Endoscopic Ultrasound-Guided Fine Needle Aspiration and
Endoscopic Ultrasound-Guided Fine Needle Aspiration and
Introduction: Endoscopic ultrasound (EUS) is now established as a valuable imaging test for diagnosing and staging pancreatic cancer. But, with significant recent improvements in spiral CT scanners, particularly higher resolution and ability to reconstruct 3D images, spiral CT is now increasingly accepted as being better for pancreatic cancer staging. The debate continues, however, about the best diagnostic test or combination of tests in patients with suspected pancreatic cancer. Spiral CT is more readily available than EUS-FNA and, therefore, more frequently used. In this study, we evaluated the use of EUS-FNA in conjunction with spiral CT for suspected pancreatic cancer.
Methods: We retrospectively evaluated 81 consecutive patients who underwent EUS and EUS-FNA for clinical suspicion of a pancreatic cancer from November 2000 to November 2001. All patients had spiral CT with a multiphasic pancreatic protocol using multidetector spiral CT scanners. In all patients, EUS-FNA and spiral CT examinations were performed less than 3 wk apart.
Results: Overall, the accuracy of spiral CT, EUS, and EUS-FNA was 74% (n = 60/81, CI 63-83%), 94% (n = 76/81, CI 87-98%), and 88% (n = 73/81, CI 81-96%), respectively, for diagnosing pancreatic cancer. In patients without an identifiable mass on spiral CT, the diagnostic accuracy of EUS and EUS-FNA for pancreatic tumors was 92% (n = 23/25, CI 74-99%). Absence of a focal "mass" lesion on EUS reliably excluded pancreatic cancer irrespective of clinical presentation (NPV 100% n = 5/5, CI 48-100%). The negative predictive value of EUS-FNA was only 22% (n = 2/9, CI 3-60%) in patients with obstructive jaundice and biliary stricture. However, in patients without obstructive jaundice at initial presentation, EUS-FNA was highly accurate (accuracy 97%, n = 33/34, CI 85-100%) and was reliable for ruling out malignancy (NPV 89%, n = 8/9, CI 52-100%). Cytologic assessment of EUS-FNA specimens was 89% accurate for identifying malignancy in suspicious lesions visualized on EUS.
Conclusions: The EUS with FNA can be a valuable adjunct to newer high-resolution multidetector spiral CT for diagnostic evaluation of patients with suspected pancreatic cancer.
The incidence of pancreatic cancer in the United States is approximately 28,000 cases a year with 8.5 deaths per 100,000. The majority of patients are between 65 and 79 yr of age. Most pancreatic cancers are greater than 3 cm in diameter at the time of initial diagnosis and are diagnosed when they become symptomatic but may be detected incidentally in a small number of patients. Eighty to ninety percent of pancreatic cancers have regional or distant spread at the time of initial diagnosis. Biologically, pancreatic adenocarcinomas behave aggressively and only 5-10% of patients are alive 5 yr after initial diagnosis.
Curative surgical resection offers the only chance of long-term survival in pancreatic cancer. Tumor size is a major determinant of survival in patients with pancreatic cancer. Meaningful improvement of the early diagnosis of pancreatic cancer implies that pancreatic tumors must be detected when they are small and still confined within the pancreas. Unfortunately, most pancreatic cancers less than 2 cm in size are asymptomatic. The current imaging modalities including single-detector computed tomography (CT), magnetic resonance imaging (MRI), and abdominal ultrasound (US) reliably diagnose tumors ≥3 cm in size. As a result, most pancreatic cancers are diagnosed late and only 5-25% of patients taken for surgery actually undergo curative resection.
Recent advances in diagnosis and management of pancreatic cancer include availability of multidetector spiral CT scanners and endoscopic ultrasound (EUS) with EUS-guided fine needle aspiration cytology (EUS-FNA). Spiral CT is now widely recognized as being a better test for staging pancreatic cancer, though EUS can provide useful additional staging information, particularly in patients where the spiral CT is equivocal about tumor resectability. Both multidetector spiral CT and EUS/EUS-FNA have been reported to be highly accurate for diagnosing pancreatic cancer. Because of its wider availability, spiral CT is more commonly used for diagnostic evaluation of pancreatic cancer. In the present study in patients with suspected pancreatic cancer, we evaluated the diagnostic accuracies of EUS, EUS-FNA, and newer generation multidetector spiral CT to reevaluate and update the role of EUS/EUS-FNA in the diagnostic work-up used alone or in conjunction with spiral CT.
Introduction: Endoscopic ultrasound (EUS) is now established as a valuable imaging test for diagnosing and staging pancreatic cancer. But, with significant recent improvements in spiral CT scanners, particularly higher resolution and ability to reconstruct 3D images, spiral CT is now increasingly accepted as being better for pancreatic cancer staging. The debate continues, however, about the best diagnostic test or combination of tests in patients with suspected pancreatic cancer. Spiral CT is more readily available than EUS-FNA and, therefore, more frequently used. In this study, we evaluated the use of EUS-FNA in conjunction with spiral CT for suspected pancreatic cancer.
Methods: We retrospectively evaluated 81 consecutive patients who underwent EUS and EUS-FNA for clinical suspicion of a pancreatic cancer from November 2000 to November 2001. All patients had spiral CT with a multiphasic pancreatic protocol using multidetector spiral CT scanners. In all patients, EUS-FNA and spiral CT examinations were performed less than 3 wk apart.
Results: Overall, the accuracy of spiral CT, EUS, and EUS-FNA was 74% (n = 60/81, CI 63-83%), 94% (n = 76/81, CI 87-98%), and 88% (n = 73/81, CI 81-96%), respectively, for diagnosing pancreatic cancer. In patients without an identifiable mass on spiral CT, the diagnostic accuracy of EUS and EUS-FNA for pancreatic tumors was 92% (n = 23/25, CI 74-99%). Absence of a focal "mass" lesion on EUS reliably excluded pancreatic cancer irrespective of clinical presentation (NPV 100% n = 5/5, CI 48-100%). The negative predictive value of EUS-FNA was only 22% (n = 2/9, CI 3-60%) in patients with obstructive jaundice and biliary stricture. However, in patients without obstructive jaundice at initial presentation, EUS-FNA was highly accurate (accuracy 97%, n = 33/34, CI 85-100%) and was reliable for ruling out malignancy (NPV 89%, n = 8/9, CI 52-100%). Cytologic assessment of EUS-FNA specimens was 89% accurate for identifying malignancy in suspicious lesions visualized on EUS.
Conclusions: The EUS with FNA can be a valuable adjunct to newer high-resolution multidetector spiral CT for diagnostic evaluation of patients with suspected pancreatic cancer.
The incidence of pancreatic cancer in the United States is approximately 28,000 cases a year with 8.5 deaths per 100,000. The majority of patients are between 65 and 79 yr of age. Most pancreatic cancers are greater than 3 cm in diameter at the time of initial diagnosis and are diagnosed when they become symptomatic but may be detected incidentally in a small number of patients. Eighty to ninety percent of pancreatic cancers have regional or distant spread at the time of initial diagnosis. Biologically, pancreatic adenocarcinomas behave aggressively and only 5-10% of patients are alive 5 yr after initial diagnosis.
Curative surgical resection offers the only chance of long-term survival in pancreatic cancer. Tumor size is a major determinant of survival in patients with pancreatic cancer. Meaningful improvement of the early diagnosis of pancreatic cancer implies that pancreatic tumors must be detected when they are small and still confined within the pancreas. Unfortunately, most pancreatic cancers less than 2 cm in size are asymptomatic. The current imaging modalities including single-detector computed tomography (CT), magnetic resonance imaging (MRI), and abdominal ultrasound (US) reliably diagnose tumors ≥3 cm in size. As a result, most pancreatic cancers are diagnosed late and only 5-25% of patients taken for surgery actually undergo curative resection.
Recent advances in diagnosis and management of pancreatic cancer include availability of multidetector spiral CT scanners and endoscopic ultrasound (EUS) with EUS-guided fine needle aspiration cytology (EUS-FNA). Spiral CT is now widely recognized as being a better test for staging pancreatic cancer, though EUS can provide useful additional staging information, particularly in patients where the spiral CT is equivocal about tumor resectability. Both multidetector spiral CT and EUS/EUS-FNA have been reported to be highly accurate for diagnosing pancreatic cancer. Because of its wider availability, spiral CT is more commonly used for diagnostic evaluation of pancreatic cancer. In the present study in patients with suspected pancreatic cancer, we evaluated the diagnostic accuracies of EUS, EUS-FNA, and newer generation multidetector spiral CT to reevaluate and update the role of EUS/EUS-FNA in the diagnostic work-up used alone or in conjunction with spiral CT.
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