Evaluation Of Pancreatic Cystic Lesions Research Articles

Factors Determining Diagnostic Yield of Endoscopic Ultrasound Guided Fine-Needle Aspiration for Pancreatic Cystic Lesions: A Multicentre Asian Study

The purpose of this study was to determine (1) the diagnostic yield for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with pancreatic cystic lesions, (2) additional value of EUS-FNA over EUS alone in the diagnosis of pancreatic cysts, and (3) diagnostic sensitivity and specificity of EUS and EUS-FNA in the subset of patients where histopathology of surgical specimens were available. All patients who underwent EUS examination for the evaluation of pancreatic cystic lesions in six Asian centres were included in the study. Of 298 patients with pancreatic cysts who underwent EUS, 132 (44.3 %) underwent FNA. In the entire cohort, pseudocysts and intraductal papillary mucinous neoplasm (IPMN) were the predominant cystic lesions. The cytologic yield of EUS-FNA was 47 %. On univariate analysis, factors associated with higher cytologic yield included vascular involvement on EUS, presence of solid cystic component, and increased number of needle passes during EUS-FNA. On multivariate analysis, presence of solid cystic components and increased number of needle passes during EUS-FNA were associated with higher diagnostic yield of EUS-FNA. For pancreatic cysts with a solid component, the diagnostic yield of EUS-FNA increased significantly from 44 % with one pass to 78 % with more than one pass (p = 0.016). In the absence of a solid component, the diagnostic yield was 29 % with one pass and was not significantly different from the diagnostic yield of 50 % with more than one pass, p = 0.081. The cytologic yield of EUS-FNA was 47 %. When a solid component was present in the cyst, doing more than one pass during EUS-FNA increased its diagnostic yield.

Imaging of cystic pancreatic lesions

Cystic lesions of the pancreas are encountered on abdominal imaging studies on a routine basis. Cystic pancreatic lesions represent a variety of both benign and malignant disease entities that present with a wide spectrum of clinical symptoms. Cystic pancreatic lesions are being detected at an ever increasing rate due to increasingly sophisticated imaging techniques. Various imaging modalities can be employed in the evaluation of cystic pancreatic lesions. While CT serves as the mainstay of routine pancreatic imaging, MR is becoming increasingly utilized in the detection and characterization of suspected cystic pancreatic lesions. Accurate characterization of such lesions is imperative in order to select the most appropriate clinical management.

VHM12 Confocal Laser Endomicroscopy (CLE): Evaluation of Pancreatic Cystic Lesions In Vivo and Ex Vivo

In this video we compare in vivo and ex vivo images of pancreatic cystic lesions as seen with confocal laser endomicroscopy (CLE). Three patient cases are presented, two whom underwent in vivo imaging of intra ductal papillary mucinous neoplasms (IPMN), and one that underwent pancreatectomy and examination of the resected IPMN lesion with ex vivo CLE imaging. For the in vivo imaging, endoscopic ultrasound with fine aspiration is first used to puncture the lining of the pancreatic cyst. The stylet is then withdrawn and a needle probe based confocal probe introduced through the needle. For the ex vivo imaging, confocal laser endomicroscopy was applied using an ultra high definition gastroflex probe (Cellvizio, Mauna Kea Tech) CLE is an imaging modality that, when used in adjunct to endoscopic ultrasound, may further help to distinguish the benign, pre malignant and malignant cystic lesions of the pancreas by visualizing the cellular lining of the cysts in vivo. The may prevent unnecessary surgery in patients with benign cysts and guide early and effective surgical removal of high risk neoplastic lesions. The in vivo and ex vivo images as viewed with confocal endomicroscopy support the hypothesis that the dark circumferential structures may represent the dysplastic papillae of IPMN.

T1431: The Yield of the Cell Block Obtained by Endoscopic Ultrasound-Guided Fine Needle Aspiration for the Diagnosis of Pancreatic Cystic Lesion

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a well established tool for the evaluation of pancreatic cystic lesions (PCLs), and pancreatic mass. The sample adequacy of EUS-FNA for the PCLs without an onsite cytopathologist was reported as about 70%. The aim of this study was to compare EUS-FNA results using the cell block technique with those using cytology without an onsite cytopathologist with regard to diagnostic and sample quality in patients with PCLs.

Pancreatic Cystic Lesions: When to Watch, When to Operate, and When to Ignore

Pancreatic cystic lesions are being increasingly identified with the widespread use of state-of-the-art imaging. These lesions are categorized into a broad range of neoplastic cysts and inflammatory pseudocysts. Identification of a pancreatic cyst requires the clinician to focus on the main clinical challenge of the benign or malignant nature of the cyst. Neoplastic cysts range the spectrum from benign, to premalignant, to frank malignancy. The management of these lesions is difficult, and the decision to resect or observe a lesion is hampered by limitations in current imaging and tissue sampling techniques that prevent the accurate characterization of all lesions. This article reviews current guidelines for the evaluation of pancreatic cystic lesions, underscores the challenges posed by these lesions, and discusses current and future studies that will aid in patient management.

Tubercular Pancreatic Abscess Presenting as Fever and Cystic Pancreatic Lesion with Endoscopic Management

Isolated pancreatic tuberculosis is a rare presentation of tubercular infection. There are few reported cases of pancreatic tuberculosis diagnosed by endoscopic ultrasound with fine-needle aspiration (EUS FNA) [1–5], though EUS is often used in the evaluation of pancreatic cystic lesions [6]. We present a case of a tubercular pancreatic abscess presenting as a cystic lesion in a patient with undiagnosed immunodeficiency. The abscess was aspirated by EUS FNA and treated with endoscopic drainage and antimycobacterial medications.

Does Size Matter? Agreement in Pancreatic Cyst Size Between EUS, CT, and MR

METHODS. A retrospective chart review was performed on all patients presenting to a tertiary referral center from 2000-08 for EUS evaluation of pancreatic cystic lesions. The largest one-dimensional cyst diameters from CT, MRI/MRCP, and EUS reports were collated. Measurements from surgical pathology, when available, were included for comparison. Eligible patients had two or more size estimates from studies occurring within 90 days of each other. Differences in cyst diameter were calculated between available imaging studies and between imaging and surgical path.

Cytologic evaluation of cystic pancreatic lesions (CPL): comparison of EchoBrush versus standard EUS-FNA techniques in a blinded prospective study

Background: Cystic pancreatic lesions (CPL) are associated with a potential for malignant transformation. EUS-guided FNA is a widely used method for evaluating these lesions, but has limited sensitivity. Recently, in a non blinded pilot study we have shown that cytology samples obtained by through-the-needle cytologic brush at the time of EUS (EchoBrush, Cook Endoscopy, Winston-Salem, NC) has superior diagnostic yield compared to conventional FNA. (Al-Haddad et al, 2007)

Diagnostic Yield and Safety of Cyst Wall Puncture During EUS-Guided Fine Needle Aspiration of Pancreatic Cystic Lesions

Introduction: Endoscopic ultrasound guided fine needle aspiration is the modality of choice for preoperative diagnosis of pancreatic cystic lesions. Cyst fluid CEA and amylase levels are used to discriminate benign from neoplastic cysts. Because the diagnostic yield from cyst fluid analysis is often inadequate, modalities to sample epithelium from the cyst wall are being investigated. Needle puncture of the cyst wall for cytology is not widely practiced due to the potential risks. Aims: To determine the diagnostic yield and safety of EUS-guided cyst wall puncture for the evaluation of pancreatic cystic lesions.

Cytologic Evaluation of Cystic Pancreatic Lesions (CPL): Comparison of EchoBrush Vs. Standard EUS-FNA Techniques in a Blinded Prospective Study

Background: Cystic pancreatic lesions (CPL) are associated with a potential for malignant transformation. EUS-guided FNA is a widely used method for evaluating these lesions, but has limited sensitivity. Recently, in a non blinded pilot study we have shown that cytology samples obtained by through-the-needle cytologic brush at the time of EUS (EchoBrush, Cook Endoscopy, Winston-Salem, NC) has superior diagnostic yield compared to conventional FNA. (Al-Haddad et al, 2007) Objectives: To evaluate the cytologic yield of EchoBrush versus EUS-FNA in a blinded prospective study. Methods: In this ongoing study 22 consecutive patients (age 43-94yrs, mean 69) with CPL were included. All cysts were sampled by standard EUS-FNA (50% of cyst volume) followed by EchoBrush cytology, then by aspiration of the remaining fluid. Fluid samples were separately submitted (EUS-FNA and EchoBrush) and were read by a study pathologist who was unaware of the sampling technique and findings in the corresponding paired sample. Cytologic specimens were evaluated for the presence of mucinous epithelium/intracellular mucin (ICM) and grade of dysplasia. The two methods were compared for presence of mucinous epithelium and grade of dysplasia. Results: ICM was detected in total 17/22 patients. ICM was detected in 16/22 patients using EchoBrush and 6/22 patients using EUS-FNA. (Table 1) For 6 patients ICM was detected in the EchoBrush sample alone, and for 1 patient ICM was detected in the EUS-FNA sample alone. For 17 patients with mucinous epithelium, high grade dysplasia was detected in 2 cases by EchoBrush alone. Conclusion: This study suggests that a higher frequency of cytologically diagnostic specimens are obtained using EchoBrush vs. EUS-FNA. Table 1Yield of EchoBrush and EUS-FNA for intracellular mucin in CPL EchoBrush (N = 22) Intracellular Mucin + Intracellular Mucin − EUS/FNA (N = 22) Intracellular Mucin + 5 1 Intracellular Mucin − 11 5 Open table in a new tab

Diagnostic evaluation of cystic pancreatic lesions

Background. Cystic pancreatic neoplasms (CPNs) present a unique challenge in preoperative diagnosis. We investigated the accuracy of diagnostic methods for CPN. Material and methods. This retrospective cases series includes 70 patients who underwent surgery at a university hospital for presumed CPNs between 1997 and 2003, and for whom a definitive diagnosis was established. Variables examined included symptoms, preoperative work-up (including endoscopic retrograde cholangiopancreatography (ERCP) in 22 cases and endoscopic ultrasound (EUS) in 12), and operative and pathological findings. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans (n=50 patients; CT=48; MRI=13) were independently reviewed by two blinded GI radiologists. Results. The final histopathologic diagnoses were mucinous cystic neoplasm (n=13), mucinous cystadenocarcinoma (10), serous cystadenoma (11), IPMN (14), simple cyst (3), cystic neuroendocrine tumor (5), pseudocyst (4), and other (10). Overall, 25 of 70 were malignant (37%), 21 premalignant (30%), and 24 benign (34%). The attending surgeon's preoperative diagnosis was correct in 31% of cases, incorrect in 29%, non-specific “cystic tumor” in 27%, and “pseuodcyst vs. neoplasm” in 11%. Eight had been previously managed as pseudocysts, and 3 pseudocysts were excised as presumed CPN. In review of the CT and MRI, a multivariate analysis of the morphologic features did not identify predictors of specific pathologic diagnoses. Both radiologists were accurate with their preferred (no. 1) diagnosis in <50% of cases. MRI demonstrated no additional utility beyond CT. Conclusions. The diagnosis of CPN remains challenging. Cross-sectional imaging methods do not reliably give an accurate preoperative diagnosis. Surgeons should continue to err on the side of resection.

Gastric Duplication Cysts Expressing Carcinoembryonic Antigen Mimicking Cystic Pancreatic Neoplasms in Two Adults

Gastric duplication cysts in adults are very rare and usually found incidentally during evaluation for an unrelated ailment. When they are found in close proximity to the pancreas, they can be confused with cystic neoplasms of the pancreas, which are typically also asymptomatic yet more common. As part of the evaluation of cystic pancreatic lesions, cyst fluid analysis for carcinoembryonic antigen (CEA) is undertaken to determine malignant potential. Herein we present two cases of cystic lesions thought to arise from the pancreas found to have elevated preoperative cystic CEA levels. At operation, they were found to be gastric duplication cysts and were resected. We report the histologic findings and review of the current literature.

Endoscopic Ultrasound with Fine Needle Aspiration (EUS-FNA) Is Valuable in the Diagnosis of Side-Branch Intraductal Papillary Mucinous Neoplasia (SB-IPMN) of the Pancreas

Background: Pancreatic SB-IPMN often are discovered incidentally by imaging and mistaken for pseudocysts or other cystic neoplasia. Recent experience suggests that SB-IPMN may cause abdominal pain or pancreatitis and can lead to adenocarcinoma. Thus accurate diagnosis of this condition is important. Currently, no large series exists on the use of EUS-FNA in diagnosing SB-IPMN. Aims: Our goal was to assess the usefulness of EUS-FNA in the evaluation of SB-IPMN in a large university practice. Methods: Using an EUS database, patients referred for evaluation of pancreatic cystic lesions between October 2002 and October 2006 were identified. Using EUS-FNA features, CT or MRI and pathology, patients were assigned as probable or definite SB-IPMN. “Definite” diagnoses had surgical resections. EUS tapes were reviewed to determine the presence of main pancreatic duct communication (MPDC) if not mentioned in the EUS report. Patients with “probable” diagnoses had strong evidence suggesting the diagnosis. Patients with combined main and SB-IPMN were excluded. Results: 31 patients (15 male, mean age 68.5) with definite or probable SB-IPMN were identified. The mean lesion size was 20.9 mm (range 5-47), and 11 had multiple lesions. 28 cases (90%) were identified by EUS-FNA features alone while 3 (10%) were identified by EUS-FNA features and dedicated radiologic imaging. In 21 cases (68%) both MPDC and viscous fluid consistent with mucin were seen. In 13 of these 21 cases, cytology and CEA (median 316 ng/mL) suggested SB-IPMN. In 8 cases (26%) MPDC alone was seen, but elevated cyst CEA (median 429 ng/mL) or mucin on cytology were seen in 6, suggesting SB-IPMN. In 2 cases (6.5%) viscous fluid alone was seen, but cyst amylase and CEA were elevated (698 IU/L, 30,640 ng/mL) in 1 suggesting MPDC and thus SB-IPMN. Dedicated CT or MRI suggested SB-IPMN in only 18 patients (58%) and was significantly less accurate than EUS-FNA findings (p = 0.0078). Cytology suggested a mucinous neoplasm in 17 patients (55%). All 13 patients with surgical resections had MPDC seen and viscous fluid aspirated on EUS-FNA. Of these 13 cases, cytology and radiologic imaging were suggestive of SB-IPMN in 6 and 8 cases, respectively. Conclusions: In our experience, key EUS-FNA features (MPDC and viscous fluid) were highly valuable in diagnosing SB-IPMN. Elevated cyst CEA and cytology further enhanced the utility of EUS-FNA. Elevated cyst amylase implies MPDC and helps differentiate SB-IPMN from other mucinous cystic neoplasia when MPDC is not visualized. Radiologic imaging may aid in the diagnosis of some SB-IPMN, but EUS-FNA was superior in this study and should be the diagnostic modality of choice.

K‐Ras and microsatellite marker analysis of fine‐needle aspirates from intraductal papillary mucinous neoplasms of the pancreas

Preoperative diagnosis of pancreatic cystic lesions is difficult despite the combination of cytomorphology, radiographic imaging characteristics, and fluid tumor markers such as carcinoembryonic antigen. Intraductal papillary mucinous neoplasms (IPMNs) represent a subset of preinvasive pancreatic cystic neoplasms and are associated with accumulated genetic mutations, especially K-ras and tumor suppressor genes such as p53. Application of molecular techniques to cyst fluid obtained by endoscopic ultrasound guided fine-needle aspiration (EUSFNA) may contribute to preoperative assessment. Sixteen patients with pancreatic cystic lesions had cyst fluid obtained by preoperative pancreatic EUSFNA or intraoperative aspiration. All patients subsequently underwent surgical resection of the pancreas and IPMN was documented in all (6 adenomas, 6 borderline tumors, and 4 carcinomas). DNA was extracted from the cyst fluids and mutational analysis for K-ras point mutations and loss of heterozygosity (LOH) analysis using a preselected panel of genomic loci were performed. LOH was observed in 3 of 4 carcinomas as compared to 4 of 11 adenomas and borderline lesions (1 was QNS). LOH and K-ras mutations were both acquired in 2 of 4 carcinomas and in 1 of 12 adenoma/borderline lesions. Although the study is small, molecular analysis for LOH and K-ras mutations is useful in the preoperative evaluation of cystic pancreatic lesions. Increasing degree of neoplasia appears to correlate with increased genetic abnormality using a panel of selected genomic markers.

Evaluation of pancreatic cystic lesions with EUS

Evaluation of pancreatic cystic lesions with EUS

Preoperative Evaluation of Pancreatic Cystic Lesions: Cost-Benefit Analysis and Proposed Management Algorithm

Preoperative Evaluation of Pancreatic Cystic Lesions: Cost-Benefit Analysis and Proposed Management Algorithm

Preoperative evaluation of pancreatic cystic lesions: Cost-benefit analysis and proposed management algorithm

This study was performed to develop a management algorithm that accurately predicts the necessity of operative intervention and results in significant cost savings for patients with cystic pancreatic tumors. We reviewed 60 patients treated between 1992 and 2003. Accuracy rates of tests used to differentiate benign from premalignant and malignant cysts were calculated. A management algorithm was generated that incorporated clinical presentation, radiologic findings, and selective use of endoscopic procedures. This algorithm was tested for predictive accuracy, and savings between actual management and proposed management were compared. There was an average of 3 preoperative tests performed per patient. Endoscopic procedures included endoscopic retrograde cholangiopancreatography in 21 patients and endoscopic ultrasound in 25 patients. A cyst fluid carcinoembryonic antigen (CEA) level of 158 ng/mL or greater had an accuracy rate of 87.5% that was significantly higher than endoscopic retrograde cholangiopancreatography (72%), endoscopic ultrasound morphology (45%), or endoscopic ultrasound cytology (66.7%). There was no combination of tests that provided greater accuracy than cyst fluid CEA level alone (P < .05). The management algorithm had a positive predictive value of 81%. The average actual cost of radiographic and endoscopic procedures was dollar 8,080 per patient. The proposed cost based on the algorithm was dollar 6,677 with a savings of dollar 1,403 per patient (P = .009). In patients with clinical symptoms or radiographic findings of mucinous or malignant tumors, further testing is excessive. Of endoscopic tests available, the cystic fluid CEA level most accurately predicts the presence of a mucinous neoplasm. A management algorithm based on presenting symptoms, radiographic findings, and cyst fluid CEA level provides a guideline for the evaluation of cystic lesions in the most cost-efficient manner while ensuring proper care.

Evaluation of pancreatic cystic lesions with EUS.

Evaluation of pancreatic cystic lesions with EUS.

EUS in the evaluation of pancreatic cystic lesions

Background: The differential diagnosis in pancreatic cystic lesions is often difficult despite the availability of various modern imaging modalities. This study assessed the role of EUS in the following: (1) discrimination of pseudocysts from pancreatic cystic tumors, (2) differential diagnosis between serous cystadenoma and mucinous cystic tumor, and (3) prediction of accompanying malignancy in intraductal papillary mucinous tumor. Methods: EUS findings in 75 patients with pancreatic cystic lesions (58 cystic tumors, 17 pseudocysts) were evaluated. In the comparison of pseudocysts and cystic tumors, the latter included intraductal papillary mucinous tumor, mucinous cystic tumors, and serous cystadenomas, but not solid-pseudopapillary tumors. Results: In univariate analysis, pseudocysts exhibited echogenic debris and parenchymal changes more often than cystic tumors did (respectively, 29% vs. 6%, p < 0.05; and 65% vs. 4%, p < 0.001). In contrast, septa and mural nodules were found more frequently in cystic tumors than pseudocysts (respectively, 69% vs. 12%, p < 0.001; 56% vs. 12%, p < 0.01). Multivariate analysis revealed that parenchymal changes (odds ratio [OR] = 83.59; p < 0.01); septa (OR = 30.75; p < 0.05); and mural nodules (OR = 21.38; p < 0.05) were independent predictors of differentiation between pseudocysts and cystic tumors. Serous cystadenoma exhibited diverse EUS features, as well as a honeycomb appearance. Mural nodules were found more often in mucinous cystic tumors than in serous cystadenomas ( p < 0.05). There were no factors that predicted malignancy in intraductal papillary mucinous tumor. Conclusions: EUS is a useful complementary imaging method for differentiation of pancreatic cystic lesions. (Gastrointest Endosc 2003;57:891-6.)

Endoscopic ultrasound techniques for pancreatic cystic neoplasms.

The role of EUS and EUS FNA in the evaluation of cystic pancreatic lesions is evolving. The detailed imaging provided by EUS and hence the ability to target the biopsy at suspicious areas within the pancreatic cystic lesion may prove to be invaluable. Improvements in EUS equipment will further secure the role of this technology when evaluating these patients.