The clinical utility of endoscopic ultrasound–guided fine-needle aspiration in the diagnosisand staging of pancreatic carcinoma,☆☆,,★★

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Abstract

Background: Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) of pancreatic lesions is being increasingly used. Our aim was to determine the safety, accuracy, and clinical utility of EUS-guided FNA in both the diagnosis and staging of pancreatic cancer. Methods: Forty-four patients (24 men/20 women) had EUS-guided FNA of pancreatic lesions (39 head/neck, 5 body, 3 tail) and/or associated lymph nodes. The mean age was 61 (range, 28 to 88 years). The indication for EUS-guided FNA was a pancreatic lesion seen initially on CT (39%), ERCP (43%), or EUS (18%). Follow-up data were collected on all patients for mean of 14.5 months (range 1 to 33 months). Results: CT detected only 15 of 61 (25%) focal lesions seen by EUS. Adequate specimens were obtained by EUS-guided FNA in 44 of 47 (94%) pancreatic lesions and 14 of 14 (100%) associated lymph nodes (overall adequacy was 95%). Of the 46 lesions in which specimens were adequate and a final diagnosis was available (32 malignant, 14 benign), EUS-guided FNA had a sensitivity of 92%, specificity of 100%, and diagnostic accuracy of 95% for pancreatic lesions and 83%, 100%, and 88% for lymph nodes, respectively. Six percent of pancreatic cases had inadequate specimens and, if included, lowered the sensitivity to 83%, specificity to 80%, and diagnostic accuracy to 88% for pancreatic lesions. In 3 patients with enlarged celiac nodes on EUS, EUS-guided FNA was able to make a tissue diagnosis of metastasis, which changed the preoperative staging and precluded surgery. EUS in combination with EUS-guided FNA precluded surgery in 12 of 44 (27%) and may have precluded surgery in an additional 6 of 44 (14%). EUS-guided FNA avoided the need for further diagnostic tests, thus expediting therapy in a total of 25 (57%) patients and influenced clinical decisions in 30 of 44 (68%) patients. The estimated cost savings based on surgeries avoided was approximately $3300 per patient. There was only one complication (2%), a post-FNA fever. Conclusion: EUS-guided FNA of the pancreas appears to be a safe and effective method that increases both the diagnostic and staging capability of EUS in pancreatic cancer. The clinical impact of EUS-guided FNA includes avoiding surgery and additional imaging studies with a substantial cost savings. (Gastrointest Endosc 1997;45:387-93.)

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Patients and Methods

Forty-four consecutive patients (24 men, 20 women) underwent EUS-guided FNA procedures between April 1993 and November 1995. The mean age of the patients was 61 years with a range from 28 to 88 years. The indication for EUS-guided FNA was a pancreatic lesion seen initially on CT (17), ERCP (19), or EUS (8). The inclusion criteria included patients with a clinical suspicion of pancreatic cancer who were referred for a diagnosis as well as those who had an established diagnosis of pancreatic

Results

Forty-four patients underwent EUS-guided FNA procedures; there were 47 pancreatic lesions (39 head/neck, 5 body, and 3 tail). In 13 patients, periluminal lymph nodes were also sampled, of which five lymph nodes were celiac.

CT detected pancreatic lesions in 15 of 47 (32%), thereby missing the diagnosis in 32 of 47 (68%). However, in 13 of the 32 cases in which no focal pancreatic lesion was detected on CT, there was nonspecific enlargement of the pancreas. Of the 17 patients in whom a pancreatic

Discussion

EUS has been used in the diagnosis of pancreatic tumors with a high sensitivity and specificity. 1, 3, 4, 5, 6 It has also been used in local tumor staging of pancreatic cancer to predict resectability. 1 However, EUS cannot always differentiate malignant from inflammatory processes of the pancreas or lymph nodes. In one large series, EUS was only 76% accurate in the diagnosis of malignancy and 46% accurate in focal inflammation.3 Therefore, EUS-guided FNA with its ability to provide a tissue

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  • Cited by (0)

    From the Division of Gastroenterology, University of California, Irvine Medical Center, Irvine, and the Veterans Affairs Medical Center, Long Beach, California.

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    This project sponsored in part by a research grant from Pentax Precision Instruments.

    Reprint requests: Kenneth J. Chang, MD, UCI Clinical Cancer Center, 101 The City Dr., Bldg. 23, Rt. 81, Orange, CA 92868.

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