- Email: [email protected]
“I think you have pancreatic cancer but I can’t prove it yet”
AJG – April, 2001
20. Kellner R. Psychosomatic syndromes, somatization and somatoform disorders. Psychother Psychosom 1994;61:4 –24. 21. Escobar JI, Waitzkin H, Silver RC, et al. Abridged somatization: A study in primary care. Psychosom Med 1998; 60:466 –72. 22. Reilly J, Baker GA, Rhodes J, Salmon P. The association of sexual and physical abuse with somatization: Characteristics of patients presenting with irritable bowel syndrome and nonepileptic attack disorder. Psychol Med 1999;29:399 – 406. 23. Drossman DA, Talley NJ, Leserman J, et al. Sexual and physical abuse and gastrointestinal illness. Review and recommendations. Ann Intern Med 1995;123:782–94. 24. Nyhlin H, Ford MJ, Eastwood J, et al. Non-alimentary aspects of the irritable bowel syndrome. J Psychosom Res 1993;37: 155– 62. 25. Simon GE, Gureje O. Stability of somatization disorder and somatization symptoms among primary care patients. Arch Gen Psychiatry 1999;56:90 –5. 26. Harvey RF, Mauad EC, Brown AM. Prognosis in the irritable bowel syndrome: A five-year prospective study. Lancet 1987; 1:963–5. 27. Kay L, Jorgensen T, Jensen KH. The epidemiology of irritable bowel syndrome in a random population: prevalence, incidence, natural history and risk factors. J Intern Med 1994;236: 23–30. 28. Garcia-Campayo J, Sanz-Carrillo C. A review of the differences between somatizing and psychologizing patients in primary care. Int J Psychiatry Med 1999;29:337– 45. 29. Cloninger C. Somatoform and dissociative disorders. In: Winokur G, Clayton P, eds. The medical basis of psychiatry, 2nd ed. Philadelphia: Saunders, 1994. 30. Martin RL. Problems in the diagnosis of somatization disorder: Effects on research and clinical practice. Psychiatr Ann 1988;18:357– 62. 31. Ruigomez A, Wallender MA, Johansson S, Garcia-Rodriguez LA. One-year follow-up of newly diagnosed irritable bowel patients. Aliment Pharmacol Ther 1999;13:1097–102. 32. Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology 1988;95:701– 8. 33. Talley NJ, Boyce PM, Jones M. Predictors of health care seeking for irritable bowel syndrome: A population based study. Gut 1997;41:394 – 8. 34. Janssen HA, Borghouts JA, Muris JW, et al. Health status and management of chronic non-specific abdominal complaints in general practice. Br J Gen Pract 2000;50:375–9. 35. Drossman DA, Whitehead WE, Toner BB, et al. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol 2000;95:974 – 80. Reprint requests and correspondence: David H. Alpers, M.D., Washington University School of Medicine, Gastroenterology Division, Box 8124, 660 South Euclid Avenue, St. Louis, MO 63110. Received Dec. 8, 2000; accepted Dec. 29, 2000.
“I Think You Have Pancreatic Cancer but I Can’t Prove It Yet” What a devastating thing to tell a patient! However diplomatically we try to say it (or sometimes avoid saying it) it leaves both the patient and endoscopist feeling terrible and in limbo. Many of us can find ourselves in this dilemma after
Editorials
945
endoscopically stenting a biliary stricture for a patient with painless jaundice. We figure that if we could just give them a definitive diagnosis, these patients could at least reach closure with this phase of their illness. We’d like to recommend and use an easy, quick, painless, and inexpensive method for making a diagnosis that’s 100% accurate. We’d like to, but we can’t. In this issue Kaufman et al. (1) describe their experience with the Simpson atherectomy catheter biopsy method for detecting pancreaticobiliary malignancies. For the select group of patients that they studied in a retrospective manner this technique was an effective method for dealing with the dilemma above. They report the sensitivity for the atherectomy catheter when used for endoluminal biliary biopsy to be 97%. The positive predictive and negative predictive values were 100% and 93%, respectively. It should be pointed out that this method of obtaining tissue required percutaneous access to the biliary tract. The catheter is relatively bulky and somewhat difficult to maneuver around acute angles. Therefore, it should not be used without first considering the other gadgets and gizmos that we have in our “tool box” as well as the unique circumstances that accompany each of our patients. Sometimes it’s good to focus on a particular aspect of a problem being studied, such as getting a correct tissue diagnosis. But, as any pyromaniac can demonstrate, sometimes if you focus too much (such as with a magnifying glass on a dried leaf) you can “get burned”! Most patients have significant clinical, psychological, and financial issues that accompany the problem we focused on above. In addition to a tissue diagnosis, the presence and extent of metastasis will play a pivotal role in determining further management. In these situations other modalities such as endoscopic ultrasonography and/or CT-guided tissue sampling have the potential for providing accurate staging information as well as a tissue diagnosis. The accuracy of these methods for making a tissue diagnosis can also be as high as 96% in select groups of patients (2– 4). Also, some patients are averse to procedures where surgery or long sharp needles are described as being “advanced” into their bodies. Many of these patients favor endoscopic management strategies where they are not left with scars or tubing dangling from their sides. This preference by the patient might be a conscious or unconscious effort to maintain a state of denial where no tubing or scar is left to remind them of their illness. For these reasons and others, the initial diagnostic evaluation in these patients often leads to an endoscopic evaluation rather than a percutaneous or surgical procedure. In some of these patients a tissue diagnosis can be made via brushings or bile cytology during an initial therapeutic endoscopy. Although the yield from these techniques is not high in many centers (44 –56% in some studies) (5, 6), a positive result can spare the individual patient more costly and time-consuming subsequent methods of making a tissue diagnosis. Furthermore,
946
Editorials
AJG – Vol. 96, No. 4, 2001
optimal conditions for these techniques, such as the presence of experienced personnel in the procedure area to determine if cytology specimens are adequate, enhance the chances that a specimen will detect a malignancy if present. In another situation, a patient with a suspected pancreaticobiliary malignancy may present with a suspected metastatic lesion that is more amenable to CT-guided biopsy, thus providing staging information as well as a tissue diagnosis without endoscopy, surgery, or a percutaneous procedure to gain access to the biliary tract. Once again, this scenario has the potential for providing both staging information and a tissue diagnosis (more bang for the buck) even though the sensitivity in some populations of patients is less than desirable. Even though the sensitivity for CT-guided fine needle aspiration in one study has been reported to be only 60% (7), it has a low risk for complications and is available in most local radiology departments. This, added to the potential for providing more information than just the tissue diagnosis, makes it a reasonable choice in certain situations. The point of all of this is that one has to be eclectic in the pursuit of a tissue diagnosis in these patients. Anyone who sees these types of patients on a regular basis should have available a wide variety of effective diagnostic techniques that can be used for making a tissue diagnosis. The different attributes of each method and its effectiveness when performed by local personnel, as well as local rates of complications and expense, should be well known so that a diagnostic strategy can be customized for each patient. For this reason, the information provided by Kaufman et al. (1) and others (8 –10) should be added to the cumulative knowledge we have in this area. The Simpson atherectomy catheter appears to be an effective method of detecting a pancreaticobiliary malignancy for a select group of patients when used by experienced personnel. For example, one might consider the use of the Simpson atherectomy catheter biopsy method in a patient with a large hepatic mass who has already had a percutaneous transhepatic cholangiogram where the brushings or bile did not contain cytological evidence of malignancy. In other situations, such as when gaining access to the area of interest requires advancing the catheter around acute angles, alternative methods for making a tissue diagnosis might be more appropriate. The Simpson atherectomy catheter may not be the initial method used for sampling pancreaticobiliary strictures and it may not even be used often in some practices. However, it should be kept in mind when choosing the best tissue sampling technique to fit a patient’s unique needs. John Affronti, M.S., M.D. Emory University School of Medicine Department of Endoscopy Emory University Hospital Atlanta, Georgia
REFERENCES 1. Kaufman D, Widlus D, Lazinger M, et al. Diagnostic accuracy of Simpson atherectomy catheter biopsy in detecting pancreaticobiliary malignancy. Am J Gastroenterol 2001;96:1053–7. 2. Bhutani MS, Hawes RH, Baron PL, et al. Endoscopic fine needle aspiration of malignant pancreatic masses. Endoscopy 1997;29:854 – 8. 3. Baron PL, Aabakken, LE, Cole DJ, et al. Differentiation of benign from malignant pancreatic masses by endoscopic ultrasound. Ann Surg Oncol 1997;4:639 – 43. 4. Suits J, Frazee R, Erikson RA. Endoscopic ultrasound and fine needle aspiration for the evaluation of pancreatic masses. Arch Surg 1999;134:639 – 42. 5. Kurzawinski TR, Deery A, Dooly JS, et al. A prospective study of biliary cytology in 100 patients with bile duct strictures. Hepatology 1993;18:1399 – 403. 6. Ferrari AP Jr, Lichtenstein DR, Slivka A, et al. Brush cytology during ERCP for the diagnosis of biliary and pancreatic malignancies. Gastrointest Endosc 1994;40:140 –5. 7. Hall-Craggs MA, Lees WR. Fine needle aspiration biopsy: Pancreatic and biliary tumors. AJR 1986;147:399 – 403. 8. Schwarten DE, Katzen BT, Simpson JB, et al. Simpson catheter for percutaneous transluminal removal of atheroma. AJR 1988;150:799 – 801. 9. Kim D, Porter DH, Siegel JB, et al. Common bile duct biopsy with the simpson atherectomy catheter. AJR 1990;154: 1213–5. 10. Schechter MS, Doemeny JM, Johnson JO. Biliary ductal shave biopsy with the use of the Simpson atherectomy catheter. J Vasc Interv Radiol 1993;4:819 –24. Reprint requests and correspondence: John Affronti, M.D., Emory University, Emory Clinic, 1365 Clifton Road NE, Building A, Atlanta, GA 30322. Received Dec. 1, 2000; accepted Jan. 10, 2001.
Colonoscopic Gamble The review by Rex, Bond, and Feld in this issue (1) addresses the problem of what might be termed colonoscopic roulette. Their concerns center on issues of a colon cancer diagnosis made at some point after a screening colonoscopy has been performed. When all of the variables of colon cancer, its diagnosis, and its management are set out, an oddsmaker can be brought in to assess the potential for loss. The authors are interested in alerting us to the medicolegal problems associated with the discovery of an incident lesion. Physicians are always in the position of assessing their potential for a malpractice action. We assess the odds and often make prudent decisions in management and in diagnosis to reduce our risk. And well we should. Understanding the potential losses involved in practicing medicine makes even the most cavalier practitioner humble. The authors tell us to do “informed consent.” This allows us to disclose the risks, benefits, and limitations of colonoscopy and the alternatives to it to the patient. This presumably makes the patient the bearer of the risks of a complication or even a failed diagnosis. Informed consent is
20. Kellner R. Psychosomatic syndromes, somatization and somatoform disorders. Psychother Psychosom 1994;61:4 –24. 21. Escobar JI, Waitzkin H, Silver RC, et al. Abridged somatization: A study in primary care. Psychosom Med 1998; 60:466 –72. 22. Reilly J, Baker GA, Rhodes J, Salmon P. The association of sexual and physical abuse with somatization: Characteristics of patients presenting with irritable bowel syndrome and nonepileptic attack disorder. Psychol Med 1999;29:399 – 406. 23. Drossman DA, Talley NJ, Leserman J, et al. Sexual and physical abuse and gastrointestinal illness. Review and recommendations. Ann Intern Med 1995;123:782–94. 24. Nyhlin H, Ford MJ, Eastwood J, et al. Non-alimentary aspects of the irritable bowel syndrome. J Psychosom Res 1993;37: 155– 62. 25. Simon GE, Gureje O. Stability of somatization disorder and somatization symptoms among primary care patients. Arch Gen Psychiatry 1999;56:90 –5. 26. Harvey RF, Mauad EC, Brown AM. Prognosis in the irritable bowel syndrome: A five-year prospective study. Lancet 1987; 1:963–5. 27. Kay L, Jorgensen T, Jensen KH. The epidemiology of irritable bowel syndrome in a random population: prevalence, incidence, natural history and risk factors. J Intern Med 1994;236: 23–30. 28. Garcia-Campayo J, Sanz-Carrillo C. A review of the differences between somatizing and psychologizing patients in primary care. Int J Psychiatry Med 1999;29:337– 45. 29. Cloninger C. Somatoform and dissociative disorders. In: Winokur G, Clayton P, eds. The medical basis of psychiatry, 2nd ed. Philadelphia: Saunders, 1994. 30. Martin RL. Problems in the diagnosis of somatization disorder: Effects on research and clinical practice. Psychiatr Ann 1988;18:357– 62. 31. Ruigomez A, Wallender MA, Johansson S, Garcia-Rodriguez LA. One-year follow-up of newly diagnosed irritable bowel patients. Aliment Pharmacol Ther 1999;13:1097–102. 32. Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology 1988;95:701– 8. 33. Talley NJ, Boyce PM, Jones M. Predictors of health care seeking for irritable bowel syndrome: A population based study. Gut 1997;41:394 – 8. 34. Janssen HA, Borghouts JA, Muris JW, et al. Health status and management of chronic non-specific abdominal complaints in general practice. Br J Gen Pract 2000;50:375–9. 35. Drossman DA, Whitehead WE, Toner BB, et al. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol 2000;95:974 – 80. Reprint requests and correspondence: David H. Alpers, M.D., Washington University School of Medicine, Gastroenterology Division, Box 8124, 660 South Euclid Avenue, St. Louis, MO 63110. Received Dec. 8, 2000; accepted Dec. 29, 2000.
“I Think You Have Pancreatic Cancer but I Can’t Prove It Yet” What a devastating thing to tell a patient! However diplomatically we try to say it (or sometimes avoid saying it) it leaves both the patient and endoscopist feeling terrible and in limbo. Many of us can find ourselves in this dilemma after
Editorials
945
endoscopically stenting a biliary stricture for a patient with painless jaundice. We figure that if we could just give them a definitive diagnosis, these patients could at least reach closure with this phase of their illness. We’d like to recommend and use an easy, quick, painless, and inexpensive method for making a diagnosis that’s 100% accurate. We’d like to, but we can’t. In this issue Kaufman et al. (1) describe their experience with the Simpson atherectomy catheter biopsy method for detecting pancreaticobiliary malignancies. For the select group of patients that they studied in a retrospective manner this technique was an effective method for dealing with the dilemma above. They report the sensitivity for the atherectomy catheter when used for endoluminal biliary biopsy to be 97%. The positive predictive and negative predictive values were 100% and 93%, respectively. It should be pointed out that this method of obtaining tissue required percutaneous access to the biliary tract. The catheter is relatively bulky and somewhat difficult to maneuver around acute angles. Therefore, it should not be used without first considering the other gadgets and gizmos that we have in our “tool box” as well as the unique circumstances that accompany each of our patients. Sometimes it’s good to focus on a particular aspect of a problem being studied, such as getting a correct tissue diagnosis. But, as any pyromaniac can demonstrate, sometimes if you focus too much (such as with a magnifying glass on a dried leaf) you can “get burned”! Most patients have significant clinical, psychological, and financial issues that accompany the problem we focused on above. In addition to a tissue diagnosis, the presence and extent of metastasis will play a pivotal role in determining further management. In these situations other modalities such as endoscopic ultrasonography and/or CT-guided tissue sampling have the potential for providing accurate staging information as well as a tissue diagnosis. The accuracy of these methods for making a tissue diagnosis can also be as high as 96% in select groups of patients (2– 4). Also, some patients are averse to procedures where surgery or long sharp needles are described as being “advanced” into their bodies. Many of these patients favor endoscopic management strategies where they are not left with scars or tubing dangling from their sides. This preference by the patient might be a conscious or unconscious effort to maintain a state of denial where no tubing or scar is left to remind them of their illness. For these reasons and others, the initial diagnostic evaluation in these patients often leads to an endoscopic evaluation rather than a percutaneous or surgical procedure. In some of these patients a tissue diagnosis can be made via brushings or bile cytology during an initial therapeutic endoscopy. Although the yield from these techniques is not high in many centers (44 –56% in some studies) (5, 6), a positive result can spare the individual patient more costly and time-consuming subsequent methods of making a tissue diagnosis. Furthermore,
946
Editorials
AJG – Vol. 96, No. 4, 2001
optimal conditions for these techniques, such as the presence of experienced personnel in the procedure area to determine if cytology specimens are adequate, enhance the chances that a specimen will detect a malignancy if present. In another situation, a patient with a suspected pancreaticobiliary malignancy may present with a suspected metastatic lesion that is more amenable to CT-guided biopsy, thus providing staging information as well as a tissue diagnosis without endoscopy, surgery, or a percutaneous procedure to gain access to the biliary tract. Once again, this scenario has the potential for providing both staging information and a tissue diagnosis (more bang for the buck) even though the sensitivity in some populations of patients is less than desirable. Even though the sensitivity for CT-guided fine needle aspiration in one study has been reported to be only 60% (7), it has a low risk for complications and is available in most local radiology departments. This, added to the potential for providing more information than just the tissue diagnosis, makes it a reasonable choice in certain situations. The point of all of this is that one has to be eclectic in the pursuit of a tissue diagnosis in these patients. Anyone who sees these types of patients on a regular basis should have available a wide variety of effective diagnostic techniques that can be used for making a tissue diagnosis. The different attributes of each method and its effectiveness when performed by local personnel, as well as local rates of complications and expense, should be well known so that a diagnostic strategy can be customized for each patient. For this reason, the information provided by Kaufman et al. (1) and others (8 –10) should be added to the cumulative knowledge we have in this area. The Simpson atherectomy catheter appears to be an effective method of detecting a pancreaticobiliary malignancy for a select group of patients when used by experienced personnel. For example, one might consider the use of the Simpson atherectomy catheter biopsy method in a patient with a large hepatic mass who has already had a percutaneous transhepatic cholangiogram where the brushings or bile did not contain cytological evidence of malignancy. In other situations, such as when gaining access to the area of interest requires advancing the catheter around acute angles, alternative methods for making a tissue diagnosis might be more appropriate. The Simpson atherectomy catheter may not be the initial method used for sampling pancreaticobiliary strictures and it may not even be used often in some practices. However, it should be kept in mind when choosing the best tissue sampling technique to fit a patient’s unique needs. John Affronti, M.S., M.D. Emory University School of Medicine Department of Endoscopy Emory University Hospital Atlanta, Georgia
REFERENCES 1. Kaufman D, Widlus D, Lazinger M, et al. Diagnostic accuracy of Simpson atherectomy catheter biopsy in detecting pancreaticobiliary malignancy. Am J Gastroenterol 2001;96:1053–7. 2. Bhutani MS, Hawes RH, Baron PL, et al. Endoscopic fine needle aspiration of malignant pancreatic masses. Endoscopy 1997;29:854 – 8. 3. Baron PL, Aabakken, LE, Cole DJ, et al. Differentiation of benign from malignant pancreatic masses by endoscopic ultrasound. Ann Surg Oncol 1997;4:639 – 43. 4. Suits J, Frazee R, Erikson RA. Endoscopic ultrasound and fine needle aspiration for the evaluation of pancreatic masses. Arch Surg 1999;134:639 – 42. 5. Kurzawinski TR, Deery A, Dooly JS, et al. A prospective study of biliary cytology in 100 patients with bile duct strictures. Hepatology 1993;18:1399 – 403. 6. Ferrari AP Jr, Lichtenstein DR, Slivka A, et al. Brush cytology during ERCP for the diagnosis of biliary and pancreatic malignancies. Gastrointest Endosc 1994;40:140 –5. 7. Hall-Craggs MA, Lees WR. Fine needle aspiration biopsy: Pancreatic and biliary tumors. AJR 1986;147:399 – 403. 8. Schwarten DE, Katzen BT, Simpson JB, et al. Simpson catheter for percutaneous transluminal removal of atheroma. AJR 1988;150:799 – 801. 9. Kim D, Porter DH, Siegel JB, et al. Common bile duct biopsy with the simpson atherectomy catheter. AJR 1990;154: 1213–5. 10. Schechter MS, Doemeny JM, Johnson JO. Biliary ductal shave biopsy with the use of the Simpson atherectomy catheter. J Vasc Interv Radiol 1993;4:819 –24. Reprint requests and correspondence: John Affronti, M.D., Emory University, Emory Clinic, 1365 Clifton Road NE, Building A, Atlanta, GA 30322. Received Dec. 1, 2000; accepted Jan. 10, 2001.
Colonoscopic Gamble The review by Rex, Bond, and Feld in this issue (1) addresses the problem of what might be termed colonoscopic roulette. Their concerns center on issues of a colon cancer diagnosis made at some point after a screening colonoscopy has been performed. When all of the variables of colon cancer, its diagnosis, and its management are set out, an oddsmaker can be brought in to assess the potential for loss. The authors are interested in alerting us to the medicolegal problems associated with the discovery of an incident lesion. Physicians are always in the position of assessing their potential for a malpractice action. We assess the odds and often make prudent decisions in management and in diagnosis to reduce our risk. And well we should. Understanding the potential losses involved in practicing medicine makes even the most cavalier practitioner humble. The authors tell us to do “informed consent.” This allows us to disclose the risks, benefits, and limitations of colonoscopy and the alternatives to it to the patient. This presumably makes the patient the bearer of the risks of a complication or even a failed diagnosis. Informed consent is