Review of endoscopic ultrasound-guided fine-needle aspiration cytology

Endoscopic ultrasound assessment and tissue acquisition of mediastinal and abdominal lymph nodes

The differential diagnosis between benign and malignant lymph nodes (LNs) has a fundamental role in the characterization and staging of malignant conditions, as well as in subsequent patients’ management. All imaging modalities (i.e. computed tomography and magnetic resonance imaging) rely mainly on size; endoscopic ultrasound (EUS) criteria based on B-mode evaluation and Doppler features fail to adequately characterize with high specificity LNs nature. The introduction of EUS-elastography and contrast-enhanced harmonic EUS are useful techniques to increase the diagnostic yield in identifying metastatic LNs, to identify which suspicious LN should require pathological characterization and, finally, to target tissue acquisition. EUS-guided tissue acquisition (EUS-TA) is increasingly being used for diagnosing lymphadenopathy whenever the characterization modifies patients’ subsequent management and when no superficial LN is accessible. Since target therapy are currently available (i.e. lung cancer, breast cancer), EUS-TA of malignant LNs could be required to identify tumor biology. In this field, both fine needle aspiration and biopsy needles are able to guarantee accurate results with almost perfect specificity and sub-optimal sensitivity. We finally propose a diagnostic algorithm based on most recent, high-level evidence for the diagnostic approach to suspected LNs assessment.

High Diagnostic Accuracy and Safety of Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Malignant Lymph Nodes: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is increasingly being used for diagnosing lymphadenopathy. We aim to systematically review the accuracy of EUS-FNA in differentiating benign and malignant mediastinal and abdominal lymph nodes (LNs).

METHODS

A comprehensive literature search was performed on multiple electronic databases through February 2020. A random or fixed effect model generated the pooled sensitivity, specificity, likelihood ratio (LR), and diagnostic odds ratio (DOR) of EUS-FNA. Subgroup analyses and meta-regression were used to explore sources of heterogeneity.

RESULTS

Twenty-six studies involving 2753 patients with 2833 LNs were included. In the differential diagnosis of benign and malignant LNs, EUS-FNA had a pooled sensitivity, specificity, positive LR, and negative LR of 87% (95% confidence interval [CI] 86-90%), 100% (95% CI 99-100%), 68.98 (95% CI 42.10-113.02), and 0.14 (95% CI 0.11-0.17), respectively. The pooled rate of adverse events associated with EUS-FNA was 1.57% (95% CI 1.06-2.24%). The summary receiver operating characteristic (SROC) yielded an area under the curve (AUC) of 0.9912. EUS-FNA performed in mediastinal LNs gained a sensitivity of 85% (95% CI 81-88%), while in abdominal LNs, it reached 87% (95% CI 82-91%). The sensitivity of the subgroup with rapid on-site evaluation (ROSE) was 91% (95% CI 89-93%), while non-ROSE was 85% (95% CI 82-87%).

CONCLUSIONS

EUS-FNA is a sensitive, highly specific, and safe method for distinguishing benign and malignant mediastinal or abdominal LNs. However, the sensitivity of EUS-FNA still varies significantly among different centers.

Induction Chemotherapy for Primarily Unresectable Locally Advanced Pancreatic Adenocarcinoma-Who Will Benefit from a Secondary Resection?

Background and Objectives: An increasing number of patients (pts) with locally advanced pancreatic cancer (LAPC) are treated with an intensive neoadjuvant therapy to obtain a secondary curative resection. Only a certain number of patients benefit from this intention. The aim of this investigation was to identify prognostic factors which may predict a benefit for secondary resection. Materials and Methods: Survival time and clinicopathological data of pts with pancreatic cancer were prospective and consecutively collected in our Comprehensive Cancer Center Database. For this investigation, we screened for pts with primarily unresectable pancreatic cancer who underwent a secondary resection after receiving induction therapy in the time between March 2017 and May 2019. Results: 40 pts had a sufficient database to carry out a reliable analysis. The carbohydrate-antigen 19-9 (CA 19-9) level of the pts treated with induction therapy decreased by 44.7% from 4358.3 U/mL to 138.5 U/mL (p = 0.001). The local cancer extension was significantly reduced (p < 0.001), and the Eastern Cooperative Oncology Group (ECOG) performance status was lowered (p = 0.03). The median overall survival (mOS) was 20 months (95% CI: 17.2–22.9). Pts who showed a normal CA 19-9 level (<37 U/mL) at diagnosis and after neoadjuvant therapy or had a Body Mass Index (BMI) below 25 kg/m² after chemotherapy had a significant prolonged overall survival (29 vs. 19 months, p = 0.02; 26 vs. 18 months, p = 0.04; 15 vs. 24 months, p = 0.01). Pts who still presented elevated CA 19-9 levels >400 U/mL after induction therapy did not profit from a secondary resection (24 vs. 7 months, p < 0.001). Nodal negativity as well as the performance of an adjuvant therapy lead to better mOS (25 vs. 15 months, p = 0.003; 10 vs. 25 months, p < 0.001). Conclusion: The pts in our investigation had different benefits from the multimodal treatment. We identified the CA 19-9 level at time of diagnosis and after neoadjuvant therapy as well as the preoperative BMI as predictive factors for overall survival. Furthermore, diagnostics of presurgical nodal status should gain more importance as nodal negativity is associated with better outcome.

Spatial-domain low-coherence quantitative phase microscopy to improve the cytological diagnosis of pancreatic cancer

Use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology to detect pancreatic cancer is limited, with a high false negative rate mainly due to the relatively fewer number of completely cancerous cells. To improve the accuracy of EUS-FNA cytological diagnosis, we evaluated a novel optical system—spatial-domain low-coherence quantitative phase microscopy (SL-QPM)—to analyze nanoscale nuclear architecture on original cytology samples, especially those diagnosed as indeterminate for malignancy, with the goal of maintaining high specificity and reducing false positive rate. We performed SL-QPM on original cytology samples obtained by EUS-FNA from 40 patients with suspicious pancreatic solid lesions (27 adenocarcinomas, 5 neuroendocrine tumor, 8 chronic pancreatitis), including 13 cases that were cytologically indeterminate. Each diagnosis had been confirmed by follow-up surgical pathology. The SL-QPM-derived nanoscale nuclear architectural parameters distinguished pancreatic cancer from cytologically indeterminate cells. A logistic regression model using nuclear entropy and SD increased the sensitivity of cytology in identifying pancreatic cancer from 72% to 94% while maintaining 100% specificity. The SL-QPM-derived nanoscale nuclear architecture properties show great promise in improving the cytological diagnosis of EUS-FNA for pancreatic cancer and could be used when traditional cytopathology does not get an accurate diagnosis, and can be easily translated into a traditional clinical device.

Recognizing intrapancreatic accessory spleen via EUS: Interobserver variability

Background and Objective:

Accessory spleen (AS) may be encountered as an intrapancreatic lesion on EUS. This can look similar to other pancreatic pathologies and may lead to unnecessary interventions. The goal of this study was to evaluate the accuracy of EUS in distinguishing intrapancreatic AS (IPAS) from other pancreatic lesions.

Materials and Methods:

Twelve sets of endoscopic images of the spleen and various pancreatic lesions confirmed on histology or cytology were gathered. Ten endosonographers were asked to characterize and identify the lesions. The responses were analyzed via Excel and the interobserver agreement was analyzed using Gwet's agreement coefficient statistic via Stata I/C v15.

Results:

In our sample, the interobserver agreement was 0.37 (−1–1; 0–0.2 poor, 0.2–0.4 fair, 0.4–0.6 moderate, 0.6–0.8 substantial, and 0.8–1.0 almost perfect) for determining whether or not the pancreatic lesion is IPAS. The reviewers were able to correctly determine IPAS endosonographically with a sensitivity of 77%, specificity of 74%, and positive and negative predictive values of 50% and 92%, respectively.

Conclusion:

There is a moderate-to-substantial interobserver agreement in describing the sonographic characteristics of the pancreatic lesions, such as the shape, echogenicity compared to spleen, echotexture, and border of the lesions. However, the interobserver agreement is only fair when deciding if the pancreatic lesion is an IPAS. The similar profile of IPAS and pancreatic neuroendocrine tumor could confound the diagnosis of IPAS, thus contributing to the decreased interobserver agreement. This study demonstrates that EUS criteria alone are not accurate for IPAS diagnosis. Fine-needle aspiration (FNA) may be required for a confirmatory diagnosis.

Duodenal gastrointestinal stromal tumors appear similar to pancreatic neuroendocrine tumors: A case report

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Duodenal GISTs and pancreatic NETs are rare.

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Duodenal GISTs often present with gastrointestinal bleeding.

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Duodenal GISTs can be misdiagnosed as a pancreatic head mass.

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The optimal surgical procedure has not yet been established for duodenal GISTs.

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The diagnosis can be established preoperatively to guide the extent of resection.

Introduction

Duodenal gastrointestinal tumors (GISTs) are rare. Duodenal GISTs and pancreatic neuroendocrine tumors (NETs) may appear similar on imaging studies. GISTs arising from the second or third portions of duodenum may be incorrectly diagnosed as pancreatic NETs.

Presentation of case

The patient is a 79-year-old man who was referred to our hospital with a history of tarry stools and loss of consciousness. Urgent upper digestive tract endoscopy revealed a bleeding submucosal duodenal lesion, which was controlled using endoscopic clips. Enhanced computed tomography scan showed a hyper-vascular mass 50 mm in diameter, at the pancreatic uncus. The patient underwent a pylorus-preserving pancreaticoduodenectomy. Histologically, the tumor was composed of spindle-shaped cells immunohistochemically positive for c-kit and CD34, and the lesion diagnosed as a duodenal GIST.

Discussion

Duodenal GISTs often present with gastrointestinal bleeding, which can necessitate emergency surgery. Surgical resection with regional lymph node dissection is the optimal treatment for pancreatic NETs. In contrast, GISTs are generally treated with a minimal resection and without lymph node dissection. Thus, establishing the diagnosis is important in the management of these tumors. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is effective to establish the diagnosis of these lesions.

Conclusion

A tumor located in the pancreatic head or mesenteric side of the duodenum cannot always be diagnosed based on imaging, and is ideally diagnosed histologically to guide the extent of resection. While EUS-FNA can establish the diagnosis, the complications of this procedure must be considered.

Adult Renal Neoplasms: Cytology, Immunohistochemistry, and Cytogenetic Characteristics

Tissue sampling of renal masses is traditionally performed using percutaneous sonographic or CT guidance core biopsy (CB) with or without touch preparation cytology and/or fine-needle aspiration cytology (FNAC). The combined used of CB and FNAC is expanding in clinical practice, especially in small renal masses and plays a pivotal role in therapeutic decision making. Grouping the renal neoplasms in differential diagnostic groups helps in choosing specific immunohistochemical markers and reaching an accurate diagnosis.

Citología por punción-aspiración con aguja fina guiada por ultrasonido endoscópico en el diagnóstico de adenocarcinoma ductal de páncreas

El cáncer de páncreas es la cuarta causa de muerte por cáncer en los Estados Unidos; en el mundo se asocia con 227.000 muertes anuales, aproximadamente. Es producto de múltiples factores, siendo el tabaquismo el principal factor de riesgo.La punción-aspiración con aguja fina guiada por ultrasonido endoscópico es una técnica muy eficaz en el diagnóstico de lesiones neoplásicas del páncreas. El diagnóstico citológico mediante esta técnica debe hacerse según los lineamientos para el sistema pancreático-biliar de la Papanicolaou Society of Cytopathology. Dichos lineamientos incluyen las indicaciones, las técnicas, la terminología y la nomenclatura, así como los estudios auxiliares, el manejo posterior al procedimiento y los criterios citológicos para el diagnóstico.La especificidad de una interpretación positiva o maligna para la punción-aspiración pancreática con aguja fina, es de 90 a 95 % en la mayoría de los estudios.

Clinical features, onsite evaluation, and follow-up results in patients with suspicious for adenocarcinoma on EUS-guided FNA of pancreas

BACKGROUND

Occasionally, an interpretation of suspicious for adenocarcinoma is made for endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of pancreas. In this study, we aimed to assess onsite evaluation and follow-up results for FNAs with suspicious for adenocarcinoma (FNA-SUS) in order to identify likely factors that are associated with this interpretation.

DESIGN

A total of 53 pancreatic FNA-SUS cases and 149 pancreatic FNAs with an interpretation of adenocarcinoma (FNA-ADC) were included in current study. Clinical characteristics, onsite evaluation results, and follow-up results were collected and analyzed.

RESULTS

Compared with FNA-ADC category, FNA-SUS category was associated with increased cystic/ill-defined lesions on imaging, increased frequency of inadequate materials (onsite evaluation), increased total smear/slide number, and increased number of cases with limited materials on permanent slides/sections. For follow-up resections, 21% of FNA-SUS cases (7 of 34) showed benign, dysplastic changes or neuroendocrine tumors and 79% (27 of 34) showed adenocarcinoma with increased frequency of well-differentiated type. In contrast, all FNA-ADC cases showed adenocarcinoma. The average age of those 7 FNA-SUS cases with non-adenocarcinoma on follow-up was significantly younger than that of 27 cases with adenocarcinoma. FNA-SUS cases with adenocarcinoma on follow-up showed even greater frequency of inadequate materials during onsite evaluation and more increased total smear slide number than FNA-ADC cases.

CONCLUSION

Our data demonstrated several clinicopathologic factors that are likely associated with a suspicious cytology. In younger patients with suspicious cytology and non-mass forming lesion, surgical management should be taken with caution as a considerable percentage of patients showed only benign or low-grade dysplastic changes.

Efficacy of endoscopic ultrasound-guided fine-needle aspiration and core needle biopsy in the diagnosis of upper gastrointestinal submucosal lesions

INTRODUCTION

Endoscopic ultrasonographically guided fine-needle aspiration (EUS-FNA) has been increasingly utilized to evaluate submucosal lesions of the upper gastrointestinal (UGI) tract. Our study aims to determine the efficacy of UGI EUS-FNA/core needle biopsy (CNB), including the frequency and cytomorphologic features of encountered submucosal lesions, and to investigate contributing factors including the role of rapid on-site evaluation (ROSE).

METHODS

We analyzed all UGI submucosal lesions diagnosed at our institution by EUS-FNA/CNB from September 2008 through August 2015.

RESULTS

During this 8-year study period, 94 patients underwent 110 UGI EUS-FNA/CNB, including 89 (81%) gastric, 11 (10%) duodenal, and 10 (9%) esophageal lesions. Twenty-seven (25%) were gastrointestinal stromal tumors (GISTs), followed by 13 (12%) leiomyomas, 5 (5%) schwannomas, 4 (4%) gastric adenocarcinomas, 3 (3%) neuroendocrine tumors (NETs), and 3 (3%) pancreatic heterotopias. All GISTs, leiomyomas, and NETs were ultimately diagnosed by EUS biopsies, as well as 75% of adenocarcinomas, 60% of schwannomas, and 33% of pancreatic heterotopias. The specificity of EUS-FNA/CNB for these 6 most commonly encountered lesions was 100%, with sensitivity of 82%. Sensitivity was 100% for esophageal and duodenal biopsies, and 80% and 75% for gastric and gastroesophageal procedures, respectively. Factors that contributed to poor yield included the lack of ROSE, small lesional size, lesion location and histology, and needle type. Neither number of needle passes nor operator experience appeared to influence specimen adequacy.

CONCLUSION

EUS-FNA/CNB is an effective modality for diagnosing UGI submucosal lesions. Awareness of potential errors due to sampling of the bowel wall, lesional cystic degeneration, as well as pancreatic heterotopia and Brunner gland hamartoma is essential in order to avoid false diagnoses.

Endoscopic Ultrasonography with Fine-needle Aspiration: New Techniques for Interpretation of Endoscopic Ultrasonography Cytology and Histology Specimens

Significant advances have been made in the last few years in the technologies for sampling pancreatic masses, and in the understanding of the biology of pancreatic cancer. Better and more targeted treatments are likely to become available. Because most pancreatic cancers are likely to remain unresectable at diagnosis, high-quality, high-cellularity specimens are essential. A tailored approach that considers indication, location, and treatment possibilities needs to be taken before embarking on a pancreatic biopsy. Because the demand from oncologists and patients for increasingly personalized therapy is likely to grow, optimal sampling beyond diagnostic accuracy is likely to become increasingly critical.

Accuracy of endoscopic ultrasound-guided tissue acquisition in the evaluation of lymph nodes enlargement in the absence of on-site pathologist

AIM

To evaluate factors that influence the diagnostic accuracy of endoscopic ultrasound (EUS)-guided tissue acquisition for lymph node enlargement in the absence of an on-site pathologist.

METHODS

A retrospective analysis of patients who underwent EUS-guided tissue acquisition for the pathological diagnosis of lymph node enlargement between April 2012 and June 2015 is reported. Tissue acquisition was performed with both cytology and biopsy needles of different calibers. The variables evaluated were lymph node location and size, number of passes and type of needle used. Final diagnosis was based on surgical histopathology or, in non-operated cases, on EUS-guided tissue acquisition and imaging assessment with a minimum clinical follow-up of 6 mo.

RESULTS

During the study period, 168 lymph nodes with a median size of 20.3 mm (range 12.5-27) were sampled from 152 patients. Ninety lymph nodes (53.6%) were located at mediastinum, and 105 (62.5%) were acquired with biopsy needles. The final diagnosis was benign/reactive origin in 87 cases (51.8%), malignant in 65 cases (38.7%), and lymphoma in 16 cases (9.5%). The sensitivity, specificity, positive predictive value and negative predictive value for the detection of malignancy were 74.1%, 100%, 100% and 80.6%, respectively. The overall accuracy was 87.5% (95%CI: 81.7-91.7). No variables were independently associated with a correct final diagnosis according to the multivariate analysis.

CONCLUSION

EUS-guided tissue acquisition is a highly accurate technique for assessing lymph node enlargement. None of the variables evaluated were associated with diagnostic accuracy.

Cytologic criteria to reduce error in EUS-FNA of solid pseudopapillary neoplasms of the pancreas

INTRODUCTION

Standardization of error classification in pathology remains an important issue. This study assesses the extent of error in cytopathologic diagnosis of solid pseudopapillary neoplasms (SPN) of the pancreas. Because of morphologic overlap of SPN and pancreatic neuroendocrine neoplasms (NET), we compared cytologic characteristics to determine which best distinguishes these entities.

MATERIALS AND METHODS

We collected cases diagnosed as SPN either by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) by cytology or surgical pathology from January 2000 to March 2013. An equal number of NET cases were randomly selected. Cytology and surgical pathology cases were evaluated for diagnostic errors and patient impact. Cytologic features in SPN and NET were scored based on presence of previously described characteristics.

RESULTS

A total of 17 patients with EUS-FNA were diagnosed with SPN by cytology or surgical pathology. Of those, 14 had surgical follow-up and 13 had adequate cell blocks and immunohistochemistry. There were 5 discrepancies between cytology and surgical pathology (5 of 14, 36%). There were no false positives or false negatives, but 5 misclassifications: 4 diagnosed as NET on cytology, and 1 as NET versus SPN. All misclassification errors were associated with no harm. When compared with NET, fine chromatin, nuclear grooves, pseud papillae, pink stroma, and hyaline globules are statistically significantly associated with SPN.

CONCLUSIONS

EUS-FNA of pancreatic SPN has excellent positive and negative predictive value, with no false positives or false negatives in this 12-year study. Only misclassification errors as pancreatic NET were made with minimal impact. We suggest that the presence of 3 of 5 major cytologic criteria offer accuracy in diagnosing SPN to prevent misclassification.

Pancreatic involvement by metastasizing neoplasms as determined by endoscopic ultrasound-guided fine needle aspiration: A clinicopathologic characterization

BACKGROUND

Pancreatic tumors often represent primary neoplasms, however organ involvement with metastatic disease can occur. The use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to determine the underlying pathology provides guidance of clinical management.

METHODS

25 cases were identified in a retrospective review of our institution's records from 2006 to 2016. Clinical parameters and prognosis are described.

RESULTS

Metastatic lesions to the pancreas diagnosed by EUS-FNA accounted for 4.2% of all pancreatic neoplastic diagnoses, each lesion had a median greatest dimension of 1.5 cm, were most often located in the head of the pancreas, and by EUS were typically hypoechoic masses with variably defined borders. Patients were of a median age of 64 years old at diagnosis of the metastatic lesion(s) and the mean interval from primary diagnosis to the diagnosis of metastasis to the pancreas was 58.7 months (95% confidence interval, CI, 35.4 to 82.0 months). The rates of 24-month overall survival after diagnoses of metastatic renal cell carcinoma or all other neoplasms to the pancreas were 90% and 7% respectively. The origin of the neoplasms included the kidney (n = 10), colon (n = 4), ovary (n = 3), lung (n = 2), et al. Smear-based cytomorphology, and a combination of histomorphology and immunohistochemical studies from cell block preparations showed features consistent with the neoplasm of derivation.

CONCLUSION

Metastases to the pancreas can be diagnosed via EUS-FNA, with enough specimen to conduct immunohistochemical studies if necessary to delineate origin. The determination of metastatic disease to the pancreas alters management and prognosis of the patient. Diagn. Cytopathol. 2017;45:418-425. © 2017 Wiley Periodicals, Inc.

Fully automated PCR detection of KRAS mutations on pancreatic endoscopic ultrasound fine-needle aspirates

AIMS

In cystic and solid pancreatic lesions, KRAS mutational status refines the diagnosis of uncertain endoscopic ultrasound (EUS) aspirates. This test should have a fast turnaround time and ideally be performed at the centre where the patient is diagnosed. The Idylla KRAS Mutation Test enables standardisation even in units without molecular expertise.

METHODS

The Idylla test was designed for use with formalin-fixed paraffin-embedded (FFPE) sections. However, we directly pipetted 3 µL (corresponding to 1/10th of a DNA preparation from the aspirate sample) in the cartridge, which was automatically run as if an FFPE sample had been inserted. The performance was compared with Sanger sequencing, Allele Specific Locked Nucleic Acid PCR (ASLNAqPCR), and 454 Next Generation Sequencing (454-NGS) in light of clinicopathological end points.

RESULTS

Idylla yielded valid results in 49/52 (94.2%) cases, in 2 h. A total of 18/49 cases showed mutation either in KRAS exon 2 (14/18) or in exon 3 (4/18). Idylla KRAS test had 100% specificity and a sensitivity (55.1%) higher than Sanger sequencing (41.3%) and identical to ASLNAqPCR (55.1%). When the low-abundant mutant allele (<5%) cases were excluded from the analysis, the Idylla KRAS Mutation Test clinical sensitivity increased to 61.9% approaching that of 454-NGS (66.6%).

CONCLUSIONS

This is the first study that applied the novel Idylla KRAS test to the clinical setting of pancreatic cancer. In particular, this system can be easily implemented in the routine assessment of pancreatic EUS-fine-needle aspiration-derived DNA samples to quickly provide information on KRAS mutational status to supplement cytological evaluation.

Initial experience with endoscopic ultrasound-guided fine needle aspiration of renal masses: indications, applications and limitations

CONTEXT

Tissue sampling of renal masses is traditionally performed via the percutaneous approach or laparoscopicaly. The utility of endoscopic ultrasound to biopsy renal lesions it remains unclear and few cases have been reported.

OBJECTIVES

To evaluate the feasibility and outcome of endoscopic ultrasound fine needle aspiration of renal tumors.

METHODS

Consecutive subjects undergoing attempted endoscopic ultrasound fine needle aspiration of a kidney mass after evaluation with computerized tomography or magnetic resonance.

RESULTS

Ten procedures were performed in nine male patients (median age 54.7 years) on the right (n = 4) and left kidney (n = 4) and bilaterally (n = 1). Kidney masses (median diameter 55 mm ; range 13-160 mm) were located in the upper pole (n = 3), the lower pole (n = 2) and the mesorenal region (n = 3). In two cases, the mass involved more than one kidney region. Surgical resection confirmed renal cell carcinoma in six patients in whom pre-operative endoscopic ultrasound fine needle aspiration demonstrated renal cell carcinoma. No complications were reported.

CONCLUSIONS

Endoscopic ultrasound fine needle aspiration appears as a safe and feasible procedure with good results and minimal morbidity.

Effect of Povidone-iodine Washing of Gastrointestinal Mucosa or Taking Proton Pump Inhibitors on Bacteremia after Endoscopic Ultrasonography-guided Fine Needle Aspiration

OBJECTIVE

Few studies have evaluated the risk of bacteremia and infectious complications after endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Therefore, we aimed to study the frequency of bacteremia and search for a method to potentially reduce bacterial infection after EUS-FNA. We also investigated the effect of taking proton pump inhibitors (PPIs) before examination on the occurrence of bacteremia.

METHODS

A total of 28 healthy adult dogs were randomly assigned into three groups: control group, povidone-iodine group and omeprazole group. The dogs in the povidone-iodine group were administered with 0.5% povidone-iodine solution (10 mL) to wash gastrointestinal mucosa, while the dogs in the omeprazole group were fed with 20 mg omeprazole orally twice a day for 3 days before the EUS-FNA procedure. Blood samples were collected for cultures before EUS examination, between EUS and FNA, and 5 min, 15 min and 30 min after FNA.

RESULTS

There were 3 true-positive cases of bacteremia in the control group while there was 1 true-positive case of bacteremia in each of the two experiment groups. The differences in the occurrences of bacteremia between the control group and both experiment groups were not statistically significant.

CONCLUSION

There are no statistically significant differences in the frequencies of bacteremia between the two experiment groups and the control group. Therefore, washing of the gastrointestinal mucosa with 0.5% povidone-iodine solution may not reduce the risk of bacterial infection and taking the PPIs does not increase the risk of bacteremia after EUS-FNA.

Intranuclear cytoplasmic inclusions are a specific feature of intraductal papillary mucinous neoplasms that distinguish contaminating gastric epithelium

INTRODUCTION

Low-grade intraductal papillary mucinous neoplasms (IPMN) are challenging to diagnose because of an absence of reliable morphologic or immunohistochemical features to distinguish them from contaminating gastric foveolar epithelium. After noting intranuclear cytoplasmic inclusions (ICIs) in some cases of IPMN, we investigated whether ICIs could be used as a specific feature to distinguish IPMN from gastric foveolar epithelium.

MATERIALS AND METHODS

A consecutive cohort of 61 transduodenal endoscopic fine-needle aspirations of histologically or clinically verified pancreatic IPMNs without high-grade dysplasia from 2005 to 2012 were identified. A control cohort of 24 endoscopic fine-needle aspirations containing gastric epithelium was selected from transgastric specimens of nonpancreatic targets from the same period. Every fragment of mucinous epithelium in the 2 cohorts was examined in alcohol-fixed and cell block sections at high magnification to identify ICIs.

RESULTS

ICIs were observed in 31% (19 of 61) of cases in mucinous epithelial fragments obtained by fine-needle aspirations from low-grade IPMNs. When present, they were seen in about 1% of all cells. No ICIs were identified in the control cohort of 24 patients with normal gastric epithelium (P = 0.001 Fisher exact test). BRAF mutation (V600E) testing was performed on 5 IPMN cases, and was negative in all cases including 2 with and 3 without ICIs. KRAS mutation testing was performed on 9 cases of IPMN cases. Two cases with ICIs tested positive for KRAS mutations. Four cases without ICIs also tested positive, and 3 cases without ICIs tested negative.

CONCLUSIONS

ICIs are a specific morphologic feature found in about one third of low-grade IPMNs, but absent in gastric foveolar epithelium. There is no obvious molecular correlate with the presence of ICIs.

Posterior mediastinal tuberculous lymphadenitis with dysphagia as the main symptom: a case report and literature review

INTRODUCTION

Mediastinal tuberculous lymphadenitis (MTL) is mostly seen in primary tuberculosis in children, uncommon observed in adults. It usually presents the toxic symptoms of tuberculosis but rarely with symptoms characteristic of esophageal compression, such as dysphagia. Such patients can easily be misdiagnosed as esophageal neoplasm and get delayed or faulty treatment.

CASE REPORT

A 32-year-old man presented with dull chest pain of one month and dysphagia of five days. CRP was elevated, and a skin test was strongly positive. At upper endoscopy, a protruding lesion covered by normal mucosa was seen at 26 cm from the upper incisor. Barium swallow showed visible external compressive stricture on the middle-lower esophagus with normal mucosal pattern. Chest computed tomography (CT) scan showed a subcarinal mass adjacent to the esophageal wall in posterior mediastinum. An endoscopic ultrasonography (EUS) revealed a hypoechoic lesion suspected of esophageal stromal tumor in the fourth layer. A tissue was obtained by ultrasound-guided fine-needle aspiration (EUS-FNA), but cytopathology, bacilliculture and PCR test had no special findings. The patient required experimental antitubercular treatment and the protruding lesion shrank gradually during therapy period.

CONCLUSIONS

MTL could not be ignored in the differential diagnosis of posterior mediastinal mass with dysphagia. Analyzing and evaluating test results comprehensively is the key to make correct diagnosis and timely treatment. The experimental antituberculous treatment should be used if MTL is highly suspected.

Diagnostic error assessment and associated harm of endoscopic ultrasound-guided fine-needle aspiration of neuroendocrine neoplasms of the pancreas

BACKGROUND

Over the past decade, the standardization of error classification in anatomic pathology has become an important issue. The objective of the current study was to assess the extent of errors occurring in the cytopathologic diagnosis of neuroendocrine lesions of the pancreas, and to classify these errors and their associated harm.

METHODS

Information on all cases diagnosed as a neuroendocrine neoplasm either by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in cytology or by surgical pathology between 2000 and 2012 was collected. Using standardized error and harm classification, the authors reviewed the cytology and surgical pathology material and evaluated the type and the cause of diagnostic errors and their impact on the patient.

RESULTS

A total of 177 patients who underwent EUS-FNA were diagnosed with a neuroendocrine neoplasm either by cytology or surgical pathology. Eighty of these cases had surgical follow-up available at the study institution. Of these 80 cases, 56 had an adequate cell block and immunohistochemistry was performed. There were 14 discrepancies noted between cytologic and surgical pathologic diagnoses. There were 9 false-negative cases, consisting of 3 interpretation errors and 6 cytology sampling errors. There were 5 misclassifications, including 4 cases of solid pseudopapillary neoplasm and 1 case of neuroendocrine carcinoma (diagnosed as adenocarcinoma on cytology). There were no surgical pathology errors noted. All errors were associated with no or minor harm.

CONCLUSIONS

EUS-FNA of pancreatic neuroendocrine neoplasms has excellent diagnostic performance, with no false-positive diagnoses reported. When an adequate sample is obtained, the most significant error is misclassification, which is most often associated with solid pseudopapillary neoplasm. The harm associated with diagnostic errors is at most minor.

Five Top Stories in Cytopathology

Context.—Cytology relies heavily on morphology to make diagnoses, and morphologic criteria have not changed much in recent years. The field is being shaped predominantly by new techniques for imaging and for acquiring and processing samples, advances in molecular diagnosis and therapeutics, and regulatory issues.

Objective.—To review the importance of classical morphology in the future of cytopathology, to identify areas in which cytology is expanding or contracting in its scope, and to identify factors that are shaping the field.

Data Sources.—Literature review.

Conclusions.—Five stories paint a picture in which classical cytomorphology will continue to have essential importance, both for diagnosis and for improving our understanding of cancer biology. New endoscopy and imaging techniques are replacing surgical biopsies with cytology samples. New molecularly targeted therapies offer a chance for cytology to play a major role, but they pose new challenges. New molecular tests have the potential to synergize with, but not replace, morphologic interpretation of thyroid fine-needle aspirations. Ultrasound-guided fine-needle aspiration performed by cytopathologists is opening a new field of “interventional cytopathology” with unique value. For the productive evolution of the field, it will be important for cytopathologists to play an active role in clinical trials that document the ability of cytology to achieve cost-effective health care outcomes.

Subtyping of nonsmall cell lung cancer on cytology specimens: reproducibility of cytopathologic diagnoses on sparse material

Cytologic examination of fine-needle aspiration (material is increasingly used in diagnosing lung cancer. High interobserver agreement in distinguishing small-cell lung cancer from nonsmall-cell lung cancer (NSCLC) on cytologic material has been demonstrated. Because of new treatment-modalities, subclassification of NSCLC into squamous cell carcinoma (SQC) and non-SQC has clinical impact. Subclassification based on morphology alone may be difficult, but applying immunohistochemistry (IHC) to clot-material has proved helpful. When insufficient material is available to make a clot from the aspirate, cytoscrape (CS) can convert cytologic material into tissue fragments useful for IHC. The purpose of this study was to test the reproducibility of pulmonary malignant diagnoses, in particular distinction between subgroups of NSCLC, based on smeared material and IHC on CS. A consecutive series of May-Grunwald-Giemsa (MGG) stained smears and CS with IHC on material from 79 patients suspected of having lung cancer was included. The material was circulated twice to four pathologists. The diagnoses were categorized in five groups: SQC, adenocarcinoma of the lung, non-SQC, benign lesion and other forms of malignancy, including metastases. Reproducibility was analyzed using Kappa statistics. Interobserver reproducibility of the diagnoses in round 1 was good to very good (kappa 0.57-0.71) and very good in round 2 (0.63-0.80). Reproducibility of subclassification of NSCLC based on MGG stained smear and IHC on CS, was very good among experienced pathologists. With only sparse material available, CS should be used to achieve reproducible diagnoses, including subtyping of NSCLC.

The yield of EUS-FNA in undiagnosed upper abdominal adenopathy is very high

PURPOSE

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) allows sampling of abdominal adenopathy easily and safely from locations that were previously deemed too risky and inaccessible. The efficacy of EUS-FNA in a large cohort of patients with abdominal adenopathy has not been previously described in the literature.

METHODS

We conducted a large retrospective study at a tertiary referral center. Two hundred twenty-five consecutive patients undergoing EUS-FNA for only abdominal adenopathy between 2004 through August 2009 were included in our study. Patient demographics, indications, EUS findings, and final cytologic diagnoses were recorded.

RESULTS

A total of 230 lymph nodes were biopsied in 225 patients. Common locations of nodes included peripancreatic (19%), porta hepatis (18%), and celiac axis (18%). Adequate specimens were obtained in 200/230 nodes (87%) and the most common diagnoses based on cytology were: benign/reactive (50%), adenocarcinoma (20%), lymphoma (8%). The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were 71%, 99%, 99%, 78%, and 85%, respectively, for EUS-FNA. Based on EUS imaging alone, malignant nodes were more likely to be larger in diameter (17 mm versus 26 mm, p < 0.001), have a round shape (p = 0.002), well-defined borders (p = 0.04), and hypoechic echotexture (p < 0.001).

CONCLUSIONS

EUS-FNA allows for excellent tissue acquisition in abdominal lymphadenopathy. Our study supports the use of traditional EUS imaging criteria to identify suspected malignant adenopathy. The results from our large cohort of patients show that EUS-FNA should be considered as a first-line diagnostic modality for ascertaining the etiology of abdominal lymphadenopathy.

Cercariform cells: another cytologic feature distinguishing solid pseudopapillary neoplasms from pancreatic endocrine neoplasms and acinar cell carcinomas in endoscopic ultrasound-guided fine-needle aspirates

BACKGROUND

Solid pseudopapillary neoplasm (SPPN) is a rare tumor of unknown origin that occurs predominantly in the body or tail of the pancreas in young women. The authors recently identified cercariform (Greek: tailed) cells, similar to those described in urothelial carcinomas, as a consistent cytologic feature in ultrasound-guided fine-needle aspiration (EUS-FNA) samples from SPPNs. The objective of the current multi-institutional study was to define the value of these cells in the differential diagnosis of SPPN with other neoplasms characterized cytologically by the presence of monotonous, uniform cells in pancreatic aspirates: pancreatic neuroendocrine tumors (Pan-NETs) and acinar cell carcinomas (ACCs).

METHODS

The files of 4 academic hospitals were searched for SPPNs, Pan-NETs, and ACCs that were diagnosed by EUS-FNA. The slides were reviewed, and several cytologic features were recorded semiquantitatively to identify discriminating features between SPPNs, Pan-NETs, and ACCs.

RESULTS

From the analysis of 18 SPPNs, 4 ACCs, and 20 Pan-NETs, the following cytologic features were identified as common to all 3 neoplasms: single cells and rosettes/acinar cell groups, round-to-plasmacytoid cells, pale-to-granular cytoplasm, fine vacuoles, and binucleated cells. Papillary structures, cercariform cells, large cytoplasmic vacuoles, reniform nuclei, hyaline globules/magenta-colored material, and degenerative features (cholesterol crystals, calcifications, foam cells, or giant cells) were significantly more common in SPPNs. Prominent nuclear grooves were encountered in only 4 of 18 SPPNs.

CONCLUSIONS

The current results indicated that the presence of cercariform cells is another useful clue for the cytologic diagnosis of SPPN in challenging cases.

Endoscopic ultrasound guided fine-needle aspiration of lymph nodes and solid masses: factors influencing the cellularity and adequacy of the aspirate

GOALS

To study the factors that influence the cellularity and adequacy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA).

BACKGROUND

An on-site cytopathology service is preferred during EUS-guided FNA. However, this is not always available. Factors that influence the aspirate cellularity and adequacy have not been well defined in the absence of on-site cytopathology.

STUDY

EUS-guided FNA procedures without an on-site cytopathologist from a single center were retrospectively studied. FNA of solid masses and lymph nodes (LN) were included. The FNA cellularity, hemorrhagic content, and endoscopists' assessment of adequacy were analyzed.

RESULTS

A total of 166 patients from January 2009 to October 2010 were included. A total of 520 FNA passes were performed. Of the 166 lesions, 70 (42.2%) were solid masses and 96 (57.8%) were LNs. A 22-G needle was used in 72.3% and 25 G in 27.7% of the patients. The median (range) number of FNA passes was 3 (1 to 7) for LNs and 3 (1 to 5) for solid masses. With this, the endoscopists had an accuracy of 92.2% (153/166) for obtaining an adequate aspirate. Of the 166 samples, 4 (2.4%) were acellular, 20 (12.0%) sparsely cellular, 52 (31.4%) moderately cellular, and 90 (54.2%) highly cellular. The 25-G needle had significantly more adequate aspirates than the 22-G needle for solid masses (P=0.011). Also, increasing passes correlated with higher cellularity (P=0.002) and an adequate aspirate (P=0.021). No correlation was found for LN FNA. Lesion size did not influence the cellularity or adequacy (P>0.05). The degree of hemorrhage was not influenced by the needle gauge, number of passes, or lesion size. The diagnostic yield was not affected by hemorrhage in the sample (P>0.05).

CONCLUSIONS

EUS-guided FNA obtains a high proportion of adequate aspirates for LNs and solid masses, even without an on-site cytopathologist. Small proportions of inadequate samples still occur. For solid masses, a 25-G needle with at least 3 passes is more likely to provide an adequate aspirate than a 22-G needle and fewer passes. Hemorrhage did not affect the cytopathology's ability to make a diagnosis.

The cytologic diagnosis of gangliocytic paraganglioma: a case report

Gangliocytic paragangliomas are rare tumors primarily found in the duodenum. We report a case of a woman who presented with a retroperitoneal lymph node involved by metastatic gangliocytic paraganglioma. Subsequently, fine-needle aspiration (FNA) cytology was used to identify the primary duodenal gangliocytic paraganglioma. The smears of the aspirate material were highly cellular and contained a dominant population of epithelioid cells, a second population of ganglion cells and a third population of small, bland spindled cells. To our knowledge, the cytologic features of gangliocytic paraganglioma have not previously been documented.

Large platelet aggregates in endoscopic ultrasound-guided fine-needle aspiration of the pancreas and peripancreatic region: a clue for the diagnosis of intrapancreatic or accessory spleen

Intrapancreatic and intraabdominal accessory spleens (IPIASs) are rarely encountered in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsies. However, as incidentally discovered IPIAS can mimic a benign or malignant pancreatic neoplasm on imaging studies, a definitive diagnosis made by EUS-FNA can avert an unnecessary surgical intervention or additional radiologic follow-up. We report five cases of intrapancreatic splenules and one case of accessory spleen (AS) in which a definitive diagnosis was made on EUS-FNA. Previously recognized FNA cytomorphologic features of splenic tissue, including ASs and splenosis, are endothelial cells and polymorphous lymphocytes admixed with neutrophils, eosinophils, plasma cells, histiocytes, and lymphoglandular bodies. We describe the additional finding of abundant large platelet aggregates as another distinguishing feature of splenic tissue on FNA. In all six cases, large platelet aggregates were identified along with polymorphous lymphoid cells, lymphoglandular bodies, loose aggregates of endothelial cells and scattered or aggregated bland spindle cells. A review of 10 consecutive cases of EUS-FNA-sampled benign intraabdominal lymph nodes showed that the presence of large platelet aggregates, three-dimensional aggregates of lymphoid cells and of bland slender spindle cells and the absence of follicular germinal cell components (tingible body macrophages and lymphohistiocytic aggregates) are useful in differentiating IPIASs from reactive lymph nodes. Immunoperoxidase stains were useful to confirm a suspected IPIASs by showing CD31-positive acellular flocculent material, consistent with large platelet aggregates and a rich CD8-positive endothelial cell network between CD45-positive lymphoid cells and CD68-positive histiocytes in all six cases.

A comparative study of endoscopic ultrasound guided fine needle aspiration with and without a stylet

BACKGROUND

Despite lack of evidence, use of a stylet during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is assumed to improve the quality and diagnostic yield of specimens.

AIM

The purpose of this study was to compare EUS-FNA specimens obtained with stylet (S+) and without stylet (S-) for: (i) cellularity, contamination, adequacy, and amount of blood and (ii) diagnostic yield of malignancy.

METHODS

Patients who underwent EUS-FNA of solid lesions by two experienced endosonographers at a tertiary referral center using a 22-gauge FNA needle with suction were included. Stylet was used for all EUS-FNA procedures performed between January 2006 and September 2007 and no stylet was used between October 2007 and April 2009 allowing comparison between the two techniques. Cytology slides were retrieved, de-identified and evaluated by two experienced cytopathologists blinded to FNA technique. Slides were evaluated for cellularity, degree of contamination, adequacy, amount of blood and cytologic diagnosis. Fisher's exact and unpaired t-test were used for comparative analysis.

RESULTS

A total of 162 patients with 228 lesions were included. FNA of 106 and 122 lesions each was performed in the S+ and S- groups, respectively. FNA sites included pancreas [41 (18%)], lymph node [125 (55%)], liver [20 (9%)], adrenal [21 (9%)] and others [21 (9%)]. No significant differences in the cellularity (P=0.37), contamination (P=0.18), significant blood (P=0.42) and adequacy of specimen (P=0.45) were found between S+ and S- specimens. There was no statistically significant difference in the diagnostic yield of malignant lesions (P=0.48).

CONCLUSIONS

The use of stylet during FNA does not appear to confer any advantage with regards to the adequacy of specimen or diagnostic yield of malignancy.

A prospective, single-blind, randomized, controlled trial of EUS-guided FNA with and without a stylet

BACKGROUND

Most endosonographers use an EUS needle with an internal stylet during EUS-guided FNA (EUS-FNA). Reinserting the stylet into the needle after every pass is tedious and time-consuming, and there are no data to suggest that it improves the quality of the cytology specimen.

OBJECTIVE

To compare the samples obtained by EUS-FNA with and without a stylet for (1) the degree of cellularity, adequacy, contamination, and amount of blood and (2) the diagnostic yield of malignancy.

DESIGN

Prospective,single-blind, randomized, controlled trial.

SETTING

Two tertiary care referral centers.

PATIENTS

Patients referred for EUS-FNA of solid lesions.

INTERVENTION

Patients underwent EUS-FNA of the solid lesions, and 2 passes each were made with a stylet and without a stylet in the needle. The order of the passes was randomized, and the cytopathologists reviewing the slides were blinded to the stylet status of passes.

MAIN OUTCOME MEASUREMENTS

Degree of cellularity, adequacy, contamination, amount of blood, and the diagnostic yield of malignancy in the specimens.

RESULTS

A total of 101 patients with 118 lesions were included in final analysis; 236 FNA passes were made, each with and without a stylet. No significant differences were seen in the cellularity (P = .98), adequacy of the specimen (P = .26), contamination (P = .92), or significant amount of blood (P = .61) between specimens obtained with and without a stylet. The diagnostic yield of malignancy was 55 of 236 specimens (23%) in the with-stylet group compared with 66 of 236 specimens (28%) in the without-stylet group (P = .29).

LIMITATIONS

Endosonographers were not blinded to the stylet status of the passes.

CONCLUSIONS

Using a stylet during EUS-FNA does not confer any significant advantage with regard to the quality of the specimen obtained or the diagnostic yield of malignancy. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT 01213290).

Cytology of the Pancreas: A Practical Review for Cytopathologists

Pancreatic cytopathology plays a critical role in the management of patients with cystic and solid pancreatic masses. The frequency of pancreatic fine-needle aspiration continues to increase and general surgical pathologists and cytopathologists need to be aware of the most commonly encountered entities as well as the pitfalls associated with gastrointestinal tract contaminants in endoscopic ultrasound-guided fine-needle aspiration. This article focuses on the most commonly encountered pancreatic lesions and the importance of correlation of cytologic features with clinical, radiologic, and ancillary studies for accurate diagnosis.

Ductal Adenocarcinoma of the Pancreas

Pancreatic ductal adenocarcinoma (PDAC) and its variants comprise between 80% and 90% of all tumors of the exocrine pancreas. Because of its silent course, late clinical manifestation, and rapid growth, it is considered a silent killer. Only 10% to 15% of cases are resectable and the 5-year survival rate remains lower than 5%. The differential diagnosis between PDAC and chronic pancreatitis is a challenge for pathologists. This article provides a guide for pathologic evaluation of PDAC specimens with the macroscopic and microscopic features of common PDAC and its variants and discusses the differential diagnosis and morphologic and immunophenotypical prognostic parameters.

PAX8 is expressed in pancreatic well-differentiated neuroendocrine tumors and in extrapancreatic poorly differentiated neuroendocrine carcinomas in fine-needle aspiration biopsy specimens

BACKGROUND

PAX (paired box) genes encode a family of transcription factors important for organogenesis. Recently, PAX8 has been recognized as a potential immunohistochemical marker of pancreatic neuroendocrine tumors. The authors evaluated PAX8 expression in fine-needle aspiration biopsies of neuroendocrine tumors to establish whether PAX8 immunohistochemistry can be used as an ancillary marker of pancreatic origin for neuroendocrine tumors.

METHODS

Fine-needle aspiration biopsies from 72 neuroendocrine tumors were evaluated for PAX8 expression: 32 primary and 23 metastatic well-differentiated neuroendocrine tumors (25 pancreatic, 13 pulmonary, 3 ileal, 2 duodenal, 1 rectal, 1 ovarian, and 10 primary site unknown) and 17 poorly differentiated neuroendocrine carcinomas (11 pulmonary, 1 pancreas, 1 breast, 1 thymus, and 3 primary site unknown).

RESULTS

Among well-differentiated neuroendocrine tumors, only tumors from the pancreas were PAX8 positive (14 of 25, 56%) whereas no cases of pulmonary (0 of 13), ileal (0 of 3), duodenal (0 of 2), rectal (0 of 1), or ovarian (0 of 1) well-differentiated neuroendocrine tumors were positive for PAX8. One of 10 (10%) well-differentiated neuroendocrine tumors of unknown primary origin was PAX8 positive. Among poorly differentiated neuroendocrine carcinomas, PAX8 expression was identified in 1 of 1 (100%) pancreatic, 1 of 1 (100%) thymic, 4 of 11 (36%) pulmonary, and 0 of 1 (0%) breast carcinomas. One of 3 (33%) poorly differentiated neuroendocrine carcinomas of unknown primary origin was PAX8 positive.

CONCLUSIONS

Pancreatic well-differentiated neuroendocrine tumors frequently express PAX8, which can help distinguish pancreatic primary tumors from tumors of other anatomic sites. In contrast, PAX8 expression in poorly differentiated neuroendocrine carcinomas is not specific for pancreatic origin and can be seen in extrapancreatic poorly differentiated neuroendocrine carcinomas.

Endoscopic ultrasound guided fine-needle aspiration diagnosis of duodenal high grade neuroendocrine carcinoma underlying a villous adenoma: report of a case

Endoscopic ultrasound guided fine-needle aspiration biopsy is a reliable and accurate method for the diagnosis of submucosal lesions of the gastrointestinal tract. We report the cytopathologic findings of a case of duodenal high-grade neuroendocrine carcinoma in a 68-year-old woman who presented with melena and marked anemia, 45 years after kidney transplantation. Imaging studies performed in the work-up of melena showed a duodenal mass, which on endoscopy proved to be an exophytic, villous duodenal lesion, 3 cm from the ampulla. Forceps biopsy of the exophytic lesion showed a villous adenoma. Endoscopic ultrasound additionally revealed an underlying submucosal lesion and EUS-guided fine needle aspiration of this submucosal mass and of the enlarged mesenteric lymph nodes was diagnostic of a high-grade neuroendocrine carcinoma. The aspirates showed abundant cellularity with tumor cells arranged in sheets and occasional loose clusters. The neoplastic cells had a moderate amount of pale cytoplasm and large round to oval hyperchromatic nuclei with focally prominent nucleoli. Mitoses, apoptotic bodies and necrotic debris were also present. The tumor cells were strongly and diffusely positive for cytokeratin AE1/AE3, synaptophysin and chromogranin and showed a very high proliferative fraction on Ki67 staining, supporting the diagnosis of a high-grade neuroendocrine carcinoma. This is to our knowledge the first case of high-grade neuroendocrine carcinoma of the duodenum diagnosed by EUS-FNA. This case also emphasizes the diagnostic value of EUS-FNA sampling of the submucosal and intramural component of villous tumors of the gastrointestinal tract when mucosal forceps biopsies show only benign findings.

Impact of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in lymph nodal and mediastinal lesions: a multicenter experience

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established procedure in lung cancer (LC) staging and in the diagnosis of mediastinal masses. Most of the experiences reported refer to single specialized centers where dedicated teams of endoscopists and pathologists perform the procedure. We report the EUS-FNA experience of a cooperation group involving clinicians and cytopathologists from three hospitals. Fifty-seven consecutive EUS-FNA of mediastinal nodes in LC patients, eight mediastinal and two subdiaphragmatic masses were collected in 3 years. EUS-FNA was performed by two endoscopists and three experienced pathologists. On-site evaluation was performed in all cases by the three cytopathologists. Lymph node negative cases underwent surgery, which confirmed the cytological diagnoses but also detected two false negatives. Four of the 10 EUS cytological diagnoses of mediastinal and subdiaphragmatic masses were histologically confirmed. All EUS diagnoses were blindly reviewed by three pathologists to assess intra and interpersonal reproducibility. FNA-EUS diagnoses were: 10 inadequate (17%), 10 negative (17%), 4 suspicious (7%) and 33 positive (59%). Diagnoses of mediastinal and subdiaphragmatic masses were: relapse of lung carcinoma (3), mesenchimal tumor not otherwise specifiable (3), gastrointestinal stromal tumor (GIST) (1), esophageal carcinoma (2) and paraganglioma (1). The sensitivity attained was 85% and the specificity 100%; revision of the slides demonstrated a significant diagnostic reproducibility of the three cytopathologists (P < 0.5). The sensitivity and specificity attained were similar to those reported in the literature suggesting that experienced cytopathologists and endoscopists from different institutions can employ the same procedure reaching comparable results.

Endoscopic ultrasonography-guided fine-needle aspiration for diagnosing upper gastrointestinal submucosal lesions: a prospective study of 50 cases

The objective was to assess EUS-FNA for diagnosing intramural upper GI tract lesions. The subjects were 50 patients (21M/29F) with upper GI submucosal lesions who underwent EUS-FNA at a referral center for GI system over a 12-month period. All cases were followed for 1 year after initial EUS-FNA. Cytologic diagnoses were categorized as benign, malignant, suspicious for malignancy, mesenchymal tumor, endocrine tumor, or nondiagnostic. All tumors were assessed for various cytomorphologic features. The accuracy of the initial FNA diagnoses was evaluated for each patient who also underwent subsequent histopathological examination of a core biopsy and/or surgical biopsy/resection material of the same lesion. According to the site of the lesions; while 84% of all esophageal lesions were diagnosed as mesenchymal; 67% of all gastric lesions were mesenchymal. The sole lesion was nonmesenchymal (benign cyst) in duodenum. The sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-FNA for diagnosing submucosal mesenchymal tumors of the upper GI tract were 82.9, 73.3, 87.9, 64.7, and 80%, respectively. The corresponding values for nonmesenchymal lesions were 100, 85.7, 80, 100, and 90.9%. Our experience confirms that EUS-FNA is an extremely valuable tool for diagnosing submucosal lesions of the upper GI, and is particularly useful in cases where endoscopic forceps biopsy does not lead to diagnosis. Optimal results can be yielded by a close working relationship between the gastroenterologist and pathologist.

An evaluation of risk factors for inadequate cytology in EUS-guided FNA of pancreatic tumors and lymph nodes

BACKGROUND

The factors associated with maximizing the cytological adequacy of EUS-guided FNA (EUS-FNA) in pancreatic tumor evaluation are not well-known.

OBJECTIVE

To examine associations of physician and procedural factors with the endpoint: the presence of an adequate cytological specimen found by using EUS-FNA in patients with pancreatic tumors and lymph nodes.

DESIGN

Retrospective cohort study.

SETTING

A U.S. tertiary care center.

PATIENTS

Patients undergoing EUS-FNA of pancreatic masses and lymph nodes.

INTERVENTIONS

Analysis of EUS-FNA procedures performed in our institution from 1997 to 2007.

MAIN OUTCOME MEASUREMENTS

Associations were evaluated between the primary endpoint of cytological adequacy and factors including the endoscopist, needle gauge, the number of needle passes attempted, the pathologist, and the presence of an onsite cytotechnologist to confirm an adequate specimen. EUS-FNA adequacy was determined by a pathologist based on the presence of definite benign or malignant tissue.

RESULTS

EUS-FNA was performed in 247 pancreatic masses and 276 lymph nodes. An adequate cytological sample was obtained in 240 (97%) pancreatic tumors (95% CI, 94%-99%) and 252 (91%) lymph nodes (95% CI, 87%-94%). For pancreatic tumors, there was no evidence of any associations between factors and cytological adequacy. For lymph nodes, cytological adequacy was improved when an onsite cytotechnologist was present (96% vs 84%, P = .002); no other factors showed statistically significant associations with cytological adequacy.

LIMITATIONS

Retrospective study, low power to detect associations.

CONCLUSIONS

The presence of an onsite cytotechnologist is an important factor in achieving successful EUS-FNA of suspicious lymph nodes in patients with pancreatic masses.

Endobronchial ultrasound-guided transbronchial needle aspiration cytology: a state of the art review

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a recently developed, accurate, safe and cost-effective technique that allows sampling of mediastinal lymph nodes and peribronchial lesions including pulmonary and mediastinal lesions. Its major indications are the nodal staging of non-small cell carcinomas of the lung, their restaging after chemotherapy and/or radiation, the diagnosis of sarcoidosis and of metastases from extrathoracic malignancies, and the diagnosis of mediastinal lymphadenopathy and masses of unknown aetiology. From our experience at the University of Minnesota and a comprehensive review of the literature, we discuss technical aspects of the procedure, its advantages and limitations in comparison with other methods of sampling mediastinal lymph nodes, focusing on the role of the cytopathologist in ensuring the effectiveness of the procedure. An algorithmic approach to the cytological diagnosis, starting with the determination of the adequacy of the sample, is also presented.

Interventional endoscopic ultrasound: Therapeutic capability and potential

The linear echoendoscope, introduced in the 1990s, opened the era of interventional endoscopic ultrasound (IEUS). The linear echoendoscope enabled EUS guided Fine Needle Aspiration (EUS-FNA) allowing the path of the needle to be traced during the puncture process. After EUS-FNA, other interventional procedures were introduced in clinical practice. Tissue acquisition was the first EUS-guided interventional procedure and its higher diagnostic quality has undoubtedly been established. After EUS-FNA, Celiac plexus neurolysis (CPN) and block (CPB), pancreatic pseudocyst drainage, abdominal and mediastinal collections/abscesses drainage, and in selected cases, pancreatic and biliary ductal system drainage, were introduced in clinical practice. EUS-guided fine needle injection with local delivery of antitumor agents is considered a promising modality. We have reviewed published data on EUS guided interventional procedures with the object of summarizing the diagnostic capability of endoscopic ultrasound and elaborates in detail its therapeutic capability and potential.

Ciliated foregut cyst of the pancreas: preoperative diagnosis using endoscopic ultrasound guided fine needle aspiration cytology--a case report with a review of the literature

A 51-year-old male presented with a 4-month history of abdominal pain, decreased appetite, and postprandial bloating. A CT scan showed a solitary, 5.3 x 4.4 cm, cystic lesion in the body/tail of the pancreas. Endoscopic retrograde cholangiopancreatography did not show communication between the pancreatic duct and the cystic lesion. Endoscopic ultrasound (EUS) examination revealed a 6.9 x 2.4 cm cystic lesion in the body/tail region of the pancreas without septae or solid components. The pancreatic parenchyma, pancreatic duct, and common bile duct were unremarkable. EUS-guided fine needle aspiration (EUS-FNA) was performed using a 22-gauge EchotipTM needle. Only a few drops of viscous fluid could be aspirated. Papanicolaou-stained direct smears and SurePath (Autocyte) preparations were evaluated. The direct smears were hypocellular; however, the concentration method producing liquid-based cytology preparation showed detached ciliary tufts (degenerated debris with ciliated cellular fragments of cell tops without nuclei) and occasional intact ciliated cells consistent with a ciliated foregut cyst. Although benign, the cyst was resected to alleviate the symptoms. The surgical pathology confirmed the benign preoperative interpretation of the ciliated foregut cyst. To the best of our knowledge, this is the first case of pancreatic ciliated foregut cyst reported to be diagnosed preoperatively by EUS-FNA. For a proper preoperative cytologic diagnosis, the needle rinses should be processed adequately. Otherwise, these hypocellular specimens with mucin may be misinterpreted as mucinous cystic lesions.

Predictors of malignancy and recommended follow-up in patients with negative endoscopic ultrasound-guided fine-needle aspiration of suspected pancreatic lesions

BACKGROUND

Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can characterize and diagnose pancreatic lesions as malignant, but cannot definitively rule out the presence of malignancy. Outcome data regarding the length of follow-up in patients with negative or nondiagnostic EUS-FNA of pancreatic lesions are not well-established.

OBJECTIVE

To determine the long-term outcome and provide follow-up guidance for patients with negative EUS-FNA diagnosis of suspected pancreatic lesions based on imaging predictors.

METHODS

A retrospective review of patients undergoing EUS-FNA for suspected pancreatic lesions, but with negative or nondiagnostic FNA results was conducted at a tertiary care referral medical centre. Patient demographics, EUS imaging characteristics and follow-up data were examined.

RESULTS

Seventeen of 55 patients (30.9%) with negative/nondiagnostic FNA were subsequently diagnosed with pancreatic malignancy. The risk of cancer was significantly higher for patients who had associated lymph nodes on EUS (P<0.001) and vascular involvement on EUS (P=0.001). The mean time to diagnosis in the group with falsenegative EUS-FNA diagnosis was 66 days. The true-negative EUSFNA patients were followed for a mean of 403 days after negative EUS-FNA results without the development of malignancy.

CONCLUSION

For patients undergoing EUS-FNA for a suspected pancreatic lesion, a negative or nondiagnostic FNA does not provide conclusive evidence for the absence of cancer. Patients for whom vascular invasion and lymphadenopathy are detected on EUS are more likely to have a true malignant lesion and should be followed closely. When a patient has been monitored for six months or more with no cancer being diagnosed, there appears to be much less chance that a pancreatic malignancy is present.

Pancreatic cytopathology: a practical approach and review

CONTEXT

Pancreatic cytopathology plays an important role in the diagnosis and management of patients with solid and cystic lesions of the pancreas.

OBJECTIVE

To serve as a practical guide to pancreatic cytopathology for the practicing pathologist. Data Sources.-A comprehensive assessment of the medical literature was performed.

CONCLUSIONS

We review pancreatic cytopathology, with specific discussions of its role in patient management, specimen types and specimen processing, specific diagnostic criteria, and the use of ancillary testing and advanced techniques.

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.

Current status of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is a rare primary liver cancer with a global increasing trend in recent years. Symptoms tend to be vague and insidious in development, often are diagnosed at an advanced stage when only palliative approaches can be used with a median survival rate of months. Comparing with HCC, ICC tends to spread to lymph nodes early, and is rarely limited to the regional lymph nodes, with a frequent postoperative recurrence. Surgery is the only choice of curative therapy for ICC, but recently no consensus has been established for operation. Thus, more data from multiple centers and more cases are needed. Generally speaking, current adjunctive therapy cannot clearly improve survival. Further research is needed to find more effective radio- and chemotherapeutic regimens.