Publications by authors named "Laurent Palazzo"

71 Publications

Confocal endomicroscopy for evaluation of pancreatic cystic lesions: a systematic review and international Delphi consensus report.

Endosc Int Open 2020 Nov 22;8(11):E1566-E1581. Epub 2020 Oct 22.

Division of Gastroenterology Mount Auburn Hospital Cambridge, Massachusetts, United States.

The aim of thi systematic review and consensus report is to standardize the practice of endoscopic ultrasound (EUS-guided needle-based confocal laser endomicroscopy (nCLE) for pancreatic cystic lesion (PCL) evaluation. We performed an international, systematic, evidence-based review of the applications, outcomes, procedural processes, indications, training, and credentialing of EUS-nCLE in management of PCLs. Based on available clinical evidence, preliminary nCLE consensus statements (nCLE-CS) were developed by an international panel of 15 experts in pancreatic diseases. These statements were then voted and edited by using a modified Delphi approach. An a priori threshold of 80 % agreement was used to establish consensus for each statement. Sixteen nCLE-CS were discussed. Thirteen (81 %) nCLE-CS reached consensus addressing indications (non-communication PCL meeting criteria for EUS-FNA or with prior non-diagnostic EUS-FNA), diagnostic outcomes (improved accuracy for mucinous PCLs and serous cystadenomas with substantial interobserver agreement of image patterns), low incidence of adverse events (fluorescein-associated and pancreatitis), procedural processes (nCLE duration, manipulation of needle with probe), and training (physician knowledge and competence). Based on a high level of agreement pertaining to expert consensus statements, this report standardizes the practice of EUS-nCLE. EUS-nCLE should be systematically considered when EUS-FNA is indicated for PCL evaluation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1229-4156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7581463PMC
November 2020

Second-generation fine-needle biopsy for autoimmune pancreatitis: ready for prime time?

Authors:
Laurent Palazzo

Endoscopy 2020 11 27;52(11):986-987. Epub 2020 Oct 27.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1231-5101DOI Listing
November 2020

22G Acquire vs. 20G Procore needle for endoscopic ultrasound-guided biopsy of pancreatic masses: a randomized study comparing histologic sample quantity and diagnostic accuracy.

Endoscopy 2020 09 14;52(9):747-753. Epub 2020 May 14.

Digestive Endoscopy Unit, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France.

BACKGROUND : Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) has been suggested for obtaining high quality tissue samples from pancreatic tumors. We performed a multicenter randomized crossover trial comparing EUS-FNB with a 20G Procore needle vs. a 22G Acquire needle. The aims were to compare the quantity of targeted tissue (pancreas) and diagnostic accuracy for the two needles. METHODS : 60 patients admitted for EUS-FNB in three endoscopy units were included. One pass was performed consecutively with each needle, in a randomized order. Histologic material was studied in a blinded manner with respect to the needle. The primary end point was mean cumulative length of tissue core biopsies per needle pass. RESULTS : Final diagnosis was adenocarcinoma (n = 46; 77 %), neuroendocrine neoplasm (n = 11; 18 %), autoimmune pancreatitis (n = 2), and mass-forming chronic pancreatitis (n = 1). The mean cumulative length of tissue core biopsies per needle pass was significantly higher with the 22G Acquire needle at 11.4 mm (95 % confidence interval [CI] 9.0 - 13.8] vs. 5.4 mm (95 %CI 3.8 - 7.0) for the 20G Procore needle ( < 0.001), as was the mean surface area (3.5 mm [95 %CI 2.7 - 4.3] vs. 1.8 mm [95 %CI 1.2 - 2.3];  < 0.001). Diagnostic adequacy and accuracy were 100 % and 87 % with the 22G Acquire needle, and 82 % and 67 % with the 20G Procore needle ( = 0.001 and  = 0.02, respectively). CONCLUSIONS : EUS-guided biopsy of pancreatic masses with the 22G Acquire needle provided more tissue for histologic evaluation and better diagnostic accuracy than the 20G Procore needle.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1160-5485DOI Listing
September 2020

A New Score to Predict the Resectability of Pancreatic Adenocarcinoma: The BACAP Score.

Cancers (Basel) 2020 Mar 25;12(4). Epub 2020 Mar 25.

The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, 31400 Toulouse, France.

Surgery remains the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). Therefore, a predictive score for resectability on diagnosis is needed. A total of 814 patients were included between 2014 and 2017 from 15 centers included in the BACAP (the national Anatomo-Clinical Database on Pancreatic Adenocarcinoma) prospective cohort. Three groups were defined: resectable (Res), locally advanced (LA), and metastatic (Met). Variables were analyzed and a predictive score was devised. Of the 814 patients included, 703 could be evaluated: 164 Res, 266 LA, and 273 Met. The median ages of the patients were 69, 71, and 69, respectively. The median survival times were 21, 15, and nine months, respectively. Six criteria were significantly associated with a lower probability of resectability in multivariate analysis: venous/arterial thrombosis ( = 0.017), performance status 1 ( = 0.032) or ≥ 2 ( = 0.010), pain ( = 0.003), weight loss ≥ 8% ( = 0.019), topography of the tumor (body/tail) ( = 0.005), and maximal tumor size 20-33 mm ( < 0.013) or >33 mm ( < 0.001). The BACAP score was devised using these criteria (http://jdlp.fr/resectability/) with an accuracy of 81.17% and an area under the receive operating characteristic (ROC) curve of 0.82 (95% confidence interval (CI): 0.78; 0.86). The presence of pejorative criteria or a BACAP score < 50% indicates that further investigations and even neoadjuvant treatment might be warranted. Trial registration: NCT02818829.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/cancers12040783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7226323PMC
March 2020

An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions.

Endosc Ultrasound 2019 Nov-Dec;8(6):418-427

Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.

Background And Objectives: Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field.

Methods: A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized.

Results: Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year.

Conclusion: Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/eus.eus_61_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927137PMC
September 2019

Impact of needle-based confocal laser endomicroscopy on the therapeutic management of single pancreatic cystic lesions.

Surg Endosc 2020 06 13;34(6):2532-2540. Epub 2019 Aug 13.

Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, 4 rue Jacqueline Auriol, 69008, Lyon, France.

Background And Aim: The diagnosis and therapeutic management of large single pancreatic cystic lesions (PCLs) represent major issues for clinicians and essentially rely on endoscopic ultrasound fine-needle aspiration (EUS-FNA) findings. Needle-based confocal laser endomicroscopy (nCLE) has high diagnostic performance for PCLs. This study aimed to evaluate the impact of nCLE on the therapeutic management of patients with single PCLs.

Methods: Retrospective and comparative study. Five independent pancreatic disease experts from tertiary hospitals independently reviewed data from a prospective database of 206 patients with single PCL, larger than 2 cm and who underwent EUS-FNA and nCLE. Two evaluations were performed. The first one included the sequential review of clinical information, EUS report and FNA results. The second one included the same data + nCLE report. Participants had to propose a therapeutic management for each case.

Results: The addition of nCLE to EUS-FNA led to significant changes in therapeutic management for 28% of the patients (p < 0.001). nCLE significantly increased the interobserver agreement of 0.28 (p < 0.0001), from 0.36 (CI 95% 0.33-0.49) to 0.64 (CI 95% 0.61-0.67). nCLE improved the rates of full agreement among the five experts of 24% (p < 0.0001), from 30 to 54%. With nCLE, the surveillance rate of benign SCAs fell by 35%, from 40 (28/70) to 5% (4/76).

Conclusion: The addition of nCLE to EUS-FNA significantly improves reliability of PCL diagnosis and could impact the therapeutic management of patients with single PCLs. ClinicalTrials.gov number, NCT01563133.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-019-07062-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214514PMC
June 2020

A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction.

Endosc Ultrasound 2018 Nov-Dec;7(6):356-365

Department of Endoscopy, Yokohama City University School of Medicine, Yokohama, Japan.

Background And Objectives: EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed.

Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD.

Results: Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the first choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended.

Conclusion: This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/eus.eus_53_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6289007PMC
December 2018

Needle-based confocal laser endomicroscopy of pancreatic cystic lesions: a prospective multicenter validation study in patients with definite diagnosis.

Endoscopy 2019 09 22;51(9):825-835. Epub 2018 Oct 22.

Unité d'Échoendoscopie et d'Endoscopie d'Oncologie Digestive, Institut Paoli Calmettes, Marseille, France.

Background: Needle-based confocal laser endomicroscopy (nCLE) enables observation of the inner wall of pancreatic cystic lesions (PCLs) during an endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). This study prospectively evaluated the diagnostic performance of nCLE for large, single, noncommunicating PCLs using surgical histopathology or EUS-FNA cytohistopathology as a reference diagnosis.

Methods: From April 2013 to March 2016, consecutive patients referred for EUS-FNA of indeterminate PCLs without evidence of malignancy or chronic pancreatitis were prospectively enrolled at five centers. EUS-FNA and nCLE were performed and cystic fluid was aspirated for cytohistopathological and carcinoembryonic antigen (CEA) analysis. The diagnostic performance of nCLE was assessed against the reference standard and compared with that of EUS and CEA. This study was registered on ClinicalTrials.gov (NCT01563133).

Results: 206 patients underwent nCLE and 78 PCLs (mean size 40 mm, range 20 - 110 mm) had reference diagnoses (53 premalignant and 25 benign PCLs). Post-procedure pancreatitis occurred in 1.3 % of the patients. nCLE was conclusive in 71 of the 78 cases (91 %). The sensitivies and specifities of nCLE for the diagnosis of serous cystadenoma, mucinous PCL, and premalignant PCL were all ≥ 0.95 (with 95 % confidence interval from 0.85 to 1.0). The AUROC was significantly larger for nCLE than for CEA or EUS.

Conclusions: nCLE had excellent diagnostic performance that surpassed that of CEA and EUS for the diagnosis of large, single, noncommunicating PCLs. The nCLE procedure should be considered in patients with indeterminate PCLs to ensure a more specific diagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-0732-5356DOI Listing
September 2019

A prospective clinical and biological database for pancreatic adenocarcinoma: the BACAP cohort.

BMC Cancer 2018 Oct 16;18(1):986. Epub 2018 Oct 16.

The Department of Gastroenterology and Pancreatology, CHU - Rangueil and the University of Toulouse, 1 avenue Jean Poulhès, TSA 50032, 31059, Toulouse Cedex 9, France.

Background: The prognosis for pancreatic cancer remains poor despite diagnostic advances and treatments with new chemotherapeutic regimens. The five year survival rate remains below 3%. Consequently, there is an urgent need for new treatments to significantly improve the prognosis. In addition, there is a big gap in terms of the screening, early diagnosis and prevention of pancreatic cancer the incidence of which is increasing dramatically.

Methods: Design: the BACAP cohort is a prospective multicenter pancreatic cancer cohort (pancreatic ductal carcinoma) with clinical and multiple biological samples; Participating centers: 15 French academic and private hospitals; Study Population: any cytologically and/or histologically proven pancreatic carcinoma regardless of the stage (resectable, borderline, locally advanced or metastatic) or treatment (surgery, palliative chemotherapy, best supportive care). At least 1500 patients will be included. Clinical data collected include: disease presentation, epidemiological and social factors, baseline biology, radiology, endoscopic ultrasound, staging, pathology, treatments, follow-up (including biological and radiological), and survival. All these data are collected and stored through an e-observation system at a centralized data center. Biological samples and derived products (i.e. before any treatment): blood, saliva, endoscopic ultrasound-guided fine needle aspiration materials from the primary tumor, fine needle biopsy of metastases and surgically resected tissue. DNA and RNA are extracted from fine needle aspiration materials and are quantified and characterized for quality. Whole blood, plasma and serum are isolated from blood samples. Frozen tissues were specifically allocated to the cohort. All derived products and saliva are stored at - 80 °C. Main end-points: i) to centralize clinical data together with multiple biological samples that are harmonized in terms of sampling, the post sampling process and storage; ii) to identify new molecular markers for the diagnosis, prognosis and possibly the predictive response to pancreatic cancer surgery and or chemotherapy.

Discussion: The BACAP cohort is a unique prospective biological clinical database that provides the opportunity to identify correlations between the presence/expression of a broad panel of biomarkers (DNA, RNA, miRNA, proteins, etc.), epidemiological and social data, various clinical situations, various stages and the differentiation of the tumor, treatments and survival.

Trial Registration: ClinicalTrials.gov Identifier: NCT02818829 . Registration date: June 30, 2016.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12885-018-4906-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6191891PMC
October 2018

Contrast harmonic EUS for the prediction of pancreatic neuroendocrine tumor aggressiveness (with videos).

Gastrointest Endosc 2018 Jun 8;87(6):1481-1488. Epub 2018 Jan 8.

Department of Endoscopy, Trocadéro Clinic, Paris, France.

Background And Aims: Contrast harmonic EUS (CH-EUS) has the ability to depict tumor microvasculature. Decreased microvascular density has been identified as a factor associated with tumor aggressiveness. We aimed to study the accuracy of CH-EUS for the prediction of pancreatic neuroendocrine tumor (PNET) aggressiveness.

Methods: Between June 2009 and March 2015, all consecutive patients with histology-proven PNETs and CH-EUS examination were included. Nine endosonographers blindly analyzed all videos. CH-EUS tumor aggressiveness was defined as a heterogeneous enhancement at the early arterial phase. The final diagnosis of tumor aggressiveness was defined as follows: G3 tumors, morphologic and/or histologic findings of metastatic disease in G1/G2 tumors. Diagnostic values were calculated. Intratumoral microvascular density and fibrosis were assessed on pathologic specimens.

Results: Eighty-one tumors were included, of which 26 were aggressive (32.1%). In CH-EUS 35 tumors (43.2%) had a heterogeneous enhancement. The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CH-EUS for the diagnosis of tumor aggressiveness were 86%, 96%, 82%, 71%, and 98%, respectively. The interobserver agreement among the 9 endosonographers was good (k = .66). The intraobserver agreement was excellent for the junior (κ = .83) and senior (κ = .82) endosonographers. Heterogeneous tumors at CH-EUS corresponded to fewer vascular and more fibrotic tumors (P < .01).

Conclusions: CH-EUS is accurate in the prediction of PNET aggressiveness and could be a decision-making element in their management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2017.12.033DOI Listing
June 2018

Low diagnostic yield of transduodenal endoscopic ultrasound-guided fine needle biopsy using the 19-gauge Flex needle: A large multicenter prospective study.

Endosc Ultrasound 2017 Nov-Dec;6(6):402-408

Digestive Endoscopy Unit, Catholic University, Rome, Italy.

Background And Objectives: Previous limited experiences have reported the 19-gauge flexible needle to be highly effective in performing endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for transduodenal lesions. We designed a large multicenter prospective study with the aim at evaluating the performance of this newly developed needle.

Patients And Methods: Consecutive patients with solid lesions who needed to undergo EUS sampling from the duodenum were enrolled in 6 tertiary care referral centers. Puncture of the lesion was performed with the 19-gauge flexible needle (Expect™ and Slimline Expect™ 19 Flex). The feasibility, procurement yield, and diagnostic accuracy were evaluated.

Results: Totally, 246 patients (144 males, mean age 65.1 ± 12.7 years) with solid lesions (203 cases) or enlarged lymph nodes (43 cases) were enrolled, with a mean size of 32.6 ± 12.2 mm. The procedure was technically feasible in 228 patients, with an overall procurement yield of 76.8%. Two centers had suboptimal procurement yields (66.7% and 64.2%). Major complications occurred in six cases: two of bleeding, two of mild acute pancreatitis, one perforation requiring surgery, and one duodenal hematoma. Considering malignant versus nonmalignant disease, the sensitivity, specificity, positive/negative likelihood ratios, and diagnostic accuracy were 70.7% (95% confidence interval [CI]: 64.3-76.6), 100% (95% CI: 79.6-100), 35.3 (95% CI: 2.3-549.8)/0.3 (95% CI: 0.2-0.4), and 73.6% (95% CI: 67.6-79). On multivariate analysis, the only determinant of successful EUS-FNB was the center in which the procedure was performed.

Conclusions: Our results suggest that the use of the 19-gauge flexible needle cannot be widely advocated and its implementation should receive local validation after careful evaluation of both the technical success rates and diagnostic yield.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/eus.eus_54_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752763PMC
December 2017

A health economic evaluation of needle-based confocal laser endomicroscopy for the diagnosis of pancreatic cysts.

Endosc Int Open 2017 Oct 9;5(10):E987-E995. Epub 2017 Oct 9.

Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France.

Background And Study Aims:  The low sensitivity of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), especially for the diagnosis of serous cystadenomas (SCAs), can be associated with diagnostic uncertainty that can regularly lead to unnecessary surgical procedures. Needle-based confocal laser endomicroscopy (nCLE) used with EUS-FNA improves diagnostic accuracy, helping to reduce unnecessary surgery and patient follow-up. This study was conducted to evaluate the economic benefit of EUS-FNA + nCLE.

Patients And Methods:  Probabilities used were derived from two studies representative of the two diagnostic strategies: a retrospective analysis of patients diagnosed by EUS-FNA alone and a prospective study of patients diagnosed by EUS-FNA + nCLE. Costs were based on French healthcare system rates; both private and public sector rates were included. A decision tree structure model used these probabilities and costs for two hypothetical cohorts of 1000 patients.

Results:  EUS-FNA + nCLE resulted in a reduction of 23 % in the total rate of surgical intervention, which translated to a reduction in clinical costs of 13 % (public sector) and 14 % (private sector). Additionally, the reduced rate of surgery would save the lives of 4 in 1000 patients. A stochastic sensitivity analysis using 100 simulations showed that in all cases the number of interventions was less for EUS-FNA + nCLE than for EUS-FNA. There was also a reduction in the incidence of false negatives using EUS-FNA + nCLE.

Conclusions:  EUS-FNA + nCLE results in significant economic benefits by reducing the incidence of misdiagnosis through improved diagnostic accuracy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0043-117947DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633408PMC
October 2017

Magnetic Resonance Imaging Compared with Rectal Endoscopic Sonography for the Prediction of Infiltration Depth in Colorectal Endometriosis.

J Minim Invasive Gynecol 2017 Nov - Dec;24(7):1218-1226. Epub 2017 Aug 9.

Department of Obstetrics and Gynecology, Bichat Hospital, Paris, France; Paris Diderot University, Paris, France.

Study Objective: To compare the accuracies of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) in the prediction of the infiltration depth of colorectal endometriosis.

Design: A retrospective cohort study (Canadian Task Force classification II-2).

Setting: A university teaching hospital.

Patients: Forty patients with symptomatic deep infiltrating endometriosis (DIE) of the rectum who underwent colorectal resection were included.

Interventions: All patients underwent abdominopelvic MRI and RES preoperatively to assess the infiltration depth of colorectal endometriosis, and segmental resection of the rectosigmoid by laparoscopy was performed if RES showed bowel invasion. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (LRs), and intermethod agreement were calculated for DIE muscularis and submucosal/mucosal infiltration confirmed by histopathological analysis.

Measurements And Main Results: For MRI detection of DIE muscularis infiltration, the sensitivity, specificity, PPV, NPV, and negative LR were 68%, 100%, 100%, 20%, and 0.32, respectively. For the MRI detection of DIE submucosal/mucosal involvement, the sensitivity, specificity, PPV, NPV, and positive and negative LRs were 47%, 81%, 69%, 63%, 2.49, and 0.65, respectively. The PPV of RES detection of DIE muscularis infiltration was 93%. For the RES detection of DIE submucosal/mucosal layers, the sensitivity, specificity, PPV, NPV, and positive and negative LRs were 79%, 48%, 58%, 71%, 1.51, and 0.44, respectively.

Conclusion: In the current study, MRI is valuable for detecting endometriosis of the rectum but is less accurate in detecting submucosal/mucosal involvement than RES. Magnetic resonance imaging was not successful for preoperative determination of segmental resection versus a more conservative approach. When bowel involvement is detected by MRI, RES is not essential. When symptoms suggest DIE in patients without intestinal lesions detected by MRI, RES is necessary to exclude bowel invasion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jmig.2017.07.026DOI Listing
April 2018

Catastrophic antiphospholipid syndrome (CAPS)-induced ischemic pancreatic ducts injury mimicking intraductal papillary mucinous neoplasm (IPMN).

Semin Arthritis Rheum 2018 02 10;47(4):565-568. Epub 2017 Jul 10.

Université Paris-Descartes, Paris, France; AP-HP, Hôpital Cochin, Centre de référence des maladies auto-immunes et systémiques rares, Service de Médecine Interne, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; INSERM U 1153, Center for Epidemiology and Statistics, Sorbonne Paris Cité (CRESS) Paris, France. Electronic address:

Objectives: Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening disease characterized by multiple small-vessel occlusions of rapid onset. Ischemic pancreatic duct lesions secondary to CAPS have never been reported.

Methods: We describe 4 patients who presented lesions suspected to be intraductal papillary mucinous neoplasm (IPMN) of the pancreas following a CAPS.

Results: All patients had a history of CAPS months or years before the IPMN diagnosis. They had abdominal pain or abnormal liver test results and had undergone radiography. In a 36-year-old man, endoscopic ultrasonography and magnetic resonance cholangiopancreatography demonstrated parietal thickening, stenoses and dilatations of the main pancreatic duct, which suggested IPMN. A pancreatic resection was performed because of presumed risk of malignancy. Histology revealed pancreatitis and thrombosis of small pancreatic vessels but no IPMN. The 3 other cases had lesions consistent with IPMN disclosed on MRI. From the first case experience, regular radiography surveillance was decided for the 3 other patients. After more than 4 years of follow-up, lesions remained unchanged.

Conclusion: Physicians must be aware that these lesions may be encountered in CAPS and may closely mimic IPMN, with subsequent risk of performing unnecessary pancreatectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.semarthrit.2017.07.001DOI Listing
February 2018

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy in solid pancreatic masses.

Endoscopy 2016 Oct 30;48(10):892-8. Epub 2016 Aug 30.

Department of Gastroenterology, Ramsay Générale de Santé, Hôpital privé Jean Mermoz, Lyon, France.

Background And Study Aims: The differential diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently suboptimal in centers that are not equipped with rapid on-site evaluation. Needle-based confocal laser endomicroscopy (nCLE) enables real-time in vivo microscopic imaging during endoscopy. This study aimed to describe nCLE interpretation criteria for the characterization of pancreatic masses, with histopathological correlation, and to perform the first validation of these criteria.

Patients And Methods: A total of 40 patients were evaluated by EUS-FNA combined with nCLE for the diagnosis of pancreatic masses. Final diagnosis was based on EUS-FNA histology and follow-up at 1 year. Five unblinded examiners defined nCLE criteria for adenocarcinoma, chronic pancreatitis, and neuroendocrine tumor (NET) using a set of video sequences from 14 patients with confirmed pathology (Step 1). These criteria were retrospectively validated by four independent, blinded examiners using sequences from 32 patients (Step 2).

Results: nCLE criteria were described for adenocarcinoma (dark cell aggregates, irregular vessels with leakages of fluorescein), chronic pancreatitis (residual regular glandular pancreatic structures), and NET (black cell aggregates surrounded by vessels and fibrotic areas). These criteria correlated with the histological features of the corresponding lesions. In the validation review, a conclusive nCLE result was obtained in 75 % of cases (96 % correct). Statistical evaluation provided promising results, with high specificity, and negative and positive predictive values for all types of pancreatic masses.

Conclusion: Considering the low negative predictive value of EUS-FNA, nCLE could help to rule out malignancy after a previous inconclusive EUS-FNA. Larger studies are required to confirm these findings and to establish the role of nCLE in the diagnosis of pancreatic masses.

Trial Registration: ClinicalTrials.gov (NCT01563133).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0042-112573DOI Listing
October 2016

The clinical impact of ultrasound contrast agents in EUS: a systematic review according to the levels of evidence.

Gastrointest Endosc 2016 Oct 14;84(4):587-596.e10. Epub 2016 Jun 14.

Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy.

Background And Aims: The use of contrast-harmonic EUS (CH-EUS) in routine clinical practice is increasing rapidly but is not yet standardized. We present the levels of evidence (LEs) found in the literature to put its clinical outcomes in the appropriate perspective.

Methods: We conducted a systematic review of the available English-language articles. The LEs were stratified according to the Oxford Centre for Evidence-Based Medicine guidelines.

Results: Overall, 210 articles were included and presented according to different pathologic conditions. For pancreatic solid neoplasms, the pooled sensitivity and specificity in the diagnosis of pancreatic carcinoma were very high (LE 1); quantitative analysis and guidance of FNA were reported as investigational research (LE 2-3). For pancreatic cystic lesions, the identification of neoplastic solid components as hyperenhanced lesions represented a promising application of CH-EUS (LE 2). For lymph nodes, CH-EUS increased the diagnostic yield of B-mode EUS for the detection of malignancy (LE 2). For submucosal tumors, CH-EUS seemed useful for differential diagnosis and risk stratification (LE 2-3). For other applications, differential diagnosis of gallbladder and vascular abnormalities by CH-EUS were reported (LE 2-3).

Conclusions: The LEs of CH-EUS in the literature have evolved from the initial descriptive studies to multicenter and prospective trials, and even meta-analyses. The differential diagnosis between benign and malignant lesions is the main field of application of CH-EUS. With regard to pancreatic solid neoplasms, the concomitant use of both CH-EUS and EUS-FNA may have additive value in increasing the overall accuracy by overcoming the false-negative results associated with each individual technique. Other applications are promising but still investigational.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2016.06.006DOI Listing
October 2016

In vivo characterization of pancreatic cystic lesions by needle-based confocal laser endomicroscopy (nCLE): proposition of a comprehensive nCLE classification confirmed by an external retrospective evaluation.

Surg Endosc 2016 06 1;30(6):2603-12. Epub 2015 Oct 1.

Department of Hepato-gastroenterology, Institut Paoli Calmettes, Marseille, France.

Background And Aims: The differential diagnosis of solitary pancreatic cystic lesions is sometimes difficult. Needle-based confocal laser endomicroscopy (nCLE) performed during endoscopic ultrasound-fine-needle aspiration (EUS-FNA) enables real-time imaging of the internal structure of such cysts. Criteria have already been described for serous cystadenoma and intraductal papillary mucinous neoplasm (IPMN). The aims of the study were to determine new nCLE criteria for the diagnosis of pancreatic cystic lesions, to propose a comprehensive nCLE classification for the characterization of those lesions, and to carry out a first external retrospective validation .

Methods: Thirty-three patients with a lone pancreatic cystic lesion were included (CONTACT 1 study). EUS-FNA was combined with nCLE. Diagnosis was based on either pathology result (Group 1, n = 20) or an adjudication committee consensus (Group 2, n = 13). Six investigators, unblinded, studied cases from Group 1 and identified nCLE criteria for mucinous cystic neoplasm (MCN), pseudocyst (PC), and cystic neuroendocrine neoplasm (NEN). Four external reviewers assessed, blinded, the yield and interobserver agreement for the newly identified (MCN, PC) and previously described (IPMN, SC) criteria in a subset of 31 cases.

Results: New nCLE criteria were described for MCN (thick gray line), PC (field of bright particles), and cystic NEN (black neoplastic cells clusters with white fibrous areas). These criteria correlated with the histological features of the corresponding lesions. In the retrospective validation, a conclusive nCLE result was obtained for 74 % of the cases (87 % "true" and 13 % "false" with respect to the final diagnosis). On this limited case series, the nCLE criteria showed a trend for high diagnostic specificity (>90 % for mucinous cysts, 100 % for non-mucinous cysts).

Conclusions: Based on this newly completed atlas of interpretation criteria, nCLE could facilitate the diagnosis of pancreatic cystic lesion types.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-015-4510-5DOI Listing
June 2016

Endoscopy and Endoscopic Ultrasound in Assessing and Managing Neuroendocrine Neoplasms.

Front Horm Res 2015 14;44:88-103. Epub 2015 Aug 14.

National Neuroendocrine Tumour Service, St. Vincent's University Hospital, Dublin, Ireland.

Despite advances in radiological and metabolic imaging, standard axial endoscopy and endoscopic ultrasonography (EUS) still play a pivotal role in a number of neuroendocrine neoplasms (NENs) of the gastrointestinal and duodenopancreatic region. Upper gastrointestinal endoscopy is essential for the detection and characterization of NEN up to the angle of Treitz (esophageal, gastric and duodenal). Ileocolonoscopy allows the assessing and diagnosing of rectal, colonic and very occasionally distal ileal lesions. Endoscopic assessment is the mainstay for diagnosing gastric NENs associated with hypergastrinemia, but is also useful in detecting and diagnosing duodenal NENs (both functional and nonfunctional) and ampullary NENs. As rectal NENs are on the increase, standard colonoscopy (often combined with endorectal EUS) is also useful in detecting and treating small rectal NENs. EUS is the modality of choice for diagnosing pancreatic NENs and for locoregional staging of esophageal, gastric, duodenal, pancreatic and rectal NENs. This chapter will expand on the diagnostic and therapeutic role of endoscopy and EUS in the field of gastrointestinal and pancreatic NENs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000382062DOI Listing
June 2016

Can pancreatic neuroendocrine tumour biopsy accurately determine pathological characteristics?

Dig Liver Dis 2015 Nov 20;47(11):973-7. Epub 2015 Jun 20.

Pancreatology Department, Beaujon Hospital, AP-HP, Clichy, Paris-Diderot University, France; Inserm U773-CRB3, Paris-Diderot University, Paris, France.

Background: Assessment of the pathological characteristics of pancreatic neuroendocrine tumours is crucial for appropriate management. We compared preoperative pathological data with surgical specimens for accuracy.

Methods: Surgical patients with pancreatic neuroendocrine tumours who underwent preoperative endoscopic ultrasound-guided fine needle aspiration of the primary tumour or biopsy of liver metastasis were retrospectively included. Tumour differentiation and the Ki67 proliferation index on biopsies were compared with pancreatic specimens.

Results: Fifty-seven patients were included. A preoperative biopsy of the primary tumour or of a liver metastasis was obtained in 48 and 9 patients respectively. Tumour differentiation was high in 98%, and poor in 2% on biopsy and high in 100% of surgical specimens. Ki67 index values were 0 (0-19) and 2 (0-15) on biopsy and surgical specimens (p=0.01). Correlation between preoperative and surgical findings was stronger for liver (r=0.62, p=0.001) than for pancreas (r=0.23, p=0.11). Correlation for pancreas varied according to the tumour pattern: solid (r=0.24, p=0.16), mixed (r=0.91, p=0.0036) or cystic (r=0.04, p=0.89). Tumour grade was different between pancreatic biopsies and surgical specimens, for grade 1 (63% vs 37%) and grade 2 (28% vs 72%), p=0.0007.

Conclusions: Tumour grade assessment is accurate in biopsies of liver metastases of pancreatic neuroendocrine tumours, while pancreatic fine-needle aspiration biopsies are less accurate.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.dld.2015.06.005DOI Listing
November 2015

EUS-derived criteria for distinguishing benign from malignant metastatic solid hepatic masses.

Gastrointest Endosc 2015 May 7;81(5):1188-96.e1-7. Epub 2015 Feb 7.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

Background: Detection of hepatic metastases during EUS is an important component of tumor staging.

Objective: To describe our experience with EUS-guided FNA (EUS-FNA) of solid hepatic masses and derive and validate criteria to help distinguish between benign and malignant hepatic masses.

Design: Retrospective study, survey.

Setting: Single, tertiary-care referral center.

Patients: Medical records were reviewed for all patients undergoing EUS-FNA of solid hepatic masses over a 12-year period.

Interventions: EUS-FNA of solid hepatic masses.

Main Outcome Measurements: Masses were deemed benign or malignant according to predetermined criteria. EUS images from 200 patients were used to create derivation and validation cohorts of 100 cases each, matched by cytopathologic diagnosis. Ten expert endosonographers blindly rated 15 initial endosonographic features of each of the 100 images in the derivation cohort. These data were used to derive an EUS scoring system that was then validated by using the validation cohort by the expert endosonographer with the highest diagnostic accuracy.

Results: A total of 332 patients underwent EUS-FNA of a hepatic mass. Interobserver agreement regarding the initial endosonographic features among the expert endosonographers was fair to moderate, with a mean diagnostic accuracy of 73% (standard deviation 5.6). A scoring system incorporating 7 EUS features was developed to distinguish benign from malignant hepatic masses by using the derivation cohort with an area under the receiver operating curve (AUC) of 0.92; when applied to the validation cohort, performance was similar (AUC 0.86). The combined positive predictive value of both cohorts was 88%.

Limitations: Single center, retrospective, only one expert endosonographer deriving and validating the EUS criteria.

Conclusion: An EUS scoring system was developed that helps distinguish benign from malignant hepatic masses. Further study is required to determine the impact of these EUS criteria among endosonographers of all experience.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2014.10.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574178PMC
May 2015

Irregular narrowing of the main pancreatic duct in association with a wall thickening is a key sign at endoscopic ultrasonography for the diagnosis of autoimmune pancreatitis.

Pancreas 2015 Mar;44(2):211-5

From the *Department of Gastroenterology-Pancreatology, Beaujon Hospital, Paris VII Denis Diderot University, Clichy; †Department of Endoscopy, Trocadero Clinic, Paris; ‡Department of Pathology, Gustave Roussy Institute, Villejuif; §Department of Pathology, Bichat Hospital, and ¶Department of Radiology, Beaujon Hospital, Paris VII Denis Diderot University, Clichy, France.

Objectives: The aim of this study was to assess the accuracy of key signs identified at endoscopic ultrasonography in diagnosing an autoimmune pancreatitis (AIP).

Methods: Between January 2007 and December 2011, a retrospective case-control study was conducted in 177 patients with AIP (n = 30), pancreatic adenocarcinoma (n = 42), pancreatic neuroendocrine tumor (n = 21), alcoholic chronic pancreatitis (n = 32), and symptomatic common bile duct stones (n = 52).

Results: An irregular narrowing of the main pancreatic duct in association with a wall thickening was seen in 28 of 30 AIP, 1 of 42 pancreatic adenocarcinoma, 0 of 21 pancreatic neuroendocrine tumor, 0 of 32 alcoholic chronic pancreatitis, and 0 of 52 common bile duct stones (P < 0.05). Sensitivity, specificity, positive and negative predictive values, and overall diagnostic accuracy of this sign for the diagnosis of AIP were 93%, 99.3%, 96.3%, 98.6%, and 98.3%, respectively. In type 1 AIP, hyperechoic parietal thickening was more frequent (92.3% vs 33.3%, P < 0.05). In type 2 AIP, hypoechoic parietal thickening was more frequent (83.3% vs 23.1%, P < 0.05).

Conclusions: An irregular narrowing of the main pancreatic duct in association with a wall thickening seen at endoscopic ultrasonography is accurate in diagnosing AIP. The type of echogenicity of the thickening is well correlated with the type of AIP.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPA.0000000000000242DOI Listing
March 2015

A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy.

Endoscopy 2015 Jan 17;47(1):26-32. Epub 2014 Oct 17.

Department of Hepatogastroenterology, Institut Paoli Calmettes, Marseille, France.

Background And Study Aims: The differential diagnosis of solitary pancreatic cystic lesions is frequently difficult. Needle-based confocal laser endomicroscopy (nCLE) performed during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a new technology enabling real-time imaging of the internal structure of such cysts. The aim of this pilot study was to identify and validate new diagnostic criteria on nCLE for pancreatic cystic lesions.

Patients And Methods: A total of 31 patients with a solitary pancreatic cystic lesion of unknown diagnosis were prospectively included at three centers. EUS-FNA was combined with nCLE. The final diagnosis was based on either a stringent gold standard (surgical specimen and/or positive cytopathology) or a committee consensus. Six nonblinded investigators reviewed nCLE sequences from patients with the most stringent final diagnosis, and identified a single feature that was only present in serous cystadenoma (SCA). The findings were correlated with the pathology of archived specimens. After a training session, four blinded independent observers reviewed a separate independent video set, and the yield and interobserver agreement for the criterion were assessed.

Results: A superficial vascular network pattern visualized on nCLE was identified as the criterion. It corresponded on pathological specimen to a dense and subepithelial capillary vascularization only seen in SCA. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of this sign for the diagnosis of SCA were 87 %, 69 %, 100 %, 100 %, and 82 %, respectively. Interobserver agreement was substantial (κ = 0.77).

Conclusion: This new nCLE criterion seems highly specific for the diagnosis of SCA. The visualization of this criterion could have a direct impact on the management of patients by avoiding unnecessary surgery or follow-up.Clinicaltrials.gov NCT01563133.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0034-1390693DOI Listing
January 2015

A feasibility study of full-field optical coherence tomography for rapid evaluation of EUS-guided microbiopsy specimens.

Gastrointest Endosc 2015 Feb 26;81(2):342-50. Epub 2014 Sep 26.

Department of Biology and Pathology, Translational Research Laboratory, Gustave Roussy, Villejuif, France.

Background: Rapid on-site evaluation of cytologic specimens is a way of determining the adequacy of fine-needle aspiration (FNA). However, alternatives may be useful when the presence of a cytotechnologist and/or pathologist is not possible.

Objective: To evaluate the feasibility of using full-field optical coherence tomography (FFOCT) for FNA specimen quality assessment.

Design: FFOCT images were acquired on gastric, pancreatic, pelvic, and lymph-node formalin-fixed FNA specimens and were compared with histology of the same samples.

Setting: Pathology suite in a hospital.

Patients: Fourteen patients undergoing gastric, pancreatic, pelvic, or lymph-node EUS-guided FNA biopsy.

Interventions: FFOCT imaging on formalin-fixed samples before histologic procedures.

Main Outcome Measurements: FFOCT imaging feasibility and visibility of normal and abnormal features on images.

Results: FFOCT imaging was possible. Blood, mucus, muscle, collagen, and digestive mucosa could be identified as well as abnormal architectural features including infiltrative pancreatic ductal carcinoma and a neuroendocrine neoplasm. Lesions at the individual cell level could not be detected.

Limitations: The study was performed on a limited number of cases.

Conclusion: FFOCT offers rapid, noninvasive, nondestructive imaging of FNA biopsy specimens. In the future, it could be performed in the endoscopy suite to improve detection of satisfactory specimens and obviate the need for rapid on-site evaluation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2014.06.037DOI Listing
February 2015

Management of serous cystic neoplasms of the pancreas.

Expert Rev Gastroenterol Hepatol 2015 Jan 1;9(1):115-25. Epub 2014 Jul 1.

Department of Gastroenterology, A.Murri Hospital, Polytechnic University of Marche, Fermo, Italy.

Pancreatic serous cystadenomas are uncommon benign tumours that are often found incidentally on routine imaging examinations. Radiological imaging techniques alone have proven to be suboptimal to fully characterize cystic pancreatic lesions. Endoscopic ultrasound, with the addition of fine-needle aspiration in difficult cases, has showed greater diagnostic accuracy than conventional imaging techniques. The best management strategy of these neoplasms is still debated. Surgery should be limited only to symptomatic and highly selected cases and most of the patients should only be strictly monitored. In the current paper, we provide an updated overview on pancreatic serous cystadenomas, focusing our attention on epidemiology, clinical characteristics and diagnostic evaluation; finally, we also discuss different management strategies and areas for future research.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1586/17474124.2014.934675DOI Listing
January 2015

[Not Available].

Endoscopy 2014 Feb;46(2):261

View Article and Find Full Text PDF

Download full-text PDF

Source
February 2014

[Not Available].

Endoscopy 2014 Feb;46(2):261

View Article and Find Full Text PDF

Download full-text PDF

Source
February 2014

[Not Available].

Endoscopy 2014 Feb;46(2):260

View Article and Find Full Text PDF

Download full-text PDF

Source
February 2014

[Not Available].

Endoscopy 2014 Feb;46(2):260

View Article and Find Full Text PDF

Download full-text PDF

Source
February 2014

[Not Available].

Endoscopy 2014 Feb;46(2):260

View Article and Find Full Text PDF

Download full-text PDF

Source
February 2014

[Not Available].

Endoscopy 2014 Feb;46(2):260

View Article and Find Full Text PDF

Download full-text PDF

Source
February 2014