Carcinoma in situ of the pancreas with pancreatic duct stricture persistent for 4 years diagnosed by serial pancreatic juice aspiration cytologic examination (SPACE)

Serial pancreatic juice aspiration cytologic examination (SPACE) by nasopancreatic tube placement can give us an opportunity to diagnose early-stage pancreatic cancer with higher sensitivity and specificity compared with conventional pancreatic cytology by one-time pancreatic juice aspiration or pancreatic duct brushing. We performed SPACE in a patient with persistent pancreatic duct stricture (PDS) with gradually advancing pancreatic parenchyma atrophy (PPA) in the pancreas tail. The result of SPACE was suggestive of pancreatic carcinoma, and distal pancreatectomy was performed. Histopathological examination of the resected specimen revealed carcinoma in situ of the pancreas. The present case could indicate that any PDS becomes a candidate for SPACE especially in a patient with PPA, although the PDS remains unchanged for a long period.

Resection of carcinoma in situ and minimally invasive carcinoma of the pancreas in a patient presenting with stenosis and post-stenotic dilatation of the main pancreatic duct on endoscopic ultrasonography and positive serial pancreatic juice aspiration cytology

We report a rare case of a 67-year-old man who underwent resection of carcinoma in situ and minimally invasive carcinoma of the pancreas. The patient presented with upper abdominal and back pain. No definite pancreatic mass was detected on abdominal ultrasonography, computed tomography, magnetic resonance imaging (MRI), or endoscopic ultrasonography (EUS). However, EUS and MRI demonstrated stenosis of the main pancreatic duct (MPD) in the body and post-stenotic dilatation, resulting in mild dilatation of MPD in the tail. Serial pancreatic juice aspiration cytology after endoscopic nasopancreatic drainage was suggestive of pancreatic adenocarcinoma. Examination of the distal pancreatectomy specimen demonstrated carcinoma in situ in MPD and branches, with multiple intraepithelial neoplastic lesions in the background pancreas and an additional focus of minimally invasive carcinoma.

Molecular Detection of Gastrointestinal Neoplasia: Innovations in Early Detection and Screening

Emerging molecular tools promise to extend the diagnostic reach of the endoscopist and open doors to population screening for gastrointestinal (GI) cancers. This review briefly addresses biological considerations in marker detection and types of markers, highlights examples of tools under development at each organ site, and appraises the possibility of universal GI cancer screening. The outlook is positive, but further technical refinement and rigorous clinical validation are needed before most of these new approaches are ready for clinical application.

Pancreatic juice cytology as sensitive test for detecting pancreatic malignancy in intraductal papillary mucinous neoplasm of the pancreas without mural nodule

OBJECTIVE

Recent studies reported that mural nodule (MN) was the most associated with malignant intraductal papillary mucinous neoplasms (IPMNs). However, IPMNs without MN cannot be diagnosed as malignant if only MN is determined to be indicator of malignancy. This study aimed to investigate role of pancreatic juice cytology for IPMNs without MN.

METHODS

Medical records of 50 patients with histologically proven malignant IPMNs were reviewed. Exclusively for non-invasive cancer, extent of high-grade dysplasia along the main pancreatic duct (MPD) was determined microscopically.

RESULTS

Thirty-six percent IPMNs had no MN. Cyst and main MPD diameter were significantly smaller in IPMN without MN compared to those in IPMN with MN (23 ± 14.1 vs 35 ± 13.2 mm, p = 0.010; 6.6 ± 4.3 vs 10.9 ± 6.1 mm, p = 0.006). Sensitivity of pancreatic juice cytology was higher in IPMN without MN compared to that in IPMN with MN (94% vs 53%, p = 0.004) although it could be affected by selection bias of study patients. Absence of MN was determined to be an independent factor associated with true positive cytology (OR = 24.3, p = 0.005). Extent of high-grade dysplasia was significantly longer in IPMN with true positive cytology compared to that in IPMN with false negative cytology (46.8 ± 20.5 vs 26.4 ± 11.0 mm, p = 0.005), and tended to be longer in IPMN without MN compared to that in IPMN with MN (47.0 ± 19.0 vs 36.0 ± 20.1 mm, p = 0.16).

CONCLUSIONS

Sensitivity of pancreatic juice cytology was excellent in IPMN without MN. Pancreatic juice cytology may be a sensitive test for detection of pancreatic malignancy in IPMN without MN compared to high-risk imaging features.

Pancreatic adenocarcinomas without secondary signs on multiphasic multidetector CT: association with clinical and histopathologic features

PURPOSE

To determine the clinical, histopathologic and imaging features of pancreatic adenocarcinomas without secondary signs on dynamic CT.

MATERIALS AND METHODS

Seventy patients (mean age 70 years) with histologically proven pancreatic adenocarcinoma underwent preoperative contrast material-enhanced multiphasic multidetector CT before pancreatic resection. In each patient, clinical data including carbohydrate antigen 19-9, frequency of isoattenuating tumours, and presence of secondary signs and histopathologic findings such as tumour location, tumour stage, and microscopic infiltrative growth grade were evaluated.

RESULTS

Ten tumours (14%) were without secondary signs, and 60 (86%) were with secondary signs. Tumours without and with secondary signs were located in the uncinate process in 5 (50%) and 3 (5%), head in 3 (30%) and 29 (48%), body in 2 (20%) and 22 (37%), and tail in 0 (0%) and 6 (10%), respectively (p = .001). The frequency of isoattenuating pancreatic adenocarcinomas without secondary signs was significantly higher than those with secondary signs (p = 0.034). The tumour stage of pancreatic adenocarcinomas without secondary signs was earlier than that in tumours with secondary signs (p = 0.041).

CONCLUSIONS

Pancreatic adenocarcinomas without secondary signs is characterized by the presence of uncinate and isoattenuating tumours and earlier tumour stage compared to tumours with secondary signs.

KEY POINTS

Frequency of pancreatic adenocarcinomas without secondary signs on multiphasic CT is 14 . Pancreatic adenocarcinomas without secondary signs are common in the uncinate process. Pancreatic adenocarcinomas without secondary signs are common in isoattenuating tumours. Pancreatic adenocarcinomas without secondary signs are characterized by earlier-stage tumours.

Clinical usefulness of repeated pancreatic juice cytology via endoscopic naso-pancreatic drainage tube in patients with pancreatic cancer

BACKGROUND

Cytological examination of pancreatic juice obtained during endoscopic retrograde cholangiopancreatography (ERCP) is well established, but its sensitivity for pancreatic cancer has not been satisfactory. The aim of this study was to evaluate the usefulness of repeated pancreatic juice cytology (PJC) via the endoscopic naso-pancreatic drainage (ENPD) tube in patients with pancreatic cancer compared with conventional PJC.

METHODS

We retrospectively investigated 139 patients with pancreatic disease. Between April 2004 and November 2007, conventional PJC was performed in 56 patients with pancreatic cancer and 23 with benign pancreatic stricture. Between January 2008 and November 2010, ENPD was used in 40 patients with pancreatic cancer and 20 with benign pancreatic stricture. The ENPD tube was placed into the main pancreatic duct for up to 3 days, and cytological samples of pancreatic juice were collected up to 6 times in total.

RESULTS

Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the ENPD method for pancreatic cancer were 80, 100, 100, 71, and 87 %, respectively, revealing significantly higher sensitivity than the conventional method (p = 0.0001). Sensitivities according to tumor location and size were 90 % (19/21), 69 % (9/13), and 67 % (4/6) in the head, body, and tail of the pancreas, 88 % (7/8), 79 % (19/24), and 75 % (6/8) in tumors with a diameter less than 20 mm including carcinoma in situ, 21-40, and greater than 41 mm, respectively.

CONCLUSIONS

The ENPD method was found to have high diagnostic yield, especially for tumors less than 20 mm or located in the pancreatic head, and might be useful for the diagnosis of early-stage pancreatic cancer.

iTRAQ reveals candidate pancreatic cancer serum biomarkers: influence of obstructive jaundice on their performance

BACKGROUND

The aims of our study were to identify serum biomarkers that distinguish pancreatic cancer (pancreatic ductal adenocarcinoma, PDAC) patients from benign pancreatic disease patients and healthy subjects, and to assess the effects of jaundice on biomarker performance.

METHODS

Isobaric tags for relative and absolute quantification were used to compare pooled serum and pancreatic juice samples from a test set of 59 and 25 subjects, respectively. Validation was undertaken in 113 independent subjects.

RESULTS

Candidate proteins Complement C5, inter-α-trypsin inhibitor heavy chain H3, α1-β glycoprotein and polymeric immunoglobulin receptor were elevated in cancer, as were the reference markers CA19-9 and Reg3A. Biliary obstruction had a significant effect on the performance of the markers, in particular within the PDAC group where the presence of jaundice was associated with a significant increase in the levels of all six proteins (P<0.01). Consequently, in the absence of jaundice, proteins showed reduced sensitivity for PDAC patients over benign subjects and healthy controls (HCs). Similarly, in the presence of jaundice, markers showed reduced specificity for PDAC patients over benign subjects with jaundice. Combining markers enabled improved sensitivity for non-jaundiced PDAC patients over HCs and improved specificity for jaundiced PDAC patients over jaundiced benign disease subjects.

CONCLUSIONS

The presence-absence of jaundice in the clinical scenario severely impacts the performance of biomarkers for PDAC diagnosis and has implications for their clinical translation.

[A study of the usefulness of pancreatic juice cytology obtained via an endoscopic nasal pancreatic drainage (ENPD) tube]

We studied the usefulness of pancreatic juice cytology obtained via an indwelling endoscopic nasal pancreatic drainage (ENPD) tube. In general, cytology was performed three times. The sensitivity was 0.35 on the first time and 0.59 after three times (p<0.01). The sensitivity in relation to tumor size of pancreatic cancer was 0.77 for Tis (3 cases) and TS1 (10 cases), 0.76 for TS2 (29 cases), 0.56 for TS3 (9 cases) and 0 for TS4 (4 cases). A significant difference of p=0.01 was recognized among the 4 groups, and the sensitivity for small tumors was higher than that for large tumors. The pancreatic juice can be obtained repeatedly via the ENPD tube and that contributes to improving the diagnostic accuracy. It is useful as a definitive diagnosis method in early stage pancreatic cancer because it is easier to detect positive results in smaller tumor, furthermore, it is possible to diagnose carcinoma in situ.

MicroRNA expression analyses in preoperative pancreatic juice samples of pancreatic ductal adenocarcinoma

CONTEXT

Cytological assessment of pancreatic juice is commonly used to diagnose pancreatic ductal adenocarcinoma; however, the sensitivity of cytological assessment has been reported to be low. MicroRNAs are small RNAs regulating various cellular processes and have recently been identified as possible markers of malignant diseases including pancreatic ductal adenocarcinoma.

OBJECTIVE

The purposes of this study were to prove the existence of microRNAs in pancreatic juice and to determine whether specific microRNAs in pancreatic juice could be used for detecting pancreatic ductal adenocarcinoma.

METHODS

Relative expression levels of microRNA-21 and microRNA-155 in formalin-fixed paraffin-embedded tissues of resected specimens (no. 13) and pancreatic juice samples collected using preoperative endoscopic retrograde cholangiopancreatography (no. 21) were quantified and their expression levels were then compared to pancreatic ductal adenocarcinoma and chronic pancreatitis.

RESULTS

Relative expression levels of microRNA-21 in tissue and pancreatic juice samples were significantly higher in pancreatic ductal adenocarcinoma than those in chronic pancreatitis (P=0.009 and P=0.021, respectively). The same results were obtained in the expression levels of microRNA-155 in tissue and pancreatic juice between pancreatic ductal adenocarcinoma and chronic pancreatitis (P=0.014 and P=0.021, respectively). Expression levels of microRNA-21 and microRNA-155 did not correlate with the preoperative cytological results of pancreatic juice.

CONCLUSION

MicroRNA-21 and microRNA-155 in pancreatic juice have the potential of becoming biomarkers for diagnosing pancreatic ductal adenocarcinoma.

Multifocal pancreatic ductal adenocarcinomas concomitant with intraductal papillary mucinous neoplasms of the pancreas detected by intraoperative pancreatic juice cytology. A case report

CONTEXT

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas have been detected with increasing frequency as a result of the progression of diagnostic modalities. Recently, invasive ductal carcinoma of the pancreas concomitant with IPMNs has been the focus of attention.

CASE REPORT

We report the case of a 57-year-old man with multifocal ductal carcinomas of the pancreas concomitant with IPMNs detected by intraoperative cytology. During a follow-up for branch duct IPMNs, a stenotic lesion of the main duct in the pancreatic body was found by ERCP, and brush cytology of the stenosis revealed an adenocarcinoma. A distal pancreatectomy was proposed; however, intraoperative pancreatic juice cytology from the pancreatic head also revealed adenocarcinoma, and a total pancreatectomy was finally carried out. Pathological examination of the resected specimen showed multifocal ductal carcinomas and IPMNs in the distal pancreas, and invasive ductal carcinoma in the pancreatic head which had not been detected by preoperative imaging studies.

CONCLUSIONS

Surgeons should be aware of the possibility of multifocal carcinomas in patients with concomitant IPMNs. Intraoperative pancreatic juice cytology should always be performed in order to confirm the absence of carcinoma in the pancreas to be left in place after planned resection.

Small pancreatic cancer with pancreas divisum preoperatively diagnosed by pancreatic juice cytology

We present a case of small pancreatic head cancer with pancreas divisum preoperatively diagnosed by pancreatic juice cytology. A 60-year-old woman was referred to our hospital for evaluation of a dilated main pancreatic duct (MPD). A small and poorly reproducible low-echoic lesion in the pancreas was suspected by ultrasonography (US) and endoscopic ultrasonography (EUS). Magnetic resonance cholangiopancreatography (MRCP) failed to visualize the ventral pancreatic duct, and the upstream dorsal pancreatic duct was dilated. Endoscopic retrograde cholangiopancreatography (ERCP) was indicative of pancreas divisum, and complete obstruction of the MPD in the pancreatic head was seen. Cytology of pancreatic juice obtained from the dorsal pancreas after minor papilla sphincterotomy revealed the presence of adenocarcinoma cells. Pancreatoduodenectomy was performed under the diagnosis of pancreatic head cancer with pancreas divisum. Histological examination revealed moderately-differentiated tubular adenocarcinoma 20 mm in diameter, located in the pancreatic head. Dilatation of the dorsal pancreatic duct is sometimes observed in cases with pancreas divisum without the presence of tumors. When pancreatic duct stenosis also exists in such cases, even if a tumor is not clearly visualized by diagnostic imaging, vigorous examinations such as pancreatic juice cytology are recommended to establish an accurate diagnosis.

Pancreatic juice cytology and subclassification of intraductal papillary mucinous neoplasms of the pancreas

OBJECTIVES

Histological subclassification of intraductal papillary mucinous neoplasms (IPMNs) is important because the malignant potential of each subtype is different. We investigated whether pancreatic juice cytology can be used to define the subtypes of IPMNs preoperatively.

METHODS

The cytological findings and pathological parameters in 19 cases of IPMN were analyzed for correlations. Pancreatic juice cytology specimens were reviewed and classified into 4 types according to the criteria previously described for histological diagnosis: intestinal (Int), gastric foveolar (GF), oncocytic (Onc), and pancreatobiliary (PB), and the resected IPMNs were classified histologically using the same criteria for comparison. Immunochemical testing for MUC proteins was also performed.

RESULTS

In 15 cases (79%), the cytological and histological subclassifications were in agreement. The cytology specimens displayed different features corresponded to their histological subtypes. The sensitivities of the cytological diagnosis of each subtype were 80.0% (Int), 72.7% (GF), and 100% (Onc/PB); and the specificities were 85.7% (Int), 87.5% (GF), and 93.8% (Onc/PB). The cytoplasm of the Int-type cells in the pancreatic juice cytology specimens was positive for MUC2.

CONCLUSIONS

Most of the cytological findings of IPMNs corresponded to the histological findings. The use of MUC2 immunocytochemistry in IPMN subtyping was also demonstrated. Subtyping of IPMNs is useful for preoperative evaluation in addition to cytomorphological grading.

Management of intraductal papillary-mucinous neoplasm of the pancreas: treatment strategy based on morphologic classification

GOALS

The aim of this study was to examine and clarify the preoperative markers that are useful for differentiating between benign and malignant lesions of intraductal papillary-mucinous neoplasms (IPMN) of the pancreas, grouped according to morphologic classification.

BACKGROUND

There are various stages of pathology in IPMN, ranging from benign to malignant lesions. Although the determination of appropriate treatment guidelines to deal with IPMN is a critical issue, no such guidelines have been established.

PATIENTS AND METHODS

One hundred twenty cases of IPMN were classified morphologically into either main or branch duct types. We compared the morphologic classification with histopathologic diagnosis using indicators of malignancy detected by imaging such as main duct diameter, the number and diameter of cysts, and the presence or absence of mural nodules. We also examined the usefulness of pancreatic juice cytology and measurement of telomerase activity as indicators of malignancy. Finally, we performed a survival analysis on the basis of morphologic classification to determine prognosis of IPMN.

RESULTS

Whereas a high incidence (64%) of malignant lesions was seen in main duct type IPMN, benign lesions were dominant (80.5%) in branch duct type IPMN. Survival analysis showed that the prognosis was significantly worse in main duct type than in branch duct type IPMN. The lesions were aggravated in all patients with main duct type who did not undergo resection, resulting in death due to progression of the pancreatic lesion. The incidence of mural nodules was a useful indicator in main duct type, whereas main duct diameter and incidence of mural nodules were useful indicators in branch duct type. Although pancreatic juice cytology showed a high accuracy rate with low sensitivity for determining malignancy, measurement of telomerase activity in this juice was very effective for differentiating between benign and malignant lesions.

CONCLUSIONS

The incidence of malignant lesions was extremely high in main duct type IPMN, indicating that surgery is required in all these patients. However, to determine whether surgery is indicated in branch duct type IPMN it is necessary to obtain an appropriate image diagnosis focusing on main duct diameter and mural nodules and also to carry out cytology and measurement of telomerase activity in samples of pancreatic juice.

Pancreatic juice cytology in the diagnosis of intraductal papillary mucinous neoplasm of the pancreas: significance of sampling by peroral pancreatoscopy

BACKGROUND

The examination of pancreatic juice cytology could hypothetically contribute to the establishment of a definite diagnosis of malignant intraductal papillary mucinous neoplasm of the pancreas (IPMN), but to the authors' knowledge, its significance has not been confirmed to date. The current study was conducted to assess the diagnostic value of pancreatic juice cytology in IPMN and to examine the usefulness of peroral pancreatoscopy (POPS) in sampling pancreatic juice.

METHODS

The study subjects were comprised of 103 patients with IPMN who underwent surgical resection of pancreatic tumors (adenoma in 29 patients, borderline in 17 patients, carcinoma in situ in 25 patients, and invasive carcinoma in 32 patients). Pancreatic juice was collected with a catheter in 71 patients and by POPS in 32 patients. Patients with pancreatic carcinoma (n = 81) and chronic pancreatitis (n = 76) also were investigated.

RESULTS

The cytologic diagnosis was found to be of nondiagnostic value in only one patient with an IPMN, whereas it was of no diagnostic value in 14 of the patients with pancreatic carcinoma (17.3%), a difference that was statically significant (P < 0.001). The location of the IPMN (either in the pancreas or the pancreatic ducts) was not found to significantly affect the diagnostic value of the test. The sensitivity for IPMN was 62.2% when pancreatic juice was collected by POPS, and was 38.2% when it was collected using a catheter. In the case of pancreatic carcinoma, the sensitivity of pancreatic juice cytology was found to be 25.4%, which was significantly lower than that for IPMN when the pancreatic juice was collected by POPS (P < 0.001).

CONCLUSIONS

Pancreatic juice cytology was found to have better diagnostic value in the patients with IPMNs compared with those with pancreatic carcinoma. POPS was found to be useful for the collection of pancreatic juice.

Role of intraoperative cytology combined with histology in detecting continuous and skip type intraductal cancer existence for intraductal papillary mucinous carcinoma of the pancreas

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) is a recently discovered pancreatic tumor that has continuous or discontinuous (skip) lesions. Recent reports suggest a higher frequency of cancer recurrence in the remnant pancreas after surgical resection of IPMN. It is therefore important to precisely detect intraductal cancer extension and skip lesions when resecting IPMN.

METHODS

Both intraoperative histologic examination of the surgical margin and cytologic examination of the pancreatic juice from each pancreatic segment (head, body, or tail) were performed on 43 IPMN patients. In addition to the preoperatively planned resection, 1 or 2 pancreatic segment(s) were additionally resected if the pancreatic juice tested positive in cytology. When a surgical margin was positive but the cytology in the remaining segment was negative, a subsegment (2-cm slice in width) was additionally resected until a negative margin was confirmed.

RESULTS

Twenty-five patients (58%) demonstrated negative results in both histology and cytology obtained from the segment(s) that were not initially intended to be removed. In contrast to the preoperative estimation, 5 patients were found to have a positive surgical margin and negative cytology, 5 patients demonstrated a negative surgical margin and positive cytology, and 8 patients demonstrated a positive surgical margin and positive cytology. Investigations of the resected specimens revealed that 8 patients (19%) had skip lesions in addition to the main lesion. Logistic regression analysis revealed that patients with a dilated main pancreatic duct, or those with cancerous lesions in the main tumors, were at high risk for positive histology and/or cytology.

CONCLUSIONS

Using intraoperative frozen-section histology and pancreatic juice cytology, 18 out of 43 patients in the current study (42%) required additional resection of the pancreas. A necessary and sufficient range of resection should be determined by intraoperative examination.

Pancreatic juice cytology in IPMN of the pancreas

BACKGROUND

Intraductal papillary-mucinous neoplasm (IPMN) of the pancreas is a disease ranging from adenoma to borderline (with moderate dysplasia) and further to carcinoma (noninvasive and invasive) and surgical strategy is different by the grades of dysplasia.

METHODS

Preoperative pancreatic juice cytology in IPMN was reviewed in 71 patients with IPMN who underwent surgical resection.

RESULTS

The IPMN was adenoma in 48 patients, borderline in 13 and carcinoma (invasive) in 10. The sensitivity of pancreatic juice cytology in malignant IPMN was 40% (4/10). In 4 patients with the 48 IPM adenomas, diagnosis of pancreatic juice cytology was class IV or V. One of the 4 cases was considered to be an overdiagnosis of cytology, but the other 3 cases were considered to be a consequence of accompanying carcinoma in situ (or PanIN-3) (2 patients) or invasive ductal adenocarcinoma (1 patient) apart from IPMN. Sensitivity of pancreatic juice cytology was higher in IPMN of the main duct type with mucin hypersecretion and with mural nodules.

CONCLUSIONS

These findings suggest that pancreatic juice cytology in IPMN is useful especially in the main duct type with mucin hypersecretion and mural nodules. When the diagnosis of pancreatic juice cytology is malignant in otherwise benign-looking IPMNs, coexistence of pancreatic carcinoma should be suspected.

Radical resection for pancreatic cancer

Ductal adenocarcinoma of the pancreas is still characterized by (1) poor prognosis after surgery and (2) extreme difficulty in early diagnosis, and we need a breakthrough. For the first problem, we have performed a wide range of lymphatic and connective tissue clearance (extended pancreatectomy) which has succeeded in improving the 5-year survival rate from 8% to 24% via decreasing the incidence of locoregional recurrence. When liver perfusion chemotherapy via the hepatic artery and the portal vein was added to the patients who had received extended pancreatectomy, the 5-year survival rate was further elevated to 40% via decreasing the incidence of hepatic metastasis. We conclude that pancreatic cancer should be treated by the better-balanced treatments between locoregional control and prevention of hepatic metastasis. For the second problem, we have more actively collected pancreatic juice to perform cytodiagnosis even though no obvious tumor was delineated by the conventional imaging diagnoses. When cancer cells were detected in the pancreatic juice, our method of intraoperative cytology was very useful in precisely locating the occult lesion indicating an appropriate range of pancreatectomy. The resected pancreas was proven to have included borderline malignancy and in situ or minimally-invasive carcinoma by the postoperative histology, and disease-free 5-year survival rate was 100%. In the future, we need to detect patients with a high risk of pancreatic cancer and develop a less-painful method to collect the pancreatic juice.

Pancreatic intraductal sampling during ERCP in patients with chronic pancreatitis and pancreatic cancer: cytologic studies and k-ras-2 codon 12 molecular analysis in 47 cases

BACKGROUND

A preoperative tissue diagnosis of pancreatic cancer is desirable but difficult to obtain.

METHODS

Pancreatic brush cytology, salvage cytology, and collection of pancreatic juice were attempted prospectively during ERCP in 34 patients with pancreatic cancer and 11 with chronic pancreatitis. K-ras-2 codon 12 was analyzed for presence and type of point mutations.

RESULTS

Brush cytology coupled with salvage cytology had a sensitivity of 74%. The addition of cytologic analysis of pancreatic juice did not substantially improve sensitivity (76%). K-ras-2 was mutated in both cancer (87%) and pancreatitis (40%). The specificity for cytology was 100% and for K-ras-2 mutations 60%. Combining cytology with mutation analysis increased sensitivity to 93% but reduced the positive predictive value. The negative predictive value never exceeded 75%. None of the patients with chronic pancreatitis had cancer develop (median follow-up 60 months).

CONCLUSIONS

Pancreatic ductal brushing with salvage cytology is useful in the diagnosis of cancer, whereas cytologic analysis of pancreatic juice can be abandoned. At present, K-ras-2 mutation is not useful for differentiating pancreatic cancer from chronic pancreatitis or the identification of patients with chronic pancreatitis at risk for malignant transformation.

Diagnostic application of CD44 variant expression in pancreatic juice for detection of pancreatic neoplasm

Recently, increased and disorganized expression of CD44 variant exons (CD44v) has been demonstrated in several types of human malignancy. We tried to investigate CD44v expression in pancreatic juice from patients who underwent endoscopic retrograde pancreatography. We analyzed 24 patients with pancreatic neoplasms diagnosed histologically (adenocarcinoma, 17; adenoma, 7) and 15 patients with non-neoplastic lesions. The expression of CD44v mRNA in pancreatic juice was detected by using the reverse-transcription polymerase chain reaction technique followed by Southern hybridization with exon-specific probes. Of 17 patients with adenocarcinoma, 14 (82%) showed expression of CD44v6 mRNA and 11 (65%) showed expression of CD44v2 mRNA. Of 7 patients with adenoma, 6 (86%) were positive CD44v6 mRNA expression and 2 (29%) for CD44v2 mRNA expression; while, out of 15 patients with non-neoplastic lesion, 5 (33%) showed positive findings for CD44V6 mRNA and 3 (20%) for CD44v2 mRNA. Comparing of diagnostic accuracy among CD44v6, CD44v2 and cytological examination, the sensitivities for adenocarcinoma were 82%, 65% and 41% respectively. However, the specificity was lower in CD44v6 (50%), CD44v2 (77%) than in cytology (100%), because CD44v was positive in adenoma cases and normal cases. A combination of RT-PCR analysis for the expression of CD44v with cytological examination in the pancreatic juice may increase the accuracy of diagnosis for pancreatic cancer.

Diagnosis of pancreatic cancer by cytology and measurement of oncogene and tumor markers in pure pancreatic juice aspirated by endoscopy

BACKGROUND/AIMS

Cytological examination of pancreatic juice is useful in the diagnosis of an occult cancer of the pancreas. The early diagnosis of pancreatic carcinoma using traditional radiographic or ultrasonographic methods is extremely difficult.

METHODOLOGY

In order to detect an early pancreatic cancer, cytological examination, measurement of tumor marker, and detection of K-ras point mutation were performed using the samples of pure pancreatic juice aspirated endoscopically in patients who had symptoms or findings that suggested pancreatic disease.

RESULTS

By routine ERP-cytology, positive cytologic results were obtained in 15 (4%) out of 359 patients without a mass. With the aid of intra-operative cytodiagnosis, all 15 occult neoplasms of the pancreas were successfully resected. One patient died from another disease without evidence of recurrence. However, the other patients were alive with no evidence of recurrence for an average of 5.5 years following surgery. The patients who had negative ERP-cytology results were observed, but no further cases of pancreatic cancer were found. The CEA levels in the pure pancreatic juice were significantly higher in patients with pancreatic cancer than in those with pancreatitis. K-ras point mutation at codon 12 was detected not only in cases of pancreatic cancer, but also in cases of chronic pancreatitis as well as control subjects.

CONCLUSIONS

Cytological examination of pancreatic juice is useful in the diagnosis of an early and potentially curable in situ cancer of the pancreas. The CEA levels in the pure pancreatic juice provided useful information for differentiating the pancreatic cancer from chronic pancreatitis. K-ras point mutation at codon 12 in pancreatic juice was considered to be useful in identifying patients at high risk for the development of pancreatic cancer.

Loss of chromosome 18q is an early event in pancreatic ductal tumorigenesis

Cytogenetic and molecular studies demonstrated that pancreatic cancer frequently shows specific chromosomal abnormalities, such as losses of 9p, 17p, and 18q, and gains of 8q and 20q. We have analyzed alterations in the copy number of specific chromosomal regions in cells from the pancreatic juices of 32 patients with various pancreatic disorders by fluorescence in situ hybridization (FISH) technique to pursue the possible clinical use of early diagnosis of pancreatic cancer. None of the chromosomal abnormalities were found in 13 specimens from individuals who had no neoplastic lesions. On the other hand, 12 specimens (63%) derived from the remaining 19 patients who had neoplastic lesions showed at least one chromosomal abnormality. Ten of these specimens were from pancreatic cancer patients; 7 cases (70%) showed chromosomal abnormalities. All but one of the 12 tumors with chromosomal abnormalities had loss of 18q. Furthermore, we detected a tumor in one patient in whom the routine cytological method and endoscopic retrograde chorangiopancreatography found nothing. Based on the results by FISH, we performed endoscopic ultrasonography and found a small serous cystadenoma in this patient. These results indicate that: (a) FISH analysis of cells from pancreatic juices obtained during endoscopic retrograde chorangiopancreatography is quite useful for detecting pancreatic ductal tumors; and (b) loss of chromosome 18q is one of the early genetic changes that provide very useful information in diagnosing pancreatic neoplasias.

Analysis of K-ras oncogene mutation directly applied to atypical cell clusters on cytologic smear slides of bile and pancreatic juice

To develop an objective reference for the cytological evaluation of atypical cells in bile and pancreatic juice, we analyzed K-ras oncogene mutation in atypical cell clusters, which were collected directly from cytological smear slides; 50 samples (cell clusters) from 31 smear slides of 21 patients with carcinomas of the pancreatic head region, and nine samples from eight cases of benign disease. These cell clusters (5-1000 cells/cluster) were selectively suspended in buffer containing proteinase K, and subjected to DNA extraction. K-ras codon 12 mutation was determined by polymerase chain reaction amplification, followed by digestion with BstNI. The K-ras gene was amplified in 20 of 21 cases with carcinoma (34/50 samples), and in seven of eight cases with non-neoplastic disease (8/9 samples). Among the cases of which primary tumors showed K-ras mutation, amplification was successful in 10 of 11 cases; mutation was demonstrated in three of seven cases with cytologically atypical cells (4/11 samples), and in three of three cases with cytologically malignant cells (5/7 samples). No mutation was identified in the 10 cases of carcinoma without K-ras mutation (0/15 samples), or in eight cases of non-neoplastic disease (0/8 samples). Cytological details could be comparatively evaluated between atypical cell clusters with or without mutation on the same smear slides in two cases. This type of direct analysis of atypical cell clusters may be useful in the self-assessment of cytological diagnosis of bile and pancreatic juice.

Usefulness of simple endoscopic aspiration cytology of pancreatic juice for diagnosis of early pancreatic neoplasm. A prospective study

For detection of early cancer of the pancreas, endoscopic aspiration cytology of pancreatic juice without endoscopic retrograde pancreatography was performed in 64 consecutive outpatients who had symptoms or findings that suggested pancreatic disease. Patients with positive or suspicious cytologic results or abnormal US findings were admitted and underwent detailed examinations. Positive and suspicious cytologic results were obtained in 2 and 10 patients, respectively. Of those with positive and suspicious cytologic results, two, and one patient, respectively, were ultimately found to have pancreatic neoplasms. Of these three resected specimens, one was in situ carcinoma and two presented marked atypia. All patients were alive with no evidence of recurrence. No further cases of pancreatic neoplasm were found. Complications from the procedure did not develop in any patient. This technique is useful in the diagnosis of early neoplasms of the pancreas, because it is simple and safe to perform for outpatients.

Diagnosis of pancreatic cancer by K-ras point mutation and cytology of pancreatic juice

OBJECTIVES

Recently, it was reported that detection of K-ras point mutation at codon 12 in pancreatic juice is an objective method for the diagnosis of pancreatic cancer, but a few reports have suggested that this might represent an early event in pancreatic oncogenesis. In the present study we examined, in various patients, the occurrence of K-ras codon 12 point mutation in pancreatic juice and compared it with pancreatic juice cytology, which is also a reliable diagnostic method.

METHODS

Pancreatic juice was obtained endoscopically from patients with various pancreatic disorders and those without definite diseases, and was examined cytologically and for the occurrence of K-ras codon 12 point mutation. The K-ras gene was amplified by polymerase chain reaction (PCR) and the mutation at codon 12 (GGT-->GAT) was examined by slot blot hybridization analysis.

RESULTS

K-ras point mutation at codon 12 was detected in seven of 14 (50%) pancreatic cancers, in four of 10 (40%) mucin-producing tumors, in four of 13 (31%) chronic pancreatitis, and in two of 10 (20%) pancreas without definite disorders. K-ras point mutation was detected in nine of 18 (50%) pancreatic juice samples containing cancer cells, in eight of 18 (44%) pancreatic juice samples containing atypical cells, but in none of such samples containing only normal cells.

CONCLUSION

Cancer cells were detected from pancreatic cancer exclusively, but K-ras point mutation at codon 12 was detected in pancreatic juice, not only from pancreatic cancer, but also from other diseases.

Detection of K-ras point mutations at codon 12 in pancreatic juice for the diagnosis of pancreatic cancer by hybridization protection assay: a simple method for the determination of the types of point mutation

The present study was undertaken to detect K-ras oncogene point mutations at codon 12 in pure pancreatic juice (PPJ) by the hybridization protection assay (HPA) method for the diagnosis of pancreatic cancer (PC). This assay can be carried out within 30 min and can determine not only the presence of a mutation, but also the mutational type of K-ras at codon 12. The minimal ratio of mutant DNA detectable by the HPA was 5-10% of the total DNA. PPJ was collected through a cannula under duodenal fiberscope control from 20 patients with PC and 20 patients with chronic pancreatitis (CP). Analysis of PPJ by the HPA revealed that the incidence of K-ras point mutations at codon 12 was 55% (11/20) in patients with PC and 0% (0/20) in those with CP. Mutational types of K-ras at codon 12 in PC were aspartic acid (Asp) in nine cases, both Asp and cysteine in one case, and arginine in one case. Analysis of K-ras point mutations at codon 12 in PPJ using the HPA method seems promising as a new genetic test for the diagnosis of PC, because the HPA method is simple, and can easily determine the mutational type.

Duct-ectatic type of mucin producing tumor of the pancreas--new concept of pancreatic neoplasia

BACKGROUND/AIMS

Although there have been recent reports of mucin-producing tumor of the pancreas, there has been no thorough clinicopathological analysis of a large number of cases.

MATERIALS AND METHODS

Two hundred forty four cases of mucin-producing tumor of the pancreas from Japanese, European and American reports, together with 15 cases of our own, were analyzed clinicopathologically.

RESULTS

Mucin-producing tumor of the pancreas was found in 177 males and 82 females (M:F = 2.2:1). The mean age was 65.5 years. Jaundice, diabetes mellitus and a past history of pancreatitis were found in 15%-19% of the cases. The tumor was most frequently (62%) found in the head of the pancreas. Pathologically, hyperplasia or adenoma was found in 58 cases, and adenocarcinoma in 160 cases. Five-year-survival rate by the Kaplan-Meier method was 82.6% in all of the cases and postoperative survival curve was much better in cases with this type of carcinoma than in cases with ordinary pancreatic duct cell carcinoma (5-year-survival rate: 82.6% vs 17.3%). Serum tumor markers such as CEA or CA 19-9 were not effective in differentiating between benign and malignant, or in determining the degree of cancerous spread, while cytology of the pancreatic juice and biopsy of the tumor could contribute to the diagnosis.

CONCLUSIONS

Mucin-producing tumor has unique clinicopathological characteristics, such as the dilated main pancreatic duct or branches, dilatation of the orifice of the papilla of Vater, or good prognosis. Since a diagnosis for benign or malignant is very difficult in some cases, methods for distinguishing benign from malignant lesions or for determining cancerous spread, such as molecular biological techniques, should be established.

Detection of K-ras point mutations at codon 12 in pure pancreatic juice for the diagnosis of pancreatic cancer by PCR-RFLP analysis

The present study was undertaken to detect K-ras point mutations at codon 12 in pure pancreatic juice (PPJ) for the diagnosis of pancreatic cancer (PC) using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. PPJ was collected through a cannula under a duodenal fiberscope from 26 patients with PC and 32 patients with chronic pancreatitis (CP). DNA was extracted from PPJ and was used as the template for PCR. Analysis of PPJ by PCR-RFLP with BstNI revealed that the incidence of K-ras point mutations at codon 12 was 81% (21/26) in patients with PC and 6% (2/32) in those with CP. With reference to the location of PC, the incidence of K-ras mutations was 79% (11/14) in the head, 86% (6/7) in the body, and 80% (4/5) in the tail of the pancreas. The incidence of K-ras mutants was 50% (1/2) in tumor size 1 (TS1; < or = 2.0 cm in size), 71% (5/7) in TS2 (2.1 to < or = 4.0 cm), 89% (8/9) in TS3 (4.1 to < or = 6.0 cm), and 88% (7/8) in TS4 (> 6.1 cm). These results suggested that analysis of K-ras point mutations at codon 12 in PPJ using the PCR-RFLP method is a promising new genetic test for the diagnosis of PC.

Effectiveness of the cytologic examination of pure pancreatic juice in the diagnosis of early neoplasia of the pancreas

BACKGROUND

The early diagnosis of pancreatic carcinoma through the use of traditional radiographic or ultrasonographic methods is extremely difficult.

METHODS

To detect an early and potentially curable cancer of the pancreas, endoscopic retrograde pancreatography (ERP) and aspiration cytology of pure pancreatic juice were performed in 295 consecutive patients who had symptoms or findings that suggested pancreatic disease but in whom there was neither a pancreatic mass nor ductal stenosis.

RESULTS

Positive cytologic results were obtained in 12 patients (4%). With the aid of intraoperative cytodiagnosis, all 12 early neoplasms of the pancreas were successfully resected. Of these 12 resected specimens, 4 were adenocarcinoma with minimal invasion, 3 were in situ adenocarcinoma and 5 were marked atypia. All 12 patients were alive with no evidence of recurrence for an average of 32 months after surgery. The 283 patients who had negative ERP-cytology results were observed, but no further cases of pancreatic cancer were found.

CONCLUSIONS

Because ERP-cytology is simple to perform, safe, and reliable, it is useful in the diagnosis of patients who have early neoplasm of the pancreas.

Evaluation of cytology and tumor markers of pure pancreatic juice for the diagnosis of pancreatic cancer at early stages

To evaluate the value of cytology of pure pancreatic juice (PPJ) and tumor marker determination in PPJ and serum for the diagnosis of early pancreatic cancer (EPC), PPJ was obtained endoscopically from 16 patients with EPC (< 20 mm, confined to pancreas), 16 patients with chronic pancreatitis (CP), and 20 controls. Cutoff levels of CEA, CA19-9, and POA in PPJ were set from ROC curves at 40 ng/ml, 7,500 U/ml, and 1.5 U/ml, respectively. For the differentiation of EPC from CP, the sensitivity of CEA, CA19-9, and POA was 71.4, 42.9, and 50%, respectively; specificity was 93.3, 46.7, and 80%, respectively; and diagnostic accuracy was 82.8, 44.8, and 65.5%, respectively. Determination of serum tumor markers was useless. Sensitivity of cytology was 75%, specificity was 93.8%, and diagnostic accuracy was 84.4%. Combined cytology and CEA determination in PPJ increased the diagnostic accuracy to 93.1%. The combination was useful in supporting and supplementing endoscopic retrograde cholangiopancreatography (ERCP) findings for the correct diagnosis in 11 and 4 patients, respectively, with EPC; in one patient EPC was correctly diagnosed on ERCP findings alone. One of 16 patients with CP showed false-positive results. We conclude that cytology and CEA determination in PPJ with ERCP is a useful combination for the diagnosis of pancreatic cancer even in early stages.

Cytologic examination of pancreatic juice for differential diagnosis of benign and malignant mucin-producing tumors of the pancreas

BACKGROUND

A new clinical type of pancreatic tumor, the mucin-producing tumor, has been recognized recently. However, it is not always easy to distinguish benign from malignant tumors preoperatively. In this study, three different methods of differentiating mucin-producing tumors of the pancreas were compared.

METHODS

Endoscopic ultrasonography, endoscopic retrograde pancreatography, and cytologic examination of pancreatic juice were performed in 14 patients who had mucin-producing pancreatic tumors (11 carcinomas and 3 adenomas). Pancreatic juice was collected endoscopically without papillotomy.

RESULTS

The sensitivity, specificity, and overall accuracy of endoscopic ultrasonography were 82%, 90%, and 79%, respectively; those of endoscopic retrograde pancreatography were 91%, 91%, and 86%; and those of cytologic examination were 91%, 100%, and 93%.

CONCLUSION

Cytologic examination of pancreatic juice was the best of these three methods for differentiating benign from malignant mucin-producing pancreatic tumors.

Identification of K-ras oncogene mutations in the pure pancreatic juice of patients with ductal pancreatic cancers

Pancreatic cancer is detected on the basis of morphological changes delineated by means of various image-diagnostic methods. However, differentiation between chronic pancreatitis and pancreatic cancer, especially at the early stage, is not always simple when based upon the morphological changes alone. Therefore, we attempted to elucidate K-ras mutations in the sediment of pure pancreatic juice (PPJ) containing exfoliated ductal pancreatic cancer cells. PPJ was collected endoscopically from 20 patients with pancreatic cancer (PC) and 18 patients with chronic pancreatitis (CP). Polymerase chain reaction and allele specific oligonucleotide dot blot hybridization for K-ras mutations were performed with the DNA extracted from these samples. A K-ras mutation at codon 12 was identified in the PPJ of 11/20 (55%) of the patients with PC. On the other hand, the same mutation was not identified in the PPJ of any patient with CP. Moreover, K-ras mutations at codons 13 and 61 were not recognized in the PPJ of any patient with either PC or CP. These findings suggested that the presence of a K-ras mutation at codon 12 in PPJ would be useful in confirming the diagnosis of PC.

Cytologic examination of pure pancreatic juice in the diagnosis of pancreatic carcinoma. The endoscopic retrograde intraductal catheter aspiration cytologic technique

BACKGROUND

Although cytologic examination of pure pancreatic juice obtained with a duodenofiberscope has been useful for the diagnosis of pancreatic carcinoma, the rate of false-negative results is reported to be high. To eliminate these false-negative results, the authors developed a new technique, endoscopic retrograde intraductal catheter aspiration cytology, especially for an accurate cytologic diagnosis of carcinoma of the body or tail of the pancreas.

METHODS

The accuracy of conventional cytologic examination of pure pancreatic juice was assessed in 25 patients with pancreatic carcinoma, 29 patients with pancreatitis, and 52 control subjects. Pure pancreatic juice was collected from the pancreatic duct by endoscopic cannulation using a videoimaging duodenoscope after intravenous administration of secretin. The new endoscopic retrograde intraductal catheter aspiration technique was used in four patients with carcinoma of the body or tail of the pancreas and five patients with localized pancreatitis in whom a correct diagnosis was not made by previous cytologic examination of pure pancreatic juice.

RESULTS

Positive cytologic findings were obtained in 76% of the patients with pancreatic carcinoma. Positive cytologic results were more frequent in patients with carcinoma of the head of the pancreas than in those with carcinoma of the body or tail. By the new technique, positive cytologic results were obtained in all of the patients with pancreatic carcinoma. This technique caused no severe complications.

CONCLUSIONS

This procedure of endoscopic retrograde intraductal catheter aspiration cytology seems useful for diagnosis of pancreatic carcinoma.

Pancreatic juice cytology for monitoring pancreatic grafts in the early postoperative period

Thirty-one pancreas transplant recipients were monitored by pancreatic juice cytology in the early postoperative period. An increase in the total amount of cells and, in particular, signs of immunoactivation with the appearance of two or more blast-transformed cells per specimen were taken as evidence of acute rejection. According to these criteria a total of 38 rejection episodes were diagnosed. The first positive cytology appeared after 9 days (mean) and lasted for 2 days (mean). Immunocytochemical analysis of the juice showed increased amounts of CD3+ cells during rejection. When rejection occurred during prophylaxis with antithymocyte globulin, neutrophils were preponderant in the pancreatic juice while during OKT-3 prophylaxis a high percentage of monocytes was a characteristic finding. Antirejection treatment was started when the cytology became positive and all rejection episodes except one were reversed. A decrease in the pancreatic juice amylase activity occurred in 66% of the rejection episodes, but in only 5 of the 38 episodes was the decrease highly significant. No correlation was found between graft rejection and volume excretion of pancreatic juice. There were no persistent or characteristic changes in serum amylase or peripheral white blood cell count at the time of rejection. Graft pancreatitis was diagnosed cytologically in 7 patients, in 5 of whom the grafts were eventually lost.

Morphology of acute rejection and corresponding cytological findings in exocrine secretion after pancreas transplantation in the rat

Reliable and timely rejection diagnosis still represents a major problem of pancreas allotransplantation. The aim of this study was to confirm the clinical findings of exocrine function impairment and pancreatic juice cytology during rejection, to refine the latter by means of flow cytometry, and to correlate these changes with graft histology. Heterotopic pancreatic transplants were performed in a modified technique in Lewis rats rendered diabetic by means of streptozotocin from LEW donors (group I, n = 10), Brown Norway rats without immunosuppression (group II, n = 16), and from BN rats where recipients were given cyclosporine 12 mg/kg/BW (group III, n = 10). Pancreatic juice was obtained by daily aspiration from a self-made fully implantable catheter reservoir system. In group II animals acute rejection diagnosed on histomorphological grounds was clearly associated with a decrease in the amount of exocrine secretion and its enzyme content from day 8 on. In contrast to groups I and III, a significant increase in lymphocytes in the pancreatic juice up to 13.5% occurred in group II between days 5 and 7. Activated lymphocytes increased from 7% to 13%, pan-T cells from 193 to 340 events. Histology revealed three distinct phases of acute rejection--phase I: diffuse infiltration of acinar structures; phase II: destruction of interlobular ducts; phase III: vasculitis associated with islet cell damage. The anatomy of the pancreas with the slackness of its highly vascularized interstitial connective tissue facilitates early infiltration of inflammatory cells and migration of these cells into the lumen of the pancreatic duct. Thus pancreatic juice cytology together with an impaired exocrine graft function is highly indicative of acute rejection.

Cytologic patterns in juice from human pancreatic transplants: correlation with histologic findings in the graft

In 19 patients who had undergone pancreatic transplantation with temporary exteriorization of the pancreatic juice, graft tissue became available for histologic examination. In these patients the cytologic patterns in the pancreatic juice were compared with the histologic findings in the graft specimens. In five samples the diagnosis by cytologic studies was rejection. Acute rejection was confirmed in all the histologic specimens. In eight cytologic samples, graft pancreatitis was suspected because of the increased amounts of neutrophils, degenerating cells, epithelial cells, monocytes, and some macrophages, with or without necrotic tissue fragments. All eight histologic specimens showed findings characteristic of pancreatitis. In three cytologic samples, bacteria or fungi were observed. Histologic examination of these patients showed graft pancreatitis. In four patients the cytologic findings were normal. Graft histologic factors were normal in two instances. In one of these grafts there was graft pancreatitis, and in one graft chronic vascular rejection was seen. Our study shows that two different pathologic events occurring in the pancreatic graft (i.e., acute rejection and pancreatitis) are reflected by characteristic changes in pancreatic juice cytology.

Pancreatic juice cytology in the monitoring of pancreas allografts

A technique for preparation of pancreatic juice for cytological examination, which was applied in 35 consecutive recipients of a pancreas allograft, is described. Pancreatic juice cytology (PJC) was performed daily, giving a total of 1116 cytological specimens. In these 35 pancreas grafts, 26 acute cellular and two vascular rejections were diagnosed on the basis of exocrine and endocrine graft function, perfusion scans, and clinical course and outcome, and were retrospectively compared with PJC findings. Histology was available only for vascular-type rejections. In uncomplicated cases, mainly neutrophil granulocytes with some ductal epithelial cells and 2-3% lymphocytes were seen. During 96% of acute cellular rejections an increase of lymphocytes was detected to more than 5% of all cells counted. In two-thirds of these episodes, eosinophil granulocytes and/or necrotic epithelial cells were found. The total number of cells was significantly increased in 60% of the cases. A minimum of two of these criteria was necessary for diagnosis of rejection. Rejections were correctly diagnosed in 234 slides (23 episodes) and missed in 36 (three episodes), PJC gave a false-positive result in 27 examinations (three rejections), but a correct negative result in the remaining 819 examinations. This gives a sensitivity of 86.6% and a specificity of 96.8%. With the exception of viral pancreatitis, where no specific changes were seen, PJC also proved very helpful in diagnosing other complications after pancreas transplantation, such as pancreatitis, bacterial or fungal contamination of the juice, and even cyclosporine toxicity. PJC facilitated the detection of isolated rejection episodes of the pancreas graft in recipients of a combined renal pancreatic graft, which happened in six instances. PJC has proved to be a simple but most helpful method for the detection of cellular rejection of pancreas allografts, as well as other complications.