Maria Chiara Petrone

Feasibility and yield of a new EUS histology needle: results from a multicenter, pooled, cohort study

BACKGROUND EUS-guided FNA is an efficacious technique for sampling intraintestinal and extraintestinal mass lesions. However, cytology has limitations to its final yield and accuracy, which may be overcome if histological specimens are provided to the pathologist. OBJECTIVE To evaluate feasibility, yield, and diagnostic accuracy of a newly developed 19-gauge, fine-needle biopsy (FNB) device. DESIGN Multicenter, pooled, cohort study. SETTING Five medical centers. PATIENTS This study involved 109 consecutive patients with 114 intraintestinal or extraintestinal mass lesions and/or peri-intestinal lymph nodes. INTERVENTION EUS-guided FNB (EUS-FNB) with a newly developed, 19-gauge, FNB device. MAIN OUTCOME MEASUREMENTS Percentage of cases in which pathologists classified the sample quality as optimal for histological evaluation and the overall diagnostic accuracy compared with a composite criterion-standard diagnosis. RESULTS We evaluated 114 lesions (mean [± standard deviation] size 35.1 ± 18.7 mm; 84 malignant [73.7%] and 30 [26.3%] benign). EUS-FNB was technically feasible in 112 lesions (98.24%). Sample quality was adequate for full histological assessment in 102 lesions (89.47%). In 98 cases (85.96%), diagnosis proved to be correct according to criterion-standard diagnosis. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for diagnosis of malignancy were 90.2%, 100%, 100%, 78.9%, and 92.9%, respectively. LIMITATIONS Use of a surrogate criterion-standard diagnosis, including clinical follow-up when no surgical specimens were available, mainly in benign diagnoses. CONCLUSION Performing an EUS-FNB with a new 19-gauge histology needle is feasible for histopathology diagnosis of intraintestinal and extraintestinal mass lesions, offering the possibility of obtaining a core sample for histological evaluation in the majority of cases, with an overall diagnostic accuracy of over 85%.

Feasibility and safety of EUS-guided cryothermal ablation in patients with locally advanced pancreatic cancer

BACKGROUND New therapies are needed for pancreatic cancer. OBJECTIVE To determine the feasibility and safety of a new endoscopic treatment. Secondary endpoints were to determine effects on tumor growth measured with CT scan and to find the overall survival. DESIGN A cohort study of patients with local progression of advanced pancreatic adenocarcinoma after neoadjuvant therapy. The cryotherm probe (CTP), a flexible bipolar device that combines radiofrequency with cryogenic cooling, was used under EUS guidance. SETTING San Raffaele Hospital, Milan, Italy; University Medical Center, Hamburg-Eppendorf, Germany. PATIENTS A total of 22 patients (male/female 11/11; mean age 61.9 years) were enrolled from September 2009 to May 2011. INTERVENTION Radiofrequency heating: 18 W; pressure for cooling: 650 psi (Pounds per Square Inch); application time: depending on tumor size. MAIN OUTCOME MEASUREMENTS Feasibility was evaluated during the procedure. A clinical and radiologic follow-up was planned. RESULTS The CTP was successfully applied in 16 patients (72.8%); in 6 it was not possible because of stiffness of the GI wall and of the tumor. Amylase arose in 3 of 16 patients; none had clinical signs of pancreatitis. Late complications arose in 4 cases: 3 were mostly related to tumor progression. Median postablation survival time was 6 months. A CT scan was performed in all patients, but only in 6 of 16 was it possible to clearly define the tumor margins after ablation. In these patients, the tumor appeared smaller compared with the initial mass (P = .07). LIMITATIONS Small sample of patients, difficulty of objectifying the size of the ablated zone by CT scan. CONCLUSION EUS-guided CTP ablation is feasible and safe. Further investigations are needed to demonstrate progression-free survival and local control.

Pancreatic Endoscopic Ultrasound-guided Fine Needle Aspiration: Complication rate and clinical course in a single centre

BACKGROUND Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-FNA) is effective for obtaining biopsy specimens from pancreatic lesions. AIM To determine the frequency and severity of complications after EUS-FNA of solid and cystic pancreatic lesions in a single centre large series of patients. PATIENTS AND METHODS From January 2005 to December 2008, information on all patients referred to our unit for pancreatic EUS was systematically entered in a computer database including clinical and morphologic data. Records were reviewed to evaluate whether complications such as haemorrhage, acute pancreatitis, intestinal perforation, or others occurred after EUS-FNA of the pancreas. RESULTS A total of 3296 pancreatic EUS were done in four years. In the 1034 pancreatic EUS-FNA, we observed 10 (0.96%) haemorrhages (7 intracystic, 2 in the pancreatic duct, and 1 in a small carcinoma), 2 (0.19%) acute severe pancreatitis and 1 (0.09%) duodenal perforation followed by complicated post-surgical hospitalization and death. The haemorrhages were all self-limiting. Overall, major complications (pancreatitis and perforation) arose in 0.29% of these examinations. CONCLUSIONS EUS-FNA is safe, with a low risk of severe haemorrhage. Although rare, acute pancreatitis is generally mild or severe, requiring prolonged hospitalization. One fatal complication occurred after duodenal perforation in a patient with duodenal neuroendocrine tumour and pancreatic infiltration.

Mucin expression pattern in pancreatic diseases: findings from EUS-guided fine-needle aspiration biopsies.

OBJECTIVES:Alterations in mucin (MUC) glycosylation and expression have been described in cancer. Endoscopic ultrasound-guided fine-needle aspiration (EUS–FNA) can provide material for molecular biology analysis. This study assessed the feasibility of evaluating MUC expression from material obtained by EUS–FNA and studied the profile of MUC expression in benign and malignant pancreatic lesions.METHODS:A total of 90 patients with solid or cystic pancreatic lesions underwent FNA. The aspirated material was used for cytological analysis and RNA extraction to assess the expression pattern of MUCs by reverse transcription-PCR with primers specific for the MUC1, MUC2, MUC3, MUC4, MUC5A, MUC5B, MUC6, and MUC7 genes.RESULTS:RNA extraction was successful in 81% of the biopsies. The prevalences of MUC1, MUC2, MUC4, and MUC7 in ductal adenocarcinoma were 57.7, 51.4, 18.9, and 73.0%, respectively. Fifty percent of benign lesions and neuroendocrine tumors (NETs), and 63% of intraductal papillary mucinous neoplasms (IPMNs) were positive for MUC1. Twenty-five percent of benign lesions, 86% of NETs, and 47% of IPMNs were positive for MUC2. Of NETs, 50% were positive for MUC1, and 14% were positive for MUC7. None of the benign lesions or NETs expressed MUC4. MUC7 expression was highly significant for adenocarcinoma (P=0.007) and borderline for IPMN (P=0.05). MUC7 was expressed in 37.5% of chronic pancreatitis cases.CONCLUSIONS:RNA can be extracted from samples obtained under EUS–FNA. MUC7 could serve as a potential biological marker to identify malignant lesions, especially pancreatic adenocarcinoma.

Chronic Pancreatitis-Like Changes Detected by Endoscopic Ultrasound in Subjects without Signs of Pancreatic Disease: Do These Indicate Age-Related Changes, Effects of Xenobiotics, or Early Chronic Pancreatitis?

Background/Aims: The threshold number of endoscopic ultrasound (EUS) criteria for diagnosing chronic pancreatitis (CP) is variable. The presence of more than three abnormal ductular or parenchymal features is typically used, but the diagnostic significance of fewer EUS criteria is currently unclear. The aim of this study was to determine the prevalence of EUS features of CP in patients without pancreaticobiliary disease and to analyze the association with specific factors of interest. Methods: Over a 24-month period, 2,614 patients underwent EUS for an indication unrelated to pancreaticobiliary disease. Main outcome measurements wereunivariate and multivariate analysis between any EUS abnormality and demographic data and habits. Results: 82 patients (16.8%) showed at least one ductular or parenchymal abnormality. 38 patients presented with only one abnormal feature, 26 patients with two, 12 patients with three, 4 patients with four, and 2 patients with five. Low-level alcohol consumption significantly increased the risk of hyperechoic parenchymal foci, main pancreatic duct (MPD) dilatation and wall hyperechogenicity. Smoking was associated with an increased risk of hyperechoic parenchymal foci. Male gender and advanced age were significantly associated with an increased risk of MPD dilatation. Conclusions: Long-term smoking and alcohol consumption, although at a low dose, induces CP-like changes. These abnormalities might represent either a clinically silent CP or a toxic effect of smoking and alcohol. Conversely, MPD dilation might represent a normal age-related variant or, alternatively, an effect of chronic low-level alcohol consumption.

Role of endosocopic ultrasound in the diagnosis of cystic tumours of the pancreas

With the increased use of sophisticated imaging, cystic lesions in the pancreas are being recognized with greater frequency. Although imaging alone may not provide a specific diagnosis in many cases, a combination of imaging characteristics, clinical presentation, and additional procedures such as endoscopic ultrasound guided fine needle aspiration of cystic lesion, allows appropriate management. Cystic lesions in the pancreas can be divided pathologically into congenital cysts, pseudocysts and cystic neoplasm. At least four different types of cystic neoplasm have been described: mucinous neoplasms, intraductal papillary mucinous neoplasms, serous neoplasms and papillary cystic neoplasms The most important diagnosis is differentiating between mucinous and non-mucinous cystic lesion because of their different potential of malignancy. Endoscopic ultrasound provides the highest resolution of the pancreas and endoscopic ultrasound-fine needle aspiration can supply further diagnostic information on the basis of cytology, fluid viscosity, concentration of tumour glycoproteins, amylase level, molecular analysis that may contribute to the better clinical outcome of these neoplasms.

Does cytotechnician training influence the accuracy of EUS-guided fine-needle aspiration of pancreatic masses?

BACKGROUND/AIM The presence of on-site cytopathologists improves the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic masses; however, on-site cytopathologists are not available to all endoscopic units. We hypothesized that experienced cytotechnicians can accurately assess whether an on-site pancreatic mass fine needle aspiration specimen is adequate. The aim of this study was to evaluate the effect of formal cytotechnician training on the diagnostic accuracy of EUS-FNA of pancreatic masses. METHODS Single-centre, prospective study. The cytotechnician made an on-site assessment of specimen adequacy with immediate evaluation of smears over a 12-month period (pre-training period) then over another 12-month period (post-training period), with a years intermediate training when the cytopathologist and the cytotechnician worked together in the room. The gold standard used to establish the final diagnosis was based on a non-equivocal fine needle aspiration biopsy reviewed by the same expert cytopathologist. The main outcome measurements were the cytotechnician diagnostic accuracy before and after the training period. RESULTS A total of 107 patients were enrolled in the pre-training period. Cytotechnician in-room adequacy was 68.2% (73/107). The diagnostic accuracy was 74.8%. The adequacy for the blind-review pathologist was 93.4% (100/107), significantly higher (p=0.008) than the cytotechnicians results. During the post-training period, 95 EUS-FNA were performed and reviewed. Cytotechnician in-room adequacy was 87.4% (83/95). The diagnostic accuracy was 90.5%. The adequacy for the blinded pathologist was 95.8% (91/95), not significantly different from the cytotechnician (p=0.23). CONCLUSIONS An adequate training period with an expert pathologist significantly improves the cytotechnician skill in terms of judging adequacy and diagnostic accuracy.

Endoscopic ultrasonography findings in autoimmune pancreatitis

Endoscopic ultrasonography is an established diagnostic tool for pancreatic masses and chronic pancreatitis. In recent years there has been a growing interest in the worldwide medical community in autoimmune pancreatitis (AIP), a form of chronic pancreatitis caused by an autoimmune process. This paper reviews the current available literature about the endoscopic ultrasonographic findings of AIP and the role of this imaging technique in the management of this protean disease.

A single-centre prospective, cohort study of the natural history of acute pancreatitis

BACKGROUND The natural history of acute pancreatitis is based on clinical studies that aim to elucidate the course of disease on the basis of predicted risk factors. AIMS To evaluate the long-term occurrence of recurrent acute pancreatitis and chronic pancreatitis in a cohort of patients following an initial episode of acute pancreatitis. METHODS 196 patients were enrolled consecutively and studied prospectively. Clinical characteristics, exogenously/endogenously-associated factors, and evolution to recurrent acute pancreatitis and chronic pancreatitis were analyzed. RESULTS 40 patients developed recurrent acute pancreatitis 13 of whom developed chronic pancreatitis. In a univariate analysis, recurrent acute pancreatitis was associated with an idiopathic aetiology (p<0.001), pancreas divisum (p=0.001), and higher usage of cigarettes and alcohol (p<0.001; p=0.023). Chronic pancreatitis was associated with a severe first episode of acute pancreatitis (p=0.048), PD (p=0.03), and cigarette smoking (p=0.038). By multivariate analysis, pancreas divisum was an independent risk factor for recurrent acute pancreatitis (OR 11.5, 95% CI 1.6-83.3). A severe first-episode of acute pancreatitis increased the risk of progressing to chronic pancreatitis by nine-fold. CONCLUSIONS Special attention should be given to patients who experience a severe first attack of acute pancreatitis as there appears to be an increased risk of developing chronic pancreatitis over the long term.

Single-step versus two-step endo–ultrasonography-guided drainage of pancreatic pseudocyst

OBJECTIVE:  The aim of this prospective study was to compare the feasibility, technical success rate and complication between single‐step endo‐ultrasonography (EUS)‐guided and two‐step EUS‐guided drainage technique for symptomatic pancreatic pseudocyst (PP).