R2 Kwang-yeol,Kim / prof. Seok-ho,Dong Endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions provides inadequate material for cytology and laboratory analysis: initial results from a prospective study K. de Jong1, J.-W. Poley2, J. E. van Hooft1, M. Visser3, M. J. Bruno2, P. Fockens1 Endoscopy May 2011; 43: 585–590 R2 Kwang-yeol,Kim / prof. Seok-ho,Dong

Introduction Pancreatic cystic lesion Increasing number of individuals More frequent use of CT and MRI Simple cysts seem to be harmless Mucinous cystic neoplasm(MCNs), intraductal papillary mucinous neoplasm(IPMNs) Have a malignant potential Difficult to distinguish between the different types of pancreatic cysts based on morphologic criteria only.

Introduction Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) Helpful in achieving a diagnosis By providing pancreatic cyst fluid Considered a valuable and safe technique BUT cytopathological examination is often nondiagnosic Low cellularity of the cystic fluid Value of tumor markers is also controversial Study aim Investigated the technical success and safety of FNA in a prospective cohort of consecutive patients with cystic pancreatic lesion

Methods Study design Patients Prospective, observational cohort study In the Netherlands Academic Medical Center at the University of Amsterdam Erasmus MC Univercity medical Center in Rotterdam Enrolment started in December 2006 and is ongoing Patients Above 18 years of age Cystic pancreatic lesion of unknown etiology seen on image(US,CT,MRI) Exclusion criteria Known coagulation disorder: PT-INR>1.5, PTT>50sec, Platelets<50,000/nL Acute pancreatitis in the previous 6 months Synchronous malignancy elsewhere in the body

Methods EUS procedure Antibiotic prophylaxis One dose of IV prophylactic quinolone prior to the procedure Followed by oral quinolone for 3days after procedure Four endosonographers(J.W.P ,J.E.H, M.J.B.,P.F.) Pancreatic head: via the duodenum Pancreatic body & tail: transgastrically Color doppler: identifiy intervening blood vessel Using 19- or 22- gauge needle Observed in the recovery areas : minimum of 2hour

Methods Cyst fluid analysis Complications For cytopathologic examination, biochemical analysis, reserch purposes cytopathogenic exam: primarily used for this, all direct sears Biochemical analysis: amylase, tumor markers(CEA, CA19-9) Amylase, tumor markers(CEA, CA19-9) Measured with immunoassays Sufficent fluid(2ml): spin cytology was also carried out. Additional fluid: stored for reserch purpose in a freezer Complications immediate(within 2hours), early(within 30days), late(more than 30 days) Severity: length of hospitalization mild <3 days, morderate 4-10 days, severe >10days or admission to ICU or department of surgery

Methods Data collection and statistical analysis Prospective database SPSS 16.0(statistical Package for the Social Sciences, Chicago,Illinois) Quantitative data : median value, mean value P value of less than 0.05 statistically significant

Result

Results EUS procedures n=143 FNA N = 128 No FNA: n=15 cyst location: 9 Small size: 1 Hyperechogenic: 1 Suspected pseudocyst with debris: 2 Suspected adenocarcinoma: 1 No cyst identified: 1 FNA N = 128

Results EUS procedures n=143 FNA N = 128 No FNA: n=15 cyst location: 9 Small size: 1 Hyperechogenic: 1 Suspected pseudocyst with debris: 2 Suspected adenocarcinoma: 1 No cyst identified: 1 FNA N = 128

Classifying cytopathologic diagnosis Results EUS procedures n=143 No FNA: n=15 cyst location: 9 Small size: 1 Hyperechogenic: 1 Suspected pseudocyst with debris: 2 Suspected adenocarcinoma: 1 No cyst identified: 1 FNA N = 128 Technical failure: n =4 Fluid analysis N = 124 No classifying cytopathologic diagnosis: n=80 No biochemical result: n=54 Insufficient material: 47 High viscosity: 7 Classifying cytopathologic diagnosis N = 44 (31%) Biochemical results N = 70 (49%)

Result Classifying cytopathologic diagnosis Biochemical result Material sent for cytology 124/143(87%) Classifying diagnosis 44/143(31%) Median size: classifying vs no classifying 29mm(9-220) vs 28mm(7-140), P=0.396 Biochemical result Sufficent fluid for biochemical analysis 80/143(56%) Biochemical analysis success 70/143(49%) Median size: biochemical perfomed vs no performed 33mm(7-220) vs 22mm(7-154), P=0.072

Results Complication: fever, abdominal pain, nausea.. Complication (2.4%) ( n=3) Infection of pancreatic cyst(n=2) Pancreatitis (n=1)

Conclusion To obtain a classifying cytopathologic diagnosis and a biochemical analysis in only a third(31%) and a half(49%) of cases EUS-FNA of cystic pancreatic lesions is safe but that the overall diagnostic value is limited