by using funnel plots and the Begg test.

PATIENTS

Patients with suspected PNETs.

INTERVENTIONS

EUS evaluation.

MAIN OUTCOME MEASUREMENTS

The pooled IBEUS for the detection of PNETs after CT scan, with or without additional investigative modalities.

RESULTS

Among 4505 citations identified, we included 17 cohort studies (612 patients). EUS identified PNETs in 97% of cases. Improved PNET identification with EUS was observed in all of the studies. After adjusting for small-study effects, meta-analysis showed that EUS alone could identify PNETs in approximately 1 in 4 patients (adjusted IBEUS 26%; 95% confidence interval, 17%-37%). The pooled IBEUS varied based on the study design, study size, type of CT scan used, and the number of modalities used prior to EUS.

LIMITATIONS

The majority of included studies were retrospective. Small-study effects were observed.

CONCLUSION

Preoperative EUS is associated with an increase in PNET detection after other modalities are attempted.

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

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

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

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

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

Pancreatic cancer early detection: Expanding higher-risk group with clinical and metabolomics parameters

Pancreatic ductal adenocarcinoma (PDAC) is the fourth and fifth leading cause of cancer death for each gender in developed countries. With lack of effective treatment and screening scheme available for the general population, the mortality rate is expected to increase over the next several decades in contrast to the other major malignancies such as lung, breast, prostate and colorectal cancers. Endoscopic ultrasound, with its highest level of detection capacity of smaller pancreatic lesions, is the commonly employed and preferred clinical imaging-based PDAC detection method. Various molecular biomarkers have been investigated for characterization of the disease, but none are shown to be useful or validated for clinical utilization for early detection. As seen from studies of a small subset of familial or genetically high-risk PDAC groups, the higher yield and utility of imaging-based screening methods are demonstrated for these groups. Multiple recent studies on the unique cancer metabolism including PDAC, demonstrate the potential for utility of the metabolites as the discriminant markers for this disease. In order to generate an early PDAC detection screening strategy available for a wider population, we propose to expand the population of higher risk PDAC group with combination clinical and metabolomics parameters.

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.

Effect of pancreatic juice cytology and/or endoscopic ultrasound-guided fine-needle aspiration biopsy for pancreatic tumor

BACKGROUND AND AIM

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) can now provide a cytopathological diagnosis of pancreatic malignancy with higher success rates. However, EUS-FNA cannot be carried out for lesions of minimally invasive carcinoma because they cannot be detected by endoscopic ultrasonography, and in cases of intraductal papillary mucinous carcinoma (IPMC) because of the potential for needle tract seeding. A recent study has shown that pancreatic juice cytology (PJC) is useful for diagnosing pancreatic cancer. This study's aim was to evaluate whether PJC strengthens the diagnostic power of EUS-FNA for pancreatic masses.

METHODS

A total of 161 patients, who were suspected to have a pancreatic mass on conventional ultrasound and/or computed tomography, was enrolled.

RESULTS

EUS-FNA was carried out in 121 cases, and PJC was performed in 83 cases. An adequate specimen was obtained for EUS-FNA in 96.0% and for PJC in 98.9%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86.0%, 100%, 100%, 70.5%, and 89.5% for EUS-FNA, and 71.4%, 100%, 100%, 84.4%, and 88.8% for PJC, respectively. EUS-FNA and/or PJC for the diagnosis of pancreatic tumor had a sensitivity of 92.5%, specificity of 100%, positive predictive value of 100%, negative predictive value of 91.7%, and accuracy of 95.9%. The diagnostic accuracy of EUS-FNA and/or PJC was significantly higher than that of EUS-FNA alone or PJC alone.

CONCLUSION

PJC improved the diagnostic utility of EUS-FNA for pancreatic tumor.

Malignancy risk associated with diagnostic categories defined by the Papanicolaou Society of Cytopathology pancreaticobiliary guidelines

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently the predominant method for obtaining a preoperative tissue diagnosis for pancreatic lesions suspicious for malignancy. The diagnostic sensitivity and specificity of EUS-FNA are well documented, but malignancy risk associated with the diagnostic categories proposed by the Papanicolaou Society of Cytopathology is poorly defined.

METHODS

The records of the Departments of Pathology at Duke University and the University of Utah were searched for all cases of EUS-FNA performed for the investigation of pancreatic lesions. All cases with follow-up surgical diagnosis or greater than 3 years of clinical follow-up were selected. Cytologic diagnostic categories were "nondiagnostic," "benign," "atypical (not otherwise specified)," "suspicious for malignancy," "neoplasm," and "malignant." Correlation of cytologic diagnosis with surgical and/or clinical follow-up was made and risk of malignancy calculated for each category.

RESULTS

Three hundred seventeen EUS-FNAs with adequate surgical or clinical follow-up were obtained. Risk of malignancy for nondiagnostic specimens was 21%;, benign specimens, 13%; atypical cases, 74%; suspicious for malignancy, 82%; the neoplasm category, 14%; and the malignant category, 97%

CONCLUSIONS

The cytologic categories proposed by the Papanicolaou Society of Cytopathology demonstrate an increasing risk for malignancy extending from benign to malignant. Aspirates designated benign have the lowest risk of malignancy (13%) and aspirates designated malignant the highest (97%). The proposed categorization scheme stratifies risk for malignancy giving useful information to clinicians treating patients with pancreatic lesions.

Performance of endoscopic ultrasound-guided fine needle aspiration in diagnosing pancreatic neuroendocrine tumors

Background:

Pancreatic neuroendocrine tumors (PNETs) are rare tumors of the pancreas, which are increasingly diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). In this retrospective study, we assessed the performance of EUS-FNA in diagnosing PNETs.

Materials and Methods:

We identified 48 cases of surgically resected PNETs in which pre-operative EUS-FNA was performed. The clinical features, cytological diagnoses, and surgical follow-up were retrospectively reviewed. The diagnostic performance of EUS-FNA was analyzed as compared to the diagnosis in the follow-up. The cases with discrepancies between cytological diagnosis and surgical follow-up were analyzed and diagnostic pitfalls in discrepant cases were discussed.

Results:

The patients were 20 male and 28 female with ages ranging from 15 years to 81 years (mean 57 years). The tumors were solid and cystic in 41 and 7 cases, respectively, with sizes ranging from 0.5 cm to 11 cm (mean 2.7 cm). Based on cytomorphologic features and adjunct immunocytochemistry results, when performed, 38 patients (79%) were diagnosed with PNET, while a diagnosis of suspicious for PNET or a diagnosis of neoplasm with differential diagnosis including PNET was rendered in the 3 patients (6%). One case was diagnosed as mucinous cystic neoplasm (2%). The remaining 6 patients (13%) had non-diagnostic, negative or atypical diagnosis.

Conclusions:

Our data demonstrated that EUS-FNA has a relatively high sensitivity for diagnosing PNETs. Lack of additional materials for immunocytochemical studies could lead to a less definite diagnosis. Non-diagnostic or false negative FNA diagnosis can be seen in a limited number of cases, especially in those small sized tumors.

Role of endoscopic ultrasonography in evaluation of metastatic lesions to the pancreas: a tertiary cancer center experience

OBJECTIVES

Metastatic lesions to the pancreas pose diagnostic challenges with regards to their differentiation from primary pancreatic cancer. Data on the yield of endoscopic ultrasonography (EUS)-guided fine-needle aspiration in detection of these lesions are limited.

METHODS

This is a retrospective review of 23 patients referred to a tertiary referral center for further evaluation of suspected pancreatic metastases. Main outcome measures were diagnostic yield of endoscopic ultrasonography-guided fine-needle aspiration in evaluation of metastatic lesions to the pancreas.

RESULTS

Of 644 patients, 23 (3.6%) undergoing EUS of the pancreas were diagnosed to have metastatic disease to the pancreas based on clinical, radiological, and cytological results. Mean (SD) age was 64.3 (11.7) years. Of the 23 patients, 18 (78.3%) were asymptomatic. Mean (SD) size of lesion on EUS was 39.1 (19.9) mm. A diagnosis of malignant lesion was made in 21 of 23 cases, with a diagnostic accuracy of 91.3%.

CONCLUSIONS

Metastatic lesions to the pancreas present as incidental, solitary mass lesions on staging or surveillance imaging. Endoscopic ultrasonography-guided fine-needle aspiration is an important tool in the characterization and further differentiation of metastatic lesions to the pancreas from primary pancreatic cancer.

EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis

BACKGROUND

Preoperative diagnosis of solid pancreatic lesions remains challenging despite advancement in imaging technologies. EUS has the benefit of being a minimally invasive, well-tolerated procedure, although results are operator-dependent. The addition of FNA (EUS-guided FNA) provides samples for cytopathologic analysis, a major advantage over other imaging techniques.

OBJECTIVE

To determine the diagnostic accuracy of EUS-FNA for pancreatic cancer.

DESIGN

This is a meta-analysis of published studies assessing the diagnostic capability of EUS-FNA. Relevant studies were identified via MEDLINE and were included if they used a reference standard of definitive surgical histology or clinical follow-up of at least 6 months.

MAIN OUTCOME MEASUREMENTS

Data from selected studies were analyzed by using test accuracy meta-analysis software, providing a pooled value for sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve. Cytology results were classified as inadequate, benign, atypical, suspicious, or malignant. Predefined subgroup analysis was performed.

RESULTS

Thirty-three studies published between 1997 and 2009 were included, with a total number of 4984 patients. The pooled sensitivity for malignant cytology was 85% (95% confidence interval [CI], 84-86), and pooled specificity was 98% (95% CI, 0.97-0.99). If atypical and suspicious cytology results were included to determine true neoplasms, the sensitivity increased to 91% (95% CI, 90-92); however, the specificity was reduced to 94% (95% CI, 93-96). The diagnostic accuracy of EUS-FNA was enhanced in prospective, multicenter studies.

LIMITATION

Publication bias was not a significant determinant of pooled accuracy.

CONCLUSION

This meta-analysis demonstrates that EUS-FNA is a highly accurate diagnostic test for solid neoplasms of the pancreas and should be considered when algorithms for investigating solid pancreatic lesions are being planned.

Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review

BACKGROUND

EUS-guided FNA (EUS-FNA) permits both morphologic and cytologic analysis of lesions within or adjacent to the GI tract. Although previous studies have evaluated the accuracy of EUS-FNA, little is known about the complications of EUS-FNA. Moreover, the frequency and severity of complications may vary from center to center and may be related to differences in individual experience.

OBJECTIVE

To systematically review the morbidity and mortality associated with EUS-FNA.

DESIGN

MEDLINE and EMBASE were searched to identify relevant English-language articles.

MAIN OUTCOME MEASUREMENTS

EUS-FNA-specific morbidity and mortality rates.

RESULTS

We identified 51 articles with a total of 10,941 patients who met our inclusion and exclusion criteria; the overall rate of EUS-FNA-specific morbidity was 0.98% (107/10,941). In the small proportion of patients with complications of any kind, the rates of pancreatitis (36/8246; 0.44%) and postprocedure pain (37/10,941; 0.34%) were 33.64% (36/107) and 34.58% (37/107), respectively. The mortality rate attributable to EUS-FNA-specific morbidity was 0.02% (2/10,941). Subgroup analysis showed that the morbidity rate was 2.44% in prospective studies compared with 0.35% in retrospective studies for pancreatic mass lesions (P=.000), whereas it was 2.33% versus 5.07% for pancreatic cysts (P=.036).

LIMITATIONS

Few articles reported well-designed, prospective studies and few focused on overall complications after EUS-FNA.

CONCLUSIONS

EUS-FNA-related morbidity and mortality rates are relatively low, and most associated events are mild to moderate in severity.

Duodenum-preserving versus pylorus-preserving pancreatic head resection for benign and premalignant lesions

BACKGROUND/PURPOSE

Pylorus-preserving pancreaticoduodenectomy (PPPD) is the treatment of choice for benign or premalignant pancreatic head lesions. Duodenum-preserving pancreatic head resection (DPPHR) has been reported in only 132 patients. This study aimed to compare the long-term results of DPPHR and PPPD.

METHODS

Patients who underwent DPPHR or PPPD for benign or borderline disease between 1991 and 2008 were followed up until December 2009 or their death. Endocrine and exocrine pancreatic functions were evaluated at their last follow-up.

RESULTS

Twenty-seven patients underwent DPPHR (Group 1) and 37 PPPD (Group 2). They were followed for a mean of 100 and 135 months, respectively. Group 1 had a higher complication rate (81.5 vs. 40.5%) and pancreatic fistula rate (40.1 vs. 18.9%). Hospital mortality was 0 and 2.7%, respectively. Two patients died 3.3 and 97 months after DPPHR. Significantly more Group 2 patients needed medical treatment for benign cholangitis (P < 0.0001). Insulin-dependent diabetes mellitus was observed in six Group 1 and 15 Group 2 patients (P = 0.077). Ten Group 1 and 21 Group 2 patients are taking pancreatic enzymes (P = 0.003).

CONCLUSIONS

DPPHR for benign or premalignant lesions is a difficult procedure with a higher complication rate than PPPD, but was without mortality. Preserving the entire duodenum and a normal biliary tree allows better long-term results.

Extended central pancreatic resection as an alternative for extended left or extended right resection for appropriate pancreatic neoplasms

BACKGROUND

Whether patients with focal pancreatic lesions of benign or borderline pathology should be treated by extended central pancreatectomy rather than by extended classic resectional procedures, such as extended right and left resections, is controversial.

METHODS

Between 1992 and 2007, 105 patients underwent operation for focal pancreatic lesions of borderline or benign neuroendocrine neoplasms, cystadenoma, intraductal papillary mucinous neoplasia (IPMN), and secondary metastasis. In all, 35 patients were subjected to extended central pancreatectomy, whereas the remaining 70 patients were treated by an extended classic right resection or an extended classic left resection. Groups were matched according to age, sex, and histopathology.

RESULTS

No peri-operative mortality occurred after extended central pancreatectomy and extended classic left resection (n = 35, each). Two (6%) patients died after extended classic right resection. Overall, in-hospital morbidity was 26% after extended central pancreatectomy, 43% after extended classic right resection, and 37% after extended classic left resection. After a median follow-up of 48 months, a local recurrence rate of 17% after extended central pancreatectomy was similar to the corresponding rates of 9% after extended classic left resection and 14% after extended classic right resection. Endocrine and exocrine impairment was less pronounced after extended central pancreatectomy (6% and 9%) than after extended classic left resection (34% and 29%) and extended classic right resection (28% and 24%; P < .05).

CONCLUSION

Extended central pancreatectomy for appropriate pancreatic neoplasms is associated with less peri-operative morbidity and mortality than after extended classic left and extended classic right resection. Long-term local recurrence after extended central pancreatectomy is similar to the recurrence rates after extended classic right and classic left resection. Our results suggest that appropriately selected patients will benefit from extended central pancreatectomy because of the maintenance of endocrine and exocrine function.

Diagnostic value of EUS-FNA in patients suspected of having pancreatic cancer with a focal lesion on CT scan/MRI but without obstructive jaundice

OBJECTIVE

Patients frequently present with suspected pancreatic neoplasm based on a focal pancreatic lesion on computed tomographic (CT) scan/magnetic resonance image (MRI) but without obstructive jaundice. We evaluated the performance characteristics of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in this patient subset.

METHODS

This is a retrospective analysis of a prospective database and included patients who underwent EUS-FNA at a university hospital for a focal pancreatic lesion noted on CT/MRI. Patients were excluded if (1) they had obstructive jaundice or (2) the lesion appear (seem)ed cystic on CT/MRI. The main outcome measurements were (1) prevalence of pancreatic cancer and (2) performance characteristics of EUS-FNA for identifying malignancy.

RESULTS

In the 213 study patients, a focal pancreatic lesion was identified in 173 patients by EUS. The final diagnosis included adenocarcinoma (n=89), neuroendocrine tumor (n=14), mucinous cystadenocarcinoma (n=1), solid pseudopapillary tumor (n=2), metastases (n=4), benign cyst (n=19), pseudocyst (n=9), abscess (n=4), chronic pancreatitis (n=32), and normal pancreas (n=39). Endoscopic ultrasound-guided FNA had an accuracy of 97.6% for diagnosing malignant neoplasm, with 96.6% sensitivity, 99.0% specificity, 96.2% negative predictive value, and 99.1% positive predictive value.

CONCLUSIONS

Endoscopic ultrasound-guided FNA is highly accurate for diagnosing malignancy in patients with a focal pancreatic lesion on CT scan/MRI but without obstructive jaundice. Endoscopic ultrasound-guided FNA can potentially be used as a definitive diagnostic test in the management of these patients.

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.

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.

Endoscopic ultrasound-guided fine-needle aspiration biopsy and trucut biopsy in gastroenterology - An overview

Endoscopic ultrasound (EUS)-guided biopsies are reliable, safe and effective techniques in obtaining samples for cytological or histological examinations either as a primary procedure or in cases where other biopsy techniques have failed. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA), as well as endoscopic ultrasound-guided trucut biopsy (EUS-TCB), has proven to be of significant value in the diagnostic evaluation of benign and malignant diseases, as well as in staging of the malignant tumours of the gastrointestinal tract and of adjacent organs. The diagnostic yield of EUS-guided biopsies depends on site, size and characteristics of target tissues as well as technical and procedural factors (type of needle, biopsy technique and material processing). Other weighting factors include expertise, training and interaction between the endosonographer and cytopathologist. Rapid on-site cytological evaluation has proven to be successful in optimising the diagnostic efficiency of EUS-FNA. A sensible alternative is to collect specimens for histological and immunohistochemical investigations in addition to the cytological smears. EUS-FNA using a 22-gauge needle is successful in harvesting core biopsies in approximately three out of four cases. Therefore, the use of 19-gauge needles for EUS-FNA or EUS-TCB may only be necessary in selected cases. The reproducibility of cytopathological diagnosis among pathologists with special experience in assessing material obtained by EUS-guided biopsies is very high. False-positive diagnosis of malignancy in EUS-guided biopsy is rare. False-negative diagnosis appears with variable frequency depending on the target tissue, technical factors and expertise of the endosonographer and cytopathologist. There are numerous challenges and pitfalls in the differential diagnostic classification of benign and malignant lesions. These problems are related to the characteristics of samples obtained by EUS-guided biopsy, as well as to the multiple diagnoses with similar or overlapping cytological or histological characteristics. The high prognostic and therapeutic relevance of the cytopathological diagnoses resulting from EUS-guided biopsy calls for a shared responsibility of an endosonographer and a cytopathologist.

Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer

Early diagnosis of pancreatic cancer remains a difficult task, and multiple imaging tests have been proposed over the years. The aim of this review is to describe the current role of endoscopic ultrasound (EUS) for the diagnosis and staging of patients with pancreatic cancer. A detailed search of MEDLINE between 1980 and 2007 was performed using the following keywords: pancreatic cancer, endoscopic ultrasound, diagnosis, and staging. References of the selected articles were also browsed and consulted. Despite progress made with other imaging methods, EUS is still considered to be superior for the detection of clinically suspected lesions, especially if the results of other cross-sectional imaging modalities are equivocal. The major advantage of EUS is the high negative predictive value that approaches 100%, indicating that the absence of a focal mass reliably excludes pancreatic cancer. The introduction of EUS-guided fine needle aspiration allows a preoperative diagnosis in patients with resectable cancer, as well as a confirmation of diagnosis before chemoradiotherapy for those that are not. This comprehensive review highlighted the diagnostic capabilities of EUS including the newest refinements such as contrast-enhanced EUS, EUS elastography, and 3-dimensional EUS. The place of EUS-guided biopsy is also emphasized, including the addition of molecular marker techniques.

Prospective pilot evaluation of a new needle prototype for endoscopic ultrasonography-guided fine-needle aspiration: comparison of cytology and histology yield

OBJECTIVES

Endoscopic ultrasonography (EUS) with the adjunct of EUS-guided fine needle aspiration has become an important diagnostic modality in gastroenterologic oncology. EUS-guided fine needle aspiration mainly relies on cytology; data are scarce that compare cytology and histology. While testing a 22-gauge prototype needle, we prospectively compared the yield for both.

METHODS

Forty-two consecutive patients (27 male, 15 female; mean age 59.2 years, range: 17-90 years) were included. In each patient we aimed to make two needle passes, and if the material acquired appeared insufficient macroscopically (no in-room cytopathology was available), further passes were done. The material was sent for cytological and histological assessment.

RESULTS

A median number of two passes (range: 2-3) were uneventfully performed for pancreatic lesions (n=30), mediastinal and other lymph nodes/masses (n=8) and various other lesions (n=4) and yielded adequate material for cytology, histology or at least one of the two investigations in 62, 67 and 74% of patients, respectively. No false positive results were found (specificity 100%). Sensitivities were 58.6 and 65.5%, respectively, for cytology and histology alone; combined assessment increased sensitivity to 79.3%. When adjusted values were calculated, based only on those cases with adequate material, sensitivity was 89.5% for cytology and 85.7% for histology, and increased to 100% with combined assessment.

CONCLUSION

The new needle achieves sensitivities similar to those previously reported with no significant differences in sensitivity between cytology and histology. More effective tissue acquisition methods must be sought to improve overall results.

Occult sporadic insulinoma: localization and surgical strategy

Insulinomas continue to pose a diagnostic challenge to physicians, surgeons and radiologists alike. Most are intrapancreatic, benign and solitary. Biochemical diagnosis is obtained and imaging techniques to localize lesions continue to evolve. Surgical resection is the treatment of choice. Despite all efforts, an occult insulinoma (occult insulinoma refers to a biochemically proven tumor with indeterminate anatomical site before operation) may still be encountered. New localization preoperative techniques decreases occult cases and the knowledge of the site of the mass before surgery allows to determine whether enucleation of the tumor or pancreatic resection is likely to be required and whether the tumor is amenable to removal via a laparoscopic approach. In absence of preoperative localization and intraoperative detection of an insulinoma, blind pancreatic resection is not recommended.

EUS elastography of the pancreas: feasibility and pattern description of the normal pancreas, chronic pancreatitis, and focal pancreatic lesions

BACKGROUND

Initial clinical applications have shown that US elastography might be able to distinguish tissues because of their specific consistency.

OBJECTIVE

(1) To investigate the feasibility of EUS elastography of the pancreas and (2) to describe elastographic patterns of the normal pancreas and the pancreas affected by inflammatory or focal disease.

DESIGN

Prospective single-center study.

SETTING

Academic center of the University of Witten/Herdecke.

PATIENTS

Twenty patients with normal pancreas, 20 patients with chronic pancreatitis, and 33 patients with focal pancreatic lesion, histologically later proven in 32 of these 33 cases.

INTERVENTIONS

Commercially available US equipment was used. The elasticity of tissue was reconstructed in real time within a sample area and was translated into a color scale imaging relative tissue elasticity within this area. Representative loops of at least 20 seconds were recorded regarding each region of interest.

RESULTS

Adequate elastographic recordings could be obtained in all 73 patients. Patients with hypoechoic and intermediately echogenic normal pancreas revealed a relatively homogeneous elastographic pattern. Thirty-one focal lesions, including 30 neoplasms and most of the chronically inflamed pancreata had a honeycomb pattern dominated by hard strands. This pattern showed analogies to the histologic structure of 10 resected tumors. Other patients with chronic pancreatitis and those with hyperechoic healthy pancreas had miscellaneous elastographic appearances.

CONCLUSIONS

EUS elastography of the pancreas is feasible and produces plausible results. The examination of homogeneous tissue is impaired by the relative scale used. Chronic pancreatitis and hard tumors cannot be distinguished by elastography, probably because of their similar fibrous structure.

Changing trends in endosonography: linear imaging and tissue are increasingly the issue

The indications and uses of endoscopic ultrasound (EUS) are expanding. The role of EUS-guided fine needle aspiration (EUS-FNA) is considered an essential aspect of EUS practice. A significant change in the indications and technology used for EUS has occurred. This study was designed to compare the use of radial, linear, and miniprobe endosonography equipment during a 10-year period in a single, large, EUS practice. A retrospective review of an EUS experience at a single high-volume center was performed. In this single-center experience, there has been an increase in the volume of EUS and EUS-FNA. For luminal cancer-staging cases, the radial echoendoscope is the predominant scope used for examination and has not changed significantly. In contrast, for pancreaticobiliary and mediastinal indications, the use of the linear array echoendoscope alone has increased and currently is the preferred scope for examination (33% vs. 76%, P < 0.001; 46% vs. 96%, P < 0.001). In these cases requiring EUS-FNA, the use of the linear array scope alone has increased from 17% to 73%. In this single-center experience, EUS has shifted from an imaging technology to an image-guided biopsy and therapeutic technology. The use of the linear array EUS alone has increased, especially in the evaluation of pancreatobiliary and mediastinal disease and when fine-needle aspiration is performed.

Aggressive surgery improves long-term survival in neuroendocrine pancreatic tumors: an institutional experience

OBJECTIVE

To evaluate surgical strategies for neuroendocrine pancreatic tumors (NEPT) in the light of the new WHO classification from 2004 and to draw conclusions for future surgical concepts.

BACKGROUND

: The extent of surgical resection in primary and recurrent NEPT is unclear.

METHODS

Between 1987 and 2004, 62 patients with sporadic NEPT were treated at our institution and sections from biopsy and resection specimen were histopathologically reclassified. Clinical presentation, surgery, metastases, and pattern of recurrence were related to survival.

RESULTS

Fifteen well-differentiated tumors (WDT, 24%), 39 low-grade carcinomas (LGC, 63%), and 8 high-grade carcinomas (HGC, 13%) were identified. Median observation time was 30.5 months; 48 of 62 patients (78%) were surgically resected, and in 45 patients R0/R1 status was achieved. Overall 2- and 5-year survival in the latter group was 80% and 64%, respectively. Retrospective WHO classification revealed that organ-preserving segmental resections had been performed in 10 LGC and 1 HGC. These patients showed equal outcome as radically resected counterparts (n = 19). Liver and other organ metastases were present in 19 of 62 patients (31%), and resection was accomplished in 7 of 19 patients, which conferred better overall survival (P = 0.026, log-rank test); 21 of 45 R0/R1-resected patients (47%) suffered from recurrence, and reoperation was accomplished in 9 patients, which resulted in better overall survival (P = 0.066).

CONCLUSION

Organ-preserving resections offer sufficient local control in LGC; therefore, radical resections do not seem to be justified. On the other hand, radical resection is indicated even in metastasized patients or in case of loco-regional recurrence. The silent and slow course of the disease facilitates long-term surgical control.

Diagnosing pancreatic cancer: the role of percutaneous biopsy and CT

AIMS

To determine the sensitivity and complications of percutaneous biopsy of pancreatic masses, and whether typical computed tomography (CT) features of adenocarcinoma can reliably predict this diagnosis.

MATERIALS AND METHODS

A 5 year retrospective analysis of percutaneous core biopsies of pancreatic masses and their CT features was undertaken. Data were retrieved from surgical/pathology databases; medical records and CT reports and images.

RESULTS

Three hundred and three patients underwent 372 biopsies; 56 of 87 patients had repeat biopsies. Malignancy was diagnosed in 276 patients, with ductal adenocarcinoma in 259 (85%). Final sensitivity of percutaneous biopsy for diagnosing pancreatic neoplasms was 90%; for repeat biopsy it was 87%. Complications occurred in 17 (4.6%) patients, in three of whom the complications were major (1%): one abscess, one duodenal perforation, one large retroperitoneal bleed. CT features typical of ductal adenocarcinoma were: hypovascular pancreatic mass with bile and/or pancreatic duct dilatation. Atypical CT features were: isodense or hypervascular mass, calcification, non-dilated ducts, cystic change, and extensive lymphadenopathy. Defining typical CT features of adenocarcinoma as true-positives, CT had a sensitivity of 68%, specificity of 95%, positive predictive value (PPV) of 98%, and negative predictive value of 41% for diagnosing pancreatic adenocarcinoma.

CONCLUSION

Final sensitivity of percutaneous biopsy for establishing the diagnosis was 90%. CT features typical of pancreatic adenocarcinoma had high specificity and PPV. On some occasions, especially in frail patients with co-morbidity, it might be reasonable to assume a diagnosis of pancreatic cancer if CT features are typical, and biopsy only if CT shows atypical features.

Endoscopic ultrasonography in the diagnosis and management of cancer

Since its development and introduction to clinical practice, endoscopic ultrasonography (EUS) has progressed rapidly from being a purely imaging modality with limited use in the detection of small pancreatic cancers to one that can provide a tissue diagnosis by fine-needle aspiration (FNA) and deliver therapy. EUS has now firmly established a place as the investigation of choice in the diagnosis, locoregional staging and management of a wide range of gastrointestinal cancers. With the increasing use of FNA, the accuracy of EUS has substantially improved and may become a stand-alone investigation in some situations. However, it is recommended that a combination of information obtained from other imaging modalities and EUS is needed to maximize the accuracy, in particular to complete staging beyond locoregional stage. In addition to well-established indications, newer applications of EUS are emerging and are no longer limited to the gastrointestinal system. In lung cancer, EUS combined with endobronchial ultrasonography is emerging as an accurate, minimally invasive, nonsurgical alternative to staging of the mediastinum. Furthermore, the ability of EUS to acquire tissue safely and conveniently results in a potential role of the molecular diagnostics to enhance the performance of EUS-guided FNA. Besides a diagnostic role of EUS, there continues to be technological advances in the field of interventional EUS, with many potential applications under investigation. This review focuses on the current and future roles of EUS in the diagnosis and management of cancers.

EUS-guided alcohol ablation of an insulinoma

BACKGROUND

Surgical resection is currently considered to be the criterion standard for treatment of insulinomas. Alternative treatments, despite medication with diazoxide, are lacking. EUS-guided ethanol ablation of endocrine tumors has not been reported before.

INTERVENTION

A 78-year-old woman was referred with typical symptoms of an insulinoma. Diagnosis was confirmed by laboratory findings, EUS, and EUS-guided FNA. Because of severe complications during several hypoglycemic episodes, a poor general condition, and strict refusal of surgical resection, the decision was made to ablate the insulinoma by EUS-guided alcohol injection. A total of 8 mL 95% ethanol was injected into the tumor.

RESULTS

The patient was discharged and exhibited no further hypoglycemic episodes, and her general condition improved rapidly. Based on clinical, morphologic, and biochemical criteria, we achieved a durable complete remission of the tumor.

CONCLUSIONS

EUS-guided ablation may become a minimally invasive alternative for patients with insulinomas in whom surgery is not feasible.

Review of endoscopic ultrasound-guided fine-needle aspiration cytology

This review, based on the Hennepin County Medical Center experience and review of the literature, vastly covers the up-to-date role of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (FNA) in evaluating tumorous lesions of the gastrointestinal tract and adjacent organs. Emphasis is given to the tumoral and nodal staging of esophageal, pulmonary, and pancreatic cancer. This review also discusses technical, pathological, and gastroenterologic aspects and the role of the pathologist and endosonographer in the evaluation of these lesions, as well as the corresponding FNA cytology and differential diagnosis.

My approach to pancreatic fine needle aspiration

Pancreatic fine needle aspiration cytopathology has earned a reputation as a rapid, safe, accurate and cost-beneficial modality of investigation of pancreatic mass lesion. Optimal results can be expected only if these procedures are undertaken regularly in gastroenterology departments processing large numbers of patients; occasional aspirators cannot exploit the technique to full potential. Professional teams following a dedicated approach to patient selection and management develop requisite expertise over time. Cytodiagnosis rests as much on morphological examination as on the milieu in which is it practised, and as much on sample quality as on cellular criteria. This article focuses attention on specimen handling, with particular reference to rapid on-site evaluation. The significance of particular cytodiagnoses in patient care is evaluated, and tumour types that may be encountered are enumerated and illustrated.

The management of insulinoma

BACKGROUND

Insulinomas are rare tumours. Their clinical presentation, localization techniques and operative management were reviewed.

METHODS

An electronic search of the Medline, Embase and Cochrane databases was undertaken for articles published between January 1966 and June 2005 on the history, presentation, clinical evaluation, use of imaging techniques for tumour localization and operative management of insulinoma.

RESULTS AND CONCLUSION

Most insulinomas are intrapancreatic, benign and solitary. Biochemical diagnosis is obtained during a supervised 72-h fast. Non-invasive preoperative imaging techniques to localize lesions continue to evolve. Intraoperative ultrasonography can be combined with other preoperative imaging modalities to improve tumour detection. Surgical resection is the treatment of choice. In the absence of preoperative localization and intraoperative detection of an insulinoma, blind pancreatic resection is not recommended.

Endoscopic ultrasound-guided fine needle aspiration cytology of pancreatic neuroendocrine tumours: cytomorphological and immunocytochemical evaluation

OBJECTIVES

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is increasingly used in preoperative localization and diagnosis of pancreatic neoplasms including neuroendocrine tumours (NETs). The objective of the present study was to identify the cytological features of pancreatic NETs obtained by EUS-FNA.

METHODS

The study group consisted of nine cases of pancreatic tumours correctly diagnosed or strongly suggestive of NETs based on EUS-FNA. Cytological smears were retrospectively reviewed. The clinical data and immunocytochemical stains applied to the cell block preparations were also reviewed and examined.

RESULTS

All cases except one showed characteristic cytomorphological features sufficient for their recognition and separation from pancreatic adenocarcinoma and other lesions. The most helpful cytological features that facilitated the cytological diagnosis of NET were a richly cellular aspirate with a monotonous, poorly cohesive population of small cells with a speckled or dusty chromatin pattern and plasmacytoid morphology. The neuroendocrine differentiation of these tumours was further confirmed by immunocytochemistry.

CONCLUSION

EUS-FNA is a valuable method in the recognition of pancreatic NETs. By adherence to the characteristic cytomorphological criteria of pancreatic NET together with collection of suitable material for ancillary immunocytochemical stains, cytopathologists could reach a correct diagnosis in most instances.

Cytologic diagnosis of pancreatic endocrine tumors by endoscopic ultrasound-guided fine-needle aspiration: A review

Precise localization and diagnosis of pancreatic endocrine tumors (PETs) is important, because pancreatic PETs have different clinical and biological behavior and treatment modalities than do exocrine pancreatic tumors. In contrast to the much more common exocrine adenocarcinomas, cytologic studies of PET are relatively rare and many cytopathologists lack experience with the cytomorphologic features of these tumors.During the last 10 yr, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has matured into an accurate, highly sensitive, and cost-effective modality for the preoperative localization of pancreatic PETs. This has resulted in an increased number of PETs first sampled as cytology specimens. This manuscript focuses on the cytomorphologic features most suggestive of pancreatic PETs, differential diagnosis, and diagnostic pitfalls of PETs. The technical development of EUS-guided FNA and the ancillary studies for pancreatic PETs are also reviewed. The data summarized in this review indicate that EUS-FNA is a valuable method in the recognition of pancreatic PETs and in most cases cytopathologists could reach a correct diagnosis of these tumors, including their hormone producing capability on aspirated cytologic material.

Usefulness of endoscopic ultrasound-guided fine-needle aspiration biopsy for the diagnosis of pancreatic cancer

BACKGROUND

Endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNAB) has come into widespread use, mainly in Western countries, as an efficient and safe method for the cytologic or histologic diagnosis of pancreatic cancer. However, it still has received relatively little attention in Japan. To evaluate the clinical status of EUS-FNAB in Japan, we retrospectively analyzed the results with regard to the ability of EUS-FNAB to diagnose pancreatic cancer, as well as its safety.

METHODS

A total of 52 patients (37 male, 15 female; mean age, 62.5 years; range, 33-85 years) with focal pancreatic lesions underwent EUS-FNAB at our group of hospitals in one region of Japan. Final diagnosis was confirmed by histologic examination of surgical specimens or clinical follow-up.

RESULTS

The final diagnoses were malignant tumors in 32 patients and benign ones in 20. Insertion of the needle into the lesion was successful in 50 of the 52 patients (96.2%). Adequate specimens were obtained by EUS-FNAB from 47 of the 50 pancreatic lesions (94.0%). With five false-negative and no false-positive results, the accuracy, sensitivity, specificity, and positive and negative predictive values were 89.4%, 82.1%, 100%, 100%, and 79.2%, respectively. No complications occurred.

CONCLUSIONS

EUS-FNAB is an efficient and safe method for the histologic diagnosis of pancreatic cancer. It should be considered as one of the indispensable modalities for the histological diagnosis of pancreatic cancer in Japan, as it is in Western countries.

ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study

BACKGROUND

The accuracy of ERCP-based brush cytology or forceps biopsy for tissue diagnosis is relatively low (usually not exceeding 70%). By contrast, reported accuracy rates for EUS-guided FNA of pancreatobiliary masses are over 80%. This prospective study compared these two modalities for the first time in the diagnosis of indeterminate biliary strictures and pancreatic tumors.

METHODS

Fifty consecutive patients (29 men, 21 women; mean age 62.1 years) with obstructive jaundice in whom a tissue diagnosis was required were included. During ERCP, intraductal specimens were obtained with a forceps and with two different types of brush (conventional and spiral suction) in random order. During EUS, only visible mass lesions or localized bile duct wall thickening were aspirated (22-gauge needle), with at least two passes yielding material sufficient for assessment. A cytopathologist was not present in the procedure room to evaluate specimen adequacy. The reference methods were surgery, other biopsy results, follow-up until death, or the conclusion of the study (mean follow-up 20 months).

RESULTS

The final diagnoses were malignancy, 28 (16 pancreatic, 12 biliary), and benign biliary stricture, 22. Sensitivity and specificity for ERCP-guided biopsy were 36% and 100%, respectively; for ERCP-guided cytology (when using conventional and spiral suction brushes), 46% and 100%, respectively; and for EUS-guided FNA, 43% and 100%, respectively. If the punctured lesions are considered (n=28) alone, the sensitivity of EUS-guided FNA was 75%. In general, sensitivity was better for ERCP-based techniques in the subgroup biliary tumor (ERCP 75% vs. EUS 25%), whereas EUS-guided biopsy was superior for pancreatic mass (EUS 60% vs. ERCP 38%).

CONCLUSIONS

For biliary strictures, combined ERCP- and EUS-guided tissue acquisition seems to be the best approach to tissue diagnosis. From a clinical standpoint, it appears reasonable, when a tissue diagnosis is required, to start with ERCP if biliary malignancy is suspected and with EUS when a pancreatic tumor is thought to be the cause of a biliary stricture.

Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions

OBJECTIVE

Preoperative diagnosis of cystic lesions of the pancreas remains difficult despite improvement in imaging modalities and cystic fluid analysis. The aim of our study was to assess the performance of endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration (FNA) in the diagnosis of pancreatic cystic lesions.

METHODS

Data from a series of 127 consecutive patients with pancreatic cystic lesions were prospectively studied. EUS and EUS-guided FNA were performed in all patients, and cystic material was used for cytological and histological analysis as well as for biochemical and tumor markers analysis. Performance of EUS diagnosis, biochemical and tumor markers, and FNA diagnosis were compared with the final histological diagnosis obtained at surgery or postmortem examination. Sixty-seven patients underwent surgery and therefore constituted our study group.

RESULTS

EUS provided a tentative diagnosis in 113 cases (89%). Cytohistological FNA provided a diagnosis in 98 cases (77%). When the results of EUS and EUS-guided FNA were compared with the final diagnosis (67 cases), EUS correctly identified 49 cases (73%), whereas FNA correctly identified 65 cases (97%). Sensitivity, specificity, positive predictive value, and negative predictive value of EUS and EUS-guided FNA to indicate whether a lesion needed further surgery were 71% and 97%, 30% and 100%, 49% and 100%, and 40% and 95%, respectively. Carbohydrate antigen 19-9 > 50,000 U/ml had a 15% sensitivity and a 81% specificity to distinguish mucinous cysts from other cystic lesions, whereas it had a 86% sensitivity and a 85% specificity to distinguish cystadenocarcinoma from other cystic lesions.

CONCLUSIONS

EUS-guided FNA is a valuable tool in the preoperative diagnostic assessment of pancreatic cystic lesions.

Low sensitivity of the ki-ras polymerase chain reaction for diagnosing pancreatic cancer from pancreatic juice and bile: a multicenter prospective trial

PURPOSE

Early detection of pancreatic cancer using molecular markers may improve outcome. Mutations of the ki-ras oncogene are detected in 70% to 90% of pancreatic adenocarcinomas. A prospective, partially blinded, multicenter diagnostic trial was performed to test the sensitivity and specificity of the ki-ras polymerase chain reaction (PCR) analysis of pancreatic juice and bile specimens.

PATIENTS AND METHODS

Specimens of pancreatic juice and bile were collected from 532 consecutive patients. Mutations in codon 12 of the ki-ras gene were identified by two independent enrichment PCRs and confirmed by direct sequencing.

RESULTS

One hundred seventy-four of 532 patients were excluded from the final analysis (reasons: no amplifiable DNA, no specimen or only duodenal juice sent, lost to follow-up). Sixty-three of 358 patients had ductal pancreatic cancer. In 24 (38.1%) of 63 patients, a mutated ki-ras gene was identified in pancreatic juice and/or bile. Ki-ras mutations were found in four (8%) of 50 cases of chronic pancreatitis, in 10 (18.7%) of 53 cases of other malignancies of the pancreaticobiliary tree, and in 14 (7.3%) of 192 cases of benign diseases or normal findings. Sensitivity and specificity of the ki-ras PCR analysis for the detection of pancreatic cancer was 38.1% and 90.5%, respectively.

CONCLUSION

In this prospective trial performed in nonselected patients, mutations of the ki-ras gene were detected in 38.1% of cases with pancreatic cancer. This test in its present form is not appropriate to confirm or screen for pancreatic cancer. More sensitive and/or quantitative PCR tests may improve the molecular diagnosis of pancreatic cancer.

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.

Endoscopic ultrasound-guided fine-needle aspiration biopsy: a study of 103 cases

BACKGROUND

Endoscopic ultrasound (EUS) provides detailed imaging of both intramural and extramural structures within the abdomen and mediastinum. However, EUS is limited in its ability to differentiate an inflammatory/reactive process from a malignancy. Fine-needle aspiration biopsy (FNAB), coupled with EUS, allows for the sampling of the target lesion under ultrasound guidance in real time. To better evaluate the clinical utility and efficiency of EUS-FNAB, a retrospective analysis of the first 103 EUS-FNABs performed at our institute was undertaken.

METHODS

EUS-FNABs was performed in 80 patients with 103 lesions. Both air-dried and alcohol-fixed smears were prepared and stained with Diff-Quik (American Scientific Products, McGraw Park, IL) and Papanicolaou stains, respectively. In addition, ThinPrep slides (Cytyc, Boxborough, MA) and cell blocks, when additional material was available, were also prepared. Immunohistochemical stains were performed on cell blocks wherever required. Cytologic diagnoses were then correlated with the final diagnoses. The latter was based on histologic examination of biopsies/resected pathology materials (n = 54) and clinical follow up (n = 48). Follow-up information was not available for one lesion.

RESULTS

Of 103 EUS-FNABs, 42 FNABs were from the pancreas, 38 from the lymph nodes (10 mediastinal and 28 intraabdominal), 10 from the gastrointestinal tract, 7 from the liver, 4 from the adrenal gland, 1 from the biliary tract, and 1 from a retroperitoneal mass. The mean number of passes to obtain diagnostic materials was 3.3. Of 103 EUS-FNABs, 45, 9, 6, and 37 were reported as malignant, suspicious, atypical, and benign, respectively. Six FNABs were nondiagnostic. The authors did not encounter any false-positive cases. There were three false-negative cases (two pancreatic carcinomas and one gastrointestinal stromal tumor of the stomach). No complications were encountered. The sensitivity, specificity, and accuracy were 71%, 100%, and 81%, respectively. If the FNABs that were classified as suspicious were considered as malignant, the sensitivity, specificity, and accuracy were 86%, 100%, and 91%, respectively.

CONCLUSIONS

EUS-FNAB is a safe and accurate diagnostic procedure for the evaluation of intramural and extramural lesions of the gastrointestinal tract. In the majority of cases, it obviates the need for more invasive diagnostic procedures to obtain a tissue diagnosis.

Role of endoscopic ultrasound in the diagnosis of cystic lesions of the pancreas

Endoscopic ultrasound (EUS) is an ideal imaging technique for pancreatic cystic lesions. Ultrasound is exquisitely sensitive for detecting and characterizing cysts arising in solid organs, and when the transducer is placed on an endoscope, high resolution imaging of the pancreas is achieved. Linear EUS can also guide needle aspiration of pancreatic cystic lesions and through the use of aspiration cytology, cystic tumors of the pancreas can be diagnosed. Since cytology is a relatively insensitive test, cyst fluid tumor markers such as CEA have been employed to improve the sensitivity for the detection of malignancy. Cyst fluid CEA values are uniformly low in serous cystadenomas, higher in mucinous lesions, and markedly elevated in mucinous cystadenocarcinomas. Through the use of these techniques, the ability to detect and diagnose early malignancies of the pancreas will be greatly enhanced.