Dilation of both pancreatic duct and the common bile duct on computed tomography and magnetic resonance imaging scans in patients with or without obstructive jaundice.

OBJECTIVES: "Double-duct sign" (strictures in both common bile duct [CBD] and pancreatic duct [PD] with proximal dilation) on endoscopic retrograde cholangiopancreatography is considered suggestive of pancreatic malignancy. Dilation of CBD and PD is frequently noted on computed tomography/magnetic resonance imaging scans, sometimes found incidentally in patients without jaundice. The prevalence of malignancy in these patients is not established. METHODS: In this retrospective analysis, consecutive patients who underwent endoscopic ultrasound (EUS) at a tertiary care hospital from 2002 to 2006 for suspected pancreatic malignancy and had double-duct sign on imaging were included. We evaluated (1) prevalence of malignancy in patients with or without obstructive jaundice and (2) performance characteristics of EUS-fine-needle aspiration (FNA) in diagnosing malignancy in this setting. RESULTS: A final diagnosis of pancreatic malignancy was made in 142 (85.5%) of 166 patients with and 4 (5.9%) of 68 without obstructive jaundice (P < 0.005). The accuracy of EUS-FNA for diagnosing malignancy in patients with or without obstructive jaundice was 92.8% versus 98.5%. CONCLUSIONS: Dilation of both PD and CBD on computed tomography/magnetic resonance imaging scans is suggestive of pancreatic malignancy. The prevalence of malignancy, however, is markedly lower in patients without obstructive jaundice but is clinically significant and merits further diagnostic evaluation. Endoscopic ultrasound-FNA is highly accurate for diagnosing malignancy in this setting.

Small and potentially resectable focal pancreatic lesions noted on CT/MRI scans in nonjaundiced patients: likelihood of neoplasia and utility of EUS.

BACKGROUND: Management of small and potentially resectable "mass" lesions encountered on CT/MRI scans in patients without obstructive jaundice (ObJ) is rather empirical since there is scant data on likelihood of neoplasm to formulate treatment strategies. We evaluated (1) the prevalence of neoplasm and (2) performance characteristics of EUS-FNA for diagnosing neoplasm in above-mentioned subset of patients. PATIENTS: This is a retrospective analysis of 232 patients (without ObJ) with a focal pancreatic lesion, ≤ 25 mm and potentially resectable on CT/MRI who underwent EUS-FNA from 2002 to 2009. RESULTS: Seventy-five patients (32.3%, 95% CI 26.6, 38.6) were finally diagnosed to have a neoplasm. Four of 92 (4.3%) lesions ≤ 15 mm, 13 of 57(22.8%) lesions 16-20 mm, and 35 of 83 (42.1%) lesions 21-25 mm had an adenocarcinoma. Larger lesion size, older patient age, and h/o recent weight loss significantly increased the likelihood of adenocarcinoma. EUS-FNA had 98.2% overall accuracy and 98.1% NPV with no significant differences based on lesion size. CONCLUSIONS: In nonjaundiced patient with a potentially resectable pancreatic lesion ≤25 mm in size noted on CT/MRI scanning, EUS-FNA can provide useful adjunctive information to optimize the use of surgery and can potentially obviate the need for "wait and watch approach" with repeat imaging in their clinical management.

EUS/EUS-FNA for suspected pancreatic cancer: influence of chronic pancreatitis and clinical presentation with or without obstructive jaundice on performance characteristics.

BACKGROUND: The clinical utility of EUS-FNA is debated in patients with obstructive jaundice (ObJ) because of a very high pretest probability of pancreatobiliary malignancy (PBM) and biliary stent-induced inflammation that can potentially confound EUS-FNA diagnosis. EUS-FNA also has lower accuracy in patients with underlying chronic pancreatitis (CP). OBJECTIVE: Our purpose was to determine the clinical value of EUS-FNA for PBM diagnosis based on clinical presentation and presence of CP. DESIGN: Retrospective analysis of prospective database. SETTING: University hospital. PATIENTS: Patients who underwent EUS-FNA from 2002 to 2006 for suspected PBM based on (1) ObJ with biliary stricture or a mass lesion or (2) abnormal pancreatic imaging by CT/MRI: a focal pancreatic "mass" lesion; dilated pancreatic duct +/- common bile duct; or an enlarged head of pancreas. INTERVENTIONS: EUS was performed with a radial echoendoscope followed by a linear echoendoscope if a focal pancreatic lesion was identified. Fine-needle aspirates were assessed immediately by an attending cytopathologist. MAIN OUTCOME MEASUREMENTS: (1) Prevalence of cancer and (2) performance characteristics of EUS-FNA. RESULTS: PBM was diagnosed in 73.9% of patients with ObJ and biliary stricture or pancreatic mass, in 49.6% of patients with pancreatic mass, and in 7.0% of patients with an enlarged head of pancreas or dilated pancreatic duct +/- common bile duct. The prevalence of PBM was lower in all 3 presentations with associated CP. Both CP and presentation with ObJ lowered performance characteristics of EUS-FNA, but CP did so only in the subset of patients with ObJ. All except 1 false-negative diagnoses were due to cytologic misinterpretation. LIMITATION: Retrospective design. CONCLUSION: Among patients with suspected PBM, the accuracy of EUS-FNA is significantly lower only in a subset of patients with ObJ with underlying CP, largely as a result of difficulty in cytologic interpretation.