胰腺疾病内镜诊断与治疗现状

内镜逆行胰胆管造影术（ ERCP）诊断技术日趋成熟,已成为胰腺疾病诊断的重要手段,是胰腺分裂症诊断的唯一方法,近年来对内镜下收集胰液、细胞刷检、穿刺及活组织检查 (简称活检 )标本进行细胞学检查,极大地丰富了胰腺疾病内镜诊断手段。长海医院采用胰管细胞刷刷取细胞涂片并结合 ERCP对 27例患者进行研究,结果显示细胞学检查阳性率为 55.6％,特异性为 100％,敏感性为 65.2％,与 ERCP结合诊断正确率可达 100％,该诊断方法快速,经济实用,安全和准确性高。经胆总管腔内活检（ endobiliary forcep biopsy ,EFB）也有助于诊断…     

内镜下胰腺细胞学检查方法对胰腺肿瘤的诊断价值

目的　探讨内镜下胰腺细胞学检查对胰腺肿瘤诊断的临床应用价值 ,提高对胰腺恶性肿瘤的检出率。方法　在ERCP检查的同时采用胰管细胞刷及放置鼻胰管方法对 47例患者进行研究。结果　刷检细胞学检查准确性为 70 4% ,敏感性为 65 2 % ,特异性为 10 0 % ;胰液细胞学准确性为 45 % ,敏感性为 8 3 %及特异性10 0 %。结论　该检查方法快速 ,经济实用 ,安全和准确性高 ,不失为胰腺肿瘤早期诊断的一种可靠且有价值的检查手段。     

ERCP下胰管刷检对胰腺癌早期诊断的研究现状与评介

胰腺癌的早期诊断非常困难，在ERCP检查的同时行胰管刷检细胞学检查对胰腺癌的早期诊断和鉴别诊断具有较高的价值，在国外已广泛开展，本主要介绍ERCP下胰腺管刷检的方法，细胞学诊断标准，临床评价以及分子生物学在恻检细胞诊断中的应用情况。     

胰管刷检标本P53蛋白检测在胰腺癌诊断中的价值

目的：探讨胰管刷检标本p53蛋白检测在胰腺癌诊断中的价值。方法：应用免疫组化法检测26例胰腺及壶腹疾病患者胰管刷检标本p53蛋白的表达,并与常规细胞学检查作比较。结果：苏木精－伊红染色常规细胞学检查诊断胰腺癌的敏感性为53％,特异性为100％,准确性为70％。胰管刷检标本p53蛋白检测诊断胰腺癌的敏感性为59％,特异性为100％, 准确性为74％。二者联合诊断胰腺癌的敏感性为71％,特异性为100％,准确性为81％,与单项细胞学检查相比差异有非常显著性（P＜0．01）。结论：胰管刷检标本细胞学检查的同时,进行p53检测可提高胰腺癌的诊断率,有助于胰腺良、恶性疾病的鉴别。     

胰管刷检标本细胞学联合VEGF检测对胰腺癌的诊断价值

目的：研究胰管刷检细胞学和VEGF检测对胰腺癌的诊断价值。方法：应用内镜逆行胰胆管造影（ERCP）下胰管刷检细胞学涂片，分别行HE染色和免疫组化法检测血管内皮生长因子（VEGF）表达，并比较其对胰腺癌的诊断价值。结果：细胞HE染色诊断胰腺癌的敏感性51．9％，特异性为100％。VEGF免疫组化法诊断胰腺癌的敏感性为63．5％，特异性为100％，与HE染色相比差异有显意义（X^2．4．17，P＝0．0412）。细胞学HE染色联合VEGF免疫组化法诊断敏感性为75％，特异性为100％，与单独细胞学HE染色（X^2＝10．08，P＝0．0015）或VEGF检测（X^2＝4．17，P＝0．0412）相比，差异均有显意义。结论：胰管刷检标本细胞学与VEGF检测相结合可显提高胰腺癌的诊断敏感性。     

ERCP下胰管刷检对胰腺癌早期诊断的研究现状与评价

胰腺癌的早期诊断非常困难,在ERCP检查的同时行胰管刷检细胞学检查对胰腺癌的早期诊断和鉴别诊断具有较高的价值,在国外已广泛开展。本文主要介绍ERCP下胰管刷检的方法、细胞学诊断标准、临床评价以及分子生物学在刷检细胞诊断中的应用情况。     

多种内镜检查方法联合应用对胆管狭窄性疾病的诊断价值

目的评估多种内镜检查方法联合应用对胆管狭窄性疾病的诊疗价值。方法回顾性分析36例胆管狭窄性疾病患者的诊断情况。36例患者均进行了超声内镜检查术（EUS）、经内镜逆行胰胆管造影术（ERCP）、胆管内超声检查术（IDUS）,胆道靶向刷检行细胞学涂片、液基薄层细胞学检查,并结合临床资料及组织学病理检查,综合诊断。结果最终诊断胆管恶性病变21例,其中胆管细胞癌9例、十二指肠乳头癌4例、胰腺癌侵犯胆总管4例、肝癌侵犯胆总管4例;胆管良性病变15例,其中胆总管结石9例、肝吸虫感染所致胆管狭窄4例、单纯胆管炎性狭窄1例、外部压迫所致胆管狭窄1例。EUS、ERCP、IDUS及ERCP＋IDUS对胆管狭窄性疾病鉴别诊断的准确率分别为77．8％、88．9％、91．7％、94．4％,ERCP、IDUS及ERCP＋IDUS均明显高于EUS（P均〈0．05）;ERCP＋IDUS对胆管狭窄性疾病鉴别诊断的敏感度、特异度、阳性预测值与阴性预测值分别为95．2％、93．3％、95．2％、93．3％,均高于EUS、ERCP及IDUS单独检查。胆道刷检细胞学、液基薄层细胞学或组织病理学检查,19例诊断为恶性狭窄,17例诊断为良性狭窄,对鉴别胆管狭窄性质诊断的敏感度为90．5％、特异度为100．0％、准确率为94．4％。结论对于胆管狭窄性病变,ERCP＋IDUS可使诊断准确率得到明显提高;联合应用ERCP＋IDUS＋病变胆管的靶向刷检等多种内镜检查方法,诊断准确率更高。     

胸膜刷检在恶性胸腔积液诊断中的应用

目的观察胸膜刷检在恶性胸腔积液的诊断上的价值。方法15例胸腔积液患者胸腔穿刺术后行胸膜活检、抽取胸液、胸膜刷检分别留取组织及胸液送细胞学检查。结果恶性胸腔积液诊断的阳性率分别为：胸膜刷检73．3％（11／15），胸液细胞学检查53．3％（8／15），胸膜活检33．3％（5／15）。胸膜刷检的阳性率高于胸液细胞学检查及胸膜活检，比较有显著性差异。结论胸膜刷检在恶性胸腔积液的诊断有重要价值。     

液基细胞学与传统细胞学方法诊断胆总管恶性狭窄的对比研究

目的探讨液基细胞学方法对胆总管恶性狭窄的诊断价值。方法对2008年10月至2009年6月间影像学怀疑为胆总管恶性狭窄的患者进行ERCP胆管细胞刷刷检,分别采用液基细胞学、传统细胞学方法进行细胞学标本制备,比较两种方法诊断的阳性率。结果疑诊胆总管恶性狭窄患者76例,经手术病理、细胞学检测及临床随访最终明确诊断为胆总管恶性狭窄的共65例。32例细胞学检测明确诊断的患者中,传统细胞学方法发现阳性17例（阳性率为26．2％,17／65）、液基细胞学方法发现阳性32例（阳性率为49．2％,32／65）,两者阳性率比较差异有统计学意义（P〈0．05）。结论液基细胞学较传统细胞学方法可提高ERCP胆管细胞刷刷检标本的阳性发现率,具有较高的临床应用价值。     

胰管刷检标本K-ras基因突变检测在胰腺癌诊断中的价值

目的 探讨胰管刷检标本K-ras基因突变检测在胰腺癌诊断中的价值。方法 应用突变富集聚合酶联反应（PCR）－单链构象多态性（SSCP）法，检测胰腺疾病胰管刷检标本K-ras基因第一外显子第12密码子点突变。结果 35例胰管刷检标本PCR扩增均获成功，成功率为100％。20例胰腺癌中14例K-ras突变（70％），7例慢性胰腺炎中1例K-ras突变（14％），两组间差异有显著性（P＜0．05）。胰腺囊腺瘤，十二指肠乳头癌均未见K-ras突变。胰管刷检标本K-ras突变与胰腺癌部位无关。胰管刷检K-ras突变检测诊断胰腺癌的敏感性，特异性和准确性分别为70％，90％和83％。结论 检测胰管刷检标本中K-ras基因突变有助于胰腺癌的诊断，具有良好的临床应用前景。     

Detection of c-Ki-ras gene codon 12 mutations from pancreatic duct brushings in the diagnosis of pancreatic tumours.

Differential diagnosis of pancreatic cancer and chronic pancreatitis is sometimes difficult and cytological examination of brushings or aspirated material collected during endoscopic retrograde cholangiopancreatography (ERCP) remains disappointing. As point mutations in codon 12 of the c-Ki-ras 2 gene are found in most pancreatic adenocarcinoma and not in chronic pancreatitis, this study analysed prospectively the presence of these mutations in brushing samples collected during ERCP in 45 patients (26 males, 19 females) showing a dominant stricture of the main pancreatic duct at pancreatography: 24 with pancreatic adenocarcinoma, 16 with chronic pancreatitis, and five intraductal mucin hypersecreting neoplasms. Twenty of 45 patients presented equivocal ERCP findings that did not permit a definite diagnosis. Ki-ras mutations at codon 12 were detected using a rapid and sensitive method based on polymerase chain reaction mediated restriction fragment length polymorphism analysis and confirmed by direct sequencing of polymerase chain reaction products. Results were compared with those provided by routine brush cytology. A definitive diagnosis was established for each patient. Mutations were detected in 20 of 24 patients with pancreatic adenocarcinoma (83%), but in none of the chronic pancreatitis patients and intraductal mucin hypersecreting neoplasms, irrespective of their location. By contrast, only 13 of 24 pancreatic adenocarcinoma (54%) were detected by conventional cytological examination, which yielded four false negative and seven non-contributive results. Sensitivity, specificity, and accuracy of molecular biological and cytological methods were 83%-76%, 100-83%, and 90%-58%, respectively. Notably the mutations could be detected in six patients with small tumour size (< or = 2 cm). In conclusion, Ki-ras analysis performed on pancreatic brushing samples is an efficient procedure, more accurate than cytology in the diagnosis of pancreatic adenocarcinoma, and highly specific in the differentiation between neoplastic and chronic inflammatory ductal changes, especially in patients showing inconclusive ERCP findings.     

Pancreatic intraductal sampling during ERCP in patients with chronic pancreatitis and pancreatic cancer: cytologic studies and k-ras-2 codon 12 molecular analysis in 47 cases.

BACKGROUND: A preoperative tissue diagnosis of pancreatic cancer is desirable but difficult to obtain. METHODS: Pancreatic brush cytology, salvage cytology, and collection of pancreatic juice were attempted prospectively during ERCP in 34 patients with pancreatic cancer and 11 with chronic pancreatitis. K-ras-2 codon 12 was analyzed for presence and type of point mutations. RESULTS: Brush cytology coupled with salvage cytology had a sensitivity of 74%. The addition of cytologic analysis of pancreatic juice did not substantially improve sensitivity (76%). K-ras-2 was mutated in both cancer (87%) and pancreatitis (40%). The specificity for cytology was 100% and for K-ras-2 mutations 60%. Combining cytology with mutation analysis increased sensitivity to 93% but reduced the positive predictive value. The negative predictive value never exceeded 75%. None of the patients with chronic pancreatitis had cancer develop (median follow-up 60 months). CONCLUSIONS: Pancreatic ductal brushing with salvage cytology is useful in the diagnosis of cancer, whereas cytologic analysis of pancreatic juice can be abandoned. At present, K-ras-2 mutation is not useful for differentiating pancreatic cancer from chronic pancreatitis or the identification of patients with chronic pancreatitis at risk for malignant transformation.     

Utility of pancreatic duct brushing for diagnosis of pancreatic carcinoma

Background The aim of this study was to evaluate the usefulness of pancreatic duct brushing for diagnosis of pancreatic carcinoma. Methods Brush cytology was attempted in 58 patients suspected of having pancreatic malignancy because of stricture of the main pancreatic duct, confirmed by endoscopic retrograde cholangiopancreatography. Thirty-eight patients were finally diagnosed by an operation or the clinical course as having pancreatic carcinoma, and the remaining 20 patients as having chronic pancreatitis. The usefulness of brush cytology for diagnosis of pancreatic carcinoma was estimated. We interpreted failures of pancreatic duct brushing to be false negatives when the lesion was malignant. Results In 48 of 58 patients (82.8%), brushing was successfully performed and satisfactory specimens were obtained. Brush cytology was positive in 25 of 38 patients with pancreatic carcinoma (sensitivity 65.8%) and negative in all patients without malignancy (specificity 100%). Overall accuracy was 76.4%. During 2001–2005, the number of back-and-forth motions of the brush was increased to more than 30 times. The sensitivity significantly improved from 43.8% in 1997–2000 to 81.8% in 2001–2005 (P < 0.05). The increased success rate of brushing by improvement of skill in manipulating the guidewire and increased number of cells smeared on glass slides by increased back-and-forth motion of the brush may account for this improvement over time. Moreover, the sensitivity in 2001–2005 was 85.7% if failures of brushing with pancreatic carcinoma are excluded. No major complications occurred, except for two patients with a moderate grade of acute pancreatitis. Conclusions Although further studies with a large number of patients are needed, our results suggest that with recent improvements of the brushing technique, pancreatic duct brushing is a useful and safe method for the differential diagnosis of malignancy from benign diseases of the pancreas.     

Cytologic brushings of ductal lesions during ERCP

Cytologic brushings of ductal lesions noted at ERCP are a reliable method of diagnosing malignancy. However, prior studies have involved only small numbers of patients. This study presents the results of attempted brushings in 69 patients. A satisfactory specimen was obtained in 62 patients (90%). The overall sensitivity was 44% with 100% specificity. Common bile duct brushings had a higher sensitivity rate than did pancreatic brushings. Similarly, biliary tract cancer was more likely to be diagnosed than was pancreatic cancer by brushing. Markedly atypical cells were identified in 36% of patients with a false negative cytology result. These findings were not seen in patients with benign disease. Two patients developed mild pancreatitis and one developed cholangitis. It is unclear what role the act of brushing had on causing these complications.     

Detection of K-ras point mutation and telomerase activity during endoscopic retrograde cholangiopancreatography in diagnosis of pancreatic cancer

AIM: To study the value of monitoring K-ras point mutation at codon 12 and telomerase activity in exfoliated cells obtained from pancreatic duct brushings during endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic cancer. METHODS: Exfoliated cells obtained from pancreatic duct brushings during ERCP were examined in 27 patients: 23 with pancreatic cancers, 4 with chronic pancreatitis. K-ras point mutation was detected with the polymerase chain reaction and restriction fragment-length polymorphism (PCR-RFLP). Telomerase activity was detected by PCR and telomeric repeat amplification protocol assay (PCR-TRAP-ELISA). RESULTS: The telomerase activities in 27 patients were measured in 21 exfoliated cell samples obtained from pancreatic duct brushings. D450 value of telomerase activities in pancreatic cancer and chronic pancreatitis were 0.446+/-0.27 and 0.041+/-0.0111, respectively. Seventy-seven point eight percent (14/18) of patients with pancreatic cancer and none of the patients with chronic pancreatitis showed telomerase activity in cells collected from pancreatic duct brushings when cutoff value of telomerase activity was set at 2.0. The K-ras gene mutation rate (72.2%) in pancreatic cancer was higher than that in chronic pancreatitis (33.3%) (P<0.05). In considering of both telomerase activities and K-ras point mutation, the total positive rate was 83.3%(15/18), and the specificity was 100%. CONCLUSION: Changes of telomerase activities and K-ras point mutation at codon 12 may be an early event of malignant progression in pancreatic cancer. Detection of telomerase activity and K-ras point mutation at codon 12 may be complementary to each other, and is useful in diagnosis of pancreatic cancer.     

A case report of pancreatic serous cystadenoma coexistent with adenosquamous carcinoma

A 70-year-old man was admitted to our hospital because a mass was incidentally found in the body of the pancreas. The mass was suspected to be serous cystadenoma from the findings of abdominal enhanced computed tomography, magnetic resonance imaging and endoscopic ultrasonography. In addition, another solid mass was detected in the pancreatic head on imaging tests. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed stenosis both of the main pancreatic duct at the head and bile duct, but the brushing cytology of the bile duct at ERCP showed no malignant cells. However, the findings of several examinations strongly suggested the coexistence of a serous cystadenoma and a pancreatic cancer, therefore we conducted spleen-preserving total pancreatectomy, and the pathological findings of the resected specimen showed serous cystadenoma coexistence with pancreatic adenosquamous carcinoma.