When to stick a needle in? 1700s Spallanzani: Ultrasound guided - - PowerPoint PPT Presentation

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When to stick a needle in? 1700s Spallanzani: Ultrasound guided - - PowerPoint PPT Presentation

Oct 11, 2022 1.05k likes •1.44k views

EUS: past, present and future Update on revised Fukuoka guidelines (2017) Review of cystic pancreatic lesions: CT / MRI / EUS When to stick a needle in? 1700s Spallanzani: Ultrasound guided navigation in bats c1880 Jacque and

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 EUS: past, present and future  Update on revised Fukuoka guidelines

(2017)

 Review of cystic pancreatic lesions: CT /

MRI / EUS

 When to stick a needle in?

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1700s Spallanzani: Ultrasound guided navigation in bats c1880 Jacque and Pierre Curie: Piezoelectric effect 1940 - 1950 Dussik / Wild & Reid: Ultrasound for medical diagnosis 1980 - 1982 DiMagno: First EUS examinations

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High risk stigmata

  • Obstructive jaundice secondary to cyst
  • Enhancing mural nodule (≥ 5mm)
  • Main pancreatic duct ≥ 10mm

Worrisome features

  • Clinical: Pancreatitis
  • Imaging: Cyst ≥ 30mm

Enhancing mural nodule < 5mm Thickened / enhancing cyst walls Main pancreatic duct 5-9mm Pancreatic duct stricture Lymphadenopathy Raised CA 19-9 Cyst growth ≥ 5mm/ 2 years

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 Viscosity  Amylase  CEA  Cytology

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Serous cystadenoma (SCA) Mucinous cystic neoplasm (MCN) IPMN Pseudocyst Viscosity + ++ / +++ +++ + Amylase + + / ++ ++ / +++ +++ CEA + ++ / +++ ++ / +++ + Cytology Glycogen Mucinous Mucinous Histiocytes + Low ++ Moderate +++ High

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Cystic lesion Positive marker Sensitivity Specificity SCA VHL chr3 LOH 74-100% 84-95% MCN None 74-100% 97-95% IPMN GNAS RNF43 chr39 LOH Chr1q aneu 66-84% 85-99%

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 2.5% of pancreatic exocrine tumours  > 95% female predominance  Surgical lesions:

› 2/3 slow-growing cystadenomas › 1/3 malignant cystadenocarcinomas

 Often unilocular in body / tail  Cyst fluid

› High CEA › Mildly elevated / high amylase

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 Benign  Older women  Septated  Calcified  Microcystic  Pancreatic head  Cyst fluid

› Low CEA › Normal / Low amylase › Glycogen on

cytology

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Key question Possible diagnosis Demographics / History Male MCN unlikely No history of pancreatitis Pseudocyst unlikely MEN Cystic neuroendocrine tumour VHL Serous cystadenoma Imaging Central calcification Serous cystadenoma Head of the gland MCN unlikely Cyst fluid High CEA / High amylase IPMN High CEA / Mildly elevated amylase MCN Low CEA / High amylase Pseudocyst Malignant potential SCA: Very rare MCN: Moderate to high IPMN: Low to high Pseudocyst: None

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 Diagnostics

› Fluid analysis

markers

› EUS micro-forceps

 Therapeutics

› EUS guided RFA

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 Predominantly an incidental finding

› High risk / worrisome features

 Patient centred, MDT focussed

management

 Novel diagnostic techniques just around

the corner

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