Fine-needle Aspiration Of Pancreatic Cystic Lesions Research Articles

Sa1443 CYST FLUID CARCINOEMBRYONIC ANTIGEN DIFFERENCE AMONG MUCINOUS CYSTIC NEOPLASMS AND INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS

Cyst fluid carcinoembryonic antigen (CEA) is a useful marker for differentiating between mucinous from nonmucinous pancreatic cystic lesions (PCLs). However, the role of cyst fluid CEA levels in differentiation between mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs) as well as between the low risk (LR) and high risk (HR) mucinous lesions are scanty. We aimed to analyse this subject. This was a retrospective study of 52 patients with mucinous PCls diagnosed by cyto/histo-pathology out of 466 patients who underwent endoscopic-ultrasonography-guided fine-needle aspiration for PCLs over a seven-year period. On histology, low- and intermediate-grade dysplasia were considered as LR, and high-grade dysplasia and invasive carcinoma were considered as HR. Cyst fluid CEA was available for 52/102 mucinous and 44/121 nonmucinous PCLs with definitive diagnoses. The median cyst fluid CEA [Range] values were significantly higher in mucinous compared with nonmucinous cysts (1079 ng/mL [0.5-266510 ] versus 6 ng/mL [0.2-309]), and LR-MCNs compared with LR-IPMNs (7954.7 ng/mL, [299.6-53445] versus 51.3 ng/mL [16.8-132.2]), and HR-IPMNs compared with LR-IPMNs (2624 ng/mL [0.5-266510] versus 100 ng/mL [16.8-53445]). The AUROC was 0.930 (95% confidence interval [CI]: 0.5-0.8) to differentiate between LR-IPMNs and LR-MCNs and 0.921 (95% CI: 0.823-1.000) to differentiate between LR-IPMNs and HR-IPMNs using cyst fluid CEA. Both showed cutoff values of >100 ng/mL and demonstrated a sensitivity of 100/100, specificity of 75/75, and positive and negative predictive values of 66.7/78.9 and 100/100, respectively. Cyst fluid CEA is useful in differentiation between LR-MCNs from LR-IPMNs and LR-IPMNs from HR-IPMNs. Diagnosis using a cyst fluid CEA cutoff value of 100 ng/mL showed a 100% negative predive value in differentiating LR-IPMNs from LR-MCNs and HR-IPMNs.

Tu1688 Single Dose Intra-Procedural Antibiotic During EUS-FNA of Pancreatic Cysts Is Safe and Effective - Results From a Single Tertiary Centre

Tu1688 Single Dose Intra-Procedural Antibiotic During EUS-FNA of Pancreatic Cysts Is Safe and Effective Results From a Single Tertiary Centre Amir Klein*, Farzan F. Bahin, Zhengyan Qi, Shyam D. Nagubandi, Eric Y. Lee, Vu Kwan Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia Background: Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is universally used for the investigation and diagnosis of pancreatic cystic lesions. The incidence of infectious complications (i.e. fever, infected cyst or bacteraemia) following EUS-FNA has been reported to be 0-6% in various studies. Antibiotic prophylaxis to reduce the risk of infection is recommended, however there is no consensus on the optimal regimen or route of administration. Potential advantages of a single dose intravenous (IV) antibiotic over a prolonged oral regimen include simplicity, guaranteed delivery and less antibiotic related adverse events, however there is only limited data to support this. Aim: To investigate the safety and efficacy of a single dose intra-procedural antibiotic (1 gram intravenous (IV) Ceftriaxone) in preventing infectious complications following EUS-FNA of pancreatic cysts. Methods: We performed a retrospective analysis of all EUS-FNA of pancreatic cysts performed at our centre. We reviewed the patient’s medical records and any presentation to a hospital in our district within 30 days of the procedure. An infectious complication was defined as fever/rigors, bacteraemia, and other evidence of a new abdominal infection within 30 days of the procedure. Data collection included patient demographics, procedural data and outcome. Results: EUS-FNA of 133 cysts (mean dimensions 29.2 x 18.0 mm) was performed. Cyst types were serous (23%), mucinous (9%), IPMN (28%), cystic tumor (20%), pseudocyst (3%), indetermined (17%). Single dose IV Ceftriaxone, and oral antibiotics for 3-5 days, were given in 81% and 19% respectively. Only one case of post procedural infection occurred a patient in whom antibiotic therapy was inadvertently omitted. In patients who received antibiotics, no infectious adverse events and no IV antibiotic related adverse events were identified. Conclusions: EUS and FNA of pancreatic cystic lesions is safe. A single dose of IV Ceftriaxone appears to be an effective intervention to prevent post FNA infectious complications. Efficacy was equivalent to the standard oral regimen and appears to be a valid alternative. Different antibiotic regimens AB560 GASTROINTESTINAL END IV Abx

EUS for Pancreas Cysts: What Should We Be Sampling?

The growing resolution and more frequent use of imagingmethods has increasingly identified pancreatic cysts,ranging from benign serous and pseudocysts to premalig-nant or malignant mucinous cystic neoplasm (MCN). Dueto the disparate course and management of benign cystsversus cystic neoplasms or pre-neoplasms, unambiguouslesion identification is essential, which is not always pos-sible with conventional cross-sectional imaging [1]. Thus,an increasing number of centers are utilizing endoscopicultrasound (EUS) for further characterization of pancreaticcysts with high resolution images of cyst morphology, size,presence and type of septations, presence of solid compo-nents, and the ability to sample cyst contents using fineneedle aspiration (FNA) and to perform biopsies. Charac-teristics such as diameter[3 cm and the presence of muralnodules may be the best predictors of malignant transfor-mation of MCN or side-branch type intraductal papillaryneoplasms (SB-IPMN) [2]. In some cases, however, biopsyof solid material or aspiration of cyst fluid is essential toconfirm the diagnosis. Thus, when a pancreas cyst isdetected on CT or MRI, the clinical question often arises asto whether EUS should be performed and, furthermore, ifadditional FNA or biopsy is helpful.In this month’s issue of Digestive Diseases and Sci-ences, Lim et al. [3] report their findings in ‘‘Factorsdetermining diagnostic yield of EUS guided fine-needleaspiration for pancreatic cystic lesions: a multicenter Asianstudy.’’ The authors include a multicenter analysis of 298patients with diverse pancreatic cystic lesions who under-went EUS of whom 132 (44 %) underwent EUS–FNA.FNA cytology with a single pass was only 29 % when solidcomponents are not present. Furthermore, their studydemonstrated a higher yield (44 %) when solid componentswere biopsied during a single pass, which increased to78 % with multiple passes. Although biochemical markerssuch as carcinogenic embryonic antigen (CEA) and amy-lase measured in cyst fluid aspirates are frequently used toaid in diagnosis of pancreatic cysts, the authors focused oncytologic yield from EUS–FNA. In the literature, theoverall yield of EUS–FNA for cytologic analysis of inde-terminate pancreatic cystic lesions is 31–37 % [2, 4].Morphologic features noted by high resolution EUSimages of small pancreatic cysts can help differentiatemucinous-type cysts from others. Nevertheless, in a recentstudy, expert endosonographers were evaluated for theirability to make a diagnosis of pancreatic MCN based onEUS appearance alone without FNA. The accuracy wasonly 23–46 % despite the use septations, mural nodules,solid components, and communication with the pancreaticduct as criteria [5]. Therefore, FNA for fluid analysis orbiopsy of solid materials may add to diagnostic yield,particularly for indeterminate cysts. Solid material within acyst may represent debris but could also arise frommalignancy.Several studies have addressed the acquisition of pan-creatic cyst specimens and types of analysis that providethe highest diagnostic yield. Cytologic analysis of aspiratedfluid is usually of low yield due to the unlikelihood thatpancreatic cysts shed adequate cells for evaluation.Accordingly, a recent study demonstrated that FNA of thecyst wall rather than fluid aspiration alone can improvediagnostic yield up to 81 %, with the majority of casesdemonstrating mucinous epithelium [6]. Other investiga-tors have examined the use of a cytology brush passedthrough a 19-gauge FNA needle to gather more cellular