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Endoscopic Ultrasonography for the Diagnosis of Chronic Pancreatitis
Abstracts
W1361 Clinicopathological Study of Intraductal Papillary-Mucinous Neoplasm (IPMN) of the Pancreas with Long-Term Follow-Up Kuniyuki Takahashi, Kenji Yamao, Nobumasa Mizuno, Akira Sawaki, Vikram Bhatia, Ahmed Sayed, Reiko Ashida, Hiroshi Imaoka, Yasuhiro Shimizu, Yasushi Yatabe, Akio Yamagisawa Objectives: Although the diagnostic criteria for IPMN have been defined, its natural history and the indications for surgery are still unclear. The objective of this study was to clarify the natural course and the choice of treatment of this tumor. Methods: From 1971 to 2005, a total of 185 patients were diagnosed as IPMN at Aichi Cancer Center. We retrospectively reviewed the natural history of 36 patients, who had serial imaging (CT, ERCP, and/or EUS) and follow up of more than 3 years duration available. Results: Surgery was performed in 9 of 36 patients after a mean follow up of 11 years (Range: 3 to 27 years). These patients had a median age of 66 years (Range: 57 to 73 years) at surgery. 3 patients had main duct (MDT) and 6 had branch duct type (BDT) tumors. Initially mural nodules were absent, and MPD dilatation was minimal or absent in all cases. Cystic branch duct dilatation was present in the 6 BDT cases. Post-operative histopathological diagnosis included 2 adenomas, 1 borderline malignancy, 3 non-invasive and 3 invasive carcinomas. Dilatation of MPD to O10 mm and/or mural nodules O10 mm in size on serial imaging could predict malignancy with 89% accuracy. Two patients have died of metastatic lung cancer from invasive IPMN and unrelated gastric cancer on follow up. 27 patients with a median age of 62 years (Range: 48-77) have been followed up. 20 of them have shown no progression on serial imaging. 7 patients (2MDT and 5BDT) have shown progression of ERCP and EUS findings, including 2 patients with MPD diameter and mural nodules of O10 mm. All but 1 patient who died of unrelated cause, are alive at a mean follow up of 5 years (Range: 3-13 years). Conclusion: IPMT is a remarkably slow growing tumor, and majority of patients can be followed up with serial imaging alone. Presence of MPD dilatation O10 mm and mural nodules O10 mm size can be used as indications for surgery.
W1363 Endoscopic Ultrasonography for the Diagnosis of Chronic Pancreatitis Inder Mainie, Rhys Vaughan, Sandra Faias, Moss Mann, Joseph Romagnuolo, Brenda Hoffman, Robert Hawes Background: Previous studies have shown the Endoscopic Ulstrasonongraphy (EUS) is very sensitive for the detection of morphologic abnormailities due to chronic pancreatitis. Unfortunately there are uncertainities about the specificity of EUS findings, particularly in the early stages of chronic pancreatitis. Since the ‘‘gold standard’’ for the diagnosis of chronic pancreatitis (tissue diagnosis) is lacking, one way to validate findings is to do clinical follow up. Aim: Our aim is to understand if in a clinical context suspect for chronic pancreatitis, patients who have a normal ERCP but an EUS that shows features of chronic pancreatitis, will develop imagilogic or clinical characteristic features of chronic pancreatitis, comfirming a higher sensitivity of EUS, or on the other hand, if they have false positive EUS for chronic pancreatitis. Method: In a retrospective review of the EUS database from a 4-year period (January of 1996 - Dec 1999), we found 240 patients less than 65 years old and clinical symptoms suggestive of chronic pancreatitis that had both EUS and ERCP. Patients with malignancy were excluded. Of these 240 patients, 48 (20%) had discrepancy between EUS and ERCP findings, withy normal ERCP but EUS features of moderate/high probability for chronic pancreatitis (O3 features on EUS). Chart review or contact by phone was used to document pancreatitis. Patients were asked if they were diagnosed with pancreatitis. If they responded yes, two questions were asked verbatim without coaxing. These questions included when the diagnosis was made and how. Results: 48 Patients (Female 34; mean age 42 (range 19 - 62 years) were reviewed. The average follow-up time was 8.4 years (range 7 - 9.6 years). 29/48 (60%) patients were contacted or chart reviewed, 19 were lost to follow-up. Of those suspected of having early chronic pancreatitis in which EUS was the only abnormality, 55% progressed clincially such that the diagnosis could be established. 13/29 (45%) of the patients did not have a diagnosis of pancreatitis on follow-up. Conclusion: EUS can be used in the preliminary diagnosis of pancreatitis. Before 2001 years ago, we use 3 or more criteria on EUS to diagnose chronic pancreatitis. We decided based on histology and the fact that we would rather have a higher specificity rather than sensitivity to label patients as ‘‘chronic pancreatitis’’, we changed our criteria from 3 or more to 5 or more. Thus, some of the 45% that did not evolve into clear chronic pancreatitis may have been read as normal by todays criteria.
W1364 Utility of EUS-FNA and Cyst Fluid Analysis in the Diagnosis of Pancreatic Cysts: Correlation with Histopathology in 51 Patients Siriboon Attasaranya, Shireen A. Pais, Julia K. Leblanc, Stuart Sherman, Lee Mchenry, John M. Dewitt
W1362 Role of Endoscopic Ultrasonography in Follow-Up of Branch Duct Type Intraductal Papillary-Mucinous Neoplasms of the Pancreas Satoshi Tanno, Yasuhiro Nakano, Kazumasa Nakamura, Madoka Minoguchi, Tsutomu Izawa, Yusuke Mizukami, Toshikatsu Okumura, Yutaka Kohgo Background/Aim: The aim of this study was to elucidate the role of endoscopic ultrasonography (EUS) in follow-up of the patients with branch duct type intraductal papillary-mucinous neoplasms of the pancreas (IPMNs). Methods: Sixtyfive patients (forty-seven men and eighteen women) with branch duct type IPMNs were selected for follow-up and examined by EUS two or more times (mean, 3 times). Patients who had apparent mural nodules were excluded from follow-up study. All patients underwent initial endoscopic retrograde pancreatography (ERP), magnetic retrograde cholangiopancreatography (MRCP), and computed tomography (CT). Serial changes of the maximum cystic diameter and the presence of mural nodule were studied during the observation periods ranged from 19 to 172 months (mean, 87 months). Results: Six (9%) of 65 patients exhibited obvious progression of cystic dilatation. New apparent mural nodules were detected in 6 cases (9%) during the observation periods. These obvious changes were observed after a 19 to 114 months follow-up period (mean, 80 months). Of six patients with mural nodules, four cases underwent surgery after follow-up study, and the pathologic diagnosis was adenoma in two and non-invasive carcinoma in two. Mural nodules were accurately diagnosed in 6 cases (100%) by EUS, whereas in one (17%) by CT and in 0 (0%) by MRCP. Six patients with cystic size enlargement were followed up without surgical resection. None of the remaining 53 patients (82%) showed increases in cystic diameter and new apparent mural nodules. Conclusions: Mural nodule is an important factor affecting the follow-up, and most of branch duct type IPMNs without apparent mural nodules remained unchanged. EUS is the most sensitive method to detect mural nodules in follow-up of branch duct type IPMNs.
AB278 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
Background: Endoscopic ultrasound (EUS) with EUS-guided fine needle aspiration (EUS-FNA) have been increasingly utilized for differentiating malignant/premalignant pancreatic cysts from those that are benign or have low malignant potential. Objective: To determine the utility of EUS morphology, EUS-FNA cytology and cyst fluid analysis in distinguishing mucinous cystic neoplasms (MCNs) from non-mucinous cystic neoplasms (NMCNs) in patients with histopathologic correlation. Methods: Endoscopy, cytology and surgery databases at our hospital from 1996 to 2005 were queried for all patients who underwent EUS evaluation of known or suspected pancreatic cysts followed by surgical resection. Clinical profiles and procedure reports were reviewed and compared between both groups. The final diagnosis in all patients was based on histopathology. Patients with intraductal papillary mucinous tumors were excluded. Results: 51 patients (mean age: 51 yrs, 32 female) with 16 MCNs (13 mucinous cystadenomas [MCAs], 3 mucinous cystadenocarcinomas [MCACs]) and 35 NMCNs (14 pseudocysts, 10 serous cystadenomas, 5 simple cysts, 3 neuroendocrine tumors, 3 solid pseudopapillary neoplasms. Mean time between EUS and surgery was 65 days. Abdominal pain (the most common symptom) was reported in 32 (63%) and 11 (22%) cysts were incidentally found. In 45 patients with available history, antecedent pancreatitis was present in 10 (22%). There were more women in MCN group compared to the NMCN group (87% vs. 51%; p Z 0.02). For same groups, however, there were no statistically significant differences in mean age, median time from onset of symptoms, previous history of pancreatitis, or number of asymptomatic patients. Similarly, between both groups EUS morphology showed no statistically significant difference between the number and location of cysts, cystic components, cyst wall thickness, internal cystic echogenicity, or cystic fluid appearance. The sensitivity, specificity, PPV, NPV and accuracy of EUS-FNA cytology for the diagnosis of all MCNs (MCAs and MCACs) was 13%, 94%, 50%, 70%, and 67% respectively. Median cyst fluid CEA for the MCNs group (276.7 ng/ml; range: 0.5-144,000; n Z 14) was significantly higher than the NMCN group (1.5 ng/ml; range: 0.5-2, 243; n Z 21; p Z 0.001). Cyst fluid CEA O800 ng/ml had a sensitivity and specificity of 43% and 95%, respectively for the diagnosis of an MCN. Pancreatic fluid amylase !10,000 U/L virtually excluded pancreatic pseudocyst. Conclusions: In this series of histopathologically confirmed pancreatic cysts, EUS-FNA cytology and cyst fluid CEA O800 ng/ml are both insensitive but very specific to differentiate MCNs from NMCNs.
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W1361 Clinicopathological Study of Intraductal Papillary-Mucinous Neoplasm (IPMN) of the Pancreas with Long-Term Follow-Up Kuniyuki Takahashi, Kenji Yamao, Nobumasa Mizuno, Akira Sawaki, Vikram Bhatia, Ahmed Sayed, Reiko Ashida, Hiroshi Imaoka, Yasuhiro Shimizu, Yasushi Yatabe, Akio Yamagisawa Objectives: Although the diagnostic criteria for IPMN have been defined, its natural history and the indications for surgery are still unclear. The objective of this study was to clarify the natural course and the choice of treatment of this tumor. Methods: From 1971 to 2005, a total of 185 patients were diagnosed as IPMN at Aichi Cancer Center. We retrospectively reviewed the natural history of 36 patients, who had serial imaging (CT, ERCP, and/or EUS) and follow up of more than 3 years duration available. Results: Surgery was performed in 9 of 36 patients after a mean follow up of 11 years (Range: 3 to 27 years). These patients had a median age of 66 years (Range: 57 to 73 years) at surgery. 3 patients had main duct (MDT) and 6 had branch duct type (BDT) tumors. Initially mural nodules were absent, and MPD dilatation was minimal or absent in all cases. Cystic branch duct dilatation was present in the 6 BDT cases. Post-operative histopathological diagnosis included 2 adenomas, 1 borderline malignancy, 3 non-invasive and 3 invasive carcinomas. Dilatation of MPD to O10 mm and/or mural nodules O10 mm in size on serial imaging could predict malignancy with 89% accuracy. Two patients have died of metastatic lung cancer from invasive IPMN and unrelated gastric cancer on follow up. 27 patients with a median age of 62 years (Range: 48-77) have been followed up. 20 of them have shown no progression on serial imaging. 7 patients (2MDT and 5BDT) have shown progression of ERCP and EUS findings, including 2 patients with MPD diameter and mural nodules of O10 mm. All but 1 patient who died of unrelated cause, are alive at a mean follow up of 5 years (Range: 3-13 years). Conclusion: IPMT is a remarkably slow growing tumor, and majority of patients can be followed up with serial imaging alone. Presence of MPD dilatation O10 mm and mural nodules O10 mm size can be used as indications for surgery.
W1363 Endoscopic Ultrasonography for the Diagnosis of Chronic Pancreatitis Inder Mainie, Rhys Vaughan, Sandra Faias, Moss Mann, Joseph Romagnuolo, Brenda Hoffman, Robert Hawes Background: Previous studies have shown the Endoscopic Ulstrasonongraphy (EUS) is very sensitive for the detection of morphologic abnormailities due to chronic pancreatitis. Unfortunately there are uncertainities about the specificity of EUS findings, particularly in the early stages of chronic pancreatitis. Since the ‘‘gold standard’’ for the diagnosis of chronic pancreatitis (tissue diagnosis) is lacking, one way to validate findings is to do clinical follow up. Aim: Our aim is to understand if in a clinical context suspect for chronic pancreatitis, patients who have a normal ERCP but an EUS that shows features of chronic pancreatitis, will develop imagilogic or clinical characteristic features of chronic pancreatitis, comfirming a higher sensitivity of EUS, or on the other hand, if they have false positive EUS for chronic pancreatitis. Method: In a retrospective review of the EUS database from a 4-year period (January of 1996 - Dec 1999), we found 240 patients less than 65 years old and clinical symptoms suggestive of chronic pancreatitis that had both EUS and ERCP. Patients with malignancy were excluded. Of these 240 patients, 48 (20%) had discrepancy between EUS and ERCP findings, withy normal ERCP but EUS features of moderate/high probability for chronic pancreatitis (O3 features on EUS). Chart review or contact by phone was used to document pancreatitis. Patients were asked if they were diagnosed with pancreatitis. If they responded yes, two questions were asked verbatim without coaxing. These questions included when the diagnosis was made and how. Results: 48 Patients (Female 34; mean age 42 (range 19 - 62 years) were reviewed. The average follow-up time was 8.4 years (range 7 - 9.6 years). 29/48 (60%) patients were contacted or chart reviewed, 19 were lost to follow-up. Of those suspected of having early chronic pancreatitis in which EUS was the only abnormality, 55% progressed clincially such that the diagnosis could be established. 13/29 (45%) of the patients did not have a diagnosis of pancreatitis on follow-up. Conclusion: EUS can be used in the preliminary diagnosis of pancreatitis. Before 2001 years ago, we use 3 or more criteria on EUS to diagnose chronic pancreatitis. We decided based on histology and the fact that we would rather have a higher specificity rather than sensitivity to label patients as ‘‘chronic pancreatitis’’, we changed our criteria from 3 or more to 5 or more. Thus, some of the 45% that did not evolve into clear chronic pancreatitis may have been read as normal by todays criteria.
W1364 Utility of EUS-FNA and Cyst Fluid Analysis in the Diagnosis of Pancreatic Cysts: Correlation with Histopathology in 51 Patients Siriboon Attasaranya, Shireen A. Pais, Julia K. Leblanc, Stuart Sherman, Lee Mchenry, John M. Dewitt
W1362 Role of Endoscopic Ultrasonography in Follow-Up of Branch Duct Type Intraductal Papillary-Mucinous Neoplasms of the Pancreas Satoshi Tanno, Yasuhiro Nakano, Kazumasa Nakamura, Madoka Minoguchi, Tsutomu Izawa, Yusuke Mizukami, Toshikatsu Okumura, Yutaka Kohgo Background/Aim: The aim of this study was to elucidate the role of endoscopic ultrasonography (EUS) in follow-up of the patients with branch duct type intraductal papillary-mucinous neoplasms of the pancreas (IPMNs). Methods: Sixtyfive patients (forty-seven men and eighteen women) with branch duct type IPMNs were selected for follow-up and examined by EUS two or more times (mean, 3 times). Patients who had apparent mural nodules were excluded from follow-up study. All patients underwent initial endoscopic retrograde pancreatography (ERP), magnetic retrograde cholangiopancreatography (MRCP), and computed tomography (CT). Serial changes of the maximum cystic diameter and the presence of mural nodule were studied during the observation periods ranged from 19 to 172 months (mean, 87 months). Results: Six (9%) of 65 patients exhibited obvious progression of cystic dilatation. New apparent mural nodules were detected in 6 cases (9%) during the observation periods. These obvious changes were observed after a 19 to 114 months follow-up period (mean, 80 months). Of six patients with mural nodules, four cases underwent surgery after follow-up study, and the pathologic diagnosis was adenoma in two and non-invasive carcinoma in two. Mural nodules were accurately diagnosed in 6 cases (100%) by EUS, whereas in one (17%) by CT and in 0 (0%) by MRCP. Six patients with cystic size enlargement were followed up without surgical resection. None of the remaining 53 patients (82%) showed increases in cystic diameter and new apparent mural nodules. Conclusions: Mural nodule is an important factor affecting the follow-up, and most of branch duct type IPMNs without apparent mural nodules remained unchanged. EUS is the most sensitive method to detect mural nodules in follow-up of branch duct type IPMNs.
AB278 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
Background: Endoscopic ultrasound (EUS) with EUS-guided fine needle aspiration (EUS-FNA) have been increasingly utilized for differentiating malignant/premalignant pancreatic cysts from those that are benign or have low malignant potential. Objective: To determine the utility of EUS morphology, EUS-FNA cytology and cyst fluid analysis in distinguishing mucinous cystic neoplasms (MCNs) from non-mucinous cystic neoplasms (NMCNs) in patients with histopathologic correlation. Methods: Endoscopy, cytology and surgery databases at our hospital from 1996 to 2005 were queried for all patients who underwent EUS evaluation of known or suspected pancreatic cysts followed by surgical resection. Clinical profiles and procedure reports were reviewed and compared between both groups. The final diagnosis in all patients was based on histopathology. Patients with intraductal papillary mucinous tumors were excluded. Results: 51 patients (mean age: 51 yrs, 32 female) with 16 MCNs (13 mucinous cystadenomas [MCAs], 3 mucinous cystadenocarcinomas [MCACs]) and 35 NMCNs (14 pseudocysts, 10 serous cystadenomas, 5 simple cysts, 3 neuroendocrine tumors, 3 solid pseudopapillary neoplasms. Mean time between EUS and surgery was 65 days. Abdominal pain (the most common symptom) was reported in 32 (63%) and 11 (22%) cysts were incidentally found. In 45 patients with available history, antecedent pancreatitis was present in 10 (22%). There were more women in MCN group compared to the NMCN group (87% vs. 51%; p Z 0.02). For same groups, however, there were no statistically significant differences in mean age, median time from onset of symptoms, previous history of pancreatitis, or number of asymptomatic patients. Similarly, between both groups EUS morphology showed no statistically significant difference between the number and location of cysts, cystic components, cyst wall thickness, internal cystic echogenicity, or cystic fluid appearance. The sensitivity, specificity, PPV, NPV and accuracy of EUS-FNA cytology for the diagnosis of all MCNs (MCAs and MCACs) was 13%, 94%, 50%, 70%, and 67% respectively. Median cyst fluid CEA for the MCNs group (276.7 ng/ml; range: 0.5-144,000; n Z 14) was significantly higher than the NMCN group (1.5 ng/ml; range: 0.5-2, 243; n Z 21; p Z 0.001). Cyst fluid CEA O800 ng/ml had a sensitivity and specificity of 43% and 95%, respectively for the diagnosis of an MCN. Pancreatic fluid amylase !10,000 U/L virtually excluded pancreatic pseudocyst. Conclusions: In this series of histopathologically confirmed pancreatic cysts, EUS-FNA cytology and cyst fluid CEA O800 ng/ml are both insensitive but very specific to differentiate MCNs from NMCNs.
www.giejournal.org