Abdul Hamid El Chafic

Performance characteristics of molecular (DNA) analysis for the diagnosis of mucinous pancreatic cysts

BACKGROUND Diagnosis of mucinous pancreatic cysts (MPCs) is challenging due to the poor sensitivity of cytology provided by EUS-guided-FNA (EUS-FNA). OBJECTIVE To quantify the test characteristics of molecular (DNA) analysis in suspected low-risk MPCs. DESIGN A prospective cohort study performed in between 2008 and 2011. SETTING Academic referral center. PATIENTS Consecutive patients who underwent EUS-FNA of suspected MPCs. INTERVENTION EUS-FNA and molecular (DNA) analysis of cyst fluid. MAIN OUTCOME MEASUREMENTS The sensitivity and specificity of molecular analysis in the diagnosis of MPCs using the criterion standard of surgical pathology in resected cysts. RESULTS Patients with suspected MPCs underwent EUS-FNA and cyst fluid DNA analysis. Surgical resection was performed in 48 patients (17%), confirming a mucinous pathology in 38 (79%). In this group, molecular analysis had a sensitivity of 50% and a specificity of 80% in identifying MPCs (accuracy of 56.3%). The combination of molecular analysis with cyst fluid carcinoembryonic antigen (CEA) and cytology resulted in higher MPC diagnostic performance than either one of its individual components, with a sensitivity, specificity, and accuracy of 73.7%, 70%, and 72.9%, respectively. There was no significant difference in accuracy between molecular analysis and CEA/cytology in this group. LIMITATIONS Single-center experience. CONCLUSION Molecular analysis aids in the diagnosis of MPCs when cytology is nondiagnostic or cyst fluid is insufficient for CEA or its level is indeterminate. Our results do not support the routine use of molecular analysis, which should be used selectively after review of imaging findings and cyst fluid studies. Further studies are needed to assess DNAs performance in malignant cysts.

Impact of preoperative endoscopic ultrasound-guided fine needle aspiration on postoperative recurrence and survival in cholangiocarcinoma patients

BACKGROUND AND STUDY AIM Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is frequently performed for suspected biliary tumors for diagnosis and staging but carries a theoretical risk of needle-track seeding. We aimed to evaluate the impact of preoperative EUS-FNA on long-term outcomes for patients with cholangiocarcinoma (CCA). PATIENTS AND METHODS In a retrospective single-center study of consecutive patients with CCA with preoperative EUS-FNA, main outcome measures were overall survival and progression-free survival. RESULTS In 150 patients with confirmed CCA, 61 underwent preoperative FNA. Median overall survival was 18.5 months (95% confidence limits [CL] 15.4, 25.7): 111 patients died and 39 survived. Of the 150 patients, 119 underwent curative-intent surgical resection, with median progression-free survival of 17.8 months (95% CL 14.5, 22.8); 89/119 patients had tumor recurrence or died, and 30/119 remained alive and disease-free. On multivariable analysis, overall survival was associated with: undergoing curative-intent surgery (hazard ratio [HR] 5.79, P = 0.001), lack of lymph node involvement (HR 1.89, P = 0.011), younger age (HR 1.51 for every 10 years, P < 0.0015), and small tumor size (HR 1.11 for every 1 cm, P = 0.029). For patients undergoing curative-intent surgery, on multivariable analysis, improved progression-free survival was associated with: lack of lymph node involvement (HR 1.88, P = 0.010), smaller tumor size (HR 1.16 for every 1 cm smaller, P = 0.003), and younger age (HR 1.53 for every 10 years, P < 0.001). Number of needle passes showed no statistically significant impact on overall survival. CONCLUSION Preoperative EUS-FNA in patients with CCA does not appear to adversely affect overall or progression-free survival.

Endoscopic resection of a giant solitary fibrous tumor of the esophagus

A 63-year-old woman with a medical history of hypertension, hypothyroidism, and GERD presented to our clinic with worsening dysphagia to solids. EGD performed by a local gastroenterologist showed a large esophageal mass. CT of the chest with contrast material revealed a highdensity, nearly occlusive, esophageal mass, beginning at the thoracic inlet, measuring 3.8 cm 2.1 cm 10.4 cm (transverse, anteroposterior, craniocaudal), and demonstrating well-delineated smooth margins without esophageal disruption (Fig. 1). EGD was repeated at our facility and revealed a large pedunculated subepithelial mass in the upper third of the esophagus, extending 17 to 30 cm from the incisors (Fig. 2). The mass was partially obstructive, and the endoscope was able to traverse it with minimal resistance. EUS revealed a hypoechoic mucosal mass without submucosal invasion, with a feeding vessel at the stalk (Fig. 3).

Does cyst growth predict malignancy in branch duct intraductal papillary mucinous neoplasms? Results of a large multicenter experience

BACKGROUND Cyst growth of BD-IPMNs on follow-up imaging remains a concerning sign. AIMS To describe cyst size changes over time in BD-IPMNs, and determine whether cyst growth rate is associated with increased risk of malignancy. METHODS This is a retrospective study performed at two high volume tertiary centers. Mean cyst size at baseline (MCSB) and mean growth rate percentage (MGRP) were calculated. Rapid cyst growth was defined as MGRP ≥30%/year. Patient and cyst related characteristics were studied. RESULTS 160 patients were followed for a median of 27.4 (12-114.5) months. MCSB was 15.1 ± 8.0 mm. During follow-up, 73 (45.6%) showed any cyst size increase, of which 15 cysts (9.4%) exhibited MGRP ≥30%/year. Rapid cyst growth was not associated with patient or cyst characteristics. Cyst fluid molecular analysis from 101 cysts showed KRAS mutation in 26. Compared to KRAS-negative cysts, neither MCSB (16.0 mm vs. 17.7 mm; p = 0.3) nor MGRP (3.9%/year vs. 5.8%/year; p = 0.7) was significantly different. Eighteen patients underwent surgery; 15 (83%) had LGD, and 3 had advanced neoplasia. Two cysts with LGD and one cyst with advanced neoplasia had MGRP ≥30%/year. CONCLUSION Increase in BD-IPMNs size was not associated with the known high risk patient or cyst-related characteristics. Rapid growth of BD-IPMNs was not associated with advanced neoplasia on surgical pathology.