Introduction
Pancreatic cystic lesions (PCLs) are common and could vary from a simple benign cyst to a highly malignant cyst.1 Mixed lesions with a solid part and a cystic part are very uncommon. They could be a sign of malignant transformation of a cyst.2 Recently the awareness of these lesions has increased, especially with the increased incidence of asymptomatic pancreatic cysts worldwide primarily due to improved detection by different advanced imaging modalities.3Therefore, the proper diagnosis, differentiation and staging of these lesions are crucial for proper management and avoiding unnecessary treatment of benign ones and missing early treatment of the pre-malignant lesions.4 EUS-guided fine needle biopsy (EUS-FNB) may overcome these limitations of EUS-FNA through acquisition of core tissue samples that provide the ability to assess cyst wall architecture via histology. At this point, ESGE does not recommand use of EUS-FNB for diagnosis of cystic lesions.5
Aims & Methods
Aim: Based to the literature, there are few reports regarding the role of EUS-FNB replacing EUS-FNA in the diagnosis of PCL. This work aims to study the feasibility and safety of EUS-FNB 22G in diagnosis of PCLs.
Methods: Of 640 consecutive EUS-FNB 22G for different lesions between January,2019 and December,2023 at our center. 60 EUS-FNB 22G were done for the patients who underwent EUS-guided sampling of pancreatic cystic or mixed lesions diagnosed by abdominal MRI and/or CT scan. The patients were retrospectively and prospectively followed. All the solid lesions, pancreatic pseudocysts (round, non-septated lesions, presence of internal debris, recent acute pancreatitis or radiologic imaging of chronic pancreatitis) and lesions interposed vessels or main pancreatic duct are excluded from this study.Patients with history of severe hemorrhagic risk (platelet count <50,000 /Lor prothrombin activity <50%) are excluded. We statistically analyse the clinical and technical success rates, in addition to evaluate the diagnostic accuracy of EUS-FNB in differentiating benign and malignant pancreatic cystic lesions. Evaluation of the cyst location, primary diagnosis, adverse events, and comparison between the cytologic fluid analyses and histopathology was performed. Technical success was defined as visible tissue present after biopsy. Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis.
Results
A total of 60 patients (mean age 65.0 ± 12.1, 36.6% females) with 60 PCLs consecutively were referred for EUS-FNB 22G and enrolled in a prospective study. 41/60 (68.3%) lesions were mixed (cystic and tissue) and 19/60 (31.7%) lesions are cystic lesions. The mean lesion size was 32.4 ± 16.6mm. The EUS-FNB 22G procedure was technically and clinically successful in all patients (100%). The mean number of needle passes, as defined as unique transluminal needle insertions into the cystic compartment, was 1.9 ± 0.6. No immediate adverse events were developed after the procedure. In 57/60 (95.0%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. Among the 10 patients who had surgical teatment, the concordance of FNB compared to surgical pathology was noticed.
Conclusion
The diagnosis of pancreatic cystic and mixed lesions with a solid and liquid component can be achieved with fine needle biopsy using a 22-gauge needle in a safe and practicable manner. This method has a great diagnostic yield and does not increase the rate of complications.
References
1. Basturk O, Coban I, Adsay NV. Pancreatic cysts: pathologic classification, differential diagnosis, and clinical implications. Arch Pathol Lab Med. 2009;133:423–438.
2.Da Silva RJ, Oliveira INF, Ribeiro TC da R, Chebli LA, Pace FH de L, Chebli JMF. A Rare Presentation of a Solid Pseudopapillary Neoplasm of the Pancreas. GE Port J Gastroenterol. mars 2022;29(2):135‑8.
3. De Jong K, Bruno MJ, Fockens P. Epidemiology, diagnosis, and management of cystic lesions of the pancreas. Gastroenterol Res Pract. 2012;2012:147465.
4. Okasha H, E Behiry M, Ramadan N, Ezzat R, Yamany A, El-Kholi S, Ahmed G. Endoscopic ultrasound-guided fine needle aspiration in diagnosis of cystic pancreatic lesions. Arab J Gastroenterol. 2019;20:86–90.
5.Polkowski M, Jenssen C, Kaye P, Carrara S, Deprez P, Gines A, et al. Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline - March 2017. Endoscopy. oct 2017;49(10):989‑1006.