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Sugiyama T, Tajiri T, Kurata M, Hiraiwa S, Fujita H, Machida T, Ito H, Muraki T, Yoshii H, Izumi H, Suzuki T, Mukai M, Nakamura N. Sensitivity of endoscopic ultrasound-guided fine-needle aspiration cytology and biopsy for a diagnosis of pancreatic ductal adenocarcinoma: A comparative analysis. Pathol Int 2023. [PMID: 37154509 DOI: 10.1111/pin.13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/16/2023] [Indexed: 05/10/2023]
Abstract
The utility of endoscopic ultrasound fine-needle aspiration cytology (EUS-FNAC) or endoscopic ultrasound fine-needle aspiration biopsy (EUS-FNAB) for diagnosis of small and large pancreatic ductal adenocarcinomas (PDACs) remains in question. We addressed this by analyzing 97 definitively diagnosed cases of PDAC, for which both EUS-FNAC and EUS-FNAB had been performed. We subclassified the 97 solid masses into small (n = 35) or large (n = 62) according to the maximum tumor diameter (<24 mm or ≥24 mm) and compared the diagnostic sensitivity (truly positive rate) of EUS-FNAC and of EUS-FNAB for small and large masses. Diagnostic sensitivity of EUS-FNAC did not differ between large and small masses (79.0% vs. 60.0%; p = 0.0763). However, the diagnostic sensitivity of EUS-FNAB was significantly higher for large masses (85.5% vs. 62.9%; p = 0.0213). Accurate EUS-FNAC-based diagnosis appeared to depend on the degree of cytological atypia of cancer cells, which was not associated with quantity of cancer cells. The accuracy of EUS-FNAB-based diagnosis appeared to depend on cancer cell viability in large masses and cancer volume in small masses. Based on the advantages or disadvantages in each modality, both modalities play an important role in the qualitative diagnosis of PDAC as a complementary procedure.
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Affiliation(s)
- Tomoko Sugiyama
- Department of Diagnostic Pathology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Takuma Tajiri
- Department of Diagnostic Pathology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Makiko Kurata
- Department of Diagnostic Pathology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Shinichiro Hiraiwa
- Department of Diagnostic Pathology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Hirotaka Fujita
- Department of Laboratory Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Tomohisa Machida
- Department of Laboratory Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Hiroyuki Ito
- Department of Gastroenterology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Takashi Muraki
- Department of Gastroenterology, Kita-Alps Medical Center Azumino Hospital, Nagano, Japan
| | - Hisamichi Yoshii
- Department of Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Hideki Izumi
- Department of Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Takayoshi Suzuki
- Department of Gastroenterology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Masaya Mukai
- Department of Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Naoya Nakamura
- Department of Pathology, Tokai University School of Medicine, Isehara, Japan
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The Utility of EUS-FNA to Determine Surgical Candidacy in Patients with Pancreatic Cancer after Neoadjuvant Therapy. J Gastrointest Surg 2020; 24:2807-2813. [PMID: 31823316 DOI: 10.1007/s11605-019-04415-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/16/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients with borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC) who undergo neoadjuvant therapy, CT imaging is the standard of care for restaging. However, differentiating residual tumor from post-treatment inflammation with CT is unreliable. The diagnosis of periarterial soft tissue cuffing (PSTC) near major vessels is key to guiding resectability. The goal of this study was to assess the utility of EUS-FNA in determining the etiology of PSTC in BRPC or LAPC after neoadjuvant treatment. METHODS We performed a retrospective analysis of patients referred for EUS-FNA of PSTC following downstaging therapy for LAPC or BRPC at our tertiary medical center. Negative EUS-FNA cytology results were compared with surgical pathology after resection. Patients with positive EUS-FNA cytology results were either followed clinically or results were compared to surgical pathology if surgery was attempted despite the positive cytology. RESULTS Fourteen patients were included in the study of whom four had positive cytology. Two of these patients had progression of disease, and two had attempted resection with positive surgical pathology (100% true positives). All ten patients with negative cytology underwent attempted surgical resection. Nine patients (90%) achieved negative margins, and one patient (10%) had a positive surgical margin. The sensitivity, specificity, and accuracy of EUS-FNA for determining resectability were 80%, 100%, and 92.9%, respectively. CONCLUSIONS In this series of patients with BRPC or LAPC and persistent PSTC after downstaging neoadjuvant treatment, EUS-FNA accurately determined surgical resectability and should be considered as part of the evaluation of such patients.
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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Spinelli P, Schiavo M, Schicchi AA. L'endoscopia Nella Diagnosi E Stadiazione Del Carcinoma Pancreatico. TUMORI JOURNAL 2018. [DOI: 10.1177/030089169908501s05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Pasquale Spinelli
- Divisione di Diagnostica e Chirurgia Endoscopica, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italia
| | - Marcello Schiavo
- Divisione di Diagnostica e Chirurgia Endoscopica, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italia
| | - Angelo Aldo Schicchi
- Divisione di Diagnostica e Chirurgia Endoscopica, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italia
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Best LMJ, Rawji V, Pereira SP, Davidson BR, Gurusamy KS, Cochrane Upper GI and Pancreatic Diseases Group. Imaging modalities for characterising focal pancreatic lesions. Cochrane Database Syst Rev 2017; 4:CD010213. [PMID: 28415140 PMCID: PMC6478242 DOI: 10.1002/14651858.cd010213.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Lawrence MJ Best
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
| | - Vishal Rawji
- University College London Medical SchoolLondonUK
| | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
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James PD, Meng ZW, Zhang M, Belletrutti PJ, Mohamed R, Ghali W, Roberts DJ, Martel G, Heitman SJ. The incremental benefit of EUS for identifying unresectable disease among adults with pancreatic adenocarcinoma: A meta-analysis. PLoS One 2017; 12:e0173687. [PMID: 28319148 PMCID: PMC5358870 DOI: 10.1371/journal.pone.0173687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 02/24/2017] [Indexed: 12/18/2022] Open
Abstract
Background and study aims It is unclear to what extent EUS influences the surgical management of patients with pancreatic adenocarcinoma. This systematic review sought to determine if EUS evaluation improves the identification of unresectable disease among adults with pancreatic adenocarcinoma. Patients and methods We searched MEDLINE, EMBASE, bibliographies of included articles and conference proceedings for studies reporting original data regarding surgical management and/or survival among patients with pancreatic adenocarcinoma, from inception to January 7th 2017. Our main outcome was the incremental benefit of EUS for the identification of unresectable disease (IBEUS). The pooled IBEUS were calculated using random effects models. Heterogeneity was explored using stratified meta-analysis and meta-regression. Results Among 4,903 citations identified, we included 8 cohort studies (study periods from 1992 to 2007) that examined the identification of unresectable disease (n = 795). Random effects meta-analysis suggested that EUS alone identified unresectable disease in 19% of patients (95% confidence interval [CI], 10–33%). Among those studies that considered portal or mesenteric vein invasion as potentially resectable, EUS alone was able to identify unresectable disease in 14% of patients (95% CI 8–24%) after a CT scan was performed. Limitations The majority of the included studies were retrospective. Conclusions EUS evaluation is associated with increased identification of unresectable disease among adults with pancreatic adenocarcinoma.
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Affiliation(s)
- Paul D. James
- Department of Medicine and the Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Medicine, University of Calgary, Calgary, Canada
- Calgary Research and Education in Advanced Therapeutic Endoscopy (CREATE), Calgary, Canada
- * E-mail:
| | - Zhao Wu Meng
- Department of Medicine and the Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Mei Zhang
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Paul J. Belletrutti
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Medicine, University of Calgary, Calgary, Canada
- Calgary Research and Education in Advanced Therapeutic Endoscopy (CREATE), Calgary, Canada
| | - Rachid Mohamed
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Medicine, University of Calgary, Calgary, Canada
- Calgary Research and Education in Advanced Therapeutic Endoscopy (CREATE), Calgary, Canada
| | - William Ghali
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Medicine, University of Calgary, Calgary, Canada
| | | | | | - Steven J. Heitman
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Medicine, University of Calgary, Calgary, Canada
- Calgary Research and Education in Advanced Therapeutic Endoscopy (CREATE), Calgary, Canada
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Xu MM, Jia HY, Yan LL, Li SS, Zheng Y. Comparison of two different size needles in endoscopic ultrasound-guided fine-needle aspiration for diagnosing solid pancreatic lesions: A meta-analysis of prospective controlled trials. Medicine (Baltimore) 2017; 96:e5802. [PMID: 28151856 PMCID: PMC5293419 DOI: 10.1097/md.0000000000005802] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This meta-analysis aimed to provide a pooled analysis of prospective controlled trials comparing the diagnostic accuracy of 22-G and 25-G needles on endoscopic ultrasonography (EUS-FNA) of the solid pancreatic mass. METHODS We established a rigorous study protocol according to Cochrane Collaboration recommendations. We systematically searched the PubMed and Embase databases to identify articles to include in the meta-analysis. Sensitivity, specificity, and corresponding 95% confidence intervals were calculated for 22-G and 25-G needles of individual studies from the contingency tables. RESULTS Eleven prospective controlled trials included a total of 837 patients (412 with 22-G vs 425 with 25-G). Our outcomes revealed that 25-G needles (92% [95% CI, 89%-95%]) have higher sensitivity than 22-G needles (88% [95% CI, 84%-91%]) on solid pancreatic mass EUS-FNA (P = 0.046). However, there were no significant differences between the 2 groups in overall diagnostic specificity (P = 0.842). The pooled positive and negative likelihood ratio of the 22-G needle were 12.61 (95% CI, 5.65-28.14) and 0.16 (95% CI, 0.12-0.21), respectively. The pooled positive likelihood ratio was 12.61 (95% CI, 5.65-28.14), and the negative likelihood ratio was 0.16 (95% CI, 0.12-0.21) for the 22-G needle. The pooled positive likelihood ratio was 8.44 (95% CI, 3.87-18.42), and the negative likelihood ratio was 0.13 (95% CI, 0.09-0.18) for the 25-G needle. The area under the summary receiver operating characteristic curve was 0.97 for the 22-G needle and 0.96 for the 25-G needle. CONCLUSION Compared to the study of 22-G EUS-FNA needles, our study showed that 25-G needles have superior sensitivity in the evaluation of solid pancreatic lesions by EUS-FNA.
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Dušková J, Krechler T, Dvořák M. Endoscopic ultrasound-guided fine needle aspiration biopsy of pancreatic lesions. An 8-year analysis of single institution material focusing on efficacy and learning progress. Cytopathology 2016; 28:109-115. [PMID: 27658926 DOI: 10.1111/cyt.12375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2016] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the efficacy and the learning curve of the endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) diagnostics of pancreatic lesions over 8 years (2007-2014). MATERIAL AND METHODS EUS-FNAB using a Linear Echoendoscope Olympus was performed in 531 patients, mostly without rapid on-site evaluation (ROSE). Smears plus cytoblock sections were used routinely. Immunocytochemistry was utilised as indicated. RESULTS The average, satisfactory sampling rate increased from the 61.2% in the first 3-year period to 72.9% in the last 3-year period (P = 0.008). The availability of the material for cytoblocks increased from 36.4% in the first period to 75.3% in the last period (P = 0.017). The efficacy of cytoblocks increased from 39.6% to 46.2% (P = 0.086). Comparing the first and last 3-year periods, the indication for immunocytochemistry did not rise substantially (5.2% and 8.5% respectively), but the predictive value of immunocytochemistry rose from 56.3% to 100.0% (P = 0.001). The most frequent diagnostic result was malignancy confirmation - both primary (41.2%) and metastatic (2.1%). In cases with representative samples and follow-up information, the specificity, sensitivity, positive predictive value and accuracy were high from the beginning. The negative predictive value decreased slightly in the last 3-year period. CONCLUSION The pancreatic EUS-FNAB without ROSE represents a suboptimal arrangement conditioned with our staff/time/location reality. Nevertheless, within the last 3 years of our activity, nearly three-quarters of patients profit from the diagnostic contribution of this procedure.
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Affiliation(s)
- J Dušková
- 1st Faculty of Medicine, Institute of Pathology, Charles University, Prague, Czech Republic
| | - T Krechler
- 4th Department of Medicine, Faculty General Hospital, Charles University, Prague, Czech Republic
| | - M Dvořák
- 4th Department of Medicine, Faculty General Hospital, Charles University, Prague, Czech Republic
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Tamburrino D, Riviere D, Yaghoobi M, Davidson BR, Gurusamy KS, Cochrane Upper GI and Pancreatic Diseases Group. Diagnostic accuracy of different imaging modalities following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 2016; 9:CD011515. [PMID: 27631326 PMCID: PMC6457597 DOI: 10.1002/14651858.cd011515.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Periampullary cancer includes cancer of the head and neck of the pancreas, cancer of the distal end of the bile duct, cancer of the ampulla of Vater, and cancer of the second part of the duodenum. Surgical resection is the only established potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Other imaging methods such as magnetic resonance imaging (MRI), positron emission tomography (PET), PET-CT, and endoscopic ultrasound (EUS) have been used to detect local invasion or distant metastases not visualised on CT scanning which could prevent unnecessary laparotomy. No systematic review or meta-analysis has examined the role of different imaging modalities in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer. OBJECTIVES To determine the diagnostic accuracy of MRI, PET scan, and EUS performed as an add-on test or PET-CT as a replacement test to CT scanning in detecting curative resectability in pancreatic and periampullary cancer. SEARCH METHODS We searched MEDLINE, Embase, Science Citation Index Expanded, and Health Technology Assessment (HTA) databases up to 5 November 2015. Two review authors independently screened the references and selected the studies for inclusion. We also searched for articles related to the included studies by performing the "related search" function in MEDLINE (OvidSP) and Embase (OvidSP) and a "citing reference" search (by searching the articles that cite the included articles). SELECTION CRITERIA We included diagnostic accuracy studies of MRI, PET scan, PET-CT, and EUS in patients with potentially resectable pancreatic and periampullary cancer on CT scan. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and quality assessment using the QUADAS-2 (quality assessment of diagnostic accuracy studies - 2) tool. Although we planned to use bivariate methods for analysis of sensitivities and specificities, we were able to fit only the univariate fixed-effect models for both sensitivity and specificity because of the paucity of data. We calculated the probability of unresectability in patients who had a positive index test (post-test probability of unresectability in people with a positive test result) and in those with negative index test (post-test probability of unresectability in people with a positive test result) using the mean probability of unresectability (pre-test probability) from the included studies and the positive and negative likelihood ratios derived from the model. The difference between the pre-test and post-test probabilities gave the overall added value of the index test compared to the standard practice of CT scan staging alone. MAIN RESULTS Only two studies (34 participants) met the inclusion criteria of this systematic review. Both studies evaluated the diagnostic test accuracy of EUS in assessing the resectability with curative intent in pancreatic cancers. There was low concerns about applicability for most domains in both studies. The overall risk of bias was low in one study and unclear or high in the second study. The mean probability of unresectable disease after CT scan across studies was 60.5% (that is 61 out of 100 patients who had resectable cancer after CT scan had unresectable disease on laparotomy). The summary estimate of sensitivity of EUS for unresectability was 0.87 (95% confidence interval (CI) 0.54 to 0.97) and the summary estimate of specificity for unresectability was 0.80 (95% CI 0.40 to 0.96). The positive likelihood ratio and negative likelihood ratio were 4.3 (95% CI 1.0 to 18.6) and 0.2 (95% CI 0.0 to 0.8) respectively. At the mean pre-test probability of 60.5%, the post-test probability of unresectable disease for people with a positive EUS (EUS indicating unresectability) was 86.9% (95% CI 60.9% to 96.6%) and the post-test probability of unresectable disease for people with a negative EUS (EUS indicating resectability) was 20.0% (5.1% to 53.7%). This means that 13% of people (95% CI 3% to 39%) with positive EUS have potentially resectable cancer and 20% (5% to 53%) of people with negative EUS have unresectable cancer. AUTHORS' CONCLUSIONS Based on two small studies, there is significant uncertainty in the utility of EUS in people with pancreatic cancer found to have resectable disease on CT scan. No studies have assessed the utility of EUS in people with periampullary cancer.There is no evidence to suggest that it should be performed routinely in people with pancreatic cancer or periampullary cancer found to have resectable disease on CT scan.
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Affiliation(s)
| | - Deniece Riviere
- Radboud University Medical Center NijmegenDepartment of SurgeryGeert Grooteplein Zuid 10route 618Nijmegen6500 HBNetherlandsP.O. Box 9101
| | - Mohammad Yaghoobi
- McMaster University and McMaster University Health Sciences CentreDivision of Gastroenterology1200 Main Street WestHamiltonONCanada
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
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10
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Banafea O, Mghanga FP, Zhao J, Zhao R, Zhu L. Endoscopic ultrasonography with fine-needle aspiration for histological diagnosis of solid pancreatic masses: a meta-analysis of diagnostic accuracy studies. BMC Gastroenterol 2016; 16:108. [PMID: 27580856 PMCID: PMC5007683 DOI: 10.1186/s12876-016-0519-z] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/11/2016] [Indexed: 11/22/2022] Open
Abstract
Background Previous studies have demonstrated that endoscopic ultrasound-fine needle aspiration (EUS-FNA) is a reliable tool for diagnosing pancreatic lesions; however, the reported sensitivity and specificity vary greatly across studies. The aim of this study was to pool the existing literature and assess the overall performance of EUS-FNA in the diagnosis of solid pancreatic lesions. Methods A systematic search of MEDLINE, Cochrane Database for Systematic Reviews, and EMBASE was performed to identify original and review articles published between January 1995 and January 2014 that reported the accuracy of EUS-FNA in the diagnosis of pancreatic masses. Quality of the included studies was assessed using the quality assessment of diagnosis accuracy studies score tool. Meta-DiSc software was used to calculate the pooled sensitivity and specificity, positive and negative likelihood ratios, and to construct the summary receiver operating characteristics curve. Results Twenty studies involving a total of 2,761 patients were included in the study. The pooled sensitivity and specificity of EUS-FNA in the diagnosis of solid pancreatic lesions were 90.8 % [95 % confidence interval (CI), 89.4–92 %] and 96.5 % (95 % CI, 94.8–97.7 %), respectively. The positive and negative likelihood ratios were 14.8 (95 % CI, 8.0–27.3) and 0.12 (95 % CI, 0.09–0.16), respectively. The overall diagnostic accuracy was 91.0 %. Conclusions Our findings suggest that EUS-FNA has high sensitivity and specificity in the diagnosis of solid pancreatic lesions.
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Affiliation(s)
- Omar Banafea
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Fabian Pius Mghanga
- Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jinfang Zhao
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Ruifeng Zhao
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Liangru Zhu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China.
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11
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Takahashi H, Moslim MA, Presser N, O'Rourke C, Wey J, Chalikonda S, Walsh MR, Morris-Stiff G. Absence of a Periampullary Mass on Cross-sectional Imaging Delays Diagnosis and Time to Pancreatoduodenectomy But Does Not Impair Outcome. J Gastrointest Surg 2016; 20:1179-87. [PMID: 26984696 DOI: 10.1007/s11605-016-3127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/04/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study was to assess whether the lack of a radiological mass in patients with periampullary malignancies led to protracted diagnosis, delayed resection, and an inferior outcome. METHODS The departmental database was interrogated to identify all patients undergoing pancreatoduodenectomy during the period 2000-2014. The absence of a mass on cross-sectional and endoscopic ultrasound was noted. The interval between imaging and surgery was evaluated and related to the absence of a mass. The relationship between mass/no mass and the pathological profile was also assessed. RESULTS Among 490 patients who underwent pancreatoduodenectomy for periampullary malignancies, masses were detected in 299 patients. Patients with undetected mass on either endoscopic ultrasonography (EUS) or computed tomography (CT)/magnetic resonance imaging (MRI) had a longer median interval from initial imaging to resection than detected mass with no difference in survival (66 vs. 41 days, p = 0.001). The absence of a mass was more common in cholangiocarcinomas (p < 0.001). The absence of a mass on imaging was associated with smaller size on final histopathology (2.4 vs. 2.8 cm; p < 0.001). CONCLUSIONS The absence of a mass with all modalities in patients with a periampullary malignancy leads to a delayed diagnosis without a significant effect on survival.
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Affiliation(s)
- Hideo Takahashi
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue A100, Cleveland, OH, 44195, USA.
| | - Maitham A Moslim
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue A100, Cleveland, OH, 44195, USA
| | - Naftali Presser
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue A100, Cleveland, OH, 44195, USA
| | - Colin O'Rourke
- Section of Biostatistics, Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Jane Wey
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue A100, Cleveland, OH, 44195, USA
| | - Sricharan Chalikonda
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue A100, Cleveland, OH, 44195, USA
| | - Matthew R Walsh
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue A100, Cleveland, OH, 44195, USA
| | - Gareth Morris-Stiff
- Department of HPB Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue A100, Cleveland, OH, 44195, USA
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12
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Abstract
The evaluation of pancreatic lesions, from solid pancreatic masses to pancreatic cysts, remains a clinical challenge. Although cross-sectional imaging remains the cornerstone of the initial evaluation of an indeterminate pancreatic lesion, advances in imaging with the advent of endoscopic ultrasound scan, elastography, contrast-enhanced endoscopic ultrasound scan, and probe-based confocal laser endomicroscopy have allowed us to visualize the pancreas in even higher resolution and diagnose premalignant and malignant lesions of the pancreas with improved accuracy. This report reviews the range of imaging tools currently available to evaluate pancreatic lesions, from solid tumors to pancreatic cysts.
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Affiliation(s)
- Ming-ming Xu
- Division of Digestive and Liver Disease, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA.
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13
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Mullapudi B, Hawkes PJ, Patel A, Are C, Misra S. Borderline resectable pancreatic cancer. Indian J Surg Oncol 2015; 6:63-68. [PMID: 25937766 DOI: 10.1007/s13193-014-0374-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 12/17/2014] [Indexed: 11/25/2022] Open
Abstract
Borderline resectable pancreatic cancer (BRPC) is an evolving diagnostic entity that blurs the distinction between resectable and locally advanced pancreatic cancer (Varadhachary et al. Ann Surg Oncol 13:1035-1046, 2006). Until recently the management of this disease has been poorly defined; however, consensus guidelines have been developed regarding the proper management of this diagnostic entity. Recent studies have shown that if appropriately identified and treated, this subset of disease can have outcomes similar to pancreatic cancer that is defined as resectable (Laurence et al. J Gastrointest Surg 15:2059-2069, 2011). The aim of this review is to outline the current consensus on definitions, workup and management of BRPC, and also provide a summary of issues that require progress as defined by the International Study Group of Pancreatic Surgery (ISGPS).
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Affiliation(s)
- Bhargava Mullapudi
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE USA
| | - Patrick J Hawkes
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE USA
| | - Asish Patel
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE USA
| | - Chandrakanth Are
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE USA
| | - Subhasis Misra
- Department of Surgery, Texas Tech University Health Sciences Center, 1400 S Coulter St, Amarillo, TX 79106 USA
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14
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Katanuma A, Itoi T, Baron TH, Yasuda I, Kin T, Yane K, Maguchi H, Yamazaki H, Sano I, Minami R, Manabu SY, Ikarashi S, Osanai M, Takahashi K. Bench-top testing of suction forces generated through endoscopic ultrasound-guided aspiration needles. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:379-85. [PMID: 25557010 DOI: 10.1002/jhbp.201] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Adequate needle size and tissue acquisition techniques for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) need further elucidation. Moreover, the actual negative pressure and suction forces of FNA needles remain unknown. We evaluated the suction forces of 19-gauge, 22-gauge, and 25-gauge conventional FNA needles and side hole aspiration needles using conventional negative pressure and the slow pull technique. METHODS Using a manometer, we determined the mean (SD) negative pressure and suction force for needle gauge, aspiration volume, and aspiration technique. We also evaluated the time to reach the maximum negative pressure. RESULTS Suction force was comparatively higher in the 19-gauge needle when 50 ml of negative pressure was applied. Suction force using the slow pull method was very weak at 5% of pressure found with conventional methods. With the use of a 20-ml syringe, the time to reach the maximum negative pressure was 4 s in the 19-gauge needle, 11 s in the 22-gauge needle, and 80 s in the 25-gauge needle. CONCLUSIONS Bench-top testing showed that suction force increases with a larger gauge needle and larger aspiration volume. The slow pull method produces a very weak suction force. The time to reach the maximum negative pressure was longest in the 25-gauge needle.
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Affiliation(s)
- Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, 1-40-1-12 Maeda, Teine-ku, Sapporo, 006-8555, Japan.
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15
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Bergeron JP, Perry KD, Houser PM, Yang J. Endoscopic ultrasound-guided pancreatic fine-needle aspiration: potential pitfalls in one institution's experience of 1212 procedures. Cancer Cytopathol 2014; 123:98-107. [PMID: 25410732 DOI: 10.1002/cncy.21497] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 10/29/2014] [Accepted: 10/29/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has emerged as the diagnostic modality of choice for mass lesions in the pancreas. The objective of the current study was to determine the accuracy and pitfalls of EUS-FNA in the diagnosis of pancreatic lesions in cases that involved follow-up surgical resection. METHODS Cases of EUS-FNA of pancreatic lesions performed from 2007 to mid-2012 for which subsequent surgical resection was performed were retrieved from the department's database. The accuracy of the cytologic diagnosis was assessed using the histological diagnosis as the gold standard. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. "Neoplastic," "suspicious," and "malignant" were classified as a positive cytologic diagnosis. In one calculation method, "atypical" was also included as a positive cytologic diagnosis whereas in another it was not considered to be a positive cytological result. The cases with a cytologic-histological discrepancy were reviewed to identify sources of errors. RESULTS A total of 1212 cases from 1104 patients (518 women and 586 men; age range, 18-94 years [average age, 63.5 years]) were identified. Cytologic diagnoses included 52 unsatisfactory, 224 benign, 129 atypical, 140 neoplasm, 35 suspicious, and 632 malignant diagnoses. Of these cases, 397 patients had histological follow-up information available. The sensitivity, specificity, positive predictive value, and negative predictive value were 83.2%, 85.9%, 95.9%, and 56.1%, respectively, with atypical cases excluded from the analysis. When atypical cases were included as a positive cytologic diagnosis, the sensitivity, specificity, positive predictive value, and negative predictive value were 86.7%, 67.9%, 90.7%, and 58.5%, respectively, and were 73.7%, 87.7%, 95.6%, and 48.0%, respectively, when atypical cases were included as a negative cytologic diagnosis. The major difficulty in EUS-FNA cytology was to differentiate pancreatic mucinous neoplasms from contaminants of gastric mucosa. Other pitfalls included differentiating mucinous neoplasm from extensive pancreatic intraepithelial neoplasia, and endocrine tumor from nesidioblastosis versus acinar cell carcinoma or intrapancreatic spleen. CONCLUSIONS EUS-FNA is a valuable tool for the diagnosis of pancreatic lesions, especially solid malignant tumors. Cytologic-radiological correlation is essential in differentiating pancreatic mucinous neoplasms from gastric mucosa, because the former usually are found to have characteristic features on imaging. Pathologists should be aware of the pitfalls in the cytologic diagnosis of pancreatic lesions that may significantly change the clinical management of the patients.
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Affiliation(s)
- Joseph P Bergeron
- Department of Pathology, Medical University of South Carolina, Charleston, South Carolina
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Mohammad Alizadeh AH, Hadizadeh M, Padashi M, Shahbaazi S, Molaee M, Shariatpanahi ZV. Comparison of two techniques for endoscopic ultrasonography fine-needle aspiration in solid pancreatic mass. Endosc Ultrasound 2014; 3:174-8. [PMID: 25184124 PMCID: PMC4145478 DOI: 10.4103/2303-9027.138790] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/02/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Endoscopic ultrasonography (EUS) is a newly imagine procedure for assessment and therapeutic in option. The aims of this study are comparison two techniques about EUS-fine-needle aspiration (EUS-FNA), including successful tissue sampling, complication, procedure time, and safety. MATERIALS AND METHODS A total of 100 patients with pancreatic solid masses were in the study, 50 patients underwent EUS-FNA with negative pressure as Group 1 and 50 patients underwent EUS-FNA without negative pressure and stylet as Group 2 over a 36 months period. RESULTS The study period was from March 2011 to January 2014. In total case, the male-to-female ratio was 1.27 with a mean age of 61.7 ± 1.3 years. The involvement of different regions of the pancreas, pancreatic head had the most frequent (69%) after that uncinate (12%), body (11%) and tail (8%). In 100 pancreatic EUS-FNA samples, 48% were interpreted as malignant on pathology evaluation, 15% as suspicious for malignancy, 27% as benign processes and 10% inadequate specimen. There were no significant differences between the adequacy of sample cells in two techniques (P < 0.148). CONCLUSION The EUS-FNA without negative pressure and stylet technique was related with less contamination by blood and raise the diagnostic yield. We recommend further studies for better evaluation of our study with higher the cases because clinically the low the inadequate samples (6% vs. 14%) and less contamination with blood (20% vs. 50%) in the second group (P < 0.002).
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Affiliation(s)
| | - Mohammad Hadizadeh
- Gastroenterology and Liver Diseases Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Padashi
- Gastroenterology and Liver Diseases Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahin Shahbaazi
- Gastroenterology and Liver Diseases Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Molaee
- Gastroenterology and Liver Diseases Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Vahdat Shariatpanahi
- Gastroenterology and Liver Diseases Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Matynia AP, Schmidt RL, Barraza G, Layfield LJ, Siddiqui AA, Adler DG. 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. J Gastroenterol Hepatol 2014; 29:697-705. [PMID: 24783248 DOI: 10.1111/jgh.12431] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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18
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Kedia P, Gaidhane M, Kahaleh M. Technical Advances in Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition for Pancreatic Cancers: How Can We Get the Best Results with EUS-Guided Fine Needle Aspiration? Clin Endosc 2013; 46:552-62. [PMID: 24143320 PMCID: PMC3797943 DOI: 10.5946/ce.2013.46.5.552] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/13/2013] [Accepted: 08/19/2013] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.
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Affiliation(s)
- Prashant Kedia
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
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19
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Hartwig W, Büchler MW. Pancreatic Cancer: Current Options for Diagnosis, Staging and Therapeutic Management. Gastrointest Tumors 2013; 1:41-52. [PMID: 26673950 DOI: 10.1159/000354992] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pancreatic cancer is characterized by frequently delayed diagnosis and aggressive tumor growth which hampers most of the current treatment modalities. This review aims to summarize the available evidence about the diagnostic and therapeutic aspects of resectable and non-resectable pancreatic cancer therapy. SUMMARY Embedded in the concept of multimodal therapy, surgery plays the central role in the treatment of pancreatic cancer. With advantageous tumor characteristics and complete tumor resection as the most relevant positive prognostic factors, the detection of premalignant or early invasive lesions combined with safe and oncologic adequate surgery is the major therapeutic aim. Most pancreatic adenocarcinomas are locally advanced or metastatic when diagnosed and need to be treated by the combination of surgery and (radio)chemotherapy or by palliative chemotherapy.
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Affiliation(s)
- Werner Hartwig
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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20
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Diagnostic ability and factors affecting accuracy of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid lesions: Japanese large single center experience. J Gastroenterol 2013; 48:973-81. [PMID: 23090002 DOI: 10.1007/s00535-012-0695-8] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 09/25/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several studies have investigated the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic lesions, but they have included only limited patient populations. This study aimed to clarify the diagnostic accuracy of EUS-FNA in a large number of pancreatic lesions, and to describe the factors that influence it. METHODS From March 1997 to May 2010, 944 consecutive patients who had undergone EUS-FNA for pancreatic solid lesions were evaluated retrospectively. Factors affecting EUS-FNA accuracy were then analyzed. RESULTS A total of 996 solid pancreatic lesions were sampled by EUS-FNA. The overall sampling adequacy and diagnostic accuracy of these lesions were 99.3 % (989/996) and 91.8 % (918/996), respectively. The sensitivity and specificity for differentiating malignant from benign lesions were 91.5 % (793/867) and 97.7 % (126/129), respectively. The diagnostic performance was significantly higher when both cytological and cell-block examinations were carried out than with only cytological examination. In multivariate analysis, final diagnosis, location of lesion, lesion size, availability of on-site cytopathological evaluation, and experience of EUS-FNA procedure were independent factors affecting the accuracy of EUS-FNA. On-site cytopathological evaluation and lesion size were found to be the most weighted factors affecting diagnostic accuracy. CONCLUSIONS EUS-FNA for pancreatic solid lesions yielded a high accuracy and low complication rate. Both cytological and cell-block preparations and on-site cytopathological evaluation contributed to improve the accuracy. The diagnostic ability of EUS-FNA was less for smaller lesions, and repeated procedures may be needed if malignancy is suspected.
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Bishop J, Zhang W, Ioffe OB, Ali SZ. Aspiration cytopathology of peripancreatic space: a clinicoradiologic and cytopathologic analyses of 42 cases. KOREAN JOURNAL OF PATHOLOGY 2013; 47:258-64. [PMID: 23837019 PMCID: PMC3701822 DOI: 10.4132/koreanjpathol.2013.47.3.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 05/20/2013] [Accepted: 05/24/2013] [Indexed: 11/25/2022]
Abstract
Background The pancreas is surrounded by soft tissue known as the peripancreatic space (PPS). Pathologic lesions of the PPS are infrequent and have only rarely been reported in the cytopathology literature. Methods A retrospective review of cytopathology files at two large institutions revealed 42 cases of PPS lesions obtained by transabdominal fine needle aspiration (FNA) or endoscopic ultrasound-guided FNA over a 16-year period. Clinicoradiologic findings and follow-up information were also reviewed. Results Patients ranged in age from 23-83 years (mean, 60 years) with an equal gender distribution. The major clinical presentations included pain, jaundice, nausea/vomiting, and abnormal liver enzymes. Radiographic characteristics included lymphadenopathy and cystic/solid soft tissue masses with a size range of 1.5 to 8 cm. Cytologically, 4 (9.5%) cases were nondiagnostic, 9 (21.5%) were diagnosed as benign, 4 (9.5%) were atypical or suspicious for cancer, and 25 (59.5%) were malignant. Six of 25 (24%) patients had metastasis of a prior known malignancy. Conclusions FNA of PPS masses is a rare occurrence. The majority of lesions are metastatic carcinomas from a variety of primary sites. Flow cytometry and immunoperoxidase studies are useful adjuncts to determine the tumor origin. The sensitivity of PPS aspiration for a malignant diagnosis is 90% with a positive predictive value of 100%.
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Affiliation(s)
- Justin Bishop
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD, USA
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22
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Hébert-Magee S, Bae S, Varadarajulu S, Ramesh J, Frost AR, Eloubeidi MA, Eltoum IA. The presence of a cytopathologist increases the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology for pancreatic adenocarcinoma: a meta-analysis. Cytopathology 2013; 24:159-71. [PMID: 23711182 PMCID: PMC4159090 DOI: 10.1111/cyt.12071] [Citation(s) in RCA: 238] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A meta-analysis has not been previously performed to evaluate critically the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solely pancreatic ductal adenocarcinoma and address factors that have an impact on variability of accuracy. The aim of this study was to determine whether the presence of a cytopathologist, variability of the reference standard and other sources of heterogeneity significantly impacts diagnostic accuracy. METHODS We conducted a comprehensive search to identify studies, in which the pooled sensitivity, specificity, likelihood ratios for a positive or negative test (LR+, LR-) and summary receiver-operating curves (SROC) could be determined for EUS-FNA of the pancreas for ductal adenocarcinoma using clinical follow-up, and/or surgical biopsy or excision as the reference standard. RESULTS We included 34 distinct studies (3644 patients) in which EUS-FNA for a solid pancreatic mass was evaluated. The pooled sensitivity and specificity for EUS-FNA for pancreatic ductal adenocarcinoma was 88.6% [95% confidence interval (CI): 87.2-89.9] and 99.3% (95% CI: 98.7-99.7), respectively. The LR+ and LR- were 33.46 (95% CI: 20.76-53.91) and 0.11 (95% CI: 0.08-0.16), respectively. The meta-regression model showed rapid on-site evaluation (ROSE) (P = 0.001) remained a significant determinant of EUS-FNA accuracy after correcting for study population number and reference standard. CONCLUSION EUS-FNA is an effective modality for diagnosing pancreatic ductal adencarcinoma in solid pancreatic lesions, with an increased diagnostic accuracy when using on-site cytopathology evaluation.
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Affiliation(s)
- S Hébert-Magee
- Division of Anatomic Pathology, Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35249-6823, USA.
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Uehara H, Ikezawa K, Kawada N, Fukutake N, Katayama K, Takakura R, Takano Y, Ishikawa O, Takenaka A. Diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration for suspected pancreatic malignancy in relation to the size of lesions. J Gastroenterol Hepatol 2011; 26:1256-61. [PMID: 21501226 DOI: 10.1111/j.1440-1746.2011.06747.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an accurate method for cytological confirmation of pancreatic malignancy, but it has been unknown whether its diagnostic accuracy for pancreatic lesions was affected by their size, location, or size of needles. Our aim was to investigate the accuracy of EUS-FNA for suspected pancreatic malignancy in relation to these factors, especially to the size of lesions. METHODS In a tertiary referral center, EUS-FNAs for 120 suspected pancreatic malignancies in 115 patients based on other imaging studies were evaluated retrospectively. RESULTS Overall accuracy of EUS-FNA was 96% (115/120), with sensitivity of 95% (76/80), specificity of 98% (39/40), positive predictive value of 99% (76/77), and negative predictive value of 91% (39/43). Accuracies for lesions less than 10mm, 11-20mm, 21-30mm, and more than 31mm were 96%, 95%, 96%, and 100%, respectively; those for lesions in the head, the body, and the tail of the pancreas were 96%, 95%, and 95%, respectively. Accuracies for 22-gauge and 25-gauge needle were 93% and 98%, respectively. CONCLUSION EUS-FNA was accurate in the evaluation of suspected pancreatic malignancy regardless of its size, location, or size of needles. It was useful also in the confirmation of small pancreatic malignancies less than 10mm.
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Affiliation(s)
- Hiroyuki Uehara
- Department of Gastroenterology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan Department of Cancer Survey, Osaka, Japan.
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Controversies in the management of borderline resectable proximal pancreatic adenocarcinoma with vascular involvement. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2009; 2008:839503. [PMID: 19283083 PMCID: PMC2654339 DOI: 10.1155/2008/839503] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 07/28/2008] [Accepted: 12/18/2008] [Indexed: 12/26/2022]
Abstract
Synchronous major vessel resection during pancreaticoduodenectomy
(PD) for borderline resectable pancreatic adenocarcinoma remains controversial.
In the 1970s, regional pancreatectomy advocated by Fortner was associated with
unacceptably high morbidity and mortality rates, with no impact on long-term survival.
With the establishment of a multidisciplinary approach, improvements in preoperative
staging techniques, surgical expertise, and perioperative care reduced mortality
rates and improved 5-year-survival rates are now achieved following resection in
high-volume centres. Perioperative morbidity and mortality following PD with portal
vein resection are comparable to standard PD, with reported 5-year-survival rates
of up to 17%. Segmental resection and reconstruction of the common hepatic
artery/proper hepatic artery (CHA/PHA) can be performed to achieve an R0 resection in
selected patients with limited involvement of the CHA/PHA at the origin of the gastroduodenal artery (GDA).
PD with concomitant major vessel resection for borderline resectable tumours should be
performed when a margin-negative resection is anticipated at high-volume centres
with expertise in complex pancreatic surgery. Where an incomplete (R1 or R2) resection
is likely neoadjuvant treatment with systemic chemotherapy followed by chemoradiation
as part of a clinical trial should be offered to all patients.
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Hartwig W, Schneider L, Diener MK, Bergmann F, Büchler MW, Werner J. Preoperative tissue diagnosis for tumours of the pancreas. Br J Surg 2009; 96:5-20. [PMID: 19016272 DOI: 10.1002/bjs.6407] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- W Hartwig
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, Germany
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Peddu P, Quaglia A, Kane PA, Karani JB. Role of imaging in the management of pancreatic mass. Crit Rev Oncol Hematol 2008; 70:12-23. [PMID: 18951813 DOI: 10.1016/j.critrevonc.2008.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2007] [Revised: 08/15/2008] [Accepted: 09/10/2008] [Indexed: 11/26/2022] Open
Abstract
Pancreatic cancer is the second commonest malignant gastrointestinal neoplasm. Modern imaging techniques have greatly increased sensitivity in diagnosing and staging pancreatic cancers. Multidetector CT in particular, plays a critical role in local staging and determining the resectability of pancreatic tumours. MR and endoscopic ultrasound are valuable in those groups of patients in whom CT findings alone are inconclusive in tumour characterisation and local staging, particularly vascular involvement. In this article we review the current established concepts and the role of imaging in the multidisciplinary management of pancreatic tumours together with a comprehensive review of the literature.
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Affiliation(s)
- P Peddu
- Department of Radiology, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
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Deprez PH, Weynand B. Collaboration entre cytopathologiste et endoscopiste: l’exemple de la ponction biopsie à l’aiguille fine sous écho-endoscopie dans la pathologie biliaire et pancréatique. ACTA ACUST UNITED AC 2006. [DOI: 10.1007/bf03006033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Volmar KE, Vollmer RT, Jowell PS, Nelson RC, Xie HB. Pancreatic FNA in 1000 cases: a comparison of imaging modalities. Gastrointest Endosc 2005; 61:854-61. [PMID: 15933687 DOI: 10.1016/s0016-5107(05)00364-0] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Image-guided FNA is a popular method for evaluating pancreatic lesions, but few large studies on pancreatic FNA exist. METHODS Cytologic material, imaging reports, and clinical follow-up information were reviewed from pancreatic FNA cases performed over a 5-year period. RESULTS A total of 1050 pancreatic FNAs were obtained by EUS (n = 843), US (n = 140), and CT (n = 67). On-site assessment was performed in 89.2% (n = 937) of cases. Findings were as follows: positive for neoplasm 48.9% (n = 503), negative 29.1% (n = 306), descriptive 10% (n = 105), suspicious 5.9% (n = 62), atypical/inconclusive 4.6% (n = 48), and nondiagnostic/inadequate 1.5% (n = 26). Follow-up in the form of histology or at least 6 months of clinical observation was available for 61.2% (n = 643). There was an overall false-positive rate of 0.3% and a false-negative rate of 14.3%. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were as follows: 79.4, 99.0, 99.4, 67.9, 84.5 for the total series, respectively; 79.9, 98.8, 99.2, 72.5, 86.5 for EUS, respectively; 77.9, 100, 100, 48.6, 81.7 for US, respectively; and 78.6, 100, 100, 47.1, 82.0 for CT, respectively. In general, accuracy was not influenced by lesion size or site, number of FNA passes, or number of procedures per patient. After controlling for lesion size, EUS resulted in greater accuracy than US or CT when evaluating lesions <3 cm ( p = 0.015). CONCLUSIONS All imaging modalities showed moderate to high sensitivity, specificity, and accuracy. Logistic regression analysis showed that for lesions <3 cm, the EUS method had higher accuracy than US or CT. No statistically significant difference was seen for larger lesions or for the number of FNA passes.
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Affiliation(s)
- Keith E Volmar
- Department of Pathology, University of North Carolina, Chapel Hill, North Carolina 27599-7525, USA
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Bettini N, Moutardier V, Turrini O, Bories E, Monges G, Giovannini M, Delpero JR. Preoperative locoregional re-evaluation by endoscopic ultrasound in pancreatic ductal adenocarcinoma after neoadjuvant chemoradiation. ACTA ACUST UNITED AC 2005; 29:659-63. [PMID: 16141999 DOI: 10.1016/s0399-8320(05)82153-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The accuracy of endoscopic ultrasound (EUS) for the diagnosis and staging of pancreatic ductal adenocarcinoma (PDA) has been confirmed. Chemo-radiotherpay (CRT) induces tumor changes which can limit the accuracy of EUS. The aim of our study was to analyze the efficacy of EUS following neoadjuvant CRT comparing findings with the pathology results. PATIENTS AND METHODS From November 1996 to October 2003, 45 patients with histologically proven and EUS-staged PDA were treated with neo-adjuvant CRT and radical surgery. All were restaged before surgery using both EUS and computed tomography. Fifteen patients were found to have developed distant metastases. Thirty patients finally underwent pancreaticoduodenectomy (N=24) or distal pancreatectomy (N=6). RESULTS Following CRT, tumor stage was correctly assessed in 12 patients (40%). The most frequent misinterpretation was overestimation of tumor size (N=13, 43.3%). Locoregional vascular invasion of veins was suspected by EUS in 13 patients (43.3%) but surgical findings and the histological examination were both negative. Node status was correctly assessed in 27 patients (90%) but nodal involvement was found on the histological specimen in only 3 patients. CONCLUSION Preoperative EUS after neoadjuvant CRT for PDA does not enable reliable definitive selection of patients for surgery, probably due to radiation-induced pancreatic changes.
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Affiliation(s)
- Nicolas Bettini
- Département de Chirurgie Oncologique, Institut Paoli-Calmettes et Université de la Méditerranée, Marseille, France
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Volmar KE, Jones CK, Xie HB. Metastases in the pancreas from nonhematologic neoplasms: report of 20 cases evaluated by fine-needle aspiration. Diagn Cytopathol 2005; 31:216-20. [PMID: 15452907 DOI: 10.1002/dc.20100] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We reviewed fine-needle aspiration (FNA) samples of metastatic tumor in the pancreas from nonhematologic neoplasms over a 5-year period. In 1,050 total procedures, 20 metastases were diagnosed: 9 renal-cell carcinomas (RCCs), 3 melanomas, 2 pulmonary small-cell carcinomas, 2 breast carcinomas, 1 prostate carcinoma, 1 colon adenocarcinoma, 1 pulmonary squamous-cell carcinoma, and 1 gastrointestinal stromal tumor. A wide range of latency from primary diagnosis was noted; the longest was RCC at 12.6 years (range, 5-28). Sites of involvement were: 13 heads, 4 bodies, and 3 tails. Eighteen cases presented as a solitary mass. The average size was 4.7 cm (range, 1.5-9.8), and a case of RCC (9.8 cm) was the largest. In seven cases, the clinical and radiographic impression was of a pancreatic primary. We conclude that metastases to the pancreas are rarely diagnosed by FNA and may clinically mimic a pancreatic primary.
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Affiliation(s)
- Keith E Volmar
- Department of Pathology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Wang L, Pitman MB, Castillo CFD, Dal Cin P, Oliva E. Choriocarcinoma involving the pancreas as first manifestation of a metastatic regressing mixed testicular germ cell tumor. Mod Pathol 2004; 17:1573-80. [PMID: 15545958 DOI: 10.1038/modpathol.3800226] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We describe an unusual case of metastatic choriocarcinoma of the pancreas arising from a regressing testicular mixed germ cell tumor that clinically mimicked a primary pancreatic tumor. A 54-year-old male presented with a 2-month history of progressive upper abdominal pain, weight loss, and jaundice. He also had a history of recurrent epididymitis associated with the presence of a right testicular mass shown to be cystic by ultrasound and stable for at least 10 years. A computed tomography scan showed an isolated 6 cm mass in the head of the pancreas. A pancreaticoduodenectomy was performed. Upon histological examination, the pancreatic tumor showed extensive hemorrhage and necrosis. In the viable area, the tumor was composed of an intimate mixture of mononuclear cytotrophoblast cells and multinucleated syncytiotrophoblasts with vascular invasion. These characteristic features led to the correct diagnosis on frozen section. The cytology of the tumor was nonspecific and suggested undifferentiated carcinoma of the pancreas. The trophoblastic origin of the tumor cells was confirmed by immunohistochemistry staining. The testicular mass showed a regressed mixed germ cell tumor of predominantly seminoma with focal teratoma but without a choriocarcinoma component. In conclusion, we present a rare and unusual case of a regressing testicular mixed germ cell tumor that presented as a primary pancreatic tumor. Cytological features of the pancreatic mass were not specific and raised the possibility of a primary undifferentiated carcinoma of the pancreas. Characteristic histological features of choriocarcinoma led to the correct diagnosis on frozen section. Subsequent resection of the testicular mass confirmed the presence of a cystic and scarring (regressing) mixed germ cell tumor but without evidence of choriocarcinoma.
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Affiliation(s)
- Lan Wang
- Department of Pathology, Harvard Medical School, Boston, MA 02114, USA
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Camp ER, Vogel SB. Blind Whipple Resections for Periampullary and Pancreatic Lesions. Am Surg 2004. [DOI: 10.1177/000313480407000102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Many patients with periampullary mass lesions lack a tissue diagnosis at referral despite advances in body imaging and aggressive biopsy techniques. This review evaluates a consecutive cohort of patients who underwent pancreatoduodenectomy (PD) with and without a diagnosis of malignancy. From 1990 to 2001, 121 patients underwent PD on a gastrointestinal surgical service by a single surgeon with a bias toward “blind” Whipple resections (BWR). Sixty-three per cent of the patients had obstructive jaundice with a mass on CT in 51 per cent. Fifty-three patients (44%) had a preoperative diagnosis of malignancy. Sixty-eight patients (56%) underwent a blind PD based on computed tomography (CT), ERCP, and clinical findings. After PD, 113 patients (94%) had a malignancy (46 pancreatic, 30 ampullary, 13 cholangiocarcinoma, 9 neuroendocrine, 4 duodenal, 10 other). Of the 68 patients (56%) who underwent a blind PD, 61 patients (90%) had a malignancy. Ten per cent of the BWR patients had a pathologic diagnosis of chronic inflammation/pancreatitis. Overall mortality was 3.3% (4 patients), with no deaths in the BWR group. In this review, clinical judgment was correct in 90 per cent of patients undergoing a “blind” PD without a prior diagnosis of malignancy. In patients with “potentially resectable” lesions (based on CT exam), biopsy information does not affect the choice of therapy since a negative biopsy still commits the patients to surgery. Combined CT and/or ERCP data with clinical findings leads most often to a correct diagnosis and procedure. These data question the practice of numerous biopsy attempts in patients with periampullary lesions.
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Affiliation(s)
- E. Ramsey Camp
- From the Department of Surgery, Division of Gastrointestinal Surgery, University of Florida, College of Medicine, Gainesville, Florida
| | - Stephen B. Vogel
- From the Department of Surgery, Division of Gastrointestinal Surgery, University of Florida, College of Medicine, Gainesville, Florida
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Eloubeidi MA, Chen VK, Eltoum IA, Jhala D, Chhieng DC, Jhala N, Vickers SM, Wilcox CM. Endoscopic ultrasound-guided fine needle aspiration biopsy of patients with suspected pancreatic cancer: diagnostic accuracy and acute and 30-day complications. Am J Gastroenterol 2003; 98:2663-8. [PMID: 14687813 DOI: 10.1111/j.1572-0241.2003.08666.x] [Citation(s) in RCA: 304] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aims of this study were to evaluate the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with suspected pancreatic cancer, and to assess immediate, acute, and 30-day complications related to EUS-FNA. METHODS All patients with suspected pancreatic cancer were prospectively evaluated. A single gastroenterologist performed all EUS-FNAs in the presence of a cytopathologist. Immediate complications were evaluated in all patients. An experienced nurse called patients 24-72 h and 30 days after the procedure. Reference standard for the classification of the final diagnosis included: surgery (n = 48), clinical or imaging follow-up (n = 63), or death from the disease (n = 47). RESULTS A total of 158 patients (mean age 62.3 yr) underwent EUS-FNA during the study period. The mean tumor size was 32 x 26 mm. The median number of passes was three (range one to 10). Of these patients, 44% had at least one failed attempt at tissue diagnosis before EUS-FNA. The sensitivity, specificity, PPV, NPV, and accuracy of EUS-FNA in solid pancreatic masses were 84.3%, 97%, 99%, 64%, and 84%, respectively. Immediate self-limited complications occurred in 10 of the 158 EUS-FNAs (6.3%). Of 90 patients contacted at 24-72 h, 78 patients (87%) responded. Of the 90 patients, 20 (22%) reported at least one symptom, all of which were minor except in three cases (one self-limited acute pancreatitis and two emergency room visits, one of which led to admission). In all, 83 patients were contacted at 30 days, and 82% responded. No additional or continued complications were reported. CONCLUSIONS EUS-FNA is highly accurate in identifying patients with suspected pancreatic cancer, especially when other modalities have failed. Major complications after EUS-FNA are rare, and minor complications are similar to those reported for upper endoscopy. It seems that follow-up at 1 wk might capture all of the adverse events related to EUS-FNA.
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Affiliation(s)
- Mohamad A Eloubeidi
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, 1530 3rd Avenue S., ZRB 636, Birmingham, AL 35294-0007, USA
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Eloubeidi MA, Jhala D, Chhieng DC, Chen VK, Eltoum I, Vickers S, Mel Wilcox C, Jhala N. Yield of endoscopic ultrasound-guided fine-needle aspiration biopsy in patients with suspected pancreatic carcinoma. Cancer 2003; 99:285-292. [PMID: 14579295 DOI: 10.1002/cncr.11643] [Citation(s) in RCA: 248] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although atypical or suspicious cytology may support a clinical diagnosis of a malignancy, it is often not sufficient for the implementation of therapy in patients with pancreatic carcinoma. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) is a relatively new method for obtaining cytology samples, and one that may decrease the number of atypical/suspicious diagnoses. The goals of the current study were to prospectively evaluate the yield of EUS-FNAB in the diagnosis of patients presenting with solid pancreatic lesions and to evaluate the significance of atypical, suspicious, and false-negative aspirates. METHODS All patients who presented with a solid pancreatic lesion and underwent EUS-FNAB over a 13-month period were included in the current study. One endoscopist performed all EUS-FNABs. On-site evaluation of specimen adequacy by a cytopathologist was available for each case. Follow-up included histologic correlation (n = 21) and clinical and/or imaging follow-up (n = 80), including 38 patients who died of the disease. RESULTS EUS-FNABs were obtained from 101 patients (mean age, 62 +/- 11.8 years; age range, 34-89 years). The male-to-female ratio was 2:1. Sixty-five percent of the lesions were located in the head of the pancreas, 12% were located in the uncinate, 17% were located in the body, and 6% were located in the tail. The mean size of the tumors was 3.3 cm (range, 1.3-7 cm). A median of 4 needle passes were performed (range, 1-11 needle passes). Sixty-two biopsies (61.4%) were interpreted as malignant on cytologic evaluation, 5 (5%) as suspicious for a malignancy, 6 (5.9%) as atypical/indeterminate, and 26 (25.7%) as benign processes. Of the 76 malignant lesions, 71 were adenocarcinomas, 3 were neuroendocrine tumors, 1 was a lymphoma, and 1 was a metastatic renal cell carcinoma. All except one of the suspicious/atypical aspirates were subsequently confirmed to be malignant. Agreement was complete for the atypical cases. Among the suspicious cases, 2 of the 5 were identified as carcinoma by one cytopathologist and as suspicious lesions by the other, yielding a 40% disagreement rate between the 2 cytopathologists. Therefore, for the 10 atypical or suspicious cases that later were confirmed to be malignant, the final diagnosis of malignant disease was not made due to scant cellularity that could be attributed to sampling error in 8 cases and to interpretative disagreement in 2 cases (20%). All four false-negative diagnoses were attributed to sampling error. Two percent of all biopsies were inadequate for interpretation. Of the 99 adequate specimens, 72 yielded true-positive results, 23 yielded true-negative results, and 4 yielded false-negative results. No false-positives were encountered. Therefore, the sensitivity, specificity, positive predictive value, and negative predictive value of EUS-FNAB for solid pancreatic masses were 94.7% (95% confidence interval [CI], 89.7-99.8%), 100%, 100%, and 85.2% (95% CI, 71.8-98.6%), respectively. CONCLUSIONS EUS-FNAB is a safe and highly accurate method for tissue diagnosis of patients with solid pancreatic lesions. Patients with suspicious and atypical EUS-FNAB aspirates deserve further clinical evaluation.
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Affiliation(s)
- Mohamad A Eloubeidi
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
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Abstract
OBJECTIVE To review the current concepts in the mediastinal staging of nonsmall cell lung cancer (NSCLC), evaluating traditional and modern staging modalities. SUMMARY BACKGROUND DATA Staging of NSCLC includes the assessment of mediastinal lymph nodes. Traditionally, computed tomography (CT) and mediastinoscopy are used. Modern staging modalities include magnetic resonance imaging (MRI), positron emission tomography (PET), and endoscopic ultrasound with fine-needle aspiration (EUS-FNA) METHODS: Literature was searched with PubMed and SUMSearch for original, peer-reviewed, full-length articles. Studies were evaluated on inclusion criteria, sample size, and operating characteristics. Endpoints were accuracy, safety, and applicability of the staging methods. RESULTS CT had moderate sensitivities and specificities. With few exceptions magnetic resonance imaging (MRI) offered no advantages when compared with CT, against higher costs. PET was significantly more accurate than CT. Mediastinoscopy and its variants were widely used as gold standard, although meta-analyses were absent. Percutaneous transthoracic needle biopsy (PTNB) and transbronchial needle biopsy (TBNA) were moderately sensitive and specific. EUS-FNA had high sensitivity and specificity, is a safe and fast procedure, and is cost-effective. EUS-FNA evaluates largely a nonoverlapping mediastinal area compared with mediastinoscopy. CONCLUSIONS PET has the highest accuracy in the mediastinal staging of NSCLC, but is not generally used yet. EUS-FNA has the potential to perform mediastinal tissue sampling more accurate than TBNA, PTNB, and mediastinoscopy, with fewer complications and costs. Although promising, EUS-FNA is still experimental. Mediastinoscopy is still considered as gold standard for mediastinal staging of NSCLC.
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Affiliation(s)
- Henk Kramer
- Department of Pulmonary Diseases, University Hospital Groningen, The Netherlands.
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Raut CP, Grau AM, Staerkel GA, Kaw M, Tamm EP, Wolff RA, Vauthey JN, Lee JE, Pisters PWT, Evans DB. Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration in patients with presumed pancreatic cancer. J Gastrointest Surg 2003; 7:118-128. [PMID: 12559193 DOI: 10.1016/s1091-255x(02)00150-6] [Citation(s) in RCA: 192] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of the pancreas allows the diagnosis of pancreatic cancer to be established without exploratory surgery. We reviewed our recent experience with EUS-FNA in patients with presumed pancreatic cancer and report the diagnostic accuracy and complications of this procedure. Data were reviewed from all patients who presented with CT evidence of a pancreatic mass or a malignant biliary stricture and underwent EUS-FNA at our institution between November 1, 1999, and October 1, 2001. Based on the findings of contrast-enhanced, multislice CT scanning, patients were categorized as having resectable, locally advanced, or metastatic disease. EUS-FNA was performed in 233 patients. A final diagnosis of cancer was established in 216 patients (93%), 15 patients (6%) were found to have benign disease, and the final diagnosis remains unknown in two patients (1%). The sensitivity, specificity, and accuracy of EUS-FNA for diagnosis of a pancreatic malignancy were 91%, 100%, and 92%, respectively. For the 216 patients subsequently proven to have cancer, the results of EUS-FNA were diagnostic in 197 (91%); 96 (90%) of 107 patients with resectable disease, 62 (97%) of 64 with locally advanced disease, and 39 (87%) of 45 with metastatic disease. Four patients (2%) developed a clinically apparent complication that required hospital admission, including two patients who required surgery for duodenal perforation. There were no EUS-related deaths. We conclude that EUS-FNA can safely and accurately establish a cytologic diagnosis in patients with both early-stage and advanced pancreatic cancer. This enables consideration of all treatment options including protocol-based therapy.
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Affiliation(s)
- Chandrajit P Raut
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 444, 77030, Houston, TX
| | - Ana M Grau
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 444, 77030, Houston, TX
| | - Gregg A Staerkel
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Madhukar Kaw
- Department of Gastrointestinal Medicine and Nutrition, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Eric P Tamm
- Department of Diagnostic Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 444, 77030, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 444, 77030, Houston, TX
| | - Peter W T Pisters
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 444, 77030, Houston, TX
| | - Douglas B Evans
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 444, 77030, Houston, TX.
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Abstract
Premalignant conditions of the pancreas include benign tumours of the pancreas, intraepithelial neoplasia arising within pancreatic ducts, and tumours of the neuroendocrine cells of the pancreas. In addition, there is a variety of rare genetic conditions that predispose to pancreatic exocrine malignancies such as Peutz-Jeghers syndrome, hereditary non-polyposis colorectal cancer syndrome, familial pancreatitis, germline BRCA2 mutations, and pancreatic endocrine malignancies such as type 1 neurofibromatosis (von Recklinghausen's disease) and multiple endocrine neoplasia type 1. More controversial is the concept of chronic pancreatitis and diabetes mellitus as conditions that increase the risk of pancreatic cancer. However, there is no doubt that smoking is a potentiating factor for pancreatic cancer, especially in people who have familial/genetic risk factors. This review will include the recently proposed new nomenclature and classification system for intraepithelial neoplasia in the pancreatic ducts, an overview of the various familial syndromes that are associated with an increased risk of pancreatic tumours, the surveillance programmes that have been introduced to monitor such families, and methods for early diagnosis.
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Affiliation(s)
- Pauline de la M Hall
- Division of Anatomical Pathology, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa,
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Fritscher-Ravens A, Brand L, Knöfel WT, Bobrowski C, Topalidis T, Thonke F, de Werth A, Soehendra N. Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis. Am J Gastroenterol 2002; 97:2768-75. [PMID: 12425546 DOI: 10.1111/j.1572-0241.2002.07020.x] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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de Bellis M, Sherman S, Fogel EL, Cramer H, Chappo J, McHenry L, Watkins JL, Lehman GA. Tissue sampling at ERCP in suspected malignant biliary strictures (Part 2). Gastrointest Endosc 2002. [PMID: 12397282 DOI: 10.1016/s0016-5107(02)70123-5] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Mario de Bellis
- Division of Gastroenterology/Hepatology, Department of Pathology and Laboratory Medicine, Indiana University Medical Center, Indianapolis 46202, USA
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De Bellis M, Sherman S, Fogel EL, Cramer H, Chappo J, McHenry L, Watkins JL, Lehman GA. Tissue sampling at ERCP in suspected malignant biliary strictures (Part 1). Gastrointest Endosc 2002. [PMID: 12297773 DOI: 10.1016/s0016-5107(02)70442-2] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Mario De Bellis
- Division of Gastroenterology/Hepatology, Department of Pathology and Laboratory Medicine, Indiana University Medical Center, Indianapolis, Indiana 46202, USA
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Abstract
BACKGROUND The role of endosonography in diagnosing and staging pancreatic adenocarcinoma is evolving. The aim of this review is to present recently published material comparing the performance of endosonography relative to other imaging modalities when evaluating a patient with a suspected or known carcinoma of the pancreas. METHODS Medline was searched using the terms 'endosonography' and 'pancreas neoplasms'. References from retrieved papers were reviewed to identify other reports. Emphasis was placed on peer-reviewed material published within the past 3 years that included comparison with other imaging modalities. RESULTS Despite advances in cross-sectional imaging modalities, endosonography remains the most sensitive and specific method to identify pancreatic mass lesions. Resectability determination of pancreatic carcinoma is best done with dual-phase helical CT, although endosonography may have slightly improved accuracy for lymph node assessment. Endosonography-guided fine-needle aspiration biopsy has high sensitivity (93%) and specificity (100%) when employed in patients with masses in whom pancreatic cancer is suspected but prior biopsies are negative. CONCLUSIONS Endosonography can aid in diagnosing patients with pancreatic neoplasms through definitive inclusion or exclusion of a mass lesion as well as biopsy confirmation of malignancy. The role of endosonography in determination of resectability has been eclipsed by dual-phase helical CT.
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Affiliation(s)
- M J Wiersema
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn., USA.
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Soria MT, Solé M, Pellisé M, Bordas JM, Ginès A. [Interventional diagnostic and therapeutic endoscopic ultrasonography]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:467-474. [PMID: 12139843 DOI: 10.1016/s0210-5705(02)70290-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- M T Soria
- Unidad de Endoscopia Digestiva, Institut de Malalties Digestives, Hospital Clínic, Barcelona, Spain
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Mallery JS, Centeno BA, Hahn PF, Chang Y, Warshaw AL, Brugge WR. Pancreatic tissue sampling guided by EUS, CT/US, and surgery: a comparison of sensitivity and specificity. Gastrointest Endosc 2002; 56:218-24. [PMID: 12145600 DOI: 10.1016/s0016-5107(02)70181-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Needle aspiration of the pancreas is performed to differentiate pancreatic malignancy, focal chronic pancreatitis, and metastasis to the pancreas. Biopsies may be directed by using EUS, CT, US, or surgery. This study retrospectively compared the accuracy of EUS-guided, CT/US-guided, and surgical tissue sampling of the pancreas over a 5-year period. METHODS The records of patients undergoing pancreatic tissue sampling were reviewed for a final clinical diagnosis based on the results of cytology, histology, and clinical history. The sensitivity, specificity, and accuracy of each technique were calculated. RESULTS One hundred forty-nine tissue samples (68 EUS-guided, 70 CT/US-guided, 11 surgical) from 128 patients were compared. There was no significant difference in accuracy rates for EUS (76.4%), CT/US (81.4%), and surgically guided (81.8%) specimens. EUS was used when masses were smaller (2.6 +/- 0.1 cm) as compared with CT/US (3.4 +/- 0.2 cm, p < 0.001) and surgery (2.9 +/- 0.4 cm, p = 0.49). In univariate analyses, factors associated with greater accuracy regardless of technique were as follows: (1) older age, (2) larger size of the mass, and (3) participation by a cytologist during the procedure. A subsequent multivariate logistic regression analysis, in which the examination of the effect of each factor controls for the effect of each of the other factors, found that only older age was a significant predictor of accuracy. CONCLUSION EUS-guided tissue sampling of pancreatic masses is as accurate as CT/US-guided sampling and surgical biopsies.
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Affiliation(s)
- J Shawn Mallery
- Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Ginès A, Vázquez-Sequeiros E, Wiersema M. Ultrasonografía endoscópica intervencionista diagnóstica y terapéutica. GASTROENTEROLOGIA Y HEPATOLOGIA 2002. [DOI: 10.1016/s0210-5705(02)70240-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Hahn PF, Gervais DA, O'Neill MJ, Mueller PR. Nonvascular interventional procedures: analysis of a 10-year database containing more than 21,000 cases. Radiology 2001; 220:730-6. [PMID: 11526275 DOI: 10.1148/radiol.2203001840] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To analyze all procedures performed during 10 years in a nonvascular interventional practice. MATERIALS AND METHODS Date, organ location, and type of all 21,324 procedures performed between October 1990 and September 2000 were recorded in a database; also included were patient age and inpatient or outpatient status. Because genitourinary procedures were not included during the first 4 years, nephrostomies were added retrospectively. Yearly interventional caseload was compared with the department caseload and the assignment of new medical record numbers. Trends in individual procedure location and type were analyzed, as well as patient age, inpatient status, daily caseloads, and day of the week when the procedure was performed. RESULTS Caseloads have increased 10.8% per year, exceeding increases in radiology department and hospital activity. Abdomen, outside of a specific organ, was the most common location; catheter deployment was the most common procedure. Abscess drainage, placement of chest tubes, and nephrostomies have increased, but biliary drainages have decreased. Inpatients outnumbered outpatients in all years except 1995, but the trend was toward an increase in the proportion of outpatients. The average patient was 59.6 years old, with average age diminishing. Friday was the busiest day, but weekend procedures have increased. CONCLUSION Nonvascular interventional procedures have increased, with more currently being performed on weekends.
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Affiliation(s)
- P F Hahn
- Department of Radiology, Massachusetts General Hospital, White 270, 55 Fruit St, Boston, MA 02114, USA.
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Fritscher-Ravens A, Sriram PV, Krause C, Atay Z, Jaeckle S, Thonke F, Brand B, Bohnacker S, Soehendra N. Detection of pancreatic metastases by EUS-guided fine-needle aspiration. Gastrointest Endosc 2001; 53:65-70. [PMID: 11154491 DOI: 10.1067/mge.2001.111771] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Metastases to the pancreas are usually found incidentally. Tissue diagnosis is imperative because imaging alone is incapable of differentiating them from primary pancreatic tumors. This study tested whether it is possible to differentiate metastases from other focal pancreatic lesions by using EUS-guided fine-needle aspiration (EUS-FNA) for cytodiagnosis. METHODS One hundred fourteen consecutive patients (mean age 61 years) with focal pancreatic masses, detected on CT, underwent EUS-FNA by using a linear-array echoendoscope and 22-gauge needles. RESULTS Adequate specimens were obtained from 112 lesions. Carcinomas were identified in 68 cases (60.7%), 56 (50%) of pancreatic origin and 12 (10.7%) from distant primary tumors. The metastases were all located in the head and body of the pancreas and measured 1.8 to 4.0 cm. The echo-texture was heterogeneous or hypoechoic in all cases and resembled that of primary tumors. Six of the 12 patients with metastatic disease had a prior diagnosis of cancer (breast, 3; renal cell, 2; salivary gland, 1), 4 of them with a recurrence and 2 with a second carcinoma metastasizing to the pancreas. Six patients without a prior diagnosis of cancer had metastases from renal cell, colonic, ovarian, and esophageal carcinomas; one metastasis was from an unknown primary and another was from a malignant lymphoma. These findings influenced the therapeutic strategy in 8 patients who underwent nonsurgical palliation. There were no complications. CONCLUSIONS Pancreatic metastasis is an important cause of focal pancreatic lesions, but the EUS features are not diagnostic. Simultaneous EUS-FNA allows cytodiagnosis and can have a decisive influence on the selection of appropriate therapeutic strategies.
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Affiliation(s)
- A Fritscher-Ravens
- Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany
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Abstract
OBJECTIVE Although endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration have been shown to aid in the diagnosis and staging of pancreatic carcinoma, whether the general use of these new techniques impacts the overall management and survival of pancreatic cancer, is less clear. METHODS Clinical data on all patients diagnosed with pancreatic carcinoma were assessed for two equal time periods during which computerized tomography-guided fine needle aspiration and biopsy was used (1/93-5/95) and then during which endoscopic ultrasound-guided fine needle aspiration was used (8/95-12/97) for the primary diagnosis of these patients. RESULTS Comparative data for the computerized tomography era versus the endosonography era showed that 1) pancreatic carcinomas diagnosed: 52 versus 84 patients (stage I-III at diagnosis: 33% vs 54%; p < 0.05); 2) diagnosis by aspiration or biopsy of a pancreatic mass, nodes, liver metastasis, or by operation: 46%, 0%, 19%, 29% versus 52%, 8% (p = 0.02 nodes plus pancreatic masses), 20%, 7% (p = 0.002); 3) pancreatic resections: 13% versus 14%; 4) median survival without liver metastases: 102 versus 205 days (p < 0.02, log-rank test). Endoscopic ultrasound detected carcinomas that were either not seen or only possibly seen by computed tomography in 34%. CONCLUSIONS More patients (62%) were diagnosed with pancreatic carcinoma when using endoscopic ultrasound and 75% fewer required operations for diagnosis. The 3-month improvement in median survival is probably multifactorial but most likely represents lead bias because of the greater sensitivity of endoscopic ultrasound for pancreatic carcinoma. Using endoscopic ultrasound with endoscopic ultrasound-guided fine needle aspiration in patients with pancreatic carcinoma significantly affects their management and outcomes.
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Affiliation(s)
- R A Erickson
- Department of Medicine, Scott & White Clinic and Memorial Hospital, Scott, Sherwood and Brindley Foundation, Texas A&M Health Science Center, College of Medicine, Temple, USA
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Fritscher-Ravens A, Izbicki JR, Sriram PV, Krause C, Knoefel WT, Topalidis T, Jaeckle S, Thonke F, Soehendra N. Endosonography-guided, fine-needle aspiration cytology extending the indication for organ-preserving pancreatic surgery. Am J Gastroenterol 2000; 95:2255-60. [PMID: 11007226 DOI: 10.1111/j.1572-0241.2000.02311.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Organ preserving pancreatic resections are considered whenever malignant disease is ruled out. In tumors of low malignant potential such as cystadenomas and neuroendocrine tumors, the diagnosis is rarely established preoperatively. We studied the feasibility of cytodiagnosis using endosonography-guided fine-needle aspiration in determining the operative approach. METHODS A total of 78 patients (16 female, 62 male; mean age 61.4 yr, range 31-82 yr) with focal pancreatic lesions underwent EUS-FNA. Final diagnosis was confirmed by histology, cytology, or clinical follow up (>9 months). Patients with tumors of low malignant potential were managed by customized pancreatic resections. RESULTS Final diagnosis was malignant tumors in 36 patients, tumors of low malignant potential in nine (six, neuroendocrine, two, borderline mucinous cystadenomas, one, borderline adenocarcinoma), and benign in 31 (two inadequate smears). No complications occurred. With six false-negative and no false-positive results, the accuracy, sensitivity, specificity, and positive and negative predictive values were 92%, 84%, 100%, 100%, and 86%, respectively. Five patients with low malignant tumors underwent duodenum-preserving pancreatic head resection, three mid segment resection, and one pylorus-preserving pancreatoduodenectomy. CONCLUSIONS EUS-FNA is useful in the preoperative cytodiagnosis of pancreatic tumors of low malignant potential. It extends the indication for organ-preserving pancreatic resections and avoids the unnecessary sacrifice of adjacent organs.
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Affiliation(s)
- A Fritscher-Ravens
- Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany
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Fritscher-Ravens A, Brand B, Bohnacker S, Sriram PV, Soehendra N. Technique of endoscopic ultrasonography-guided fine-needle aspiration of the lymph nodes. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2000. [DOI: 10.1053/tgie.2000.7732] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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