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Shafi S, Frankel WL, Li Z, Jones D, Krishna SG, Esnakula AK, Yearsley M, Sun S, Lujan G, Vazzano J, Weldemichael W, Lee P, Shah H, Burlen J, Papachristou G, Chen W. Endoscopic ultrasound-guided pancreatic core-needle/microforceps biopsy is a valuable diagnostic tool for pancreatic lesions: Experience from a large academic institution. Am J Clin Pathol 2025:aqaf050. [PMID: 40414818 DOI: 10.1093/ajcp/aqaf050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2025] [Accepted: 04/23/2025] [Indexed: 05/27/2025] Open
Abstract
OBJECTIVE Endoscopic ultrasound (EUS)-guided, fine-needle core biopsy (FNB), and through-the-needle microforceps biopsy (TTNB) are latest tools for evaluating pancreatic lesions. We aim to provide subspecialty surgical pathologists' experience with EUS-FNB/TTNB in diagnosing pancreatic lesions at a large academic center. METHODS A 3-year review identified 101 EUS pancreatic specimens submitted for surgical pathology: 87 biopsy specimens (FNB = 58, TTNB = 29) and 14 fine-needle aspirations (FNAs). Diagnoses were compared with cytology and resection specimens when available. RESULTS Of the 101 cases, 10 had previous EUS-FNA cytology with inconclusive diagnoses. Rebiopsy with EUS-FNB/TTNB provided definitive diagnoses in 9 cases. Thirty-five cases (18 cystic and 17 solid lesions) had concurrent surgical pathology and cytology specimens. The diagnostic yield of EUS-FNB/TTNB biopsy specimens (69%) was significantly higher than that of cytology specimens (26%, P = .0017), as was the diagnostic accuracy (P = .0012). This diagnostic advantage was statistically significant in cystic lesions (FNB/TTNB [83.3%] vs cytology [16.7%] for achieving a specific diagnosis, P = .0002) but not in solid lesions (61.5% vs 46.2%, P = .6951). Only in 1 case did cytology (adenocarcinoma) provide a more definitive diagnosis than surgical pathology (high-grade dysplasia cannot exclude adenocarcinoma). CONCLUSIONS The EUS-FNB/TTNB methods complement EUS-FNA cytology in diagnosing pancreatic lesions, and they often outperforms concurrent cytology specimens, particularly in cystic lesions.
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Affiliation(s)
- Saba Shafi
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Wendy L Frankel
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Zaibo Li
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dan Jones
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ashwini K Esnakula
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Martha Yearsley
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Shaoli Sun
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Giovanni Lujan
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jennifer Vazzano
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Wegahta Weldemichael
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Peter Lee
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Hamza Shah
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jordan Burlen
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - George Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Wei Chen
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Facciorusso A, Arvanitakis M, Crinò SF, Fabbri C, Fornelli A, Leeds J, Archibugi L, Carrara S, Dhar J, Gkolfakis P, Haugk B, Iglesias Garcia J, Napoleon B, Papanikolaou IS, Seicean A, Stassen PMC, Vilmann P, Tham TC, Fuccio L. Endoscopic ultrasound-guided tissue sampling: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review. Endoscopy 2025; 57:390-418. [PMID: 40015316 DOI: 10.1055/a-2524-2596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2025]
Abstract
This Technical and Technology Review from the European Society of Gastrointestinal Endoscopy (ESGE) represents an update of the previous document on the technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including the available types of needle, technical aspects of tissue sampling, new devices, and specimen handling and processing. Among the most important new recommendations are:ESGE recommends end-cutting fine-needle biopsy (FNB) needles over reverse-bevel FNB or fine-needle aspiration (FNA) needles for tissue sampling of solid pancreatic lesions; FNA may still have a role when rapid on-site evaluation (ROSE) is available.ESGE recommends EUS-FNB or mucosal incision-assisted biopsy (MIAB) equally for tissue sampling of subepithelial lesions ≥20 mm in size. MIAB could represent the first choice for smaller lesions (<20 mm) if proper expertise is available.ESGE does not recommend the use of antibiotic prophylaxis before EUS-guided tissue sampling of solid masses and EUS-FNA of pancreatic cystic lesions.
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Affiliation(s)
- Antonio Facciorusso
- Department of Experimental Medicine, Section of Gastroenterology, University of Salento, Lecce, Italy
| | - Marianna Arvanitakis
- Department of Gastroenterology, Digestive Oncology and Hepatopancreatology, HUB Hôpital Erasme, Brussels, Belgium
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Adele Fornelli
- Pathology Unit, Ospedale Maggiore "C.A. Pizzardi", AUSL Bologna, Bologna, Italy
| | - John Leeds
- Department of Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Livia Archibugi
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Carrara
- Department of Biomedical Sciences, Humanitas Pieve Emanuele University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Jahnvi Dhar
- Department of Gastroenterology and Hepatology, Punjab Institute of Liver and Biliary Sciences, Mohali, India
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital of Nea Ionia, Athens, Greece
| | - Beate Haugk
- Department of Cellular Pathology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Julio Iglesias Garcia
- Department of Gastroenterology and Hepatology, Health Research Institute of Santiago de Compostela (IDIS), University Hospital of Santiago de Compostela, Santiago, Spain
| | - Bertrand Napoleon
- Department of Gastroenterology, Hôpital privé Jean Mermoz, Lyon, France
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodastrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Andrada Seicean
- Department of Gastroenterology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter Vilmann
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland
| | - Lorenzo Fuccio
- Department of Medical Sciences and Surgery, University of Bologna, Bologna, Italy
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Das KK, Chen D, Akshintala VS, Chen YI, Girotra M, Han S, Kahn A, Mishra G, Muthusamy VR, Obando JV, Onyimba FU, Pawa S, Rustagi T, Sakaria S, Trikudanathan G, Law R. Pancreas and biliary ablation devices. Gastrointest Endosc 2024; 100:980-993. [PMID: 39396364 DOI: 10.1016/j.gie.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 10/15/2024]
Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Dennis Chen
- Digestive Diseases Center, University of Chicago, Chicago, Illinois, USA
| | - Venkata S Akshintala
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology & Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mohit Girotra
- Department of Gastroenterology, Swedish Medical Center, Issaquah, Washington, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Allon Kahn
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Girish Mishra
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - V Raman Muthusamy
- Division of Digestive Diseases, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jorge V Obando
- Division of Gastroenterology, Duke University Health System, Raleigh, North Carolina, USA
| | - Frances U Onyimba
- Department of Gastroenterology, WellSpan Digestive Health, York, Pennsylvania, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Tarun Rustagi
- Department of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Sonali Sakaria
- Department of Gastroenterology, Emory University, Atlanta, Georgia, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ryan Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Cheng B, Du C, He Z, Feng X, Li H, Wang Z, Gao F, Zhao Y, Chai N, Linghu E. Value of EUS-guided through-the-needle biopsy in the diagnosis of pancreatic cystic neoplasms: An 8-year experience. Endosc Ultrasound 2024; 13:345-350. [PMID: 39802104 PMCID: PMC11723696 DOI: 10.1097/eus.0000000000000091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 09/18/2024] [Indexed: 01/16/2025] Open
Abstract
Background and Objectives An accurate diagnosis is crucial for the clinical management of pancreatic cystic neoplasm (PCN). EUS-guided through-the-needle biopsy (EUS-TTNB) is a novel technique for improving the accuracy of PCN diagnosis. There is insufficient evidence about the efficacy of EUS-TTNB. This study aims to evaluate the feasibility and diagnostic performance of EUS-TTNB for PCN. Methods Between June 2015 and July 2023, we prospectively enrolled 454 patients with a clinical concern for PCN in our database. After excluding those diagnosed with pancreatic cancer, pseudocysts, or other no-neoplasms, we assessed 326 patients with 329 cysts undergoing EUS-guided fine-needle-aspiration (EUS-FNA) or EUS-TTNB for evaluation. The primary indicators were tissue acquisition yield and diagnostic yield. The cyst characteristics (size, location, the presence of septation, mural nodule, and solid mass) and the number of biopsy samples were chosen for the analysis of factors associated with diagnostic performance. Results There were 220 (67.5%) females and 106 (32.5%) males, and the median patient age was 50 years (range, 18-88). There were 329 cysts sampled by FNA and 143 by TTNB. The median cyst size was 31.5 mm (range, 6.9-114.0). The diagnostic yields of FNA and TTNB were 35.7% (112/314) and 57.5% (73/127), respectively (P < 0.001). Special cyst types were diagnosed by TTNB in 58 (45.7%, 58/127) cysts, 19 of which had surgical pathology. Fifteen of 19 TTNB diagnoses were concordant with the surgical pathology. Conclusion EUS-TTNB is an option to improve the diagnosis of PCN. Standardized procedures and appropriate indications for TTNB need to be studied.
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Affiliation(s)
- Bingqian Cheng
- Medical School of Chinese PLA, 100853 Beijing, China
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
| | - Chen Du
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
| | - Zhengting He
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
| | - Xiuxue Feng
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
| | - Huikai Li
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
| | - Zhanbo Wang
- Department of Pathology, the First Medical Center, Chinese PLA General Hospital, 100853 Beijing, China
| | - Fei Gao
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
- Department of Healthcare, Agency for Offices Administration, Central Military Commission, Beijing 100082, China
| | - Yunyun Zhao
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
| | - Ningli Chai
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
| | - Enqiang Linghu
- Department of Gastroenterology, the First Medical Center, Chinese PLA General Hospital, Beijing 100083, China
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Koshita S, Noda Y, Kanno Y, Ogawa T, Kusunose H, Sakai T, Yonamine K, Miyamoto K, Kozakai F, Okano H, Matsuoka Y, Hosokawa K, Sumiya H, Oikawa M, Tsuchiya T, Sawai T, Ito K. Digital peroral pancreatoscopy to determine surgery for patients who have intraductal papillary mucinous neoplasms of the pancreas with mural nodules. Endosc Int Open 2024; 12:E1401-E1410. [PMID: 39610945 PMCID: PMC11604303 DOI: 10.1055/a-2452-2919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 10/25/2024] [Indexed: 11/30/2024] Open
Abstract
Background and study aims Because more than a few patients have intraductal papillary mucinous neoplasms of the pancreas (IPMNs) with mural nodules (MNs) that are benign, clinical plans should be determined by using histocytological specimens especially, for patients with high risk for surgery or with a small MN. Patients and methods This study included 27 patients to evaluate the efficacy of peroral pancreatoscopy using a SpyGlass DS system (POPS-DS) for patients with MN-positive IPMN, mainly focusing on the ability of POPS-DS to detect malignancy. Results Biopsy specimens obtained under POPS-DS guidance could be used for histological evaluation of all patients with MNs in the main pancreatic duct and 67% of the patients with MNs in the branch ducts, whereas fluid specimens collected during POPS-DS could be used for histocytological evaluation for all patients. For the 13 patients who underwent surgery just after POPS-DS, the sensitivity, specificity, and accuracy of POPS-DS to detect malignancy were 89%, 100%, and 92%, respectively. For the 12 patients who underwent surveillance without surgery, the cumulative 3-year progression rates for nine benign IPMNs and three malignant ones determined using POPS-DS were 0% and 100%, respectively. However, the sensitivity of POPS to detect IPMN epithelium in the resection margin was 20%. Only one patient developed procedure-related pancreatitis (mild). Conclusions POPS-DS could be used to accurately detect malignancy in patients with MN-positive IPMN. Therefore, histocytological evaluation using POPS-DS can contribute to selection of patients for whom surgery would be appropriate.
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Affiliation(s)
- Shinsuke Koshita
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Yutaka Noda
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Yoshihide Kanno
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Takahisa Ogawa
- Department of Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Hiroaki Kusunose
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Toshitaka Sakai
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Keisuke Yonamine
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Kazuaki Miyamoto
- Department of Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Fumisato Kozakai
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Haruka Okano
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Yuto Matsuoka
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Kento Hosokawa
- Department of Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Hidehito Sumiya
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Masaya Oikawa
- Surgery, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Takashi Tsuchiya
- Surgery, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Takashi Sawai
- Pathology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
| | - Kei Ito
- Gastroenterology, Public Interest Incorporated Foundation Sendai City Medical Center, Sendai, Japan
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Magahis PT, Chhoda A, Berzin TM, Farrell JJ, Wright DN, Rizvi A, Hanscom M, Carr-Locke DL, Sampath K, Sharaiha RZ, Mahadev S. Risk of Pancreatitis After Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2024; 119:2174-2186. [PMID: 38976379 DOI: 10.14309/ajg.0000000000002942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/21/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is frequently used to risk-stratify pancreatic cystic lesions (PCLs). Rising PCL incidence and developments in tissue acquisition and specimen analysis necessitate updated appraisal of EUS-FNA safety, particularly the risk of postprocedure pancreatitis, the most common EUS-FNA-related adverse event. Our systematic review aims to accurately quantify the risk of EUS-FNA-related pancreatitis to best inform decisions regarding EUS-FNA's optimal role in PCL workup. METHODS We performed systematic searches in 4 databases from inception to April 2024 for original English-language studies investigating EUS-FNA-related pancreatitis. We extracted data on demographics and EUS-FNA-related pancreatitis risk, severity, and risk factors. These were meta-analyzed through the DerSimonian Laird Method using a random-effects model. Meta-regression of pancreatitis risk was performed to delineate associations with clinical and procedural characteristics. RESULTS Sixty-four studies comprised 8,086 patients and reported 110 EUS-FNA-related pancreatitis events. Pooled risk of EUS-FNA-related pancreatitis was 1.4% (95% confidence intervals, -0.8% to 3.5%; I2 = 0.00), which was predominantly of mild severity (67%) and uniformly nonfatal. Pancreatitis risk lacked significant association with sample size, age, sex, cyst size, needle caliber, or passes, although we noted trends toward higher risk in studies published after 2015, those using higher gauge needles (19 G vs 22 G/25 G), and those performing EUS-guided through-the-needle biopsy. DISCUSSION We note with high certainty that pancreatitis after EUS-FNA of PCLs is infrequent and mild in severity with no mortality in the included cohort. EUS-guided through-the-needle biopsy may serve as a significant risk factor for EUS-FNA-related pancreatitis risk; however, further studies are needed to delineate other predisposing characteristics.
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Affiliation(s)
- Patrick T Magahis
- Weill Cornell Medical College, MD Program, New York, New York, USA
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Ankit Chhoda
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Tyler M Berzin
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - James J Farrell
- Department of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Drew N Wright
- Samuel J. Wood Library, Weill Cornell Medical College, New York, New York, USA
| | - Anam Rizvi
- Weill Cornell Medical College, MD Program, New York, New York, USA
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Mark Hanscom
- Weill Cornell Medical College, MD Program, New York, New York, USA
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - David L Carr-Locke
- Weill Cornell Medical College, MD Program, New York, New York, USA
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Kartik Sampath
- Weill Cornell Medical College, MD Program, New York, New York, USA
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Reem Z Sharaiha
- Weill Cornell Medical College, MD Program, New York, New York, USA
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - SriHari Mahadev
- Weill Cornell Medical College, MD Program, New York, New York, USA
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
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7
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Doi T, Ishiwatari H, Sato J, Sakamoto H. Usefulness of micro forceps biopsy for cystic degenerated pancreatic neuroendocrine neoplasm. Clin Endosc 2024; 57:688-689. [PMID: 39169575 PMCID: PMC11474469 DOI: 10.5946/ce.2024.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 08/23/2024] Open
Affiliation(s)
- Takuya Doi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroki Sakamoto
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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8
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Vilas-Boas F, Ribeiro T, Macedo G, Dhar J, Samanta J, Sina S, Manfrin E, Facciorusso A, Conti Bellocchi MC, De Pretis N, Frulloni L, Crinò SF. Endoscopic Ultrasound-Guided Through-the-Needle Biopsy: A Narrative Review of the Technique and Its Emerging Role in Pancreatic Cyst Diagnosis. Diagnostics (Basel) 2024; 14:1587. [PMID: 39125463 PMCID: PMC11311500 DOI: 10.3390/diagnostics14151587] [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: 07/03/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Pancreatic cystic lesions (PCLs) pose a diagnostic challenge due to their increasing incidence and the limitations of cross-sectional imaging and endoscopic-ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-guided through the needle biopsy (EUS-TTNB) has emerged as a promising tool for improving the accuracy of cyst type determination and neoplastic risk stratification. EUS-TTNB demonstrates superior diagnostic performance over EUS-FNA, providing critical preoperative information that can significantly influence patient management and reduce unnecessary surgeries. However, the procedure has risks, with an overall adverse event rate of approximately 9%. Preventive measures and further prospective studies are essential to optimize its safety and efficacy. This review highlights the potential of EUS-TTNB to enhance the diagnostic and management approaches for patients with PCLs. It examines the current state of EUS-TTNB, including available devices, indications, procedural techniques, specimen handling, diagnostic yield, clinical impact, and associated adverse events.
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Affiliation(s)
- Filipe Vilas-Boas
- Gastroenterology Department, Centro Hospitalar e Universitário de São João, Faculdade de Medicina da Universidade do Porto, 4200-349 Porto, Portugal; (F.V.-B.); (T.R.); (G.M.)
| | - Tiago Ribeiro
- Gastroenterology Department, Centro Hospitalar e Universitário de São João, Faculdade de Medicina da Universidade do Porto, 4200-349 Porto, Portugal; (F.V.-B.); (T.R.); (G.M.)
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar e Universitário de São João, Faculdade de Medicina da Universidade do Porto, 4200-349 Porto, Portugal; (F.V.-B.); (T.R.); (G.M.)
| | - Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.D.); (J.S.)
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.D.); (J.S.)
| | - Sokol Sina
- Department of Diagnostics and Public Health, University of Verona, 37129 Verona, Italy; (S.S.); (E.M.)
| | - Erminia Manfrin
- Department of Diagnostics and Public Health, University of Verona, 37129 Verona, Italy; (S.S.); (E.M.)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy;
| | - Maria Cristina Conti Bellocchi
- Gastroenterology and Digestive Endoscopy Unit, University Hospital of Verona, 37134 Verona, Italy; (M.C.C.B.); (N.D.P.); (L.F.)
| | - Nicolò De Pretis
- Gastroenterology and Digestive Endoscopy Unit, University Hospital of Verona, 37134 Verona, Italy; (M.C.C.B.); (N.D.P.); (L.F.)
| | - Luca Frulloni
- Gastroenterology and Digestive Endoscopy Unit, University Hospital of Verona, 37134 Verona, Italy; (M.C.C.B.); (N.D.P.); (L.F.)
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, University Hospital of Verona, 37134 Verona, Italy; (M.C.C.B.); (N.D.P.); (L.F.)
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Iwashita T, Uemura S, Shimizu M. Endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: a comprehensive review. J Med Ultrason (2001) 2024; 51:219-226. [PMID: 38051460 DOI: 10.1007/s10396-023-01389-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/09/2023] [Indexed: 12/07/2023]
Abstract
Advancements in diagnostic radiology have amplified the incorporation of these techniques into routine clinical practice. Concurrently, the frequency of incidentally identifying pancreatic cystic lesions (PCLs) has surged. PCLs encompass diverse categories contingent upon their origin. Among them, branch duct-intraductal papillary mucinous neoplasms (BD-IPMN) and mucinous cystic neoplasms (MCN) are categorized as mucinous cystic lesions that have malignant potential. Even solid neoplasms occasionally show cystic degeneration. Therefore, precise differential PCL diagnosis is crucial to optimize clinical management strategies and detect malignant transformations. Endoscopic ultrasound (EUS) affords comprehensive visualization of the pancreas with high-resolution ultrasound, complemented by fine-needle aspiration (FNA) under real-time EUS guidance, which is a minimally invasive procedure for obtaining pathological samples. This synergy has established EUS and EUS-FNA as vital procedures in the management of PCLs, enabling differentiation of PCLs. Cyst fluid analysis has played a pivotal role in deciding the optimal management strategy. The efficacy of cytological analysis is limited by scant cytologic material. The "string sign" test evaluates fluid viscosity, and its simplicity warrants initial consideration. Amylase and tumor markers, such as CEA, have been studied, but they yield varied sensitivity and specificity. Glucose and genetic mutations (KRAS, GNAS) exhibit promise, while comprehensive genomic profiling underscores genetic insights. Through-the-needle biopsy and needle-based confocal laser endomicroscopy also show high diagnostic yield. EUS-FNA, however, entails risks like infection and needle tract seeding, emphasizing the need for proper utilization. Pancreatic cyst fluid analysis augments diagnostic accuracy and informs clinical decisions, making it a valuable adjunct to imaging.
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Affiliation(s)
- Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 502-0061, Japan.
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 502-0061, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 502-0061, Japan
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10
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Cao T, Sun S, Krishna SG. A Seemingly Benign Pancreatic Cyst With an Unsettling Trend of Enlarging Size and Associated Symptoms. Gastroenterology 2024; 166:e5-e8. [PMID: 37949251 DOI: 10.1053/j.gastro.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Troy Cao
- College of Medicine, Ohio State University, Columbus, Ohio
| | - Shaoli Sun
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio.
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11
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Gopakumar H, Puli SR. Value of Endoscopic Ultrasound-Guided Through-the-Needle Biopsy in Pancreatic Cystic Lesions. A Systematic Review and Meta-Analysis. J Gastrointest Cancer 2024; 55:15-25. [PMID: 37341913 DOI: 10.1007/s12029-023-00949-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) has been used over the past few years to increase diagnostic accuracy for pancreatic cystic lesions (PCLs). However, many concerns remain regarding its widespread use. This systematic review and meta-analysis aimed to pool the data from high-quality studies to evaluate the utility of EUS-TTNB in diagnosing PCLs. METHODS Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the diagnostic performance of EUS-TTNB in the diagnosis of pancreatic cystic lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. RESULTS The initial search identified 635 studies, of which 35 relevant articles were reviewed. We extracted data from 11 studies that met the inclusion criterion, comprising a total of 575 patients. Mean patient age was 62.25 years ± 6.12 with females constituting 61.39% of the study population. Pooled sensitivity of EUS-TTNB in differentiating a PCL as neoplastic or non-neoplastic was 76.60% (95% CI = 72.60-80. 30). For the same indication, EUS TTNB had a pooled specificity of 98.90% (95% CI = 93.80-100.00). The positive likelihood ratio was 10.28 (95% CI = 4.77-22.15), and the negative likelihood ratio was 0.26 (95% CI = 0.22-0.31). The pooled diagnostic odds ratio for EUS-TTNB in diagnosing PCLs as malignant/pre-malignant vs. non-malignant was 41.34 (95% CI = 17.42-98.08). Pooled adverse event rates were 3.04% (95% CI = 1.83-4.54) for pancreatitis, 4.02% (95% CI = 2.61-5.72) for intra-cystic bleeding, 0.94% (95% CI = 0.33-1.86) for fever, and 1.73% (95% CI = 0.85-2.91) for other minor events. CONCLUSIONS EUS-TTNB has good sensitivity with excellent specificity in accurately classifying PCLs as neoplastic or non-neoplastic. Adding EUS-TTNB to EUS-FNA increases the accuracy of EUS-guided approach in diagnosing PCLs. However, it could significantly increase the risk of post-procedural pancreatitis.
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Affiliation(s)
- Harishankar Gopakumar
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, Peoria, IL, USA.
| | - Srinivas R Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, Peoria, IL, USA
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12
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Al-Taee AM, Taylor JR. Endoscopic Imaging of Pancreatic Cysts. Gastrointest Endosc Clin N Am 2023; 33:583-598. [PMID: 37245937 DOI: 10.1016/j.giec.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pancreatic cystic lesions (PCLs) have been diagnosed with increasing frequency likely due to the widespread use of cross-sectional imaging. A precise diagnosis of the PCL is important because it helps identify patients in need of surgical resection and those who can undergo surveillance imaging. A combination of clinical and imaging findings as well as cyst fluid markers can help classify PCLs and guide management. This review focuses on endoscopic imaging of PCLs including endoscopic and endosonographic features and fine needle aspiration. We then review the role of adjunct techniques, such as microforceps, contrast-enhanced endoscopic ultrasound, pancreatoscopy, and confocal laser endomicroscopy.
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Affiliation(s)
- Ahmad M Al-Taee
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Digestive Health Institute, 611 West Park Street, Urbana, IL 61801, USA.
| | - Jason R Taylor
- St Luke's Hospital, 224 South Woods Mill Road, Suite 410, Chesterfield, MO 63017, USA
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13
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Mohapatra S, Krishna SG, Pannala R. Pancreatic Cystic Neoplasms: Translating Guidelines into Clinical Practice. Diagnostics (Basel) 2023; 13:749. [PMID: 36832238 PMCID: PMC9955807 DOI: 10.3390/diagnostics13040749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
A combination of several factors, including the increasing use of cross-sectional imaging and an aging population, has led to pancreatic cystic lesions (PCLs) becoming the most detected incidental pancreatic lesions. Accurate diagnosis and risk stratification of PCLs is challenging. In the last decade, several evidence-based guidelines have been published addressing the diagnosis and management of PCLs. However, these guidelines cover different subsets of patients with PCLs and offer varying recommendations regarding diagnostic assessment, surveillance, and surgical resection. Further, recent studies comparing the accuracy of various guidelines have reported significant variations in the rate of missed cancer versus unnecessary surgical resections. In clinical practice, it is challenging to decide which guideline to follow specifically. This article reviews the varying recommendations of the major guidelines and results of comparative studies, provides an overview of newer modalities not included in the guidelines, and offers perspectives on translating the guidelines into clinical practice.
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Affiliation(s)
- Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA
| | - Somashekar G. Krishna
- Department of Gastroenterology and Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA
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14
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Li SY, Wang ZJ, Pan CY, Wu C, Li ZS, Jin ZD, Wang KX. Comparative Performance of Endoscopic Ultrasound-Based Techniques in Patients With Pancreatic Cystic Lesions: A Network Meta-Analysis. Am J Gastroenterol 2023; 118:243-255. [PMID: 36563321 DOI: 10.14309/ajg.0000000000002088] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/02/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Evidence on the comparative diagnostic performance of endoscopic ultrasound (EUS)-based techniques for pancreatic cystic lesions (PCLs) is limited. This network meta-analysis comprehensively compared EUS-based techniques for PCL diagnosis. METHODS A comprehensive literature search was performed for all comparative studies assessing the accuracy of 2 or more modalities for PCL diagnosis. The primary outcome was the diagnostic efficacy for mucinous PCLs. Secondary outcomes were the diagnostic efficacy for malignant PCLs, diagnostic success rate, and adverse event rate. A network meta-analysis was conducted using the ANOVA model to assess the diagnostic accuracy of each index. RESULTS Forty studies comprising 3,641 patients were identified. The network ranking of the superiority index for EUS-guided needle-based confocal laser endomicroscopy (EUS-nCLE) and EUS-guided through-the-needle biopsy (EUS-TTNB) were significantly higher than other techniques for differentiating mucinous PCLs; besides, EUS-TTNB was also the optimal technique in identifying malignant PCLs. The evidence was inadequate for EUS-nCLE diagnosing malignant PCLs and contrast-enhanced harmonic EUS diagnosing both mucinous and malignant PCLs. Glucose showed a high sensitivity but low specificity, and molecular analysis (KRAS, GNAS, and KRAS + GNAS mutations) showed a high specificity but low sensitivity for diagnosing mucinous PCLs. Satisfactory results were not obtained during the evaluation of the efficiency of pancreatic cyst fluid (PCF) biomarkers in detecting malignant PCLs. DISCUSSION For centers with relevant expertise and facilities, EUS-TTNB and EUS-nCLE were better choices for the diagnosis of PCLs. Further studies are urgently required for further improving PCF biomarkers and validating the diagnostic performance of the index techniques.
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Affiliation(s)
- Shi-Yu Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhi-Jie Wang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Cheng-Ye Pan
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Cheng Wu
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Kai-Xuan Wang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
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15
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Rift CV, Melchior LC, Kovacevic B, Klausen P, Toxværd A, Grossjohann H, Karstensen JG, Brink L, Hassan H, Kalaitzakis E, Storkholm J, Scheie D, Hansen CP, Lund EL, Vilmann P, Hasselby JP. Targeted next-generation sequencing of EUS-guided through-the-needle-biopsy sampling from pancreatic cystic lesions. Gastrointest Endosc 2023; 97:50-58.e4. [PMID: 35964683 DOI: 10.1016/j.gie.2022.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/27/2022] [Accepted: 08/06/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Recent advances have introduced molecular subtyping of pancreatic cystic lesions (PCLs) as a possible amendment to the diagnostic algorithm. The study evaluated the feasibility and diagnostic accuracy of molecular analysis and subtyping of PCLs using the recently introduced EUS-guided through-the-needle-biopsy (TTNB) sampling. METHODS We prospectively included 101 patients in the study who presented with PCLs >15 mm in the largest cross-section. EUS-guided TTNB samples were obtained by a micro-biopsy forceps introduced through a 19-gauge needle. The TTNB samples were analyzed by next-generation sequencing (NGS) for point mutations in tumor suppressors and oncogenes using a 51-gene customized hotspot panel. Sensitivity and specificity were calculated with the histologic diagnosis as reference. RESULTS After initial microscopic evaluation of the samples, 91 patients had residual TTNB samples available for NGS. Of these, 49 harbored mutations, most frequently in KRAS and GNAS, reflecting an excess frequency of intraductal papillary mucinous neoplasms (IPMNs) in the study population. A sensitivity and specificity of 83.7% (95% confidence interval [CI], 70.3-92.7) and 81.8% (95% CI, 48.2-97.7), respectively, were demonstrated for the diagnosis of a mucinous cyst and 87.2% (95% CI, 74.2-95.2) and 84.6% (95% CI, 54.5-98.1) for the diagnosis of an IPMN. CONCLUSIONS Thus, molecular analysis of TTNB samples by NGS has high sensitivity and specificity for diagnosing mucinous cysts and IPMNs. Although the procedure comes with a risk of adverse events of 9.9%, TTNB samples are a robust alternative to cyst fluid for a combined histologic and molecular diagnosis of PCLs. (Clinical trial registration number: NCT03578445.).
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Affiliation(s)
- Charlotte Vestrup Rift
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Linea Cecilie Melchior
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bojan Kovacevic
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Pia Klausen
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Anders Toxværd
- Department of Pathology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Hanne Grossjohann
- Department of Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - John Gásdal Karstensen
- Pancreatitis Centre East, Gastroenterology Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Brink
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Hazem Hassan
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Evangelos Kalaitzakis
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan Storkholm
- Department of Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - David Scheie
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Palnæs Hansen
- Department of Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Eva Løbner Lund
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Vilmann
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jane Preuss Hasselby
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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16
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Vázquez-Sequeiros E. Endoscopic ultrasound-guided through-the-needle biopsy for the diagnosis of cystic tumors of the pancreas: not for all patients. Endoscopy 2022; 54:1169-1170. [PMID: 35926540 DOI: 10.1055/a-1901-8718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Enrique Vázquez-Sequeiros
- Endoscopy Unit, Gastroenterology and Hepatology Service, University Hospital Ramon y Cajal (IRYCIS), Madrid, Spain
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17
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Facciorusso A, Kovacevic B, Yang D, Vilas-Boas F, Martínez-Moreno B, Stigliano S, Rizzatti G, Sacco M, Arevalo-Mora M, Villarreal-Sanchez L, Conti Bellocchi MC, Bernardoni L, Gabbrielli A, Barresi L, Gkolfakis P, Robles-Medranda C, De Angelis C, Larghi A, Di Matteo FM, Aparicio JR, Macedo G, Draganov PV, Vilmann P, Pecchia L, Repici A, Crinò SF. Predictors of adverse events after endoscopic ultrasound-guided through-the-needle biopsy of pancreatic cysts: a recursive partitioning analysis. Endoscopy 2022; 54:1158-1168. [PMID: 35451041 DOI: 10.1055/a-1831-5385] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS : Endoscopic ultrasound-guided through-the-needle biopsy (TTNB) of pancreatic cystic lesions (PCLs) is associated with a non-negligible risk for adverse events (AEs). We aimed to identify the hierarchic interaction among independent predictors for TTNB-related AEs and to generate a prognostic model using recursive partitioning analysis (RPA). PATIENTS AND METHODS : Multicenter retrospective analysis of 506 patients with PCLs who underwent TTNB. RPA of predictors for AEs was performed and the model was validated by means of bootstrap resampling. RESULTS : Mean cysts size was 36.7 mm. Most common diagnoses were intraductal papillary mucinous neoplasm (IPMN, 45 %), serous cystadenoma (18.8 %), and mucinous cystadenoma (12.8 %). Fifty-eight (11.5 %) AEs were observed. At multivariate analysis, age (odds ratio [OR] 1.32, 1.09-2.14; p = 0.05), number of TTNB passes (OR from 2.17, 1.32-4.34 to OR 3.16, 2.03-6.34 with the increase of the number of passes), complete aspiration of the cyst (OR 0.56, 0.31-0.95; p = 0.02), and diagnosis of IPMN (OR 4.16, 2.27-7.69; p < 0.001) were found to be independent predictors of AEs, as confirmed by logistic regression and random forest analyses. RPA identified three risk classes: high-risk (IPMN sampled with multiple microforceps passes, 28 % AEs rate), low-risk (1.4 % AE rate, including patients < 64 years with other-than-IPMN diagnosis sampled with ≤ 2 microforceps passes and with complete aspiration of the cyst) and middle-risk class (6.1 % AEs rate, including the remaining patients). CONCLUSION : TTNB should be selectively used in the evaluation of patients with IPMN. The present model could be applied during patient selection as to optimize the benefit/risk of TTNB.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical and Surgical Sciences, Section of Gastroenterology, University of Foggia, Foggia, Italy
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Bojan Kovacevic
- Division of Endoscopy, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Dennis Yang
- Center of Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Filipe Vilas-Boas
- Department of Gastroenterology, Centro Hospitalar e Universitário de São João-Porto, Porto, Portugal
| | - Belén Martínez-Moreno
- Unidad de Endoscopia. ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | - Serena Stigliano
- Operative Endoscopy Department, Campus Bio-Medico University Hospital, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Sacco
- Gastroenterology Division, AOU Cittá della Salute e della Scienza di Torino, Turin, Italy
| | | | | | - Maria Cristina Conti Bellocchi
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Laura Bernardoni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Claudio De Angelis
- Gastroenterology Division, AOU Cittá della Salute e della Scienza di Torino, Turin, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - José R Aparicio
- Unidad de Endoscopia. ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | - Guilherme Macedo
- Department of Gastroenterology, Centro Hospitalar e Universitário de São João-Porto, Porto, Portugal
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Peter Vilmann
- Division of Endoscopy, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | | | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
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Shipley LC, Ahmed AM. New and emerging technology in the diagnosis and treatment of pancreatic cysts. Transl Gastroenterol Hepatol 2022; 7:15. [PMID: 35548473 PMCID: PMC9081918 DOI: 10.21037/tgh-2020-09] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 06/05/2020] [Indexed: 08/27/2023] Open
Abstract
Pancreatic cysts have always presented as a diagnostic dilemma due to the difficulties in identifying patients with current imaging modalities that could most benefit from surgical intervention. Intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystadenomas (MCNs) carry the highest malignant potential of all pancreatic cysts and pancreatic adenocarcinoma carries a high mortality as the fourth leading cause of cancer-related deaths. However, surgery to remove benign cysts also carries a high morbidity and occasional mortality. Opportunities to identify and reduce pre-cancer lesions must be aggressively pursued. Multidetector helical CT (MDHCT) or an up-to-date MRI is the first diagnostic tool to evaluate a suspected pancreatic lesion. Currently, review by a multidisciplinary group who specialize in pancreatic cysts and pancreatic cancer is advised to review factors such as a patient's comorbidities, the type of surgery needed to remove the cyst and the estimated morbidity and mortality associated with the procedure. Some recent data are emerging to assist with identifying those at highest risk such as cyst fluid analysis, laser endomicroscopy, and artificial intelligence (AI). This article reviews the current status, benefits, challenges and future prospects on diagnosis and treatment of pancreatic cysts. Further prospective randomized control trials are needed to determine the optimal management and treatment for patients with pancreatic cysts.
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Affiliation(s)
- Lindsey C. Shipley
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - Ali M. Ahmed
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL, USA
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19
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Robles-Medranda C, Olmos JI, Puga-Tejada M, Oleas R, Baquerizo-Burgos J, Arevalo-Mora M, Del Valle Zavala R, Nebel JA, Calle Loffredo D, Pitanga-Lukashok H. Endoscopic ultrasound-guided through-the-needle microforceps biopsy and needle-based confocal laser-endomicroscopy increase detection of potentially malignant pancreatic cystic lesions: A single-center study. World J Gastrointest Endosc 2022; 14:129-141. [PMID: 35432747 PMCID: PMC8984536 DOI: 10.4253/wjge.v14.i3.129] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 12/15/2021] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Currently, there is insufficient data about the accuracy in the diagnosing of pancreatic cystic lesions (PCLs), especially with novel endoscopic techniques such as with direct intracystic micro-forceps biopsy (mFB) and needle-based confocal laser-endomicroscopy (nCLE).
AIM To compare the accuracy of endoscopic ultrasound (EUS) and associated techniques for the detection of potentially malignant PCLs: EUS-guided fine needle aspiration (EUS-FNA), contrast-enhanced EUS (CE-EUS), EUS-guided fiberoptic probe cystoscopy (cystoscopy), mFB, and nCLE.
METHODS This was a single-center, retrospective study. We identified patients who had undergone EUS, with or without additional diagnostic techniques, and had been diagnosed with PCLs. We determined agreement among malignancy after 24-mo follow-up findings with detection of potentially malignant PCLs via the EUS-guided techniques and/or EUS-guided biopsy when available (EUS malignancy detection).
RESULTS A total of 129 patients were included, with EUS performed alone in 47/129. In 82/129 patients, EUS procedures were performed with additional EUS-FNA (21/82), CE-EUS (20/82), cystoscopy (27/82), mFB (36/82), nCLE (44/82). Agreement between EUS malignancy detection and the 24-mo follow-up findings was higher when associated with additional diagnostic techniques than EUS alone [62/82 (75.6%) vs 8/47 (17%); OR 4.35, 95%CI: 2.70-7.37; P < 0.001]. The highest malignancy detection accuracy was reached when nCLE and direct intracystic mFB were both performed, with a sensitivity, specificity, positive predictive value, negative predictive value and observed agreement of 100%, 89.4%, 77.8%, 100% and 92.3%, respectively (P < 0.001 compared with EUS-alone).
CONCLUSION The combined use of EUS-guided mFB and nCLE improves detection of potentially malignant PCLs compared with EUS-alone, EUS-FNA, CE-EUS or cystoscopy.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Juan I Olmos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Martha Arevalo-Mora
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Raquel Del Valle Zavala
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Joao Autran Nebel
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Daniel Calle Loffredo
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
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20
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Robles-Medranda C, Olmos JI, Puga-Tejada M, Oleas R, Baquerizo-Burgos J, Arevalo-Mora M, Del ValleZavala R, Nebel JA, Calle Loffredo D, Pitanga-Lukashok H. Endoscopic ultrasound-guided through-the-needle microforceps biopsy and needle-based confocal laser-endomicroscopy increase detection of potentially malignant pancreatic cystic lesions: A single-center study. World J Gastrointest Endosc 2022; 14:130-142. [DOI: 10.4253/wjge.v14.i3.130] [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] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Currently, there is insufficient data about the accuracy in the diagnosing of pancreatic cystic lesions (PCLs), especially with novel endoscopic techniques such as with direct intracystic micro-forceps biopsy (mFB) and needle-based confocal laser-endomicroscopy (nCLE).
AIM To compare the accuracy of endoscopic ultrasound (EUS) and associated techniques for the detection of potentially malignant PCLs: EUS-guided fine needle aspiration (EUS-FNA), contrast-enhanced EUS (CE-EUS), EUS-guided fiberoptic probe cystoscopy (cystoscopy), mFB, and nCLE.
METHODS This was a single-center, retrospective study. We identified patients who had undergone EUS, with or without additional diagnostic techniques, and had been diagnosed with PCLs. We determined agreement among malignancy after 24-mo follow-up findings with detection of potentially malignant PCLs via the EUS-guided techniques and/or EUS-guided biopsy when available (EUS malignancy detection).
RESULTS A total of 129 patients were included, with EUS performed alone in 47/129. In 82/129 patients, EUS procedures were performed with additional EUS-FNA (21/82), CE-EUS (20/82), cystoscopy (27/82), mFB (36/82), nCLE (44/82). Agreement between EUS malignancy detection and the 24-mo follow-up findings was higher when associated with additional diagnostic techniques than EUS alone [62/82 (75.6%) vs 8/47 (17%); OR 4.35, 95%CI: 2.70-7.37; P < 0.001]. The highest malignancy detection accuracy was reached when nCLE and direct intracystic mFB were both performed, with a sensitivity, specificity, positive predictive value, negative predictive value and observed agreement of 100%, 89.4%, 77.8%, 100% and 92.3%, respectively (P < 0.001 compared with EUS-alone).
CONCLUSION The combined use of EUS-guided mFB and nCLE improves detection of potentially malignant PCLs compared with EUS-alone, EUS-FNA, CE-EUS or cystoscopy.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Juan I Olmos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Martha Arevalo-Mora
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Raquel Del ValleZavala
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Joao Autran Nebel
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Daniel Calle Loffredo
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
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21
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Sun L, Peng L, Jiang F, Zhu H, Jin Z. Comment on "Intraductal Papillary Mucinous Neoplasms: Have International Association of Pancreatology Consensus Guidelines Changed our Approach?: Results From a Multi-institutional Study". Ann Surg 2021; 274:e705-e706. [PMID: 32224734 DOI: 10.1097/sla.0000000000003869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Liqi Sun
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
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22
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Facciorusso A, Ramai D, Gkolfakis P, Shapiro A, Arvanitakis M, Lisotti A, Triantafyllou K, Fusaroli P, Papanikolaou IS, Crinò SF. Through-the-needle biopsy of pancreatic cystic lesions: current evidence and implications for clinical practice. Expert Rev Med Devices 2021; 18:1165-1174. [PMID: 34842023 DOI: 10.1080/17434440.2021.2012450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/26/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION There is increasing evidence to support the efficacy of endoscopic ultrasound (EUS)-guided through-the-needle biopsy (TTNB) technique as a means of sampling pancreatic cystic lesions (PCLs). Results provide evidence demonstrating the benefits of this procedure over standard EUS fine-needle aspiration (FNA), thus supporting a push for its widespread implementation in clinical practice. Though this technique has demonstrated advantages, achieving these advantages in clinical practice is contingent upon careful considerations to ensure safety and efficacy. AREAS COVERED The purpose of this review is to assess the level of evidence supporting the use of through-the-needle biopsy, revise its main technical and procedural characteristics, and to develop suggested guidelines outlining the safe assimilation of this device in clinical practice. EXPERT OPINION EUS-TTNB enables more definitive and accurate diagnosis of PCLs by providing higher-quality histological samples. However, EUS-TTNB is not appropriate for all PCLs. Selection of suitable patients as well as morphology and risk factors of the cystic lesion is a crucial component of achieving the described benefits of this procedure while minimizing risks of adverse effects. Subjects with weak or absent indications for this procedure are susceptible to a range of complications and may even result in fatality.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical and Surgical Sciences, Section of Gastroenterology, University of Foggia, Foggia, Italy
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT, USA
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cub Erasme Hospital, Université Libre de Bruxelles (Ulb), Brussels, Belgium
| | - Alexandra Shapiro
- Department of Medicine, St. George's University School of Medicine, True Blue, Grenada
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cub Erasme Hospital, Université Libre de Bruxelles (Ulb), Brussels, Belgium
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
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23
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Buerlein RCD, Shami VM. Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc 2021; 14:26317745211045769. [PMID: 34589706 PMCID: PMC8474323 DOI: 10.1177/26317745211045769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022] Open
Abstract
The prevalence of pancreatic cysts has increased significantly over the last
decade, partly secondary to increased quality and frequency of cross-sectional
imaging. While the majority never progress to cancer, a small number will and
need to be followed. The management of pancreatic cysts can be both confusing
and intimidating due to the multiple guidelines with varying recommendations.
Despite the differences in the specifics of the guidelines, they all agree on
several high-risk features that should get the attention of any clinician when
assessing a pancreatic cyst: presence of a mural nodule or solid component,
dilation of the main pancreatic duct (or presence of main duct intraductal
papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology
on pancreatic cyst fluid aspiration. Other important criteria to consider
include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9
levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related
to the cystic lesion.
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Affiliation(s)
| | - Vanessa M Shami
- University of Virginia Digestive Health, 1215 Lee Street, Charlottesville, VA 22903, USA
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24
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Stigliano S, Covotta F, Di Matteo FM. A new micro‐forceps for endoscopic ultrasound‐guided through‐the‐needle biopsy in the diagnosis of pancreatic cystic lesions: Single center experience. JGH Open 2021; 5:1004-1008. [PMID: 34584967 PMCID: PMC8454469 DOI: 10.1002/jgh3.12601] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Serena Stigliano
- Operative Endoscopy Department Campus Bio‐Medico University Hospital Rome Italy
- Department of Translational and Precision Medicine Sapienza University Rome Italy
| | - Francesco Covotta
- Operative Endoscopy Department Campus Bio‐Medico University Hospital Rome Italy
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25
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Sun L, Huang H, Jin Z. Application of EUS-based techniques in the evaluation of pancreatic cystic neoplasms. Endosc Ultrasound 2021; 10:230-240. [PMID: 34213426 PMCID: PMC8411565 DOI: 10.4103/eus-d-20-00216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/21/2021] [Indexed: 12/04/2022] Open
Abstract
Pancreatic cystic neoplasms (PCNs) are being detected increasingly frequently due to the widespread use of high-resolution abdominal imaging modalities. Some subtypes of PCNs have the potential for malignant transformation. Therefore, accurate diagnosis of PCNs is crucial to determine whether surgical resection or surveillance is the best management strategy. However, the current cross-section imaging modalities are not accurate enough to enable definite diagnoses. In the last decade, EUS-based techniques have emerged, aiming to overcome the limitations of standard cross-section imaging modalities. These novel EUS-based techniques were primarily designed to acquire distinct images to make radiological diagnoses, collect cyst fluid to undergo biochemical or molecular analyses, and obtain tissue to conclude the pathological diagnoses. In this article, we present a comprehensive and critical review of these emerging EUS techniques for the diagnosis of PCNs, with emphasis being placed on the advantages, feasibilities, diagnostic performances, and limitations of these novel techniques.
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Affiliation(s)
- Liqi Sun
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Haojie Huang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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26
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Okasha HH, Awad A, El-meligui A, Ezzat R, Aboubakr A, AbouElenin S, El-Husseiny R, Alzamzamy A. Cystic pancreatic lesions, the endless dilemma. World J Gastroenterol 2021; 27:2664-2680. [PMID: 34135548 PMCID: PMC8173383 DOI: 10.3748/wjg.v27.i21.2664] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
Cystic pancreatic lesions involve a wide variety of pathological entities that include neoplastic and non-neoplastic lesions. The proper diagnosis, differentiation, and staging of these cystic lesions are considered a crucial issue in planning further management. There are great challenges for their diagnostic models. In our time, new emerging methods for this diagnosis have been discovered. Endoscopic ultrasonography-guided fine-needle aspiration cytology with chemical and molecular analysis of cyst fluid and EUS-guided fine needle-based confocal laser endomicroscopy, through the needle microforceps biopsy, and single-operator cholangioscopy/pancreatoscopy are promising methods that have been used in the diagnosis of cystic pancreatic lesions. Hereby we discuss the diagnosis of cystic pancreatic lesions and the benefits of various diagnostic models.
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Affiliation(s)
- Hussein Hassan Okasha
- Department of Internal Medicine and Gastroenterology, Hepatology Unit, Kasr Al-Aini Hospitals, Cairo University, Cairo 11562, Egypt
| | - Abeer Awad
- Department of Internal Medicine and Gastroenterology, Hepatology Unit, Kasr Al-Aini Hospitals, Cairo University, Cairo 11562, Egypt
| | - Ahmed El-meligui
- Department of Internal Medicine and Gastroenterology, Hepatology Unit, Kasr Al-Aini Hospitals, Cairo University, Cairo 11562, Egypt
| | - Reem Ezzat
- Department of Internal Medicine and Gastroenterology, Hepatology Unit, Assuit University, Assuit 71515, Egypt
| | - Ashraf Aboubakr
- Department of Gastroenterology and Hepatology, Maadi Armed Forces Medical Complex, Military Medical Academy, Cairo 11441, Egypt
| | - Sameh AbouElenin
- Department of Gastroenterology and Hepatology, Military Medical Academy, Cairo 11441, Egypt
| | - Ramy El-Husseiny
- Department of Hepatology and Tropical Medicine, National Hepatology and Tropical Medicine Research Institute (NHTMRI), Cairo 11441, Egypt
| | - Ahmed Alzamzamy
- Department of Gastroenterology and Hepatology, Maadi Armed Forces Medical Complex, Military Medical Academy, Cairo 11441, Egypt
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27
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Rift CV, Melchior LC, Scheie D, Hansen CP, Lund EL, Hasselby JP. Molecular heterogeneity of pancreatic intraductal papillary mucinous neoplasms and implications for novel endoscopic tissue sampling strategies. J Clin Pathol 2021; 75:jclinpath-2021-207598. [PMID: 34039665 DOI: 10.1136/jclinpath-2021-207598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
AIMS Intraductal papillary mucinous neoplasms (IPMNs) may be precursor lesions of pancreatic cancer. The path towards malignancy is associated with mutations in tumour suppressor-and oncogenes that may serve as biomarkers during diagnostic investigation. A novel micro forceps has made it possible to obtain biopsies from the cyst wall for analysis by next generation sequencing (NGS), providing an opportunity for early detection and intervention. However, the impact of spatial tumour heterogeneity on the representability of the biopsies has not been determined. The primary aim is to characterise the impact of molecular heterogeneity of the luminal cyst wall on tissue sampling strategies with small biopsies. METHODS We performed NGS and immunohistochemical phenotyping on 18 resected IPMNs with varying degrees of dysplasia and for a subset, concomitant carcinoma, using a commercially available NGS-panel of 51 oncogenes. We simulated endoscopic biopsies by performing punch biopsies (PBs) of the cyst wall from resected specimens. RESULTS In total, 127 NGS analyses were performed. Concomitant KRAS and GNAS was a common feature of the IPMNs. Mutations in KRAS and GNAS were associated with low-grade dysplasia whereas alterations in TP53, SMAD4, CDKN2A and PIK3CA were associated with high-grade dysplasia and/or carcinoma. The mutational analysis of the PBs from the cyst wall was compared with the whole lesion. No difference was detected between PBs and whole lesions when the cumulated mutational profile in increasing order of randomly performed PBs was compared. CONCLUSIONS Small IPMN biopsies from the cyst wall are adequate to yield a molecular diagnosis.
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Affiliation(s)
| | | | - David Scheie
- Department of Pathology, Rigshospitalet, Copenhagen, Denmark
| | | | - Eva Løbner Lund
- Department of Pathology, Rigshospitalet, Copenhagen, Denmark
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28
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Rift CV, Lund EL, Scheie D, Hansen CP, Hasselby JP. Histopathological evaluation of resected intraductal papillary mucinous neoplasms reveals distinct patterns of invasion in associated carcinomas. Hum Pathol 2021; 113:47-58. [PMID: 33915115 DOI: 10.1016/j.humpath.2021.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
Invasive intraductal papillary mucinous neoplasms (inv-IPMNs) have a better prognosis than regular pancreatic ductal adenocarcinoma (PDAC), but no association with status of surgical margins and microscopic infiltration patterns has previously been described. The aim of this study is to review patterns of invasion and the predictive value of clinical guidelines in terms of rates of resection of high-grade dysplasia (HGD) and cancer among intraductal papillary mucinous neoplasms (IPMNs). Consecutively, resected IPMNs between 2011 and 2017 were analyzed. Data were obtained from a prospectively maintained database. A total of 132 patients were identified. Out of these, 38 patients with inv-IPMNs, initially identified as solid lesions suspicious of cancer, were compared with a control group of 101 patients with ordinary PDAC. Lower rates of vascular invasion, perineural invasion, lymph node metastasis, advanced T stage, and R1 status were characteristic of the inv-IPMNs in addition to better overall survival (OS) for a low tumor stage. Furthermore, as novel findings, the PDACs presented with resection margin involvement of 3 or more positive margins (31.3% vs. 9.5%, p = 0.044), associated with poor OS. Of the patients presenting as pT3, the inv-IPMN less often invaded more than one extrapancreatic anatomical structure (40.1% vs. 63.9%, p = 0.03). Regarding the predictive value of clinical guidelines, the frequency of resected HGD in IPMNs with high-risk stigmata (n = 54) and IPMNs with worrisome features was 30.7%, and the frequency of invasive carcinoma was 5.7%. In conclusion, we report a low resection rate of high-risk IPMNs and present novel findings describing inv-IPMNs as a less infiltrative phenotype compared with regular PDAC.
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Affiliation(s)
- Charlotte Vestrup Rift
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
| | - Eva Løbner Lund
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - David Scheie
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Carsten Palnæs Hansen
- Department of Surgery, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK 2100 Copenhagen, Denmark
| | - Jane Preuss Hasselby
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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29
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Keane MG, Afghani E. A Review of the Diagnosis and Management of Premalignant Pancreatic Cystic Lesions. J Clin Med 2021; 10:1284. [PMID: 33808853 PMCID: PMC8003622 DOI: 10.3390/jcm10061284] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cystic lesions are an increasingly common clinical finding. They represent a heterogeneous group of lesions that include two of the three known precursors of pancreatic cancer, intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN). Given that approximately 8% of pancreatic cancers arise from these lesions, careful surveillance and timely surgery offers an opportunity for early curative resection in a disease with a dismal prognosis. This review summarizes the current evidence and guidelines for the diagnosis and management of IPMN/MCN. Current pre-operative diagnostic tests in pancreatic cysts are imperfect and a proportion of patients continue to undergo unnecessary surgical resection annually. Balancing cancer prevention while preventing surgical overtreatment, continues to be challenging when managing pancreatic cysts. Cyst fluid molecular markers, such as KRAS, GNAS, VHL, PIK3CA, SMAD4 and TP53, as well as emerging endoscopic technologies such as needle-based confocal laser endomicroscopy and through the needle microbiopsy forceps demonstrate improved diagnostic accuracy. Differences in management and areas of uncertainty between the guidelines are also discussed, including indications for surgery, surveillance protocols and if and when surveillance can be discontinued.
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Affiliation(s)
| | - Elham Afghani
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
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30
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Rift CV, Scheie D, Toxværd A, Kovacevic B, Klausen P, Vilmann P, Hansen CP, Lund EL, Hasselby JP. Diagnostic accuracy of EUS-guided through-the-needle-biopsies and simultaneously obtained fine needle aspiration for cytology from pancreatic cysts: A systematic review and meta-analysis. Pathol Res Pract 2021; 220:153368. [PMID: 33652239 DOI: 10.1016/j.prp.2021.153368] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/21/2021] [Accepted: 01/25/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To address the diagnostic accuracy of endoscopic ultrasound guided through-the-needle-biopsies (TTNBs) and simultaneously obtained cytology samples from pancreatic cysts compared to the final histopathological diagnosis of the surgical specimen, and to give an overview of ancillary tests performed on TTNBs. METHODS A literature search was conducted in MEDLINE, Embase and Scopus. Studies were included in the meta-analysis, if they had data for TTNB, cytology and a surgical specimen of pancreatic cysts as reference standard. The assessment of the risk of bias and quality of the included studies was conducted using the modified QUADAS-2 tool. RESULTS Ten studies with 99 patients were included in the meta-analysis. Data regarding study design and clinicopathological features were extracted systematically. For TTNB, pooled sensitivity was 0.86 (95 % CI 0.62-0.96), specificity 0.95 (95 % CI 0.79-0.99) and area under the curve (AUC) 0.86 for the diagnosis of a mucinous cyst and pooled sensitivity was 0.78 (95 % CI 0.61-0.89), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.92 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.69 (95 % CI 0.50-0.83), specificity 0.47 (95 % CI 0.28-0.68) and AUC 0.49. For cytology performed simultaneously, pooled sensitivity was 0.46 (95 % CI 0.35-0.57), specificity 0.90 (95 % CI 0.46-0.99) and AUC 0.64 for the diagnosis of mucinous cysts, and pooled sensitivity was 0.38 (95 % CI 0.23-0.55), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.84 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.29 (95 % CI 0.21-0.39), specificity 0.45 (95 % CI 0.25-0.66) and AUC 0.30. Furthermore, immunohistochemical stains can be useful to establish the specific cyst subtype. CONCLUSIONS TTNBs have a higher sensitivity and specificity than cytology for the diagnosis of mucinous cyst and high- risk cysts of the pancreas.
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Affiliation(s)
- Charlotte Vestrup Rift
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark.
| | - David Scheie
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Anders Toxværd
- Department of Pathology, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, DK 2730, Herlev, Denmark
| | - Bojan Kovacevic
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, DK 2730, Herlev, Denmark
| | - Pia Klausen
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, DK 2730, Herlev, Denmark
| | - Peter Vilmann
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, DK 2730, Herlev, Denmark
| | - Carsten Palnæs Hansen
- Department of Surgery, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Eva Løbner Lund
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Jane Preuss Hasselby
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
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31
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Qumseya BJ. Quality assessment for systematic reviews and meta-analyses of cohort studies. Gastrointest Endosc 2021; 93:486-494.e1. [PMID: 33068610 DOI: 10.1016/j.gie.2020.10.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS There is a growing need for valid, efficient, and easy scoring scales to rate the quality of cohort studies. We aimed to develop and validate a quality assessment score to be used for cohort studies. METHODS We followed a rigorous process to establish content, face, and construct validity. Most questions were scored at 0 or 1. Inter-rater reliability and test-retest reliability were assessed using the Spearman correlation coefficient (rs) and Cohen's κ statistic. Internal consistency was measured using the Kuder-Richardson formula 20 (KR20). RESULTS The final tool consists of 9 questions with a maximum score of 10. The inter-rater reliability was high with the Spearman correlation coefficient (rs = .66). Agreement for inclusion was 90%. Test-retest reliability was high. For rater 1, rs = .91, κ = .38 for scores, and κ = 1 for inclusion. For rater 2, r = .94, 80% agreement for scores, and 100% agreement for inclusion. Internal consistency was reasonable based on 2 studies: KR20 = .21 and KR20 = .65. The novel scale rated highest in efficiency, understandably, ease of use, and ease of interpretation when compared with 3 other scales. CONCLUSIONS This novel scale has favorable performance characteristics, is efficient to conduct, and is easy to interpret and will be very helpful for physicians and researchers conducting systematic reviews and meta-analyses.
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Affiliation(s)
- Bashar J Qumseya
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA.
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Kovacevic B, Klausen P, Rift CV, Toxværd A, Grossjohann H, Karstensen JG, Brink L, Hassan H, Kalaitzakis E, Storkholm J, Hansen CP, Hasselby JP, Vilmann P. Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts. Endoscopy 2021; 53:44-52. [PMID: 32693411 DOI: 10.1055/a-1214-6043] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The limited data on the utility of endoscopic ultrasound (EUS)-guided through-the-needle biopsies (TTNBs) in patients with pancreatic cystic lesions (PCLs) originate mainly from retrospective studies. Our aim was to determine the clinical impact of TTNBs, their added diagnostic value, and the adverse event rate in a prospective setting. METHODS This was a prospective, single-center, open-label controlled study. Between February 2018 and August 2019, consecutive patients presenting with a PCL of 15 mm or more and referred for EUS were included. Primary outcome was a change in clinical management of PCLs following TTNB compared with cross-sectional imaging and cytology. Adverse events were defined according to the ASGE lexicon. RESULTS 101 patients were included. TTNBs led to a change in clinical management in 11.9 % of cases (n = 12). Of these, 10 had serous cysts and surveillance was discontinued, while one of the remaining two cases underwent surgery following diagnosis of a mucinous cystic neoplasm. The diagnostic yield of TTNBs for a specific cyst diagnosis was higher compared with FNA cytology (69.3 % vs. 20.8 %, respectively; P < 0.001). The adverse event rate was 9.9 % (n = 10; 95 % confidence interval 5.4 % - 17.3 %), with the most common event being acute pancreatitis (n = 9). Four of the observed adverse events were severe, including one fatal outcome. CONCLUSIONS TTNBs resulted in a change of clinical management in about one in every 10 patients; however, the associated adverse event risk was substantial. Further studies are warranted to elucidate in which subgroups of patients the clinical benefit outweighs the risks.
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Affiliation(s)
- Bojan Kovacevic
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Pia Klausen
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | | | - Anders Toxværd
- Department of Pathology, Herlev Hospital, Herlev, Denmark
| | - Hanne Grossjohann
- Department of Gastrointestinal Surgery, Rigshospitalet, Copenhagen, Denmark
| | - John Gásdal Karstensen
- Gastroenterology Unit, Pancreatitis Centre East, Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Brink
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Hazem Hassan
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | | | - Jan Storkholm
- Department of Gastrointestinal Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Peter Vilmann
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Balaban VD, Cazacu IM, Pinte L, Jinga M, Bhutani MS, Saftoiu A. EUS-through-the-needle microbiopsy forceps in pancreatic cystic lesions: A systematic review. Endosc Ultrasound 2021; 10:19-24. [PMID: 32611848 PMCID: PMC7980686 DOI: 10.4103/eus.eus_23_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/09/2020] [Indexed: 12/16/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are being increasingly encountered in clinical practice, and sometimes, they can represent a diagnostic challenge. Recently, a through-the-needle micro forceps biopsy (MFB) device was introduced in the endosonography practice to facilitate EUS-guided sampling of PCLs. The aim was to perform a systematic review of studies evaluating the technical aspects, safety, and efficacy of the EUS-guided MFB for PCLs. A literature search was performed in three major databases, PubMed, Embase, and Web of Science in September 2019 using the search terms: "through-the-needle," "biopsy forceps," "microforceps," "endoscopic ultrasound," and "endosonography." Case reports and case series with <10 patients were excluded from the analysis. Altogether nine studies reporting on 463 patients were included in our systematic review. The mean age of the patients was 68.3 years, with a slight female predominance (60.9%). Most of the cysts were located in the body/tail of the pancreas (61.2%), with an overall mean size of 33 mm. The technical success of EUS-guided MFB was reported in 98.5%. The tissue acquisition yield reported was 88.2%, and the diagnostic accuracy was 68.6%. Adverse events were reported in 9.7%. EUS-guided MFB is technically feasible, safe, and has a high diagnostic accuracy for PCLs.
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Affiliation(s)
- Vasile Daniel Balaban
- Internal Medicine and Gastroenterology Clinic, “Carol Davila” University of Medicine and Pharmacy, Craiova, Romania
- Department of Gastroenterology, “Dr. Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania
| | - Irina M. Cazacu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Larisa Pinte
- Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Clinic, “Carol Davila” University of Medicine and Pharmacy, Craiova, Romania
- Department of Gastroenterology, “Dr. Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Adrian Saftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
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Kovacevic B, Antonelli G, Klausen P, Hassan C, Larghi A, Vilmann P, Karstensen JG. EUS-guided biopsy versus confocal laser endomicroscopy in patients with pancreatic cystic lesions: A systematic review and meta-analysis. Endosc Ultrasound 2021; 10:270-279. [PMID: 34290168 PMCID: PMC8411554 DOI: 10.4103/eus-d-20-00172] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives: Pancreatic cystic lesions (PCLs) are frequent incidental findings on cross-sectional imaging and represent a diagnostic challenge as different kinds of PCLs harbor a dissimilar risk of malignancy. Two diagnostic tools have recently been developed and introduced: through-the-needle biopsy (TTNB) and needle-based confocal laser endomicroscopy (nCLE). The aim of this meta-analysis was to compare the diagnostic yield and performance, as well as the safety profile of the two methods. Methods: This meta-analysis was performed in accordance with the PRISMA statement. Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies with five or more patients undergoing either endoscopic ultrasound (EUS)-TTNB or EUS-nCLE for a PCL. Reviews, case reports, editorials, conference abstracts, and studies on exclusively solid pancreatic lesions were excluded. Outcomes of interest were diagnostic yield and performance, safety, and technical success. Results: Twenty studies with 1023 patients were included in the meta-analysis. Pooled diagnostic yield of EUS-nCLE was higher compared to EUS-TTNB (85% vs. 74%, P < 0.0001), while diagnostic performance was high and comparable for both methods (pooled sensitivity: 80% vs. 86% and pooled specificity: 80% vs. 83% for TTNB and nCLE, respectively, P > 0.05). Pooled estimate of total adverse event (AE) rate was 5% in the TTNB group and 3% in the nCLE group, P = 0.302. Technical success rates were high and comparable (94% and 99% for EUS-TTNB and nCLE, respectively; P = 0.07). Conclusion: EUS-TTNB and EUS-nCLE have a similar safety profile with a relatively low number of AEs. Technical success, sensitivity, and specificity are comparable; however, EUS-nCLE seems to have a slightly higher diagnostic yield.
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Affiliation(s)
- Bojan Kovacevic
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Giulio Antonelli
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Pia Klausen
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - John Gásdal Karstensen
- Gastro Unit, Pancreatitis Centre East, Hvidovre Hospital, Hvidovre; Department of Clinical Medicine, University of Copenhagen, København, Denmark
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Kovacevic B, Hansen MC, Kristensen TS, Karstensen JG, Klausen P, Storkholm J, Hansen CP, Vilmann P. Diagnostic performance of current guidelines and postoperative outcome following surgical treatment of cystic pancreatic lesions - a 10-year single center experience. Scand J Gastroenterol 2020; 55:1447-1453. [PMID: 33147090 DOI: 10.1080/00365521.2020.1841283] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Pancreatic cystic lesions (PCLs) are diagnostically challenging and there are currently several different guidelines. The aim of this study was to compare diagnostic performance of the most widely utilized International Association of Pancreatology (IAP) guidelines and the recent evidence-based European guidelines and to report on postoperative outcomes following surgical treatment of PCLs. METHODS This is a retrospective single-center study of patients undergoing surgery due to a PCL between 2010 and 2019. Primary outcome was a comparison of diagnostic performance between IAP and European guidelines, measured in area under the receiver operating characteristic curve (AUC). Other outcomes included diagnostic performance of different risk features, 30-day postoperative mortality and major morbidity, final diagnosis, and overall survival. RESULTS We identified 137 patients, three of whom did not undergo curative surgery due to metastatic disease. Overall, there was no difference in the performance of the two guidelines with AUC values ranging from 0.572-0.610 and 0.607-0.621 for IAP and European guidelines respectively. Postoperative 30-day mortality and major morbidity were 0% (95% CI 0.0-2.7%) and 37.3% (95% CI 29.1-46.1%), respectively. More than half of the resected lesions (52.6%) were low-grade dysplastic or non-neoplastic. CONCLUSIONS Overall, the IAP and the European guidelines performed equally, although European guidelines had a slightly higher mean specificity. Pancreatic surgery is associated with high major morbidity, and there is a need for new diagnostic tools and strategies in order to decrease the amount of overtreatment in patients with PCL.
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Affiliation(s)
- Bojan Kovacevic
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | | | | | - John Gásdal Karstensen
- Gastro Unit, Pancreatitis Centre East, Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Pia Klausen
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Jan Storkholm
- Department of Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Tacelli M, Celsa C, Magro B, Barchiesi M, Barresi L, Capurso G, Arcidiacono PG, Cammà C, Crinò SF. Diagnostic performance of endoscopic ultrasound through-the-needle microforceps biopsy of pancreatic cystic lesions: Systematic review with meta-analysis. Dig Endosc 2020; 32:1018-1030. [PMID: 31912580 DOI: 10.1111/den.13626] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/24/2019] [Accepted: 01/06/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Endoscopic ultrasound through-the-needle biopsy (EUS-TTNB) is a useful tool for differential diagnosis among pancreatic cystic lesions (PCLs). Cystic fluid cytology (CFC) is recommended by guidelines, but its diagnostic accuracy is about 50%. The aim of this meta-analysis is to assess the clinical impact of EUS-TTNB in terms of technical success (TS), histological accuracy (HA) and diagnostic yield (DY). METHODS Original studies in English language on EUS-TTNB were searched in MEDLINE and EMBASE until October 2019. Diagnostic accuracy of EUS-TTNB for identification of mucinous PCLs was calculated using individual diagnostic data of patients who underwent CFC and surgery. RESULTS Nine studies, including 454 patients who underwent EUS-TTNB, met the inclusion criteria for the meta-analysis. TS and HA of EUS-TTNB were, respectively, 98.5% (95% Confidence Interval [CI] 97.3%-99.6%) and 86.7% (95%CI 80.1-93.4). DY was 69.5% (95%CI 59.2-79.7) for EUS-TTNB and 28.7% (95%CI 15.7-41.6) for CFC. Heterogeneity persisted significantly high in most of subgroup analyses. In the multivariate meta-regression, cyst size was independently associated with higher DY. Sensitivity and specificity for mucinous PCLs were 88.6 and 94.7% for EUS-TTNB, and 40 and 100% for CFC. Adverse events rate was 8.6% (95%CI 4.0-13.1). CONCLUSIONS This meta-analysis shows that EUS-TTNB is a feasible technique that allows a high rate of adequate specimens to be obtained for histology; in about two-thirds of patients a specific histotype diagnosis could be assessed. The number of adverse events is slightly higher respect to standard EUS-FNA, but complications are very rarely severe.
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Affiliation(s)
- Matteo Tacelli
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Bianca Magro
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Marco Barchiesi
- Department of Internal Medicine, ASST FBF-Sacco, Milan, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Gabriele Capurso
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Calogero Cammà
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
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McCarty T, Rustagi T. Endoscopic ultrasound-guided through-the-needle microforceps biopsy improves diagnostic yield for pancreatic cystic lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1280-E1290. [PMID: 33015329 PMCID: PMC7508652 DOI: 10.1055/a-1194-4085] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/09/2020] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Given variable diagnostic yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for pancreatic cystic lesions (PCLs), a through-the-needle (TTN) microforceps biopsy device passed through a 19-gauge FNA needle has been devised to improve tissue sampling. This was a systematic review and meta-analysis to evaluate the feasibility, diagnostic yield, and safety of EUS-guided TTN microforceps biopsy for diagnosis of PCLs. Methods Individualized searches were developed in accordance with PRISMA and MOOSE guidelines. This was a cumulative meta-analysis performed by calculating pooled proportions with rates estimated using random effects models. Measured outcomes included pooled technical success, diagnostic yield, accuracy, and procedure-associated adverse events (AEs) as well as comparison to conventional FNA. Results Eleven studies (n = 518 patients; mean age 64.13 ± 5.83 years; 58.19 % female) were included. Mean PCL size was 33.39 ± 3.72 mm with the pancreatic head/uncinate (35.50 %) being the most common location. A mean of 2.47 ± 0.92 forceps passes were performed with a mean of 2.79 ± 0.81 microbiopsies obtained per lesion. Pooled technical success was 97.12 % (95 % CI, 93.73-98.71; I 2 = 34.49) with a diagnostic yield of 79.60 % (95 % CI, 72.62-85.16; I 2 = 56.00), and accuracy of 82.76 % [(95 % CI, 77.80-86.80; I 2 = 0.00). The pooled serious adverse event rate was 1.08 % (95 % CI, 0.43-2.69; I 2 = 0.00). Compared to conventional FNA, TTN microforceps biopsy resulted in significant improvement in diagnostic yield [OR 4.79 (95 % CI: 1.52-15.06; P = 0.007)] and diagnostic accuracy [OR 8.69 (95 % CI, 1.12-67.12; P = 0.038)], respectively. Conclusions EUS-guided TTN microforceps biopsy appears to be safe and effective for diagnosis of PCLs with improvement in diagnostic yield and accuracy when compared to FNA alone.
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Affiliation(s)
- Thomas McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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Luthra AK, Krishna SG. Through-the-needle forceps biopsy for pancreatic cystic lesions: multiple meta-analyses but limited prospective data. Endosc Int Open 2020; 8:E1134-E1136. [PMID: 32898200 PMCID: PMC7458749 DOI: 10.1055/a-1198-4785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Anjuli K. Luthra
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
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Guzmán-Calderón E, Martinez-Moreno B, Casellas JA, de Madaria E, Aparicio JR. Endoscopic ultrasound-guided, through-the-needle forceps biopsy for diagnosis of pancreatic cystic lesions: a systematic review. Endosc Int Open 2020; 8:E1123-E1133. [PMID: 32904862 PMCID: PMC7458739 DOI: 10.1055/a-1149-1647] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Pancreatic cystic lesions (PCL), are a heterogeneous group of cystic lesions. Some patients with PCLs have a significantly higher overall risk of pancreatic cancer and the only test that can differentiate benign and malignnat PCL is fine-needle aspiration plus cytological analysis, but its sensitivity is very low. Through-the-needle direct intracystic biopsy is a technique that allows acquisition of targeted tissue from PCLs and it may improve the diagnostic yield for them. The aim of this study was to review articles about endoscopic ultrasound (EUS)-guided through-the-needle intracystic biopsy for targeted tissue acquisition and diagnosis of PCLs. Methods A systematic review of computerized bibliographic databases was carried out for studies of EUS-guided through-the-needle forceps biopsy (EUS-TTNB) of PCLs. The percentages and their 95 % confidence intervals (CIs) were calculated for all the considered endpoints (technical success, adequate specimens, adverse events (AEs), and overall diagnosis). Results Overall, eight studies with a total of 423 patients were identified. Pooled technical success was 95.6 % of the cases (399/423), (95 % CI, 93.2 %-97.3 %). Technical failure rate was 5.1 % (24 cases). Frequency of adequate specimens was 82.2 %, (95 % CI, 78.5 %-85.8 %). Adverse events were reported in seven of the eight studies. Forty-two total adverse events were reported (10.1 %) (95 % CI, 7.3 %-13.6 %). The overall ability to provide a specific diagnosis with EUS-TTNB for diagnosis of pancreatic cystic lesions was 74.6 % (313 cases), (95 % CI: 70.2 %-78.7 %). The most frequent diagnoses found with EUS-TTNB were mucinous cystic neoplasms (MCN) in 96 cases (30.6 %), IPMN in 80 cases (25.5 %), and serous cystoadenoma neoplasm (SCN) in 48 cases (15.3 %). Conclusions Through-the-needle forceps biopsy appears to be effective and safe, with few AE for diagnosis of pancreatic cystic lesions. This technique had acceptable rates of technical and clinical success and an excellent safety profile. TTNB is associated with a high tissue acquisition yield and provided additional diagnostic yield for mucinous pancreatic lesions. TTNB may be a useful adjunctive tool for EUS-guided assessment of PCLs.
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Affiliation(s)
- Edson Guzmán-Calderón
- Gastroenterology Unit of Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru,Universidad Peruana de Ciencias Aplicadas (UPC), Alicante, Spain
| | | | - Juan A. Casellas
- Gastroenterology Unit oh Hospital General Universitario de Alicante, Alicante, Spain
| | - Enrique de Madaria
- Gastroenterology Unit oh Hospital General Universitario de Alicante, Alicante, Spain
| | - José Ramón Aparicio
- Gastroenterology Unit oh Hospital General Universitario de Alicante, Alicante, Spain
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40
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Rift CV, Kovacevic B, Toxværd A, Klausen P, Hansen CP, Vilmann P, Hasselby JP. EUS-guided through-the-needle biopsy sampling of pancreatic cystic lesions: a pathologist's guide for the endoscopist. Gastrointest Endosc 2020; 92:252-258. [PMID: 32334016 DOI: 10.1016/j.gie.2020.04.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/15/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Charlotte Vestrup Rift
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bojan Kovacevic
- Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Anders Toxværd
- Department of Pathology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Pia Klausen
- Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Carsten Palnæs Hansen
- Department of Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Vilmann
- Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Jane Preuss Hasselby
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Current Status of Needles in the Optimization of Endoscopic Ultrasound-Guided Procedures. Diagnostics (Basel) 2020; 10:diagnostics10070463. [PMID: 32650628 PMCID: PMC7400280 DOI: 10.3390/diagnostics10070463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/05/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
Endoscopic ultrasound (EUS) is among the most important tools for the evaluation of gastrointestinal tumors and affected areas around the gastrointestinal tract. It enables the acquisition of material from abnormal lesions via the gastrointestinal wall for tissue confirmation via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA has played a vital role in oncological care and has become the standard method for tissue sampling. The choice of needle type is an important factor determining tissue acquisition and has been evaluated by many researchers. New needles are introduced into the market almost every year, and opinions vary regarding proper needle selection. While there are diverse opinions but no definitive recommendations about the use of one particular device, fine-needle biopsy needles may provide detailed information on a tissue’s architecture based on greater sample yields. This permits additional analyses, including genetic sequencing and phenotyping, thereby enabling the provision of more personalized treatment plans. Furthermore, other EUS-guided procedures have been developed, including interventional EUS and through-the-needle devices. Given the continued attempts to improve the diagnostic ability and therapeutic techniques, we review in detail the available types of puncture needles to provide guidance on the selection of the appropriate needle types.
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Cheesman AR, DiMaio CJ. Response. Gastrointest Endosc 2020; 92:223. [PMID: 32586545 DOI: 10.1016/j.gie.2020.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/05/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Antonio R Cheesman
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher J DiMaio
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Larghi A, Crinò SF, Napoleon B. Pancreatic cystic lesions: time to move to 19-gauge needle with EUS-guided microforceps biopsy or needle-based confocal laser endomicroscopy. Gastrointest Endosc 2020; 92:222. [PMID: 32586544 DOI: 10.1016/j.gie.2020.01.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/20/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy; Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Stefano Francesco Crinò
- Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Bertrand Napoleon
- Department of Gastroenterology, Jean Mermoz Private Hospital, Lyon, France
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Facciorusso A, Del Prete V, Antonino M, Buccino VR, Wani S. Diagnostic yield of EUS-guided through-the-needle biopsy in pancreatic cysts: a meta-analysis. Gastrointest Endosc 2020; 92:1-8.e3. [PMID: 32014422 DOI: 10.1016/j.gie.2020.01.038] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS There is currently limited evidence supporting the use of EUS-guided through-the-needle biopsy for sampling pancreatic cystic lesions. The aim of this meta-analysis was to provide a pooled estimate of the diagnostic performance of through-the-needle biopsy for sampling of pancreatic cysts. METHODS A bibliographic search on the main databases was performed in September 2019. Pooled effects were calculated using a random-effects model by means of the DerSimonian and Laird test. The primary outcome was sample adequacy. Additional endpoints were diagnostic accuracy, optimal histologic core procurement, mean number of needle passes, pooled specificity, and sensitivity. Adverse event rates were also analyzed. RESULTS Eleven studies enrolling 490 patients were included. Eight articles compared through-the-needle biopsy with cytology/cystic fluid analysis. Most patients were female, and the body/tail was the most frequent location of cystic lesions. Sample adequacy with through-the-needle biopsy was 85.3% (78.2%-92.5%), and subanalysis performed according to cyst morphology, size, and location confirmed the result. Through-the-needle biopsy clearly outperformed FNA both in terms of sample adequacy (odds ratio, 4.83; 95% confidence interval, 1.63-14.31; P =.004) and diagnostic accuracy (odds ratio, 3.44; 95% confidence interval, 1.32-8.96; P =.01). The pooled diagnostic accuracy rate, sensitivity, and specificity of through-the-needle biopsy were 78.8%, 82.2%, and 96.8%, respectively. A mean of 3.121 (2.98-3.25) passes through the cyst was needed to obtain adequate histologic samples. The incidence rates of mild bleeding and pancreatitis were 4% and 2%, respectively. CONCLUSION Our meta-analysis speaks in favor of the use of through-the-needle biopsy as a safe and effective tool in EUS-guided tissue acquisition of pancreatic cysts.
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Affiliation(s)
| | | | | | | | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Eiterman A, Lahooti A, Krishna SG. Endosonographic diagnosis of advanced neoplasia in intraductal papillary mucinous neoplasms. World J Gastroenterol 2020; 26:3201-3212. [PMID: 32684735 PMCID: PMC7336327 DOI: 10.3748/wjg.v26.i23.3201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/25/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer has a high mortality rate with minimal proven interventions. Intraductal Papillary Mucinous Neoplasms (IPMNs) are known precursor lesions for pancreatic cancer. Identification of pancreatic cysts has improved from advances in abdominal imaging. Despite multiple revisions of the international consensus recommendations and various guidelines by other major societies, successful risk stratification of the malignant potential of mucinous pancreatic cysts remains challenging. Specifically, detection and accurate classification of advanced neoplasia (high-grade dysplasia and/or adenocarcinoma) in IPMNs is suboptimal with current diagnostic strategies. Development of interventional techniques utilizing endoscopic ultrasound include - through-the-needle microforceps biopsy, next-generation or whole genome molecular analysis of cyst fluid, and needle-based confocal laser endomicroscopy. These techniques suffer from a series of limitations in technical success, diagnostic yield, and clinical feasibility, but a combination approach may offer a solution that optimizes their cyst evaluation and risk stratification. Assessment and comparison of these techniques is restricted by lack of adequate surgical specimens for testing of diagnostic accuracy, resulting in a possible sample bias. Additional large-scale multicenter studies are needed to accumulate evidence for the utility and feasibility of their translation into clinical practice. Great strides have been made in pancreatic cyst evaluation, but further research is required to improve diagnostic accuracy and clinical management of IPMNs.
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Affiliation(s)
- Andrew Eiterman
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Ali Lahooti
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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Westerveld DR, Ponniah SA, Draganov PV, Yang D. Diagnostic yield of EUS-guided through-the-needle microforceps biopsy versus EUS-FNA of pancreatic cystic lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E656-E667. [PMID: 32355885 PMCID: PMC7164999 DOI: 10.1055/a-1119-6543] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/15/2020] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Accurate diagnosis and risk stratification of pancreatic cysts (PCs) is challenging. The aim of this study was to perform a systematic review and meta-analysis to assess the feasibility, safety, and diagnostic yield of endoscopic ultrasound-guided through-the-needle biopsy (TTNB) versus fine-needle aspiration (FNA) in PCs. Methods Comprehensive search of databases (PubMed, EMBASE, Cochrane, Web of Science) for relevant studies on TTNB of PCs (from inception to June 2019). The primary outcome was to compare the pooled diagnostic yield and concordance rate with surgical pathology of TTNB histology and FNA cytology of PCs. The secondary outcome was to estimate the safety profile of TTNB. Results: Eight studies (426 patients) were included. The diagnostic yield was significantly higher with TTNB over FNA for a specific cyst type (OR: 9.4; 95 % CI: [5.7-15.4]; I 2 = 48) or a mucinous cyst (MC) (OR: 3.9; 95 % CI: [2.0-7.4], I 2 = 72 %). The concordance rate with surgical pathology was significantly higher with TTNB over FNA for a specific cyst type (OR: 13.5; 95 % CI: [3.5-52.3]; I 2 = 48), for a MC (OR: 8.9; 95 % [CI: 1.9-40.8]; I 2 = 29), and for MC histologic severity (OR: 10.4; 95 % CI: [2.9-36.9]; I 2 = 0). The pooled sensitivity and specificity of TTNB for MCs were 90.1 % (95 % CI: [78.4-97.6]; I 2 = 36.5 %) and 94 % (95 % CI: [81.5-99.7]; I 2 = 0), respectively. The pooled adverse event rate was 7.0 % (95 % CI: [2.3-14.1]; I 2 = 82.9). Conclusions TTNB is safe, has a high sensitivity and specificity for MCs and may be superior to FNA cytology in risk-stratifying MCs and providing a specific cyst diagnosis.
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Affiliation(s)
- Donevan R. Westerveld
- Department of Internal Medicine, University of Florida, Gainesville, Florida, United States
| | - Sandeep A. Ponniah
- Department of Internal Medicine, University of Florida, Gainesville, Florida, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
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47
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Krishna SG, Hart PA, Malli A, Kruger AJ, McCarthy ST, El-Dika S, Walker JP, Dillhoff ME, Manilchuk A, Schmidt CR, Pawlik TM, Porter K, Arnold CA, Cruz-Monserrate Z, Conwell DL. Endoscopic Ultrasound-Guided Confocal Laser Endomicroscopy Increases Accuracy of Differentiation of Pancreatic Cystic Lesions. Clin Gastroenterol Hepatol 2020; 18:432-440.e6. [PMID: 31220640 DOI: 10.1016/j.cgh.2019.06.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/18/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Imaging patterns from endoscopic ultrasound (EUS)-guided needle-based confocal laser endomicroscopy (nCLE) have been associated with specific pancreatic cystic lesions (PCLs). We compared the accuracy of EUS with nCLE in differentiating mucinous from nonmucinous PCLs with that of measurement of carcinoembryonic antigen (CEA) and cytology analysis. METHODS We performed a prospective study of 144 consecutive patients with a suspected PCL (≥20 mm) who underwent EUS with fine-needle aspiration of pancreatic cysts from June 2015 through December 2018 at a single center; 65 patients underwent surgical resection. Surgical samples were analyzed by histology (reference standard). During EUS, the needle with the miniprobe was placed in the cyst, which was analyzed by nCLE. Fluid was aspirated and analyzed for level of CEA and by cytology. We compared the accuracy of nCLE in differentiating mucinous from nonmucinous lesions with that of measurement of CEA and cytology analysis. RESULTS The mean size of dominant cysts was 36.4 ± 15.7 mm and the mean duration of nCLE imaging was 7.3 ± 2.8 min. Among the 65 subjects with surgically resected cysts analyzed histologically, 86.1% had at least 1 worrisome feature based on the 2012 Fukuoka criteria. Measurement of CEA and cytology analysis identified mucinous PCLs with 74% sensitivity, 61% specificity, and 71% accuracy. EUS with nCLE identified mucinous PCLs with 98% sensitivity, 94% specificity, and 97% accuracy. nCLE was more accurate in classifying mucinous vs nonmucinous cysts than the standard method (P < .001). The overall incidence of postprocedure acute pancreatitis was 3.5% (5 of 144); all episodes were mild, based on the revised Atlanta criteria. CONCLUSIONS In a prospective study, we found that analysis of cysts by nCLE identified mucinous cysts with greater accuracy than measurement of CEA and cytology analysis. EUS with nCLE can be used to differentiate mucinous from nonmucinous PCLs. ClincialTrials.gov no: NCT02516488.
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Affiliation(s)
- Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio.
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Ahmad Malli
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Andrew J Kruger
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Sean T McCarthy
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Samer El-Dika
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Jon P Walker
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Mary E Dillhoff
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Andrei Manilchuk
- Department of General Surgery, The Ohio State University, Columbus, Ohio
| | - Carl R Schmidt
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Christina A Arnold
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
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48
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Affiliation(s)
- Chieh Sian Koo
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Khek Yu Ho
- Division of Gastroenterology and Hepatology, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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49
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Kovacevic B, Kalaitzakis E, Klausen P, Brink L, Hassan H, Karstensen JG, Vilmann P. EUS-guided through-the-needle microbiopsy of pancreatic cysts: Technical aspects (with video). Endosc Ultrasound 2020; 9:220-224. [PMID: 32611847 PMCID: PMC7529000 DOI: 10.4103/eus.eus_12_20] [Citation(s) in RCA: 6] [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] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cystic lesions are frequently encountered and diagnostically challenging as some of the cysts may have malignant potential (mucinous) while others are completely benign (serous). EUS-guided through-the-needle biopsy (EUS-TTNB) of the cyst wall has recently been introduced as an alternative to cyst fluid cytology. Several studies have shown that microbiopsies outperform cytology in terms of distinction between mucinous and nonmucinous lesions, but also in determining the specific cyst diagnosis. However, little is known about the technical aspects of tissue sampling with TTNB. Herein, we summarize our experience with the procedure in a tertiary referral center and discuss indications, technical aspects, and safety of the procedure. Most adverse events (AEs) associated with the procedure are mild, but there is emerging evidence that the rate of postprocedural pancreatitis is higher compared to standard fine-needle aspiration. The added diagnostic yield should therefore be placed in perspective with an increased risk of AEs. Prospective studies are warranted to fully identify which patient groups could benefit from EUS-TTNB.
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Affiliation(s)
- Bojan Kovacevic
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - Evangelos Kalaitzakis
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - Pia Klausen
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - Lene Brink
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - Hazem Hassan
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - John G Karstensen
- Gastroenterology Unit, Pancreatitis Centre East, Hvidovre Hospital, Department of Clinical Medicine, Copenhagen University, Hvidovre, Denmark
| | - Peter Vilmann
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
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50
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Iwashita T, Uemura S, Mita N, Iwasa Y, Ichikawa H, Senju A, Yasuda I, Shimizu M. Utility of endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration for the diagnosis and management of pancreatic cystic lesions: Differences between the guidelines. Dig Endosc 2020; 32:251-262. [PMID: 31709639 DOI: 10.1111/den.13579] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/29/2019] [Accepted: 11/07/2019] [Indexed: 12/18/2022]
Abstract
Recent advances and frequent use of cross-sectional imaging studies have increased opportunities for incidental diagnoses of pancreatic cystic lesions (PCL). In the management of PCL, distinguishing between mucinous versus non-mucinous and malignant versus benign cysts is important to diagnose pancreatic cancer in its early stage. For this reason, there have been several guidelines to manage PCL. Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (FNA) play important roles in the guidelines, although there are some differences in their roles. In this review, we aimed to evaluate the current status of EUS and EUS-FNA in the management of PCL and the status of these procedures in the guidelines.
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Affiliation(s)
- Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Naoki Mita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Yuhei Iwasa
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Hironao Ichikawa
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Akihiko Senju
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama Hospital, Toyama, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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