pathology positive for malignancy, or death within 12 months from causes related to malignancy. Neuroendocrine tumors, IPMN, lymphomas, Schwannomas, pseudopapillary tumors and mucinous cystadenomas were grouped as ‘other neoplasms’. ROC curve was used to determine the threshold for age, lesion size and serum CA19-9 to differentiate malignant from benign lesions. Univariate analysis was performed to compare age, gender, size, solid/ cystic characteristics, lesion location, pancreatitis, serum CA 19-9, and cyst fluid CEA between benign and malignant lesions. Multivariate analysis was performed using binary logistic regression with final diagnosis of malignant or benign as the outcome variable. Covariates included age (⬍70 or ⱖ70), appearance (solid/ cystic), size (⬍20 or ⱖ20 mm), and serum CA19-9 (⬍40 or ⱖ40). Results: There were 70 patients (63% female, mean age 62 yrs) with suspicious or indeterminate cytology on pancreatic EUS-FNA. Final diagnosis was adenocarcinoma in 33/70 (47%), ‘other neoplasms’ in 13/70 (18%) and benign in 24/70 (35%). Lesions were solid in 38/70 (54%), cystic in 30/70 (43%) and mixed solid/cystic in 2/70 (3%). Mean size was 29.4 mm (range 5-80). 90% of adenocarcinomas were ⬎20 mm in size and 67% of benign cases were less than 20 mm. Cytology was suspicious in 36/70 (51%) and indeterminate in 34/70 (49%). Majority of solid pancreatic lesions with suspicious cytology were adenocarcinomas (79%). Univariate analysis revealed no significant difference in gender, location, pancreatitis, and fluid CEA between patients with benign compared with malignant lesions, while age, size, solid/cystic characteristic, and serum CA 19-9 showed a significant difference between the two groups. Only serum CA19-9 showed a significant association with the final diagnosis on multivariate analysis, indicating that patients with a serum CA19-9 ⱖ40 with suspicious or indeterminate cytology have a significantly higher probability of a malignant outcome. Conclusions: Patients with pancreatic lesions with suspicious or indeterminate cytology and elevated serum CA19-9 should be treated aggressively as having a malignant diagnosis.
Sa1535 Preoperative EUS-FNA Does Not Adversely Affect Outcomes in Resectable Pancreatic Cancer Vasco Eguia*, Megan Winner, Amrita Sethi, John M. Poneros, Charles J. Lightdale, John D. Allendorf, John a. Chabot, Beth Schrope, James a. Lee, Tamas a. Gonda Columbia University Medical Center - NYPH, New York, NY Introduction: EUS-FNA is the preferred method to sample pancreatic masses. Concerns have been raised that EUS-FNA may adversely affect outcomes in resectable pancreatic cancer, via mechanisms such as tumor seeding. The purpose of this study is to evaluate preoperative EUS-FNA as a risk factor for tumor recurrence and survival in patients with pancreatic adenocarcinoma. Methods: In a prospectively maintained database of pancreatic cancer patients, we identified all cases of resectable disease from 2000 to 2010. Analyses were restricted to patients who were resected with final stage I - III disease and who did not receive neoadjuvant treatment. We collected demographic, clinical and tumor data and assessed time to recurrence or death. We performed univariate and multivariate Cox proportional hazards modeling, to identify factors associated with recurrence and survival. Results: We identified 220 patients, of which 146 patients were evaluated preoperatively with EUS-FNA and 74 did not undergo preoperative biopsy. Overall, 101(47.4%) had recurrent disease, 42 (19.7%) local and 79(37.1%) distant, which for most was diagnosed at an imaging encounter. 114 (53.5%) of the cohort had died at the time of this analysis. The median clinical follow-up time was 18.3 months. Among those who recurred, the median time to recurrence was 10.8 months. In univariate analysis, there was no significant difference in time to recurrence with respect to performing EUS-FNA (Log rank p⫽0.20). In a multivariate analysis only perineural invasion was an independent predictor of time to recurrence (p value ⬍ 0.001). In univariate analysis, there was no significant difference in survival with respect to performing EUS-FNA (Log rank p⫽0.1628). In a univariate Cox proportional hazards model, EUS-FNA was not a significant predictor of time to recurrence (p⫽0.16). In a multivariate Cox proportional hazards model only perineural invasion was an independent predictor of time to survival. Conclusion: We found no association between EUS-FNA and recurrence or survival in patients with resectable pancreatic cancer. Therefore, in patients with pancreatic masses, utilizing EUS-FNA as a diagnostic tool when needed is reasonable and safe.
Sa1536 Cystic Pancreatic Neuroendocrine Neoplasms: Results of Endoscopic Ultrasound-Guided Fine Needle Aspiration Fluid Analysis Won Jae Yoon*, Ebubekir Daglilar, William R. Brugge Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA Background: Cystic pancreatic neuroendocrine neoplasms (cPNENs) account for up to 10% of pancreatic neuroendocrine neoplasms. Limited data are available on the nature of cyst fluid in cPNENs. Aims: The aims of this study are to characterize the nature of cystic fluid including carcinoembryonic antigen (CEA)
levels and cytology, to describe endoscopic ultrasound (EUS) characteristics of cPNEN patients, and to compare cyst fluid CEA level between cPNEN patients and age- and sex-matched mucinous pancreatic cystic neoplasm (mPCN, i.e. intraductal papillary mucinous neoplasm and mucinous cystic neoplasm) patients. Methods: From the prospective endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) database, patients who underwent EUS-FNA for pancreatic cystic lesions and were ultimately diagnosed cPNENs with pathological confirmation between 1999 and 2011 were collected. Patient characteristics, cyst CEA levels, pathology results, and EUS findings were analyzed. For the comparison of cyst fluid CEA levels, age- and sex-matched mPCN patients were chosen from the same database. Results: A total of 20 patients were identified (male : female⫽14 : 6). The median age at diagnosis was 60 (range, 34-80) years. Eighteen patients underwent surgery, and two patients were diagnosed on cytological basis. Ten patients were asymptomatic. Among the symptomatic patients, one patient presented with Cushing syndrome attributable to the functioning cPNEN (ACTH-producing tumor). MEN-1 was present in 2 patients. No patient had multiple cPNENs. Two patients had documented metastasis (one in the liver and the other in a regional lymph node). Five cPNENs were located in the head, 8 in the body, and 7 in the tail of the pancreas. The median diameter of the lesions measured by EUS was 24 (range 13-70) mm. Cysts were unilocular in 12 and septated in 8. Thick wall (⬎ 2 mm) was present in 12 patients. Eleven patients had associated mass lesions. Among the nine patients with the fluid viscosity reported, 3 had mucoid and 6 had thin fluid. Among the 18 patients who had histological confirmation, EUSFNA cytology was diagnostic in 11 patients. For the 7 patients whose cytologies were not diagnostic, 6 had inconclusive cytology and 1 was diagnosed as adenocarcinoma. Cyst fluid CEA level was checked in 16 patients, with the median level of 1.15 (range, 0.3 - 500) ng/mL. The median cyst fluid CEA level of the matched mPCNs was 500 (range, 2.8-87780) ng/mL. cPNEN patients demonstrated significantly lower levels of cyst fluid CEA than mPCN patients (P⬍0.001, Mann-Whitney U test). Conclusions: Half of the cPNENs were incidentally found. EUS findings of cPNENs were heterogeneous. The median cyst fluid CEA level was lower than 5 ng/mL in cPNEN patients, and was significantly lower than that of mPCN patients. Among the surgical patients, cytology was diagnostic in 61%.
Sa1537 Prospective Randomized Trial Comparing 19-G Tru-Cut Needle (TCB) and New 19-G Core Histology Needle (CHN) for Endoscopic Ultrasound (EUS) Guided Liver Biopsy in a Porcine Model Do Hyun Park*1,3, Hee Jin Lee2, Seng-Mo Hong2, Takuji Iwashita3, Yousuke Nakai3, Jason B. Samarasena3, John G. Lee3, Kenneth J. Chang3 1 Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea; 2Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea; 3 H.H. Chao Comprehensive Digestive Disease Center, University of California Irvine, California, Irvine, CA Background: Histologic biopsy specimen is important for evaluating/staging liver disease. Non-operative liver tissue acquisition is usually obtained by percutaneous or transvascular routes. However, these have technical limitations and procedure-related complications. EUS-guided Trucut biopsy (TCB) has been proposed as an alternative because it may provide sufficient histologic diagnosis after a limited number of passes under real-time visualization. However, TCB also has been limited given the low core yield, need for multiple passes, and difficulty with angulation. Recently, a new EUS 19 g core histology needle (ProCore, Cook Medical) has been introduced for core tissue acquisition of various lesions under EUS guidance. It has not been reported for use in benign liver disease. Aim: The aim of this study was to compare the technical feasibility of TCB and CHN needle, core yield and histologic quality of specimen obtained from the liver using TCB versus CHN in a porcine model. Methods: Under EUS guidance, 4 consecutive trans-gastric needle passes were performed into the left lobe of the liver with each needle type. The order of needle type used was randomly assigned to TCB (Quick-Core needle, Cook Medical) or CHN. A total of 64 needle passes were performed in eight pigs. To compare the technical feasibility of both needles, the visibility of needle and technical difficulty during EUS were evaluated. Technical difficulty was defined as any needle change due to needle malfunction during each needle pass. Specimen were placed in formalin and processed for histologic assessment (hematoxylin and eosin stain). 88 slides (44, TCB; 44, CHN) were made from paraffin blocks of 64 core biopsy specimens. Each slide was reviewed by two experienced pathologists, who were blinded regarding needle information. Quantitative (gross specimen length) and qualitative (histologic adequacy, e.g complete portal tract) analysis was performed. Results: Both needles showed good visibility during EUS. Three TCB (9%) had technical difficulty during transgastric needle passes. No difficulty in the use of CHN during transgastric passes was seen. The median number of complete portal tracts using TCB and CHN was 2 (range, 0⫺7) and 2 (range,
AB194 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012