Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: The PIPE Study

Background and study aims: There have been concerns about peritoneal seeding after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mucinous pancreatic cystic lesions. The aims of this study were to determine the frequency of postoperative peritoneal seeding in patients with intraductal papillary mucinous neoplasm (IPMN) who had undergone pre-operative EUS-FNA and to compare it with that of patients with IPMN who had surgery with no pre-operative tissue sampling.

Patients and methods: A total of 175 patients who had undergone resection of IPMNs with pre-operative EUS-FNA (EUS-FNA group) were analyzed and compared with 68 patients who had undergone resection with no pre-operative tissue sampling (No Sampling group). Patient characteristics, pathology, and frequency of peritoneal seeding after surgery were analyzed and compared. Peritoneal seeding was diagnosed based on pathology or image findings.

Results: The two groups were comparable with respect to sex, age, follow-up duration, involvement of the pancreatic head, involvement of the main duct, grade of dysplasia, and size of histologically proven branch-duct IPMNs. Four patients (2.3 %) with invasive IPMN developed peritoneal seeding in the EUS-FNA group, whereas three (4.4 %, two with invasive IPMN and one with high-grade dysplasia) developed peritoneal seeding in the No Sampling group (P  = 0.403). No peritoneal seeding was noted during surgery in these cases. Except for one patient in the EUS-FNA group, no spillage occurred during resection in these patients.

Conclusions: In this cohort of patients undergoing resection of IPMN, the difference in the frequency of peritoneal seeding in the EUS-FNA group and the No Sampling group was not significant.

• References

• 1 Hawes RH, Fockens P, Varadarajulu S. Endosonography. 2nd edn. Philadelphia: Elsevier Saunders; 2011
• 2 Yoon WJ, Brugge WR. Pancreatic cystic neoplasms: diagnosis and management. Gastroenterol Clin N Am 2012; 41: 103-118
• 3 Cizginer S, Turner B, Bilge AR et al. Cyst fluid carcinoembryonic antigen is an accurate diagnostic marker of pancreatic mucinous cysts. Pancreas 2011; 40: 1024-1028
• 4 Brugge WR, Lewandrowski K, Lee-Lewandrowski E et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004; 126: 1330-1336
• 5 Lee LS, Saltzman JR, Bounds BC et al. EUS-guided fine needle aspiration of pancreatic cysts: a retrospective analysis of complications and their predictors. Clin Gastroenterol Hepatol 2005; 3: 231-236
• 6 Tanaka M, Fernandez del Castillo C, Adsay V et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183-197
• 7 Brugge WR. The role of EUS in the diagnosis of cystic lesions of the pancreas. Gastrointest Endosc 2000; 52: 18-22
• 8 Walkey MM, Friedman AC, Sohotra P et al. CT manifestations of peritoneal carcinomatosis. AJR Am J Roentgenol 1988; 150: 1035-1041
• 9 Raptopoulos V, Gourtsoyiannis N. Peritoneal carcinomatosis. Eur Radiol 2001; 11: 2195-2206
• 10 Yan TD, Morris DL, Shigeki K et al. Preoperative investigations in the management of peritoneal surface malignancy with cytoreductive surgery and perioperative intraperitoneal chemotherapy: expert consensus statement. J Surg Oncol 2008; 98: 224-227
• 11 Gonzalez-Moreno S, Gonzalez-Bayon L, Ortega-Perez G et al. Imaging of peritoneal carcinomatosis. Cancer J 2009; 15: 184-189
• 12 Tanaka M, Chari S, Adsay V et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 2006; 6: 17-32
• 13 Nakagohri T, Kinoshita T, Konishi M et al. Surgical outcome of intraductal papillary mucinous neoplasms of the pancreas. Ann Surg Oncol 2007; 14: 3174-3180
• 14 Chari ST, Yadav D, Smyrk TC et al. Study of recurrence after surgical resection of intraductal papillary mucinous neoplasm of the pancreas. Gastroenterology 2002; 123: 1500-1507
• 15 Micames C, Jowell PS, White R et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percutaneous FNA. Gastrointest Endosc 2003; 58: 690-695
• 16 Dumonceau JM, Polkowski M, Larghi A et al. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2011; 43: 897-912
• 17 Paquin SC, Gariepy G, Lepanto L et al. A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma. Gastrointest Endosc 2005; 61: 610-611
• 18 Ahmed K, Sussman JJ, Wang J et al. A case of EUS-guided FNA-related pancreatic cancer metastasis to the stomach. Gastrointest Endosc 2011; 74: 231-233
• 19 Chong A, Venugopal K, Segarajasingam D et al. Tumor seeding after EUS-guided FNA of pancreatic tail neoplasia. Gastrointest Endosc 2011; 74: 933-935
• 20 Katanuma A, Maguchi H, Hashigo S et al. Tumor seeding after endoscopic ultrasound-guided fine-needle aspiration of cancer in the body of the pancreas. Endoscopy 2012; 44 : E160-161
• 21 Ngamruengphong S, Xu C, Woodward TA et al. Risk of gastric or peritoneal recurrence, and long-term outcomes, following pancreatic cancer resection with preoperative endosonographically guided fine needle aspiration. Endoscopy 2013; 45: 619-626
• 22 Shah JN, Fraker D, Guerry D et al. Melanoma seeding of an EUS-guided fine needle track. Gastrointest Endosc 2004; 59: 923-924
• 23 Doi S, Yasuda I, Iwashita T et al. Needle tract implantation on the esophageal wall after EUS-guided FNA of metastatic mediastinal lymphadenopathy. Gastrointest Endosc 2008; 67: 988-990
• 24 Hirooka Y, Goto H, Itoh A et al. Case of intraductal papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination. J Gastroenterol Hepatol 2003; 18: 1323-1324