Neeraj Kaushik

Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study

BACKGROUND The role of pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts remains unclear. OBJECTIVE Our purpose was to evaluate the utility of a detailed DNA analysis of pancreatic cyst fluid to diagnose mucinous and malignant cysts. DESIGN Prospective, multicenter study. PATIENTS Patients with pancreatic cysts presenting for EUS evaluation. INTERVENTION EUS-guided pancreatic cyst aspirates cytology evaluation, carcinoembryonic antigen (CEA) level determination, and a detailed DNA analysis; incorporating DNA quantification, k-ras mutation and multiple allelic loss analysis, mutational amplitude, and sequence determination. MAIN OUTCOME MEASUREMENTS Cyst fluid analysis compared with surgical pathologic or malignant cytologic examination. RESULTS The study cohort consisted of 113 patients with 40 malignant, 48 premalignant, and 25 benign cysts. Cyst fluid k-ras mutation was helpful in the diagnosis of mucinous cysts (odds ratio 20.9, specificity 96%), whereas receiver-operator characteristic curve analysis indicated optimal cutoff points for allelic loss amplitude (area under the curve [AUC] 0.79; optimal value > 65%) and CEA (AUC 0.74; optimal value >148 ng/mL). Components of DNA analysis detecting malignant cysts included allelic loss amplitude over 82% (AUC 0.9) and high DNA amount (optical density ratio >10, AUC 0.79). The criteria of a high amplitude k-ras mutation followed by allelic loss showed maximum specificity (96%) for malignancy. All malignant cysts with negative cytologic evaluation (10/40) could be diagnosed as malignant by using DNA analysis. LIMITATIONS Limited follow-up, selection bias. CONCLUSIONS Elevated amounts of pancreatic cyst fluid DNA, high-amplitude mutations, and specific mutation acquisition sequences are indicators of malignancy. The presence of a k-ras mutation is also indicative of a mucinous cyst. DNA analysis should be considered when cyst cytologic examination is negative for malignancy.

EUS Yield in Evaluating Biliary Dilatation in Patients with Normal Serum Liver Enzymes

The finding of common bile duct (CBD) dilatation on abdominal imaging frequently results in additional testing. It has been our impression that endoscopic ultrasound (EUS) evaluation of a dilated CBD is a low-yield examination in the setting of normal serum liver enzymes. We therefore sought to evaluate the EUS yield in evaluating CBD dilatation in patients with normal as compared to elevated serum liver enzymes. A retrospective review was performed to identify patients referred for EUS evaluation of a dilated CBD in the absence of obvious pathology on prior imaging. Charts were reviewed for patient symptoms, presence of elevated serum liver enzymes, imaging studies before EUS, and EUS findings. Exclusion criteria included clinical jaundice, known biliary stricture, mass lesion or stone, and previously sphincterotomy and/or stent placement. Forty-seven patients were identified: 32 with normal and 15 with elevated serum liver enzymes. There was no difference in mean CBD diameter between these two groups (8.51 vs. 8.79 mm, p=0.854). Of the entire group, 15 patients had undergone prior magnetic resonance cholangiopancreatography (MRCP); an additional 7 patients had undergone prior endoscopic retrograde cholangiopancreatography (ERCP). EUS findings to explain CBD dilatation were found more commonly in patients with elevated compared with normal serum liver enzymes (53% vs. 6%, p=0.001). Periampullary diverticula and choledocholithiasis were the most common findings; of 32 patients with normal serum liver enzymes, one periampullary diverticulum and one CBD stone were found, respectively. The CBD stone had been missed by prior MRCP examination. Of 15 patients with elevated serum liver enzymes, there were 3 cases of choledocholithiasis, 4 periampullary diverticula, and 1 ampullary tumor. EUS should be the test of choice for further evaluation of CBD dilatation when index imaging is normal. Although the EUS yield is low in cases of biliary dilatation in the setting of normal serum liver enzymes, its preferential use would potentially avoid unnecessary MRCP and ERCP.

Gastric Outlet Obstruction Caused by Gallstones: Case Report and Review of the Literature

An 80-year-old male presented with a 2-day history of upper abdominal pain, nausea, and nonbilious vomiting. He did not have hematemesis or melena. Significant comorbidities included unstable angina, severe congestive heart failure, diabetes, and dementia. He had no history of gallstones or cholecystitis. Physical examination was significant for mild epigastric tenderness without peritoneal signs. Plain abdominal radiographs showed a dilated stomach, so a nasogastric tube was placed and drained bilious fluid. CT scan of the abdomen demonstrated pneumobilia (Figure 1) and a 2.8 × 5.8-cm gallstone at the junction of the second and third portions of the duodenum (Figure 2). The clinical features and imaging results were consistent with a cholecystoduodenal fistula resulting from the passage of a large gallstone from the gallbladder into the proximal duodenum, with subsequent impaction at the junction of the second and third portions of the duodenum. Due to his severe comorbidities and high anesthetic risk, the patient was initially treated with endoscopic electrohydraulic lithotripsy (EHL), using a STORZ Calcutript 27080 Lithotripsy Unit (Karl Storz Lithotripsy-America, Inc., Kennesaw, GA), under monitored anesthesia care (MAC). On endoscopy, a large gallstone was impacted in the distal duodenal sweep. There was surrounding inflammation, edema, and ulceration of the duodenal mucosa (Figure 3). The side-viewing duodenoscope (Pentax ED3430TK: Pentax Precision Instrument Corp., Orangeburg, NY) was used for the remainder of the procedure to provide optimal visualization. The duodenum was irrigated with 0.5 L of water with continuous aspiration via the endoscope. The duodenal lumen was then filled with water to

Basaloid squamous cell cancer arising in Barrett’s esophagus

Basaloid squamous cell carcinoma (BSCC) is a rare form of cancer that arises primarily in the upper aerodigestive tract. Esophageal BSCC is extremely rare, accounting for less than 2% of primary esophageal malignancies. It is histopathologically distinct from squamous cell carcinoma and has an aggressive biological behavior with poor survival outcomes. There is no known association of Barrett’s esophagus with esophageal BSCC. Here, we report what we believe is the first such case of esophageal BSCC occurring in the setting of Barrett’s esophagus.