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A Prospective Evaluation of an Algorithm Incorporating Routine Preoperative Endoscopic Ultrasound-Guided Fine Needle Aspiration in Suspected Pancreatic Cancer

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Whether tissue diagnosis is required in the preoperative evaluation of patients with suspected pancreatic cancer remains controversial. We prospectively evaluated the accuracy, safety, and potential impact on surgical intervention of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the preoperative evaluation of suspected pancreatic cancer.

Methods

All patients who underwent EUS-FNA at our institution (n = 547) over a 4.5-year period were enrolled. Patients underwent surgical exploration and resection based on their comorbidity status, evidence of resectability based on spiral computed tomography (CT) and EUS imaging reviewed in a multidisciplinary approach.

Results

Of 547 patients enrolled (median age 64 years, 60% male), 49% presented with obstructive jaundice. The operating characteristics of EUS-FNA of solid pancreatic masses were: sensitivity 95% (95% CI: 93.2–95.4), specificity 92% (95% CI: 86.6–95.7), positive predictive value 98% (95% CI: 97–99), negative predictive value 80% (95% CI: 74.9–82.7). The overall accuracy of EUS-FNA was 94.1% (95% CI: 92.0–94). Of the 414 true positive patients by EUS-FNA, 138 (33%) were explored. Of patients deemed operable by combined imaging, 42% had surgical resection. Eighty-two percent of true positive patients were ultimately found inoperable and received palliative therapy or chemotherapy. Of the 94 patients with true negative cytology based on extended follow-up, only 7 (7%) underwent surgical resection. Of those with false negative diagnoses (n = 24), 5 patients underwent exploration/resection based on detection of mass lesions by EUS. The remaining patients had unresectable disease. Mild self-limiting pancreatitis occurred in (0.91%).

Conclusions

EUS-FNA is a safe and highly accurate method for tissue diagnosis in suspected pancreatic cancer. This approach allows for preoperative counseling of patients, minimizing surgeon’s operative time in cases of unresectable disease, and avoids surgical biopsies in the majority of patients with inoperable disease. In addition, it allows for conservative management of patients with benign biopsies. We still, however, recommend exploration of patients with clinical scenario suspicious for pancreatic cancer, a mass found on EUS or CT, but inconclusive or negative cytology.

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References

  1. Jemal A, Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A et al. Cancer statistics, 2005. CA Cancer J Clin 2005;55(1):10–30, Feb.

    Article  PubMed  Google Scholar 

  2. Eloubeidi MA, Desmond RA, Wilcox CM, Wilson RJ, Manchikalapati P, Fouad MN et al. Prognostic factors for survival in pancreatic cancer: a population based study. Am J Surg 2006;192:322–329.

    Article  PubMed  Google Scholar 

  3. Yeo CJ, Abrams RA, Grochow LB, Sohn TA, Ord SE, Hruban RH et al. Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperative adjuvant chemoradiation improves survival. A prospective, single-institution experience. Ann Surg 1997;225(5):621–633; discussion 633–636.

    Article  PubMed  CAS  Google Scholar 

  4. Eloubeidi MA, Chen VK, Eltoum IA, Jhala D, Chhieng DC, Jhala N et al. Endoscopic ultrasound-guided fine needle aspiration biopsy of patients with suspected pancreatic cancer: diagnostic accuracy and acute and 30-day complications. Am J Gastroenterol 1899;98(12):2663–2668.

    Google Scholar 

  5. Gress F, Gottlieb K, Sherman S, Lehman G. Endoscopic ultrasonography-guided fine-needle aspiration biopsy of suspected pancreatic cancer. Ann Intern Med 1900;134(6):459–464.

    Google Scholar 

  6. Harewood GC, Wiersema MJ. Endosonography-guided fine needle aspiration biopsy in the evaluation of pancreatic masses. Am J Gastroenterol 1900;97(6):1386–1391.

    Article  Google Scholar 

  7. Chen VK, Arguedas MR, Kilgore ML, Eloubeidi MA. A cost-minimization analysis of alternative strategies in diagnosing pancreatic cancer. Am J Gastroenterol 2004;99(11):2223–2234.

    Article  PubMed  Google Scholar 

  8. Wakatsuki T, Irisawa A, Bhutani MS, Hikichi T, Shibukawa G, Takagi T et al. Comparative study of diagnostic value of cytologic sampling by endoscopic ultrasonography-guided fine-needle aspiration and that by endoscopic retrograde pancreatography for the management of pancreatic mass without biliary stricture. J Gastroenterol Hepatol 1920;(11):1707–1711.

  9. Sahai AV, Zimmerman M, Aabakken L, Tarnasky PR, Cunningham JT, van Velse A et al. Prospective assessment of the ability of endoscopic ultrasound to diagnose, exclude, or establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography. [see comments.]. Gastrointest Endosc 1998;48(1):18–25.

    Article  PubMed  CAS  Google Scholar 

  10. Zubarik R, Fleischer DE, Mastropietro C, Lopez J, Carroll J, Benjamin S et al. Prospective analysis of complications 30 days after outpatient colonoscopy. [comment]. Gastrointest Endosc 1999;50(3):322–328.

    Article  PubMed  CAS  Google Scholar 

  11. Zubarik R, Eisen G, Mastropietro C, Lopez J, Carroll J, Benjamin S et al. Prospective analysis of complications 30 days after outpatient upper endoscopy. [comment]. Am J Gastroenterol 1999;94(6):1539–1545.

    PubMed  CAS  Google Scholar 

  12. Eloubeidi MA, Tamhane A, Varadarajulu S, Wilcox CM. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006;63(4):622–629.

    Article  PubMed  Google Scholar 

  13. Eloubeidi MA, Gress FG, Savides TJ, Wiersema MJ, Kochman ML, Ahmad NA et al. Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States. Gastrointest Endosc 2004;60(3):385–389.

    Article  PubMed  Google Scholar 

  14. Levin DP, Bret PM. Percutaneous fine-needle aspiration biopsy of the pancreas resulting in death. Gastrointest Radiol 1991;16(1):67–69.

    Article  PubMed  CAS  Google Scholar 

  15. Mueller PR, Miketic LM, Simeone JF, Silverman SG, Saini S, Wittenberg J et al. Severe acute pancreatitis after percutaneous biopsy of the pancreas. AJR 1988;151(3):493–494.

    PubMed  CAS  Google Scholar 

  16. Paquin SC, Gariepy G, Lepanto L, Bourdages R, Raymond G, Sahai AV. A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma. Gastrointest Endosc 2005;61(4):610–611.

    Article  PubMed  Google Scholar 

  17. Micames C, Jowell PS, White R, Paulson E, Nelson R, Morse M et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percutaneous FNA. Gastrointest Endosc 2003;58(5):690–695.

    Article  PubMed  Google Scholar 

  18. Varadarajulu S, Eloubeidi MA. The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer. Review 57 refs. Gastrointest Endosc Clin N Am 2005;15(3):497–511, viii–ix.

    Article  PubMed  Google Scholar 

  19. Eltoum IA, Eloubeidi MA, Chhieng DC, Tamhane A, Crowe R, Jhala D et al. Cytologic grade independently predicts survival of patients with pancreatic adenocarcinoma. Am J Clin Pathol 2005;124(5):697–707.

    Article  PubMed  Google Scholar 

  20. Eloubeidi MA, Tamhane A. EUS-guided FNA of solid pancreatic masses: a learning curve with 300 consecutive procedures. Gastrointest Endosc 2005;61(6):700–708.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama, Birmingham, Alabama, USA

    Mohamad A. Eloubeidi, Shyam Varadarajulu, Shilpa Desai, Rhett Shirley, Mohit Mehra & Charles M. Wilcox

  2. Department of Surgical Oncology, University of Alabama, Birmingham, Alabama, USA

    Martin J. Heslin & Juan P. Arnoletti

  3. Department of Pathology, University of Alabama, Birmingham, Alabama, USA

    Mohamad A. Eloubeidi & Isam Eltoum

  4. Department of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama, USA

    Selwyn M. Vickers

  5. Department of Medicine and Endoscopic Ultrasound Program, 408 Lyons Harrison Research Building, 701 19th Street South, Birmingham, Alabama, 35294-0007, USA

    Mohamad A. Eloubeidi

Authors
  1. Mohamad A. Eloubeidi
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  2. Shyam Varadarajulu
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  3. Shilpa Desai
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  4. Rhett Shirley
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  5. Martin J. Heslin
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  6. Mohit Mehra
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  7. Juan P. Arnoletti
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  8. Isam Eltoum
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  9. Charles M. Wilcox
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  10. Selwyn M. Vickers
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Corresponding author

Correspondence to Mohamad A. Eloubeidi.

Additional information

Received a Poster of Distinction Award at the Annual Meeting of the Society for Surgery of the Alimentary Tract held May 20 to 24, 2006 in Los Angeles, California.

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Eloubeidi, M.A., Varadarajulu, S., Desai, S. et al. A Prospective Evaluation of an Algorithm Incorporating Routine Preoperative Endoscopic Ultrasound-Guided Fine Needle Aspiration in Suspected Pancreatic Cancer. J Gastrointest Surg 11, 813–819 (2007). https://doi.org/10.1007/s11605-007-0151-x

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