Ramu Raju

Intraprocedural tissue diagnosis during ERCP employing a new cytology preparation of forceps biopsy (Smash protocol).

OBJECTIVES:Techniques of tissue sampling at endoscopic retrograde cholangiopancreatography (ERCP) have been underutilized due to technical demands, low yield, and lack of immediate intraprocedural diagnosis. The objective of this study was to describe a new inexpensive, highly efficient ERCP tissue processing, and interpretation technique to address these issues.METHODS:A retrospective, institutional review board approved, single-center study was done at a tertiary-care medical center. Between June 2004 and February 2009, 133 patients (age 38–95 years; men 53%) with suspicious biliary strictures underwent ERCP with tissue sampling using a new technique. Small forceps biopsy specimens were forcefully smashed between two dry glass slides, immediately fixed, stained with rapid Papanicolaou, and interpreted by an on-site pathologist during the procedure (Smash protocol).RESULTS:Of the 117 proven to have cancer, true-positive Smash preps included pancreatic cancer 49/66 (74%), cholangiocarcinoma 23/29 (79%), metastatic cancer 8/15 (53%), and other 4/7 (57%). The median number of Smash biopsies to diagnosis was 3 (range 1–17). Suspicious or atypical results were considered to be negative in this study. There were no false positives and no complications. Smash had an overall sensitivity of 89/117 (76%) for all cases. The true-positive yield of immediate Smash prep cytology, combined with ERCP fine needle aspirate (FNA) and forceps biopsy histology was 77/95 (81%) for primary pancreaticobiliary cancers.CONCLUSIONS:Immediate cytopathologic diagnosis at ERCP was established in 72% of patients presenting with suspected malignant biliary obstruction using a new cytological preparation of forceps biopsies. This approach to ERCP tissue sampling permits immediate diagnosis and avoids the need for subsequent procedures, adds little cost and time, and is safe to perform.

T1468: Neuroendocrine Tumors of Gastrointestinal Tract and the Pancreas: Diagnostic Modalities, Accuracy, and Outcomes

Purpose: Th e aim of the study was to evaluate the utility of various diagnostic modalities including computed tomography (CT) scan, endoscopy, and endoscopic ultrasound (EUS) in gastrointestinal (GI) neuroendocrine tumors (NET). Methods: Retrospective chart review of patients who underwent endoscopic evaluation from January 2003 to June 2009 at a cancer center was done. Th e accuracy of EUS-guided fi ne needle aspiration (FNA) was evaluated. Th e Tand Nstaging of NET by EUS was compared to histological staging. Results: Results: A total of 85 patients (35 men) with a mean age 60.3 years were found to have GI NET. Th ere were 50 patients with pancreatic endocrine neoplasm (PEN) including 5 with multiendocrine neoplasia 1 (MEN1), 15 with duodenal carcinoids, 2 ampullary carcinoids, 12 gastric carcinoids, 3 rectal carcinoids, 1 ileal carcinoid, 2 NET of unknown primary. Among PEN, 5 were in the uncinate process, 14 in the head, 3 in the neck, 8 in the body, and 15 in the tail, and 5 MEN1. Th e median size was 2.3 cm (range; 0.52-7 cm) for PEN, 1cm (range; 0.6-7 cm) for gastric carcinoids, 1cm (range; 0.5-3 cm) for duodenal carcinoids, and 1.8 cm (range; 0.5-3.1 cm) for rectal carcinoids. EUS was performed in 78 patients. Th e CT fi ndings were unremarkable in 25, positive for a mass in 26, and metastasis in 30. For patients with no abnormalities seen on CT scan (25 patients), upper endoscopy (EGD) and sigmoidoscopy showed a discrete nodule or lesion in all patients. 46 had EUS for PEN; EUS FNA was performed in 33 and all were positive (accuracy 100%). EUS staging was compared to histologic staging for carcinoids and the accuracy for T-staging was 61% (if T1a and T1b were separated, accuracy was 52%) with understaging of 13% and overstaging of 26%. All carcinoids smaller than 1cm in the stomach (2), duodenum (3), and rectum (1) did not progress aft er endoscopic resection and/or biopsy during a median follow-up period of 92 days (range 24-758). No complications were seen in endoscopic procedures. Conclusion: Endoscopic evaluation is the most sensitive modality in detecting and diagnosing carcinoids smaller than 1cm. EUS FNA is highly accurate in the diagnosis of PEN. EUS is moderately accurate in T-staging of carcinoids. Carcinoids, smaller than 1cm in the stomach, duodenum, and rectum, may not have an aggressive behavior in a short term follow-up period. [245] Analysis of senstivities for EUS-guided trucut biopsy for pancreatic masses

T1386 Risk of Pancreatic Cancer Development in Cancer Survivors in the United States – A Population-Based Epidemiological Study Using the SEER Cancer Database

Introduction Smokers are at risk for pancreatic cancer and other pancreatic diseases. Cigarette smoking also aggravates the risk of pancreatic cancer in patients with hereditary and chronic pancreatitis and results in a higher incidence of acute pancreatitis and relapses in chronic pancreatitis. Both pancreatic cancer and chronic pancreatitis are characterized by a progressive fibrosis. Recently, two studies on rats reported that tobacco smoking is associated with chronic pancreatic inflammation with fibrosis, and scarring of pancreatic acinar structures. In this study we aim to confirm a relation between cigarette smoking and pancreatic fibrosis (PF) in humans. Methods In this retrospective study, pancreatic tissue acquired during autopsy was collected and revised. Pancreatic fibrosis (PF) was gradually scored by analyzing intra-lobular, extra-lobular and total PF: grade 0 (normal or mild; 0-25% PF), grade 1 (moderate; 25-50%PF), grade 2 (severe; >50%). Information on smoking habits was extracted from (electronic) medical files. Results Of 900 autopsies, performed from January 2005 till December 2007, the minority of available histology material (n=111) was of significant quality to be included for analysis. Grade 2-3 total PF and intra-lobular PF was significantly more present in “smokers” versus “never smokers” (total: 42.9% vs 26.5%, p=0,027 and intra-lobular: 39.3% vs 15.6%, p=0.013), whereas no differences could be found between “never smokers” and “abstinent smokers” and “abstinent smokers” and “smokers”. When taking into account interlobular PF, no differences between all groups were observed. Conclusion To date no human study studied the effect of tobacco smoking on pancreatic tissue. We demonstrate for the first time that current cigarette smoking is associated with total pancreatic fibrosis and more specific intra-lobular pancreatic fibrosis, compared to non-smokers.