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FNA of the Pancreas

FNA of the Pancreas. David Kindelberger, MD Divisions of Cytopathology and Women’s and Perinatal Pathology, Department of Pathology, Brigham and Women’s Hospital. Financial Disclosures.

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FNA of the Pancreas

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  1. FNA of the Pancreas David Kindelberger, MD Divisions of Cytopathology and Women’s and Perinatal Pathology, Department of Pathology, Brigham and Women’s Hospital

  2. Financial Disclosures • Dr. Kindelberger has no relationships to commercial interests relating to the content of this presentation.

  3. Oncologic History 59 year old woman 10/04: RUQ pain radiating to R flank, decreased appetite, early satiety, diarrhea followed by pale stools/dark urine 11/04: Abd CT showed 3x3 cm mass in head of pancreas with both intra and extra-hepatic BDD 12/04: ERCP with EUS (+FNA) showed hypoechoic mass in pancreatic head with probable portal vein invasion. FNA performed. Sphincterotomy performed and stent placed

  4. EUS-guided Pancreatic FNA

  5. EUS-guided Pancreatic FNA

  6. Cytologic Diagnosis • POSITIVE FOR MALIGNANT CELLS • Consistent with adenocarcinoma

  7. Oncologic History (cont.) 1/05-2/05: XRT 1/05: Begin concurrent CI 5-FU, CEA 11.9, CA19-9 1346 3/05: Abd CT showed multiple liver lesions and increasing size of pancreatic mass. CA19-9 5403 4/05: Increasing N/V with worsening fatigue and elevated LFTs

  8. Endoscopic Ultrasound Guided FNA of the Pancreas • Introduction • Solid Lesions • Cystic Lesions • Conclusions

  9. Introduction • 1851 Lebert was among the first to publish on using “percutaneous tumor puncture” • 1966 Dahlgren and Nordenstrom first reported using FNA of lung tumors under fluoroscopy • 1970 Oscarson used selective angiography to guide percutaneous biopsy of the pancreas • 1975 Smith used US guidance for percutaneous biopsy of the pancreas • 1982 Endoscopic ultrasonography introduced • 1992 Vilmann used endoscopic ultrasound to guide FNA of the pancreas.

  10. The Pentax Echoendoscope

  11. EUS-Guided FNA

  12. EUS-Guided FNA

  13. Advantages of EUS-Guided FNA • Allows for biopsy of smaller lesions (lesions less than 0.5 cm have been accurately biopsied) • Much shorter needle path (only pass through gastric or duodenal wall) • Can be performed at time of initial staging

  14. Disadvantages of EUS-Guided FNA • Risks associated with endoscopy/conscious sedation • Time consuming (1-1.5 hours per procedure) • Results highly dependent on level of operator and cytology experience

  15. Sensitivity and Specificity • Large series (179 cases) from MD Anderson • Sensitivity: 83.5 % • Specificity: 100% (also 100% PPV) • Diagnostic accuracy: 80.3% (using resection as gold standard in 70 cases)

  16. Solid Lesions

  17. Ductal Adenocarcinoma • 85-90% of pancreatic neoplasms • Incidence rates in developed countries range from 3 to 20 per 100,000 males (incidence and mortality almost identical) • 5th leading cause of cancer death in Western countries • Over 80% of cases present between 60-80 yrs. old • Male/female = 1.6

  18. Ductal Adenocarcinoma • Risk Factors • Smoking • Chronic pancreatitis • Past gastric surgery • Diabetes • Chlorinated hydrocarbons • Location • 60-70% found in head (mainly in upper half)

  19. Ductal Adenocarcinoma • Diagnostic Approaches • US or CT/MRI • Tumor markers (CA19-9, CEA, etc) • EUS-guided FNA

  20. Cytology of Normal Ductal Epithelium

  21. Cytology of Ductal Adenocarcinoma

  22. Histology of Ductal Adenocarcinoma

  23. Variants of Ductal Adenocarcinoma • Adenosquamous carcinoma • Undifferentiated (Giant Cell) carcinoma • Mucinous, non-cystic carcinoma • Signet-ring cell carcinoma • Undifferentiated carcinoma with osteoclast-like giant cells • Mixed ductal-endocrine carcinoma

  24. Adenosquamous Carcinoma

  25. Ductal Adenocarcinoma • Poor Prognosis: • Mean untreated survival time is 3 months • Mean survival time (after radical resection) is 10-20 months • Overall 5 year survival is 3-4%

  26. Acinar Cell Carcinoma • 1-2% of exocrine pancreatic neoplasms • Most occur in older patients (mean age = 62) • Male:Female 2 • 10-15% of patients develop lipase hypersecretion syndrome (subcutaneous fat necrosis with polyarthralgia)

  27. Cytology of Normal Acinar Cells

  28. Cytology of Acinar Cell Carcinoma

  29. Histology of Acinar Cell Carcinoma

  30. Acinar Cell Carcinoma • Immunostains for pancreatic enzymes may be helpful (esp trypsin and chymotrypsin) • Poor Prognosis: • Median survival time is 8 months • Overall 5 year survival is <10% (particularly short in pts. with lipase hypersecretion syndrome)

  31. Solid Pseudopapillary Tumor • 1-2% of pancreatic exocrine tumors • Predominantly in adolescent and young adult women (mean age = 35); rare in men • Etiology unknown • Typically found incidentally

  32. Cytology of Solid Pseudopapillary Tumor

  33. Histology of Solid Pseudopapillary Tumor Resection Specimen PAS Stain

  34. Solid Pseudopapillary Tumor • Immunostains for a-1-antitrypsin, a-1-antichymotrypsin, b-catenin, and vimentin may be helpful • Very good prognosis • >95% survival following complete resection • Local spread within peritoneal cavity and rare deaths from metastatic disease have ben reported

  35. Pancreatic Endocrine Neoplasms • 1-5% of pancreatic neoplasms • Often occur in middle-aged adults (mean age 55-60) • Many present with symptoms related to hormone production by tumors

  36. Cytology of Pancreatic Endocrine Neoplasms

  37. Pancreatic Endocrine Neoplasms • Immunostains for chromogranin, synaptophysin, and specific hormone products may be helpful • Variable prognosis

  38. Clinical Features of Solid, Cellular Pancreatic Tumors

  39. Cystic Lesions

  40. Cystic Neoplasms of the Pancreas • Must integrate diagnostic modalities • Imaging • Cyst fluid chemistry • Cyst aspiration cytology • Three main questions must be answered • Pseudocyst vs. Neoplastic cyst? • If neoplastic, is it serous or mucinous? • If mucinous, is it malignant?

  41. Serous Cystadenoma • Most common true cystic tumor of pancreas • Usually microcystic • F>M (median age = 66 • Pts. With VHL have similar appearing cysts)

  42. Serous Cystadenoma Cytology and Histology

  43. Serous Cystadenoma • Immunostains for keratins, EMA, MART-1 may be helpful • Are benign neoplasms

  44. Mucinous Cystic Neoplasm • Second most common cystic tumor of pancreas • Usually macrocystic • F>>>>>>>>>>>M (median age = 50) • No communication with pancreatic duct • Presence of ovarian-type stroma

  45. Mucinous Cystic Neoplasm Cytology

  46. Mucinous Cystic Neoplasm • Immunostains for EMA, and CEA (epithelial components) or SMA, vimentin, desmin (stromal components) may be helpful • Prognosis is excellent if tumor completely resected

  47. Differential Diagnosis of Pancreatic Cysts

  48. Summary • EUS alone is very sensitive (80-90%)—particularly well suited for small lesions—but not specific (53%) • When combined with FNA, sensitivity remains high (80-90%) and specificity approaches 100% • EUS guided FNA has greater sensitivity, specificity, and negative predictive value than CT guided biopsy

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