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Prevalence and Clinical Significance of Pancreatic Cysts in Association with Cysts in Other Intraabdominal Organs
Abstracts
attributed to post-cholecystectomy changes. After a mean follow-up period of 16 months (range 6-28), no further cause for CBD dilation has been found on subsequent imaging and all patients remain well. Pathology accounting for the CBD dilation was found in 11 patients (42%). The most common pathology was choledocholithiasis (5 patients). Chronic pancreatitis was identified in 2 patients, ampullary adenoma in 2, cholangiocarcinoma in 1 patient and a small pancreatic lesion in 1 patient. Two of these patients had undergone prior MRCP that did not detect choledocholithiasis in 1 patient and an ampullary adenoma in another. There was no difference in the mean CBD diameter between the group with demonstrable pathology compared with those without (10.3cm vs. 10.6cm, pZ0.80). Six of 11 patients (55%) with abnormal liver function tests had EUS findings accounting for the CBD dilation compared with 5 of 15 patients (33%) with normal liver function tests (pZ0.28). Conclusion: EUS maintains an important role in imaging the biliary tree. In our cohort, 42% of patients with otherwise normal imaging had underlying pathology accounting for the CBD dilation with 38% requiring further endoscopic intervention or surgery. EUS is also accurate in the exclusion of underlying pathology. The study found that mean CBD diameter and the presence of normal liver function tests were not predictive of underlying pathology.
M1472 EUS-FNA Predicts 5-Year Survival in Pancreatic Endocrine Tumors (PETs) Fatima A. Figueiredo, Marc Giovannini, Genevieve Monges, Erwan Bories, Christian Pesenti, Fabrice Caillol, Jean Robert Delpero Background: PETs differ in clinical behavior and prognosis. Determination of malignant potential by EUS-FNA can help management. Aim: To determine the performance of EUS-FNA for diagnosing and classifying the malignant potential of PETs based on WHO classification. Methods: Single-center retrospective study. A review of medical records from 01/1999 to 08/2008 was performed to identify patients who had been diagnosed with PETs and submitted to EUS-FNA. The diagnosis of PET was established by EUS-FNA and/or histopathologic evaluation obtained by surgical resection. Antibodies against synaptophysin, chromogranin A, p53, Ki-67 were used. The lesions were classified as recommended by the WHO. Results: In overall, 90% (77/86) of patients had the diagnosis obtained by EUS-FNA. The sensitivity did not vary with size, type, location, and presence of hormonal secretion. Of 86 patients, 30 (35%) were submitted to surgery. The kappa index between the classification obtained by EUS-FNA and by surgery was 0.38 (pZ0.003). Major discrepancies were found in the group of endocrine tumor of uncertain behavior(UBWDET) obtained by EUS-FNA, since 72% turned out to be well-differentiated endocrine carcinoma(WDEC). Sixteen patients(27%) died during a mean follow-up of 34 27 months. The 5-year survival rates were 100% for endocrine tumors, 68% for WDEC, and 30% for poorly-differentiated endocrine carcinomas(PDEC)(pZ0,008). Conclusions: This largest single-center experience demonstrated the accuracy of EUS-FNA in diagnosing and determining the malignant behavior of PETs. EUS-FNA predicts 5-year survival. Notes: BBWETZwell differentiated endocrine tumor of benign behaviour
M1473 Prevalence and Clinical Significance of Pancreatic Cysts in Association with Cysts in Other Intraabdominal Organs Deepak Agrawal, Santo Maimone, Joseph Willis, Gerard Isenberg, Richard C. Wong, Ashley L. Faulx, Amitabh Chak Background: Pancreatic cysts may also be associated with cysts in other abdominal organs, especially the liver and kidneys. Genetic variants at loci on chromosome 10q and 3p are associated with serous cysts of the pancreas and cysts in other organs such as the liver and kidney in Von Hippel Lindau disease. We hypothesized that pancreatic cysts that occur in association with cysts in other organs might be a form fruste of Von Hippel Lindau disease and be more likely to be serous cystadenomas (SCA). Methods: A retrospective chart review was performed on consecutive patients who presented to a tertiary referral center from 2000-08 and underwent endoscopic ultrasound (EUS) for suspected pancreatic cysts. Patients with cysts identified in other organs (liver, kidneys, spleen) on CT, MRI, abdominal ultrasound or EUS were included in the study. Patients with known pseudocysts and metastases were excluded. The pancreatic cysts were categorized based on surgical pathology, imaging characteristics and cytology results. The following definitions were used: 1) Mucinous: IPMN (definite communication between the cyst and the pancreatic duct on any imaging) and uncategorized (CEA O192 ng/mL but no definitive communication described on imaging (uncategorized mucinous cysts) 2) Serous cystadenoma (SCA): CEA !20 ng/mL; 3) Malignant: confirmed by surgical pathology including adenocarcinoma and mucinous cystic neoplasm (MCN); 4) Unknown: cysts of unknown status including cysts with CEA levels between 20 and 192ng/mL and without other identifying information. Results: Pancreatic cysts were identified in 156 patients (SCA 32, IPMN 36, uncategorized mucinous 11, MCN 5, other malignant 14, unknown 58). 85 patients (54.5%) had at least 1 cyst in the pancreas and a second abdominal organ, as follows: SCA 21 (24.7%), IPMN 18 (21.2%), uncategorized mucinous cyst 4 (4.7%), MCN 2 (2.4%), other malignant 8 (9.5%) and unknown 32 (37.6%). The breakdown of cysts in
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other abdominal organs was as follows: kidney 50, liver 6, kidney and liver 24, kidney/liver and spleen 5. Fisher’s exact found no significant association of multiple abdominal cysts with serous pancreatic cysts compared to other cysts (p O 0.05). Conclusion: Pancreatic cysts are associated with cysts in other intraabdominal organs in 54.5% patients. The presence of cysts in other organs is not associated with a serous etiology. This finding does not assist in predicting the etiology of pancreatic cysts.
Cysts in other organs Pancreatic cyst only
Serous
Mucinous
Malignant
Unknown
Total
21 11 32
21 25 47
10 9 19
32 26 58
85 71 156
M1474 Quality EUS-FNA: The Potential for Malignant Cell Carry-Over and False-Positive Cytology During Luminal Tumor Staging Marianne Fahmy, Walter Coyle, Farnaz Hasteh, Michael R. Peterson, Mary L. Krinsky Background: Endoscopic Ultrasound (EUS) is considered the best modality for the locoregional staging of all gastrointestinal(GI) luminal cancers. No studies have investigated the possibility of false-positive lymph node FNA in patients with GI cancers or the potential for malignant cell carry-over and needle contamination. Endoscopes that traverse a luminal tumor (LT) may cause cancer cells to shed and contaminate the endoscope tip and the biopsy channel. This may result in falsepositive cytology of an aspirate obtained from a sampled lymph node. Our primary aim was to determine if malignant cells carry-over and contaminate the (EUS) endoscope or FNA needle with passage of an endoechoscope through a LT. Methods: In this pilot study, we recruited 16 subjects who were referred for preoperative staging of gastrointestinal cancers; 13 patients with LT (esophageal cancers or gastric cancers) and 3 subjects for a control-arm with non-LT. All patients underwent a radial EUS for preoperative staging. A linear endoechoscope was then passed into their esophagus and stomach to perform either a sham FNA and when indicated a FNA for staging. Cytology samples were taken from the FNA needle, scope channel (brushings of and debris from the channel for cell block and histology), and the scope tip exterior. Direct tumor sampling was obtained for a control. Two blinded pathologists, with expertise in cytologic interpretations, read all slides. Results: Luminal cancers included 10 esophageal cancers, and 3 gastric cancers. Non-LT were pancreatic(2) or lung cancer(1). Of 13 luminal cancers, 7 (54%) had tumor cell carry-over detected by cytologic or histologic interpretation. Four(30%) had cell carry-over onto the cytology brush, 4 (30%) on the exterior scope, 4 (30%) from the cell block, and 2 (15%) from the FNA catheter tip. 29 percent of all patients with tumor cell carry-over had malignant cells found on the FNA needle. The 3 non-LT had no cell carry-over and all had negative controls. Conclusions: 1. Malignant cell contamination of endoechoscopes and FNA needles does occur when staging luminal cancers. 2. The FNA needle can be contaminated with tumor cells prior to obtaining non-peritumoral lymph node cytology, and has potential for false positive aspirates. 3. Endoscopist should be aware of the risks.
M1475 The Utility of Repeat Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) for Suspected Pancreatic Cancer Mark Nicaud, Dennis Collins, Mihir S. Wagh, Shailendra S. Chauhan, Peter V. Draganov Background: EUS-FNA is the gold standard for tissue diagnosis in patients with pancreatic cancer. The utility of repeat EUS-FNA in patients with clinical suspicion for pancreatic cancer after non-diagnostic EUS-FNA study is not well established. Aim: To determine the yield of repeat EUS-FNA in patients with suspected pancreatic cancer with prior non-diagnostic EUS-FNA. Methods: This was a retrospective review of prospectively collected data in searchable electronic database. All patients who underwent more then one EUS-FNA in our institution for evaluation of suspected pancreatic cancer were included in this analysis. Results: From 1/21/2002 to 11/25/2008 total of 3895 EUS procedures were performed in our institution. Of these, 31 patients (12 M, 19 F), (mean age 61.7, range 41-82) had repeat EUS-FNA done for the evaluation of possible pancreatic cancer. Preprocedure CT or MRI showed definitive or possible pancratic mass in 29 (93.5%), and no desecrate mass in 1 (3.2%) patient. No imaging study was available in 1 (3.2%) patient. Initial EUS evaluation showed pancreatic mass in 25 (80.6%), and no mass in 5 (16.2%) patients. In 1 (3.2%) patient at the first EUS the mass was thought to arise from the duodenum but on the repeat EUS was found to also be a pancreatic lesion. The mean number of FNA passes on initial EUS was 4 (range 17). Cytologic evaluation was atypical/suspicious in 8 (25.8%), and benign/reactive in 23 (74.2%). At the second EUS-FNA definitive malignancy was diagnosed in 2 (6.45%) of the patients with prior atypical/suspicious findings at the first EUS-FNA, and in 3 (9.67%) of the patients with benign/reactive initial cytology. In 19 (59.3%)
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB251
attributed to post-cholecystectomy changes. After a mean follow-up period of 16 months (range 6-28), no further cause for CBD dilation has been found on subsequent imaging and all patients remain well. Pathology accounting for the CBD dilation was found in 11 patients (42%). The most common pathology was choledocholithiasis (5 patients). Chronic pancreatitis was identified in 2 patients, ampullary adenoma in 2, cholangiocarcinoma in 1 patient and a small pancreatic lesion in 1 patient. Two of these patients had undergone prior MRCP that did not detect choledocholithiasis in 1 patient and an ampullary adenoma in another. There was no difference in the mean CBD diameter between the group with demonstrable pathology compared with those without (10.3cm vs. 10.6cm, pZ0.80). Six of 11 patients (55%) with abnormal liver function tests had EUS findings accounting for the CBD dilation compared with 5 of 15 patients (33%) with normal liver function tests (pZ0.28). Conclusion: EUS maintains an important role in imaging the biliary tree. In our cohort, 42% of patients with otherwise normal imaging had underlying pathology accounting for the CBD dilation with 38% requiring further endoscopic intervention or surgery. EUS is also accurate in the exclusion of underlying pathology. The study found that mean CBD diameter and the presence of normal liver function tests were not predictive of underlying pathology.
M1472 EUS-FNA Predicts 5-Year Survival in Pancreatic Endocrine Tumors (PETs) Fatima A. Figueiredo, Marc Giovannini, Genevieve Monges, Erwan Bories, Christian Pesenti, Fabrice Caillol, Jean Robert Delpero Background: PETs differ in clinical behavior and prognosis. Determination of malignant potential by EUS-FNA can help management. Aim: To determine the performance of EUS-FNA for diagnosing and classifying the malignant potential of PETs based on WHO classification. Methods: Single-center retrospective study. A review of medical records from 01/1999 to 08/2008 was performed to identify patients who had been diagnosed with PETs and submitted to EUS-FNA. The diagnosis of PET was established by EUS-FNA and/or histopathologic evaluation obtained by surgical resection. Antibodies against synaptophysin, chromogranin A, p53, Ki-67 were used. The lesions were classified as recommended by the WHO. Results: In overall, 90% (77/86) of patients had the diagnosis obtained by EUS-FNA. The sensitivity did not vary with size, type, location, and presence of hormonal secretion. Of 86 patients, 30 (35%) were submitted to surgery. The kappa index between the classification obtained by EUS-FNA and by surgery was 0.38 (pZ0.003). Major discrepancies were found in the group of endocrine tumor of uncertain behavior(UBWDET) obtained by EUS-FNA, since 72% turned out to be well-differentiated endocrine carcinoma(WDEC). Sixteen patients(27%) died during a mean follow-up of 34 27 months. The 5-year survival rates were 100% for endocrine tumors, 68% for WDEC, and 30% for poorly-differentiated endocrine carcinomas(PDEC)(pZ0,008). Conclusions: This largest single-center experience demonstrated the accuracy of EUS-FNA in diagnosing and determining the malignant behavior of PETs. EUS-FNA predicts 5-year survival. Notes: BBWETZwell differentiated endocrine tumor of benign behaviour
M1473 Prevalence and Clinical Significance of Pancreatic Cysts in Association with Cysts in Other Intraabdominal Organs Deepak Agrawal, Santo Maimone, Joseph Willis, Gerard Isenberg, Richard C. Wong, Ashley L. Faulx, Amitabh Chak Background: Pancreatic cysts may also be associated with cysts in other abdominal organs, especially the liver and kidneys. Genetic variants at loci on chromosome 10q and 3p are associated with serous cysts of the pancreas and cysts in other organs such as the liver and kidney in Von Hippel Lindau disease. We hypothesized that pancreatic cysts that occur in association with cysts in other organs might be a form fruste of Von Hippel Lindau disease and be more likely to be serous cystadenomas (SCA). Methods: A retrospective chart review was performed on consecutive patients who presented to a tertiary referral center from 2000-08 and underwent endoscopic ultrasound (EUS) for suspected pancreatic cysts. Patients with cysts identified in other organs (liver, kidneys, spleen) on CT, MRI, abdominal ultrasound or EUS were included in the study. Patients with known pseudocysts and metastases were excluded. The pancreatic cysts were categorized based on surgical pathology, imaging characteristics and cytology results. The following definitions were used: 1) Mucinous: IPMN (definite communication between the cyst and the pancreatic duct on any imaging) and uncategorized (CEA O192 ng/mL but no definitive communication described on imaging (uncategorized mucinous cysts) 2) Serous cystadenoma (SCA): CEA !20 ng/mL; 3) Malignant: confirmed by surgical pathology including adenocarcinoma and mucinous cystic neoplasm (MCN); 4) Unknown: cysts of unknown status including cysts with CEA levels between 20 and 192ng/mL and without other identifying information. Results: Pancreatic cysts were identified in 156 patients (SCA 32, IPMN 36, uncategorized mucinous 11, MCN 5, other malignant 14, unknown 58). 85 patients (54.5%) had at least 1 cyst in the pancreas and a second abdominal organ, as follows: SCA 21 (24.7%), IPMN 18 (21.2%), uncategorized mucinous cyst 4 (4.7%), MCN 2 (2.4%), other malignant 8 (9.5%) and unknown 32 (37.6%). The breakdown of cysts in
www.giejournal.org
other abdominal organs was as follows: kidney 50, liver 6, kidney and liver 24, kidney/liver and spleen 5. Fisher’s exact found no significant association of multiple abdominal cysts with serous pancreatic cysts compared to other cysts (p O 0.05). Conclusion: Pancreatic cysts are associated with cysts in other intraabdominal organs in 54.5% patients. The presence of cysts in other organs is not associated with a serous etiology. This finding does not assist in predicting the etiology of pancreatic cysts.
Cysts in other organs Pancreatic cyst only
Serous
Mucinous
Malignant
Unknown
Total
21 11 32
21 25 47
10 9 19
32 26 58
85 71 156
M1474 Quality EUS-FNA: The Potential for Malignant Cell Carry-Over and False-Positive Cytology During Luminal Tumor Staging Marianne Fahmy, Walter Coyle, Farnaz Hasteh, Michael R. Peterson, Mary L. Krinsky Background: Endoscopic Ultrasound (EUS) is considered the best modality for the locoregional staging of all gastrointestinal(GI) luminal cancers. No studies have investigated the possibility of false-positive lymph node FNA in patients with GI cancers or the potential for malignant cell carry-over and needle contamination. Endoscopes that traverse a luminal tumor (LT) may cause cancer cells to shed and contaminate the endoscope tip and the biopsy channel. This may result in falsepositive cytology of an aspirate obtained from a sampled lymph node. Our primary aim was to determine if malignant cells carry-over and contaminate the (EUS) endoscope or FNA needle with passage of an endoechoscope through a LT. Methods: In this pilot study, we recruited 16 subjects who were referred for preoperative staging of gastrointestinal cancers; 13 patients with LT (esophageal cancers or gastric cancers) and 3 subjects for a control-arm with non-LT. All patients underwent a radial EUS for preoperative staging. A linear endoechoscope was then passed into their esophagus and stomach to perform either a sham FNA and when indicated a FNA for staging. Cytology samples were taken from the FNA needle, scope channel (brushings of and debris from the channel for cell block and histology), and the scope tip exterior. Direct tumor sampling was obtained for a control. Two blinded pathologists, with expertise in cytologic interpretations, read all slides. Results: Luminal cancers included 10 esophageal cancers, and 3 gastric cancers. Non-LT were pancreatic(2) or lung cancer(1). Of 13 luminal cancers, 7 (54%) had tumor cell carry-over detected by cytologic or histologic interpretation. Four(30%) had cell carry-over onto the cytology brush, 4 (30%) on the exterior scope, 4 (30%) from the cell block, and 2 (15%) from the FNA catheter tip. 29 percent of all patients with tumor cell carry-over had malignant cells found on the FNA needle. The 3 non-LT had no cell carry-over and all had negative controls. Conclusions: 1. Malignant cell contamination of endoechoscopes and FNA needles does occur when staging luminal cancers. 2. The FNA needle can be contaminated with tumor cells prior to obtaining non-peritumoral lymph node cytology, and has potential for false positive aspirates. 3. Endoscopist should be aware of the risks.
M1475 The Utility of Repeat Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) for Suspected Pancreatic Cancer Mark Nicaud, Dennis Collins, Mihir S. Wagh, Shailendra S. Chauhan, Peter V. Draganov Background: EUS-FNA is the gold standard for tissue diagnosis in patients with pancreatic cancer. The utility of repeat EUS-FNA in patients with clinical suspicion for pancreatic cancer after non-diagnostic EUS-FNA study is not well established. Aim: To determine the yield of repeat EUS-FNA in patients with suspected pancreatic cancer with prior non-diagnostic EUS-FNA. Methods: This was a retrospective review of prospectively collected data in searchable electronic database. All patients who underwent more then one EUS-FNA in our institution for evaluation of suspected pancreatic cancer were included in this analysis. Results: From 1/21/2002 to 11/25/2008 total of 3895 EUS procedures were performed in our institution. Of these, 31 patients (12 M, 19 F), (mean age 61.7, range 41-82) had repeat EUS-FNA done for the evaluation of possible pancreatic cancer. Preprocedure CT or MRI showed definitive or possible pancratic mass in 29 (93.5%), and no desecrate mass in 1 (3.2%) patient. No imaging study was available in 1 (3.2%) patient. Initial EUS evaluation showed pancreatic mass in 25 (80.6%), and no mass in 5 (16.2%) patients. In 1 (3.2%) patient at the first EUS the mass was thought to arise from the duodenum but on the repeat EUS was found to also be a pancreatic lesion. The mean number of FNA passes on initial EUS was 4 (range 17). Cytologic evaluation was atypical/suspicious in 8 (25.8%), and benign/reactive in 23 (74.2%). At the second EUS-FNA definitive malignancy was diagnosed in 2 (6.45%) of the patients with prior atypical/suspicious findings at the first EUS-FNA, and in 3 (9.67%) of the patients with benign/reactive initial cytology. In 19 (59.3%)
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB251