EUS AND FNA IN INFLAMMATORY AND CYSTIC PANCREATIC...
Transcript of EUS AND FNA IN INFLAMMATORY AND CYSTIC PANCREATIC...
EUS AND FNA IN INFLAMMATORY AND EUS AND FNA IN INFLAMMATORY AND CYSTIC PANCREATIC PATHOLOGY CYSTIC PANCREATIC PATHOLOGY
Enrique Enrique VVaazquezzquez--Sequeiros MD, PhDSequeiros MD, PhD
Gastroenterology Service. University Hospital RamGastroenterology Service. University Hospital Ramóón y Cajal. Madrid.n y Cajal. Madrid.
2nd European Meeting EGEUS European Group for Endos copic Ultrasonography
14th – 15th september, 2007 – Torino, Lingotto Congre ss Center
PERIGASTRIC REGION
Pancreas >
Stomach
PERIDUODENAL REGION
Ao
IVC >
Spine
< Pancreas
<< SMA/SMV
< Tail
< Body< Istm
< Head
ECOENDOSCOPESECOENDOSCOPESRadial Radial
DiagnDiagnosticosticLinear Linear FNAFNA
CYSTIC TUMORS OFCYSTIC TUMORS OF PANCREASPANCREAS
MUCINOUS
SEROUS
PSEUDOCYST
CLASSIFICATION PANCREAS CYSTSCLASSIFICATION PANCREAS CYSTS• PSEUDOCYSTS (70-90%)
• CYSTIC NEOPLASMS 10-15%
– SEROUS CYSTOADENOMA
– MUCINOUS CYSTIC NEOPLASMS– INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)
– SOLID PSEUDOPAPILAR NEOPLASM
– CYSTIC ENDOCRINE TUMOR – DUCTAL ADENOCARCINOMA WITH CYSTIC DEGENERATION
– CHORIOCARCINOMA, TERATOMA
• TRUE CYSTS
– POLYCYSTIC DISEASE– SIMPLE (RETENTION) CYST
– DERMOID CYST
• OTHERS: LYMPHOEPITELIAL CYST, ENDOMETRIOSIS CYSTS, MACROCYSTIC CYSTS IN CYSTIC FIBROSIS, PARASITIC CYSTS
Forsmark C. Sleisenger 2002
DifferentialDifferential Diagnosis Pancreas CystsDiagnosis Pancreas Cysts
1.Clinical presentation
2.Morphology (EUS)
3.Cyst aspirate analysis (EUS-FNA)
SEROSUS MUCINOUS PSEUDOCYST
SEROUS CYSTADENOMASEROUS CYSTADENOMA
Serous Cystadenoma
History/Demographics • 32-39% pancreas cysts. • Incidental finding; Female; >60 a.
Structure (Multilocular/Multiseptated/Calcified central scar: Honeycomb pattern)
• Microcystic*: (cysts < 1 cm) • Micro/macrocystic: (cysts < & > 1 cm) • Macrocystic: (cysts > 1 cm)
Wall • Thin (Cuboidal epitelium)
Solid Component • -
Comunicate with Wirsung • -
Cyst aspirate (EUS-FNA) • Content: Serous
• Amylase: -
• Mucin stain: -
Citology: • Cuboidal epitelium • Clear cytoplams PAS+.
• Dx in 50% • CEA: +/-
Prognosis • Benign**
BruggeBrugge WR. N WR. N EnglEngl J Med 2004. Gastroenterology 2004J Med 2004. Gastroenterology 2004
SEROUSSEROUS CYSTADENOMACYSTADENOMA
CYSTIC MUCINOUS TUMORCYSTIC MUCINOUS TUMOR
Mucinous Tumor: Mucinous Cystadenoma/CA
History/Demographics • 10-45% pancreas cysts. • Pancreatitis (+/-); Female; 40-50 y.o.
Structure (Uni*/Oligo/Multilocular/No central scar)
• Macrocystic*: (cysts > 1-2 cm. Mucin secreting cells. Thin septa)
Wall • Thick
Solid component • +/- (suggests malignancy)
Comunicates con Wirsung • +/-
Cyst aspirate (EUS-FNA) • Content: Mucinous, viscous
Citology: • Columnar Epitelium +/- atypia. • Mucin
• Dx in 50%.
• Amylase: +/- • Mucin stain: ++ • CEA: ++ (accuracy: 79%)
Pronosis • Premalignant/Malignant**
BruggeBrugge WR. N WR. N EnglEngl J Med 2004. Gastroenterology 2004J Med 2004. Gastroenterology 2004
CYSTIC MUCINOUS TUMORCYSTIC MUCINOUS TUMOR
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM
IPMN
History/Demographics • 10-21% pancreas cysts. • Relapsing pancreatitis; Female/Male.
• ¨Ductal epitelium formed by mucin producing cells¨.
• ¨Cystic dilatation of ducts due to obstructing mucin plug¨
Structure • Difuse vs localized.
• Main branch type: (Wirsung: Dilated) Side branch type: (Wirsung: normal;
Side braches: Dilated)
Endoscopy/ERCP/MRI • Mucin protuding from the ampulla • Filling defects in Wirsung:
mucin +/- parietal nodules
Solid component • +/- (suggests malignization)
Comunicates with Wirsung • Arises from Wirsung or side branches
Cyst aspirate (EUS-FNA) • Content: Mucinous
(Cytology: ~ Mucinous cystoadenoma. Dx in 50-60%)
• Mucin stain: ++
Prognosis • Premalignant/Malignant** • Side branch type: better prognosis
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMINTRADUCTAL PAPILLARY MUCINOUS NEOPLASM
BruggeBrugge WR. N WR. N EnglEngl J Med 2004. Gastroenterology 2004J Med 2004. Gastroenterology 2004
Mucin
Mucin
Wirsung
Papillary projection
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMINTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)(IPMN)
Pseudocyst
History/Demographics • 32-39% pancreas cysts. • History of pancreatitis; Male; 50-60 y.o.
Structure • Unilocular*: (large size cysts) • Septated (+/-)
Wall • Thin (except chronic)
Solid component • +/-
Comunicates with Wirsung • +
Cyst aspirate(EUS-FNA) • Content: Turbid (brown)
Citology:
• Inflammatory cells; no mucin, no epitelial cells.
• Amylase: ++++
• Mucin stain: -
• CEA: +/-
Prognosis • Benign*
INFLAMMATORY CYSTIC LESION: PSEUDOCYSTINFLAMMATORY CYSTIC LESION: PSEUDOCYST
BruggeBrugge WR. N WR. N EnglEngl J Med 2004. Gastroenterology 2004J Med 2004. Gastroenterology 2004
Seudoquistesimple
Simple Pseudocyst
Wirsung >
Stone
Complex Pseudocyst >
Detritus < Varices
<
INFLAMMATORY CYSTIC LESION: PSEUDOCYSTINFLAMMATORY CYSTIC LESION: PSEUDOCYST
Mucinous Serous Pseudocyst
History Pancreatitis (+/-) Incidental Hx Pancreatitis (+)
Demographics 40-50 y.o. Female >60 y.o. Anyone
Structure Unilocular Multilocular Multiseptated
Unilocular
Wall Thick Thin Thin
Solid component +/- - +/-
Comunictes with MPD
+/- - +
Content Mucoid Serous Turbid
Amylase +/- - ++++
Mucin stain ++ - -
CEA* ++ +/- +/-
Diagnostic accuracyDiagnostic accuracy:: 8080--90%.90%. Vazquez Sequeiros E, et al. Curr Gastroenterol 2000
SUMMARYSUMMARY CYSTIC TUMORSCYSTIC TUMORS PANCREASPANCREASH
IST
OR
YM
OR
PH
OLO
GY
CY
ST
AS
PIR
AT
E
van van derder waijwaij LA. LA. GastrointestGastrointest EndoscEndosc 20052005
Systematic RevSystematic Rev
12 12 studies studies
450 450 patientspatients
MANAGEMENT ALGORITHMMANAGEMENT ALGORITHM
Pancreas cyst
History/CT/MRIEUS-FNA
SEROUS CYST MUCINOUS CYST PSEUDOCYST
BENIGN(Tumor)
BENIGN(No tumor)
PREMALIGNANTMALIGNANT
•SURGERY*•FOLLOW-UP: if
•< 3 cm•Poor surg candidate
•THERAPY*•X-Ray
•Endoscopy/EUS•SURG
•FOLLOW-UP*•SURG: if symptoms
•Pancreatitis•Jaundice
Diagnostic accuracyDiagnostic accuracy:: 8080--90%90%
Risk/BenefitRisk/Benefit Risk/BenefitRisk/Benefit
Observe?Observe?
Treat?Treat?TreatTreatCHRONIC PcystCHRONIC Pcyst
((>> 6 6 weeks)weeks)
ObserveObserveTreatTreatACUTE PcystACUTE Pcyst(< 6 (< 6 weeks)weeks)
AsymptomaticAsymptomaticSymptomaticSymptomatic
TECHNIQUE PSEUDOCYST DRAINAGETECHNIQUE PSEUDOCYST DRAINAGE
TTéécnicacnica DrenajeDrenaje PseudoquistePseudoquiste
SURGSURG????Complete stenosisComplete stenosis
Stenosis DilatatioStenosis Dilatationn
++
Endoscopy/EUS/Endoscopy/EUS/
PercutPercutaneousaneous
YesYesPartial stenosisPartial stenosis
Endoscopy/EUS/Endoscopy/EUS/
PercutPercutaneousaneousYesYesNormalNormal
Drainage Drainage ComunicatesComunicates PcystPcystWirsungWirsung
Baron TH. N. Engl. J. Med. 1999Baron TH. N. Engl. J. Med. 1999
TECHNIQUETECHNIQUE PSEUDOCYST DRAINAGEPSEUDOCYST DRAINAGE
PSEUDOCYST DRAINAGEPSEUDOCYST DRAINAGE
• : Gastrointest Endosc. 2005 Sep;62(3):383-9.Links– Comment in:
• Gastrointest Endosc. 2005 Sep;62(3):390-1.
– Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis.– van der Waaij LA, van Dullemen HM, Porte RJ.– Department of Gastroenterology, Martini Ziekenhuis, Groningen, The Netherlands.– BACKGROUND: Pancreatic cystic tumors commonly include serous cystadenoma (SCA), mucinous
cystadenoma (MCA), and mucinous cystadenocarcinoma (MCAC). A differential diagnosis with pseudocysts(PC) can be difficult. Radiologic criteria are not reliable. The objective of the study is to investigate the valueof cyst fluid analysis in the differential diagnosis of benign (SCA, PC) vs. premalignant or malignant (MCA, MCAC) lesions. METHODS: A search in PubMed was performed with the search terms cyst, pancrea, andfluid. Articles about cyst fluid analysis of pancreatic lesions that contained the individual data of at least 7 patients were included in the study. Data of all individual patients were combined and were plotted in scattergrams. Cutoff levels were determined. RESULTS: Twelve studies were included, which comprised data of 450 patients. Cysts with an amylase concentration <250 U/L were SCA, MCA, or MCAC (sensitivity 44%, specificity 98%) and, thus, virtually excluded PC. A carcinoembryonic antigen (CEA) <5 ng/mL suggested a SCA or PC (sensitivity 50%, specificity 95%). A CEA >800 ng/mL strongly suggested MCA or MCAC (sensitivity 48%, specificity 98%). A carbohydrate-associated antigen (CA) 19-9 <37 U/mL strongly suggestedPC or SCA (sensitivity 19%, specificity 98%). Cytologic examination revealed malignant cells in 48% ofMCAC (n = 111). DISCUSSION: Most pancreatic cystic tumors should be resected without the need for cystfluid analysis. However, in asymptomatic patients, in patients with an increased surgical risk, and, in patients in whom there is a diagnostic uncertainty about the presence of a PC, cyst fluid analysis helps to determine theoptimal therapeutic strategy.
Table 4 . Suggested management forasymptomatic patients and for patients with anincreased surgical risk with a pancreatic cysticlesion Cyst fluid analysisDiagnosisSuggestedmanagement Cytology: malignantcellsMalignancyConsider resectionCEA > 800 ng/mLMCA, MCACConsider resectionCEA < 5 ng/mLSCA, PCNo resection neededCA 19-9 < 37 U/mLSCA, PCNo resection neededAmylase < 250 U/LNo pseudocystNo endoscopic cystdrainageCEA, Carcinoembryonic antigen; MCA,mucinous cystadenoma; MCAC, mucinouscystadenocarcinoma; SCA, serous cystadenoma;
Líquido del quiste
acuosoviscosoviscosoacuosoFLUIDO
Macrófagos/ cell
inflamatorias/histiocitos
mucinaMg,mucina
Cell cuboideCITOLOGÍA
⇑⇑⇑⇑⇑⇑⇑⇑⇓⇓⇓⇓⇓⇓⇓⇓AMILASA
⇓⇓⇓⇓⇓⇓⇓⇓⇑⇑⇑⇑⇓⇓⇓⇓CA 15.3
⇓⇓⇓⇓⇓⇓⇓⇓≈⇓⇓⇓⇓CA 125
⇑⇑⇑⇑≈≈≈CA 19.9
⇓⇓⇓⇓Ó≈⇑⇑⇑⇑⇑⇑⇑⇑⇓⇓⇓⇓CA 72.4
⇓⇓⇓⇓Ó≈⇑⇑⇑⇑⇑⇑⇑⇑⇓⇓⇓⇓CEA
Seudoquiste
TIMPNQMCaseroso
DrenajeDrenaje PseudoquistesPseudoquistes
221 (2?)1 (2?)NNúúmeromero prpróótesistesis
SSííNo (?)No (?)IrrigaciIrrigacióónn PQPQ
SSííNo (?)No (?)DrenajeDrenaje nasoqunasoquíísticostico
10 Fr10 Fr77--10 Fr10 FrTamaTamaññoo prpróótesistesis
PQ PQ Complejo Complejo
Material Material NecrNecróóticoticoPQ SimplePQ Simple
Baron TH. N. Engl. J. Med. 1999Baron TH. N. Engl. J. Med. 1999
Algoritmo de manejo
TAC ó RMN
Riesgo/beneficio tto quirúrgico
Riesgo ⇓Beneficio⇑
Riesgo ≈Beneficio ≈
Riesgo ⇑Beneficio ⇓
RESECCIÓNQUIRÚRGICA
SEGUIMIENTOTAC/USE
REEVALUAR USE + PAAF
Brugge .N Engl J Med2004
TTéécnicascnicas DrenajeDrenaje PseudoquistePseudoquiste
+++++/+/--++SeguridadSeguridad
++
++++
+/+/--
+/+/--
PercutPercutááneoneo
++++++++EfectividadEfectividad
----FFíístulasstulas CutCutááneasneas
++--VisualizaciVisualizacióónnVasosVasos
++--DcoDco DiferencialDiferencialQuistesQuistes
USEUSEEndoscopiaEndoscopia
EPIDEMIOLOGÍA Y CARACTERÍSTICAS BIOLÓGICAS
= sólidos
Muy Frecuente
<160-70sMCistoadeCAcell-acinar
Muy Frecuente
<160-70sMadeCa.ductalquístico
= sólidos<1050-60s=N.Endocrina quística
Raro<1040sFN.Pseudopapilar sólida
Frecuente21-3360-70s=TIPM
Frecuente10-4550sFNQM
Raro32-3970sFC.Seroso
MALIGNO%EDADSEXOTIPO
Brugge. N Engl J Med2004
Límites marcadores
100?48MCACCitologíamaligna
38949819SCA
PC
CA19.9<37U/mL
75949848MCAMCAC
CEA>800ng/mL
55949550SCA
PC
CEA<5ng/mL
53989844SCA,MCA,MCAC
Amilasa<250U/L
VPN(%)VPP(%)E(%)S(%)DxPto corte
van der Waaij. GastrointestEndosc 2005.
CARACTERÍTICAS MORFOLÓGICAS
Aspirado cell c/ estructuras
papilares, cellblanda núcleo
redondo, glóbulos PAS+, estroma
mixoide,
Detritus necróticosMixta:sólido/fuido/hemorragia
Neoplasia pseudopapilar sólida
Mucina/cellsvariables/ep.columnar atipia variable
Viscoso/claro/mucina
Macro/microquistes, dilatación
TIPM
Mucina/cellsvariables/ep.columnar atipia variable
Viscoso/claro/mucina
Macroquiste,mg: pared
gruesa/septos
Neoplasia quísticamucinosa
Ep.cuboideassimple, citop.claro
PAS+
Diluido/claro/no mucinoso/hemorra
gico
Microquiste/panal
C.seroso
CITOLOGÍAFLUIDOECO/TACCARACTERÍSTICAS
CITOLOGÍAFLUIDOECO/TACCARACTERÍSTICAS
Cellinflamatorias
(PMN/ macrófagos) sin
Diluido, oscuro, opaco, no mucinoso
Unilocular, gruesa pared,
datos pancreatitis
Pseudoquiste
Cilíndrico o cuboidal con gránulos de zimógeno
Diluido/claroMicro/macroCistoadeCa acinar
Celladenocarcinomatosas variadas
Diluido, hemorrágico
Masa con localización adyacente a
colección
AdenoCa ductalquística
Cell pequeñas citoplasma
escaso, núcleo monomorfo
cromatina sal y pimienta
No mucinosoVariableNeoplasia quísticaendocrina
TRATAMIENTO DOLOR VISCERALTRATAMIENTO DOLOR VISCERAL
SNCSNC
SNPSNP
NEUROLISIS PLEXO CELNEUROLISIS PLEXO CELIIACOACOAlcohol/Alcohol/TriamcinolonaTriamcinolona
Gunaratnam NT et al. Gastrointest Endosc 2001Gunaratnam NT et al. Gastrointest Endosc 2001
1
2
3
4
5
6
7
0 2 4 8 12 16 20 24
Time (weeks)
Mea
n P
ain
S
core
s p<0.0005
n = 58n = 58
VASVAS
NEUROLISIS PLEXO CELNEUROLISIS PLEXO CELIIACOACOCCarciarcinoma Pnoma Pááncreasncreas
HIPERTENSION PORTAL
Colaterales >
<
<
<< Pliegues Gástricos
Pseudoquiste
EfectividadEfectividad DrenajeDrenaje PseudoquistesPseudoquistes
USEUSEUSEUSEEndoscopiaEndoscopiaTTéécnicacnica
0%0%InfecciInfeccióónn 48%48%20%20%ComplicacionesComplicaciones((sangrado/infeccisangrado/infeccióónn))
94%94%78%78%90%90%ResoluciResolucióónn PQPQ
91%91%89%89%94%94%ExitoExito ttéécnicocnico
8.5 Fr8.5 Fr7 Fr7 Fr10 Fr10 FrPrPróótesistesis
8 cm8 cm11 cm11 cm10 cm10 cmTamaTamaññoo
35352727437437PacientesPacientes
GiovanniniGiovannini 0101BinmoellerBinmoeller 9595Baron 98Baron 98
Efectividad Drenaje Pseudoquistes
USEEndoscopiaTécnica
0%20%Complicaciones(sangrado/infección)
94%90%Resolución PQ
91%94%Exito técnico
8.5 Fr10 FrPrótesis
8 cm10 cmTamaño
35437Pacientes
Giovannini 01Baron 98
PPááncreas/Benignancreas/Benigna:: Pseudoquiste Pseudoquiste
PSEUDOQUISTEPSEUDOQUISTE
Pseudoquiste simple
Wirsung >
Litiasis
Pseudoquiste > complejo
Detritus
DRENAJE PSEUDOQUISTEDRENAJE PSEUDOQUISTEUSEUSEEndoscopiaEndoscopiaTTéécnicacnica
0%0%20%20%ComplicacionesComplicaciones((sangrado/infeccisangrado/infeccióónn))
94%94%90%90%ResoluciResolucióónn PQPQ
91%91%94%94%ExitoExito ttéécnicocnico
8.5 Fr8.5 Fr10 Fr10 FrPrPróótesistesis
8 cm8 cm10 cm10 cmTamaTamaññoo
3535437437PacientesPacientes
GiovanniniGiovannini 0101Baron 98Baron 98
USE vs CPRE: = efectividad. > Seguridad/< complicaciones
USE: Pacientes con hipertensión portal y/o no compresión de la pared