A Promising Diagnostic Role of Immunohistochemical Expression of Insulin-Like Growth Factor II mRNA Binding Protein3 (IMP3) in Pancreatic Lesions Using Endoscopic Ultrasound –Guided –Fine Needle Aspiration (EUS-FNA) Cytology

A Promising Diagnostic Role of Immunohistochemical Expression of Insulin-Like Growth Factor II mRNA Binding Protein3 (IMP3) in Pancreatic Lesions Using Endoscopic Ultrasound –Guided –Fine Needle Aspiration (EUS-FNA) Cytology | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Promising Diagnostic Role of Immunohistochemical Expression of Insulin-Like Growth Factor II mRNA Binding Protein3 (IMP3) in Pancreatic Lesions Using Endoscopic Ultrasound –Guided –Fine Needle Aspiration (EUS-FNA) Cytology Hayam Rashed, Nora Wasfi, Awatef Nasr, Ramy ElHendawy, Nelly Mohammed Said This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1032716/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Poor prognosis and short survival of patients harboring pancreatic cancer emerge how advanced disease it is. In a trial to achieve the earliest and most accurate diagnosis to manage this progressive disease, we proposed that using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with an adjuvant diagnostic immunohistochemical marker would give better diagnostic results. IMP3 has gained recently wide attention, as many studies found that IMP3 has not only diagnostic but also prognostic role in different types of malignancies. A im of the study : this prospective work is to assess the diagnostic role of EUS-FNA combined with the immunohistochemical expression of IMP3 on different benign and malignant pancreatic lesions. Material and Method : the included pancreatic lesions (n=140) were obtained by EUS-FNA technique and stained for IMP3 immunohistochemically. Paraffin blocks from patients who underwent excision (n=92) or core biopsies (n=48) were performed for confirming diagnosis. Results : the combined method for diagnosis showed that IMP3 was positive in 78.7%, 91.7%, 100% PAC, Mucinous neoplasm with high grade dysplasia, IPMN with high grade dysplasia, respectively, while almost all benign lesions showed negative IMP3. Also, this method showed sensitivity (78.26%), specificity (95.83%), and accuracy (84.3%). Conclusion: EUS-FNA cytology with IMP3 could be a reliable diagnostic tool especially for assessment of malignant pancreatic lesions. Gastroenterology & Hepatology IMP3 Endoscopic ultrasound-guided fine needle aspiration pancreatic cancer Immunohistochemistry Figures Figure 1 Figure 2 Figure 3 I. Introduction Pancreatic cancer (PC) is considered one of the most lethal cancers with high mortality and morbidity. In 2021, an estimated 60,430 new cases of PC will be diagnosed in the US and 48,220 people will die from the disease. The death rate for PC has increased slightly (by 0.3% per year) since around 2000 ( 1 ). The 5-year relative survival of PC decreases with advanced stages at time of diagnosis, as the survival in localized disease is 39.4%, while apparently declines with regional (13.3%) and distant disease (2.9%) ( 2 ). Patients with PC are usually presented with an advanced disease, so they are inoperable at time of diagnosis. An early and feasible diagnostic tool for diagnosis is needed. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is considered a safe and effective procedure for diagnosis of pancreatic lesions which is very important because of the risk for simultaneous or later malignancy development associated with benign lesions ( 3 ). Insulin-like growth factor II messenger ribonucleic acid (mRNA) binding protein 3 (IMP3), a member of IMP family which involves IMP1, IMP2 and IMP3, is an oncofetal protein that contributes to different organs development including intestine, thymus, pancreas, and kidneys during embryogenesis ( 4 , 5 ). The evaluation of immunohistochemical markers like IMP3 protein to reach an appropriate discrimination between malignant and benign pancreatic lesions would essentially help in early diagnosis of pancreatic cancer and optimum patient management as several studies concluded that IMP3 is a promising marker for various malignancies ( 6 – 9 ). Overexpression was frequently seen in different tumor types and typically related to progressive tumor features. However, IMP3 was not expressed in various normal tissues, e.g., heart, striated muscle, uterus, esophagus, stomach, colon, kidney, urinary bladder, ovary, fat, skin, oral cavity, ectocervix, gallbladder, liver, pancreas, bone marrow, prostate, lung, breast, thyroid gland, cerebellum and cerebrum ( 10 ). The aim of this work was to assess the diagnostic value of EUS-FNA procedure with the immunohistochemical expression of IMP3 in pancreatic lesions then comparing results with surgical resected specimens or core biopsies of unresectable specimens to reach an early and accurate diagnosis. Ii. Material And Method Patients’ selection This prospective study was held up in Pathology, Tropical and Surgical Departments, Faculty of Medicine, Zagazig University, Egypt, including 140 patients with pancreatic lesions. Samples were obtained by EUS-FNA procedure, and cytology specimens and/or cell blocks were prepared. Specimens from patients who underwent surgical resection or core biopsies were histopathologically evaluated for reaching the gold standard diagnosis, however cases who did not undergo either procedure were excluded. Approval has been obtained from the Institutional Review Board (IRB), Faculty of Medicine, Zagazig University. (approval number: 6130, May 30th, 2020). Patients’ data was assessed including age, sex, site of the lesion, duct communication. EUS-FNA specimens EUS-FNA was performed with a 19, 22, or 25 gauge needle and an average of 3.1 ± 1.0 passes per session. The aspirate material was smeared onto a glass slide by air pressure and fixed with 95% ethanol for cytological evaluation. Cytology/ cell blocks specimens were fixed in formalin then embedded in paraffin. Staining with hematoxylin and eosin was done for histopathological diagnosis and with IMP3 marker for evaluation of protein expression. The diagnosis was considered as benign and malignant. Cystic fluid aspirates were investigated for levels of amylase enzyme and tumor markers CEA and CA19-9, IgG4. IMP3 Immunohistochemical staining Formalin-fixed paraffin-embedded cell blocks were serially sectioned into 3-5 𝜇m and deparaffinized in xylene, then rehydrated in descending series of alcohols. For antigen retrieval processing, 10 mM citrate buffer (pH 6.0) at the microwave for nearly 20 min was used. Blocking of endogenous peroxidase was done by using 3% hydrogen peroxide for 10 min. Repeated washing in PBS was performed, then the slides were incubated with primary antibody for mouse monoclonal antibody IMP3 (IGF2BP3 (E-2): sc-365640, 1:100 dilution, Santa Cruz Biotechnology). The polymer detection system; Dako EnVisionTM kit (Dako, Copenhagen, Denmark) was used. Finally, the tissue sections were counterstained with Meyer’s hematoxylin. IMP3 cytoplasmic expression was assessed semi-quantitatively according to both the extent of positively stained cancer cells and the intensity of stain at x100 then x400 HPF. The Intensity of staining was none, weak, moderate, and strong considered as 0, 1, 2, 3, respectively. The percentage of positive cells was calculated as <5 %; ≥5-<25 %; ≥25-<50 %; and ≥50 % and evaluated as 0, 1, 2, 3, respectively. A score was set by adding the two previous scores. A final score was considered as negative if <2, and positive if ≥2 ( 11 ). Gold standard diagnosis (Surgically resected specimens or core biopsies) The pancreatic specimens from patients who underwent surgical excision (n=92), and core biopsies (n=48) were collected, fixed in formalin, embedded in paraffin then stained with hematoxylin and eosin for setting the gold standard diagnosis relying on the clinical presentation and radiological findings. Then, the diagnosis was considered as benign and malignant to compare results with cytologic diagnosis and combined method. STATISTICAL ANALYSIS All data were collected, tabulated and statistically analyzed using SPSS 22.0 for windows (IBM Inc., Chicago, IL, USA) and MedCalc 13 for windows (MedCalc Software bvba, Ostend, Belgium). Diagnostic performance of cytology, IMP3 IHC and their combination in diagnosis of pancreatic lesions was calculated depending on sample 2x2 contingency tables generation using the Tru-cut needle biopsy/surgical specimen pathology as the reference (Gold) standard. Sensitivity, specificity, positive predictive value, negative predicitive value, positive likelihood ratio, negative likelihood ratio and accuracy were calculated to compare between them. All tests were two sided. p-value < 0.05 was considered statistically significant (S), p-value < 0.001 was considered highly statistically significant (HS), and p-value ≥ 0.05 was considered statistically non-significant (NS). Iii. Results Patients’ characteristics This study included 140 specimens of different pancreatic lesions. The incidence rate of pancreatic lesions is higher in males (53.6%). The malignant lesions were higher in age group 55 years with slightly higher incidence in males. Diagnosis of these lesions comprises malignant lesions (n=92): pancreatic adenocarcinoma carcinoma (PAC) (n=47), intraductal papillary mucinous carcinoma (IPMN) with low (n=6) and high grade dysplasia (n=12), Mucinous cystic neoplasm (MCN) with low (n=6) and high grade dysplasia (n=12), solid pseudopapillary neoplasm (SPN) (n=9), and benign lesions (n=48): Serous Microcystic Adenoma (SMA) (n=9), Pseudocyst (n=19), autoimmune pancreatitis (n=12) and chronic pancreatitis (n=8). The most common site for malignant lesions was the head followed by the body-tail (50%, 28.6%). Grossly, the pancreatic lesions were; mass nature (50%) are slightly higher than cystic lesions (45.7%) while the least common form is the mixed pattern (4.3%). Most of lesions present without duct communication (86.4%) (Table 1, 2, 3, 4) . Results of the combined method of diagnosis (EUS-FNA with IMP3 immunohistochemistry) The results of cytologic sampling obtained by EUS-FNA demonstrated that from 47 PAC, 72.3% were malignant by cytology compared by 78.7% by combined method (EUS-FNA with IMP3 immunohistochemistry). Regarding high grade MCN and IPMN, 1 case of MCN and 3 cases were detected by IMP3 immunohistochemistry over cytologic diagnosis. Two cases of low grade MCN, 2 of low grade IPMN and 2 of solid-pseudopapillary neoplasms were mistakenly considered benign by cytology, and correctly diagnosed as malignant depending on IMP3 expression. As regard the benign lesion, including serous microcystic adenoma, pseudocyst, chronic pancreatitis, and autoimmune pancreatitis were accurately benign by cytology, but only 1/9 of serous microcystic adenoma and 1/8 of autoimmune pancreatitis were positive for IMP3 and considered malignant (Table 5, 6) Considering benign and malignant diagnosis only by the three methods, the results of combined method showed higher efficacy in diagnosing the malignant pancreatic lesions than depending on cytology only, and that was proved by reaching 78.2% of malignant lesions diagnosis compared with 64.1% by cytology only (Table 6) Fig. 1 , 2 , 3 . Assessment of sensitivity, specificity, and accuracy Regarding using cytology (EUS-FNA) only for diagnosis of pancreatic lesions, the sensitivity was 64.13%; the specificity was (100%), and the accuracy was 89%. But the combination of cytological diagnosis using EUS-FNA with the expression of IMP3 in diagnosis showed sensitivity (78.26%), specificity (95.83%), and accuracy (84.3%). So, IMP3 with cytology has higher sensitivity, while cytology has more specificity and accuracy (Table7). Vi. Discussion Pancreatic cancer (PC) is characterized by poor prognosis, decreased survival and inoperable advanced stages. Presenting at advanced stages is considered a crucial point in patients’ survival. Therefore, an early and accurate diagnosis is needed for those patients, hoping for early management that could improve prognosis and prolong survival. A study done by Pasiliao et al 2015 observed a decrease in motility, invasion, and matrix adhesion following IMP3 knockdown suggesting that IMP3 promotes PAC progression by enhancing the pro-metastatic behavior of tumor cells ( 12 ). Moreover, the immunohistochemical IMP3 expression was considered a poor prognostic predictor in different malignancies as mucoepidermoid carcinoma of salivary glands, duodenal papillary carcinoma and pilocytic and pilomyxoid astrocytomas ( 13 – 15 ). Also confirming the diagnostic importance of IMP3, using quantitative real-time RT-PCR by Yantiss et al 2005 showed that mRNA IMP3 was highly expressed in pancreatic carcinomas (79%) ( 16 ). Also, Wang et al 2015 demonstrated that increased mRNA IMP3 expression was associated with poor overall survival and considered as an independent risk factor and they suggested that combination with microdissection techniques to evaluate IMP3 mRNA expression in frozen pancreatic lesions can be worthy for diagnosis of PC ( 17 ). Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) combined with evaluation of IMP3 immunohistochemical expression is a promising tool for achieving this goal. A meta-analysis study showed that the results of IMP3 immunostaining may be a useful diagnostic tool for confirming PAC but should be evaluated in parallel with the gold standard of histopathological morphology and clinical findings. Also IMP3 was suggested to be diagnostic tool for duodenal papillary carcinoma and endometrial cancers and their premalignant lesions ( 14 , 18 – 19 ). EUS approach is not only minimally invasive technique with low complications but also it provides us with high resolution images for different pancreatic lesions and may determine tumor stage. Many studies studied the combined diagnostic tool of (EUS-FNA) with IMP3 expression for discriminating malignant from benign lesions. As Yantiss et al 2008 demonstrated that EUS-FNA for PAC expressed IMP3 in 92% of the cases, while all cases of chronic pancreatitis were IMP3 negative ( 20 ). Zhao et al 2007 found that all benign cases expressed negative IMP3; IMP3 was expressed in 88% of PAC; suspicious cases were positive for IMP3; Cytology results combined with IMP3 expression revealed 95% positivity in PAC ( 21 ). IMP3 staining was positive in 97%, 79% of PAC, high grade dysplasia, respectively, while in mild to moderate dysplasia, IMP3 showed negative staining. Generally, IMP3 showed strong to moderate intensity ( 16 ). These results were agreeing with ours, as we found that high IMP3 was expressed in 77.8%, 78.7%, 91.7%, and 100% of SPN, PAC, mucinous neoplasm with high grade dysplasia, and IPMN with high grade dysplasia, respectively. In low grade dysplasia, 2/6 cases of mucinous neoplasm and 3/6 cases of IPMN were positive for IMP3 staining. However, benign lesions showed negative staining in all cases of benign lesions except one case of serous microcystic adenoma and a case of autoimmune pancreatitis which were diagnosed by cytology as benign. Also, A study analyzed the expression of 26 immunohistochemical markers confirmed the diagnosis of PAC in both surgical and fine-needle aspiration specimens using the best diagnostic panel of immunomarkers including pVHL, maspin, S100P, and IMP3. IMP3 was 90% positive (intermediate to weak intensity) in PAC in surgical specimens and normal pancreatic ducts were usually negative for IMP-3, while in FNA specimens, IMP3 was positive in 93% of PAC compared with 77% and 10% for suspicious and benign cases, respectively ( 22 ). The incidence of pancreatic cystic lesions is rising due to increase use of imaging techniques as part of routine clinical practice. Some cystic lesions have the potential for malignant neoplastic transformation and are considered malignant precursor for pancreatic ductal adenocarcinoma such as intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) whereas serous cystic neoplasms (SCNs) are considered benign lesions. Ezzat et al 2016 and Senoo et al 2018 demonstrated sensitivity, and specificity of IMP3 on cytology specimens for PAC were 91.2%, 86.7%, and 87.9%, 100%, respectively, with total accuracy 90.3% and 90.8%, respectively ( 23 – 24 ). Our findings concluded that using of combined IMP3 immunohistochemical staining with cytology diagnosis of malignant and benign pancreatic lesions has sensitivity, and specificity of 78.2% and 95.8% with total accuracy 84.3% compared with 64.1%, 100%, and 89% sensitivity, specificity, and total accuracy of cytology diagnosis only, respectively. Limitations of the study : Many problematic issues may arise due to limited skills of the endoscopy operator in terms of insufficient tissue yield and targeting-error, misinterpretation and misdiagnosis by pathologists and absence of on-site cytopathologists for adequacy assessment. In conclusion , for diagnosing malignant pancreatic lesions, IMP3 expression based on EUS-FNA sampling could be very valuable. However, benign lesions rely more accurately on cytologic findings by EUS-FNA than IMP3 expression. Further research is recommended on largest samples of malignant and benign pancreatic lesions. Declarations Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Declaration of Competing Interest The authors declare that they have no conflict of interest. References American Cancer Society. Facts & Figures 2021 . American Cancer Society. Atlanta, Ga. 2021. Howlader N, Noone AM, Krapcho M, et al (eds). SEER Cancer Statistics Review, 1975-2017, National Cancer Institute, Bethesda, MD, https://seer.cancer . gov/csr/1975_2017/ , based on November 2018 SEER data submission, posted to the SEER website, April 2019 Puli SR, Bechtold ML, Buxbaum JL, Eloubeidi MA. 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Lung. 2016 Feb 1;194(1):137-46. Pasiliao CC, Chang CW, Sutherland BW, Valdez SM, Schaeffer D, Yapp DT, Ng SS. The involvement of insulin-like growth factor 2 binding protein 3 (IMP3) in pancreatic cancer cell migration, invasion, and adhesion. BMC Cancer. 2015 Apr 11;15:266. Elshafey MR, Ahmed RA, Mourad MI, Gaballah ET. The oncofetal protein IMP3 is an indicator of early recurrence and poor outcome in mucoepidermoid carcinoma of salivary glands. Cancer Biol Med . 2016;13(2):286–95. Tanaka H, Kawashima H, Ohno E, Ishikawa T, Iida T, Ishikawa E, Furukawa K, Nakamura M, Honda T, Shimoyama Y, Miyahara R, Kawabe N, Kuzuya T, Hashimoto S, Ishigami M, Hirooka Y, Fujishiro M. Immunohistochemical staining for IMP3 in patients with duodenal papilla tumors: assessment of the potential for diagnosing endoscopic resectability and predicting prognosis. BMC Gastroenterol. 2021 May 18;21(1):224. Barton VN, Donson AM, Birks DK, Kleinschmidt-DeMasters BK, Handler MH, Foreman NK, Rush SZ. Insulin-like growth factor 2 mRNA binding protein 3 expression is an independent prognostic factor in pediatric pilocytic and pilomyxoid astrocytoma. J Neuropathol Exp Neurol. 2013 May;72(5):442–9. Yantiss RK, Woda BA, Fanger GR, Kalos M, Whalen GF, Tada H, Andersen DK, Rock KL, Dresser K. KOC (K homology domain containing protein overexpressed in cancer): a novel molecular marker that distinguishes between benign and malignant lesions of the pancreas. The American Journal of Surgical Pathology. 2005 Feb;29(2):188–95. Wang BJ, Wang L, Yang SY, Liu ZJ. Expression and clinical significance of IMP3 in microdissected premalignant and malignant pancreatic lesions. Clin Transl Oncol . 2015 Mar;17(3):215–22. Wang Q, Wang T, Wang Z, Zheng H. Diagnostic value of IMP3 in pancreatic cancer: a meta-analysis [Retraction] Int J Clin Exp Med. 2016;9(6):12417. Zheng W, Yi X, Fadare O, Liang SX, Martel M, Schwartz PE, Jiang Z. The oncofetal protein IMP3: a novel biomarker for endometrial serous carcinoma. Am J Surg Pathol. 2008 Feb;32(2):304–15. Yantiss RK, Cosar E, Fischer AH. Use of IMP3 in identification of carcinoma in fine needle aspiration biopsies of pancreas. Acta Cytol. 2008;52(2):133–8. Zhao H, Mandich D, Cartun RW, Ligato S. Expression of K homology domain containing protein overexpressed in cancer in pancreatic FNA for diagnosing adenocarcinoma of pancreas. Diagn Cytopathol. 2007 Nov;35(11):700–4. Liu H, Shi J, Anandan V, Wang HL, Diehl D, Blansfield J, Gerhard G, Lin F. Reevaluation and identification of the best immunohistochemical panel (pVHL, Maspin, S100P, IMP-3) for ductal adenocarcinoma of the pancreas. Arch Pathol Lab Med. 2012;136(6):601–9. Ezzat NE, Tahoun NS, Ismail YM. The role of S100P and IMP3 in the cytologic diagnosis of pancreatic adenocarcinoma. J Egypt Natl Canc Inst. 2016 Dec;28(4):229–34. Senoo J, Mikata R, Kishimoto T, Hayashi M, Kusakabe Y, Yasui S, Yamato M, Ohyama H, Sugiyama H, Tsuyuguchi T, Yoshitomi H, Ohtsuka M, Maeda J, Ota S, Nakatani Y, Kato N. Immunohistochemical analysis of IMP3 and p53 expression in endoscopic ultrasound-guided fine needle aspiration and resected specimens of pancreatic diseases. Pancreatology 2018;18: 176–83. Tables Table (1): Diagnosis of the studied patients (N=140). Diagnosis The studied patients (N=140) Number Percent Cytologic diagnosis Malignant 59 42.1% Benign 81 57.9% Cytologic + IMP3 diagnosis Malignant 74 52.9% Benign 66 47.1% Gold standard diagnosis Malignant 92 65.7% Benign 48 34.3% Table (2): Gold standard diagnosis of the studied patients (N=140). Gold standard diagnosis The studied patients (N=140) Number Percent Pancreatic Adenocarcinoma 47 33.6% Mucinous neoplasm with high grade dysplasia 12 8.6% Mucinous neoplasm with low grade dysplasia 6 4.3% IPMN with low grade dysplasia 6 4.3% IPMN with high grade dysplasia 12 8.6% SPN 9 6.4% Serous microcystic Adenoma Pseudocyst Pancreatitis Autoimmune pancreatitis Total 9 19 12 8 140 6.4% 13.6% 8.6% 5.7% 100% Table (3): Comparison between benign and malignant pancreatic lesions regarding demographic data Demographic data All Studied patients (N=140) Gold standard diagnosis Test p-value (Sig.) Malignant (N=92) Benign (N=48) No. % No. % No. % Age (years) > 55 years 56 40% 27 29.3% 29 60.4% 12.686 a 55 years 84 60% 65 70.7% 19 39.6% Mean ± SD 56±14.5749 58.3261±15.56561 53.2917±11.92166 -2.956 b <0.003 (HS) Median (Range) 58 (12 – 85) 62.5 (12 – 85) 52 (30 – 77) Sex Male 75 53.6% 52 56.5% 23 47.9% 0.939 a 0.333 (NS) Female 65 46.4% 40 43.5% 25 52.1% a: Chi-square test; b: Mann Whitney U test; p-value< 0.05 is significant; Sig.: Significance. Table (4): Comparison between benign and malignant pancreatic lesions regarding imaging findings Imaging findings All Studied patients (N=140) Gold standard diagnosis Test a p-value (Sig.) Malignant (N=92) Benign (N=48) No. % No. % No. % Site of lesion Head 70 50% 59 64.1% 11 22.9% 52.156 a <0.001 (HS) Body-tail 40 28.6% 29 31.5% 11 22.9% Entire pancreas 11 7.9% 4 4.3% 7 14.6% Extra-pancreatic 19 13.6% 0 0% 19 39.6% Nature Mass 70 50% 54 58.7% 16 33.3% 9.395 a 0.009 (S) Cyst 64 45.7% 36 39.1% 28 58.3% Mixed 6 4.3% 2 2.2% 4 8.3% Duct communication No 121 86.4% 73 79.3% 48 100% 11.470 a 0.001 (S) Yes 19 13.6% 19 20.7% 0 0% a: Chi-square test; p-value< 0.05 is significant; Sig.: Significance. Table (5): Comparison between cytological diagnosis and gold standard diagnosis Cytologic diagnosis Gold standard diagnosis Total Malignant Benign Malignant No. 59 0 59 % 42.1% 0% 42.1% Benign No. 33 48 81 % 23.6% 34.3% 57.9% Total No. 92 48 140 % 65.7% 34.3% 100% Test c 31.030 p-value (Sig.) <0.001 (HS) c: McNemar’s test; p-value< 0.05 is significant; Sig.: Significance. Table (6): Comparison between Cytologic+IMP3 and gold standard diagnosis Cytologic+IMP3 diagnosis Gold standard diagnosis Total Malignant Benign Malignant No. 72 2 74 % 51.4% 1.4% 52.9% Benign No. 20 46 66 % 14.3% 32.9% 47.1% Total No. 92 48 140 % 65.7% 34.3% 100% Test c 13.136 p-value (Sig.) <0.001 (HS) c: McNemar’s test; p-value< 0.05 is significant; Sig.: Significance. Table (7): Diagnostic performance of cytology and cytology+IMP3 IHC for diagnosis of malignant pancreatic lesions Cytology Cytology+ IMP3 IHC TP 59 72 FP 0 2 TN 48 46 FN 33 20 SN (95%CI) 64.13% (53.457 – 73.867) 78.26% (68.44 – 86.187) SP (95%CI) 100% (92.06 – 100) 95.83% (85.746 – 99.49) PPV (95%CI) 100% 97.297% (90.225 – 99.293) NPV (95%CI) 59.259% (52.534 – 65.654) 69.69% (60.843 – 77.296) Positive LR (95%CI) 18.78 (4.871 – 73.255) Negative LR (95%CI) 0.359 (0.273 – 0.471) 0.227 (0.153 – 0.336) Accuracy (95%CI) 89% (52.2 – 97.6) 84.3% (74.4 – 90. 7) AUC (95%CI) 0.821 (0.747 – 0.88) 0.870 (0.803 – 0.921) TP: True positive; FP: False positive; TN: True negative; FN: False negative; SN: Sensitivity; SP: Specificity; PPV: Positive Predictive Value; NPV: Negative Predictive Value; LR: Likelihood Ratio; AUC: Area Under Curve; CI: Confidence Interval. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 02 Nov, 2021 Reviewers invited by journal 02 Nov, 2021 Editor assigned by journal 01 Nov, 2021 First submitted to journal 29 Oct, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1032716","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":60709771,"identity":"7f8f0d45-c9e0-40fb-baf1-4590f16abc84","order_by":0,"name":"Hayam Rashed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYBACAzhLAog+MDAkkKZFcgbJWqR5iNFizn7G8NMNhnvy8rObD962bbPL42dvYPzwMQe3FsueHGPpHIZiww13jiVb57YlF0v2HGCWnLkNj8MO5BgAtSQwbpDIMZPObWNO3HAjgY2ZF5+W82+MfwO12M+fkf9N2rKtnggtN4CGA7UkNtzIYZNmbDtMjJZnZdZALckbbqQZW/acO544s+dgM36/nE/efBuoxXb+jOSHN36UVSf2szcf/PARjxYGBg4DBsZ/UDYjG5hswKceCNgfIHH+EFA8CkbBKBgFIxIAAA9NU6thyjycAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-8204-9937","institution":"Zagazig university","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hayam","middleName":"","lastName":"Rashed","suffix":""},{"id":60709772,"identity":"132bc135-9fb0-4564-9a1a-be6fb493456b","order_by":1,"name":"Nora Wasfi","email":"","orcid":"","institution":"Zagazig University Faculty of Human Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nora","middleName":"","lastName":"Wasfi","suffix":""},{"id":60709773,"identity":"23bbf64e-ce23-45a6-91c8-6f5dc1cff5b7","order_by":2,"name":"Awatef Nasr","email":"","orcid":"","institution":"Zagazig University Faculty of Human Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Awatef","middleName":"","lastName":"Nasr","suffix":""},{"id":60709774,"identity":"acdb681c-7204-4723-a93a-db73a4f7b924","order_by":3,"name":"Ramy ElHendawy","email":"","orcid":"","institution":"Zagazig University Faculty of Human Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ramy","middleName":"","lastName":"ElHendawy","suffix":""},{"id":60709775,"identity":"50ef6e5a-9699-499d-9aa2-eb841af07d4d","order_by":4,"name":"Nelly Mohammed Said","email":"","orcid":"","institution":"Zagazig University Faculty of Human Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nelly","middleName":"Mohammed","lastName":"Said","suffix":""}],"badges":[],"createdAt":"2021-10-29 20:46:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1032716/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1032716/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":15259266,"identity":"4b473505-6419-4e2e-9b96-fb653061b240","added_by":"auto","created_at":"2021-11-05 16:55:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5829440,"visible":true,"origin":"","legend":"A- Cytology showed pleomorphic malignant cells with hyperchromatic nuclei of pancreatic adenocarcinoma (H\u0026E x400)\nB- IMP3 immunohistochemical expression was positive in cell block of PAC (IHC x400).\n","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-1032716/v1/d7986355cb2ecb4e6467b12f.png"},{"id":15259267,"identity":"60c4f2e7-81b9-4e84-9120-80f7dff10841","added_by":"auto","created_at":"2021-11-05 16:55:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34519878,"visible":true,"origin":"","legend":"A- MCN high grade showed dysplastic mucinous cells with high grade dysplasia in cell block (H\u0026E x400) \nB- MCN high grade showed high expression of IMP3 in cell block (IMP3 IHC x400) \n","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-1032716/v1/1532cc898108322b7d3e7e2b.png"},{"id":15259268,"identity":"70660a25-f652-4a3a-926c-b1d6f5c17707","added_by":"auto","created_at":"2021-11-05 16:55:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":24249451,"visible":true,"origin":"","legend":"Core biopsy showed well differentiated pancreatic duct adenocarcinoma (H\u0026E x400)","description":"","filename":"fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-1032716/v1/07f3377c47e6aa8dab48bb04.png"},{"id":15259270,"identity":"12ffa059-09f0-4ee3-a37c-fd4feab362a9","added_by":"auto","created_at":"2021-11-05 16:55:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":383630,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1032716/v1/eb6589ca-2b47-4eb5-9cfc-e0f5a06c877a.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eA Promising Diagnostic Role of Immunohistochemical Expression of Insulin-Like Growth Factor II mRNA Binding Protein3 (IMP3) in Pancreatic Lesions Using Endoscopic Ultrasound –Guided –Fine Needle Aspiration (EUS-FNA) Cytology\u003c/p\u003e","fulltext":[{"header":"I. Introduction","content":"\u003cp\u003ePancreatic cancer (PC) is considered one of the most lethal cancers with high mortality and morbidity. In 2021, an estimated 60,430 new cases of PC will be diagnosed in the US and 48,220 people will die from the disease. The death rate for PC has increased slightly (by 0.3% per year) since around 2000 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The 5-year relative survival of PC decreases with advanced stages at time of diagnosis, as the survival in localized disease is 39.4%, while apparently declines with regional (13.3%) and distant disease (2.9%) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients with PC are usually presented with an advanced disease, so they are inoperable at time of diagnosis. An early and feasible diagnostic tool for diagnosis is needed. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is considered a safe and effective procedure for diagnosis of pancreatic lesions which is very important because of the risk for simultaneous or later malignancy development associated with benign lesions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInsulin-like growth factor II messenger ribonucleic acid (mRNA) binding protein 3 (IMP3), a member of IMP family which involves IMP1, IMP2 and IMP3, is an oncofetal protein that contributes to different organs development including intestine, thymus, pancreas, and kidneys during embryogenesis (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe evaluation of immunohistochemical markers like IMP3 protein to reach an appropriate discrimination between malignant and benign pancreatic lesions would essentially help in early diagnosis of pancreatic cancer and optimum patient management as several studies concluded that IMP3 is a promising marker for various malignancies (\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Overexpression was frequently seen in different tumor types and typically related to progressive tumor features. However, IMP3 was not expressed in various normal tissues, e.g., heart, striated muscle, uterus, esophagus, stomach, colon, kidney, urinary bladder, ovary, fat, skin, oral cavity, ectocervix, gallbladder, liver, pancreas, bone marrow, prostate, lung, breast, thyroid gland, cerebellum and cerebrum (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of this work was to assess the diagnostic value of EUS-FNA procedure with the immunohistochemical expression of IMP3 in pancreatic lesions then comparing results with surgical resected specimens or core biopsies of unresectable specimens to reach an early and accurate diagnosis.\u003c/p\u003e"},{"header":"Ii. Material And Method","content":"\u003cp\u003e \u003cb\u003ePatients\u0026rsquo; selection\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis prospective study was held up in Pathology, Tropical and Surgical Departments, Faculty of Medicine, Zagazig University, Egypt, including 140 patients with pancreatic lesions. Samples were obtained by EUS-FNA procedure, and cytology specimens and/or cell blocks were prepared. Specimens from patients who underwent surgical resection or core biopsies were histopathologically evaluated for reaching the gold standard diagnosis, however cases who did not undergo either procedure were excluded. Approval has been obtained from the Institutional Review Board (IRB), Faculty of Medicine, Zagazig University. (approval number: 6130, May 30th, 2020). Patients\u0026rsquo; data was assessed including age, sex, site of the lesion, duct communication.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEUS-FNA specimens\u003c/b\u003e \u003c/p\u003e \u003cp\u003eEUS-FNA was performed with a 19, 22, or 25 gauge needle and an average of 3.1 \u0026plusmn; 1.0 passes per session. The aspirate material was smeared onto a glass slide by air pressure and fixed with 95% ethanol for cytological evaluation. Cytology/ cell blocks specimens were fixed in formalin then embedded in paraffin. Staining with hematoxylin and eosin was done for histopathological diagnosis and with IMP3 marker for evaluation of protein expression. The diagnosis was considered as benign and malignant. Cystic fluid aspirates were investigated for levels of amylase enzyme and tumor markers CEA and CA19-9, IgG4.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIMP3 Immunohistochemical staining\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFormalin-fixed paraffin-embedded cell blocks were serially sectioned into 3-5 \u0026#120583;m and deparaffinized in xylene, then rehydrated in descending series of alcohols. For antigen retrieval processing, 10 mM citrate buffer (pH 6.0) at the microwave for nearly 20 min was used. Blocking of endogenous peroxidase was done by using 3% hydrogen peroxide for 10 min. Repeated washing in PBS was performed, then the slides were incubated with primary antibody for mouse monoclonal antibody IMP3 (IGF2BP3 (E-2): sc-365640, 1:100 dilution, Santa Cruz Biotechnology). The polymer detection system; Dako EnVisionTM kit (Dako, Copenhagen, Denmark) was used. Finally, the tissue sections were counterstained with Meyer\u0026rsquo;s hematoxylin.\u003c/p\u003e \u003cp\u003e IMP3 cytoplasmic expression was assessed semi-quantitatively according to both the extent of positively stained cancer cells and the intensity of stain at x100 then x400 HPF. The Intensity of staining was none, weak, moderate, and strong considered as 0, 1, 2, 3, respectively. The percentage of positive cells was calculated as \u0026lt;5 %; \u0026ge;5-\u0026lt;25 %; \u0026ge;25-\u0026lt;50 %; and \u0026ge;50 % and evaluated as 0, 1, 2, 3, respectively. A score was set by adding the two previous scores. A final score was considered as negative if \u0026lt;2, and positive if \u0026ge;2 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eGold standard diagnosis (Surgically resected specimens or core biopsies)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe pancreatic specimens from patients who underwent surgical excision (n=92), and core biopsies (n=48) were collected, fixed in formalin, embedded in paraffin then stained with hematoxylin and eosin for setting the gold standard diagnosis relying on the clinical presentation and radiological findings. Then, the diagnosis was considered as benign and malignant to compare results with cytologic diagnosis and combined method.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSTATISTICAL ANALYSIS\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAll data were collected, tabulated and statistically analyzed using SPSS 22.0 for windows (IBM Inc., Chicago, IL, USA) and MedCalc 13 for windows (MedCalc Software bvba, Ostend, Belgium). Diagnostic performance of cytology, IMP3 IHC and their combination in diagnosis of pancreatic lesions was calculated depending on sample 2x2 contingency tables generation using the Tru-cut needle biopsy/surgical specimen pathology as the reference (Gold) standard. Sensitivity, specificity, positive predictive value, negative predicitive value, positive likelihood ratio, negative likelihood ratio and accuracy were calculated to compare between them. All tests were two sided. p-value \u0026lt; 0.05 was considered statistically significant (S), p-value \u0026lt; 0.001 was considered highly statistically significant (HS), and p-value \u0026ge; 0.05 was considered statistically non-significant (NS).\u003c/p\u003e"},{"header":"Iii. Results","content":"\u003cp\u003e\u003cstrong\u003ePatients\u0026rsquo; characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included 140 specimens of different pancreatic lesions. The incidence rate of pancreatic lesions is higher in males (53.6%). The malignant lesions were higher in age group 55 years with slightly higher incidence in males. Diagnosis of these lesions comprises malignant lesions (n=92): pancreatic adenocarcinoma carcinoma (PAC) (n=47), intraductal papillary mucinous carcinoma (IPMN) with low (n=6) and high grade dysplasia (n=12), Mucinous cystic neoplasm (MCN) with low (n=6) and high grade dysplasia (n=12), solid pseudopapillary neoplasm (SPN) (n=9), and benign lesions (n=48): Serous Microcystic Adenoma (SMA) (n=9), Pseudocyst (n=19), autoimmune pancreatitis (n=12) and chronic pancreatitis (n=8). The most common site for malignant lesions was the head followed by the body-tail (50%, 28.6%). Grossly, the pancreatic lesions were; mass nature (50%) are slightly higher than cystic lesions (45.7%) while the least common form is the mixed pattern (4.3%). Most of lesions present without duct communication (86.4%) \u003cstrong\u003e(Table 1, 2, 3, 4)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults of the combined method of diagnosis (EUS-FNA with IMP3 immunohistochemistry)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of cytologic sampling obtained by EUS-FNA demonstrated that from 47 PAC, 72.3% were malignant by cytology compared by 78.7% by combined method (EUS-FNA with IMP3 immunohistochemistry). Regarding high grade MCN and IPMN, 1 case of MCN and 3 cases were detected by IMP3 immunohistochemistry over cytologic diagnosis. Two cases of low grade MCN, 2 of low grade IPMN and 2 of solid-pseudopapillary neoplasms were mistakenly considered benign by cytology, and correctly diagnosed as malignant depending on IMP3 expression. As regard the benign lesion, including serous microcystic adenoma, pseudocyst, chronic pancreatitis, and autoimmune pancreatitis were accurately benign by cytology, but only 1/9 of serous microcystic adenoma and 1/8 of autoimmune pancreatitis were positive for IMP3 and considered malignant \u003cstrong\u003e(Table 5, 6)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsidering benign and malignant diagnosis only by the three methods, the results of combined method showed higher efficacy in diagnosing the malignant pancreatic lesions than depending on cytology only, and that was proved by reaching 78.2% of malignant lesions diagnosis compared with 64.1% by cytology only \u003cstrong\u003e(Table 6)\u003c/strong\u003e Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of sensitivity, specificity, and accuracy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding using cytology (EUS-FNA) only for diagnosis of pancreatic lesions, the sensitivity was 64.13%; the specificity was (100%), and the accuracy was 89%. But the combination of cytological diagnosis using EUS-FNA with the expression of IMP3 in diagnosis showed sensitivity (78.26%), specificity (95.83%), and accuracy (84.3%). So, IMP3 with cytology has higher sensitivity, while cytology has more specificity and accuracy \u003cstrong\u003e(Table7).\u003c/strong\u003e\u003c/p\u003e"},{"header":"Vi. Discussion","content":"\u003cp\u003ePancreatic cancer (PC) is characterized by poor prognosis, decreased survival and inoperable advanced stages. Presenting at advanced stages is considered a crucial point in patients\u0026rsquo; survival. Therefore, an early and accurate diagnosis is needed for those patients, hoping for early management that could improve prognosis and prolong survival. A study done by \u003cb\u003ePasiliao et al 2015\u003c/b\u003e observed a decrease in motility, invasion, and matrix adhesion following IMP3 knockdown suggesting that IMP3 promotes PAC progression by enhancing the pro-metastatic behavior of tumor cells (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Moreover, the immunohistochemical IMP3 expression was considered a poor prognostic predictor in different malignancies as mucoepidermoid carcinoma of salivary glands, duodenal papillary carcinoma and pilocytic and pilomyxoid astrocytomas (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlso confirming the diagnostic importance of IMP3, using quantitative real-time RT-PCR by \u003cb\u003eYantiss et al 2005\u003c/b\u003e showed that mRNA IMP3 was highly expressed in pancreatic carcinomas (79%) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Also, \u003cb\u003eWang et al 2015\u003c/b\u003e demonstrated that increased mRNA IMP3 expression was associated with poor overall survival and considered as an independent risk factor and they suggested that combination with microdissection techniques to evaluate IMP3 mRNA expression in frozen pancreatic lesions can be worthy for diagnosis of PC (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEndoscopic ultrasound-guided fine needle aspiration (EUS-FNA) combined with evaluation of IMP3 immunohistochemical expression is a promising tool for achieving this goal. A meta-analysis study showed that the results of IMP3 immunostaining may be a useful diagnostic tool for confirming PAC but should be evaluated in parallel with the gold standard of histopathological morphology and clinical findings. Also IMP3 was suggested to be diagnostic tool for duodenal papillary carcinoma and endometrial cancers and their premalignant lesions (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEUS approach is not only minimally invasive technique with low complications but also it provides us with high resolution images for different pancreatic lesions and may determine tumor stage. Many studies studied the combined diagnostic tool of (EUS-FNA) with IMP3 expression for discriminating malignant from benign lesions. As \u003cb\u003eYantiss et al 2008\u003c/b\u003e demonstrated that EUS-FNA for PAC expressed IMP3 in 92% of the cases, while all cases of chronic pancreatitis were IMP3 negative (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). \u003cb\u003eZhao et al 2007\u003c/b\u003e found that all benign cases expressed negative IMP3; IMP3 was expressed in 88% of PAC; suspicious cases were positive for IMP3; Cytology results combined with IMP3 expression revealed 95% positivity in PAC (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). IMP3 staining was positive in 97%, 79% of PAC, high grade dysplasia, respectively, while in mild to moderate dysplasia, IMP3 showed negative staining. Generally, IMP3 showed strong to moderate intensity (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These results were agreeing with ours, as we found that high IMP3 was expressed in 77.8%, 78.7%, 91.7%, and 100% of SPN, PAC, mucinous neoplasm with high grade dysplasia, and IPMN with high grade dysplasia, respectively.\u003c/p\u003e \u003cp\u003eIn low grade dysplasia, 2/6 cases of mucinous neoplasm and 3/6 cases of IPMN were positive for IMP3 staining. However, benign lesions showed negative staining in all cases of benign lesions except one case of serous microcystic adenoma and a case of autoimmune pancreatitis which were diagnosed by cytology as benign. Also, A study analyzed the expression of 26 immunohistochemical markers confirmed the diagnosis of PAC in both surgical and fine-needle aspiration specimens using the best diagnostic panel of immunomarkers including pVHL, maspin, S100P, and IMP3. IMP3 was 90% positive (intermediate to weak intensity) in PAC in surgical specimens and normal pancreatic ducts were usually negative for IMP-3, while in FNA specimens, IMP3 was positive in 93% of PAC compared with 77% and 10% for suspicious and benign cases, respectively (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe incidence of pancreatic cystic lesions is rising due to increase use of imaging techniques as part of routine clinical practice. Some cystic lesions have the potential for malignant neoplastic transformation and are considered malignant precursor for pancreatic ductal adenocarcinoma such as intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) whereas serous cystic neoplasms (SCNs) are considered benign lesions. \u003cb\u003eEzzat et al 2016 and Senoo et al 2018\u003c/b\u003e demonstrated sensitivity, and specificity of IMP3 on cytology specimens for PAC were 91.2%, 86.7%, and 87.9%, 100%, respectively, with total accuracy 90.3% and 90.8%, respectively (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Our findings concluded that using of combined IMP3 immunohistochemical staining with cytology diagnosis of malignant and benign pancreatic lesions has sensitivity, and specificity of 78.2% and 95.8% with total accuracy 84.3% compared with 64.1%, 100%, and 89% sensitivity, specificity, and total accuracy of cytology diagnosis only, respectively.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations of the study\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eMany problematic issues may arise due to limited skills of the endoscopy operator in terms of insufficient tissue yield and targeting-error, misinterpretation and misdiagnosis by pathologists and absence of on-site cytopathologists for adequacy assessment.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIn conclusion\u003c/b\u003e, for diagnosing malignant pancreatic lesions, IMP3 expression based on EUS-FNA sampling could be very valuable. However, benign lesions rely more accurately on cytologic findings by EUS-FNA than IMP3 expression. Further research is recommended on largest samples of malignant and benign pancreatic lesions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Cancer Society. \u003cem\u003eFacts \u0026amp; Figures 2021\u003c/em\u003e. American Cancer Society. Atlanta, Ga. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHowlader N, Noone AM, Krapcho M, et al (eds). 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Scand J Clin Lab Invest Suppl. 2001;234:93\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMueller-Pillasch F, Pohl B, Wilda M, Lacher U, Beil M, Wallrapp C, Hameister H, Kn\u0026ouml;chel W, Adler G, Gress TM. Expression of the highly conserved RNA binding protein KOC in embryogenesis. Mech Dev. 1999 Oct;88(1):95\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan J, Wei Q, Jian W, Qiu B, Wen J, Liu J, Fu B, Zhou X, Zhao T. IMP3 predicts invasion and prognosis in human lung adenocarcinoma. Lung. 2016;194:137\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLok T, Chen L, Lin F, Wang HL. Immunohistochemical distinction between intrahepatic cholangiocarcinoma and pancreatic ductal adenocarcinoma. Hum Pathol. 2014;45:394\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamasceno EA, Carneiro FP, Magalh\u0026atilde;es AV, Carneiro MV, Takano GH, Vianna LM, Seidler HB, Castro TM, Muniz-Junqueira MI, Amorim RF, Ferreira VM. IMP3 expression in gastric cancer: Association with clinicopathological features and HER2 status. J Cancer Res Clin Oncol. 2014;140:2163\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi D, Yan D, Tang H, Zhou C, Fan J, Li S, Wang X, Xia J, Huang F, Qiu G, Peng Z. IMP3 is a novel prognostic marker that correlates with colon cancer progression and pathogenesis. Ann Surg Oncol. 2009 Dec;16(12):3499\u0026ndash;506.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurdelski C, Jakani-Karimi N, Jacobsen F, M\u0026ouml;ller-Koop C, Minner S, Simon R, Sauter G, Steurer S, Clauditz TS, Wilczak W. IMP3 overexpression occurs in various important cancer types and is linked to aggressive tumor features: a tissue microarray study on 8,877 human cancers and normal tissues. Oncology reports. 2018 Jan 1;39(1):3-12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan J, Wei Q, Jian W, Qiu B, Wen J, Liu J, Fu B, Zhou X, Zhao T. IMP3 predicts invasion and prognosis in human lung adenocarcinoma. Lung. 2016 Feb 1;194(1):137-46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePasiliao CC, Chang CW, Sutherland BW, Valdez SM, Schaeffer D, Yapp DT, Ng SS. The involvement of insulin-like growth factor 2 binding protein 3 (IMP3) in pancreatic cancer cell migration, invasion, and adhesion. BMC Cancer. 2015 Apr 11;15:266.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElshafey MR, Ahmed RA, Mourad MI, Gaballah ET. The oncofetal protein IMP3 is an indicator of early recurrence and poor outcome in mucoepidermoid carcinoma of salivary glands. \u003cem\u003eCancer Biol Med\u003c/em\u003e. 2016;13(2):286\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanaka H, Kawashima H, Ohno E, Ishikawa T, Iida T, Ishikawa E, Furukawa K, Nakamura M, Honda T, Shimoyama Y, Miyahara R, Kawabe N, Kuzuya T, Hashimoto S, Ishigami M, Hirooka Y, Fujishiro M. Immunohistochemical staining for IMP3 in patients with duodenal papilla tumors: assessment of the potential for diagnosing endoscopic resectability and predicting prognosis. BMC Gastroenterol. 2021 May 18;21(1):224.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarton VN, Donson AM, Birks DK, Kleinschmidt-DeMasters BK, Handler MH, Foreman NK, Rush SZ. Insulin-like growth factor 2 mRNA binding protein 3 expression is an independent prognostic factor in pediatric pilocytic and pilomyxoid astrocytoma. J Neuropathol Exp Neurol. 2013 May;72(5):442\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYantiss RK, Woda BA, Fanger GR, Kalos M, Whalen GF, Tada H, Andersen DK, Rock KL, Dresser K. KOC (K homology domain containing protein overexpressed in cancer): a novel molecular marker that distinguishes between benign and malignant lesions of the pancreas. The American Journal of Surgical Pathology. 2005 Feb;29(2):188\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang BJ, Wang L, Yang SY, Liu ZJ. Expression and clinical significance of IMP3 in microdissected premalignant and malignant pancreatic lesions. \u003cem\u003eClin Transl Oncol\u003c/em\u003e. 2015 Mar;17(3):215\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Q, Wang T, Wang Z, Zheng H. Diagnostic value of IMP3 in pancreatic cancer: a meta-analysis [Retraction] Int J Clin Exp Med. 2016;9(6):12417.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng W, Yi X, Fadare O, Liang SX, Martel M, Schwartz PE, Jiang Z. The oncofetal protein IMP3: a novel biomarker for endometrial serous carcinoma. Am J Surg Pathol. 2008 Feb;32(2):304\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYantiss RK, Cosar E, Fischer AH. Use of IMP3 in identification of carcinoma in fine needle aspiration biopsies of pancreas. Acta Cytol. 2008;52(2):133\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao H, Mandich D, Cartun RW, Ligato S. Expression of K homology domain containing protein overexpressed in cancer in pancreatic FNA for diagnosing adenocarcinoma of pancreas. Diagn Cytopathol. 2007 Nov;35(11):700\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu H, Shi J, Anandan V, Wang HL, Diehl D, Blansfield J, Gerhard G, Lin F. Reevaluation and identification of the best immunohistochemical panel (pVHL, Maspin, S100P, IMP-3) for ductal adenocarcinoma of the pancreas. Arch Pathol Lab Med. 2012;136(6):601\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzzat NE, Tahoun NS, Ismail YM. The role of S100P and IMP3 in the cytologic diagnosis of pancreatic adenocarcinoma. J Egypt Natl Canc Inst. 2016 Dec;28(4):229\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSenoo J, Mikata R, Kishimoto T, Hayashi M, Kusakabe Y, Yasui S, Yamato M, Ohyama H, Sugiyama H, Tsuyuguchi T, Yoshitomi H, Ohtsuka M, Maeda J, Ota S, Nakatani Y, Kato N. Immunohistochemical analysis of IMP3 and p53 expression in endoscopic ultrasound-guided fine needle aspiration and resected specimens of pancreatic diseases. Pancreatology 2018;18: 176\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable (1):\u003c/strong\u003e Diagnosis of the studied patients (N=140).\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.15492957746479%\"\u003e\n \u003cp\u003eThe studied patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=140)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003ePercent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u003cu\u003eCytologic diagnosis\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e42.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e57.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u003cu\u003eCytologic + IMP3 diagnosis\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e52.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e47.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u003cu\u003eGold standard diagnosis\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e65.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.84507042253521%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e34.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable (2):\u003c/strong\u003e Gold standard diagnosis of the studied patients (N=140).\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003eGold standard diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.15492957746479%\"\u003e\n \u003cp\u003eThe studied patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=140)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003ePercent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePancreatic Adenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMucinous neoplasm with high grade dysplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMucinous neoplasm with low grade dysplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIPMN with low grade dysplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIPMN with high grade dysplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSPN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"40.84507042253521%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSerous microcystic Adenoma\u003c/p\u003e\n \u003cp\u003ePseudocyst\u003c/p\u003e\n \u003cp\u003ePancreatitis\u003c/p\u003e\n \u003cp\u003eAutoimmune pancreatitis\u003c/p\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"29.577464788732396%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.4%\u003c/p\u003e\n \u003cp\u003e13.6%\u003c/p\u003e\n \u003cp\u003e8.6%\u003c/p\u003e\n \u003cp\u003e5.7%\u003c/p\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable (3):\u003c/strong\u003e Comparison between benign and malignant pancreatic lesions regarding demographic data\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 13.316%;\" valign=\"bottom\" width=\"18.51851851851852%\"\u003e\n \u003cp\u003eDemographic data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 14.2672%;\" valign=\"bottom\" width=\"16.225749559082892%\"\u003e\n \u003cp\u003eAll Studied patients\u003c/p\u003e\n \u003cp\u003e(N=140)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 1.4267%;\" valign=\"bottom\" width=\"2.6455026455026456%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 22.1058%;\" width=\"45.5026455026455%\"\u003e\n \u003cp\u003eGold standard diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 6.0636%;\" width=\"8.994708994708995%\"\u003e\n \u003cp\u003eTest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 5.588%;\" width=\"8.112874779541446%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003cp\u003e(Sig.)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 20.093%;\" width=\"47.08171206225681%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003cp\u003e(N=92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.3861%;\" width=\"47.08171206225681%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003cp\u003e(N=48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.9447%;\" valign=\"top\" width=\"12.275449101796408%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.3225%;\" valign=\"top\" width=\"15.269461077844312%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.6792%;\" valign=\"top\" width=\"16.46706586826347%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4137%;\" valign=\"top\" width=\"19.760479041916167%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.8258%;\" valign=\"top\" width=\"16.46706586826347%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5603%;\" valign=\"top\" width=\"19.760479041916167%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.316%;\" valign=\"top\" width=\"18.551236749116608%\"\u003e\n \u003cp\u003e\u003cu\u003eAge (years)\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.9447%;\" valign=\"top\" width=\"7.243816254416961%\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.3225%;\" valign=\"top\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4267%;\" valign=\"top\" width=\"2.65017667844523%\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.6792%;\" valign=\"top\" width=\"9.717314487632509%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4137%;\" valign=\"top\" width=\"11.66077738515901%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.8258%;\" width=\"9.717314487632509%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5603%;\" width=\"11.66077738515901%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.0636%;\" valign=\"top\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.588%;\" valign=\"top\" width=\"8.12720848056537%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.316%;\" width=\"18.551236749116608%\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026gt;\u003c/span\u003e55 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.9447%;\" width=\"7.243816254416961%\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.3225%;\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4267%;\" valign=\"top\" width=\"2.65017667844523%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.6792%;\" valign=\"top\" width=\"9.717314487632509%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4137%;\" valign=\"top\" width=\"11.66077738515901%\"\u003e\n \u003cp\u003e29.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.8258%;\" valign=\"top\" width=\"9.717314487632509%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5603%;\" valign=\"top\" width=\"11.66077738515901%\"\u003e\n \u003cp\u003e60.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 6.0636%;\" valign=\"top\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e12.686\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 5.588%;\" valign=\"top\" width=\"8.12720848056537%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(HS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.316%;\" width=\"22.388059701492537%\"\u003e\n \u003cp\u003e=\u0026gt;55 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.9447%;\" width=\"8.742004264392325%\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.3225%;\" width=\"10.874200426439232%\"\u003e\n \u003cp\u003e60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4267%;\" valign=\"top\" width=\"3.1982942430703623%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.6792%;\" valign=\"top\" width=\"11.727078891257996%\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4137%;\" valign=\"top\" width=\"14.072494669509595%\"\u003e\n \u003cp\u003e70.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.8258%;\" valign=\"top\" width=\"11.727078891257996%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5603%;\" valign=\"top\" width=\"14.072494669509595%\"\u003e\n \u003cp\u003e39.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.316%;\" valign=\"top\" width=\"18.551236749116608%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.2672%;\" width=\"16.25441696113074%\"\u003e\n \u003cp\u003e56\u0026plusmn;14.5749\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4267%;\" valign=\"top\" width=\"2.65017667844523%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 20.093%;\" valign=\"top\" width=\"21.37809187279152%\"\u003e\n \u003cp\u003e58.3261\u0026plusmn;15.56561\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.3861%;\" valign=\"top\" width=\"21.37809187279152%\"\u003e\n \u003cp\u003e53.2917\u0026plusmn;11.92166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 6.0636%;\" valign=\"top\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e-2.956 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 5.588%;\" valign=\"top\" width=\"8.12720848056537%\"\u003e\n \u003cp\u003e\u0026lt;0.003\u003c/p\u003e\n \u003cp\u003e(HS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.316%;\" valign=\"top\" width=\"22.388059701492537%\"\u003e\n \u003cp\u003eMedian (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.2672%;\" width=\"19.616204690831555%\"\u003e\n \u003cp\u003e58 (12 \u0026ndash; 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4267%;\" valign=\"top\" width=\"3.1982942430703623%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 20.093%;\" valign=\"top\" width=\"25.79957356076759%\"\u003e\n \u003cp\u003e62.5 (12 \u0026ndash; 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14.3861%;\" valign=\"top\" width=\"25.79957356076759%\"\u003e\n \u003cp\u003e52 (30 \u0026ndash; 77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.316%;\" width=\"18.551236749116608%\"\u003e\n \u003cp\u003e\u003cu\u003eSex\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.9447%;\" width=\"7.243816254416961%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.3225%;\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4267%;\" valign=\"top\" width=\"2.65017667844523%\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.6792%;\" valign=\"top\" width=\"9.717314487632509%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4137%;\" valign=\"top\" width=\"11.66077738515901%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.8258%;\" width=\"9.717314487632509%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5603%;\" width=\"11.66077738515901%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.0636%;\" valign=\"top\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.588%;\" valign=\"top\" width=\"8.12720848056537%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.316%;\" width=\"18.551236749116608%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.9447%;\" width=\"7.243816254416961%\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.3225%;\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e53.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4267%;\" valign=\"top\" width=\"2.65017667844523%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.6792%;\" valign=\"top\" width=\"9.717314487632509%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4137%;\" valign=\"top\" width=\"11.66077738515901%\"\u003e\n \u003cp\u003e56.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.8258%;\" valign=\"top\" width=\"9.717314487632509%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5603%;\" valign=\"top\" width=\"11.66077738515901%\"\u003e\n \u003cp\u003e47.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 6.0636%;\" valign=\"top\" width=\"9.010600706713781%\"\u003e\n \u003cp\u003e0.939\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 5.588%;\" valign=\"top\" width=\"8.12720848056537%\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003cp\u003e(NS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.316%;\" width=\"22.388059701492537%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.9447%;\" width=\"8.742004264392325%\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.3225%;\" width=\"10.874200426439232%\"\u003e\n \u003cp\u003e46.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.4267%;\" valign=\"top\" width=\"3.1982942430703623%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.6792%;\" valign=\"top\" width=\"11.727078891257996%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4137%;\" valign=\"top\" width=\"14.072494669509595%\"\u003e\n \u003cp\u003e43.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.8258%;\" valign=\"top\" width=\"11.727078891257996%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5603%;\" valign=\"top\" width=\"14.072494669509595%\"\u003e\n \u003cp\u003e52.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea: Chi-square test; b: Mann Whitney U test; p-value\u0026lt; 0.05 is significant; Sig.: Significance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (4):\u003c/strong\u003e Comparison between benign and malignant pancreatic lesions regarding imaging findings\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 19.0249%;\" valign=\"bottom\" width=\"22.47787610619469%\"\u003e\n \u003cp\u003eImaging findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 22.8029%;\" valign=\"bottom\" width=\"18.4070796460177%\"\u003e\n \u003cp\u003eAll Studied patients\u003c/p\u003e\n \u003cp\u003e(N=140)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 2.2938%;\" valign=\"bottom\" width=\"2.831858407079646%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 21.0718%;\" width=\"38.93805309734513%\"\u003e\n \u003cp\u003eGold standard diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 6.8814%;\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003eTest\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 6.3416%;\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003cp\u003e(Sig.)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 19.9694%;\" width=\"45.90909090909091%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003cp\u003e(N=92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 9.445%;\" width=\"46.36363636363637%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003cp\u003e(N=48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10.9292%;\" valign=\"top\" width=\"16.938110749185668%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" valign=\"top\" width=\"16.938110749185668%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"16.612377850162865%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"16.286644951140065%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"16.938110749185668%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"16.286644951140065%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"22.47787610619469%\"\u003e\n \u003cp\u003e\u003cu\u003eSite of lesion\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"2.831858407079646%\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"9.026548672566372%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8814%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.3416%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"22.47787610619469%\"\u003e\n \u003cp\u003eHead\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"2.831858407079646%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"9.026548672566372%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e64.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e22.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 6.8814%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e52.156\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 6.3416%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(HS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"27.194860813704498%\"\u003e\n \u003cp\u003eBody-tail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e28.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"3.4261241970021414%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"10.920770877944326%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e31.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e22.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"27.194860813704498%\"\u003e\n \u003cp\u003eEntire pancreas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e7.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"3.4261241970021414%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"10.920770877944326%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e14.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"27.194860813704498%\"\u003e\n \u003cp\u003eExtra-pancreatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e13.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"3.4261241970021414%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"10.920770877944326%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e39.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"22.47787610619469%\"\u003e\n \u003cp\u003e\u003cu\u003eNature\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"2.831858407079646%\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"9.026548672566372%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8814%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.3416%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"22.47787610619469%\"\u003e\n \u003cp\u003eMass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"2.831858407079646%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"9.026548672566372%\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e58.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e33.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 6.8814%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e9.395\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 6.3416%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003cp\u003e(S)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"27.194860813704498%\"\u003e\n \u003cp\u003eCyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e45.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"3.4261241970021414%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"10.920770877944326%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e39.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e58.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"27.194860813704498%\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"3.4261241970021414%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"10.920770877944326%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 29.9541%;\" width=\"31.68141592920354%\"\u003e\n \u003cp\u003e\u003cu\u003eDuct communication\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"2.831858407079646%\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"9.026548672566372%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.8814%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6.3416%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"22.47787610619469%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e86.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"2.831858407079646%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"9.026548672566372%\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e79.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"9.20353982300885%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"8.849557522123893%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 6.8814%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e11.470\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 6.3416%;\" valign=\"top\" width=\"8.672566371681416%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003cp\u003e(S)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.0249%;\" width=\"27.194860813704498%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.9292%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.8737%;\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e13.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.2938%;\" valign=\"top\" width=\"3.4261241970021414%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.6594%;\" valign=\"top\" width=\"10.920770877944326%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.3101%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e20.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.778%;\" valign=\"top\" width=\"11.13490364025696%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.667%;\" valign=\"top\" width=\"10.70663811563169%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea: Chi-square test; p-value\u0026lt; 0.05 is significant; Sig.: Significance.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (5):\u0026nbsp;\u003c/strong\u003eComparison between cytological diagnosis and gold standard diagnosis\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"bottom\" width=\"31.81019332161687%\"\u003e\n \u003cp\u003eCytologic diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"48.68189806678383%\"\u003e\n \u003cp\u003eGold standard diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"19.507908611599298%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.90252707581227%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.09747292418773%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"15.992970123022847%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.817223198594025%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.780316344463973%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.90158172231986%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.507908611599298%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.828451882845187%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.497907949790793%\"\u003e\n \u003cp\u003e42.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.451882845188283%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.221757322175733%\"\u003e\n \u003cp\u003e42.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"15.992970123022847%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.817223198594025%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.780316344463973%\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.90158172231986%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.507908611599298%\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.828451882845187%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.497907949790793%\"\u003e\n \u003cp\u003e23.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.451882845188283%\"\u003e\n \u003cp\u003e34.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.221757322175733%\"\u003e\n \u003cp\u003e57.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"15.992970123022847%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.817223198594025%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.780316344463973%\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.90158172231986%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.507908611599298%\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.828451882845187%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.497907949790793%\"\u003e\n \u003cp\u003e65.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.451882845188283%\"\u003e\n \u003cp\u003e34.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.221757322175733%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"31.866197183098592%\"\u003e\n \u003cp\u003eTest\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"68.13380281690141%\"\u003e\n \u003cp dir=\"RTL\"\u003e31.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"31.866197183098592%\"\u003e\n \u003cp\u003ep-value (Sig.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"68.13380281690141%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026lt;0.001 (HS)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ec: McNemar\u0026rsquo;s test; p-value\u0026lt; 0.05 is significant; Sig.: Significance.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (6):\u0026nbsp;\u003c/strong\u003eComparison between Cytologic+IMP3 and gold standard diagnosis\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"bottom\" width=\"31.81019332161687%\"\u003e\n \u003cp\u003eCytologic+IMP3 diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"48.68189806678383%\"\u003e\n \u003cp\u003eGold standard diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"19.507908611599298%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.90252707581227%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.09747292418773%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"15.992970123022847%\"\u003e\n \u003cp\u003eMalignant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.817223198594025%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.780316344463973%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.90158172231986%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.507908611599298%\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.828451882845187%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.497907949790793%\"\u003e\n \u003cp\u003e51.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.451882845188283%\"\u003e\n \u003cp\u003e1.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.221757322175733%\"\u003e\n \u003cp\u003e52.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"15.992970123022847%\"\u003e\n \u003cp\u003eBenign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.817223198594025%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.780316344463973%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.90158172231986%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.507908611599298%\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.828451882845187%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.497907949790793%\"\u003e\n \u003cp\u003e14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.451882845188283%\"\u003e\n \u003cp\u003e32.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.221757322175733%\"\u003e\n \u003cp\u003e47.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"15.992970123022847%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.817223198594025%\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.780316344463973%\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.90158172231986%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.507908611599298%\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.828451882845187%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.497907949790793%\"\u003e\n \u003cp\u003e65.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.451882845188283%\"\u003e\n \u003cp\u003e34.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.221757322175733%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"31.866197183098592%\"\u003e\n \u003cp\u003eTest\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"68.13380281690141%\"\u003e\n \u003cp\u003e13.136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"31.866197183098592%\"\u003e\n \u003cp\u003ep-value (Sig.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"68.13380281690141%\"\u003e\n \u003cp\u003e\u0026lt;0.001 (HS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ec: McNemar\u0026rsquo;s test; p-value\u0026lt; 0.05 is significant; Sig.: Significance.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (7):\u0026nbsp;\u003c/strong\u003eDiagnostic performance of cytology and cytology+IMP3 IHC for diagnosis of malignant pancreatic lesions\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003eCytology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003eCytology+ IMP3 IHC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eTP\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eFP\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eTN\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eFN\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eSN\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e64.13%\u003c/p\u003e\n \u003cp\u003e(53.457 \u0026ndash; 73.867)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e78.26%\u003c/p\u003e\n \u003cp\u003e(68.44 \u0026ndash; 86.187)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eSP\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e(92.06 \u0026ndash; 100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e95.83%\u003c/p\u003e\n \u003cp\u003e(85.746 \u0026ndash; 99.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003ePPV\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e97.297%\u003c/p\u003e\n \u003cp\u003e(90.225 \u0026ndash; 99.293)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eNPV\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e59.259%\u003c/p\u003e\n \u003cp\u003e(52.534 \u0026ndash; 65.654)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e69.69%\u003c/p\u003e\n \u003cp\u003e(60.843 \u0026ndash; 77.296)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003ePositive LR\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e18.78\u003c/p\u003e\n \u003cp\u003e(4.871 \u0026ndash; 73.255)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eNegative LR\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e0.359\u003c/p\u003e\n \u003cp\u003e(0.273 \u0026ndash; 0.471)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e0.227\u003c/p\u003e\n \u003cp\u003e(0.153 \u0026ndash; 0.336)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eAccuracy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e89%\u003c/p\u003e\n \u003cp\u003e(52.2 \u0026ndash; 97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e84.3%\u003c/p\u003e\n \u003cp\u003e(74.4 \u0026ndash; 90. 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.120772946859905%\"\u003e\n \u003cp\u003eAUC\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e0.821\u003c/p\u003e\n \u003cp\u003e(0.747 \u0026ndash; 0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"37.43961352657005%\"\u003e\n \u003cp\u003e0.870\u003c/p\u003e\n \u003cp\u003e(0.803 \u0026ndash; 0.921)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTP: True positive; FP: False positive; TN: True negative; FN: \u0026nbsp;False negative; SN: Sensitivity; SP: Specificity; PPV: Positive Predictive Value; NPV: Negative Predictive Value; LR: Likelihood Ratio; AUC: Area Under Curve; CI: Confidence Interval.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-gastrointestinal-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijgc","sideBox":"Learn more about [Journal of Gastrointestinal Cancer](https://www.springer.com/journal/12029)","snPcode":"12029","submissionUrl":"https://submission.nature.com/new-submission/12029/3","title":"Journal of Gastrointestinal Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"IMP3, Endoscopic ultrasound-guided fine needle aspiration, pancreatic cancer, Immunohistochemistry ","lastPublishedDoi":"10.21203/rs.3.rs-1032716/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1032716/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Poor prognosis and short survival of patients harboring pancreatic cancer emerge how advanced disease it is. In a trial to achieve the earliest and most accurate diagnosis to manage this progressive disease, we proposed that using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with an adjuvant diagnostic immunohistochemical marker would give better diagnostic results. IMP3 has gained recently wide attention, as many studies found that IMP3 has not only diagnostic but also prognostic role in different types of malignancies. \u003c/p\u003e\u003cp\u003eA\u003cstrong\u003eim of the study\u003c/strong\u003e: this prospective work is to assess the diagnostic role of EUS-FNA combined with the immunohistochemical expression of IMP3 on different benign and malignant pancreatic lesions. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMaterial and Method\u003c/strong\u003e: the included pancreatic lesions (n=140) were obtained by EUS-FNA technique and stained for IMP3 immunohistochemically. Paraffin blocks from patients who underwent excision (n=92) or core biopsies (n=48) were performed for confirming diagnosis. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: the combined method for diagnosis showed that IMP3 was positive in 78.7%, 91.7%, 100% PAC, Mucinous neoplasm with high grade dysplasia, IPMN with high grade dysplasia, respectively, while almost all benign lesions showed negative IMP3. Also, this method showed sensitivity (78.26%), specificity (95.83%), and accuracy (84.3%). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e EUS-FNA cytology with IMP3 could be a reliable diagnostic tool especially for assessment of malignant pancreatic lesions.\u003c/p\u003e","manuscriptTitle":"A Promising Diagnostic Role of Immunohistochemical Expression of Insulin-Like Growth Factor II mRNA Binding Protein3 (IMP3) in Pancreatic Lesions Using Endoscopic Ultrasound –Guided –Fine Needle Aspiration (EUS-FNA) Cytology","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-11-05 16:55:45","doi":"10.21203/rs.3.rs-1032716/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-11-02T19:00:01+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-11-02T07:25:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-11-01T23:23:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Gastrointestinal Cancer","date":"2021-10-29T16:46:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-gastrointestinal-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijgc","sideBox":"Learn more about [Journal of Gastrointestinal Cancer](https://www.springer.com/journal/12029)","snPcode":"12029","submissionUrl":"https://submission.nature.com/new-submission/12029/3","title":"Journal of Gastrointestinal Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"93104079-9320-44ed-9647-65f55d39597f","owner":[],"postedDate":"November 5th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":8323925,"name":"Gastroenterology \u0026 Hepatology"}],"tags":[],"updatedAt":"2021-11-16T12:10:57+00:00","versionOfRecord":[],"versionCreatedAt":"2021-11-05 16:55:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1032716","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1032716","identity":"rs-1032716","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}