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Clinical Journal of Gastroenterology
Published in: Clinical Journal of Gastroenterology 2/2019

01-04-2019 | Clinical Review

Current indications and yield of endoscopic ultrasound and ancillary techniques in pancreatic cystic neoplasms

Authors: Federico Salom, Frédéric Prat

Published in: Clinical Journal of Gastroenterology | Issue 2/2019

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Abstract

An increase in the diagnosis of pancreatic cystic neoplasm has been described lately. Surgical treatment or surveillance is advised depending on the type of lesion diagnosed. The most accurate diagnostic approach is needed to make the best therapeutic decision. Endoscopic ultrasound is a very valuable tool in the evaluation of pancreatic cystic neoplasm. It generates high-quality images and allows the possibility of sampling the cystic fluid for cytology, microbiological and molecular evaluation. Even with this evaluation, the sensitivity of this approach is not always adequate. New technological resources have been developed to try to improve the diagnostic accuracy of pancreatic cystic neoplasms. The two most promising techniques are needle-based confocal laser endomicroscopy and contrast-enhanced harmonic endoscopic ultrasound. Needle-based confocal laser endomicroscopy allows a microscopic evaluation of mucosal glands and vascular pattern, to differentiate mucinous from non-mucinous lesions. Contrast-enhanced harmonic endoscopic ultrasound is used for the vascular evaluation of the microcirculation of the cyst wall and mural nodule, mainly to make the difference between malignant nodules and mucus plugs. A combination of these different diagnostic techniques can improve the diagnostic accuracy of pancreatic cystic neoplasms to offer the adequate therapeutic decision.
Literature
1.
Laffan TA, Horton KM, Klein AP, et al. Prevalence of unsuspected pancreatic cysts on MDCT. AJR. 2008;191:802–7.CrossRefPubMed
2.
Kimura W, Nagai H, Kuroda A, et al. Analysis of small cystic lesions of the pancreas. Int J Pancreatol. 1995;18:197–206.PubMed
3.
Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology. 2015;148:824–48.CrossRefPubMed
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;148:819–22.CrossRefPubMed
5.
6.
Khurana B, Mortele KJ, Glickman J, et al. Macrocystic serous adenoma of the pancreas: radiologic-pathologic correlation. AJR. 2003;181:119–23.CrossRefPubMed
7.
Terris B, Fukishima N, Hruban RH. Serous neoplasms of the pancreas. World Health Organization classification of tumors of the digestive system. 4th ed. Lyon: IARC; 2010. pp. 296–9.
8.
Yoon WJ, Lee JK, Lee KH, et al. Cystic neoplasms of the exocrine pancreas: an update of a nationwide survey in Korea. Pancreas. 2008;37:254–8.CrossRefPubMed
9.
Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, et al. Primary pancreatic cystic neoplasms revisited. Part I. Serous cystic neoplasms. Surg Oncol. 2011;20:e84 –92.CrossRefPubMed
10.
Prasad HL, Ballai R, Upadhyay V, et al. Serous microcystic adenoma to adenocarcinoma of the pancreas—a case report. Indian J Surg Oncol. 2015;6:82–5.CrossRefPubMed
11.
Petrone MC, Arcidiacono PG. Role of endosocopic ultrasound in the diagnosis of cystic tumours of the pancreas. Dig Liver Dis. 2008;40:847–53.CrossRefPubMed
12.
Mohr VH, Vortmeyer AO, Zhuang Z, et al. Histopathology and molecular genetics of multiple cysts and microcystic (serous) cystadenomas of the pancreas in Von Hipple–Lindau patients. Am J Pathol. 2000;157:1615–21.CrossRefPubMedPubMedCentral
13.
14.
Zamboni G, Fukushima N, Hruban RH. Mucinous cystic neoplasms of the pancreas. World Health Organization classification of tumors of the digestive system. 4th ed. Lyon: IARC; 2010. pp. 300–3.
15.
Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology. 2004;126:1330–6.CrossRefPubMed
16.
Fasanella KE, McGrath K. Cystic lesions and intraductal neoplasms of the pancreas. Best Pract Res Clin Gastroenterol. 2009;23:35–48.CrossRefPubMed
17.
Nilsson L, Keane M, Shamali A, et al. Nature and management of pancreatic mucinous cystic neoplasm (MCN): systematic review of the literature. Pancreatology. 2016;16:1028–36.CrossRefPubMed
18.
Crippa S, Salvia R, Warshaw AL, et al. Mucinous cystic neoplasm of the pancreas is not an aggressive entity: lessons from 163 resected patients. Ann Surg. 2008;247:571–9.CrossRefPubMed
19.
Hruban RH, Takaori K, Klimstra DS, et al. An illustrated consensus on the classification of pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasms. Am J Surg Pathol. 2004;28:977–87.CrossRefPubMed
20.
Fernández-del Castillo C, Adsay NV. Intraductal papillary mucinous neooplasms of the pancreas. Gastroenterology. 2010;139:708 – 13.CrossRefPubMed
21.
Adsay NV, Fukushima N, Furukawa T. Intraductal neoplasms of the pancreas. In: World Health Organization classification of tumors of the digestive system. 4th ed. Lyon: IARC; 2010. pp. 304–13.
22.
Crippa S, Fernández-Del Castillo C, Salvia R, et al. Mucin-producing neoplasms of the pancreas: an analysis of distinguishing clinical and epidemiologic characteristics. Clin Gastroenterol Hepatol. 2010;8:213–9.CrossRefPubMed
23.
Kloppel G, Hruban RH, Klimstra D. Solid-pseudopapillary neoplasm of the pancreas. In: World Health Organization classification of tumors of the digestive system. 4th ed. Lyon: IARC; 2010. pp. 327–30.
24.
Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in English literature. J Am Coll Surg. 2005;200:965–72.CrossRefPubMed
25.
Bordeianou L, Vagefi PA, Sahani DV, et al. Cystic pancreatic endocrine neoplasms: a distinct tumor type? J Am Coll Surg. 2008;206:1154–8.CrossRefPubMed
26.
Boninsegna L, Partelli S, D’Innocenzio MM, et al. Pancreatic cystic endocrine tumors: a different morphological entity associated with a less aggressive behavior. Neuroendocrinology. 2010;92:246 – 51.CrossRefPubMed
27.
Gaujoux S, Tang L, Klimstra D, et al. The outcome of resected cystic pancreatic endocrine neoplasms: a case-matched analysis. Surgery. 2012;151:518 – 25.CrossRefPubMed
28.
Koh YX, Chok AY, Zheng HL, et al. A systematic review and meta-analysis of the clinicopathologic characteristics of cystic versus solid pancreatic neuroendocrine neoplasms. Surgery. 2014;156:83–96.CrossRefPubMed
29.
Partelli S, Cirocchi R, Crippa S, et al. Systematic review of active surveillance versus surgical management of asymptomatic small non-functioning pancreatic neuroendocrine neoplasms. Br J Surg. 2017;104:34–41.CrossRefPubMed
30.
Cloyd JM, Kopecky KE, Norton JA, et al. Neuroendocrine tumors of the pancreas: degree of cystic component predicts prognosis. Surgery. 2016;160:708–13.CrossRefPubMed
31.
Hurtado-Pardo L, Cienfuegos A, Ruiz-Canela J. M, et al. Cystic pancreatic neuroendocrine tumors (cPNETs): a systematic review and meta-analysis of case series. Rev Esp Enferm Dig. 2017;109:778–87.CrossRefPubMed
32.
Tseng JF, Warshaw AL, Sahani DV, et al. Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment. Ann Surg. 2005;242:413–9.PubMedPubMedCentral
33.
Le Baleur Y, Couvelard A, Vullierme MP, et al. Mucinous cystic neoplasms of the pancreas: definition of preoperative imaging criteria for high-risk lesions. Pancreatology. 2011;11:495–9.CrossRefPubMed
34.
Tanaka M, Chari S, Adsay V, et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology. 2006;6:17–32.CrossRefPubMed
35.
Tanaka M, Fernández-del Castillo C, Adsay V, et al. International consensus guidelines 2012 for management of IPMN and MCN of the pancreas. Pancreatology. 2012;12:183–97.CrossRefPubMed
36.
Balci NC, Semelka RC. Radiologic features of cystic, endocrine and other pancreatic neoplasms. Euro J Radiol. 2001;38:113–9.CrossRef
37.
Kim JH, Eun HW, Park HJ, et al. Diagnostic performance of MRI and EUS in the differentiation of benign from malignant pancreatic cyst and cyst communication with the main duct. Eur J Radiol. 2012;81:2927–35.CrossRefPubMed
38.
Zhang XM, Mitchell DG, Dohke M, et al. Pancreatic cysts: depiction on single-shot fast spin-echo MR images. Radiology. 2002;223:547–53.CrossRefPubMed
39.
Sainani NI, Saokar A, Deshpande V, et al. Comparative performance of MDCT and MRI with MR cholangiopancreatography in characterizing small pancreatic cysts. AJR AM J Roentgenol. 2009;193:722–31.CrossRefPubMed
40.
Lee HJ, Kim MJ, Choi JY, et al. Relative accuracy of CT and MRI in the differentiation of benign from malignant pancreatic cystic lesions. Clin Radiol. 2011;66:315–21.CrossRefPubMed
41.
Jang DK, Song BJ, Ryu JK, et al. Preoperative diagnosis of pancreatic cystic lesions: the accuracy of endoscopic ultrasound and cross-sectional imaging. Pancreas. 2015;44:1329–33.CrossRefPubMed
42.
Gerke H, Jaffe TA, Mitchell RM, et al. Endoscopic ultrasound and computer tomography are inaccurate methods of classifying cystic pancreatic lesions. Dig Liver Dis. 2006;38:39–44.CrossRefPubMed
43.
Ahmad NA, Kochman ML, Brensinger C, et al. Interobserver agreement among endosonographers for the diagnosis of neoplastic versus non-neoplastic pancreatic cystic lesions. Gastrointest Endosc. 2003;58:59–64.CrossRefPubMed
44.
De Jong K, Verlaan T, Dijkgraaf MG, et al. Interobserver agreement for endosonography in the diagnosis of pancreatic cysts. Endoscopy. 2011;43:579–84.CrossRefPubMed
45.
Kim YC, Choi JY, Chung YE, et al. Comparison of MRI and endoscopic ultrasound in the characterization of pancreatic cystic lesions. AJR Am J Roentgenol. 2010;195:947–52.CrossRefPubMed
46.
Adimoolam V, Sanchez MJ, Siddiqui UD, et al. Endoscopic ultrasound identifies synchronous pancreas cystic lesions not seen on initial cross-sectional imaging. Pancreas. 2011;40:1070–2.CrossRefPubMed
47.
Zhong N, Zhang L, Takahashi N, et al. Histologic and imaging features of mural nodules in mucinous pancreatic cysts. Clin Gastroenterol Hepatol. 2012;10:192–8.CrossRefPubMed
48.
Kim KW, Park SH, Pyo J, et al. Imaging features to distinguish malignant and benign branch-duct type intraductal papillary mucinous neoplasms of the pancreas: a meta-analysis. Ann Surg. 2014;259:72–81.CrossRefPubMed
49.
Anand N, Sampath K, Wu BU. Cyst features and risk of malignancy in intraductal papillary mucinous neoplasms of the pancreas: a meta-analysis. Clin Gastroenterol Hepatol. 2013;11:913–21.CrossRefPubMed
50.
Hinoro S, Tani M, Kawai M, et al. The carcinoembryonic antigen level in pancreatic juice and mural nodule size are predictors of malignancy for branch duct type IPMN. Ann Surg. 2012;255:517–22.CrossRef
51.
Shimizu Y, Yamaue H, Maguchi H, et al. Predictors of malignancy in intraductal papillary mucinous neoplasm of the pancreas: analysis of 310 pancreatic resection patients at multiple high-volume centers. Pancreas. 2013;42:883–8.CrossRefPubMed
52.
Al-Haddad M, Schmidt MC, Sandrasegaran K, et al. Diagnosis and treatment of cystic pancreatic tumors. Clin Gastroenterol Hepatol. 2011;9:635–48.CrossRefPubMed
53.
Tanno S, Nakano Y, Sugiyama Y, et al. Incidence of synchronous and metachronus pancreatic cancer in 168 patients with branch-duct intraductal papillary mucinous neoplasm. Pancreatology. 2010;10:173–8.CrossRefPubMed
54.
Uehara H, Nakaizumi A, Ishikawa O, et al. Development of ductal carcinoma of the pancreas during follow-up of branch-duct intraductal papillary mucinous of the pancreas. Gut. 2008;57:1561–5.CrossRefPubMed
55.
Sawai Y, Yamao K, Chiba T, et al. Development of pancreatic cancers during long-term follow-up of side-branch intraductal papillary mucinous neoplasms. Endoscopy. 2010;42:1077–84.CrossRefPubMed
56.
Miller JR, Meyer JE, Waters JA, et al. Outcome of pancreatic remnant following segmental pancreatectomy for non-invasive intraductal papillary mucinous neoplasm. HPB (Oxford). 2011;13:759–66.CrossRef
57.
Yoon WJ, Brugge WR. The safety of endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions. Endosc ultrasound. 2015;4:289–92.CrossRefPubMedPubMedCentral
58.
Wang KX, Ben QW, Jin ZD, et al. Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review. Gastrointest Endosc. 2011;73:283–90.CrossRefPubMed
59.
Early DS, Acosta RD, Chandrasekhara V, et al. Adverse events associated with EUS and EUS with FNA. Gastrointest Endosc. 2013;77:839–43.CrossRefPubMed
60.
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/MRI for prediction of cystic neoplasms. Pancreas. 2013;42:717–21.CrossRefPubMed
61.
Thornton GD, McPhail MJ, Nayagam S, et al. Endoscopic ultrasound guided fine needle aspiration for the diagnosis of pancreatic cystic neoplasms: a meta-analysis. Pancreatology. 2013;13:48–57.CrossRefPubMed
62.
Park W, Wu M, Bowen R, et al. Metabolomic-derived novel cyst fluid biomarkers for pancreatic cysts: glucose and kynurenine. Gastrointest Endosc. 2013;78:295–302.CrossRefPubMedPubMedCentral
63.
Zykos T, Pham K, Bowen R, et al. Cyst fluid glucose is rapidly feasible and accurate in diagnosing mucinous pancreatic cysts. Am J Gastroenterol. 2015;110:909–14.CrossRef
64.
Khalid A, Zahid M, Finkelstein SD, et al. Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study. Gastrointest Endosc. 2009;69:1095–102.CrossRefPubMed
65.
Lee LS, Doyle LA, Houghton J, et al. Differential expression of GNAS and KRAS mutations in pancreatic cysts. JOP. 2014;15:581–6.PubMed
66.
Yip-Schneider M, Wu H, Dumas R, et al. Vascular endothelial growth factor, a novel and highly accurate pancreatic fluid biomarker for serous pancreatic cysts. J Am Coll Surg. 2014;218:608–17.CrossRefPubMed
67.
Reid MD, Choi H, Balci S, et al. Serous cystic neoplasms of the pancreas: clinicopathologic and molecular characteristics. Semin Diagn Pathol. 2014;31:475–83.CrossRefPubMed
68.
Al-Haddad M, DeWitt J, Sherman S, et al. Performance characteristics of molecular (DNA) analysis for the diagnosis of mucinous pancreatic cysts. Gastrointest Endosc. 2014;79:79–87.CrossRefPubMed
69.
Bhutani MS, Koduru P, Joshi V, et al. EUS-guided needle-based confocal laser endomicroscopy: a novel technique with emerging applications. Gastroenterol Hepatol. 2015;11:235–40.
70.
Becker V, Wallace MB, Fockens P, et al. Needle-based confocal endomicroscopy for in vivo histology of intra-abdominal organs: first results in a porcine model (with videos). Gastrointest Endosc. 2010;71:1260–6.CrossRefPubMed
71.
Konda VJ, Aslanian HR, Wallace MB, et al. First assessment of needle-based confocal laser endomicroscopy during EUS-FNA procedures of the pancreas (with videos). Gastrointest Endosc. 2011;74:1049–60.CrossRefPubMed
72.
Konda VJ, Meining A, Jamil LH, et al. A pilot study of in vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy under endosonographic guidance. Endoscopy. 2013;45:1006–13.CrossRefPubMed
73.
Nakai Y, Iwashita T, Park DH, et al. Diagnosis of pancreatic cysts: EUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study. Gastrointest Endosc. 2015;81:1204–14.CrossRefPubMed
74.
Napoléon B, Lemaistre AI, Pujol B, et al. A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy. Endoscopy. 2015;47:26–32.CrossRefPubMed
75.
Krishna SG, Swanson B, Conwell DL, et al. In vivo and ex vivo needle-based confocal endomicroscopy of intraductal papillary mucinous neoplasm of the pancreas. Gastrointest Endosc. 2015;82:571–2.CrossRefPubMed
76.
Song TJ, Kim JH, Lee SS, et al. The prospective randomized, controlled trial of endoscopic ultrasound-guided fine-needle aspiration using 22G and 19G aspiration needles for solid pancreatic or peripancreatic masses. Am J Gastroenterol. 2010;105:1739–45.CrossRefPubMed
77.
Napoleon B, Alvarez-Sanchez MV, Gincoul R, et al. Contrast-enhanced harmonic endoscopic ultrasound in solid lesions of the pancreas: results of a pilot study. Endoscopy. 2010;42:564–70.CrossRefPubMed
78.
Kitano M, Sakamoto H, Matsui U, et al. A novel perfusion imaging technique of the pancreas: contrast-enhanced harmonic EUS (with video). Gastrointest Endosc. 2008;67:141–50.CrossRefPubMed
79.
De Jong N, Frinking PJ, Bouakaz A, et al. Detection procedures of ultrasound contrast agents. Ultrasonics. 2000;38:87–92.CrossRefPubMed
80.
Kamata K, Kitano M, Omoto S, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of pancreatic cysts. Endoscopy. 2016;48:35–41.CrossRefPubMed
81.
Fusaroli P, Spada A, Mancino MG, et al. Contrast harmonic echo–endoscopic ultrasound improves accuracy in diagnosis of solid pancreatic masses. Clin Gastroenterol Hepatol. 2010;8:629–34.CrossRefPubMed
82.
Fusaroli P, Kypraios D, Mancino MG, et al. Interobserver agreement in contrast harmonic endoscopic ultrasound. J Gastroenterol Hepatol. 2012;27:1063–9.CrossRefPubMed
83.
Saftoiu A, Dietrich CF, Vilmann P. Contrast-enhanced harmonic endoscopic ultrasound. Endoscopy. 2012;44:612–7.CrossRefPubMed
84.
Yamamoto N, Kato H, Tomoda T, et al. Contrast-enhanced harmonic endoscopic ultrasonography with time-intensity curve analysis for intraductal papillary mucinous neoplasms of the pancreas. Endoscopy. 2016;48:26–34.PubMed
85.
Ohno E, Hirooka Y, Itoh A, et al. Intraductal papillary mucinous neoplasms of the pancreas: differentiation of malignant and benign tumors by endoscopic ultrasound findings of mural nodules. Ann Surg. 2009;249:628–34.CrossRefPubMed
Metadata
Title
Current indications and yield of endoscopic ultrasound and ancillary techniques in pancreatic cystic neoplasms
Authors
Federico Salom
Frédéric Prat
Publication date
01-04-2019
Publisher
Springer Japan
Published in
Clinical Journal of Gastroenterology / Issue 2/2019
Print ISSN: 1865-7257
Electronic ISSN: 1865-7265
DOI
https://doi.org/10.1007/s12328-018-00930-2

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