Brenna Casey

Cystic pancreatic neuroendocrine tumors: The value of cytology in preoperative diagnosis

Cystic pancreatic neuroendocrine tumors (cPanNETs) account for 13% to 17% of PanNETs. Although the value of endoscopic ultrasound (EUS) imaging and cyst fluid analysis (CFA) in their preoperative diagnosis has been well described, limited information is available about the diagnostic role of cytology samples obtained from fine‐needle aspiration (FNA).

Variation in Aptitude of Trainees in Endoscopic Ultrasonography, Based on Cumulative Sum Analysis

BACKGROUND & AIMS Studies have reported substantial variation in the competency of advanced endoscopy trainees, indicating a need for more supervised training in endoscopic ultrasound (EUS). We used a standardized, validated, data collection tool to evaluate learning curves and measure competency in EUS among trainees at multiple centers. METHODS In a prospective study performed at 15 centers, 17 trainees with no prior EUS experience were evaluated by experienced attending endosonographers at the 25th and then every 10th upper EUS examination, over a 12-month training period. A standardized data collection form was used (using a 5-point scoring system) to grade the EUS examination. Cumulative sum analysis was applied to produce a learning curve for each trainee; it tracked the overall performance based on median scores at different stations and also at each station. Competency was defined by a median score of 1, with acceptable and unacceptable failure rates of 10% and 20%, respectively. RESULTS Twelve trainees were included in the final analysis. Each of the trainees performed 265 to 540 EUS examinations (total, 4257 examinations). There was a large amount of variation in their learning curves: 2 trainees crossed the threshold for acceptable performance (at cases 225 and 245), 2 trainees had a trend toward acceptable performance (after 289 and 355 cases) but required continued observation, and 8 trainees needed additional training and observation. Similar results were observed at individual stations. CONCLUSIONS A specific case load does not ensure competency in EUS; 225 cases should be considered the minimum caseload for training because we found that no trainee achieved competency before this point. Ongoing training should be provided for trainees until competency is confirmed using objective measures.

Value of adding GNAS testing to pancreatic cyst fluid KRAS and carcinoembryonic antigen analysis for the diagnosis of intraductal papillary mucinous neoplasms.

Molecular analysis of pancreatic cyst fluid (PCF) has been proposed as a novel method for differentiating pancreatic cystic lesions (PCL). The present study aimed to investigate the value of GNAS testing when added to KRAS and carcinoembryonic antigen (CEA) testing of PCF for the diagnosis of intraductal papillary mucinous neoplasms (IPMN).

The Value of Adding GNAS Testing to Pancreatic Cyst Fluid KRAS and CEA Analysis for the Diagnosis of Intraductal Papillary Mucinous Neoplasms

Molecular analysis of pancreatic cyst fluid (PCF) has been proposed as a novel method for differentiating pancreatic cystic lesions (PCL). The present study aimed to investigate the value of GNAS testing when added to KRAS and carcinoembryonic antigen (CEA) testing of PCF for the diagnosis of intraductal papillary mucinous neoplasms (IPMN).

The value of KRAS mutation testing with CEA for the diagnosis of pancreatic mucinous cysts

Background and aims: Pancreatic cyst fluid (PCF) CEA has been shown to be the most accurate preoperative test for detection of cystic mucinous neoplasms (CMNs). This study aimed to assess the added value of PCF KRAS mutational analysis to CEA for diagnosis of CMNs. Patients and methods: This is a retrospective study of prospectively collected endoscopic ultrasonography (EUS) fine-needle aspiration (FNA) data. KRAS mutation was determined by direct sequencing or equivalent methods. Cysts were classified histologically (surgical cohort) or by clinical (EUS or FNA) findings (clinical cohort). Performance characteristics of KRAS, CEA and their combination for detection of a cystic mucinous neoplasm (CMN) and malignancy were calculated. Results: The study cohort consisted of 943 patients: 147 in the surgical cohort and 796 in the clinical cohort. Overall, KRAS and CEA each had high specificity (100 % and 93.2 %), but low sensitivity (48.3 % and 56.3 %) for the diagnosis of a CMN. The positivity of KRAS or CEA increased the diagnostic accuracy (80.8 %) and AUC (0.84) significantly compared to KRAS (65.3 % and 0.74) or CEA (65.8 % and 0.74) alone, but only in the clinical cohort (P < 0.0001 for both). KRAS mutation was significantly more frequent in malignant CMNs compared to histologically confirmed non-malignant CMNs (73 % vs. 37 %, P = 0.001). The negative predictive value of KRAS mutation was 77.6 % in differentiating non-malignant cysts. Conclusions: The detection of a KRAS mutation in PCF is a highly specific test for mucinous cysts. It outperforms CEA for sensitivity in mucinous cyst diagnosis, but the data does not support its routine use.

Pancreas Divisum and Minor Papilla Interventions

Pancreas divisum is the most common congenital anomaly of the pancreas. Defined in its classic form by absence of fusion of the dorsal and ventral pancreatic ducts, pancreas divisum has been associated with pancreatitis. Despite this association, its clinical relevance remains uncertain. Endoscopic therapies aimed at improving dorsal pancreatic duct drainage have improved over the years, although its role in the treatment of patients with chronic pancreatitis and chronic abdominal pain, however, is much less established. A randomized, large multi-center, prospective therapeutic trial of endotherapy in symptomatic patients with pancreas divisum is much needed. For now, the risk-benefit ratio of performing ERCP with possible therapeutic intervention needs to be thoroughly reviewed with the patient and care team.

88 Comparison of the International Consensus Guidelines for Management of Intraductal Papillary Mucinous Neoplasm (IPMN) With Analysis of Pancreatic Cyst Fluid Aspirates for mAb-Das-1 Reactivity in Identifying High-Risk and Malignant IPMN

invasive carcinoma. A median time to recurrence after resection was 31 months (range 183) for non-invasive tumors and 11 months (range 1-145) for those with invasion (P=0.05). No clinical or pathological predictors of recurrence were found for non-invasive IPMNs. Among invasive tumors, predictors for recurrence were macroscopic invasion (P=0.003), N1 status (P<0.001) and a pancreatic resection margin positive for HGD or IC (P<0.001). At Cox regression model, tubular carcinoma had higher risk for recurrence over the colloid (P=0.019 HR 3.7). Conclusions: In the absence of HGD or IC, recurrence following resection for IPMN is uncommon (8.3%). Once invasive carcinoma is present, type and size of invasion, N status and pancreatic resection margin identify patients at higher risk for recurrence, who therefore should follow the same surveillance protocol of conventional PDAC.