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CC BY-NC-ND 4.0 · Endosc Int Open 2018; 06(12): E1423-E1430
DOI: 10.1055/a-0770-2700
Original article
Owner and Copyright © Georg Thieme Verlag KG 2018

Endoscopic ultrasound-guided through-the-needle microforceps biopsy in the evaluation of pancreatic cystic lesions: a multicenter study

Dennis Yang
1   Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
,
Jason B. Samarasena
2   Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
,
Laith H. Jamil
3   Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
,
Kenneth J. Chang
2   Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
,
David Lee
2   Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
,
Mel A. Ona
2   Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
,
Simon K. Lo
3   Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
,
Srinivas Gaddam
3   Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
,
Quin Liu
3   Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
,
Peter V. Draganov
1   Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
› Author Affiliations
Further Information

Publication History

submitted 08 May 2018

accepted after revision 24 July 2018

Publication Date:
05 December 2018 (online)

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Abstract

Background and study aims Accurate diagnosis and classification of pancreatic cysts (PCs) remains a challenge. The aims of this study were to: (1) evaluate the safety and technical success of a novel microforceps for EUS-guided through-the-needle biopsy (TTNB) of PCs; and (2) assess its diagnostic yield for mucinous PCs when compared to FNA cyst fluid analysis and cytology.

Patients and methods This was a multicenter retrospective analysis of 47 patients who underwent EUS-FNA and TTNB for PCs between January 2014 and June 2017. Technical success was defined as acquisition of a specimen adequate for cytologic or histological evaluation. Cyst fluid carcinoembryonic antigen (CEA) was used to initially categorize cysts as non-mucinous (CEA < 192 ng/mL) or mucinous (CEA ≥ 192 ng/mL). Final diagnosis was based on identifiable mucinous pancreatic cystic epithelium on cytology, microforceps histology and/or surgical histology when available.

Results Forty-seven patients with PCs (mean size 30.7 mm) were included. TTNB was successfully performed in 46 of 47 (97.9 %). Technical success was significantly lower with FNA (48.9 %) compared to TTNB (85.1 %) (P < .001). For cysts with insufficient amount of fluid for CEA (n = 19) or CEA < 192 ng/mL, the cumulative incremental diagnostic yield of a mucinous PC was significantly higher with TTNB vs. FNA (52.6 % vs 18.4 %; P = .004). TTNB alone (34.4 %) diagnosed more mucinous PCs than either CEA ≥ 192 ng/mL alone (6.3 %) or when combined with FNA cytology (9.4 %). One episode of self-limited bleeding (2.1 %) and one of pancreatitis (2.1 %) occurred.

Conclusions EUS-TTNB is safe and effective for evaluating PCs. TTNB may help increase the diagnostic yield of mucinous PCs.

 

  • References

  • 1 Stark A, Donahue TR, Reber HA. et al. Pancreatic Cyst Disease. JAMA 2016; 315: 1882-1893
    CrossrefPubMedGoogle Scholar
  • 2 Lee KS, Sekhar A, Rofsky NM. et al. Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol 2010; 105: 2079-2084
    CrossrefPubMedGoogle Scholar
  • 3 Khashab MA, Kim K, Lennon AM. et al. Should we do EUS/FNA on patients with pancreatic cysts? The incremental diagnostic yield of EUS over CT/RMI for prediction of cystic neoplasms. Pancreas 2013; 42: 717-721
    CrossrefPubMedGoogle Scholar
  • 4 Vege SS, Ziring B, Jain R. et al. American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts. Gastroenterology 2015; 148: 819-822
    CrossrefPubMedGoogle Scholar
  • 5 Alkaade S, Chahla E, Levy M. Role of endoscopic ultrasound-guided fine-needle aspiration, cytology, viscosity, and carcinoembryonic antigen in pancreatic cyst fluid. Endosc Ultrasound 2015; 4: 299-303
    CrossrefPubMedGoogle Scholar
  • 6 Brugge WR, Lewandrowski K, Lee-Lewandrowski E. et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004; 126: 1330-1336
    CrossrefPubMedGoogle Scholar
  • 7 Hata T, Dal Molin M, Hong SM. et al. Predicting the grade of dysplasia of pancreatic cystic neoplasms using cyst fluid DNA methylation markers. Clin Cancer Res 2017; 23: 3935-3944
    CrossrefPubMedGoogle Scholar
  • 8 Krishna SG, Brugge WR, Dewitt JM. et al. Needle-based confocal laser endomicroscopy for the diagnosis of pancreatic cystic lesions: an international external interobserver and intraobserver study (with videos). Gastrointest Endosc 2017; 86: 644-654
    CrossrefPubMedGoogle Scholar
  • 9 Karia K, Waxman I, Konda VJ. et al. Needle-based confocal endomicroscopy for pancreatic cysts: the current agreement in interpretation. Gastrointest Endosc 2016; 83: 924-927
    CrossrefPubMedGoogle Scholar
  • 10 Rogart JN, Loren DE, Singu BS. et al. Cyst wall puncture and aspiration during EUS-guided Fine Needle Aspiration may increase the diagnostic yield of mucinous cysts of the pancreas. J Clin Gastroenterol 2011; 45: 164-169
    CrossrefPubMedGoogle Scholar
  • 11 Hong SS, Loren DE, Rogart JN. et al. Targeted cyst wall puncture and aspiration during EUS-FNA increases the diagnostic yield of premalignant and malignant pancreatic cysts. Gastrointest Endosc 2012; 75: 775-782
    CrossrefPubMedGoogle Scholar
  • 12 Samarasena JB, Nakai Y, Shinoura S. et al. EUS-guided, through-the-needle forceps biopsy: a novel tissue acquisition technique. Gastrointest Endosc 2015; 81: 225-226
    CrossrefPubMedGoogle Scholar
  • 13 Coman RM, Schlachterman A, Esnakula AK. et al. EUS-guided, through-the-needle forceps: clenching down the diagnosis. Gastrointest Endosc 2016; 84: 372-373
    PubMedGoogle Scholar
  • 14 Pham KD, Engjom T, Gjelberg Kollesete H. et al. Diagnosis of a mucinous pancreatic cyst and resection of an intracystic nodule using a novel through-the-needle micro forceps. Endoscopy 2016; 48 (Suppl. 01) E125-126
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Attili F, Pagliari D, Rimbas M. et al. Endoscopic ultrasound-guided histological diagnosis of a mucinous non-neoplastic pancreatic cyst using a specially designed through-the-needle microforceps. Endoscopy 2016; 48 (Suppl. 01) E188-189
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Huelsen A X, Cooper C X, Saad N X. et al. Endoscopic ultrasound-guided, through-the-needle forceps biopsy in the assessment of an incidental large pancreatic cystic lesion with prior inconclusive fine-needle aspiration. Endoscopy 2017; 49: E109-E110
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 450-454
    PubMedGoogle Scholar
  • 18 Yoon WJ, Brugge WR. The safety of endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions. Endosc Ultrasound 2015; 4: 289-292
    CrossrefPubMedGoogle Scholar
  • 19 Zhu H, Jian F, Zhu J. et al. Assessment of morbidity and mortality associated with endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: A systematic review and meta-analysis. Dig Endosc 2017; 29: 667-675
    CrossrefPubMedGoogle Scholar
  • 20 Barresi L, Tarantino I, Traina M. et al. Endoscopic ultrasound-guided fine needle aspiration and biopsy using a 22-gauge needle with side fenestration in pancreatic cystic lesions. Dig Liver Dis 2014; 46: 45-50
    CrossrefPubMedGoogle Scholar
  • 21 Van der Waaij LA, van Dullemen HM, Porte RJ. Cyst fluid analysis in the differential diagnosis of cystic pancreatic lesions: a pooled analysis. Gastrointest Endosc 2005; 62: 383-389
    CrossrefPubMedGoogle Scholar
  • 22 Frossard JL, Amouyal P, Amouyal G. et al. Performance of endosonography-guide fine needle aspiration and biopsy in the diagnosis of cystic pancreatic lesions. Am J Gastroenterol 2003; 98: 1516-1524
    CrossrefPubMedGoogle Scholar
  • 23 Mittal C, Obuch JC, Hammad H. et al. Technical feasibility, diagnostic yield, and safety of microforceps biopsies during EUS evaluation of pancreatic cystic lesions (with video). Gastrointest Endosc 2018; 87: 1263-1269
    CrossrefPubMedGoogle Scholar
  • 24 Basar O, Yuksel O, Yang D. et al. Feasibility and safety of micro-forceps biopsy in the diagnosis of pancreatic cysts. Gastrointest Endosc 2018; 88: 79-86
    CrossrefPubMedGoogle Scholar
  • 25 Barresi L, Crino SF, Fabbri C. et al. Endoscopic Ultrasound-Through-the-Needle Biopsy in Pancreatic Cystic Lesions: A Multicenter Study. Dig Endosc 2018; DOI: 10.1111/den.13197. [Epub ahead of print].
    PubMedGoogle Scholar
  • 26 Correa-Gallego C, Ferrone CR, Thayer SP. et al. Incidental pancreatic cysts: do we really know what we are watching?. Pancreatology 2008; 8: 236-251
    CrossrefPubMedGoogle Scholar
  • 27 Cho CS, Russ AJ, Loeffler AG. et al. Preoperative classification of pancreatic cystic neoplasms: the clinical significance of diagnostic inaccuracy. Ann Surg Oncol 2013; 20: 3112-3119
    CrossrefPubMedGoogle Scholar
  • 28 Del Chiaro M, Segersvard R, Pozzi Mucelli R. et al. Comparison of preoperative conference-based diagnosis with histology of cystic tumors of the pancreas. Ann Surg Oncol 2014; 21: 1539-1544
    CrossrefPubMedGoogle Scholar
  • 29 Pergolini I, Sahora K, Ferrone CR. et al. Long-term risk of pancreatic malignancy in patients with branch duct intraductal papillary mucinous neoplasm in a referral center. Gastroenterology 2017; 153: 1284-1294
    CrossrefPubMedGoogle Scholar
  • 30 Tanaka M, Fernandez-del Castillo C, Adsay V. et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183-197
    CrossrefPubMedGoogle Scholar