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How to improve the differential diagnosis of solid pancreatic masses? A prospective comparative study of contrast-enhanced harmonic endoscopic ultrasound vs quantitative-elastography
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Abstracts / Pancreatology 12 (2012) 502–597
Introduction: Pancreatic neuropathy and pain in pancreatic adenoarcinoma (PCa) and chronic pancreatitis (CP) are associated with decreased sympathetic innervation of the pancreas and “neural remodelling”. Aims/objectives: To complete the characterization of pancreatic neuropathy, the degree of myelination and glia content were investigated in intrapancreatic nerves in PCa and CP. Patients and methods: Intrapancreatic nerves of patients with PCa (n¼20), CP (n¼20) and normal human pancreas (n¼10) were immunolabeled with the neural myelination marker neurofilament-H (NFH), and the glial activation markers Glial-Fibrillary-Acidic-Protein (GFAP) und p75 receptor (p75NTR). The neural immunoreactivity of each marker was correlated to the neuropathic pain sensation, the degree of neural invasion (NI) in PCa and to the degree of pancreatic neuritis in PCa and CP. Results: PCa, and not CP, is associated with decreased neural immunoreactivity of GFAP, p75 and NFH. PCa patients with pain possess even less GFAP and NFH in their intrapancreatic nerves when compared to those without pain. Intrapancreatic nerves with increasing degree of pancreatic neuritis in PCa and NI harbour higher amounts of NFH and p75. Contrastingly, pancreatic neuritis in CP is mostly encountered around nerves with small NFH content. Conclusion: Pain in PCa is associated with increased appearance of unmyelinated intrapancreatic nerve fibers and a relative decrease of glia cells. However, pancreatic neuritis and NI in PCa are directed towards myelinated nerve fibers which are accompanied by activated glia cells. Therefore, pancreatic neuropathy in PCa induces a selective – non-global – glial activation and the dominance of unmyelinated and thus pain-transmitting intrapancreatic nerve fibers.
S11-1. Personal consultation on endoscopy and cytology could increase effectivity of intraductal brushing at ercp even in early cases of biliary and pancreatic cancer Á. Pap 1, Á. Tarpay 1, M. Burai 1, T. Nagy 2, M. Bak 3. 1 National Institute of Oncology, Dept. of Gastroenterology, Budapest, Hungary 2 National Institute of Oncology, Dept. of Chemotherapy, Budapest, Hungary 3 National Institute of Oncology, Dept. of Cytopathology, Budapest, Hungary
Background: Intraductal brush cytology (IBC) can be effective even in early cases of biliary and pancreatic cancers because the stenosis indicates optimal place of sampling at ERCP increasing sensitivity. During 40 months, 125 IBCs in 113 pts were performed by our oncoteam. Mean age of 61 females and 52 males was 65 years (34-85); 43 biliary and 57 pancreatic cancers were diagnosed by ERCP, ultrasonography, CT and/or MR. Method: For biliary cancers we performed papillotomy at ERCP and the cytological brush was introduced into the bile duct to the level of the sticture and several brushing were made. For pancreatic cancer IBC was performed alongside a guidewire without papillotomy. Samples were fixed and stained by routine methodes. ERCP pictures and personal consultation were supplied in all cases to increase efficacy. All patients were followedup in the clinical records until death or end of March, 2011. Results: ERCP was negative in 13 cases and positive in 100 patients with 57 pancreatic and 43 biliary strictures. Intraductal sampling from the strictured pancreatic (46) and biliary (47) ducts resulted in positive cytology. Sensitivities were calculated in patients with definitive diagnosis confirmed by death, surgery or progression during chemotherapy in 98 patients (86.7%): they proved to be 89.3%vs 97.6% at ERCP and 90.4% vs 86.7% with IBC from the pancreatic and biliary strictures, respectively. Decompression of bile duct and chemotherapy could be applied immediately without surgery in these mostly advanced cases, but resection-rate remained low even in patients with early cancer because of technical reasons. No complication occurred after the combined ERCP and IBC except a moderate pancreatitis after removal of the nasopancreatic drain at Day 5 and 1 death in a patient with COPD and mild pancreatitis 3 days after ERCP excluding cancer. In 5 cases>3x normal amylase elevation occurred.
Conclusion: IBC can be performed with almost 90% sensitivity and 100% specificity by expert endoscopists and cytologists if detailed consultation on both morphological techniques is assured in the every-day practice. Surgeons have to be involved in the personal consultation to increase resection-rate in early cases.
S11-2. How to improve the differential diagnosis of solid pancreatic masses? A prospective comparative study of contrast-enhanced harmonic endoscopic ultrasound vs quantitative-elastography J. Iglesias-Garcia 1, 2, B. Lindkvist 3,1, J.B. Cruz-Soares 4,1, L.M. Silva Araujo Lopes 5,1, C. Marra-Lopez 6,1, J. Lariño-Noia 1,2, J.E. Dominguez-Muñoz 1, 2. 1
Gastroenterology Department, University Hospital of Santiago de Compostela, Spain 2 Foundation for Research in Digestive Diseases (FIENAD), Spain 3 Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden 4 Gastroenterology Department, Braga Hospital, Portugal 5 Gastroenterology Department, Santa Luzia Hospital, Brazil 6 Gastroenterology Department, Txagorritxu Hospital, Spain Contrast-enhanced harmonic endoscopic ultrasound (CEHEUS) and quantitative-elastography endoscopic ultrasound (QE-EUS) are considered useful tools for the evaluation of solid pancreatic tumors (SPT). Aim of our study was to evaluate the diagnostic accuracy of CEHEUS, QE-EUS and the combination of both for the differential diagnosis of SPT. Methods: 62 consecutive patients (mean age 64.3 years, range 32-89 years, 44 male) who underwent EUS for the evaluation of SPT were prospectively included. EUS was performed with linear Pentax-EUS and Hitachi-Preirus processor. The mass (area A) and a reference area B were selected during QE-EUS, and results expressed as B/A (strain ratio). Microvascularization of the tumor was evaluated over two minutes during CEHEUS after i.v. injection of 4.8ml SonovueÒ. Final diagnosis was based on histopathology of surgical specimens or imaging assessment and clinical follow-up in non-operated cases. Data are shown as meanSD. Diagnostic accuracy of CEHEUS, QE-EUS, and their combination (either both or at least one positive) was calculated. Results: Size of the masses was 3616mm. Final diagnosis was pancreatic adenocarcinoma (n¼47), neuroendocrine tumor (n¼3), inflammatory mass (n¼10), pancreatic metastasis (n¼1), and autoimmune pancreatitis (n¼1). Overall diagnostic accuracy of QE-EUS, CEHEUS, and their combination is shown in the table. Conclusion: Diagnostic accuracy of QE-EUS for SPT is very high and superior to CEHEUS. Addition of CEHEUS does not significantly increase the diagnostic accuracy of QE-EUS.
QE-EUS CEHEUS Both-positive At least one positive
Sensitivity
Specificity
PPV
NPV
Accuracy
96.1% 90.2% 86.3% 100%
90.9% 81.8% 100% 72.4%
98% 95.8% 100% 94.4%
83.3% 64.3% 61.1% 100%
95.2% 88.7% 88.7% 95.2%
S11-3. Nucleotide transporters and dCK1 as prognostic markers for patients with resected pancreatic ductal adenocarcinoma with or without adjuvant gemcitabine or 5FU hENT1 tested with samples from patients randomized in the ESPAC1/3 trials J.P. Neoptolemos, T.F. Cox, W. Greenhalf, L. Garner, F. Campbell, D. Palmer, J. Mackey, C. Dervenis, A. Scarpa, C. Bassi, M.W. Buchler. for the European Study Group for Pancreatic Cancer; University of Liverpool, Liverpool, United Kingdom Department of Surgery, University of Heidelberg, Heidelberg, Germany
Abstracts / Pancreatology 12 (2012) 502–597
Introduction: Pancreatic neuropathy and pain in pancreatic adenoarcinoma (PCa) and chronic pancreatitis (CP) are associated with decreased sympathetic innervation of the pancreas and “neural remodelling”. Aims/objectives: To complete the characterization of pancreatic neuropathy, the degree of myelination and glia content were investigated in intrapancreatic nerves in PCa and CP. Patients and methods: Intrapancreatic nerves of patients with PCa (n¼20), CP (n¼20) and normal human pancreas (n¼10) were immunolabeled with the neural myelination marker neurofilament-H (NFH), and the glial activation markers Glial-Fibrillary-Acidic-Protein (GFAP) und p75 receptor (p75NTR). The neural immunoreactivity of each marker was correlated to the neuropathic pain sensation, the degree of neural invasion (NI) in PCa and to the degree of pancreatic neuritis in PCa and CP. Results: PCa, and not CP, is associated with decreased neural immunoreactivity of GFAP, p75 and NFH. PCa patients with pain possess even less GFAP and NFH in their intrapancreatic nerves when compared to those without pain. Intrapancreatic nerves with increasing degree of pancreatic neuritis in PCa and NI harbour higher amounts of NFH and p75. Contrastingly, pancreatic neuritis in CP is mostly encountered around nerves with small NFH content. Conclusion: Pain in PCa is associated with increased appearance of unmyelinated intrapancreatic nerve fibers and a relative decrease of glia cells. However, pancreatic neuritis and NI in PCa are directed towards myelinated nerve fibers which are accompanied by activated glia cells. Therefore, pancreatic neuropathy in PCa induces a selective – non-global – glial activation and the dominance of unmyelinated and thus pain-transmitting intrapancreatic nerve fibers.
S11-1. Personal consultation on endoscopy and cytology could increase effectivity of intraductal brushing at ercp even in early cases of biliary and pancreatic cancer Á. Pap 1, Á. Tarpay 1, M. Burai 1, T. Nagy 2, M. Bak 3. 1 National Institute of Oncology, Dept. of Gastroenterology, Budapest, Hungary 2 National Institute of Oncology, Dept. of Chemotherapy, Budapest, Hungary 3 National Institute of Oncology, Dept. of Cytopathology, Budapest, Hungary
Background: Intraductal brush cytology (IBC) can be effective even in early cases of biliary and pancreatic cancers because the stenosis indicates optimal place of sampling at ERCP increasing sensitivity. During 40 months, 125 IBCs in 113 pts were performed by our oncoteam. Mean age of 61 females and 52 males was 65 years (34-85); 43 biliary and 57 pancreatic cancers were diagnosed by ERCP, ultrasonography, CT and/or MR. Method: For biliary cancers we performed papillotomy at ERCP and the cytological brush was introduced into the bile duct to the level of the sticture and several brushing were made. For pancreatic cancer IBC was performed alongside a guidewire without papillotomy. Samples were fixed and stained by routine methodes. ERCP pictures and personal consultation were supplied in all cases to increase efficacy. All patients were followedup in the clinical records until death or end of March, 2011. Results: ERCP was negative in 13 cases and positive in 100 patients with 57 pancreatic and 43 biliary strictures. Intraductal sampling from the strictured pancreatic (46) and biliary (47) ducts resulted in positive cytology. Sensitivities were calculated in patients with definitive diagnosis confirmed by death, surgery or progression during chemotherapy in 98 patients (86.7%): they proved to be 89.3%vs 97.6% at ERCP and 90.4% vs 86.7% with IBC from the pancreatic and biliary strictures, respectively. Decompression of bile duct and chemotherapy could be applied immediately without surgery in these mostly advanced cases, but resection-rate remained low even in patients with early cancer because of technical reasons. No complication occurred after the combined ERCP and IBC except a moderate pancreatitis after removal of the nasopancreatic drain at Day 5 and 1 death in a patient with COPD and mild pancreatitis 3 days after ERCP excluding cancer. In 5 cases>3x normal amylase elevation occurred.
Conclusion: IBC can be performed with almost 90% sensitivity and 100% specificity by expert endoscopists and cytologists if detailed consultation on both morphological techniques is assured in the every-day practice. Surgeons have to be involved in the personal consultation to increase resection-rate in early cases.
S11-2. How to improve the differential diagnosis of solid pancreatic masses? A prospective comparative study of contrast-enhanced harmonic endoscopic ultrasound vs quantitative-elastography J. Iglesias-Garcia 1, 2, B. Lindkvist 3,1, J.B. Cruz-Soares 4,1, L.M. Silva Araujo Lopes 5,1, C. Marra-Lopez 6,1, J. Lariño-Noia 1,2, J.E. Dominguez-Muñoz 1, 2. 1
Gastroenterology Department, University Hospital of Santiago de Compostela, Spain 2 Foundation for Research in Digestive Diseases (FIENAD), Spain 3 Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden 4 Gastroenterology Department, Braga Hospital, Portugal 5 Gastroenterology Department, Santa Luzia Hospital, Brazil 6 Gastroenterology Department, Txagorritxu Hospital, Spain Contrast-enhanced harmonic endoscopic ultrasound (CEHEUS) and quantitative-elastography endoscopic ultrasound (QE-EUS) are considered useful tools for the evaluation of solid pancreatic tumors (SPT). Aim of our study was to evaluate the diagnostic accuracy of CEHEUS, QE-EUS and the combination of both for the differential diagnosis of SPT. Methods: 62 consecutive patients (mean age 64.3 years, range 32-89 years, 44 male) who underwent EUS for the evaluation of SPT were prospectively included. EUS was performed with linear Pentax-EUS and Hitachi-Preirus processor. The mass (area A) and a reference area B were selected during QE-EUS, and results expressed as B/A (strain ratio). Microvascularization of the tumor was evaluated over two minutes during CEHEUS after i.v. injection of 4.8ml SonovueÒ. Final diagnosis was based on histopathology of surgical specimens or imaging assessment and clinical follow-up in non-operated cases. Data are shown as meanSD. Diagnostic accuracy of CEHEUS, QE-EUS, and their combination (either both or at least one positive) was calculated. Results: Size of the masses was 3616mm. Final diagnosis was pancreatic adenocarcinoma (n¼47), neuroendocrine tumor (n¼3), inflammatory mass (n¼10), pancreatic metastasis (n¼1), and autoimmune pancreatitis (n¼1). Overall diagnostic accuracy of QE-EUS, CEHEUS, and their combination is shown in the table. Conclusion: Diagnostic accuracy of QE-EUS for SPT is very high and superior to CEHEUS. Addition of CEHEUS does not significantly increase the diagnostic accuracy of QE-EUS.
QE-EUS CEHEUS Both-positive At least one positive
Sensitivity
Specificity
PPV
NPV
Accuracy
96.1% 90.2% 86.3% 100%
90.9% 81.8% 100% 72.4%
98% 95.8% 100% 94.4%
83.3% 64.3% 61.1% 100%
95.2% 88.7% 88.7% 95.2%
S11-3. Nucleotide transporters and dCK1 as prognostic markers for patients with resected pancreatic ductal adenocarcinoma with or without adjuvant gemcitabine or 5FU hENT1 tested with samples from patients randomized in the ESPAC1/3 trials J.P. Neoptolemos, T.F. Cox, W. Greenhalf, L. Garner, F. Campbell, D. Palmer, J. Mackey, C. Dervenis, A. Scarpa, C. Bassi, M.W. Buchler. for the European Study Group for Pancreatic Cancer; University of Liverpool, Liverpool, United Kingdom Department of Surgery, University of Heidelberg, Heidelberg, Germany