- Email: [email protected]
T1462: EUS Impacts the Decision to Resect Small (≤ 3 cm), Asymptomatic Pancreatic Cystic Lesions
Abstracts safety and utilities in the diagnose gallbladder (GB) mass lesions is not yet well unknown. ObjectiveTo assess the diagnostic utility and safety of EUS-FNA in the evaluation of gallbladder mass lesions.Methods: Retrospectively we evaluated the medical records of 14 patients (mean age, 66.8 ⫾8.2) who underwent EUS-FNA for GB mass lesions determined by US or CT between March, 1997 and November, 2009. In 9 cases, unresectable gallbladder carcinoma (GBC) was suspected and the aim of the puncture was to obtain histological evidence before management. In 4 of 9 cases suspected GBC, intra-abdominal lymph nodes (LNs) were detected and initially punctured LNs but were negative for carcinoma. In another 5 cases, xanthogranulomatous cholecystitis (XGC) was suspected but could not be distinguished from GB malignancy. Results: A total of 18 punctures (14 GB and 4 LNs) were performed EUS-FNA for GB mass itself in 14 patients. In the 9 unresectable GBC, EUS-FNA revealed adenocarcinoma in 8 of them and cellular atypia in one cases only. All these 9 cases received chemotherapy with a median survival of 231.5 days. In the 5 suspected XGC cases, EUS-FNA was sufficient in 4 cases (in 3 of them, foam cells were found and followed-up for a median observation period of 1008 days and in one case simple cholecystectomy was done). In the remaining case, EUS-FNA was insufficient and XGC was proved later by extended hepatectomy. In the overall, EUS-FNA samples from the 14 GB mass lesions were sufficient in 85.7% and it yielded a diagnostic accuracy figure of 92.8%(95% CI was 62.4-⬎99.9%) with sensitivity, and specificity figures of 88.8%(95% CI 42.2-97.6%), 100%(95% CI 47.9-100%), respectively. No serious complications were reported.Conclusion : EUS-FNA of GB mass lesions was safe and effective for differentially diagnosing malignancy and XGC. Hence, we can recommend the incorporation of EUS-FNA in the diagnostic workup of GB mass lesions when malignancy is clinically suspected.
T1461 Diagnostic Accuracy of Pancreatic Cyst Fluid Tumor Markers Obtained by EUS-Guided Sampling Mohammad A. Al-Haddad, John M. Dewitt, Stuart Sherman, C. Max Schmidt, Beth E. Juliar, Jennifer S. Stuart, Julia K. Leblanc, Lee Mchenry, Gregory A. Cote, Thomas F. Imperiale Introduction: Mucinous pancreatic cystic lesions (MPCLs) are premalignant but can be difficult to diagnose preoperatively. Pancreatic cyst fluid tumor markers and molecular analyses obtained by EUS-FNA have been increasingly utilized and may complement cytopathology. Aim: Prospectively compare cytopathology, CEA, and DNA molecular analysis of pancreatic cyst fluid to surgical pathology. Methods: Patients with suspected mucinous PCLs referred to our institution were prospectively enrolled into a pancreas cyst registry. Data collected included FNA cytology, cyst fluid CEA, DNA molecular analysis (RedPath; Pittsburgh, PA) and surgical pathology, if available. In the absence of surgical pathology, a mucinous cyst was defined by presence of columnar mucinous epithelium on cytology, CEA ⱖ 192 ng/ml, DNA quantity ⱖ40ng/ul, k-ras-mutation or ⱖ2 allelic imbalance mutations. Results: Between 8/08 and 10/09, 184 patients (57% male, median age 65 yrs) with suspected mucinous PCLs were enrolled and 179 (97%) underwent FNA. Median cyst diameter was 12 mm (range 4-75). Cyst fluid CEA and DNA were available in 114 (64%) and 78 (44%) respectively, and all 3 (FNA, CEA and DNA results) were available in 57 (32%) patients. FNA was diagnostic of a mucinous cyst in 26 (15%) of cases, CEA in 51 (45%) and DNA in 33 (42%). Agreement was minimal between FNA and CEA (n⫽114, kappa⫽0.07) and between CEA and DNA (n⫽ 57, kappa⫽0.06) but was fair between FNA and DNA (n⫽78, kappa⫽0.23). Pathology from 19 who underwent surgery: intraductal papillary mucinous neoplasms in 14, mucinous cystic neoplasm in 2 and serous cystadenoma in 3. DNA molecular analysis provided the diagnosis of a mucinous PCL in 3 out of 16 (19%) patients with pathologically confirmed MPCLs (21%) in whom FNA and CEA were either inconclusive or insufficient. The performance of each of the pre-operative diagnostic tests compared to surgical pathology is summarized in Table 1. When CEA and DNA molecular analysis results were combined, the sensitivity increased to 92%. Conclusion: Overall agreement between FNA, CEA and DNA analysis was poor. The combination of CEA and DNA analyses appears to improve the sensitivity for the diagnosis of MPCLs. Negative predictive value remains poor with all cyst fluid markers analyzed. Larger studies with pathologic correlation are needed to confirm these findings. Diagnostic test Sensitivity Specificity PPV NPV Agreement with Surgical (n) (%) (%) (%) (%) Pathology FNA (17) CEA (13) DNA analysis (14) CEA⫹DNA (12)
26 64 50 92
www.giejournal.org
100 100 50
100 100 86
15 33 14
0.08 0.35 ⬍0.001
T1462 EUS Impacts the Decision to Resect Small (< 3 cm), Asymptomatic Pancreatic Cystic Lesions Christopher J. Dimaio, Paul J. Belletrutti, Arnold J. Markowitz, Mark A. Schattner, Peter J. Allen, Hans Gerdes Background: The role of EUS in the evaluation of asymptomatic pancreatic cystic lesions (PCL) ⱕ 3 cm in size is controversial. The majority of these lesions are felt to be at low risk for malignancy and thus radiologic surveillance for changes in cyst size and characteristics may be sufficient to identify high-risk or malignant lesions. Aim: To determine the utility of EUS in the management of small, asymptomatic PCL. Methods: Patients with an asymptomatic PCL measuring ⱕ 3 cm, and who had undergone EUS evaluation, were identified from a prospectively-maintained pancreatic cyst registry. Demographic characteristics, radiographic findings, EUS findings, cyst fluid characteristics, and factors influencing decision for surgery were recorded. Results: A total of 231 patients fitting the inclusion criteria were identified, of which 44 underwent surgical resection. The mean age of this group was 63.9 years (12 M; 32 F). The mean cyst size was 27.3 mm. Thirty-one of 44 (70%) resected lesions were mucinous cysts (IPMN ⫽26, MCN ⫽5). Of the mucinous lesions, 4/31 (13%) were found to have malignant pathology (IPMN with invasive carcinoma). Overall, 4/44 (9%) resected cysts demonstrated invasive cancer on surgical pathology. In 15/44 (34%) cases, features suggestive of IPMN or a high risk lesion were found on EUS but not cross-sectional imaging (CT⫽31, MR⫽13). These EUS features were: mural nodules (3), associated mass (5), thick septae (1), pancreatic duct (PD) dilation (2), PD communication (7). Median time interval between imaging studies was 44 days. FNA was performed in 39/44 (89%). Cyst fluid CEA was obtained in 24/44 (55%). Mean CEA concentration for mucinous cysts was 7392 ng/ml and for non-mucinous cysts was 77ng/ml. Results of EUS factored into the decision to resect the PCL in 31/44 (70%) of cases. Influencing factors were: cytology (11), morphologic finding (7), CEA concentration (6), viscous cyst fluid (1), both morphology and CEA (3), both morphology and cytology (2), both cytology and CEA (1). Of the cases with malignant pathology, EUS detected high-risk features not seen on cross-sectional imaging in 2/4 cases (mural nodules and thick septae in both cases), and one additional case had a positive cytology for cancer. Conclusions: Although cross-sectional imaging and EUS are imperfect in the evaluation of PCLs, in our patients with small, asymptomatic PCL, EUS impacts the decision to resect in 70% of cases. High-risk morphologic features, cytology, and chemical analysis of aspirated fluid help identify patients at greatest risk for malignancy.
T1463 Spontaneous Resolvement of Focal Pancreatic Lesions in EUS Screening of Individuals At High Risk of Pancreatic Cancer Femme Harinck, Jan-Werner Poley, Jeanin E. Hooft Van, Dirk J. Gouma, Casper H. Van Eijck, Chung Y. Nio, John Hermans, Annemieke Cats, Anja Wagner, Cora M. Aalfs, Irma Kluijt, Paul Fockens, Marco J. Bruno Introduction:Individuals at high risk of pancreatic cancer (PC) are either (1) mutation-carriers of PC prone hereditary tumor-syndromes or (2) first-degreerelatives of patients with familial-PC (FPC). These high-risk individuals could benefit from a surveillance-program by diagnosing the disease at an early and potentially curable stage. To test the applicability, yield and safety of such a surveillance-program, a multicenter study is being conducted. The spectrum of abnormalities encountered in these investigations is a learning experience of which we present some interesting and clinically relevant findings.Methods: Asymptomatic high-risk individuals prospectively underwent endoscopic ultrasound (EUS). Individuals without pancreatic abnormalities were scheduled for annual follow-up (FU). Whenever abnormalities were detected, management was based on consensus agreement of an expert panel (experienced endosonographists, surgeons and radiologists). This could either be (1) surgical resection in case of a highly suspicious lesion or (2) shortening of the FU interval to three months. Results:For this analysis we included 82 high-risk individuals. In six cases (7.3%) EUS showed a focal area of hypoechogenicity of undetermined significance. All were rescheduled for interval-screening after 3 months. Remarkably, at interval-screening, the focal area of hypoechogenicity (diameter range 4-11mm) had disappeared in 4 cases. Of these 4 cases, 3 were asymptomatic and one suffered from an attack of acute pancreatitis three months prior to EUS. FU EUS after 12 months confirmed the absence of the previously detected lesions in 3 of these 4 cases with a ‘transient’ lesion. In the fourth case FU EUS is pending. In the remainder 2 cases the focal area of hypoechogenicity was still present after 3 months. In one case, size and aspect remained unchanged and was classified as a prominent lobule in a greatly lobulated pancreas. In the other case, size increased from 7 to 11 mm and partial pancreatectomy was performed. The exact area of hypoechogenicity could not be identified at pathological investigation, but focal areas of PanIN-2 and an incipient IPMN were detected. ConclusionIn the surveillance of individuals at high risk of PC, EUS detected areas of hypoechogenicity of which four were transient and disappeared spontaneously within three months time. Such lesions could easily be misinterpreted as potential malignant mass lesions with the
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB283
T1461 Diagnostic Accuracy of Pancreatic Cyst Fluid Tumor Markers Obtained by EUS-Guided Sampling Mohammad A. Al-Haddad, John M. Dewitt, Stuart Sherman, C. Max Schmidt, Beth E. Juliar, Jennifer S. Stuart, Julia K. Leblanc, Lee Mchenry, Gregory A. Cote, Thomas F. Imperiale Introduction: Mucinous pancreatic cystic lesions (MPCLs) are premalignant but can be difficult to diagnose preoperatively. Pancreatic cyst fluid tumor markers and molecular analyses obtained by EUS-FNA have been increasingly utilized and may complement cytopathology. Aim: Prospectively compare cytopathology, CEA, and DNA molecular analysis of pancreatic cyst fluid to surgical pathology. Methods: Patients with suspected mucinous PCLs referred to our institution were prospectively enrolled into a pancreas cyst registry. Data collected included FNA cytology, cyst fluid CEA, DNA molecular analysis (RedPath; Pittsburgh, PA) and surgical pathology, if available. In the absence of surgical pathology, a mucinous cyst was defined by presence of columnar mucinous epithelium on cytology, CEA ⱖ 192 ng/ml, DNA quantity ⱖ40ng/ul, k-ras-mutation or ⱖ2 allelic imbalance mutations. Results: Between 8/08 and 10/09, 184 patients (57% male, median age 65 yrs) with suspected mucinous PCLs were enrolled and 179 (97%) underwent FNA. Median cyst diameter was 12 mm (range 4-75). Cyst fluid CEA and DNA were available in 114 (64%) and 78 (44%) respectively, and all 3 (FNA, CEA and DNA results) were available in 57 (32%) patients. FNA was diagnostic of a mucinous cyst in 26 (15%) of cases, CEA in 51 (45%) and DNA in 33 (42%). Agreement was minimal between FNA and CEA (n⫽114, kappa⫽0.07) and between CEA and DNA (n⫽ 57, kappa⫽0.06) but was fair between FNA and DNA (n⫽78, kappa⫽0.23). Pathology from 19 who underwent surgery: intraductal papillary mucinous neoplasms in 14, mucinous cystic neoplasm in 2 and serous cystadenoma in 3. DNA molecular analysis provided the diagnosis of a mucinous PCL in 3 out of 16 (19%) patients with pathologically confirmed MPCLs (21%) in whom FNA and CEA were either inconclusive or insufficient. The performance of each of the pre-operative diagnostic tests compared to surgical pathology is summarized in Table 1. When CEA and DNA molecular analysis results were combined, the sensitivity increased to 92%. Conclusion: Overall agreement between FNA, CEA and DNA analysis was poor. The combination of CEA and DNA analyses appears to improve the sensitivity for the diagnosis of MPCLs. Negative predictive value remains poor with all cyst fluid markers analyzed. Larger studies with pathologic correlation are needed to confirm these findings. Diagnostic test Sensitivity Specificity PPV NPV Agreement with Surgical (n) (%) (%) (%) (%) Pathology FNA (17) CEA (13) DNA analysis (14) CEA⫹DNA (12)
26 64 50 92
www.giejournal.org
100 100 50
100 100 86
15 33 14
0.08 0.35 ⬍0.001
T1462 EUS Impacts the Decision to Resect Small (< 3 cm), Asymptomatic Pancreatic Cystic Lesions Christopher J. Dimaio, Paul J. Belletrutti, Arnold J. Markowitz, Mark A. Schattner, Peter J. Allen, Hans Gerdes Background: The role of EUS in the evaluation of asymptomatic pancreatic cystic lesions (PCL) ⱕ 3 cm in size is controversial. The majority of these lesions are felt to be at low risk for malignancy and thus radiologic surveillance for changes in cyst size and characteristics may be sufficient to identify high-risk or malignant lesions. Aim: To determine the utility of EUS in the management of small, asymptomatic PCL. Methods: Patients with an asymptomatic PCL measuring ⱕ 3 cm, and who had undergone EUS evaluation, were identified from a prospectively-maintained pancreatic cyst registry. Demographic characteristics, radiographic findings, EUS findings, cyst fluid characteristics, and factors influencing decision for surgery were recorded. Results: A total of 231 patients fitting the inclusion criteria were identified, of which 44 underwent surgical resection. The mean age of this group was 63.9 years (12 M; 32 F). The mean cyst size was 27.3 mm. Thirty-one of 44 (70%) resected lesions were mucinous cysts (IPMN ⫽26, MCN ⫽5). Of the mucinous lesions, 4/31 (13%) were found to have malignant pathology (IPMN with invasive carcinoma). Overall, 4/44 (9%) resected cysts demonstrated invasive cancer on surgical pathology. In 15/44 (34%) cases, features suggestive of IPMN or a high risk lesion were found on EUS but not cross-sectional imaging (CT⫽31, MR⫽13). These EUS features were: mural nodules (3), associated mass (5), thick septae (1), pancreatic duct (PD) dilation (2), PD communication (7). Median time interval between imaging studies was 44 days. FNA was performed in 39/44 (89%). Cyst fluid CEA was obtained in 24/44 (55%). Mean CEA concentration for mucinous cysts was 7392 ng/ml and for non-mucinous cysts was 77ng/ml. Results of EUS factored into the decision to resect the PCL in 31/44 (70%) of cases. Influencing factors were: cytology (11), morphologic finding (7), CEA concentration (6), viscous cyst fluid (1), both morphology and CEA (3), both morphology and cytology (2), both cytology and CEA (1). Of the cases with malignant pathology, EUS detected high-risk features not seen on cross-sectional imaging in 2/4 cases (mural nodules and thick septae in both cases), and one additional case had a positive cytology for cancer. Conclusions: Although cross-sectional imaging and EUS are imperfect in the evaluation of PCLs, in our patients with small, asymptomatic PCL, EUS impacts the decision to resect in 70% of cases. High-risk morphologic features, cytology, and chemical analysis of aspirated fluid help identify patients at greatest risk for malignancy.
T1463 Spontaneous Resolvement of Focal Pancreatic Lesions in EUS Screening of Individuals At High Risk of Pancreatic Cancer Femme Harinck, Jan-Werner Poley, Jeanin E. Hooft Van, Dirk J. Gouma, Casper H. Van Eijck, Chung Y. Nio, John Hermans, Annemieke Cats, Anja Wagner, Cora M. Aalfs, Irma Kluijt, Paul Fockens, Marco J. Bruno Introduction:Individuals at high risk of pancreatic cancer (PC) are either (1) mutation-carriers of PC prone hereditary tumor-syndromes or (2) first-degreerelatives of patients with familial-PC (FPC). These high-risk individuals could benefit from a surveillance-program by diagnosing the disease at an early and potentially curable stage. To test the applicability, yield and safety of such a surveillance-program, a multicenter study is being conducted. The spectrum of abnormalities encountered in these investigations is a learning experience of which we present some interesting and clinically relevant findings.Methods: Asymptomatic high-risk individuals prospectively underwent endoscopic ultrasound (EUS). Individuals without pancreatic abnormalities were scheduled for annual follow-up (FU). Whenever abnormalities were detected, management was based on consensus agreement of an expert panel (experienced endosonographists, surgeons and radiologists). This could either be (1) surgical resection in case of a highly suspicious lesion or (2) shortening of the FU interval to three months. Results:For this analysis we included 82 high-risk individuals. In six cases (7.3%) EUS showed a focal area of hypoechogenicity of undetermined significance. All were rescheduled for interval-screening after 3 months. Remarkably, at interval-screening, the focal area of hypoechogenicity (diameter range 4-11mm) had disappeared in 4 cases. Of these 4 cases, 3 were asymptomatic and one suffered from an attack of acute pancreatitis three months prior to EUS. FU EUS after 12 months confirmed the absence of the previously detected lesions in 3 of these 4 cases with a ‘transient’ lesion. In the fourth case FU EUS is pending. In the remainder 2 cases the focal area of hypoechogenicity was still present after 3 months. In one case, size and aspect remained unchanged and was classified as a prominent lobule in a greatly lobulated pancreas. In the other case, size increased from 7 to 11 mm and partial pancreatectomy was performed. The exact area of hypoechogenicity could not be identified at pathological investigation, but focal areas of PanIN-2 and an incipient IPMN were detected. ConclusionIn the surveillance of individuals at high risk of PC, EUS detected areas of hypoechogenicity of which four were transient and disappeared spontaneously within three months time. Such lesions could easily be misinterpreted as potential malignant mass lesions with the
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB283