review of literature on clinical pancreatology - The Pancreapedia

which is essential in tumor and nodal staging <strong>of</strong> gastrointestinal cancers. In the recentdecade, however, many therapeutic applications <strong>of</strong> EUS have become possible. Currently,interventional EUS endoscopy involves celiac plexus neurolysis, pseudocyst drainage, andintratumoral fine-needle injection therapy for inoperable pancreatic malignancy. Emergingtechniques include the accurate endoscopic delivery <strong>of</strong> radioactive beads to localize tumortherapy as well as other therapies, such as radi<strong>of</strong>requency ablation or cryotherapy.Diagnostic and therapeutic access to the biliary tree and pancreatic duct is increasingly beingused successfully in failed endoscopic retrograde cholangiopancreatography (ERCP)procedures. A <strong>review</strong> discusses these procedures and several evolving future applications,including vascular access and EUS-guided enteral anastomosis [420].The role <strong>of</strong> EUS to evaluate subtle radiographic abnormalities <strong>of</strong> the pancreas is not welldefined. To assess the yield <strong>of</strong> EUS + FNA for focal or diffuse pancreaticenlargement/fullness seen on abdominal CT scan in the absence <strong>of</strong> discrete mass lesions aretrospective database <strong>review</strong> <strong>of</strong> 691 pancreatic EUS exams were <strong>review</strong>ed. Sixty-nine metinclusion criteria <strong>of</strong> having been performed for focal enlargement or fullness <strong>of</strong> the pancreas.Known chronic pancreatitis, pancreatic calcifications, acute pancreatitis, discrete mass onimaging, pancreatic duct dilation (greater than 4 mm) and obstructive jaundice wereexcluded. FNA was performed in 19/69 (28 %) with 4 new diagnoses <strong>of</strong> pancreaticadenocarcinoma, one metastatic renal cell carcinoma, one metastatic colon cancer, onechronic pancreatitis and 12 benign results. Eight patients had discrete mass lesions on EUS;two were cystic. All malignant diagnoses had a discrete solid mass on EUS. It was concludedthat pancreatic enlargement/fullness is <strong>of</strong>ten a benign finding related to anatomic variation,but was related to malignancy in 9 percent <strong>of</strong> these patients (6/69). EUS should be stronglyconsidered as the next step in the evaluation <strong>of</strong> patients with focal enlargement <strong>of</strong> thepancreas when clinical suspicion <strong>of</strong> malignancy exists [421].Hyperechogenic pancreas suggestive <strong>of</strong> fatty replacement is a common finding duringendoscopic ultrasound. Recent data have implicated pancreatic steatosis as a risk factor forpancreatitis and pancreatic malignancy. Hepatic steatosis has been linked to obesity,increased age, hypertriglyceridemia, hyperglycemia, and hyperinsulinemia. The objective <strong>of</strong>one study was to evaluate the effect <strong>of</strong> body mass index (BMI), hepatic steatosis, and othermetabolic risk factors on HP seen on EUS. Patients with hyperechogenic pancreas wereidentified by a <strong>review</strong> <strong>of</strong> a structured EUS database. The degree <strong>of</strong> echogenicity was judgedrelative to the liver (or spleen if the liver is hyperechogenic) at a similar depth. Variousdemographic and metabolic risk factors were assessed. Chronic pancreatitis was excludedbased on normal findings on prior imaging studies. Each case was age matched and sexmatched to 1 control with a normal pancreas on EUS. By multivariate logistic regressionanalysis, BMI, hepatic steatosis, and alcohol use in excess <strong>of</strong> 14 g/wk were highly associatedwith the presence <strong>of</strong> hyperechogenic pancreas compared with controls. Hepatic steatosiswas the strongest predictor with an odds ratio <strong>of</strong> nearly 14-fold [422].Endoscopic ultrasound-guided fine-needle aspiration biopsiEndoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an effective method forproviding tissue diagnosis, but problems occur when lesions are small or the cytologicaldiagnosis is indeterminate. To prospectively evaluate the utility <strong>of</strong> EUS-FNA in patients withsmall solid pancreatic lesions and those with initial indeterminate or negative cytologicaldiagnosis a total <strong>of</strong> 119 EUS-FNA procedures on 46 patients (mean age 56 years) for 47small solid pancreatic lesions (range 7-30 mm, mean 17 mm in diameter) were studied.FNAs were performed in the presence <strong>of</strong> a cytopathologist. If cytological diagnoses wereindeterminate, EUS-FNA was repeated within 3 weeks. Diagnoses were confirmedhistologically or by follow-up (clinical and imaging: EUS + FNA and CT). On average, 3.7passes were performed. It was not observed any complications. Initial cytological findingswere: malignant 17 (36 %), benign 21 (45 %), and indeterminate 9 (19 %). Eight (78 %) <strong>of</strong>