Nidhi Malhotra

Gastric emptying scintigraphy: is four hours necessary?

Introduction: Recommendations for gastric emptying scintigraphy (GES) suggest imaging over 4 hours to better define gastroparesis. Aims: To determine the value of defining delayed gastric emptying at time points earlier than 4 hours. Methods: GES was performed with ingestion of a liquid egg white meal with imaging at 0, 0.5, 1, 2, 3, and 4 hours. Patients completed the Patient Assessment of Gastrointestinal Symptoms questionnaire immediately before GES. Results: Of 1499 patients undergoing GES from September 2007 to January 2010 (76.2% were female, mean age of 45.5±0.5 y, 21.3% had diabetes, 9.5% had earlier gastric surgery), 160 (10.7%) had increased gastric retention at 1 hour (>90%), 404 (27%) had increased retention at 2 hours (>60%), 576 (38.4%) had increased retention at 3 hours (>30%), and 629 (42%) had increased retention at 4 hours (>10%). Gastric retention at 4 hours correlated with retention at 3 hours (r=0.890; P<0.001), 2 hours (r=0.738; P<0.001), and 1 hour (r=0.510; P<0.001). Symptoms correlated better with the gastric retention at later time points. The symptoms correlating with gastric retention at 4 hours included early satiety (r=0.170; P<0.01), vomiting (r=0.143; P<0.01), feeling excessively full after meals (r=0.123; P<0.01), and loss of appetite (r=0.122; P<0.01). Conclusions: Gastric retention at 4 hours correlates well with gastric retention at 3 hours, good at 2 hours, but only fair with gastric retention at 1 hour. Gastric retention at 1 hour may miss 36% of patients found to have delayed gastric emptying at 4 hours. Symptoms (early satiety, vomiting, feeling excessively full after meals, and loss of appetite) correlated better with the gastric retention at later time points.

The added value of using mutational profiling in addition to cytology in diagnosing aggressive pancreaticobiliary disease: review of clinical cases at a single center

BackgroundThis study aimed to better understand the supporting role that mutational profiling (MP) of DNA from microdissected cytology slides and supernatant specimens may play in the diagnosis of malignancy in fine-needle aspirates (FNA) and biliary brushing specimens from patients with pancreaticobiliary masses.MethodsCytology results were examined in a total of 30 patients with associated surgical (10) or clinical (20) outcomes. MP of DNA from microdissected cytology slides and from discarded supernatant fluid was analyzed in 26 patients with atypical, negative or indeterminate cytology.ResultsCytology correctly diagnosed aggressive disease in 4 patients. Cytological diagnoses for the remaining 26 were as follows: 16 negative (9 false negative), 9 atypical, 1 indeterminate. MP correctly determined aggressive disease in 1 false negative cytology case and confirmed a negative cytology diagnosis in 7 of 7 cases of non-aggressive disease. Of the 9 atypical cytology cases, MP correctly diagnosed 7 as positive and 1 as negative for aggressive disease. One specimen that was indeterminate by cytology was correctly diagnosed as non-aggressive by MP. When first line malignant (positive) cytology results were combined with positive second line MP results, 12/21 cases of aggressive disease were identified, compared to 4/21 cases identified by positive cytology alone.ConclusionsWhen first line cytology results were uncertain (atypical), questionable (negative), or not possible (non-diagnostic/indeterminate), MP provided additional information regarding the presence of aggressive disease. When used in conjunction with first line cytology, MP increased detection of aggressive disease without compromising specificity in patients that were difficult to diagnose by cytology alone.

Management of Patients With Pancreatic Cysts: Analysis of Possible False-Negative Cases of Malignancy.

Goals: To examine the utility of integrated molecular pathology (IMP) in managing surveillance of pancreatic cysts based on outcomes and analysis of false negatives (FNs) from a previously published cohort (n=492). Background: In endoscopic ultrasound with fine-needle aspiration (EUS-FNA) of cyst fluid lacking malignant cytology, IMP demonstrated better risk stratification for malignancy at approximately 3 years’ follow-up than International Consensus Guideline (Fukuoka) 2012 management recommendations in such cases. Study: Patient outcomes and clinical features of Fukuoka and IMP FN cases were reviewed. Practical guidance for appropriate surveillance intervals and surgery decisions using IMP were derived from follow-up data, considering EUS-FNA sampling limitations and high-risk clinical circumstances observed. Surveillance intervals for patients based on IMP predictive value were compared with those of Fukuoka. Results: Outcomes at follow-up for IMP low-risk diagnoses supported surveillance every 2 to 3 years, independent of cyst size, when EUS-FNA sampling limitations or high-risk clinical circumstances were absent. In 10 of 11 patients with FN IMP diagnoses (2% of cohort), EUS-FNA sampling limitations existed; Fukuoka identified high risk in 9 of 11 cases. In 4 of 6 FN cases by Fukuoka (1% of cohort), IMP identified high risk. Overall, 55% of cases had possible sampling limitations and 37% had high-risk clinical circumstances. Outcomes support more cautious management in such cases when using IMP. Conclusions: Adjunct use of IMP can provide evidence for relaxed surveillance of patients with benign cysts that meet Fukuoka criteria for closer observation or surgery. Although infrequent, FN results with IMP can be associated with EUS-FNA sampling limitations or high-risk clinical circumstances.