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A novel protocol for K-ras analysis using endopancreatic cytology
ERCP-PANCREAS t517
+519
A NOVEL PROTOCOL FOR K-ras ANALYSIS USING ENDOPANCREATIC CYTOLOGY. R.D. Brown. D. George, G. Dodda, R.P. Venu, and R. Banya. University of Illinois at Chicago, Chicago, IL Introduction. Early diagnosis of pancreatic adenocarcinoma remains difficult, but K-ras analysis of pancreatic cytology has been shown to improve sensitivity. Endoscopic methods of sampling for K-ras published to date involve procedure time and equipment beyond single brush cytology. In addition, current laboratory techniques are technically difficult and require specialized equipment. Utilizing single endopancreatic brush cytology and cleavage fragment length polymorphism analysis (CPLP) may overcome these limitations. Aim To determine whether sufficient RNA for K-ras analysis can be isolated from a single cytology brush previously smeared for routine cytologic examination ("spent" brush), to compare fixative media to preserve specimens, and to determine whether K-ras mutation can be identified by CFLP. Methods. Fourteen subjects with suspected pancreatic cancer or chronic pancreatitis underwent ERCP with endopancreatic brush cytology performed using a Geenen brush system. In 4 subjects, RNA yield from a "spent" first brash was compared 9 to of a flesh second brush. Time required for brushing was recorded. In 10 subjects, brushes were f'L~edin 2 m/4M guanidium isothiocyanate {(/IT) or commercial RNAzol. and RNA yields contpared Mutation pattern detection was performed after PCR amplification with CFLP bands compared to normal controls. Results. RNA yield from "spent" brushes was identical to that from second fresh brushes in all 4 patients. Time of each brushing averaged 10 minutes. All samples collected in 2 ml GIT had successful RNA isolation, whereas no samples collected in RNAzol had RNA successfully isolated. Overall l0 subjects had RNA evaluable by CFLP. Of those, all 3 subjects with a confirmed diagnosis of pancreatic adenocarcinoma had K-ras mutation patterns demonstrated by CFLP. Conclusion. Sufficient RNA for K-ras can be obtained from a single cytology brush after smearing for routine cytology, thus avoiding time and expense of a second brush. GIT appears to be an effective brush fixative in this setting. CFLP is capable of detecting K-ras mutation patterns in pancreatic carcinoma. This technique combined with single brush sampling may comprise a simplified and effective approach for K-ras mutation analysis.
PANCREATIC DUCTAL (PD) STONES IN PATIENTS WITH PANCREAS DIVISUM: SUCCESS OF REMOVAL AND SYMPTOMATIC IMPROVEMENT: MULTI-CENTER STUDY. MF Catalano. R Kozarek, S Sherman, G Lehman, J Baillie. J Geenen, C Deitch. J Vandervoort. D Cart-Locke, 1 Raijman. P Jowell. Milwaukee/BostordSeattle/Durham/Houstordlndianapolis. PD stones can cause acute exacerbation of pencreatitis or chronic abdonlinal pain. Successful removal of PD stones from the duct of Wirsung (ventral duct) has been achieved in over 70% with symptomatic improvement in most pts. The anatomic variant, pancreas divisum (PDIV), may hinder suc-cessful stone removal. METHODS: Twenty-eight pts (15M, 13F, age 34-62) with PDIV and dorsal PD stones in the setting of chronic pancreatitis presented over a 10-yr period. Fifteen pts presented with acute episode of pancreatitis while 13 presented with exacerbation of their chronic abdominal pain. Etiology ofpancreatitis was Idiopathic (17), ETOH (8), Familial (3). Sixteen of 28 pts had pancreatic insufficiency documented by secretin test (7) or fecal fat (9). Nine pts had a single stone, while 19 pts had multiple stones (2-10, mean 5.6 stones). Stone size ranged from 3-12mm. The dorsal duct was dilated in all pts (6-15ram). RESULTS: Successful stone extraction required 1-4 (mean 2.0) ERCPs. ES of the minor papilla was performed at the time of initial ERCP in 19 of 28 pts. Stone extraction was accomplished in 20 pts (14 complete, 6 partial). Single stones were successfully extracted in 6 of 9 pts (67%), multiple stones in 14 of 19 (74%). PD stents were placed after initial attempt at extraction (17) and palliation (4). Six pts required ESWL because of large or adherent stones (3 with subsequent complete, 3 partial removalL Of the 8 pts with unsuccessful stone extraction, 4 underwent pancreaticojejunostomy, 1 partial pancrearectomy, with good long-term results, while 2 were managed with stent therapy with reduction of symptoms and 1 no Rx with recurrent pain (mean F/U 3.8 yrs). Of the 6 pts with partial stone extraction 3 had surgical drainage procedures with good longterm response; 2 with good response with no further Rx; I with recurrent pain Imean F/U 2.3 yrs). Of the 14 pts with complete stone extraction; 1 underwent partial pancreatectomy because of a co-existing PD stricture; 13 had good long-term response (no pain/pancreatitis) at a mean F/U of 3.5 yrs. STONE EXTRACT LONG-TERM RESP PD Pt STONES NO YES NO PART ENDO RX SURG RX SINGLE 9 5 3 1 6 3 MULTIPLE 19 9 5 5 10 5 'ONCLUSIO/~ 3scoplc remow stones in the : can be accomplished in the majority of pts with good long-tern1 outcome. Those failing endoscopic therapy will often respond to surgical options.
518
+520
MAGNETIC RESONANCE PANCREATOGRAPHY: CORRELATION WITH ENDOSCOPIC RETROGRADE PANCREATOGRAPHY. M Carter, R. Pica, G Brodmerkel, Jr,, A. Lupetin, A. Thomas, R. Agrawal. Allegheny General Hospital, Pittsburgh Campus, Allegheny University of the Health Sciences, Pittsburgh, PA. INTRODUCTION; Magnetic resonance pancreatography (MRP) is a new, noninvastve method o f imaging the pancreatic duct (PD). The capability of this technique to obtain accurate images of the PD versus the standard o f endoscopic retrograde pancreatography (ERP) needs to be determined. AIMS: To measure PD size and assess dilatation o f secondary branches using MRP and correlate the findings with those obtained by ERP. METHODS: The PD was imaged using 18 second breath hold HalfFourier Acquisition Single-Shot Turbo Spin-Echo (HASTE) technique MRP in 11 patients with chronic pancreatitis or suspected pancreatic disease who were also evaluated by ERP. PD size was measured at the head, body, and tail regions, and secondary branches were assessed for dilatation. RESULTS: The entire main PD was imaged by MRP in all 11 patients, including 3 in whom ERP was unsuccessful. PD size was accurately measured to within l m m when compared with ERE in 6/8 cases; in one, MRP overestimated duct size by 2ram and in the other, underestimated it by 2mm in the head and body. Secondary branches were not visualized by MRP except in cases where they were dilated (3/ll). CONCLUSIONS: MRP is a reliable and accurate method to depict the main PD and can provide information when ERP is unsuccessful. Secondary branches are not visualized unless they are dilated.
THE ROLE OF ERCP IN PATIENTS PRESENTING WITH CLINICAL DISORDERS FOLLOWING PANCREATICOJEJUNOSTOMY(PJ): PRESENTATION. FINDINGS AND OUTCOME OF ENDOSCOPIC THERAPY. MF Catalano. S Lahoti, JE Geenen, I Raijman, WJ Hogan. Pancreatic Biliary Cent, St. Luke's Medical Cent, Milwaukee, WI. U. of Tx. Pancreatic drainage procedures have been used in the Rx. of obstructive disorders of the pancreas including chronic pancreatitis (CP), strictures, pancreatic ducl (PD) stones, acute recurrent pancreatitis CARP), papillary stenosis (PS) and others. However. some pts may develop recurrent/new symptoms following surgery caused by anastomotic strictures and recurrent PD stones. AIM: Determine the efficacy ofERCP inpts with recurrent symptoms following PJ for pancreatic disease. METHODS: Twemy-eight pts (9M, 19F, age 13-72, mean 48) with prior history of PJ underwent evaluation by ERCP. Indications included: pain (10), ARP (4), CP (9), acute and CP (5). Pts presented 8 mos to 10.5 yrs after PJ (mean 3.4 yrs). Therapeutic results were graded according to symptoms: excellent= no symptoms, good = rare, fair = occasional, poor = no change. RESULTS: ERCP findings; anastomotic strictures (121, PD strictures (6), PD stones (4), sphincter of Oddi dysfunction (SOD)/PS (21, ampullary Ca (1), normal post-op duct (3). Ten of 12 with anastomotic strictures [AS) had endoscopic Rx (dilation and/or stent); 6 of 12 (50%) ultimately required repeat operation (including 4 who failed endoscopic Rx). Three of 4 with PD strictures (PD-S) had endoscopic Rx (dilation and/or stent) while 2 of these t50%) ultimately bad repeat operation (including 1 who failed endoscopic Rx). All 4 pts with PD stones were treated successfully, (3 endoacoptc removal, I partial pancreatectomy. Endoscopic sphincterotomy resulted in good long-term outcome in 1 of 2 pts with SOD. Results of Endoscopic Rx Pancreatic Total(28) Disease No
Exc
Good
Fair
4
2
A-S
12
PD-S
6
Stone
4
SOD
2
1
Other
4
Repeat Poor !No Rx Surgery 3
2
6 (50%)
1
3
1
2 (33%)
3
1
1 (25%)
1
0
2 1 0 terapy appears to Ey m the initial therapy of pts presenting with recurrent pancreatic disease following PJ. Use of ERCP may obviate the need for repeat surgery in most patients except those with non-anastomotic strictures.
AB154
GASTROINTESTINAL ENDOSCOPY
VOLUME 45, NO. 4, 1997
+519
A NOVEL PROTOCOL FOR K-ras ANALYSIS USING ENDOPANCREATIC CYTOLOGY. R.D. Brown. D. George, G. Dodda, R.P. Venu, and R. Banya. University of Illinois at Chicago, Chicago, IL Introduction. Early diagnosis of pancreatic adenocarcinoma remains difficult, but K-ras analysis of pancreatic cytology has been shown to improve sensitivity. Endoscopic methods of sampling for K-ras published to date involve procedure time and equipment beyond single brush cytology. In addition, current laboratory techniques are technically difficult and require specialized equipment. Utilizing single endopancreatic brush cytology and cleavage fragment length polymorphism analysis (CPLP) may overcome these limitations. Aim To determine whether sufficient RNA for K-ras analysis can be isolated from a single cytology brush previously smeared for routine cytologic examination ("spent" brush), to compare fixative media to preserve specimens, and to determine whether K-ras mutation can be identified by CFLP. Methods. Fourteen subjects with suspected pancreatic cancer or chronic pancreatitis underwent ERCP with endopancreatic brush cytology performed using a Geenen brush system. In 4 subjects, RNA yield from a "spent" first brash was compared 9 to of a flesh second brush. Time required for brushing was recorded. In 10 subjects, brushes were f'L~edin 2 m/4M guanidium isothiocyanate {(/IT) or commercial RNAzol. and RNA yields contpared Mutation pattern detection was performed after PCR amplification with CFLP bands compared to normal controls. Results. RNA yield from "spent" brushes was identical to that from second fresh brushes in all 4 patients. Time of each brushing averaged 10 minutes. All samples collected in 2 ml GIT had successful RNA isolation, whereas no samples collected in RNAzol had RNA successfully isolated. Overall l0 subjects had RNA evaluable by CFLP. Of those, all 3 subjects with a confirmed diagnosis of pancreatic adenocarcinoma had K-ras mutation patterns demonstrated by CFLP. Conclusion. Sufficient RNA for K-ras can be obtained from a single cytology brush after smearing for routine cytology, thus avoiding time and expense of a second brush. GIT appears to be an effective brush fixative in this setting. CFLP is capable of detecting K-ras mutation patterns in pancreatic carcinoma. This technique combined with single brush sampling may comprise a simplified and effective approach for K-ras mutation analysis.
PANCREATIC DUCTAL (PD) STONES IN PATIENTS WITH PANCREAS DIVISUM: SUCCESS OF REMOVAL AND SYMPTOMATIC IMPROVEMENT: MULTI-CENTER STUDY. MF Catalano. R Kozarek, S Sherman, G Lehman, J Baillie. J Geenen, C Deitch. J Vandervoort. D Cart-Locke, 1 Raijman. P Jowell. Milwaukee/BostordSeattle/Durham/Houstordlndianapolis. PD stones can cause acute exacerbation of pencreatitis or chronic abdonlinal pain. Successful removal of PD stones from the duct of Wirsung (ventral duct) has been achieved in over 70% with symptomatic improvement in most pts. The anatomic variant, pancreas divisum (PDIV), may hinder suc-cessful stone removal. METHODS: Twenty-eight pts (15M, 13F, age 34-62) with PDIV and dorsal PD stones in the setting of chronic pancreatitis presented over a 10-yr period. Fifteen pts presented with acute episode of pancreatitis while 13 presented with exacerbation of their chronic abdominal pain. Etiology ofpancreatitis was Idiopathic (17), ETOH (8), Familial (3). Sixteen of 28 pts had pancreatic insufficiency documented by secretin test (7) or fecal fat (9). Nine pts had a single stone, while 19 pts had multiple stones (2-10, mean 5.6 stones). Stone size ranged from 3-12mm. The dorsal duct was dilated in all pts (6-15ram). RESULTS: Successful stone extraction required 1-4 (mean 2.0) ERCPs. ES of the minor papilla was performed at the time of initial ERCP in 19 of 28 pts. Stone extraction was accomplished in 20 pts (14 complete, 6 partial). Single stones were successfully extracted in 6 of 9 pts (67%), multiple stones in 14 of 19 (74%). PD stents were placed after initial attempt at extraction (17) and palliation (4). Six pts required ESWL because of large or adherent stones (3 with subsequent complete, 3 partial removalL Of the 8 pts with unsuccessful stone extraction, 4 underwent pancreaticojejunostomy, 1 partial pancrearectomy, with good long-term results, while 2 were managed with stent therapy with reduction of symptoms and 1 no Rx with recurrent pain (mean F/U 3.8 yrs). Of the 6 pts with partial stone extraction 3 had surgical drainage procedures with good longterm response; 2 with good response with no further Rx; I with recurrent pain Imean F/U 2.3 yrs). Of the 14 pts with complete stone extraction; 1 underwent partial pancreatectomy because of a co-existing PD stricture; 13 had good long-term response (no pain/pancreatitis) at a mean F/U of 3.5 yrs. STONE EXTRACT LONG-TERM RESP PD Pt STONES NO YES NO PART ENDO RX SURG RX SINGLE 9 5 3 1 6 3 MULTIPLE 19 9 5 5 10 5 'ONCLUSIO/~ 3scoplc remow stones in the : can be accomplished in the majority of pts with good long-tern1 outcome. Those failing endoscopic therapy will often respond to surgical options.
518
+520
MAGNETIC RESONANCE PANCREATOGRAPHY: CORRELATION WITH ENDOSCOPIC RETROGRADE PANCREATOGRAPHY. M Carter, R. Pica, G Brodmerkel, Jr,, A. Lupetin, A. Thomas, R. Agrawal. Allegheny General Hospital, Pittsburgh Campus, Allegheny University of the Health Sciences, Pittsburgh, PA. INTRODUCTION; Magnetic resonance pancreatography (MRP) is a new, noninvastve method o f imaging the pancreatic duct (PD). The capability of this technique to obtain accurate images of the PD versus the standard o f endoscopic retrograde pancreatography (ERP) needs to be determined. AIMS: To measure PD size and assess dilatation o f secondary branches using MRP and correlate the findings with those obtained by ERP. METHODS: The PD was imaged using 18 second breath hold HalfFourier Acquisition Single-Shot Turbo Spin-Echo (HASTE) technique MRP in 11 patients with chronic pancreatitis or suspected pancreatic disease who were also evaluated by ERP. PD size was measured at the head, body, and tail regions, and secondary branches were assessed for dilatation. RESULTS: The entire main PD was imaged by MRP in all 11 patients, including 3 in whom ERP was unsuccessful. PD size was accurately measured to within l m m when compared with ERE in 6/8 cases; in one, MRP overestimated duct size by 2ram and in the other, underestimated it by 2mm in the head and body. Secondary branches were not visualized by MRP except in cases where they were dilated (3/ll). CONCLUSIONS: MRP is a reliable and accurate method to depict the main PD and can provide information when ERP is unsuccessful. Secondary branches are not visualized unless they are dilated.
THE ROLE OF ERCP IN PATIENTS PRESENTING WITH CLINICAL DISORDERS FOLLOWING PANCREATICOJEJUNOSTOMY(PJ): PRESENTATION. FINDINGS AND OUTCOME OF ENDOSCOPIC THERAPY. MF Catalano. S Lahoti, JE Geenen, I Raijman, WJ Hogan. Pancreatic Biliary Cent, St. Luke's Medical Cent, Milwaukee, WI. U. of Tx. Pancreatic drainage procedures have been used in the Rx. of obstructive disorders of the pancreas including chronic pancreatitis (CP), strictures, pancreatic ducl (PD) stones, acute recurrent pancreatitis CARP), papillary stenosis (PS) and others. However. some pts may develop recurrent/new symptoms following surgery caused by anastomotic strictures and recurrent PD stones. AIM: Determine the efficacy ofERCP inpts with recurrent symptoms following PJ for pancreatic disease. METHODS: Twemy-eight pts (9M, 19F, age 13-72, mean 48) with prior history of PJ underwent evaluation by ERCP. Indications included: pain (10), ARP (4), CP (9), acute and CP (5). Pts presented 8 mos to 10.5 yrs after PJ (mean 3.4 yrs). Therapeutic results were graded according to symptoms: excellent= no symptoms, good = rare, fair = occasional, poor = no change. RESULTS: ERCP findings; anastomotic strictures (121, PD strictures (6), PD stones (4), sphincter of Oddi dysfunction (SOD)/PS (21, ampullary Ca (1), normal post-op duct (3). Ten of 12 with anastomotic strictures [AS) had endoscopic Rx (dilation and/or stent); 6 of 12 (50%) ultimately required repeat operation (including 4 who failed endoscopic Rx). Three of 4 with PD strictures (PD-S) had endoscopic Rx (dilation and/or stent) while 2 of these t50%) ultimately bad repeat operation (including 1 who failed endoscopic Rx). All 4 pts with PD stones were treated successfully, (3 endoacoptc removal, I partial pancreatectomy. Endoscopic sphincterotomy resulted in good long-term outcome in 1 of 2 pts with SOD. Results of Endoscopic Rx Pancreatic Total(28) Disease No
Exc
Good
Fair
4
2
A-S
12
PD-S
6
Stone
4
SOD
2
1
Other
4
Repeat Poor !No Rx Surgery 3
2
6 (50%)
1
3
1
2 (33%)
3
1
1 (25%)
1
0
2 1 0 terapy appears to Ey m the initial therapy of pts presenting with recurrent pancreatic disease following PJ. Use of ERCP may obviate the need for repeat surgery in most patients except those with non-anastomotic strictures.
AB154
GASTROINTESTINAL ENDOSCOPY
VOLUME 45, NO. 4, 1997