Optimal number of EUS-guided fine needle passes needed to obtain a correct diagnosis

Mediastinal staging of NSCLC with endoscopic and endobronchial ultrasound

Mediastinal staging of non-small-cell lung cancer (NSCLC) is of paramount importance. It distinguishes operable from inoperable disease, guides prognosis and allows accurate comparison of outcomes in clinical trials. Noninvasive imaging modalities for mediastinal staging include CT, PET and integrated PET-CT. Mediastinoscopy is considered the current gold standard; however, each of these techniques has limitations in sensitivity or specificity. These inadequacies mean that 10% of operations performed with curative intent in patients with NSCLC are futile, owing to inaccurate locoregional lymph-node staging. Endoscopic and endobronchial ultrasound-guided mediastinal lymph-node aspiration are important and promising innovative techniques with reported sensitivities and specificities higher than standard investigations. The role of these techniques in mediastinal lymph-node staging is evolving rapidly and early data suggest that they may diminish the need for invasive surgical staging of the mediastinum. Furthermore, these are outpatient procedures that do not require general anesthesia and may be combined safely in the same sitting, for optimal accuracy of mediastinal staging. We propose a new algorithm for the diagnosis and staging of NSCLC, based on the current evidence, which incorporates endoscopic and endobronchial ultrasound as a first investigation after CT in patients with intrathoracic disease.

EUS-guided FNA of solid pancreatic masses: high yield of 2 passes with combined histologic-cytologic analysis

BACKGROUND

EUS-guided FNA (EUS-FNA) is an established tissue-acquisition technique, with most studies concentrating on cytologic analyses of specimens, with only few data existing on histologic assessment.

OBJECTIVE

To assess the sensitivity of a combined analysis of histologic followed by cytologic tissue diagnosis.

DESIGN

A retrospective 3-center study.

METHODS

In consecutive patients undergoing FNA of solid pancreatic masses, core specimens were harvested for histology; residual tissue was examined cytologically. Only unequivocally positive results were regarded as malignant. Criterion standards were positive results from EUS-FNA or other histologic findings, or, if negative, clinical follow-up data (minimum 12 months).

RESULTS

Among 192 patients (110 men; mean age 63 years) with mostly pancreatic-head masses (72.4%), overall, adequate tissue was obtained in 98.9% of all cases, with a mean of 1.88 needle passes and an overall sensitivity of 82.9% (95% CI, 76.0%-88.5%). Histology and subsequent cytology provided adequate tissue and sensitivities of 86.5% and 60%, and 92.7% and 68.1%, respectively. Excluding cases with inadequate specimens, sensitivities rose by 4% to 10%. Histology showed a trend for superiority over cytology only in characterizing nonadenocarcinoma tumor types. No differences in sensitivity were found between the centers involved.

LIMITATIONS

Retrospective design, different processing of cytologic specimens.

CONCLUSIONS

At EUS-FNA in pancreatic masses, combined histologic-cytologic analysis achieved a sensitivity of more than 80%, despite a low number of needle passes and may thus save time. Histology alone did not reach higher sensitivity than cytology. In particular situations, eg, rare tumors, histology may still be required.

Randomized controlled trial of endoscopic ultrasound-guided fine-needle sampling with or without suction for better cytological diagnosis

OBJECTIVE

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a highly accurate method to obtain specific diagnosis in various diseases. The optimal method of EUS-guided sampling of material for pathologic diagnosis has not been clearly established. The aim of our study was to compare two different techniques of EUS-guided sampling of solid masses, using either non-suction or suction with a 10-ml syringe.

MATERIAL AND METHODS

Patients assessed during a 6-month period were randomized to three passes of EUS-guided sampling with suction (26 patients) or non-suction (26 patients). The samples were characterized for cellularity and bloodiness, with a final cytology diagnosis established blindly. The final diagnosis was reached either by EUS-FNA if malignancy was definite, or by surgery and/or clinical follow-up of a minimum of 6 months in the cases of non-specific benign lesions.

RESULTS

EUS-guided fine-needle sampling with suction of solid masses increased the number of pathology slides (17.8+/-7.1 slides for suction as compared with 10.2+/-5.5 for non-suction, p=0.0001), without increasing the overall bloodiness of each sample. Sensitivity and the negative predictive values were higher when suction was applied, as compared to the non-suction group (85.7% as compared with 66.7%, p=0.05).

CONCLUSIONS

This prospective randomized study showed that EUS-guided fine-needle sampling of solid masses using suction yields a higher number of slides without increasing bloodiness. Although, the proportion of target cells was relatively similar between the suction and non-suction sampling techniques, the sensitivity and negative predictive values of the procedure were significantly higher when suction was added.

Endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic masses with rapid on-site cytological evaluation by endosonographers without attendance of cytopathologists

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with rapid on-site evaluation (ROSE) has been reported to provide a more accurate diagnosis than EUS-FNA without such evaluation. However, even endosonographers can evaluate ROSE regarding sample adequacy. The aim of this study was to evaluate the diagnostic accuracy of EUS-FNA with ROSE by endosonographers compared to ROSE by cytopathologists in patients with solid pancreatic masses.

METHODS

Between September 2001 and October 2005, of the 73 EUS-FNA procedures with the final diagnoses, 38 procedures after the introduction of ROSE by endosonographers (September 2001-September 2003, period 1), and 35 procedures after the introduction of ROSE by cytopathologists (October 2003-October 2005, period 2) were included. The specimens were stained with Diff-Quik stain and assessed. When the on-site assessors (endosonographers or cytopathologists) indicated that the amounts of cell samples were adequate, the procedure was stopped.

RESULTS

Results are presented with 95% confidence limits. The average numbers of needle passes were 4.0 +/- 1.6 and 3.4 +/- 1.5 in periods 1 and 2, respectively (P = 0.06). The specimen collection rates were 97.4 and 97.1% in periods 1 and 2, respectively (P = 0.51). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for malignancy and benign were 92.9, 100, 100, 83.3, and 94.7%, respectively, in period 1, and 93.1, 100, 100, 75.0, and 94.3%, respectively, in period 2 (P = 0.97, P = 1.0, P = 1.0, P = 0.65, P = 0.93, respectively). No complications were seen.

CONCLUSIONS

For accurate diagnosis, ROSE should be performed during EUS-FNA by the endosonographer, if no cytopathologist is available.

Does onsite cytotechnology evaluation improve the accuracy of endoscopic ultrasound-guided fine-needle aspiration biopsy?

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the preferred modality for the cytological diagnosis of various cancers. Onsite cytopathology interpretation is not available in most centres.

OBJECTIVE

To assess whether the the adequacy of tissue sampling assessed by an onsite cytotechnologist improves the diagnostic accuracy of EUS-FNA.

METHODS

The present study is a retrospective review of all patients undergoing solid mass EUS-FNA between September 2005 and August 2007. Patients in group I (September 2005 to August 2006) had cytology slides prepared by an endoscopy nurse. Patients in group II (September 2006 to August 2007) had cytology slides prepared, stained and assessed for adequacy of tissue sampling by a cytotechnologist in the endoscopy suite. The final cytopathological diagnosis (definitely positive, definitely negative or inconclusive) was compared between the two groups.

RESULTS

A total of 49 EUS-FNA procedures were performed in 47 patients in group I and 60 EUS-FNA procedures in 55 patients in group II. Pancreatic masses were the most common target site in both groups. The total number of needle passes was 105 in group I (mean 2.14 passes per patient; range one to five needle passes) and 158 in group II (mean 2.63 passes per patient; range one to four needle passes). The difference in the number of needle passes was not statistically significant between groups. The final diagnosis was definite in 53% in group I compared with 77% in group II (P=0.01). The percentage of inconclusive diagnoses was 47% in group I and 23% in group II (P=0.001).

CONCLUSION

Onsite cytotechnologist interpretation of adequacy of tissue sampling significantly improves the diagnostic yield of EUS-FNA. This appears to be independent of the total number of needle passes undertaken for tissue sampling.

Prospective comparative study of the EUS guided 25-gauge FNA needle with the 19-gauge Trucut needle and 22-gauge FNA needle in patients with solid pancreatic masses

BACKGROUND AND STUDY AIMS

The aim of this prospective study was to compare fine-needle aspiration guided by endoscopic ultrasonography (EUS-FNA) using 25-gauge and 22-gauge needles with the EUS-guided 19-gauge Trucut needle biopsy (EUS-TNB) in patients with solid pancreatic mass.

PATIENTS AND METHODS

Twenty-four consecutive patients with pancreatic mass underwent biopsies by both EUS-FNA and EUS-TNB. Three needles were compared with respect to technical success rate, tissue size obtained, overall diagnostic accuracy and accuracy for histological and cytological diagnosis.

RESULTS

The 25-gauge EUS-FNA was technically easier and obtained superior overall diagnostic accuracy than the 22-gauge and Trucut needles, especially in lesions of the pancreas head and uncinate process. Overall accuracy for the 25-gauge, 22-gauge and Trucut needle was 91.7%, 79.7% and 54.1%, respectively. Accuracy for cytological diagnosis irrespective the site of lesions with 25-gauge, 22-gauge and Trucut needles was 91.7%, 75.0%, and 45.8%, respectively. For uncinate masses, it was 100%, 33.3%, and 0.0%, respectively. These differences were significant. Among technically successful patients, the accuracy for histological diagnosis using the 25-gauge was significantly inferior (P < 0.05) to 22-gauge and Trucut needles and the rates were 45.8%, 78.9% and 83.3%.

CONCLUSIONS

The 25-gauge FNA needle was significantly superior in terms of technical success rate and overall diagnostic accuracy, especially for the head and uncinate lesions, compared to the 22-gauge and Trucut needles and could be considered 'the best choice needle for cytological diagnosis' of solid pancreatic lesions. If histological diagnosis is required, the 22-gauge FNA needle and Trucut needle may be advantageous for use in head/uncinate and body/tail lesions, respectively.

Transaortic EUS-guided FNA in the diagnosis of lung tumors and lymph nodes

BACKGROUND

Obtaining tissue from a para-aortal lymph node or tumor is a challenge that currently requires invasive surgical procedures. Para-aortic lung tumors can be clearly visualized by EUS. Although the accessibility of lesions adjacent to the esophagus is well documented, the para-aortic region has never been systematically explored.

OBJECTIVE

To assess the feasibility, yield, and safety of transaortic biopsy specimens in the diagnosis of lung tumors and nodal masses located lateral to the aorta.

DESIGN

A retrospective case series of 14 consecutive patients.

SETTING

Pulmonary Department, Leiden University Medical Center, Leiden, The Netherlands.

PATIENTS

Fourteen patients with known or suspected lung cancer. Nine patients presented with a left-sided lung mass (mean size 27 mm), whereas 5 patients had an enlarged para-aortic node (mean size 16 mm).

INTERVENTIONS

Real-time EUS-guided transaortic biopsy of a para-aortic lesion.

MAIN OUTCOME MEASUREMENTS

Feasibility, diagnostic yield, and complication rates of transaortic EUS-guided FNA (EUS-FNA).

RESULTS

The final diagnosis was known in 12 patients (10 non-small-cell lung carcinoma [NSCLC], 1 small-cell lung carcinoma [SCLC], and 1 renal-cell carcinoma). EUS-FNA established malignancy in 9 of 14 patients (64%) (8 NSCLC and 1 SCLC). One aspirate revealed reactive nodal tissue, and 4 demonstrated nonrepresentative material. Malignancy was further assessed in 3 patients after subsequent diagnostics. Transaortic FNA was found to be safe. In 2 patients, EUS images after biopsy were suspicious for a small para-aortic hematoma. These patients recovered uneventfully.

CONCLUSIONS

These results demonstrate that a single EUS-guided transaortic biopsy of para-aortic lymph nodes and tumors is a feasible and probably safe method that results in a diagnosis in the majority of cases.

Preoperative tissue diagnosis for tumours of the pancreas

BACKGROUND

Preoperative biopsy of pancreatic lesions suspected of malignancy is controversial.

METHODS

A systematic Medline literature search was carried out. Diagnostic studies reporting quantitative preoperative pancreatic biopsy data were evaluated.

RESULTS

The analysis included 53 studies, mostly of a retrospective nature. Despite acceptable rates for sensitivity and specificity, the negative predictive value of percutaneous and endoscopic ultrasonography-guided biopsies was 60-70 per cent. Biopsy results were considered to be essential for directing non-surgical therapy in advanced disease. However, they were of limited value in planning the treatment of resectable solid or cystic tumours, or focal lesions in the setting of chronic pancreatitis.

CONCLUSIONS

Biopsy of suspected pancreatic malignancies with systemic spread or local irresectability is indicated for planning palliative or neoadjuvant therapy. Preoperative biopsy of potentially resectable pancreatic tumours is not generally advisable, as malignancy cannot be ruled out with adequate reliability.

Endoscopic ultrasound guided fine needle aspiration of solid pancreatic lesions: Performance and outcomes

BACKGROUND AND AIM

We report our single-centre experience with endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of solid pancreatic lesions with regard to clinical utility, diagnostic accuracy and safety.

METHODS

We prospectively reviewed data on 100 consecutive EUS-FNA procedures performed in 93 patients (54 men, mean age 60.6 +/- 12.9 years) for evaluation of solid pancreatic lesions. Final diagnosis was based on a composite standard: histologic evidence at surgery, or non-equivocal malignant cytology on FNA and follow-up. The operating characteristics of EUS-FNA were determined.

RESULTS

The location of the lesions was pancreatic head in 73% of cases, the body in 20% and the tail in 7%. Mean lesion size was 35.1 +/- 12.9 mm. The final diagnosis revealed malignancy in 87 cases, including adenocarcinomas (80.5%), neuroendocrine tumours (11.5%), lymphomas (3.4%) and other types (4.6%). The FNA findings were: 82% interpreted as malignant cytology, 1% as suspicious for neoplasia, 1% as atypical, 7% as benign process and 9% as non-diagnostic. No false-positive results were observed. There was a false-negative rate of 5%. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 94.3%, 100%, 100%, 72.2% and 95%, respectively. In 23 (88.5%) of 26 aspirated lymph nodes malignancy was found. Minor complications occurred in two patients.

CONCLUSIONS

Our experience confirms that EUS-FNA in patients with suspected solid pancreatic lesions is safe and has a high diagnostic accuracy. This technique should be considered the preferred test when a cytological diagnosis of a pancreatic mass lesion is required.

Neuroendocrine tumors of the pancreas: endoscopic diagnosis

PURPOSE OF REVIEW

Endoscopic ultrasound (EUS) is a valuable tool in the diagnosis and management of pancreatic neuroendocrine tumors. This review highlights advances over the last year in EUS in the evaluation of pancreatic neuroendocrine tumors.

RECENT FINDINGS

We will focus on recent findings regarding the accuracy of EUS, EUS-guided fine needle aspiration (EUS-fine needle aspiration), emerging cytologic markers obtained from fine needle aspiration samples, and the role of EUS screening for patients with multiple endocrine neoplasia type 1 syndrome. Additionally, we will introduce potential therapeutic EUS interventions in the treatment of pancreatic neuroendocrine tumors.

SUMMARY

The present review highlights recent advances in the utility of EUS in the clinical management of pancreatic neuroendocrine tumors. Key studies from the last year demonstrate the important role of EUS in the diagnosis, prognosis, and treatment of pancreatic neuroendocrine tumors.

Utility of a repeated EUS at a tertiary-referral center

BACKGROUND

The utility of a repeated EUS by experts is not known.

OBJECTIVE

To define the utility of a repeated EUS for the same indication.

DESIGN

A retrospective case series.

SETTING

Tertiary-referral hospital in Indianapolis, Indiana.

PATIENTS

Consecutive subjects, with and without cancer, who, between January 2000 and September 2006, underwent an initial EUS elsewhere within 6 and 12 weeks of a repeated EUS at our hospital.

INTERVENTIONS

A repeated EUS.

MAIN OUTCOME MEASUREMENTS

Clinical impact of a repeated EUS.

RESULTS

Of 8936 EUS examinations, 73 repeated procedures (0.8%) were identified, and 24 were excluded. The 49 initial EUS procedures (26 men, median age 59 years) were done in Indiana (n = 44) or another state (n = 5) by one of 15 physicians in private practice (n = 48) or at a teaching hospital (n = 1). An EUS-guided FNA (EUS-FNA) was performed during an initial EUS in 21 patients (no biopsy diagnostic for cancer) and was not attempted in 14 patients. The principle indication for a repeated EUS (n = 35) was for an EUS-FNA after the initial tissue sampling was benign, nondiagnostic, or not done. A second EUS had no clinical impact in 18 patients (37%). In the remaining 31 patients (63%), a repeated EUS provided a new or changed clinical diagnosis (n = 12), the initial diagnosis of primary pancreatic cancer (n = 5) or GI stromal tumor (GIST) (n = 1) after a previous nondiagnostic biopsy; or the initial diagnosis of primary (n = 4) or metastatic (n = 2) pancreatic cancer, metastatic esophageal cancer (n = 1), hilar cholangiocarcinoma (n = 1), GIST (n = 1), or pancreatic neuroendocrine tumor (n = 1), or an initial aspiration of a pancreatic cyst (n = 3) after a previous EUS-FNA was not able to be performed.

LIMITATIONS

A retrospective design; a small number of nonpancreatic indications.

CONCLUSIONS

In this study, a repeated EUS at a tertiary-referral center had a clinical impact in 63% of patients when performed by experts for a similar clinical indication.

Prospective pilot evaluation of a new needle prototype for endoscopic ultrasonography-guided fine-needle aspiration: comparison of cytology and histology yield

OBJECTIVES

Endoscopic ultrasonography (EUS) with the adjunct of EUS-guided fine needle aspiration has become an important diagnostic modality in gastroenterologic oncology. EUS-guided fine needle aspiration mainly relies on cytology; data are scarce that compare cytology and histology. While testing a 22-gauge prototype needle, we prospectively compared the yield for both.

METHODS

Forty-two consecutive patients (27 male, 15 female; mean age 59.2 years, range: 17-90 years) were included. In each patient we aimed to make two needle passes, and if the material acquired appeared insufficient macroscopically (no in-room cytopathology was available), further passes were done. The material was sent for cytological and histological assessment.

RESULTS

A median number of two passes (range: 2-3) were uneventfully performed for pancreatic lesions (n=30), mediastinal and other lymph nodes/masses (n=8) and various other lesions (n=4) and yielded adequate material for cytology, histology or at least one of the two investigations in 62, 67 and 74% of patients, respectively. No false positive results were found (specificity 100%). Sensitivities were 58.6 and 65.5%, respectively, for cytology and histology alone; combined assessment increased sensitivity to 79.3%. When adjusted values were calculated, based only on those cases with adequate material, sensitivity was 89.5% for cytology and 85.7% for histology, and increased to 100% with combined assessment.

CONCLUSION

The new needle achieves sensitivities similar to those previously reported with no significant differences in sensitivity between cytology and histology. More effective tissue acquisition methods must be sought to improve overall results.

Contrast-enhanced endoscopic ultrasound in discrimination between benign and malignant mediastinal and abdominal lymph nodes

BACKGROUND

Enlarged lymph nodes in the mediastinum reflect neoplastic, infectious or other diseases. The classification of these nodes is crucial in the management of the patient. Currently, only invasive measures obtaining tissue samples reach satisfying specificity. Contrast-enhanced endoscopic ultrasound (EUS) may offer a non-invasive alternative.

MATERIALS AND METHODS

A total of 122 patients (age: 63 +/- 15 years, 92 males, 30 females) with enlarged mediastinal and/or paraaortic lymph nodes diagnosed by CT scan were included in the study. EUS-guided fine needle aspiration was performed and cytologic specimens were diagnosed as representing a malignant or benign process in case of Papanicolau IV and V, or Papanicolau I and II, respectively.

RESULTS

Based on cytology results, the investigated lymph nodes were classified as neoplastic (n = 48) or non-neoplastic lymph nodes. Using the B-mode criteria the preliminary diagnosis was confirmed in 64 out of 74 benign lymph nodes (specificity 86%). Regarding malignant lymph nodes 33 of 48 were confirmed (sensitivity 68%). Using the advanced contrast-enhanced EUS criteria the diagnosis was confirmed in 68 of 74 benign lymph nodes (specificity 91%). However, in case of malignant lymph nodes the number of correct diagnoses dropped to 29 of 48 lymph nodes (sensitivity 60%). The contrast-enhanced EUS criteria to identify benign lymph nodes and node enlargement in malignant lymphoma do not differ. If those ten patients with malignant lymphoma are excluded, the sensitivity of the contrast enhanced EUS for malignant lymph nodes rises to 73%.

CONCLUSION

Contrast-enhanced EUS improves the specificity in diagnosing benign lymph nodes as compared to B-mode EUS. It does not improve the correct identification of malignant lymph nodes and cannot replace EUS-guided fine-needle aspiration.

[I Brazilian consensus of endoscopic ultrasonography]

BACKGROUND

In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology.

METHODS

A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70% of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval.

RESULTS

Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer, indirect signs of peritoneal involvement of gastric cancer, MALT gastric lymphoma and rectal cancer staging, diagnosis of common bile duct and gallbladder stones, diagnosis of chronic pancreatitis and differential diagnosis of a solid mass in chronic pancreatitis, differential diagnosis of the pancreatic cyst, prediction of the results of the endoscopic treatment of esophageal varices and diagnosis and staging of non-small cell lung cancer.

CONCLUSIONS

There are the highest levels of evidences that support the indication of endoscopic ultrasonography for several digestive diseases and even for non-small cell lung cancer.

Presence of intratumoral anechoic foci predicts an increased number of endoscopic ultrasound-guided fine-needle aspiration passes required for the diagnosis of pancreatic adenocarcinoma

BACKGROUND AND AIM

For reduction in cost, time and risk of complications, the number of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) passes should be minimized. Previous studies have shown that tumor differentiation and site of aspiration will affect the number of passes in patients with pancreatic cancer. There have been no reports that EUS features of pancreatic malignancies per se will influence the number of passes. Our aim was to prospectively assess various factors that would affect the number of passes in patients with pancreatic cancer.

METHODS

Between May 2003 and December 2004, 41 patients with presumed pancreatic cancer were studied. EUS-guided FNA was performed with an Olympus GF-UC2000P echoendoscope and a 22-gauge needle. On-site assessment of the specimen by a cytopathologist was available during the procedure.

RESULTS

Adenocarcinomas were confirmed in 25 patients. Pancreatic adenocarcinomas with intratumoral anechoic foci required a higher number of diagnostic passes than those without anechoic change (3.40 vs 2.27, P < 0.05). An average of 4.00 FNA passes for diagnosing a well-differentiated adenocarcinoma was also significantly higher than the 2.40 diagnostic passes for a moderately differentiated adenocarcinoma and the 2.00 passes for a poorly differentiated one (P < 0.05).

CONCLUSIONS

The existence of intratumoral anechoic foci was not a rare finding under detailed EUS investigation of pancreatic cancer. Both the existence of intratumoral anechoic foci and the differentiation of the cancer are significant predictive factors for the number of diagnostic EUS-FNA passes.

A randomized comparison of EUS-guided FNA versus CT or US-guided FNA for the evaluation of pancreatic mass lesions

BACKGROUND

Diagnosing pancreatic cancer by EUS-FNA is a potentially appealing alternative to percutaneous biopsy.

AIM

To compare EUS-FNA with CT or US-guided FNA for diagnosing pancreatic cancer.

DESIGN

Single center, prospective, randomized, cross-over.

SETTING

Duke University Medical Center.

POPULATION

Eighty-four patients referred with suspicious solid pancreatic mass lesions randomized to CT/US-FNA (n = 43) or EUS-FNA (n = 41).

INTERVENTION

Patients underwent an imaging procedure/FNA. If cytology was nondiagnostic, cross over to the other modality was offered. Final outcome was determined by clinical follow-up every 6 months for 2 years and/or surgical pathology for patients with negative FNA.

MAIN OUTCOME MEASUREMENTS

Sensitivity and accuracy of EUS-FNA versus CT/US-FNA for pancreatic cancer.

RESULTS

There were 16 true positive (TP) by CT/US-FNA and 21 TP by EUS-FNA. Sixteen of the 20 CT/US-FNA negative patients crossed over to EUS-FNA; 12 underwent FNA, 4 had no mass at EUS. Seven of the 12 had positive EUS-FNA. Eight EUS-FNA negative crossed over to CT/US; 4 had no mass at CT/US, 3 remained true negative throughout follow-up, 1 had chronic pancreatitis at surgery. The sensitivity of CT/US-FNA and EUS-FNA for detecting malignancy was 62% and 84%, respectively. A comparison of the accuracy for CT/US-FNA and EUS-FNA was not statistically significant (P = .074, chi(2)).

LIMITATIONS

Failure to meet target enrollment resulted in an inability to demonstrate a statistically significant difference between the 2 modalities.

CONCLUSIONS

EUS-FNA is numerically (though not quite statistically) superior to CT/US-FNA for the diagnosis of pancreatic malignancy.

Review of endoscopic ultrasound-guided fine-needle aspiration cytology

This review, based on the Hennepin County Medical Center experience and review of the literature, vastly covers the up-to-date role of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (FNA) in evaluating tumorous lesions of the gastrointestinal tract and adjacent organs. Emphasis is given to the tumoral and nodal staging of esophageal, pulmonary, and pancreatic cancer. This review also discusses technical, pathological, and gastroenterologic aspects and the role of the pathologist and endosonographer in the evaluation of these lesions, as well as the corresponding FNA cytology and differential diagnosis.

Proteomic classification of pancreatic adenocarcinoma tissue using protein chip technology

BACKGROUND & AIMS

Pancreatic adenocarcinoma is a most devastating cancer that presents late and is rapidly progressive. This study aimed to identify unique, tissue-specific protein biomarkers capable of differentiating pancreatic adenocarcinoma (PC) from adjacent uninvolved pancreatic tissue (AP), benign pancreatic disease (B), and nonmalignant tumor tissue (NM).

METHODS

Tissue samples representing PC (n = 31), AP (n = 44), and B (n = 19) tissue were analyzed on hydrophobic protein chip arrays by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry. Training models were developed using logistic regression and validated using the 10-fold cross-validation approach.

RESULTS

The hydrophobic protein chip array revealed 13 protein peaks differentially expressed between PC and AP (receiver operating characteristic [ROC] area under the curve [AUC], 0.64-0.85), 8 between PC and B (ROC AUC, 0.67-0.78), and 12 between PC and NM tissue (ROC AUC, 0.63-0.81). Logistic regression and cross-validation identified overlapping panels of peaks to develop a training model that distinguished PC from AP (77.4% sensitivity, 84.1% specificity), B (83.9% sensitivity, 78.9% specificity), and NM tissue (58.1% sensitivity, 90.5% specificity). The final panels selected correctly classified 80.6% of PC and 88.6% of AP samples (ROC AUC, 0.92), 93.5% of PC and 89.5% of B samples (ROC AUC, 0.99), and 71.0% of PC and 92.1% of NM samples (ROC AUC, 0.91).

CONCLUSIONS

This study used surface-enhanced laser desorption/ionization time-of-flight mass spectrometry to discover a number of protein panels that can distinguish effectively between pancreatic adenocarcinoma, benign, and adjacent pancreatic tissue. Identification of these proteins will add to our understanding of the biology of pancreatic cancer. Furthermore, these protein panels may have important diagnostic implications.

A prospective control study of the safety and cellular yield of EUS-guided FNA or Trucut biopsy in patients taking aspirin, nonsteroidal anti-inflammatory drugs, or prophylactic low molecular weight heparin

BACKGROUND

Although the ASGE recommends that high-risk endoscopic procedures can safely be performed on patients taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) in standard doses, there is a paucity of data on EUS-FNA per se in this setting.

OBJECTIVE

We studied the safety and cellular yield of EUS-FNA and/or Trucut biopsy (TCB) in patients taking aspirin, NSAIDS, or prophylactic low molecular weight heparins (LMWH).

DESIGN

Prospective control study.

PATIENTS

Consecutive patients undergoing EUS-FNA and/or TCB were recruited over an 18-month period. The usage of aspirin, NSAIDS, or LMWH were recorded and patients who were not taking these medications served as controls.

MAIN OUTCOME MEASUREMENTS

The bleeding events (endosonographic findings of extraluminal bleeding, intraluminal bleeding requiring hemostatic procedures, hematemesis, or melena) and cellular yield were compared between patients and controls.

RESULTS

Two hundred fourteen patients (8 had repeat procedures) underwent EUS-FNA and/or TCB on 241 lesions. Bleeding events occurred in none (0 of 26), 33.3% (2 of 6), and 3.7% (7 of 190) of the patients in the aspirin/NSAIDS, LMWH, and control groups, respectively (p = 0.023). The mean numbers of FNA passes, applications of suction, bloody specimens, and cellular yield were not significantly different between patients who were or were not receiving medications. No significant difference in bleeding events was noted between the FNA and TCB groups.

CONCLUSION

EUS-FNA or TCB is safe in patients taking aspirin or NSAIDS. Consideration should be given to stopping LMWH before the procedure. The cellular yield and blood contamination of the specimen from FNA are similar to those in controls.

Interventional endoscopic ultrasound in pancreatic diseases

During the last 15 years, endoscopic ultrasound (EUS) has become an important imaging procedure for diagnosis and management of pancreatic diseases. The clinical interest of EUS is now enhanced by interventional procedures. Noteworthy, fine-needle aspiration biopsy is one of the most important contributions of EUS, in particular for the investigation of patients with pancreatic cancer and cystic tumors. EUS-guided fine-needle aspiration appears to be a safe and reliable technique to obtain tissue from pancreatic masses with a low risk of complications. EUS became also a therapeutic procedure, especially applied for celiac plexus neurolysis, pseudocyst drainage, and pancreaticogastrostomy. Further developments are expected by improvement of needle devices such as pancreatic pseudocyst drainage kits. In the future, EUS might be also a support for local application of new treatments of pancreatic tumors, such as gene or cellular therapy products. In this review, we discuss the current clinical applications of interventional EUS and the future development for diagnosis and management of pancreatic diseases.

Endoscopic ultrasound-guided tissue sampling by combined fine needle aspiration and trucut needle biopsy: a prospective study

BACKGROUND AND AIMS

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has a diagnostic accuracy of 70-90%, depending on the site under evaluation. In order to improve EUS-guided tissue sampling a novel 19-gauge trucut-type needle has been designed to obtain core biopsies during EUS. We prospectively evaluated the safety and accuracy of EUS-FNA alone versus combined EUS-FNA and trucut needle biopsy (TNB) in patients referred to our Unit over a 3-year period.

PATIENTS AND METHODS

A total of 159 patients underwent EUS-FNA alone (lesions<2 cm) or the combination of both sampling modalities (lesions>or=2 cm). The adequacy of sampling, sensitivity, specificity and overall accuracies of EUS-FNA or EUS-TNB alone and combined EUS-FNA/TNB were determined.

RESULTS

Adequate samples were obtained by EUS-FNA, EUS-TNB and EUS-FNA/TNB in 91%, 88% and 97% of patients, respectively. From the pancreas (n=83), adequate samples were obtained by FNA in 94% and by TNB in 81%, compared with 87% and 92% from non-pancreatic sites (n=76), respectively. The combination of both techniques resulted in more adequate samples from non-pancreatic cases than EUS-FNA alone (P=0.044). The specificity was 100%. Overall accuracy for EUS-FNA alone was 77%, for EUS-TNB alone 73% and for EUS-FNA/TNB 91% (P=0.008). For pancreatic sampling, the accuracy of EUS-FNA alone was 77%, for EUS-TNB alone 56% and for EUS-FNA/TNB 83%. For non-pancreatic sampling, the accuracy for EUS-FNA alone was 78%, for EUS-TNB alone 83% and for EUS-FNA/TNB 95% (P=0.006). The complication rate was 0.6%.

CONCLUSIONS

Combined EUS-FNA/TNB for lesions>or=2 cm improves adequacy of sampling and diagnostic accuracy compared with either technique alone and is safe.

Contrast-enhanced endoscopic ultrasound in discrimination between focal pancreatitis and pancreatic cancer

AIM

To evaluate the contrast-enhanced endosonography as a method of differentiating inflammation from pancreatic carcinoma based on perfusion characteristics of microvessels.

METHODS

In 86 patients with suspected chronic pancreatitis (age: 62+/-12 years; sex: f/m 38/48), pancreatic lesions were examined by conventional endoscopic B-mode, power Doppler ultrasound and contrast-enhanced power mode (Hitachi EUB 525, SonoVue, 2.4 mL, Bracco) using the following criteria for malignant lesions: no detectable vascularisation using conventional power Doppler scanning, irregular appearance of arterial vessels over a short distance using SonoVue contrast-enhanced technique and no detectable venous vessels inside the lesion. A malignant lesion was assumed if all criteria were detectable [gold standard endoscopic ultrasound (EUS)-guided fine needle aspiration cytology, operation]. The criteria of chronic pancreatitis without neoplasia were defined as no detectable vascularisation before injection of SonoVue, regular appearance of vessels over a distance of at least 20 mm after injection of SonoVue and detection of arterial and venous vessels.

RESULTS

The sensitivity and specificity of conventional EUS were 73.2% and 83.3% respectively for pancreatic cancer. The sensitivity of contrast-enhanced EUS increased to 91.1% in 51 of 56 patients with malignant pancreatic lesion and the specificity increased to 93.3% in 28 of 30 patients with chronic inflammatory pancreatic disease.

CONCLUSION

Contrast-enhanced endoscopic ultrasound improves the differentiation between chronic pancreatitis and pancreatic carcinoma.

A single-center experience of endoscopic ultrasonography for enlarged pancreas on computed tomography

BACKGROUND & AIMS

The clinical significance of "fullness" or enlargement of the pancreas (FP/EP) is not well established. The objective of this study was to report our experience with endoscopic ultrasonography (EUS) in evaluating patients referred for FP/EP found on computed tomography (CT).

METHODS

Patients referred to our center for EUS evaluation of FP/EP between January 1998 and December 2003 were studied. Patient demographics, clinical history, endoscopic findings, and follow-up were recorded. Multivariate analysis was used to identify predictors of pancreatic malignancy.

RESULTS

A total of 50 patients: 46% (23/50) male, mean age 59 years (range, 18-90) made up our studied population. EUS demonstrated normal findings in 42% (21/50), prominent ventral anlage (embryologic variant) in 14% (7/50), and chronic pancreatitis in 22% (11/50). In 22% (11/50), a suspicious mass was noted and fine-needle aspiration (FNA) was performed. Cytology revealed chronic inflammation in 7 patients, while adenocarcinoma was found in the remaining 4. Median follow-up was 27 months, and the diagnosis did not change in any of the 50 patients. There were no procedure-related complications. After multivariant regression analysis, the factors that were statistically associated with malignancy were a CA19-9 level >300 (P = .0002) and weight loss (P < .006).

CONCLUSIONS

The majority of patients presenting with FP/EP had benign disease, but 8% had pancreatic cancer. Elevated CA19-9 and weight loss were predictive of pancreatic malignancy. EUS and EUS-FNA are safe and accurate diagnostic tests and can play an important role in evaluating patients with FP/EP.

EUS-guided fine needle tissue acquisition by using high negative pressure suction for the evaluation of solid masses: a pilot study

BACKGROUND

The capability of obtaining tissue samples for histologic examination during EUS has theoretical advantages over cytology alone. The objective was to evaluate the feasibility and the yield of EUS-guided FNA tissue acquisition (EUS-FNTA) by using high negative pressure suction.

METHODS

The study design is a prospective, observational pilot study set at a tertiary referral center. Twenty-seven patients with a solid mass amenable to sampling with EUS were included in the study. FNA with a 22-gauge needle was used for a total of 5 passes. An additional pass with the same needle was performed by applying continuous high negative pressure suction using the Alliance II inflation system. The main outcome measurements were the rate of tissue acquisition and the diagnostic accuracy of EUS-FNTA.

OBSERVATIONS

Tissue samples were obtained in 26 of the 27 patients (96%). Malignancy was detected in 20 of the 26 biopsy specimens obtained by FNTA and in 20 of the 27 FNA specimens. In 3 patients, EUS-FNTA failed to disclose malignancy, which in two of the patients was diagnosed by FNA. Conversely, EUS-FNTA diagnosed a recurrent malignant thymoma and a schwannoma in two FNA-negative patients. In 3 patients with both FNTA and FNA negative for malignancy, a definitive diagnosis could not be established. Overall, diagnostic accuracy was 76.9% for both EUS-FNTA and EUS-FNA. When combined, a correct diagnosis was achieved in 84.6% of the patients. Immunostaining of the retrieved tissue allowed characterization of the primary tumor in 5 cases and the diagnosis of a schwannoma and two neuroendocrine tumors. Limitations of the study were small sample size and a pilot study.

CONCLUSIONS

EUS-FNTA has a high yield for the retrieval of core tissue samples. Further studies in which EUS-FNTA is performed before FNA and with variable number of passes are needed to better define its diagnostic role and performance characteristics.