Efficacy and safety of endoscopic drainage of peripancreatic fluid collections: a retrospective multicenter European study.

Background: Endoscopic ultrasound (EUS)-guided transmural drainage allows treatment of symptomatic peripancreatic fluid collections (PFCs), with lumen-apposing metal stents (LAMS) and double pigtail plastic stents (DPPS) being the 2 most frequently used modalities. Methods: Consecutive patients undergoing PFC drainage in 10 European centers were retrospectively retrieved. Technical success (successful deployment), clinical success (satisfactory drainage), rate and type of early adverse events, drainage duration and complications on stent removal were evaluated. Results: A total of 128 patients-92 men (71.9%), age 57.2±11.9 years-underwent drainage, with pancreatic pseudocyst (PC) and walled-off necrosis (WON) in 92 (71.9%) and 36 (28.1%) patients, respectively. LAMS were used in 80 (62.5%) patients and DPPS in 48 (37.5%). Technical success was achieved in 124 (96.9%) of the cases, with no difference regarding either the type of stent (P>0.99) or PFC type (P=0.07). Clinical success was achieved in 119 (93%); PC had a better response than WON (91/92 vs. 28/36, P<0.001), but the type of stent did not affect the clinical success rate (P=0.29). Twenty patients (15.6%) had at least one early complication, with bleeding being the most common (n=7/20, 35%). No difference was detected in complication rate per type of stent (P=0.61) or per PFC type (P=0.1). Drainage duration was significantly longer with DPPS compared to LAMS: 88 (70-112) vs. 35 (29-55.3) days, P<0.001. Conclusions: EUS-guided drainage of PFCs achieves high percentages of technical and clinical success. Drainage using LAMS is of shorter duration, but the complication rate is similar between the 2 modalities.

Endoscopic ultrasonography in pancreatic diseases: advances in tissue acquisition.

Background and study aims Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) improved the diagnostic performance and upgraded the role of endoscopic ultrasonography (EUS) into an interventional modality, able to guide patient management and treatment.This review aimed to highlight the advances, emerging practices, procedural techniques and technological innovations in EUS tissue acquisition in pancreatic diseases. Methods A thorough review of the literature was performed using PubMed to identify articles that describe techniques, advances, and practices in EUS tissue acquisition in gastrointestinal diseases. Conclusion Since the first EUS-FNA procedure, EUS guided-tissue acquisition has been evolving continuously. Development of needles with innovative tip design enabled procurement of larger samples with preserved histological architecture. Moreover, sampling techniques and complementary methods, such as contrast harmonic imaging and EUS-elastography, have been introduced in an effort to improve diagnostic performance and sample adequacy.

Magnetic Resonance Imaging or Endoscopic Ultrasonography for Detection and Surveillance of Pancreatic Neuroendocrine Neoplasms in Patients with Multiple Endocrine Neoplasia Type 1?

Our aim was to compare the clinical utility of Magnetic Resonance Imaging (MRI) and Endoscopic Ultrasonography (EUS) in identifying Pancreatic Neurondocrine Neoplasms (PanNENs) and monitoring size alterations in Multiple Endocrine Neoplasia type 1 (MEN1) patients. Thirty-one MEN1 patients with PanNENs and concurrent screening by EUS and abdominal MRI were included and 129 pancreatic lesions were detected in total. MRI detected fewer lesions than EUS (n=73 vs. 110, p=0.006). MRI sensitivity and specificity compared to EUS at 20 and 10 mm cut-offs of maximal lesion diameter were 96 and 88% (20 mm cut-off) and 90 and 82%(10 mm cut-off), respectively (concordance rates of 97 and 87% and Cohen's kappa=0.912 and 0.718, respectively). Lesions<1 cm were more often detected with EUS (p=0.025). Data from sequential concurrent imaging on lesion growth rate [n=7 (mean±SD: 2 mm/year±3.4 mm vs. 1.9 mm/year±3.6 mm)] over a period of at least two years as well as pathology data in connection to preoperative concurrent imaging were available in a small number of patients (n=7, p=0.933 for mean differences in maximal lesion diameter). MRI of the pancreas was more readily available and less expensive than EUS in an outpatient setting. In conclusion, MRI performs well compared to EUS for the detection and subsequent surveillance of MEN1-related panNENs larger than 10 mm and seems to be cost-effective. Both modalities could be used at initial assessment and MRI alone could be utilized thereafter in patient surveillance. EUS retains its value in surgical planning and the detection of small mostly functional PanNENs.

Recurrence and metastatic potential in Type 1 gastric neuroendocrine neoplasms.

BACKGROUND: The aim of our study was to assess clinico-pathological and biochemical parameters of Type 1 Gastric Neuroendocrine Neoplasms (GNEN1) with respect to tumours propensity for recurrence and metastasis. METHODS: Hospital charts of GNEN1 patients were reviewed at a single tertiary referral centre. RESULTS: We included 114 consecutive patients (74 women; age at baseline 54.5 ± 12.7 years [mean ± SD]) with GNEN1. All tumours (n = 114) were well differentiated; Grade 1 (G1) accounted for 56 patients (49%), whereas 46 (40%) were Grade 2 (G2) and 12 (11%) of unknown Grade. Overall follow-up encompassed 45.3 ± 46 (mean ± SD) months in 84 patients who were subjected to annual surveillance; 44 (52%) developed recurrence in the stomach during follow-up with 22 experiencing multiple recurrences; three (2.6%) presented with metastases in locoregional lymph nodes (n = 3) and/or the liver (n = 2); No metastasis or death was reported during follow-up. Median recurrence-free survival (RFS) was 31 months (95% CI: 7.6-54.4). Among clinico-pathological and biochemical parameters investigated, endoscopic intervention compared with surgery (P-value = .009) and higher serum-gastrin levels (s-gastrin) at baseline and first-year follow-up were associated with recurrence (P-value = .022 and .003 respectively) and also shorter RFS (log-rank P = .009 for type of intervention and .014 for s-gastrin, respectively). Receiver Operator Curve analysis of s-gastrin levels at first-year follow-up for recurrence demonstrated an area under the curve of 0.702. CONCLUSION: Despite the relatively high prevalence of G2 tumours, endoscopically and/or surgically treated GNEN1 remains an indolent disease with a low metastatic propensity and no disease-specific mortality reported in our series. Many patients though will experience local recurrence, warranting long-term endoscopic surveillance with s-gastrin biomarker being a complementary tool in recurrence prediction.

Imaging and Cytopathological Criteria Indicating Malignancy in Mucin-Producing Pancreatic Neoplasms: A Series of 68 Histopathologically Confirmed Cases.

OBJECTIVES: This study aims to evaluate the performance of clinical, imaging, and cytopathological criteria in the identification of high-grade dysplasia/carcinoma (HGD/Ca) in pancreatic mucin-producing cystic neoplasms. METHODS: Sixty-eight consecutive, histopathologically confirmed mucin-producing cystic neoplasms, evaluated by endoscopic ultrasound-guided fine-needle aspiration, were enrolled; specifically, 39 branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), 21 main duct IPMNs, and 8 mucinous cystic neoplasms. The associations between HGD/Ca in histopathology and findings of endoscopic ultrasound and cytology, demographic, lifestyle, and clinical parameters were evaluated, separately in IPMNs and mucinous cystic neoplasms. RESULTS: Age 65 years or more was associated with HGD/Ca in IPMNs. In BD-IPMNs, cyst diameter 3 cm or greater (sensitivity, 68.8%; specificity, 65.2%), a mural nodule (sensitivity, 56.3%; specificity, 78.3%), main pancreatic duct diameter 5 to 9 mm (sensitivity, 50.0%; specificity, 87.0%), and suspicious cytology (sensitivity, 81.3%; specificity, 100%) signaled the presence of HGD/Ca. Similarly, in main duct IPMNs, suspicious cytology predicted HGD/Ca with high sensitivity (88.9%) and excellent specificity (100%). Regarding cytopathological criteria, in BD-IPMNs, HGD/Ca was associated with a high nuclear/cytoplasmic ratio, background necrosis, presence of papillary structures, hypochromatic nuclei, hyperchromatic nuclei, and major nuclear membrane irregularities (thickening and/or indentations). CONCLUSIONS: Clinical, imaging, and cytopathological criteria are useful in the identification of HGD/Ca in IPMNs.

Large adrenal cyst masquerading as a pancreatic cystic tumor: a rare diagnosis based on endoscopic ultrasound.

Adrenal cystic lesions constitute a rare finding and usually are diagnosed incidentally as retroperitoneal cysts during imaging studies. A major issue, especially for the large-sized ones, is their preoperative diagnosis and management, as imaging modalities often fail to detect their exact origin prior to surgery. We report a case of a big adrenal cyst that was mistakenly diagnosed and followed up as pancreatic cystic tail tumor. Our thorough workup, which included endoscopic ultrasound (EUS), managed to delineate an adrenal gland-originated cyst and altered further management of the patient. According to our knowledge, this is the first report in literature in which EUS proved its superiority over other imaging studies in clarifying the origin of an ambiguous big retroperitoneal cyst. We believe that for cases of large retroperitoneal cystic lesions, EUS consists the optimal diagnostic and sampling tool.

Advances and Current Concepts in the Medical Management of Gastroenteropancreatic Neuroendocrine Neoplasms.

Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare and heterogeneous group of tumors presenting as localised or metastatic disease and in a subset with distinct clinical syndromes. Treatment is aimed at controlling the functional syndrome, eradicating the tumor, and/or preventing further tumor growth. Surgery is the treatment of choice in removing the primary tumor and/or reducing tumor burden but cannot be applied to all patients. Somatostatin analogs (SS-analogs) obtain control of functional syndromes in the majority of GEP-neuroendocrine tumors (NETs); phase III trials have shown that SS-analogs can be used as first-line antiproliferative treatment in patients with slow-growing GEP-NETs. The role of the recently approved serotonin inhibitor, telotristat ethyl, and gastrin receptor antagonist, netazepide, is evolving. Streptozotocin-based chemotherapy has been used for inoperable or progressing pancreatic NENs but the orally administered combination of capecitabine/temozolomide is becoming more popular due to its better tolerability and potential effect in other GEP-NENs. Phase III trials have shown efficacy of molecular targeted therapies in GEP-NETs and of radionuclide treatment in patients with midgut carcinoid tumors expressing somatostatin receptors. Most patients will develop disease progression necessitating further therapeutic options. A combination of currently available treatments along with the molecular signature of each tumor will guide future treatment.

Laparoscopic surgery for pancreatic insulinomas: an update.

Insulinomas are the most common functioning neuroendocrine tumors of the pancreas, occurring in almost 1-4 per 1 million persons each year. In contrast to other pancreatic neuroendocrine tumors, they are usually benign and solitary at the time of diagnosis. Due to their benign nature, surgical excision is the treatment of choice, with excellent long-term results. The introduction of minimally invasive techniques in the surgical treatment of insulinoma has been gaining popularity due to shorter length of hospital stay and better cosmetic results, with serious complications being comparable to those of open surgery. Preoperative localization is of paramount importance in the determination of the appropriate surgical approach. Many invasive and non-invasive methods exist for localization of an insulinoma. A combination of these modalities is usually adequate to preoperatively localize the vast majority of tumors. Laparoscopic ultrasound is mandatory to localize these tumors intraoperatively. Despite extensive experience in highly specialized centers producing encouraging results, no randomized trials have been realized to conclusively validate these case series, this partly due to the rarity of insulinoma in the population. In this article we present the current state of laparoscopic management of insulinoma delineating still unanswered issues and we underscore some of the technical details of the most common laparoscopic procedures employed.

Cystic lesions of the pancreas.

Different types of benign or malignant cystic lesions can be observed in the pancreas. Pancreatic cystic lesions are classified under pathology terms into simple retention cysts, pseudocysts and cystic neoplasms. Mucinous cystic neoplasm is a frequent type of cystic neoplasm and has a malignant potential. Serous cystadenoma follows in frequency and is usually benign. Intraductal papillary mucinous neoplasms are the most commonly resected cystic pancreatic neoplasms characterized by dilated segments of the main pancreatic duct and/or side branches, the wall of which is covered by mucus secreting cells. These neoplasms can occupy the pancreatic head or any part of the organ. Solid pseudopapillary tumor is rare, has a low tendency for malignancy, and is usually located in the pancreatic body or tail. Endoscopic ultrasound with the use of fine-needle aspiration and cytology permits discrimination of those lesions. In this review, the main characteristics of those lesions are presented, as well as recommendations regarding their follow up and management according to recent guidelines.

Endoscopic ultrasound staging and guided fine needle aspiration biopsy in patients with resectable pancreatic malignancies: a single-center prospective experience.

BACKGROUND: Endoscopic ultrasound staging and guided fine needle aspiration biopsy (EUS-FNA) is a highly accurate diagnostic method, useful in characterizing pancreatic lesions, obtaining definitive tissue diagnosis in patients with suspected pancreatic lesions, and providing accurate locoregional staging that enhances diagnostic certainty and evaluation of appropriateness of surgical intervention. The aims of this study were to evaluate the preoperative contribution of EUS staging and EUS-FNA in patients with suspected resectable pancreatic malignancies. PATIENTS AND METHODS: A prospective study was conducted in a tertiary referral center. During a 54-month period, a total of 103 consecutive patients were prospectively evaluated with EUS and EUS-FNA. Enrolled in the study were patients with resectable pancreatic lesions, who underwent surgery. RESULTS: The overall operating characteristics of EUSFNA were sensitivity 96.7%, specificity 90.0%, positive predictive value 98.9%, negative predictive value 75.0%, and diagnostic accuracy 96.1%. CONCLUSION: EUS and EUS-FNA have a high accuracy and positive predictive value in the preoperative determination of resectability in pancreatic cancer.

Endoscopic treatment for high-risk bleeding peptic ulcers: a comparison of epinephrine alone with epinephrine plus ethanolamine.

BACKGROUND: Among the various methods of combined endoscopic therapy for high-risk bleeding peptic ulcers the use of adrenaline followed by injection of ethanolamine is minimally demanding in terms of the endoscopic skills and instrumentation but has not been adequately studied. The aim of the present study is to determine whether the injection of ethanolamine in combination with epinephrine compared to injection of epinephrine alone reduces rebleeding rates, need for surgery and overall mortality of patients with bleeding ulcers. METHODS: Patients with ulcers and endoscopic features indicative of a high risk for spontaneous recurrent bleeding were included. High risk was defined by the Forrest classification. Patients were assigned to injection of epinephrine alone (n = 284) or epinephrine plus ethanolamine (n = 131). RESULTS: Initial hemostasis was achieved in 96% of patients in both groups. We detected significant difference in rates of recurrent bleeding, 16.4% vs. 8.7%, for epinephrine and epinephrine plus ethanolamine respectively (P<0.05). When patients were stratified according to Forrest criteria, no significant difference could be found, although there was a trend towards less recurrent bleeding in the case of dual injection therapy in all patient subgroups. There was no significant difference in the proportions of patients who required surgery, 7.7% vs. 7.6% respectively. Mortality was equal (3.2 vs. 3.1%) in the two groups. No major complications from endoscopic treatment were observed in either group. CONCLUSION: Adding ethanolamine to epinephrine for injection treatment of bleeding peptic ulcers decreases bleeding recurrence rates and represents a safe endoscopic treatment for high-risk bleeding ulcers.

Endoscopic ultrasound-guided fine-needle aspiration cytology of pancreatic neuroendocrine tumors: a study of 48 cases.

BACKGROUND: Neuroendocrine tumors (NETs) of the pancreas are relatively uncommon tumors. The objective of this report was to describe the cytopathologic and immunocytochemical features of NETs obtained by endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). METHODS: Forty-eight patients who were diagnosed with pancreatic NETs based on EUS-guided FNA were studied retrospectively (from 2002 to 2007). Clinical data, EUS findings, cytopathologic features, and immunocytochemical stains were reviewed for this study. The final histopathologic diagnosis from each patient also was available for comparison. RESULTS: Forty-eight patients (28 men and 20 women) who ranged in age from 16 years to 86 years were selected and had the following clinical findings: solid or multiple pancreatic masses diagnosed by computed tomography or magnetic resonance imaging studies; simultaneous, suspicious, metastatic masses in the liver, mediastinum, and/or lung; hypoglycemia; multiple endocrine neoplasia type 1 syndrome; von Hippel-Lindau syndrome; and primary NET of the small bowel. EUS findings revealed solid or multiple masses in the pancreatic head/uncinate, or in the pancreatic body/tail, or simultaneously in the pancreatic head/uncinate and body/tail. Cytologically, 40 patients were diagnosed with NETs (histopathogically confirmed), and 8 patients had findings that were suspicious of NETs (2 patients had false-positive results, and 6 patients had histopathologically confirmed NETs). The most helpful cytologic findings for the diagnosis of NET were a richly cellular sample with a monotonous, poorly cohesive population of small or medium-sized cells with granular chromatin (salt and pepper) and plasmacytoid morphology. Immunocytochemistry confirmed the neuroendocrine origin of tumors in 40 patients (material for immunocytochemistry was inadequate in 8 patients). CONCLUSIONS: The current results indicated that EUS-guided FNA is a useful method for the diagnosis of pancreatic NETs. Cytopathologic examination in coordination with immunocytochemistry can provide an accurate diagnosis in most patients.

Endoscopic ultrasound-guided fine needle aspiration biopsy in the diagnosis of gastrointestinal stromal tumors of the stomach. A study of 17 cases.

AIM: The gastrointestinal stromal tumor (GIST) is an uncommon tumor usually diagnosed by endoscopic biopsy or surgical resection. We evaluated the efficacy and accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) biopsy in the diagnosis of GIST. METHOD: Seventeen patients with gastric GIST diagnosed by EUS-guided FNA were included in this study (from 2005 to 2007). A single endosonographer performed all procedures. An attending cytopathologist was present on site to assess specimen adequacy. All tumors were reviewed for EUS, cytomorphologic, histologic and immunohistochemical features. RESULTS: Eleven patients (64.7%) were male and six (35.5%) were female, with a median age of 60.7 years. The clinical indication for EUS-FNA procedure in all patients was the evaluation of submucosal tumor. EUS revealed a solid hypoechoic tumor in all cases with the largest diameter being from 9.5 mm to 70 mm (median diameter 31.9 mm). Cytologic specimen was adequate upon on-site evaluation in all cases, with an average of two passes performed. Spindle cells were present in the cytologic material in all cases and epithelial cells in two cases. Nuclear irregularities and mitoses were not observed. Immunohistochemical (IHC) stain in cell blocks confirmed the c-kit and CD34 positivity in all cases. There were no false negative or false positive findings. CONCLUSIONS: This is the first study of EUS-guided FNA procedure in the diagnosis of gastric GIST in Greece. We demonstrated that EUS-FNA provides accurate diagnosis of GIST in combination with IHC reactivity for c-kit, performed in adequate cytology specimens obtained by FNA.

Endoscopic ultrasound-guided fine-needle aspiration cytology in the diagnosis of intraductal papillary mucinous neoplasms of the pancreas. A study of 8 cases.

CONTEXT: Intraductal papillary mucinous neoplasm (IPMN) is an increasingly recognized neoplasm of the pancreas, accounting for 5% of pancreatic neoplasms, it is considered difficult to diagnose by fine-needle aspiration (FNA) cytology. OBJECTIVE: The aim of this study was to investigate the role of EUS-guided FNA cytology in the diagnosis of IPMN of the pancreas. PATIENTS: Eight cases of surgically proven IPMN with pre-operative endoscopic ultrasound-guided (EUS-guided) FNA cytology were collected for retrospective analysis. MAIN OUTCOME MEASURES: EUS-FNA cytology was performed with the on-site attendance of a cytopathologist in all cases. EUS/clinical findings, macroscopic/microscopic features of cell blocks and smears, and immunocytochemical stains accompanied by histopathologic diagnosis were recorded and studied. RESULTS: EUS revealed hypoechoic masses in the head of pancreas (n=6) and in the body/tail (n=2), measuring from 16.6 to 35.8 mm. In all cases, the hypoechoic mass had a distinctive distribution, involving the main pancreatic duct and/or the associated large branch ducts while intraductal nodules or multiple cysts were detected. Cytological specimens were characterized by a background containing abundant mucin in all cases and rarely by inflammation (neutrophils and histiocytes) (n=4). Neoplastic cells were entrapped in a mucinous background either single or loosely cohesive, and forming papillae in 7 cases. Mucinous epithelium was observed in all cases. Single atypical and irregular clusters were found in 3 cases (which were cytologically described as highly suggestive malignant IPMNs, and were histologically confirmed). Two cases were diagnosed as benign IPMN and, in 3 cases, the biological behavior was not easy to determine by cytology alone (histologically diagnosed as borderline). The histological diagnosis confirmed the FNA cytology diagnosis: 3 malignant IPMNs, 2 benign IPMNs and 3 borderline IPMNs. Immunostains were available in 5 out of 8 cases. Mucin 1 (MUC-1) was positive in 2 cases of malignant IPMN (histologically classified as null type ad intestinal type), mucin 2 (MUC-2) was positive in 3 cases (2 malignant both of the intestinal type, and 1 benign of the intestinal type I) and c-erbB2 was positive in 3 cases (2 benign - null and intestinal type - and 1 malignant null type). CONCLUSIONS: The characteristic pre-operative EUS findings and cytomorphologic features, in addition to the immunocytochemical profile, were accurate indications and coincided with the final/post-operative histological diagnosis of IPMN.

Endoscopic ultrasound-guided fine-needle aspiration cytology diagnosis of solid pseudopapillary tumor of the pancreas: a case report and literature review.

We describe the clinical, imaging and cytopathological features of solid pseudopapillary tumor of the pancreas (SPTP) diagnosed by endoscopic ultrasound-guided (EUS-guided) fine-needle aspiration (FNA). A 17-year-old woman was admitted to our hospital with complaints of an unexplained episodic abdominal pain for 2 mo and a short history of hypertension in the endocrinology clinic. Clinical laboratory examinations revealed polycystic ovary syndrome, splenomegaly and low serum amylase and carcinoembryonic antigen (CEA) levels. Computed tomography (CT) analysis revealed a mass of the pancreatic tail with solid and cystic consistency. EUS confirmed the mass, both in body and tail of the pancreas, with distinct borders, which caused dilation of the peripheral part of the pancreatic duct (major diameter 3.7 mm). The patient underwent EUS-FNA. EUS-FNA cytology specimens consisted of single cells and aggregates of uniform malignant cells, forming microadenoid structures, branching, papillary clusters with delicate fibrovascular cores and nuclear overlapping. Naked capillaries were also seen. The nuclei of malignant cells were round or oval, eccentric with fine granular chromatin, small nucleoli and nuclear grooves in some of them. The malignant cells were periodic acid Schiff (PAS)-Alcian blue (+) and immunocytochemically they were vimentin (+), CA 19.9 (+), synaptophysin (+), chromogranin (-), neuro-specific enolase (-), a1-antitrypsin and a1-antichymotrypsin focal positive. Cytologic findings were strongly suggestive of SPTP. Biopsy confirmed the above cytologic diagnosis. EUS-guided FNA diagnosis of SPTP is accurate. EUS findings, cytomorphologic features and immunostains of cell block help distinguish SPTP from pancreatic endocrine tumors, acinar cell carcinoma and papillary mucinous carcinoma.

EUS-FNA contribution in the identification of autoimmune pancreatitis: a case report.

CONTEXT: Autoimmune pancreatitis is a benign inflammatory disease of the pancreas which mimics pancreatic malignancy both clinically and radiologically. Autoimmune pancreatitis is presented as a diffuse enlargement of the pancreas and as a diffuse irregular narrowing of the main pancreatic duct. CASE REPORT: We report the endoscopic-ultrasound-guided (EUS-guided) fine needle aspiration (FNA) cytology features of a case with autoimmune pancreatitis. A 24-year-old woman with diabetes mellitus was admitted to our hospital after having painless jaundice for 15 days. She denied any alcohol consumption. The biochemical profile showed a marked elevation of bilirubin and hyperglycemia while gamma-GT and CA 19-9 levels were increased fivefold. The immunologic profile of the patient was negative. EUS revealed diffuse hypoechoic pancreatic enlargement (sausage-like appearance of the pancreas). EUS-FNA was performed and the smears were rich in inflammatory cells (mainly lymphoplasmacytes) with sparse epithelial cells lacking atypia, elements which show a strong correlation between the histopathological and cytological findings. The patient underwent steroid therapy which led to resolution of the clinical symptoms and imaging abnormalities within a month. CONCLUSION: The FNA-cytology findings in conjunction with clinical and EUS findings could potentially establish a diagnosis of autoimmune pancreatitis and exclude carcinoma, thus preventing pancreatic resection.