Endoscopic ultrasound guided fine-needle aspiration vs core needle biopsy for solid pancreatic lesions: Comparison of diagnostic accuracy and procedural efficiency.

BACKGROUND: Endoscopic ultrasound (EUS) guided core needle biopsies (CNB) are increasingly being performed to diagnose solid pancreatic lesions. However, studies have been conflicting in terms of CNB improving diagnostic accuracy and procedural efficiency vs fine-needle aspiration (FNA), which this study aims to elucidate. METHODS: Data were prospectively collected on consecutive patients with solid pancreatic or peripancreatic lesions at a single tertiary care center from November 2015 to November 2016 that underwent either FNA or CNB. Patient demographics, characteristics of lesions, diagnostic accuracy, final and follow-up pathology, use of rapid on-site evaluation (ROSE), complications, and procedure variables were obtained. RESULTS: A total of 75 FNA and 48 CNB were performed; of these, 13 patients had both. Mean passes were lower with CNB compared to FNA (2.4 vs 2.9, P = .02). Use of ROSE was higher for FNA (97.3% vs 68.1%, P = .001). Mean procedure time was shorter with CNB (34.1 minutes vs 51.2 minutes, P = .02) and diagnostic accuracy was similar (89.2% vs 89.4%, P = .98). There was no difference in diagnostic accuracy when ROSE was performed for CNB vs not performed (93.5% vs 85.7%, P = .58). Additionally, diagnostic accuracy of combined FNA and CNB procedures was 92.3%, which was comparable to FNA (P = .73) or CNB (P = .52) alone. CONCLUSION: FNA and CNB had comparable safety and diagnostic accuracy. Use of CNB resulted in less number of passes and shorter procedure time as compared to FNA. Moreover, diagnostic accuracy for CNB with or without ROSE was similar.

Performance of a Multidisciplinary Pancreatic Cancer Conference in Predicting and Managing Resectable Pancreatic Cancer.

OBJECTIVES: Surgery is the curative treatment for pancreatic ductal adenocarcinoma (PDA). Guidelines recommend utilizing a multidisciplinary pancreatic cancer conference (MDPC) in treatment; however, data are limited. The objective of this study was to assess the accuracy of an MDPC. METHODS: Patients with PDA presented at an MDPC were prospectively collected from April 2013 to August 2016. Patients were included if the MDPC predicted them to have resectable PDA and underwent upfront surgery. Secondary aims were to compare differences in tumor characteristics, time to surgery, and resection rates with patients prior to MDPC implementation (pre-MDPC). RESULTS: A total of 278 patients were presented at the MDPC. After excluding borderline and nonresectable cases, 91 patients were predicted as resectable on evaluation, and 70 were fit for surgery. The MDPC predicted resection in 91.4%. The MDPC had larger tumor size (32.6 vs 24.0 mm), greater proportion of stage II tumor, and a shorter time from diagnosis to resection (27.3 vs 35.5 days) compared with the pre-MDPC. Microscopically negative resections were similar between MDPC and pre-MDPC (85.9% vs 88.0%) despite advanced tumor size and stage. CONCLUSIONS: The MDPC demonstrates a high resection rate. Compared with a pre-MDPC, MDPC provides shorter time to surgery and selects for advanced tumors.

Fluoroscopy Dose and Time Characteristics During Endoscopic Retrograde Cholangiopancreatography (ERCP).

Radiation exposure during endoscopic retrograde cholangiopancreatography is known, however, data in relation to radiation usage is unclear. We evaluate radiation exposure using fluoroscopy dose (FD) and time (FT). A prospective analysis of 197 patients undergoing endoscopic retrograde cholangiopancreatography was completed. Univariate and multivariate analyses were performed to determine characteristics associated with higher FD and FT. The mean FT was 307 seconds; the mean FD was 16.5 centigray. On univariate and multivariate analysis, indication of common bile duct stricture and pancreatic stricture, interventions including dilation and the use of plastic stents placement, procedures that were moderately or very difficult, and procedures that used magnification and high-resolution images were associated with higher FD± and longer FT. Indications of common bile duct stricture and pancreatic stricture as well as interventions of dilation, plastic stents placement, and procedures that are moderately or very difficult, involve high-resolution image leading to a higher radiation exposure. Special care should be considered in these settings.

Ocular Radiation Threshold Projection Based off of Fluoroscopy Time During ERCP.

OBJECTIVES: Current international guidelines for ocular radiation exposure suggest a threshold of 20 millisieverts (mSv)/year. Although endoscopists wear lead aprons, use of protective eye wear is optional. This study was conducted to analyze the lens radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) for endoscopists to determine the time of fluoroscopy needed to warrant using lens protection during ERCP. METHODS: ERCP patients were prospectively enrolled. Indications, interventions, fluoroscopy time, dose, and attending ± fellow involvement were recorded. Radiation exposure was collected from body dosimeters and dosimeters placed between the eyes. Cumulative radiation doses were obtained at study completion and averaged over the total fluoroscopy time to determine the mSv/hour exposure. RESULTS: A total of 187 cases were included. Attendings and fellows wore lens dosimeters in 178 and 126 cases, respectively, and body dosimeters in 174 and 128 cases, respectively. Attendings and fellows wore lens dosimeters throughout 15.89 and 11.24 h of fluoroscopy, respectively. The cumulative radiation dose absorbed per lens dosimeters was 5.35 mSv for attendings and 2.55 mSv for fellows. The projected lens absorption by the body dosimeters was 19.03 mSv for attendings and 5.21 mSv for fellows. The hourly fluoroscopy lens exposure was 0.34 mSv/hour for attendings and 0.23 mSv/hour for fellows. CONCLUSIONS: The amount of fluoroscopy hours needed to reach the currently suggested lens threshold limit (20 mSv/year) was 59.41 h for attendings and 88.17 h for fellows. Radioprotective eye wear should be worn by physicians with yearly fluoroscopy times in similarly structured practices that meet or exceed these thresholds.

Argon Plasma Coagulation for Extraction of an Impacted Trapezoid Basket in the Pancreatic Duct.

We performed endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy for pancreatic stent placement on a 55-year-old woman with a dilated pancreatic duct, pancreatic duct stone, and chronic pancreatitis. During follow-up ERCP, the lithotripter traction wire fractured during electrohydraulic lithotripsy and mechanical lithotripsy. Multiple attempts using standard techniques to clear the lithotripter and stone failed. Argon plasma coagulation (APC) was used to ablate 2 of the lithotripter wires, and the lithotripter was disengaged from the stone and removed.

Intraductal oncocytic papillary neoplasm of the pancreas: a case of a second neoplasm in a pancreas cancer survivor.

CONTEXT: Cystic neoplasms, which are less common forms of exocrine pancreatic neoplasms, consist of mainly intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms. Mucinous cystic neoplasms, unlike IPMN, are not associated with ductal growth, are usually multilocular in nature, and have ovarian type stroma. Mucinous cystadenocarcinoma is a type of mucinous cystic neoplasm more commonly found in women. Intraductal oncocytic papillary neoplasms of the pancreas are the least common variant of IPMN. Despite this classification, intraductal oncocytic papillary neoplasms have been compared to mucinous cystic neoplasms in previous studies and the classification is still questioned. CASE REPORT: We report a rare case of an intraductal oncocytic papillary neoplasm of the pancreas occurring in a 52-year-old male with a prior history of surgically excised mucinous cystadenocarcinoma. This is the first known case of an intraductal oncocytic papillary neoplasm occurring after a prior pancreatic neoplasm. CONCLUSIONS: As the diagnosis of intraductal oncocytic papillary neoplasms are rare, having only a few case reports and small series on which to understand its disease process, it is imperative to discuss each case and detail possible correlations with other pancreatic cystic neoplasms as well as distinctions from its current association within IPMN.