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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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Ohno E, Kuzuya T, Kawabe N, Nakaoka K, Tanaka H, Nakano T, Funasaka K, Miyahara R, Hashimoto S, Hirooka Y. Current status of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms. DEN OPEN 2025; 5:e413. [PMID: 39040523 PMCID: PMC11260769 DOI: 10.1002/deo2.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 07/02/2024] [Accepted: 07/06/2024] [Indexed: 07/24/2024]
Abstract
The new Kyoto guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) provide evidence-based recommendations for the diagnosis and treatment of IPMN. Endoscopic ultrasonography (EUS) is a diagnostic modality with a high spatial resolution that allows detailed observation and obtaining cyst fluid or tissue samples via EUS-guided fine needle aspiration (EUS-FNA). Currently, EUS is an indispensable examination method for the diagnosis of pancreatic diseases. On the other hand, there have been concerns that EUS imaging tends to be highly operator-dependent, and may lack objectivity. Previous guidelines have assigned EUS as an option for patients with worrisome features. However, recent reports indicate that the sensitivity of EUS for the diagnosis of mural nodules (MNs) is more than 90%, comparable or superior to that of contrast-enhanced computed tomography or magnetic resonance cholangiopancreatography. The specific advantages of EUS in the diagnosis of IPMN are: (1) high spatial resolution imaging for the diagnosis of MNs, (2) contrast-enhanced EUS for differentiation of intra-cystic MNs from mucous clots, and (3) pathological diagnosis using EUS-FNA and differential diagnosis of a pancreatic cystic tumor by cystic fluid analysis. In order to utilize EUS in the diagnosis of IPMN, endoscopists are required to have the skills to provide sufficiently objective imaging findings.
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Affiliation(s)
- Eizaburo Ohno
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
| | - Teiji Kuzuya
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
| | - Naoto Kawabe
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
| | - Kazunori Nakaoka
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
| | - Hiroyuki Tanaka
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
| | - Takuji Nakano
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
| | - Kohei Funasaka
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
| | - Ryoji Miyahara
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
| | - Senju Hashimoto
- Department of Gastroenterology and HepatologyFujita Health University Bantane HospitalAichiJapan
| | - Yoshiki Hirooka
- Department of Gastroenterology and HepatologyFujita Health University School of MedicineAichiJapan
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Assawasirisin C, Qadan M, Aimprasittichai S, Kambadakone A, Servin-Rojas M, Warshaw AL, Lillemoe KD, Fernández-Del Castillo C. Pancreatic Serous Cystadenoma: A Continuing Diagnostic Challenge. Ann Surg 2025; 281:501-507. [PMID: 38230538 DOI: 10.1097/sla.0000000000006203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To understand the natural history of serous cystadenoma (SCA), and the diagnostic accuracy of SCA and identify possible factors that lead to the correct diagnosis. BACKGROUND SCA is a benign cystic pancreatic neoplasm of the pancreas, accounting for ~15% of resected pancreatic cysts. Current recommendations are to proceed with surgical resection in symptomatic patients or when there is uncertainty regarding diagnosis. The latter continues to be a challenge since intentional resection of an SCA accounts for only a minority of resected cases. METHODS Retrospective single-institution review of patients who on final pathology had a diagnosis of pancreatic SCA and of patients who had this diagnosis and were managed nonoperatively. Demographic data, cyst characteristics, and growth rate were collected for analysis. RESULTS A total of 250 patients were analyzed. Median age was 62 (range: 22-89), 65% were females, and 34% had symptoms. Tumor size ranged from 0.6 to 20, with a median of 3.4 cm. The morphologic appearance was microcystic in 58%, macrocystic in 16%, mixed-type in 23%, and solid in 3%. Pancreatic duct dilation and pancreatic atrophy were found in 22% and 14%, respectively. The average growth rate was 1.8 mm/year regardless of tumor size. Of the 172 patients who underwent surgery, SCA was the preoperative diagnosis in only 33%. A correct diagnosis was independently associated with large tumors and cyst fluid carcinoembryonic antigen analysis. Pancreatic duct dilation was independently associated with an in-growing cyst and the presence of calcification. CONCLUSIONS SCA is a slow-growing pancreatic cystic neoplasm that is mostly asymptomatic but can lead to pancreatic duct dilation and atrophy in some patients. A surprisingly small number of correct preoperative diagnoses confirms that this entity continues to be a diagnostic challenge. A more thorough preoperative workup that includes endoscopic ultrasonography should improve the rate of misdiagnosis.
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Affiliation(s)
- Charnwit Assawasirisin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Satita Aimprasittichai
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Avinash Kambadakone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Şal O, Göksoy B, Uzunyolcu G, Ercan CC, Berker N, Ekiz F, Serin KR. From Misdiagnosis to Management of Pancreatic Cystic Tumors Initially Identified as Pseudocysts and Treated with Cystogastrostomy: Experience from a Tertiary Care Center. Pancreatology 2025; 25:286-288. [PMID: 39988523 DOI: 10.1016/j.pan.2025.02.001] [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: 12/20/2024] [Revised: 01/28/2025] [Accepted: 02/03/2025] [Indexed: 02/25/2025]
Affiliation(s)
- Oğuzhan Şal
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Beslen Göksoy
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Görkem Uzunyolcu
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Celal Caner Ercan
- Department of Radiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Neslihan Berker
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Feza Ekiz
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Kürşat Rahmi Serin
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye.
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Ding C, Yang JF, Wang X, Zhou YF, Gu Y, Liu Q, Shen HZ, Zhang XF. Diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration-based cytology for distinguishing malignant and benign pancreatic cystic lesions: A systematic review and meta-analysis. PLoS One 2025; 20:e0314825. [PMID: 39977415 PMCID: PMC11841914 DOI: 10.1371/journal.pone.0314825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 11/16/2024] [Indexed: 02/22/2025] Open
Abstract
BACKGROUND Preoperative diagnosis of malignancy in patients with pancreatic cystic lesions (PCLs) remains challenging. The aim of this study was to assess the sensitivity, specificity, and positive and negative likelihood ratios (LRs) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA)-based cytology in differentiating malignant PCLs from benign PCLs. METHODS A comprehensive search was performed in multiple databases in November 2023. Studies differentiating benign and malignant PCLs via EUS-FNA-based cytology, in which the results were compared with those of surgical excision histopathology, were included in this meta-analysis. Data from the selected studies were pooled to summarize the sensitivity, specificity, positive and negative LRs, diagnostic odds ratios and summary receiver operating characteristic (SROC) curves. RESULTS We included 755 patients from 15 distinct studies who underwent EUS-FNA-based cytology and had a histopathological diagnosis. The pooled sensitivity and specificity in diagnosing malignant PCLs were 0.62 (95% CI, 0.42-0.78) and 0.96 (95% CI, 0.91-0.98), respectively. The positive and negative LRs for diagnosing malignant PCLs were 16.3 (95% CI, 7.2-37.0) and 0.40 (95% CI, 0.25-0.64), respectively. The area under the curve (AUC) was 0.94 (95% CI, 0.91-0.95). CONCLUSIONS EUS-FNA-based cytology has overall high specificity, medium sensitivity and good diagnostic accuracy in differentiating malignant from benign PCLs. Further research is needed to improve the overall sensitivity of EUS-FNA-based cytology for the diagnosis of malignant PCLs.
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Affiliation(s)
- Cong Ding
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
| | - Jian-feng Yang
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
| | - Xia Wang
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
| | - Yi-feng Zhou
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
| | - Ye Gu
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
| | - Qiang Liu
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
| | - Hong-zhang Shen
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
| | - Xiao-feng Zhang
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
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Iglesias-Garcia J, de la Iglesia D, Fusaroli P. Endoscopic Ultrasound armamentarium for precise and early diagnosis of biliopancreatic lesions. Best Pract Res Clin Gastroenterol 2025; 74:101987. [PMID: 40210338 DOI: 10.1016/j.bpg.2025.101987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2025] [Accepted: 02/03/2025] [Indexed: 03/04/2025]
Abstract
The diagnostic paradigm for biliopancreatic lesions has been revolutionized by continuous advancements in endoscopic ultrasound (EUS) technologies and techniques. This review examines the expanding diagnostic toolkit available to clinicians, emphasizing innovations that have significantly enhanced precision and early detection capabilities. One of the most transformative advancements is the development of fine-needle biopsy (FNB) needles. Modern designs, including Franseen, and fork-tip configurations, have optimized tissue sampling, achieving diagnostic accuracies exceeding 90 % while minimizing the number of needle passes required. These innovations facilitate the acquisition of high-quality histological specimens suitable for comprehensive molecular profiling, paving the way for personalized therapeutic approaches. Concurrent advancements in sampling techniques have bolstered these needle design improvements. The fanning technique has been particularly effective, increasing diagnostic yields from 71 % to 88 %. Wet suction methods preserve tissue integrity better than traditional approaches, while standardized protocols for needle passes enhance procedural efficiency. For specimen evaluation, Rapid On-Site Evaluation (ROSE) offers 93 % sensitivity, while alternatives like Macroscopic On-Site Evaluation (MOSE) provide comparable accuracy while reducing dependency on specialized personnel and resources. Image enhancement technologies have markedly improved the ability to characterize lesions. Contrast Harmonic EUS (CH-EUS) is particularly effective in differentiating pancreatic cancer from other solid lesions, with meta-analyses confirming sensitivity and specificity of 94 % and 89 %, respectively. Its ability to detect lesions as small as 15 mm makes it invaluable for early diagnosis. In cystic lesions, CH-EUS excels in identifying malignant mural nodules, with diagnostic accuracies reaching 96 %. The integration of elastography and advanced digital imaging technologies has further expanded diagnostic capabilities. Strain elastography provides qualitative insights into tissue characteristics, while shear wave elastography offers quantitative measurements of stiffness, adding diagnostic precision. Similarly, technologies like detective flow imaging match the accuracy of contrast-enhanced techniques in pancreatic cancer detection and enhance vascular assessment. For cystic lesions, diagnostics have progressed beyond traditional fluid analysis. Techniques such as through-the-needle biopsy (TTNB) have improved diagnostic yields to 74 %, albeit with a modest risk of complications. Incorporating molecular markers and next-generation sequencing allows differentiation between cystic lesion subtypes and more accurate assessment of malignant potential. This array of diagnostic tools offers unprecedented potential for early and precise diagnosis of biliopancreatic lesions. Integrating these innovations into clinical practice requires careful consideration of their strengths and limitations. Future research should aim to standardize protocols and establish evidence-based algorithms for their combined use, with the ultimate goal of improving patient outcomes through earlier detection and tailored management of biliopancreatic pathologies.
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Affiliation(s)
- Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Health Research Institute of Santiago de Compostela, Spain
| | - Daniel de la Iglesia
- Gastroenterology Department, University Hospital of Puerta de Hierro, Madrid, Spain.
| | - Pietro Fusaroli
- Gastrointestinal Unit, University of Bologna/Hospital of Imola, Italy
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Gao F, Li H, Feng X, Chen Q, Du C, Cheng B, Han K, Chai N, Linghu E. EUS-guided lauromacrogol ablation with different concentrations of lauromacrogol for the treatment of pancreatic cystic neoplasm: A randomized controlled study. Endosc Ultrasound 2025; 14:4-12. [PMID: 40151595 PMCID: PMC11939937 DOI: 10.1097/eus.0000000000000105] [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: 10/11/2024] [Accepted: 01/02/2025] [Indexed: 03/29/2025] Open
Abstract
Objectives To explore the safety and efficacy of injections of 1%, 2%, or 3% lauromacrogol during EUS-guided lauromacrogol ablation (EUS-LA) for the treatment of pancreatic cystic neoplasms (PCNs) and to determine the optimal concentration of lauromacrogol for use in EUS-LA therapeutic regimens. Methods From May 2021 to January 2023, patients who met the indications for EUS-LA were randomly divided into 3 groups: A, B, and C; the patients in these groups were injected with 1%, 2%, and 3% lauromacrogol during EUS-LA, respectively. Safety was evaluated based on the incidence of postoperative complications. Efficacy was comprehensively evaluated by assessing the ablation rate and ablation effect. Results Forty-two patients underwent EUS-LA, and 31 patients completed at least 1 postoperative re-examination. No acute pancreatitis was observed in the 1% and 2% lauromacrogol groups, and 1 case of acute pancreatitis occurred in the 3% lauromacrogol group. The total complication rate was 2.4%. The median ablation rates of the groups were 94.1%, 82.0%, and 100.0%, respectively. There were statistically significant differences in the EUS-LA ablation rate between the 1% and 3% lauromacrogol groups and between the 2% and 3% lauromacrogol groups. There was a statistically significant difference in complete disappearance between the 1% and 3% lauromacrogol groups as well as between the 2% and 3% lauromacrogol groups. Conclusion The short-term outcomes showed that injections of 1%, 2%, and 3% lauromacrogol were safe for use in EUS-LA, and injection of 3% lauromacrogol was the most effective for EUS-LA.
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Affiliation(s)
- Fei Gao
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
- Government Offices Administration of the Central Military Commission, Beijing 100034, China
| | - Huikai Li
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiuxue Feng
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Qianqian Chen
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Chen Du
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Bingqian Cheng
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Medical School, Beijing 100853, China
| | - Ke Han
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Medical School, Beijing 100853, China
| | - Ningli Chai
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Enqiang Linghu
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
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Seyithanoglu D, Durak G, Keles E, Medetalibeyoglu A, Hong Z, Zhang Z, Taktak YB, Cebeci T, Tiwari P, Velichko YS, Yazici C, Tirkes T, Miller FH, Keswani RN, Spampinato C, Wallace MB, Bagci U. Advances for Managing Pancreatic Cystic Lesions: Integrating Imaging and AI Innovations. Cancers (Basel) 2024; 16:4268. [PMID: 39766167 PMCID: PMC11674829 DOI: 10.3390/cancers16244268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Revised: 12/08/2024] [Accepted: 12/19/2024] [Indexed: 01/11/2025] Open
Abstract
Pancreatic cystic lesions (PCLs) represent a spectrum of non-neoplasms and neoplasms with varying malignant potential, posing significant challenges in diagnosis and management. While some PCLs are precursors to pancreatic cancer, others remain benign, necessitating accurate differentiation for optimal patient care. Conventional approaches to PCL management rely heavily on radiographic imaging, and endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA), coupled with clinical and biochemical data. However, the observer-dependent nature of image interpretation and the complex morphology of PCLs can lead to diagnostic uncertainty and variability in patient management strategies. This review critically evaluates current PCL diagnosis and surveillance practices, showing features of the different lesions and highlighting the potential limitations of conventional methods. We then explore the potential of artificial intelligence (AI) to transform PCL management. AI-driven strategies, including deep learning algorithms for automated pancreas and lesion segmentation, and radiomics for analyzing heterogeneity, can improve diagnostic accuracy and risk stratification. These advanced techniques can provide more objective and reproducible assessments, aiding clinicians in decision-making regarding follow-up intervals and surgical interventions. Early results suggest that AI-driven methods can significantly improve patient outcomes by enabling earlier detection of high-risk lesions and reducing unnecessary procedures for benign cysts. Finally, this review emphasizes that AI-driven approaches could potentially reshape the landscape of PCL management, ultimately leading to improved pancreatic cancer prevention.
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Affiliation(s)
- Deniz Seyithanoglu
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
- Istanbul Faculty of Medicine, Istanbul University, Istanbul 38000, Turkey; (Y.B.T.); (T.C.)
| | - Gorkem Durak
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
| | - Elif Keles
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
| | - Alpay Medetalibeyoglu
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
- Istanbul Faculty of Medicine, Istanbul University, Istanbul 38000, Turkey; (Y.B.T.); (T.C.)
| | - Ziliang Hong
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
| | - Zheyuan Zhang
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
| | - Yavuz B. Taktak
- Istanbul Faculty of Medicine, Istanbul University, Istanbul 38000, Turkey; (Y.B.T.); (T.C.)
| | - Timurhan Cebeci
- Istanbul Faculty of Medicine, Istanbul University, Istanbul 38000, Turkey; (Y.B.T.); (T.C.)
| | - Pallavi Tiwari
- Department of Radiology, BME, University of Wisconsin-Madison, Madison, WI 53707, USA;
- William S. Middleton Memorial Veterans Affairs (VA) Healthcare, 2500 Overlook Terrace, Madison, WI 53705, USA
| | - Yuri S. Velichko
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
| | - Cemal Yazici
- Department of Gastroenterology, University of Illinois at Chicago, Chicago, IL 60611, USA;
| | - Temel Tirkes
- Department of Radiology, Indiana University, Indianapolis, IN 46202, USA;
| | - Frank H. Miller
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
| | - Rajesh N. Keswani
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
| | - Concetto Spampinato
- Department of Electrical, Electronics and Computer Engineering, University of Catania, 95124 Catania, Italy;
| | - Michael B. Wallace
- Department of Gastroenterology, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
| | - Ulas Bagci
- Machine and Hybrid Intelligence Lab, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; (D.S.); (G.D.); (E.K.); (A.M.); (Z.H.); (Z.Z.); (Y.S.V.); (F.H.M.); (R.N.K.)
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9
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Dhar J, Samanta J, Nabi Z, Aggarwal M, Conti Bellocchi MC, Facciorusso A, Frulloni L, Crinò SF. Endoscopic Ultrasound-Guided Pancreatic Tissue Sampling: Lesion Assessment, Needles, and Techniques. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:2021. [PMID: 39768901 PMCID: PMC11727853 DOI: 10.3390/medicina60122021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2024] [Revised: 11/15/2024] [Accepted: 12/03/2024] [Indexed: 01/12/2025]
Abstract
Endoscopic ultrasound (EUS)-guided tissue sampling includes the techniques of fine needle aspiration (FNA) and fine needle biopsy (FNB), and both procedures have revolutionized specimen collection from the gastrointestinal tract, especially from remote/inaccessible organs. EUS-FNB has replaced FNA as the procedure of choice for tissue acquisition in solid pancreatic lesions (SPLs) across various society guidelines. FNB specimens provide a larger histological tissue core (preserving tissue architecture) with fewer needle passes, and this is extremely relevant in today's era of precision and personalized molecular medicine. Innovations in needle tip design are constantly under development to maximize diagnostic accuracy by enhancing histological sampling capabilities. But, apart from the basic framework of the needle, various other factors play a role that influence diagnostic outcomes, namely, sampling techniques (fanning, aspiration or suction, and number of passes), collection methods, on-site evaluation (rapid, macroscopic, or visual), and specimen processing. The choice taken depends strongly on the endoscopist's preference, available resources at the disposal, and procedure objectives. Hence, in this review, we explicate in detail the concepts and available literature at our disposal on the topic of EUS-guided pancreatic tissue sampling to best guide any practicing gastroenterologist/endoscopist in a not-to-ideal set-up, which EUS-guided tissue acquisition technique is the "best" for their case to augment their diagnostic outcomes.
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Affiliation(s)
- Jahnvi Dhar
- Department of Gastroenterology, Adesh Medical College and Hospital, Kurukshetra 136134, India;
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India;
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500082, India;
| | - Manik Aggarwal
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Maria Cristina Conti Bellocchi
- Department of Medicine, Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, 37134 Verona, Italy; (M.C.C.B.); (L.F.)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy;
- Clinical Effectiveness Research Group, Faculty of Medicine, Institute of Health and Society, University of Oslo, 0372 Oslo, Norway
| | - Luca Frulloni
- Department of Medicine, Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, 37134 Verona, Italy; (M.C.C.B.); (L.F.)
| | - Stefano Francesco Crinò
- Department of Medicine, Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, 37134 Verona, Italy; (M.C.C.B.); (L.F.)
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10
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Moris D, Liapis I, Gupta P, Ziogas IA, Karachaliou GS, Dimitrokallis N, Nguyen B, Radkani P. An Overview for Clinicians on Intraductal Papillary Mucinous Neoplasms (IPMNs) of the Pancreas. Cancers (Basel) 2024; 16:3825. [PMID: 39594780 PMCID: PMC11593033 DOI: 10.3390/cancers16223825] [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: 10/10/2024] [Revised: 11/11/2024] [Accepted: 11/12/2024] [Indexed: 11/28/2024] Open
Abstract
Currently, there is no reliable method of discerning between low-risk and high-risk intraductal papillary mucinous neoplasms (IPMNs). Operative resection is utilized in an effort to resect those lesions with high-grade dysplasia (HGD) prior to the development of invasive disease. The current guidelines recommend resection for IPMN that involve the main pancreatic duct. Resecting lesions with HGD before their progression to invasive disease and the avoidance of resection in those patients with low-grade dysplasia is the optimal clinical scenario. Therefore, the importance of developing preoperative models able to discern HGD in IPMN patients cannot be overstated. Low-risk patients should be managed with nonsurgical treatment options (typically MRI surveillance), while high-risk patients would undergo resection, hopefully prior to the formation of invasive disease. Current research is evolving in multiple directions. First, there is an ongoing effort to identify reliable markers for predicting malignant transformation of IPMN, mainly focusing on genomic and transcriptomic data from blood, tissue, and cystic fluid. Also, multimodal models of combining biomarkers with clinical and radiographic data seem promising for providing robust and accurate answers of risk levels for IPMN patients.
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Affiliation(s)
- Dimitrios Moris
- MedStar Georgetown Transplant Institute, Washington, DC 20007, USA; (P.G.); (B.N.); (P.R.)
| | - Ioannis Liapis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA;
| | - Piyush Gupta
- MedStar Georgetown Transplant Institute, Washington, DC 20007, USA; (P.G.); (B.N.); (P.R.)
| | - Ioannis A. Ziogas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO 80045, USA;
| | - Georgia-Sofia Karachaliou
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA;
| | - Nikolaos Dimitrokallis
- 1st Department of Surgery & Organ Transplant Unit, Evangelismos General Hospital, 10676 Athens, Greece;
| | - Brian Nguyen
- MedStar Georgetown Transplant Institute, Washington, DC 20007, USA; (P.G.); (B.N.); (P.R.)
| | - Pejman Radkani
- MedStar Georgetown Transplant Institute, Washington, DC 20007, USA; (P.G.); (B.N.); (P.R.)
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11
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Soltani A, Salimi M, Nemati M, Mirshamsi A. Recurrent gastric intramural pseudocyst: A case report and comprehensive literature review of reported cases. Radiol Case Rep 2024; 19:5429-5441. [PMID: 39285981 PMCID: PMC11403908 DOI: 10.1016/j.radcr.2024.08.041] [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: 08/04/2024] [Revised: 08/07/2024] [Accepted: 08/10/2024] [Indexed: 09/19/2024] Open
Abstract
Intramural gastric pseudocysts are extremely rare and are often associated with pancreatitis and pancreatic pseudocysts; they can lead to complex clinical presentations requiring careful diagnosis and management. We present a case of a 57-year-old man with a history of pancreatitis and pancreatic pseudocysts who was diagnosed with intramural gastric pseudocysts. The patient was diagnosed with multiple gastric intramural pseudocysts at different locations during separate admissions and imaging studies. This indicates a recurrence of gastric intramural pseudocysts. In these cases, studies rarely discuss recurrence and its underlying causes. This highlights a significant gap in the existing literature. To provide a broader understanding, we reviewed the literature by searching major databases (PubMed, Scopus, and Web of Science) and then extracted and analyzed data from 18 articles, reaching 24 similar cases. Of the 25 patients studied (including our case), 92% were male and 8% were female. Cases had a mean age of 47.68 ± 14.82 years. Additionally, 84% of the patients had a history of alcohol consumption, and 88% had a positive history of pancreatitis. Common symptoms were abdominal pain (especially in the epigastric region), vomiting, nausea, and weight loss. In conclusion, results showed that intramural gastric pseudocysts generally occur in middle-aged men with a history of chronic or heavy alcohol consumption and pancreatitis.
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Affiliation(s)
- Amirhossein Soltani
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
- Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohsen Salimi
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Nemati
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Mirshamsi
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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12
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Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1724-1785. [PMID: 39389105 DOI: 10.1055/a-2338-3716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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13
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Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:e874-e995. [PMID: 39389103 DOI: 10.1055/a-2338-3533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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14
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Koo JGA, Liau MYQ, Kryvoruchko IA, Habeeb TAAM, Chia C, Shelat VG. Pancreatic pseudocyst: The past, the present, and the future. World J Gastrointest Surg 2024; 16:1986-2002. [PMID: 39087130 PMCID: PMC11287700 DOI: 10.4240/wjgs.v16.i7.1986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/19/2024] [Accepted: 06/17/2024] [Indexed: 07/22/2024] Open
Abstract
A pancreatic pseudocyst is defined as an encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis. The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis. The clinical presentation is often nonspecific, with abdominal pain being the most common symptom. If a diagnosis is suspected, contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst. Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty. Pseudocyst of the pancreas can lead to complications such as hemorrhage, infection, and rupture. The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications, such as biliary or gastric outlet obstruction. Management options include endoscopic or surgical drainage. The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions, diagnosis, and management of this condition.
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Affiliation(s)
- Jonathan GA Koo
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore
| | - Matthias Yi Quan Liau
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Igor A Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, Kharkiv 61022, Ukraine
| | - Tamer AAM Habeeb
- Department of General Surgery, Faculty of Medicine Zagazig University, Sharkia 44511, Egypt
| | - Christopher Chia
- Department of Gastroenterology, Woodlands General Hospital, Singapore 737628, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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15
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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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16
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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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17
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Kwan MC, Pitman MB, Fernandez-Del Castillo C, Zhang ML. Revisiting the performance of cyst fluid carcinoembryonic antigen as a diagnostic marker for pancreatic mucinous cysts: a comprehensive 20-year institutional review. Gut 2024; 73:629-638. [PMID: 38195219 DOI: 10.1136/gutjnl-2023-331138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/27/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE Elevated pancreatic cyst fluid carcinoembryonic antigen (CEA) has been routinely used to classify mucinous cysts. This study incorporates original data that established the CEA ≥192 ng/mL threshold with over 20 years of additional data and reassesses the diagnostic performance of CEA for differentiating mucinous from non-mucinous cysts. DESIGN 1169 pancreatic cysts (1999-2021) with CEA results were identified. 394 cases had histological confirmation as the diagnostic standard. Additionally, 237 cysts without histological confirmation demonstrated KRAS, GNAS, or RNF43 mutations by molecular testing and were combined with the histologically confirmed cysts for separate analysis on a total cohort of 631 cysts. RESULTS Median CEA was significantly higher in mucinous cysts (323.9 ng/mL, n=314) versus non-mucinous cysts (204.6 ng/mL, n=80) (p<0.001). Receiver operating characteristic curve analysis demonstrated an optimal CEA cut-off of 20 ng/mL (area under the curve: 80%), though the specificity was lower than desired (sensitivity 89%, specificity 64%). At the previously established threshold of 192 ng/mL, sensitivity and specificity were 56% and 78%, respectively. To achieve a specificity of 85% as originally reported, a CEA threshold of 250 ng/mL was needed; the 13 false positive cases at this threshold included 4 benign simple cysts, 2 squamoid cysts, 1 serous cystadenoma, 1 lymphoepithelial cyst and 5 more uncommon entities. All results remained similar within the total cohort after including additional cases with KRAS/GNAS/RNF43 mutations only. CONCLUSION Cyst fluid CEA continues to be a useful test in the diagnosis of mucinous pancreatic cysts but does not appear as specific as previously reported. Raising the CEA threshold to 250 ng/mL to maintain specificity for differentiating mucinous from non-mucinous cysts may be considered.
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Affiliation(s)
- Melanie C Kwan
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Martha Bishop Pitman
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Fernandez-Del Castillo
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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18
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Yip-Schneider MT, Muraru R, Kim RC, Wu HH, Sherman S, Gutta A, Al-Haddad MA, Dewitt JM, Schmidt CM. EUS-guided fine needle aspiration-based clues to mistaken or uncertain identity: serous pancreatic cysts. HPB (Oxford) 2023; 25:1587-1594. [PMID: 37749004 PMCID: PMC10843000 DOI: 10.1016/j.hpb.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/21/2023] [Accepted: 09/05/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND/OBJECTIVES Pancreatic serous cystic neoplasms (SCN) present a diagnostic challenge given their increasing frequency of detection and benign nature yet relatively high rate of misdiagnosis. Here, imaging and analyses associated with EUS-guided fine-needle aspiration (EUS-FNA) are evaluated for their ability to provide a correct preoperative diagnosis of SCN. METHODS A surgical cohort with confirmed pathological diagnosis of SCN (n = 62) and a surveillance cohort with likely SCN (n = 31) were assessed for imaging (CT/MRI/EUS) and EUS-FNA-based analyses (cytology/DNA analysis for Von Hippel-Lindau [VHL] gene alterations/biomarkers). RESULTS In the surgical cohort, CT/MRI and EUS respectively predicted SCN in 4 of 58(7%) and 19 of 62(31%). Cyst fluid cytology and VHL alterations predicted SCN in 1 of 51(2%) and 5 of 21(24%), respectively. High specificity cyst fluid biomarkers (vascular endothelial growth factor [VEGF]/glucose/carcinoembryonic antigen [CEA]/amylase) correctly identified SCN in 25 of 27(93%). In the surveillance cohort, cyst fluid biomarkers predicted SCN in 12 of 12(100%) while VHL alterations identified SCN 3 of 10(30%). CONCLUSION High specificity cyst fluid biomarkers provided the most sensitive means of diagnosing SCN preoperatively. To obtain a preoperative diagnosis of SCN at the highest level of certainty, a multidisciplinary approach should be taken to inform appropriate SCN management.
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Affiliation(s)
- Michele T Yip-Schneider
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Walther Oncology Center, Indianapolis, IN, USA; Indiana University Simon Cancer Center, Indianapolis, IN, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN, USA.
| | - Rodica Muraru
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rachel C Kim
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Howard H Wu
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stuart Sherman
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Aditya Gutta
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad A Al-Haddad
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John M Dewitt
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA; Walther Oncology Center, Indianapolis, IN, USA; Indiana University Simon Cancer Center, Indianapolis, IN, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN, USA.
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Carrara S, Fantin A, Khalaf K, Rizkala T, Koleth G, Andreozzi M, Spadaccini M, Colombo M, Gruppo M, Bonifacio C, Gavazzi F, Capretti GL, Ridolfi C, Nappo G, Spaggiari P, Tommaso LD, Sollai M, Zerbi A, Maselli R, Fugazza A, Hassan C, Facciorusso A, Repici A. Exploring a novel composite method using non-contrast EUS enhanced microvascular imaging and cyst fluid analysis to differentiate pancreatic cystic lesions. Dig Liver Dis 2023; 55:1548-1553. [PMID: 37612214 DOI: 10.1016/j.dld.2023.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 07/07/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND AND AIMS Differentiating pancreatic cystic lesions (PCLs) remains a diagnostic challenge. The use of high-definition imaging modalities which detect tumor microvasculature have been described in solid lesions. We aim to evaluate the usefulness of cystic microvasculature when used in combination with cyst fluid biochemistry to differentiate PCLs. METHODS We retrospectively analyzed 110 consecutive patients with PCLs from 2 Italian Hospitals who underwent EUS with H-Flow and EUS fine needle aspiration to obtain cystic fluid. The accuracy of fluid biomarkers was evaluated against morphological features on radiology and EUS. Gold standard for diagnosis was surgical resection. A clinical and radiological follow up was applied in those patients who were not resected because not surgical indication and no signs of malignancy were shown. RESULTS Of 110 patients, 65 were diagnosed with a mucinous cyst, 41 with a non-mucinous cyst, and 4 with an undetermined cyst. Fluid analysis alone yielded 76.7% sensitivity, 56.7% specificity, 77.8 positive predictive value (PPV), 55.3 negative predictive value (NPV) and 56% accuracy in diagnosing pancreatic cysts alone. Our composite method yielded 97.3% sensitivity, 77.1% specificity, 90.1% PPV, 93.1% NPV, 73.2% accuracy. CONCLUSIONS This new composite could be applied to the holistic approach of combining cyst morphology, vascularity, and fluid analysis alongside endoscopist expertise.
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Affiliation(s)
- Silvia Carrara
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy.
| | - Alberto Fantin
- Unit of Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy
| | - Kareem Khalaf
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Tommy Rizkala
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy
| | - Glenn Koleth
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Marta Andreozzi
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Marco Spadaccini
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Matteo Colombo
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Mario Gruppo
- Unit of Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy
| | | | - Francesca Gavazzi
- Humanitas Research Hospital -IRCCS, Pancreatic Surgery Unit, Rozzano, Italy
| | | | - Cristina Ridolfi
- Humanitas Research Hospital -IRCCS, Pancreatic Surgery Unit, Rozzano, Italy
| | - Gennaro Nappo
- Humanitas Research Hospital -IRCCS, Pancreatic Surgery Unit, Rozzano, Italy
| | - Paola Spaggiari
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Luca Di Tommaso
- Humanitas Research Hospital -IRCCS, Pathology Unit, Rozzano, Italy
| | - Mauro Sollai
- Humanitas Research Hospital -IRCCS, Pathology Unit, Rozzano, Italy
| | - Alessandro Zerbi
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy; Humanitas Research Hospital -IRCCS, Pancreatic Surgery Unit, Rozzano, Italy
| | - Roberta Maselli
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy
| | | | - Cesare Hassan
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Alessandro Repici
- Humanitas Research Hospital -IRCCS-, Endoscopy Unit, Rozzano, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy
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20
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Wood LD, Adsay NV, Basturk O, Brosens LAA, Fukushima N, Hong SM, Kim SJ, Lee JW, Luchini C, Noë M, Pitman MB, Scarpa A, Singhi AD, Tanaka M, Furukawa T. Systematic review of challenging issues in pathology of intraductal papillary mucinous neoplasms. Pancreatology 2023; 23:878-891. [PMID: 37604731 DOI: 10.1016/j.pan.2023.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are frequently treated with surgical resection, and pathological examination of the pancreatectomy specimen is a key component of the clinical care of IPMN patients. METHODS Systematic literature reviews were conducted around eight topics of clinical relevance in the examination of pathological specimens in patients undergoing resection of IPMN. RESULTS This review provides updated perspectives on morphological subtyping of IPMNs, classification of intraductal oncocytic papillary neoplasms, nomenclature for high-grade dysplasia, assessment of T stage, distinction of carcinoma associated or concomitant with IPMN, role of molecular assessment of IPMN tissue, role of intraoperative assessment by frozen section, and preoperative evaluation of cyst fluid cytology. CONCLUSIONS This analysis provides the foundation for data-driven approaches to several challenging issues in the pathology of IPMNs.
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Affiliation(s)
- Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - N Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Noriyoshi Fukushima
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae W Lee
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Michaël Noë
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
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21
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Rogowska JO, Durko Ł, Malecka-Wojciesko E. The Latest Advancements in Diagnostic Role of Endosonography of Pancreatic Lesions. J Clin Med 2023; 12:4630. [PMID: 37510744 PMCID: PMC10380545 DOI: 10.3390/jcm12144630] [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: 05/18/2023] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Endosonography, a minimally invasive imaging technique, has revolutionized the diagnosis and management of pancreatic diseases. This comprehensive review highlights the latest advancements in endosonography of the pancreas, focusing on key technological developments, procedural techniques, clinical applications and additional techniques, which include real-time elastography endoscopic ultrasound, contrast-enhanced-EUS, EUS-guided fine-needle aspiration or EUS-guided fine-needle biopsy. EUS is well established for T-staging and N-staging of pancreaticobiliary malignancies, for pancreatic cyst discovery, for identifying subepithelial lesions (SEL), for differentiation of benign pancreaticobiliary disorders or for acquisition of tissue by EUS-guided fine-needle aspiration or EUS-guided fine-needle biopsy. This review briefly describes principles and application of EUS and its related techniques.
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Affiliation(s)
| | - Łukasz Durko
- Department of Digestive Tract Diseases, Medical University of Lodz, 90-647 Lodz, Poland
| | - Ewa Malecka-Wojciesko
- Department of Digestive Tract Diseases, Medical University of Lodz, 90-647 Lodz, Poland
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22
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Siddappa PK, Park WG. Pancreatic Cyst Fluid Analysis. Gastrointest Endosc Clin N Am 2023; 33:599-612. [PMID: 37245938 DOI: 10.1016/j.giec.2023.03.006] [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 cyst fluid analysis can help diagnose pancreatic cyst type and the risk of high-grade dysplasia and cancer. Recent evidence from molecular analysis of cyst fluid has revolutionized the field with multiple markers showing promise in accurate diagnosis and prognostication of pancreatic cysts. The availability of multi-analyte panels has great potential for more accurate prediction of cancer.
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Affiliation(s)
- Pradeep K Siddappa
- Division of Gastroenterology & Hepatology, Stanford University, Stanford, CA, USA
| | - Walter G Park
- Division of Gastroenterology & Hepatology, Stanford University, Stanford, CA, USA.
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23
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Cattelani A, Perri G, Marchegiani G, Salvia R, Crinò SF. Risk Models for Pancreatic Cyst Diagnosis. Gastrointest Endosc Clin N Am 2023; 33:641-654. [PMID: 37245940 DOI: 10.1016/j.giec.2023.03.011] [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
The overall prevalence of pancreatic cysts (PCs) is high in the general population. In clinical practice PCs are often incidentally discovered and are classified into benign, premalignant, and malignant lesions according to the World Health Organization. For this reason, in the absence of reliable biomarkers, to date clinical decision-making relies mostly on risk models based on morphological features. The aim of this narrative review is to present the current knowledge regarding PC's morphologic features with related estimated risk of malignancy and discuss available diagnostic tools to minimize clinically relevant diagnostic errors.
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Affiliation(s)
- Alice Cattelani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy.
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24
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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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25
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Rangwani S, Juakiem W, Krishna SG, El-Dika S. Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review. Diagnostics (Basel) 2023; 13:705. [PMID: 36832193 PMCID: PMC9955397 DOI: 10.3390/diagnostics13040705] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023] Open
Abstract
Pancreatic cystic lesions are being discovered as incidental lesions during cross-sectional imaging studies of the abdomen with increasing frequency. Endoscopic ultrasound is an important diagnostic modality for managing pancreatic cystic lesions. There are various types of pancreatic cystic lesions, from benign to malignant. Endoscopic ultrasound has a multifactorial role in delineating the morphology of pancreatic cystic lesions, ranging from fluid and tissue acquisition for analysis-fine needle aspiration and through-the-needle biopsy, respectively-to advanced imaging techniques, such as contrast-harmonic mode endoscopic ultrasound and EUS-guided needle-based confocal laser endomicroscopy. In this review, we will summarize and provide an update on the specific role of EUS in the management of pancreatic cystic lesions.
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Affiliation(s)
- Shiva Rangwani
- Department of Internal Medicine, Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - Wasseem Juakiem
- Department of Internal Medicine, Stanford University, Stanford, CA 94305, USA
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA 94305, USA
| | - Somashekar G. Krishna
- Department of Gastroenterology, Hepatology, and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Samer El-Dika
- Department of Internal Medicine, Stanford University, Stanford, CA 94305, USA
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA 94305, USA
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26
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AlNuaimi D, Akmal Y, AlDuaij A, Sherif A, Abdulghaffar S, Cem Balci N. Pancreatic endometrioma : a rare differential diagnosis for a pseudocyst. BJR Case Rep 2023; 9:20220141. [PMID: 36873241 PMCID: PMC9976728 DOI: 10.1259/bjrcr.20220141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022] Open
Abstract
Pancreatic endometriosis is extremely rare with only 14 cases reported in the medical literature and its diagnosis on radiological imaging poses a great challenge. We report a case of a 31-year-old female patient with recurrent admissions for pancreatitis of unknown aetiology and no relevant previous medical history. Sectional imaging showed a cystic lesion in the tail of the pancreas and the diagnosis of a post-pancreatitis pseudocyst or a less likely pre-malignant mucinous cystadenoma was considered. On post-robotic resection of the pancreatic cyst, the histopathology analysis was positive for endometrial stroma. Pancreatic endometriosis although rare should be considered as a differential diagnosis for cystic lesions especially in patients who are known to have pelvic endometriosis. Nevertheless, the gold standard for the definite diagnosis of pancreatic endometriosis remains histopathological.
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Affiliation(s)
- Dana AlNuaimi
- Fatima College of Health Sciences, Radiology and Medical Imaging Department, Abu Dhabi, United Arab Emirates
| | | | | | - Ahmed Sherif
- Cleveland Clinic Abu Dhabi, AlMaryah Island, Abu Dhabi, United Arab Emirates
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27
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Approach to FNA of Pancreatic Cysts. Adv Anat Pathol 2022; 29:349-357. [DOI: 10.1097/pap.0000000000000378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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28
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Khan I, Baig M, Bandepalle T, Puli SR. Utility of Cyst Fluid Carcinoembryonic Antigen in Differentiating Mucinous and Non-mucinous Pancreatic Cysts: An Updated Meta-Analysis. Dig Dis Sci 2022; 67:4541-4548. [PMID: 34783970 DOI: 10.1007/s10620-021-07315-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 11/02/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Mucinous pancreatic cysts are considered premalignant and managed differently compared to benign pancreatic cystic lesions. The aim of this updated meta-analysis is to assess the diagnostic accuracy of cyst carcinoembryonic antigen (CEA) in differentiating between mucinous and non-mucinous pancreatic cysts. METHODS Studies comparing the diagnostic accuracy of CEA (cutoff level of 192 ng/mL) in differentiating between mucinous and non-mucinous pancreatic cysts were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooled estimates of diagnostic precision were calculated using random and fixed effects models. RESULTS Initial search identified 526 reference articles, of these 34 relevant articles were selected and reviewed. Data were extracted from 15 studies (n = 2063) which met the inclusion criteria. The pancreatic cystic fluid CEA level at a 192 ng/mL cutoff value had pooled specificity of 88.6% (95% CI 85.9-90.9) and pooled sensitivity was found to be 60.4% (95% CI 57.7-62.9). The pooled positive likelihood ratio was 4.5 (95% CI 2.9-6.9) and the pooled negative likelihood ratio was 0.45 (95% CI 0.38-0.52). The pooled diagnostic odds ratio, the odds of having mucinous cyst with elevated CEA, was 11.4 (95% CI 6.9-18.7). The P for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. CONCLUSIONS This meta-analysis suggests that the cyst fluid CEA level at a 192 ng/mL cutoff value is highly specific in the diagnosis of mucinous cystic lesions with reasonable sensitivity.
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Affiliation(s)
- Imadh Khan
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, Peoria, IL, 61637, USA
| | - Muhammad Baig
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, Peoria, IL, 61637, USA.
| | - Thrisha Bandepalle
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, Peoria, IL, 61637, USA
| | - Srinivas R Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, Peoria, IL, 61637, USA
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29
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Abstract
Early detection of high-risk pancreatic cystic lesions enables potentially curative surgical resection, and early detection of lesions without worrisome features may lead to appropriate surveillance. Regrettably, differentiating premalignant and malignant cysts from nonmalignant ones remains challenging. However, emerging additional diagnostic tools, including the needle biopsy with microforceps and needle-based confocal laser endomicroscopy, are of exciting potential along with cyst fluid analysis".
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Affiliation(s)
- Sahin Coban
- Department of Gastroenterology, Mount Auburn Hospital, 330 Mt Auburn St, Cambridge, MA 02138, USA.
| | - Omer Basar
- Department of Gastroenterology, The University of Missouri, Columbia, MO 65211, USA
| | - William R Brugge
- Department of Gastroenterology, Harvard Medical School, Mount Auburn Hospital, 330 Mt Auburn St, Cambridge, MA 02138, USA
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30
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Pancreatic Incidentaloma. J Clin Med 2022; 11:jcm11164648. [PMID: 36012893 PMCID: PMC9409921 DOI: 10.3390/jcm11164648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic incidentalomas (PIs) represent a clinical entity increasingly recognized due to advances in and easier access to imaging techniques. By definition, PIs should be detected during abdominal imaging performed for indications other than a pancreatic disease. They range from small cysts to invasive cancer. The incidental diagnosis of pancreatic cancer can contribute to early diagnosis and treatment. On the other hand, inadequate management of PIs may result in overtreatment and unneeded morbidity. Therefore, there is a strong need to evaluate the nature and clinical features of individual PIs. In this review, we summarize the major characteristics related to PIs and present suggestions for their management.
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Prinz C, Fehring L, Frese R. MicroRNAs as Indicators of Malignancy in Pancreatic Ductal Adenocarcinoma (PDAC) and Cystic Pancreatic Lesions. Cells 2022; 11:cells11152374. [PMID: 35954223 PMCID: PMC9368175 DOI: 10.3390/cells11152374] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 12/04/2022] Open
Abstract
The dysregulation of microRNAs has recently been associated with cancer development and progression in pancreatic ductal adenocarcinoma (PDAC) and cystic pancreatic lesions. In solid pancreatic tumor tissue, the dysregulation of miR-146, miR-196a/b, miR-198, miR-217, miR-409, and miR-490, as well as miR-1290 has been investigated in tumor biopsies of patients with PDAC and was reported to predict cancer presence. However, the value of the predictive biomarkers may further be increased during clinical conditions suggesting cancer development such as hyperinsulinemia or onset of diabetes. In this specific context, the dysregulation of miR-486 and miR-196 in tumors has been observed in the tumor tissue of PDAC patients with newly diagnosed diabetes mellitus. Moreover, miR-1256 is dysregulated in pancreatic cancer, possibly due to the interaction with long non-coding RNA molecules that seem to affect cell-cycle control and diabetes manifestation in PDAC patients, and, thus, these three markers may be of special or “sentinel value”. In blood samples, Next-generation sequencing (NGS) has also identified a set of microRNAs (miR-20a, miR-31-5p, miR-24, miR-25, miR-99a, miR-185, and miR-191) that seem to differentiate patients with pancreatic cancer remarkably from healthy controls, but limited data exist in this context regarding the prediction of cancer presences and outcomes. In contrast to solid pancreatic tumors, in cystic pancreatic cancer lesions, as well as premalignant lesions (such as intraductal papillary neoplasia (IPMN) or mucinous-cystic adenomatous cysts (MCAC)), the dysregulation of a completely different expression panel of miR-31-5p, miR-483-5p, miR-99a-5p, and miR-375 has been found to be of high clinical value in differentiating benign from malignant lesions. Interestingly, signal transduction pathways associated with miR-dysregulation seem to be entirely different in patients with pancreatic cysts when compared to PDAC. Overall, the determination of these different dysregulation “panels” in solid tumors, pancreatic cysts, obtained via fine-needle aspirate biopsies and/or in blood samples at the onset or during the treatment of pancreatic diseases, seems to be a reasonable candidate approach for predicting cancer presence, cancer development, and even therapy responses.
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Sharma RK, Bush N, Rana SS, Srinivasan R, Nada R, Gupta R, Rana S, Singh T. Lower cyst fluid carcinoembryonic antigen cutoff is helpful in the differential diagnosis of mucinous versus non-mucinous pancreatic cysts. Indian J Gastroenterol 2022; 41:397-404. [PMID: 36057043 DOI: 10.1007/s12664-022-01269-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 06/02/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Pancreatic cystic lesions (PCLs) are being diagnosed with increased frequency and have varying neoplastic potential. We conducted this multimodal, prospective study to evaluate the role of tumor cytology and molecular markers to differentiate PCL subtypes. METHODS Consecutive undiagnosed patients with PCLs (n = 100, mean age: 50.37 years; 41% males) were prospectively studied. Cyst fluid carcinoembryonic antigen (CEA), CA19.9, CA125, CA72.4, and vascular endothelial growth factor-alpha (VEGF-α) levels were measured by quantitative enzyme-linked immunosorbent assay (ELISA) method. Mutational analysis of the KRAS gene (exon 2, Codon 12 and 13) and GNAS gene (Exon 8, Codon 201) were performed by Sanger's sequencing. RESULTS The mean cyst size was 4.32 ± 2.4 cm. Fluid cytology revealed definitive diagnosis in 21 (22.3%) patients. All malignant PCLs could be identified on cytology whereas 10/14 (71%) non-malignant mucinous PCLs could also be identified on cytology based on mucin staining. Among the tested tumor markers, cyst fluid CEA had the best diagnostic performance for differentiation between mucinous and non-mucinous PCLs (AUC 0.933 [95% CI 0.86-0.91]). At a cyst fluid CEA cutoff level of 45.0 ng/mL, the sensitivity, specificity, positive predictive value, and negative predictive value for differentiation between mucinous and non-mucinous cysts were 88.5%, 96.8%, 92.0%, and 95.3%, respectively (p < 0.05). KRAS and GNAS mutation had no significant diagnostic benefit in comparison to fluid cytology and CEA levels. CONCLUSIONS Fluid CEA at a lower cutoff of 45 ng/mL is the most accurate marker to differentiate between mucinous and non-mucinous PCL. The KRAS and GNAS mutational analysis does not improve upon the diagnostic performance of fluid cytology and tumor markers.
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Affiliation(s)
- Ravi Kumar Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Nikhil Bush
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
| | - Radhika Srinivasan
- Department of Cytology and Gynecology Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Satyavati Rana
- Department of Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Tarundeep Singh
- Department of Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
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Pușcașu CI, Rimbaş M, Mateescu RB, Larghi A, Cauni V. Advances in the Diagnosis of Pancreatic Cystic Lesions. Diagnostics (Basel) 2022; 12:diagnostics12081779. [PMID: 35892490 PMCID: PMC9394320 DOI: 10.3390/diagnostics12081779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are a heterogenous group of lesions ranging from benign to malignant. There has been an increase in PCLs prevalence in recent years, mostly due to advances in imaging techniques, increased awareness of their existence and population aging. Reliable discrimination between neoplastic and non-neoplastic cystic lesions is paramount to ensuring adequate treatment and follow-up. Although conventional diagnostic techniques such as ultrasound (US), magnetic resonance imaging (MRI) and computer tomography (CT) can easily identify these lesions, assessing the risk of malignancy is limited. Endoscopic ultrasound (EUS) is superior to cross-sectional imaging in identifying potentially malignant lesions due to its high resolution and better imaging characteristics, and the advantage of allowing for cyst fluid sampling via fine-needle aspiration (FNA). More complex testing, such as cytological and histopathological analysis and biochemical and molecular testing of the aspirated fluid, can ensure an accurate diagnosis.
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Affiliation(s)
- Claudia Irina Pușcașu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
| | - Mihai Rimbaş
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
- Department of Internal Medicine, Carol Davila University of Medicine, 050474 Bucharest, Romania
- Correspondence: ; Tel.: +40-723-232-052
| | - Radu Bogdan Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
- Department of Internal Medicine, Carol Davila University of Medicine, 050474 Bucharest, Romania
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Victor Cauni
- Urology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania;
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Abstract
Andrew Canakis.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Linda S Lee
- Division of Gastroenterology Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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Pancreatic cystic lesions. Differential diagnosis and treatment strategy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2022; 87:188-197. [DOI: 10.1016/j.rgmxen.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/05/2021] [Indexed: 11/20/2022]
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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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Lira-Treviño A, Carranza Mendoza IG, Borbolla Arizti JP, Soriano-Ríos A, Uscanga-Domínguez L, Peláez-Luna M. Pancreatic cystic lesions. Differential diagnosis and treatment strategy. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:188-197. [PMID: 35610168 DOI: 10.1016/j.rgmx.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/05/2021] [Indexed: 04/14/2025]
Abstract
The differential diagnosis of pancreatic cystic lesions (PCLs) includes non-neoplastic lesions and neoplastic epithelial lesions. Given that management is determined by the risk for malignant progression, associated symptoms, and other characteristics, an accurate diagnosis is imperative. The present review attempts to provide a critical path that facilitates the characterization and management of PCLs.
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Affiliation(s)
- A Lira-Treviño
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - A Soriano-Ríos
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - L Uscanga-Domínguez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - M Peláez-Luna
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; División de Investigación, Facultad de Medicina, UNAM, Mexico City, Mexico.
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Hu F, Hu Y, Wang D, Ma X, Yue Y, Tang W, Liu W, Wu P, Peng W, Tong T. Cystic Neoplasms of the Pancreas: Differential Diagnosis and Radiology Correlation. Front Oncol 2022; 12:860740. [PMID: 35299739 PMCID: PMC8921498 DOI: 10.3389/fonc.2022.860740] [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] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/04/2022] [Indexed: 12/18/2022] Open
Abstract
Although the probability of pancreatic cystic neoplasms (PCNs) being detected is raising year by year, their differential diagnosis and individualized treatment are still a challenge in clinical work. PCNs are tumors containing cystic components with different biological behaviors, and their clinical manifestations, epidemiology, imaging features, and malignant risks are different. Some are benign [e.g., serous cystic neoplasms (SCNs)], with a barely possible that turning into malignant, while others display a low or higher malignant risk [e.g., solid pseudopapillary neoplasms (SPNs), intraductal papillary mucinous neoplasms (IPMNs), and mucinous cystic neoplasms (MCNs)]. PCN management should concentrate on preventing the progression of malignant tumors while preventing complications caused by unnecessary surgical intervention. Clinically, various advanced imaging equipment are usually combined to obtain a more reliable preoperative diagnosis. The challenge for clinicians and radiologists is how to accurately diagnose PCNs before surgery so that corresponding surgical methods and follow-up strategies can be developed or not, as appropriate. The objective of this review is to sum up the clinical features, imaging findings and management of the most common PCNs according to the classic literature and latest guidelines.
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Affiliation(s)
- Feixiang Hu
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yue Hu
- Hefei Cancer Hospital, Chinese Academy of Sciences (CAS), Hefei, China
| | - Dan Wang
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Xiaowen Ma
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yali Yue
- Children's Hospital, Fudan University, Shanghai, China
| | - Wei Tang
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Liu
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Puye Wu
- General Electric (GE) Healthcare, Shanghai, China
| | - Weijun Peng
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tong Tong
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Impact of Antibiotic Prophylaxis on Infection Rate after Endoscopic Ultrasound Through-the-Needle Biopsy of Pancreatic Cysts: A Propensity Score-Matched Study. Diagnostics (Basel) 2022; 12:diagnostics12010211. [PMID: 35054378 PMCID: PMC8774428 DOI: 10.3390/diagnostics12010211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Despite weak evidence, antibiotic prophylaxis prior to endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) of pancreatic cystic lesions (PCLs) is routinely used in clinical practice. We aim to compare a group of patients treated with antibiotics before EUS-TTNB of PCLs and a group who did not undergo antimicrobial prophylaxis. Methods: Out of 236 patients with pancreatic cystic lesions referred to two high-volume centers between 2016 and 2021, after propensity score matching, two groups were compared: 98 subjects who underwent EUS-TTNB under antibiotic prophylaxis and 49 subjects without prophylaxis. Results: There was no difference in terms of baseline parameters between groups. Final diagnosis was serous cystadenoma in 36.7% of patients in the group not treated with prophylaxis and in 37.7% of patients in the control group, whereas IPMN and mucinous cystadenoma were diagnosed in 3 (6.1%) and 16 (32.6%) versus 6 (6.1%) and 32 (32.6%) patients in the two groups, respectively (p = 0.23). Overall, the adverse event rate was 6.1% in the group not treated with antibiotic prophylaxis and 5.1% in the control group (p = 0.49). Only a single infectious adverse event occurred in each group (p = 0.48). The diagnostic yields were 89.7% and 90.8% in the two groups (p = 0.7), and the diagnostic accuracy rate was 81.6% in both groups (p = 1.0). Conclusions: Prophylactic antibiotics do not seem to influence the risk of infection, and their routine use should be discouraged.
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Gorris M, Janssen QP, Besselink MG, van den Broek BLJ, van Eijck CHJ, van Gils MJ, Koerkamp BG, Struik F, van Driel LMJW, van Hooft JE. Sensitivity of CT, MRI, and EUS-FNA/B in the preoperative workup of histologically proven left-sided pancreatic lesions. Pancreatology 2022; 22:136-141. [PMID: 34857486 DOI: 10.1016/j.pan.2021.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Left-sided pancreatic lesions are often treated surgically. Accurate diagnostic work-up is therefore essential to prevent futile major abdominal surgery. Large series focusing specifically on the preoperative work-up of left-sided pancreatic lesions are lacking. This surgical cohort analysis describes the sensitivity of CT, MRI, and EUS-FNA/B in the diagnostic work-up of left-sided pancreatic lesions. METHODS We performed a post-hoc analysis of patients who underwent surgery for a left-sided pancreatic lesion between April 2010 and August 2017 and participated in the randomized CPR trial. Primary outcome was the sensitivity of CT, MRI, and EUS-FNA/B. Sensitivity was determined as the most likely diagnosis of each modality compared with the postoperative histopathological diagnosis. Additionally, the change in sensitivity of EUS versus EUS-FNA/B (i.e., cyst fluid analysis, and/or tissue acquisition) was measured. RESULTS Overall, 181 patients were included (benign: 23%, premalignant: 27%, malignant: 50%). Most patients had solid lesions (65%). Preoperative imaging included CT (86%), MRI (41%), EUS (68%). Overall, CT and EUS-FNA/B reached a sensitivity of both 71%, compared with 66% for MRI. When EUS was combined with FNA/B, sensitivity rose from 64% to 71%. For solid lesions, CT reached the highest sensitivity (75%) when compared with MRI (70%) and EUS-FNA/B (69%). For cystic lesions, EUS-FNA/B reached the highest sensitivity (75%) when compared with CT and MRI (both 62%). CONCLUSIONS CT is the most sensitive diagnostic modality for solid and EUS-FNA/B for cystic left-sided pancreatic lesions. EUS-FNA/B was associated with an increased sensitivity when compared to EUS alone.
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Affiliation(s)
- Myrte Gorris
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | - Quisette P Janssen
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bram L J van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marjon J van Gils
- Department of Radiology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Femke Struik
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
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Nista EC, Schepis T, Candelli M, Giuli L, Pignataro G, Franceschi F, Gasbarrini A, Ojetti V. Humoral Predictors of Malignancy in IPMN: A Review of the Literature. Int J Mol Sci 2021; 22:ijms222312839. [PMID: 34884643 PMCID: PMC8657857 DOI: 10.3390/ijms222312839] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cystic lesions are increasingly detected in cross-sectional imaging. Intraductal papillary mucinous neoplasm (IPMN) is a mucin-producing subtype of the pancreatic cyst lesions arising from the pancreatic duct system. IPMN is a potential precursor of pancreatic cancer. The transformation of IPMN in pancreatic cancer is progressive and requires the occurrence of low-grade dysplasia, high-grade dysplasia, and ultimately invasive cancer. Jaundice, enhancing mural nodule >5 mm, main pancreatic duct diameter >10 mm, and positive cytology for high-grade dysplasia are considered high-risk stigmata of malignancy. While increased levels of carbohydrate antigen 19-9 (CA 19-9) (>37 U/mL), main pancreatic duct diameter 5-9.9 mm, cyst diameter >40 mm, enhancing mural nodules <5 mm, IPMN-induced acute pancreatitis, new onset of diabetes, cyst grow-rate >5 mm/year are considered worrisome features of malignancy. However, cross-sectional imaging is often inadequate in the prediction of high-grade dysplasia and invasive cancer. Several studies evaluated the role of humoral and intra-cystic biomarkers in the prediction of malignancy in IPMN. Carcinoembryonic antigen (CEA), CA 19-9, intra-cystic CEA, intra-cystic glucose, and cystic fluid cytology are widely used in clinical practice to distinguish between mucinous and non-mucinous cysts and to predict the presence of invasive cancer. Other biomarkers such as cystic fluid DNA sequencing, microRNA (mi-RNA), circulating microvesicles, and liquid biopsy are the new options for the mini-invasive diagnosis of degenerated IPMN. The aim of this study is to review the literature to assess the role of humoral and intracystic biomarkers in the prediction of advanced IPMN with high-grade dysplasia or invasive carcinoma.
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Affiliation(s)
- Enrico C. Nista
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.C.N.); (T.S.); (L.G.); (A.G.)
| | - Tommaso Schepis
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.C.N.); (T.S.); (L.G.); (A.G.)
| | - Marcello Candelli
- Department of Emergency Medicine, Fondazione Policlinico Universitario, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.C.); (G.P.); (F.F.)
| | - Lucia Giuli
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.C.N.); (T.S.); (L.G.); (A.G.)
| | - Giulia Pignataro
- Department of Emergency Medicine, Fondazione Policlinico Universitario, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.C.); (G.P.); (F.F.)
| | - Francesco Franceschi
- Department of Emergency Medicine, Fondazione Policlinico Universitario, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.C.); (G.P.); (F.F.)
| | - Antonio Gasbarrini
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.C.N.); (T.S.); (L.G.); (A.G.)
| | - Veronica Ojetti
- Department of Emergency Medicine, Fondazione Policlinico Universitario, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.C.); (G.P.); (F.F.)
- Correspondence: ; Tel.: +39-063-0153-188
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Lisotti A, Napoleon B, Facciorusso A, Cominardi A, Crinò SF, Brighi N, Gincul R, Kitano M, Yamashita Y, Marchegiani G, Fusaroli P. Contrast-enhanced EUS for the characterization of mural nodules within pancreatic cystic neoplasms: systematic review and meta-analysis. Gastrointest Endosc 2021; 94:881-889.e5. [PMID: 34217751 DOI: 10.1016/j.gie.2021.06.028] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Pancreatic cystic neoplasms (PCNs) carry a considerable malignancy risk. Along with main duct dilation, the presence of enhanced mural nodules represents a significant risk factor for malignancy. Several articles assessed the role of contrast-enhanced EUS (CE-EUS) for the identification of malignant features in mural nodules. We evaluate the pooled diagnostic performance of CE-EUS for the identification of high-grade dysplasia or invasive carcinoma among mural nodules in PCNs. METHODS A systematic review (Medline, PubMed, EMBASE) and meta-analysis were conducted. Subgroup analysis was used to assess the usefulness of a dedicated contrast-harmonic (CH-EUS). The primary outcome was pooled sensitivity for identification of high-grade dysplasia or invasive carcinoma. RESULTS Ten studies (532 patients) were included. Pooled sensitivity of CE-EUS was 88.2% (95% confidence interval [CI], 82.7%-92.5%), specificity 79.1% (95% CI, 74.5%-83.3%), and diagnostic accuracy 89.6% (95% CI, 83.4%-95.8%). Eight studies (320 patients) were conducted using CH-EUS: pooled sensitivity increased to 97.0% (95% CI, 92.5%-99.2%), specificity to 90.4% (95% CI, 85.2%-94.2%), and diagnostic accuracy to 95.6% (95% CI, 92.6%-98.7%). At 42% disease prevalence (pretest probability), a positive CH-EUS increased the disease probability to 88%, whereas a negative test decreased the disease probability to 2%. The number needed to diagnose was 1.5 (95% CI, 1.7-1.3) for CE-EUS and just 1.2 (95% CI, 1.3-1.1) for CH-EUS. CONCLUSIONS This study provided robust evidence on CE-EUS value for the characterization of mural nodules within PCNs. A dedicated contrast-harmonic mode, namely CH-EUS, provided an increased diagnostic yield in the identification and characterization of malignant mural nodules.
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Affiliation(s)
- Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy; Endoscopy Unit, Hôpital privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Bertrand Napoleon
- Endoscopy Unit, Hôpital privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Antonio Facciorusso
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per Lo Studio Dei Tumori (IRST) "Dino Amadori," Meldola, Itally
| | - Anna Cominardi
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Nicole Brighi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Rodica Gincul
- Endoscopy Unit, Hôpital privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | | | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
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Watase C, Fuse M, Ino Y, Naito C, Hiraoka N. Novel insights into immunohistochemical analysis for diagnosing serous neoplasm of the pancreas: aquaporin 1, stereocilin, and transmembrane protein 255B. Histopathology 2021; 79:872-879. [PMID: 34288030 DOI: 10.1111/his.14456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/08/2021] [Accepted: 07/18/2021] [Indexed: 11/26/2022]
Abstract
AIMS Serous (cystic) neoplasm (SCN) of the pancreas is generally benign, and surgical treatment is recommended in only a limited number of cases. To avoid unnecessary surgery, an accurate diagnosis of SCN is essential. In the present study, we aimed to identify new immunohistochemical markers with which to distinguish SCN from other tumours. METHODS AND RESULTS We compared the comprehensive gene expression profiles of SCN with those of normal pancreas and pancreatic ductal adenocarcinoma (PDAC). We selected the candidate molecules that were up-regulated in SCN, were minimally expressed or unexpressed in PDAC, and had specific and available antibodies suitable for immunohistochemistry, and then analysed their immunohistochemical expression in various tumours. We selected aquaporin 1 (AQP1), stereocilin (STRC), fibroblast growth factor receptor 3 (FGFR3), and transmembrane protein 255B (TMEM255B), which were diffusely expressed in SCN cells in 79%, 100%, 100% and 100% of SCN cases. AQP1 was not expressed in other tumours, except in 20% of mucinous cystic neoplasms (MCNs) and 19% of PDACs. STRC was rarely expressed in MCNs, neuroendocrine neoplasms (NENs), and PDACs. FGFR3 was expressed in 31% of intraductal papillary mucinous neoplasms (IPMNs), 50% of intraductal oncocytic papillary neoplasms, 40% of NENs, 30% of acinar cell carcinomas, 40% of solid pseudopapillary neoplasms, and 52% of PDACs. TMEM255B was not expressed in the other tumours, except in 50% of MCNs, 80% of gastric-subtype IPMNs, and 29% of PDACs. All antigens were usually expressed in a small proportion of cells when they were positive in tumours other than SCN. CONCLUSIONS These findings indicate that AQP1 and STRC, and potentially TMEM255B, may act as SCN markers.
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Affiliation(s)
- Chikashi Watase
- Division of Molecular Pathology, National Cancer Centre Research Institute, Tokyo, Japan
- Department of Analytical Pathology, National Cancer Centre Research Institute, Tokyo, Japan
- Department of Molecular Oncology, Graduate School of Medicine, Jikei University, Tokyo, Japan
| | - Masanori Fuse
- Division of Molecular Pathology, National Cancer Centre Research Institute, Tokyo, Japan
- Department of Analytical Pathology, National Cancer Centre Research Institute, Tokyo, Japan
| | - Yoshinori Ino
- Division of Molecular Pathology, National Cancer Centre Research Institute, Tokyo, Japan
- Department of Analytical Pathology, National Cancer Centre Research Institute, Tokyo, Japan
| | - Chie Naito
- Division of Molecular Pathology, National Cancer Centre Research Institute, Tokyo, Japan
- Department of Analytical Pathology, National Cancer Centre Research Institute, Tokyo, Japan
| | - Nobuyoshi Hiraoka
- Division of Molecular Pathology, National Cancer Centre Research Institute, Tokyo, Japan
- Department of Analytical Pathology, National Cancer Centre Research Institute, Tokyo, Japan
- Department of Molecular Oncology, Graduate School of Medicine, Jikei University, Tokyo, Japan
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Barutcuoglu B, Oruc N, Ak G, Kucukokudan S, Aydın A, Nart D, Harman M. Co-analysis of pancreatic cyst fluid carcinoembryonic antigen and glucose with novel cut-off levels better distinguishes between mucinous and non-mucinous neoplastic pancreatic cystic lesions. Ann Clin Biochem 2021; 59:125-133. [PMID: 34719238 DOI: 10.1177/00045632211053998] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cyst fluid analysis plays an important role in distinguishing between mucinous and non-mucinous cyst lesions. We aimed to compare the diagnostic performances of cyst fluid carcinoembryonic antigen (CEA), CA 19-9, and glucose in differentiating mucinous from non-mucinous neoplastic pancreatic cystic lesions (PCLs) and determine the best cut-off levels. METHODS Patients' data were evaluated retrospectively. 102 patients' PCLs were grouped as non-neoplastic (n = 25), non-mucinous neoplastic (n = 20), mucinous neoplastic (n = 47) and pancreatic adenocarcinomas with cystic degeneration (n = 10); and CEA, CA 19-9, and glucose levels were compared. Receiver-operating characteristic analysis was performed, and the ideal cut-off values were determined. RESULTS Cyst fluid CEA and CA 19-9, levels were significantly higher (P < 0.001, P < 0.001, respectively) and glucose levels were significantly lower (P = 0.001) in mucinous than in non-mucinous neoplastic PCLs. Area under curve with 95% confidence interval of CEA, glucose and CEA and glucose test combination was 0.939 (95% CI = 0.885-0.993, P = 0.001), 0.809 (95% CI = 0.695-0.924, P < 0.001) and 0.937 (95% CI = 0.879-0.995), respectively. CEA cut-offs to rule-in and rule-out mucinous neoplastic were 135.1 ng/mL (sensitivity = 62%, specificity = 94.7%) and 6.12 ng/mL (sensitivity = 94.1%, specificity = 80.4%), respectively. Glucose cut-off of 2.8 mmol/L was chosen both to rule-in and rule-out mucinous neoplastic PCLs (sensitivity = 78%, specificity = 80%). Co-analysis of CEA and glucose to distinguish mucinous from non-mucinous neoplastic PCLs had sensitivity = 87.8%, specificity = 93.3%, and diagnostic accuracy = 89.3%. CONCLUSIONS We concluded that co-analysis of cyst fluid CEA (cut-off = 135.1 ng/mL) and glucose (cut-off = 2.8 mmol/L) at novel cut-offs had the best testing performance to rule-in mucinous neoplastic PCLs. To rule-out mucinous PCLs co-analysis of CEA (cut-off = 6.12 ng/mL) and glucose (cut-off = 2.8 mmol/L) added value to prediction.
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Affiliation(s)
- Burcu Barutcuoglu
- Department of Clinical Biochemistry, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Nevin Oruc
- Department of Gastroenterology, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Güneş Ak
- Department of Clinical Biochemistry, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Serdar Kucukokudan
- Department of Medical Biochemistry, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Ahmet Aydın
- Department of Gastroenterology, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Deniz Nart
- Department of Pathology, 60521Ege University, Faculty of Medicine, Izmir, Turkey
| | - Mustafa Harman
- Department of Radiology, 60521Ege University, Faculty of Medicine, Izmir, Turkey
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45
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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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46
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Lee LS. Updates in diagnosis and management of pancreatic cysts. World J Gastroenterol 2021; 27:5700-5714. [PMID: 34629795 PMCID: PMC8473602 DOI: 10.3748/wjg.v27.i34.5700] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/14/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
Incidental pancreatic cysts are commonly encountered with some cysts having malignant potential. The most common pancreatic cystic neoplasms include serous cystadenoma, mucinous cystic neoplasm and intraductal papillary mucinous neoplasm. Risk stratifying pancreatic cysts is important in deciding whether patients may benefit from endoscopic ultrasound (EUS) or surgical resection. Surgery should be reserved for patients with malignant cysts or cysts at high risk for developing malignancy as suggested by various risk features including solid mass, nodule and dilated main pancreatic duct. EUS may supplement magnetic resonance imaging findings for cysts that remain indeterminate or have concerning features on imaging. Various cyst fluid markers including carcinoembryonic antigen, glucose, amylase, cytology, and DNA markers help distinguish mucinous from nonmucinous cysts. This review will guide the practicing gastroenterologist in how to evaluate incidental pancreatic cysts and when to consider referral for EUS or surgery. For presumed low risk cysts, surveillance strategies will be discussed. Managing pancreatic cysts requires an individualized approach that is directed by the various guidelines.
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Affiliation(s)
- Linda S Lee
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
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47
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Yip-Schneider MT, Wu H, Allison HR, Easler JJ, Sherman S, Al-Haddad MA, Dewitt JM, Schmidt CM. Biomarker Risk Score Algorithm and Preoperative Stratification of Patients with Pancreatic Cystic Lesions. J Am Coll Surg 2021; 233:426-434.e4. [PMID: 34166836 PMCID: PMC8403144 DOI: 10.1016/j.jamcollsurg.2021.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pancreatic cysts are incidentally detected in up to 13% of patients undergoing radiographic imaging. Of the most frequently encountered types, mucin-producing (mucinous) pancreatic cystic lesions may develop into pancreatic cancer, while nonmucinous ones have little or no malignant potential. Accurate preoperative diagnosis is critical for optimal management, but has been difficult to achieve, resulting in unnecessary major surgery. Here, we aim to develop an algorithm based on biomarker risk scores to improve risk stratification. STUDY DESIGN Patients undergoing surgery and/or surveillance for a pancreatic cystic lesion, with diagnostic imaging and banked pancreatic cyst fluid, were enrolled in the study after informed consent (n = 163 surgical, 67 surveillance). Cyst fluid biomarkers with high specificity for distinguishing nonmucinous from mucinous pancreatic cysts (vascular endothelial growth factor [VEGF], glucose, carcinoembryonic antigen [CEA], amylase, cytology, and DNA mutation) were selected. Biomarker risk scores were used to design an algorithm to predict preoperative diagnosis. Performance was tested using surgical (retrospective) and surveillance (prospective) cohorts. RESULTS In the surgical cohort, the biomarker algorithm outperformed the preoperative clinical diagnosis in correctly predicting the final pathologic diagnosis (91% vs 73%; p < 0.000001). Specifically, nonmucinous serous cystic neoplasms (SCN) and mucinous cystic neoplasms (MCN) were correctly classified more frequently by the algorithm than clinical diagnosis (96% vs 30%; p < 0.000008 and 92% vs 69%; p = 0.04, respectively). In the surveillance cohort, the algorithm predicted a preoperative diagnosis with high confidence based on a high biomarker score and/or consistency with imaging from ≥1 follow-up visits. CONCLUSIONS A biomarker risk score-based algorithm was able to correctly classify pancreatic cysts preoperatively. Importantly, this tool may improve initial and dynamic risk stratification, reducing overdiagnosis and underdiagnosis.
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Affiliation(s)
- Michele T Yip-Schneider
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Walther Oncology Center, Indianapolis, IN; Indiana University Simon Cancer Center, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - Huangbing Wu
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | | | - Jeffrey J Easler
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - Stuart Sherman
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - Mohammad A Al-Haddad
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - John M Dewitt
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Biochemistry/Molecular Biology, Indianapolis, IN; Walther Oncology Center, Indianapolis, IN; Indiana University Simon Cancer Center, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN.
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HooKim K, Reid MD. Atypical cells in fine needle aspiration biopsies of pancreas: Causes, work-up, and recommendations for management. Diagn Cytopathol 2021; 50:196-207. [PMID: 34378874 DOI: 10.1002/dc.24848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/22/2022]
Abstract
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a sensitive and specific method for diagnosing cancer in solid pancreatic masses. However, some cases receive indeterminate atypical diagnoses, which creates management dilemmas. In the 2014 Papanicolaou Society of Cytopathology (PSC) standardized guidelines for pancreatobiliary cytology, specimens in the "Atypical" category show a spectrum of architectural and/or cellular changes beyond normal or reactive, but, quantitatively or qualitatively, insufficient for classification as neoplastic (benign/other), suspicious or positive for malignancy. Implementation of the PSC system decreased atypical diagnoses, particularly for cystic lesions, and redistributed many cases into benign and neoplastic categories. Because no set cytologic criteria exist for the "Atypical" category there is wide variability in its use, and its frequency ranges from 0%-16% (mean 6%). It consists of a heterogeneous mix of cases that occur because of preanalytic, lesion-specific (low cellularity, necrosis, cystic, reactive and premalignant changes), to pathologist-dependent factors (experience, expertise, training and institutional case volume). Outcomes of atypical diagnoses in solid pancreatic masses range from benign to premalignant and malignant and include reactive atypia in pancreatitis, well differentiated adenocarcinoma, and non-ductal malignancies. The associated risk of malignancy (ROM) ranges from 28%-100%, with an overall intermediate ROM in large-scale studies. Cytopathologists and institutions should monitor and keep their personal and/or laboratory's atypical rates low by judiciously using rapid onsite evaluation, ancillary studies, consensus or expert review, as well as correlation with clinical and radiologic findings. Early repeat EUS-FNA is indicated for unresolved cases.
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Affiliation(s)
- Kim HooKim
- Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michelle D Reid
- Department of Pathology, Emory University Hospital, Atlanta, Georgia, USA
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Cystic pancreatic lesions: MR imaging findings and management. Insights Imaging 2021; 12:115. [PMID: 34374885 PMCID: PMC8355307 DOI: 10.1186/s13244-021-01060-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/17/2021] [Indexed: 12/14/2022] Open
Abstract
Cystic pancreatic lesions (CPLs) are frequently casual findings in radiological examinations performed for other reasons in patients with unrelated symptoms. As they require different management according to their histological nature, differential diagnosis is essential. Radiologist plays a key role in the diagnosis and management of these lesions as imaging is able to correctly characterize most of them and thus address to a correct management. The first step for a correct characterization is to look for a communication between the CPLs and the main pancreatic duct, and then, it is essential to evaluate the morphology of the lesions. Age, sex and a history of previous pancreatic pathologies are important information to be used in the differential diagnosis. As some CPLs with different pathologic backgrounds can show the same morphological findings, differential diagnosis can be difficult, and thus, the final diagnosis can require other techniques, such as endoscopic ultrasound, endoscopic ultrasound-fine needle aspiration and endoscopic ultrasound-through the needle biopsy, and multidisciplinary management is important for a correct management.
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Pancreatic cystic neoplasms: a review of current recommendations for surveillance and management. Abdom Radiol (NY) 2021; 46:3946-3962. [PMID: 33742217 DOI: 10.1007/s00261-021-03030-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 12/12/2022]
Abstract
Pancreatic cystic neoplasms (PCN) comprise of a diverse array of pancreatic cysts, including intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), cystic neuroendocrine tumors (cNET), and many others. Increasing use of cross-sectional imaging has resulted in greater numbers of PCNs discovered incidentally. The overall risk of malignancy is low, but can vary considerably between different classes of PCNs. Furthermore, many pancreatic cysts are indeterminate on imaging, and the inability to reliably predict the course of disease remains a challenge for radiologists. Due to the variability in disease course and a lack of high-quality studies on PCNs, there is no universal consensus when it comes to balancing optimal surveillance while avoiding the risk for overtreatment. Currently, there are three widely accepted international guidelines outlining guidelines for surveillance and management of PCNs: the American Gastroenterological Association (AGA) in 2015, the International Association of Pancreatology (IAP) last revised in 2017, and the European Study Group on Cystic Tumours of the Pancreas (European) last revised in 2018. In 2017, the American College of Radiology released its own comprehensive set of recommendations for managing indeterminate pancreatic cysts that are detected incidentally on CT or MRI. The purpose of this paper is to describe the key differences between the ACR recommendations and the aforementioned three sets of guidelines regarding cyst management, imaging surveillance, performance, and cost-effectiveness.
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