Clin Endosc.  2023 May;56(3):353-366. 10.5946/ce.2022.021.

Pancreatic duct lavage cytology combined with a cell-block method for patients with possible pancreatic ductal adenocarcinomas, including pancreatic carcinoma in situ

• Kusunose H
• Koshita S
• Kanno Y
• Ogawa T
• Sakai T
• Yonamine K
• Miyamoto K
• Kozakai F
• Anan H
• Endo K
• Okano H
• Oikawa M
• Tsuchiya T
• Sawai T
• Noda Y
• Ito K

• KMID: 2542463
• DOI: http://doi.org/10.5946/ce.2022.021

Abstract

Background/Aims
This study aimed to clarify the efficacy and safety of pancreatic duct lavage cytology combined with a cell-block method (PLC-CB) for possible pancreatic ductal adenocarcinomas (PDACs).
Methods
This study included 41 patients with suspected PDACs who underwent PLC-CB mainly because they were unfit for undergoing endoscopic ultrasonography-guided fine needle aspiration. A 6-Fr double lumen catheter was mainly used to perform PLC-CB. Final diagnoses were obtained from the findings of resected specimens or clinical outcomes during surveillance after PLC-CB.
Results
Histocytological evaluations using PLC-CB were performed in 87.8% (36/41) of the patients. For 31 of the 36 patients, final diagnoses (invasive PDAC, 12; pancreatic carcinoma in situ, 5; benignancy, 14) were made, and the remaining five patients were excluded due to lack of surveillance periods after PLC-CB. For 31 patients, the sensitivity, specificity, and accuracy of PLC-CB for detecting malignancy were 94.1%, 100%, and 96.8%, respectively. In addition, they were 87.5%, 100%, and 94.1%, respectively, in 17 patients without pancreatic masses detectable using endoscopic ultrasonography. Four patients developed postprocedural pancreatitis, which improved with conservative therapy.
Conclusions
PLC-CB has an excellent ability to detect malignancies in patients with possible PDACs, including pancreatic carcinoma in situ.

Keyword

Carcinoma; Cytology; Endoscopic retrograde cholangiopancreatography; Pancreatic ductal adenocarcinoma; Pancreatic juice

Figure

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  Fig. 1. Flowchart for patient selection in this study. PDACs, pancreatic ductal adenocarcinomas; EUS-FNA, endoscopic ultrasound-guided fine needle aspiration; PLC-CB, pancreatic duct lavage cytology combined with a cell-block method.

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  Fig. 2. Tip of a double lumen sampling catheter used in this study (Uneven Double Lumen Cannula; Piolax Medical Devices Inc.).

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  Fig. 3. Endoscopic procedure for pancreatic duct lavage cytology by using a double lumen catheter (endoscopy assistant). The injection of saline into the main pancreatic duct (A) and the suction of fluid in the main pancreatic duct with negative pressure by using a syringe (B) were simultaneously performed through two separate lumens (0.025- and 0.035-inch lumen, respectively).

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  Fig. 4. A 64-year-old patient with an initial diagnosis of acute pancreatitis (patient no. 14 in Table 2). The enlargement of the pancreatic tail with mild pancreatitis and localized atrophy of the pancreatic parenchyma at the proximal site of the enlarged pancreatic tail were detected (A, contrast-enhanced computed tomography, arrowhead). Endoscopic ultrasonography did not detect mass lesions, and magnetic resonance cholangiopancreatography did not show the main pancreatic duct stenosis at the pancreatic tail. We suspected pancreatic carcinoma in situ and performed pancreatic duct lavage cytology combined with a cell-block method using a double lumen catheter. Endoscopic retrograde pancreatography did not show clear stenosis of the main pancreatic duct at the pancreatic tail (B, pancreatography). Cell-block specimens obtained were firstly evaluated by using hematoxylin and eosin staining (C, ×10; D, ×40). Histocytological diagnosis was shown to be adenocarcinoma (Class V), and distal pancreatectomy was performed. For the histological findings of resected specimens, the atypical ductal epithelium was continuously observed from the main pancreatic duct (E, ×20; arrowhead) to branch pancreatic duct, and invasive components derived from this atypical epithelium were not found. Thus, this patient was diagnosed with pancreatic carcinoma in situ (high-grade pancreatic intraepithelial neoplasm).

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  Fig. 5. An 82-year-old patient (patient no. 17 in Table 2) with recurrent acute pancreatitis had a localized parenchymal atrophy of the pancreatic body (A, contrast-enhanced computed tomography; arrowhead, localized atrophic parenchyma in the pancreatic body). Although magnetic resonance cholangiopancreatography (B) showed a stenosis of the main pancreatic duct (MPD) in the pancreatic body (arrowhead), endoscopic ultrasonography did not detect mass lesions in this MPD stenosis. Pancreatic duct lavage cytology combined with a cell-block method using a double lumen catheter was conducted due to the diagnosis of suspected pancreatic carcinoma in situ. For histocytology of the specimens obtained through pancreatic duct lavage cytology combined with a cell-block method, some clusters of atypical cells were observed by using hematoxylin and eosin staining (C, ×20). MUC1 staining (D, ×40) was focally positive, a Ki-67 labeling index (E, ×40) was approximately 20% and p53 staining was negative, indicating adenocarcinoma (Class IV). She underwent distal pancreatectomy, and histology (hematoxylin and eosin staining) of resected specimens showed an atypical epithelium mainly located in the MPD and branch ducts (F, ×4; G, ×20; black arrowhead: MPD, yellow arrowhead: branch duct), resulting in the final diagnosis of pancreatic carcinoma in situ (high-grade pancreatic intraepithelial neoplasm).

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