1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. Result

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

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

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

12. 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

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

14. 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