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PANCREATIC CANCER SCREENING IN HIGH RISK INDIVIDUALS
Ten precent of pancreatic cancers are due to genetic predisposition. Individuals at
high risk (HRI) of developing pancreatic cancer (PC) include those with familial
pancreatic cancer (FPC, ≥2 first-degree family members with PC), Peutz-Jeghers
syndrome, hereditary pancreatitis and BRCA2 mutation carriers with a family
history of PC. Screening programs in high risk individuals have been developed to
identify precursor lesions and early cancers.
Aim: To describe the endoscopic ultrasound (EUS) abnormalities in high risk
individuals and examine the risk factors and possible associations in this cohort. To
determine the effect of genetic counseling and screening on cancer worry and to
evaluate participant perception of the value of such intervention.
Methods: Individuals at high risk for pancreatic cancer were prospectively
enrolled in a screening and surveillance program using EUS, the study being
approved by St Vincent’s Human Research Office. A comprehensive questionnaire
including family history, demographics, ethnicity, environmental exposures
(alcohol and smoking), medications and relevant medical history was administered.
Patients were referred for genetic counselling +/- genetic testing after which EUS
was performed. A follow up adverse effects phone call was done at one week.
Cancer risk perception, quality of life and screening specific anxiety was
determined pre and post EUS.
Results: Forty two individuals completed their first screening program [FPC 33,
BRCA2+ 9; M 12, F30; mean age 54 (range 39-78); smokers 4]. Seven individuals
had a previous cancer (breast 5, brain 1, prostate 1). EUS results: 14 (33%) had an
identifiable focal lesion (12 cysts, 2 hypoechoic areas) and 16 (38%) had “chronic
pancreatitis”-like parenchymal changes. The cysts had morphological features
compatible with BD-IPMN (mean size 5mm; range 3-14mm) and were located
predominantly in the body and tail. EUS-guided FNA was done in 1 patient only.
No pancreatic malignancy was identified and no patient was referred for surgery.
Several incidental extrapancreatic lesions were found: multifocal hepatoma 1,
duodenal GIST 1, coeliac disease 1, splenic cyst. There were no significant adverse
events post EUS. Thirty seven (87%) of the cohort found genetic counselling
useful. Prior to screening the majority of the cohort were moderately to severely
worried about developing PC but following EUS, 36 (86%) reported reduced
anxiety regarding their future cancer risk.
Conclusion HRI have a higher rate of cystic lesions (BD-IPMN) compared to the
general population (33% vs 2.6%1), findings similar to other reported screening
programs2. EUS changes of “chronic pancreatitis”, found in 38% of our cohort, are
thought to represent imaging correlates of lobular atrophy which is associated with
precursor lesions (PanIN, IPMN)3-5. Genetic counseling was found to be very
useful by participants and involvement in a screening program reduced anxiety
regarding future cancer risk. However, the natural history of precursor lesions
remains unclear and it is uncertain if surveillance programs will ultimately reduce
cancer incidence.
1
Lafan T, Horton K Prevalence of unsuspected pancreatic cysts by MDCT,
American Journal of Roentgenology.2008;191:802-807
2
Canto MI, Hruban RH, Fishman EK, et al. Frequent Detection of Pancreatic
Lesions in Asymptomatic High-Risk Individuals. Gastroenterology 2012.
3
Brune K, Hruban R Multifocal neoplastic precursor lesions associated with
lobular atrophy of the pancreas in patients having a strong family history of
pancreatic cancer. Am J Surg Pathol. 2006 Sep;30(9):1067-76.