Thyroid Fine-Needle Aspiration Cytology: Focusing on Adherence to Guidelines and Hospital Organization.

BACKGROUND The complications of fine-needle aspiration cytology (FNAC) are rare but can be challenging for performing physicians to diagnose and manage. This type of procedure is perceived as routine and devoid of substantial risks, but uncommon complications can occur and need to be addressed with careful workup. CASE REPORT A FNAC procedure for a young female patient with multiple thyroid nodules was requested by her general practitioner. After the FNAC thyroid procedure, a carotid wall hematoma was suspected and could not be excluded with ultrasound (US) alone. Thus, the patient underwent a computed tomography angiogram (CTA) that excluded blood extravasation from the carotid, confirming the suspicion of perivascular blood accumulation. As a precaution, the patient was hospitalized, with US follow-up; she was dismissed the day after her hospital admission with a diagnosis of a benign thyroid nodule in multinodular goiter according to SIAPEC-IAP classification. CONCLUSIONS This case highlights how a routine-perceived procedure such as FNAC could present a challenge to the performing physicians, pathologist, and radiologist, raising the suspicion of a severe complication that needs to be addressed with a readily available emergency service that may be accessible only within a central hospital-level organization. This case reinforces the point that more careful adherence to clinic-radiological guidelines is needed to avoid potentially inappropriate and harmful procedures. A review of the literature concerning guidelines for FNAC procedure, diagnostic classifications, and reported complications is provided as part of this case report.

Technique, safety, and feasibility of EUS-guided radiofrequency ablation in unresectable pancreatic cancer.

BACKGROUND AND AIMS: Radiofrequency ablation (RFA) is a well-recognized local ablative technique applied in the treatment of different solid tumors. Intraoperative RFA has been used for non-metastatic unresectable pancreatic ductal adenocarcinoma (PDAC), showing increased overall survival in retrospective studies. A novel RFA probe has recently been developed, allowing RFA under endoscopic ultrasound (EUS) guidance. Aim of the present study was to assess the feasibility and safety of EUS-guided RFA for unresectable PDACs. METHODS: Patients with unresectable non-metastatic PDAC were included in the study following neoadjuvant chemotherapy. EUS-guided RFA was performed using a novel monopolar 18-gauge electrode with a sharp conical 1 cm tip for energy delivery. Pre- and post-procedural clinical and radiological data were prospectively collected. RESULTS: Ten consecutive patients with unresectable PDAC were enrolled. The procedure was successful in all cases and no major adverse events were observed. A delineated hypodense ablated area within the tumor was observed at the 30-day CT scan in all cases. CONCLUSIONS: EUS-guided RFA is a feasible and safe minimally invasive procedure for patients with unresectable PDAC. Further studies are warranted to demonstrate the impact of EUS-guided RFA on disease progression and overall survival.

Quantitative Assessment of Pancreatic Texture Using a Durometer: A New Tool to Predict the Risk of Developing a Postoperative Fistula.

BACKGROUND: Pancreatic texture is one of the key predictors of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Currently, the "gold standard" for assessment of pancreatic texture is surgeon's subjective evaluation through manual palpation. AIM: To evaluate a new "durometer" that is able to assess quantitatively the pancreatic stiffness by measuring its elastic module (i.e., the resistance offered by the pancreatic stump when elastically deformed expressed in mPa). METHODS: Measurements were obtained from the pancreatic remnant during 138 consecutive PDs performed at the Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust. Values were correlated to clinical features and, in particular, with the senior surgeon's evaluation of pancreatic texture (hard/soft). Sixteen beating-heart donors were used as a control group to assess the stiffness of a non-pathologic pancreas. Univariate analysis was performed for the assessment of POPF predictors. RESULTS: Durometry allowed segregating between non-pathologic, soft and hard pancreas according to surgeon's evaluation (mean values 111 vs. 196 vs. 366 mPa, p < 0.01). There were no significant differences in stiffness with regard to histology, BMI, and neoadjuvant therapy. Larger tumors (>20 mm) and male sex were associated with greater stiffness on univariate analysis. Pancreatic texture, pancreatic duct size, BMI, prior neoadjuvant therapy, and histology were predictors of POPF. Patients who developed POPF showed a lesser stiffness (178 vs. 261 mPa, p = 0.05). CONCLUSION: Assessment of pancreatic stiffness using a durometer correlated with the surgeon's evaluation of pancreatic texture. Measurement of pancreatic parenchymal stiffness is reliable and correlates with the development of POPF.

Extent of Surgery and Implications of Transection Margin Status after Resection of IPMNs.

Appropriate surgical strategies for management of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a matter of debate. Preoperative and intraoperative evaluation of malignant potential of IPMN and of patient's comorbidities is of paramount importance to balance potential complications of surgery with tumors' risk of being or becoming malignant; the decision about the extent of pancreatic resection and the eventual total pancreatectomy needs to be determined on individual basis. The analysis of frozen-section margin of pancreas during operation is mandatory. The goal should be the complete resection of IPMN reaching negative margin, although there is still no agreed definition of "negative margin." Of note, the presence of deepithelization is often wrongly interpreted as absence of neoplasia. Management of resection margin status and stratification of surveillance of the remnant pancreas, based on characteristics of primary tumour, are of crucial importance in the management of IPMNs in order to decrease the risk of tumor recurrence after resection. Although risk of local and distant recurrence for invasive IPMNs is increased even in case of total pancreatectomy, also local recurrence after complete resection of noninvasive IPMNs is not negligible. Therefore, a long-term/life-time follow-up monitoring is of paramount importance to detect eventual recurrences.

Molecular pathology of intraductal papillary mucinous neoplasms of the pancreas.

Since the first description of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas in the eighties, their identification has dramatically increased in the last decades, hand to hand with the improvements in diagnostic imaging and sampling techniques for the study of pancreatic diseases. However, the heterogeneity of IPMNs and their malignant potential make difficult the management of these lesions. The objective of this review is to identify the molecular characteristics of IPMNs in order to recognize potential markers for the discrimination of more aggressive IPMNs requiring surgical resection from benign IPMNs that could be observed. We briefly summarize recent research findings on the genetics and epigenetics of intraductal papillary mucinous neoplasms, identifying some genes, molecular mechanisms and cellular signaling pathways correlated to the pathogenesis of IPMNs and their progression to malignancy. The knowledge of molecular biology of IPMNs has impressively developed over the last few years. A great amount of genes functioning as oncogenes or tumor suppressor genes have been identified, in pancreatic juice or in blood or in the samples from the pancreatic resections, but further researches are required to use these informations for clinical intent, in order to better define the natural history of these diseases and to improve their management.

Pancreatic resections for cystic neoplasms: from the surgeon's presumption to the pathologist's reality.

BACKGROUND: Current guidelines for the management of pancreatic cystic neoplasms are based on the assumption that these lesions can be classified correctly on the basis of features of cross-sectional imaging. However, a certain degree of overlap between different lesions exists, and little is known about the rate of inaccurate preoperative diagnoses. To address this issue, preoperative and final pathologic diagnoses of patients resected for a presumed pancreatic cystic neoplasm were compared. METHODS: Retrospective analysis was undertaken of patients managed operatively between 2000 and 2010. Preoperative workup was reviewed to identify diagnostic pitfalls and potential risk factors for incorrect preoperative characterization of cystic lesions presumed to be neoplastic. RESULTS: We analyzed 476 patients. Final pathologic diagnosis matched the preoperative diagnosis in 78% of cases. The highest accuracy was reached for solid pseudopapillary neoplasms (95%) and for main duct/mixed duct intraductal papillary mucinous neoplasms (81%). Surprisingly, 23 cysts (5%) were found to be ductal adenocarcinoma, whereas 45 patients (9%) underwent a pancreatic resection for a non-neoplastic condition. The use of a routine radiologic workup, including contrast-enhanced ultrasonography and magnetic resonance imaging, was associated with a favorably correct characterization of the cystic lesion. Endoscopic ultrasonography did not seem to improve diagnostic accuracy. Increased levels of serum carbohydrate antigen (CA)19-9 resulted as risk factors for an incorrect diagnosis as well as for a final diagnosis of a ductal adenocarcinoma. CONCLUSION: The overall rate of inaccurate preoperative diagnoses in a tertiary care center with a broad experience in pancreatology approached 22%. Serum CA19-9 is an important complementary tool within the context of preoperative investigation of cystic neoplasms of the pancreas.

Growth pattern of serous cystic neoplasms of the pancreas: observational study with long-term magnetic resonance surveillance and recommendations for treatment.

BACKGROUND AND AIMS: The natural history and growth pattern of pancreatic serous cystic neoplasms (SCNs) are not well understood. This study was designed in order to get insight into the growth rate of SCNs and to suggest recommendations for their management. METHODS: Patients with well-documented incidentally discovered or minimally symptomatic SCNs who underwent yearly surveillance MRI were analysed using a linear mixed model. The growth rate and the effects of different fixed factors (sex, personal history of other non-pancreatic malignancies, radiological pattern, clinical presentation, tumour site) and random factors (age and tumour diameter at the time of diagnosis) on tumour growth were investigated. RESULTS: Study population consisted of 145 patients. Estimated overall mean growth rate was 0.28 cm/year, but the growth curve analysis showed a different trend between the first 7 years after the baseline evaluation (growth rate of 0.1 cm/year) and the subsequent period (years 7 to 10, growth rate of 0.6 cm/year, p<0.0001). Tests for fixed effects demonstrated that an oligocystic/macrocystic pattern and a personal history of other tumours are significant predictors of a more rapid mean tumour growth (p<0.0001 and 0.022, growth rates of 0.34 cm/year). Furthermore, tumour growth significantly increased with age (p = 0.0001). CONCLUSION: Overall, SCNs grow slowly, and an initial non-operative approach is feasible in all the asymptomatic or minimally symptomatic patients. The oligocystic/macrocystic variant, a history of other non-pancreatic malignancies and patients' age impact on tumour growth. In any case, a significant growth is unlikely to occur before 7 years from the baseline evaluation. Tumour size at the time of diagnosis should not be used for decisional purposes.

Differences between main-duct and branch-duct intraductal papillary mucinous neoplasms of the pancreas.

In the last decade, intraductal papillary mucinous neoplasms (IPMNs) have become commonly diagnosed. From a morphological standpoint, they are classified in main-duct IPMNs (MD-IPMNs) and branch-duct IPMNs (BD-IPMNs), depending on the type of involvement of the pancreatic ductal system by the neoplasm. Despite the fact that our understanding of their natural history is still incomplete, recent data indicate that MD-IPMNs and BD-IPMNs show significant differences in terms of biological behaviour with MD-IPMNs at higher risk of malignant degeneration. In the present paper, clinical and epidemiological characteristics, rates of malignancy and the natural history of MD-IPMNs and BD-IPMNs are analyzed. The profile of IPMNs involving both the main pancreatic duct and its side branches (combined-IPMNs) are also discussed. Finally, general recommendations for management based on these differences are given.