Manmeet S. Padda

EUS-guided FNA of solid pancreatic masses: a prospective, randomized trial comparing 22-gauge and 25-gauge needles

BACKGROUND There is a lack of prospective, randomized studies comparing the diagnostic yield and complication rates of 22-gauge and 25-gauge needles during EUS-FNA of solid pancreatic masses. OBJECTIVES Our primary aim was to compare the diagnostic yield of 22-gauge and 25-gauge needles. Secondary aims included determining the number of needle passes performed, ease of needle passage, and complications. DESIGN Prospective, randomized study. SETTING Tertiary referral centers at Yale University School of Medicine, New Haven, Connecticut, and Virginia Piper Cancer Institute, Minneapolis, Minnesota. PATIENTS Patients with a suspected solid pancreatic mass from February 2007 to June 2008 were enrolled. INTERVENTIONS Patients were randomized to EUS-FNA with a 22-gauge or 25-gauge needle. MAIN OUTCOME MEASUREMENTS A diagnostic result was defined as cytology findings positive for malignant cells. RESULTS A total of 131 patients were enrolled: EUS-FNA was performed with a 22-gauge needle in 64 patients and with a 25-gauge needle in 67 patients. Cytology was diagnostic in 120 (91.6%) of 131 patients overall: 56 (87.5%) of 64 with 22-gauge needles and 64 (95.5%) of 67 with 25-gauge needles (no statistically significant difference was found between the 2 groups; P=.18). A similar number of passes was performed in both arms (mean [SD] 2.6 [1.2] each; P=.96). There were no complications in either group. LIMITATION A larger number of patients is needed to determine small differences in diagnostic yield. CONCLUSIONS This is the first prospective, randomized trial comparing 22-gauge and 25-gauge needles in EUS-FNA of solid pancreatic masses. We achieved equally high diagnostic yields by using a similar number of passes, showing that 25-gauge needles are an effective alternative to 22-gauge needles.

Endoscopic ultrasound identifies synchronous pancreas cystic lesions not seen on initial cross-sectional imaging.

Objectives: A retrospective review conducted to determine the utility of endoscopic ultrasound (EUS) examination of the pancreas after initial pancreatic cyst detection with cross-sectional imaging. Methods: A retrospective review of 145 patients referred for EUS for evaluation of pancreas cystic lesions. Initial cross-sectional imaging reports were reviewed and compared to subsequent EUS findings. Findings evaluated included cyst size, number, multifocality, presence in different surgical fields, cyst wall nodularity, main pancreatic duct (PD) dilation, communication with PD, and features suggestive of serous cystadenoma. Results: Compared to computed tomographic scan, EUS more frequently identified pancreatic cystic lesion multifocality (47% vs 13%, P < 0.0001) and their presence in different surgical fields (33.3% vs 4.2%, P < 0.0001). Compared to magnetic resonance imaging, EUS was superior in identifying multifocality (58% vs 34%, P = 0.0002) and the presence of cysts in different surgical fields (42% vs. 26%, P = 0.021). Malignancy was suspected or confirmed in 3 patients by EUS fine-needle aspiration cytology, not suspected by cross-sectional imaging. Endoscopic ultrasound identified unappreciated features of serous cystadenomas in 10 patients. Conclusion: Endoscopic ultrasound identified synchronous pancreatic cystic lesions unappreciated by initial cross-sectional imaging, with undetected cysts frequently outside of typical resection margins. In addition, EUS identified the presence of unappreciated high- or low-risk characteristics in a small percentage of patients.

Pancreatic and Gastric Plasmacytoma Presenting with Obstructive Jaundice, Diagnosed with Endoscopic Ultrasound-Guided Fine Needle Aspiration.

Pancreatic plasmacytoma is a rare disorder which may present with obstructive jaundice. Only eighteen cases have been reported in the English language literature. We present the first case of pancreatic plasmacytoma and gastric plasmacytoma diagnosed with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). A 75-year-old male with a known history of multiple myeloma presented with obstructive jaundice and a pancreatic mass. A concomitant gastric mass due to gastric plasmacytoma was seen. The diagnosis was established via EUS-FNA of the pancreatic mass. Pancreatic plasmacytoma should be suspected in patients with a history of myeloma. EUS-FNA is a safe and effective modality in the diagnosis of pancreatic plasmacytoma. Radiation therapy should be the first-line of therapy in treating pancreatic plasmacytomas.

Anxiety and perception of cancer risk in patients undergoing endoscopic ultrasonography for pancreas cystic lesions.

To the Editor: The increase in availability and use of high-quality abdominal imaging has resulted in the increased detection of incidental pancreatic cysts, but estimation of the malignant potential of suspected mucinous pancreas cysts, however, remains difficult. Several studies have demonstrated that patients do not accurately predict their personal risk of cancer, even when they are enrolled in cancer screening or surveillance programs. We suspect that the identification of cystic neoplasms of the pancreas creates a great deal of patient anxiety due to association with the poor outcomes of pancreas adenocarcinoma, despite their very different natural histories. It is therefore our intent to investigate anxiety levels and cancer risk estimates of patients undergoing endoscopic ultrasonography (EUS) to evaluate their cystic pancreatic lesions and compare risk estimates to those of the endosonographer.

A rare cause of dysphagia

A 54-year-old woman, with a history of partial strumectomy due to hyperthyroidism, was referred for evaluation of chronic dysphagia for solids for more than 10 years. In the last few months, she was only fed on a liquid diet and lost approximately 6 kg in weight. Neither reflux symptoms nor thoracic pain were present. Physical examination and screening blood tests were unremarkable. Upper endoscopy (supplementary video, figure 1), oesophageal high-resolution manometry (figure 2 …

Patient preferences after endoscopic ultrasound with fine needle aspiration (EUS-FNA) diagnosis of pancreas cancer: rapid communication valued over long-term relationships.

Background: Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is used for the diagnosis of pancreatic malignancy. However, there are limited data as to patient preferences regarding the delivery of cancer diagnoses. Objectives: This study aimed to assess if patients had met the endosonographer before their EUS, their suspicion of having cancer, and whether they would like the cytology results given to them by their referring physician (with whom they had a previous relationship) or the endosonographer. This question was also asked with respect to the timing of receiving cytology results. Methods: A total of 131 patients with a suspected solid pancreatic mass undergoing EUS-FNA at 2 tertiary referral centers were prospectively enrolled and completed a preprocedure questionnaire. Results: One hundred twenty patients (92%) had not met the endosonographer before their EUS-FNA, and only 37 patients (28%) thought they had a pancreatic malignancy. Of the 131 patients, 89 (68%) stated that they wanted to hear results from the endosonographer (P = 0.0001) and 100 patients (76%) chose to hear results as soon as possible from the endosonographer (P = 0.001). Conclusions: Our data highlight the importance of the endosonographers role in the delivery of cancer diagnoses and that patients value expediency of reporting results over long-term physician relationships.

Young Female With Pancreatic Mass

C uestion: A previously healthy, 22-year-old woman unerwent computed tomography and magnetic resonance maging of the abdomen to evaluate acute-onset, selfimited, lower abdominal pain. A 5.8-cm cystic mass with ome solid components was seen in the head of the ancreas (Figure A). She had no history of pancreatitis or bdominal trauma and no family history of pancreatitis r malignancy. Her only medication use was oral contraeptive pills. The physical examination was unremarkble. Laboratory studies including pancreas enzymes and iver function tests were normal. Endoscopic ultrasound examination (EUS) revealed a eterogeneous, hypoechoic 5.3 4.5 cm mass that apeared predominantly solid, with multiple, small anechoic/ ystic spaces (Figure B). The lesion was not obstructing the ancreatic or bile duct. The pancreas parenchyma in the ody and tail was normal and no lymphadenopathy was een. EUS-guided fine needle aspiration (FNA) was performed ith a 22-gauge needle. Cytology identified a 3-layered papllary architecture composed of a central capillary layer, a iddle layer of myxoid stroma and an outer layer of monoorphic neoplastic cells (Figure C, papanicolaou stain). Indiidual cells showed high nuclear/cytoplasmic ratio, scant ytoplasm, and grooved/clefted nuclei. Immunophenotype taining was positive for CD10, -catenin, vimentin, neuon-specific enolase, progesterone receptor, and CD56, and egative for estrogen receptor and synaptophysin. What is the diagnosis? Look on page 1189 for the answer and see the ASTROENTEROLOGY web site (www.gastrojournal.org) or more information on submitting your favorite mage to Clinical Challenges and Images in GI. MANMEET S. PADDA, MD HARRY R. ASLANIAN, MD Department of Digestive Diseases C. THEOHARIS, MD Department of Cytopathology Yale University School of Medicine New Haven, Connecticut