Endoscopic ultrasound guided fine-needle aspiration: What variables influence diagnostic yield?

Endoscopic ultrasound-guided fine-needle aspiration in the diagnostic value of focal liver lesions: A systematic analysis of 88 cases (with video)

BACKGROUND AND AIMS

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions in the gastrointestinal tract and adjacent organs. Our study aimed to evaluate the safety and effectiveness of EUS-FNA in focal liver lesions (FLLs).

METHOD

Data from 88 patients diagnosed with FLLs by imaging who underwent EUS-FNA from 1 January 2017 to 31 August 2022 were reviewed in our retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of the School of Medicine of Shanghai Jiao Tong University. The EUS-FNA biopsy results were compared with the final diagnosis to evaluate diagnostic value. The relevant factors were analysed to determine their influence on EUS-FNA biopsy results.

RESULTS

The 88 patients analysed in this study resulted in a final diagnosis of 86 malignant and two benign cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18 % (82/88; 95 % Confidence Interval [CI], 87.9-98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02 % (80/86; 95 %CI, 87.6-98.4), 100 % (2/2; 95 %CI, 100-100), 100 % (80/80; 95 %CI, 100-100), and 25 % (2/8; 95 %CI, -5-55.0), respectively. The parameters related to lesion and procedure were not significantly different between these two groups (p > 0.05). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001).

CONCLUSION

Our data revealed that EUS-FNA is a safe and reliable diagnostic method for FLLs that shows high accuracy.

Doing more with less: integrating small biopsies in cytology practice

Cytopathologists are at the forefront of specimen acquisition during many different procedures while providing rapid on site evaluation (ROSE). This has added pressure to cytopathologists as more and more ancillary testing is being requested on smaller amounts of tissue. By focusing on the most common organ sites: lung, head and neck, and pancreas, there is a discussion of what the cytopathologist needs to know to triage tissue successfully. Finally, there is a discussion of the logistical aspects of integrating small biopsies into everyday practice.

Avoid non-diagnostic EUS-FNA: a DNN model as a possible gatekeeper to distinguish pancreatic lesions prone to inconclusive biopsy

OBJECTIVE

This work aimed to explore the utility of CT radiomics with machine learning for distinguishing the pancreatic lesions prone to non-diagnostic ultrasound-guided fine-needle aspiration (EUS-FNA).

METHODS

498 patients with pancreatic EUS-FNA were retrospectively reviewed [Development cohort: 147 pancreatic ductal adenocarcinoma (PDAC); Validation cohort: 37 PDAC]. Pancreatic lesions not PDAC were also tested exploratively. Radiomics extracted from contrast-enhanced CT was integrated with deep neural networks (DNN) after dimension reduction. The receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were performed for model evaluation. And, the explainability of the DNN model was analyzed by integrated gradients.

RESULTS

The DNN model was effective in distinguishing PDAC lesions prone to non-diagnostic EUS-FNA (Development cohort: AUC = 0.821, 95% CI: 0.742-0.900; Validation cohort: AUC = 0.745, 95% CI: 0.534-0.956). In all cohorts, the DNN model showed better utility than the logistic model based on traditional lesion characteristics with NRI >0 (p < 0.05). And, the DNN model had net benefits of 21.6% at the risk threshold of 0.60 in the validation cohort. As for the model explainability, gray-level co-occurrence matrix (GLCM) features contributed the most averagely and the first-order features were the most important in the sum attribution.

CONCLUSION

The CT radiomics-based DNN model can be a useful auxiliary tool for distinguishing the pancreatic lesions prone to nondiagnostic EUS-FNA and provide alerts for endoscopists preoperatively to reduce unnecessary EUS-FNA.

ADVANCES IN KNOWLEDGE

This is the first investigation into the utility of CT radiomics-based machine learning in avoiding non-diagnostic EUS-FNA for patients with pancreatic masses and providing potential pre-operative assistance for endoscopists.

Pancreatic ductal adenocarcinoma (PDAC) regional nodal disease at standard lymphadenectomy: is MRI accurate for identifying node-positive patients?

OBJECTIVE

To determine the accuracy of qualitative and quantitative MRI features for the diagnosis of pathologic regional lymph nodes at standard lymphadenectomy in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

All adult patients with pancreatic MRI performed from 2011 to 2021 within 3 months of a pancreaticoduodenectomy were eligible for inclusion in this single-center retrospective cohort study. Regional nodes at standard lymphadenectomy were independently reviewed by two fellowship-trained abdominal radiologists for the following qualitative features: heterogeneous T2 signal, round shape, indistinct margin, peri-nodal fat stranding, and restricted diffusion greater than the spleen. Quantitative characteristics including primary tumor size, largest node short- and long-axes length, number of regional nodes, absolute apparent diffusion coefficient (ADC) values, and ADC node-to-spleen signal index were assessed. Analysis was at the patient-level with surgical pathology as the reference standard.

RESULTS

Of 75 patients, 85% (64/75) were positive for regional nodal disease on histopathology. None of the qualitative variables evaluated on MRI was associated with pathologic nodes. Median primary tumor maximum diameter was slightly larger for patients with pathologic nodes compared to those without (18 mm (10-42 mm) vs 16 mm (9-22 mm), p = 0.027). None of the other quantitative features was associated with pathologic nodes. Radiologist opinion was not associated with pathologic nodes (p = 0.520). Interobserver agreement was fair (kappa = 0.257).

CONCLUSIONS

Lymph node morphologic features and radiologist opinion using MRI are of limited value for diagnosing PDAC regional nodal disease. Improved diagnostic techniques are needed given the prognostic implications of pathologic lymph nodes in these patients.

KEY POINTS

• Multiple lymph node morphologic features routinely assessed on MRI for malignancies elsewhere in the body are likely not applicable when assessing for pancreatic ductal adenocarcinoma nodal disease. • Interobserver agreement for the presence or absence of pancreatic ductal adenocarcinoma lymph node morphologic features on MRI is fair (kappa = 0.257). • Many more lymph nodes are resected at PDAC standard lymphadenectomy than are detectable on MRI, median 25 vs 5 (p < 0.001), suggesting improved diagnostic techniques are needed to identify PDAC nodal disease.

Is the radiomics-clinical combined model helpful in distinguishing between pancreatic cancer and mass-forming pancreatitis?

PURPOSE

To develop CT-based radiomics models for distinguishing between resectable PDAC and mass-forming pancreatitis (MFP) and to provide a non-invasive tool for cases of equivocal imaging findings with EUS-FNA needed.

METHODS

A total of 201 patients with resectable PDAC and 54 patients with MFP were included. Development cohort: patients without preoperative EUS-FNA (175 PDAC cases, 38 MFP cases); validation cohort: patients with EUS-FNA (26 PDAC cases, 16 MFP cases). Two radiomic signatures (LASSOscore, PCAscore) were developed based on the LASSO model and principal component analysis. LASSOCli and PCACli prediction models were established by combining clinical features with CT radiomic features. ROC analysis and decision curve analysis (DCA) were performed to evaluate the utility of the model versus EUS-FNA in the validation cohort.

RESULTS

In the validation cohort, the radiomic signatures (LASSOscore, PCAscore) were both effective in distinguishing between resectable PDAC and MFP (AUC_LASSO = 0.743, 95% CI: 0.590-0.896; AUC_PCA = 0.788, 95% CI: 0.639-0.938) and improved the diagnostic accuracy of the baseline onlyCli model (AUC_onlyCli = 0.760, 95% CI: 0.614-0.960) after combination with variables including age, CA19-9, and the double-duct sign (AUC_PCACli = 0.880, 95% CI: 0.776-0.983; AUC_LASSOCli = 0.825, 95% CI: 0.694-0.955). The PCACli model showed comparable performance to FNA (AUC_FNA = 0.810, 95% CI: 0.685-0.935). In DCA, the net benefit of the PCACli model was superior to that of EUS-FNA, avoiding biopsies in 70 per 1000 patients at a risk threshold of 35%.

CONCLUSIONS

The PCACli model showed comparable performance with EUS-FNA in discriminating resectable PDAC from MFP.

T, Manikandan A, Ravichandar S. Petals of rose: Application of rapid on-site evaluation in bronchoscopy

In present day scenario, procedures that are minimally invasive like FNAs and Core needle biopsies are on the rise. Rapid on-site evaluation (ROSE) is a laboratory service that assesses the cytomorphologic features from FNA smears or biopsy contact imprints in the biopsy room and can provide on the spot input and suggestions for the clinician through immediate cytological examination of the biopsy sample. ROSE also allows for a preliminary diagnosis, allowing for the requirement of additional material for ancillary studies. We are presenting two cases which highlights the merits of ROSE in cytological diagnosis.   In the first case, a thirty four year old male patient came with complaints of productive cough, breathlessness and fever. Bronchoscopic needle aspiration and biopsy was done with Rapid Onsite Evaluation. ROSE revealed two non-caseating epithelioid granulomas on the 4th pass. Bronchoscopic lymph node biopsy was non- contributory. With other clinical and biochemical parameters, diagnosis of Sarcoidosis was made. This case study underscores the significance of ROSE in arriving at the diagnosis.   In the other case, a fifty seven year old male patient came to hospital with productive cough and breathlessness (MMRC grade II). CT chest revealed features suggestive of bronchogenic carcinoma. ROSE was performed along with bronchial brush cytology in which presence of atypical cells with increased nuclear cytoplasmic ratio, nuclear hyperchromatism and nuclear molding was noted. On histopathological examination, it was diagnosed as a case of non-small cell carcinoma of lung – poorly differentiated type. This case proves the advantage of ROSE in avoiding repeated invasive procedures for the patient.

Evaluation of Pancreatic Lesions With Endoscopic Ultrasound and Fine Needle Aspiration

Background. Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are commonly used for assessing pancreatic lesions. This study aimed to evaluate the diagnostic yield and accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in a single tertiary institution. Methods. Consecutive patients who underwent EUS-FNA of the pancreas at Queen Mary Hospital, Hong Kong, from January 2015 to March 2016 were retrospectively reviewed. Endoscopic findings and FNA results were analysed. For patients who subsequently underwent surgical resection of pancreatic lesion, EUS-FNA diagnoses were compared to histopathological findings of surgical specimens to determine its diagnostic accuracy. Results. One hundred twelve EUS-FNA were performed in 99 patients within the study time period and were included for analysis. Sixty-six (66.7%) pancreatic lesions were solid in nature and 33 (33.3%) were cystic. The overall diagnostic yield of EUS-FNA was 70.5% (n = 79). On multivariate analysis, more passes of needle were associated with a higher diagnostic yield (odds ratio = 2.000, P = .049). 57.1% (n = 64) of EUS-FNA results had an impact on management. Sixteen patients with diagnostic EUS-FNA subsequently underwent surgery for resection of the pancreatic lesion. Upon correlation to the histopathological findings of surgical specimens, there were 12 true-positive, 2 true-negative, 0 false-positive, and 2 false-negative cases. Sensitivity was 85.7%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 50%. The diagnostic accuracy of EUS-FNA was 87.5%. Conclusion. EUS-FNA is accurate and reliable for diagnosing pancreatic lesions.

Factors affecting cytological results of endoscopic ultrasound guided-fine needle aspiration during learning

Background

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a standard procedure used to obtain tissue samples for diagnosis of solid retroperitoneal tumours. However, this procedure demands high technical expertise and requires a strong learning curve. Our aim was to identify factors associated with false-negative EUS-FNA results during the learning for endoscopists.

Methods

Our retrospective analysis was based on the EUS-FNA specimens collected by two novice endoscopists in 200 patients with retroperitoneal lesions who had confirmed image- or tissue-based diagnoses of malignancy or benign lesions.

Results

In the first 40 performances endoscopists, the false-negative diagnostic rate of EUS-FNA was higher among patients with chronic pancreatitis than in patients without chronic pancreatitis. Patients who underwent FNA through the trans-duodenal puncture route also had lower success cytological diagnosis rate than through the trans-gastric puncture route. The rate of successful cytological diagnoses with EUS-FNA improved after 40 procedures and was not influenced by chronic pancreatitis presentation or difference puncture route.

Conclusion

Regarding the learning curve, more than 40 procedures were required to achieve a stable success rate of EUS-FNA. Chronic pancreatitis and trans-duodenal puncture route are the predictive factors for a false-negative FNA cytological result during learning.

Trial registration

This was a retrospective study.

Endoscopic ultrasonography in pancreatic diseases: advances in tissue acquisition

Background and study aims  Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) improved the diagnostic performance and upgraded the role of endoscopic ultrasonography (EUS) into an interventional modality, able to guide patient management and treatment.This review aimed to highlight the advances, emerging practices, procedural techniques and technological innovations in EUS tissue acquisition in pancreatic diseases. Methods  A thorough review of the literature was performed using PubMed to identify articles that describe techniques, advances, and practices in EUS tissue acquisition in gastrointestinal diseases. Conclusion  Since the first EUS-FNA procedure, EUS guided-tissue acquisition has been evolving continuously. Development of needles with innovative tip design enabled procurement of larger samples with preserved histological architecture. Moreover, sampling techniques and complementary methods, such as contrast harmonic imaging and EUS-elastography, have been introduced in an effort to improve diagnostic performance and sample adequacy.

Diagnostic Efficacy of Liquid-Based Cytology in Endoscopic Ultrasound-Guided Fine Needle Aspiration for Pancreatic Mass Lesions During the Learning Curve: A Retrospective Study

OBJECTIVES

The diagnostic yield of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology widely varies depending on the treatment method used. Liquid-based cytology (LBC) has gained popularity in the gynecological field because of its efficacy in collection of target cells and simplicity in the manipulation of specimens. Since the introduction of EUS-FNA at our institution, we have used LBC for the diagnosis of pancreatic mass lesions. This study aims to investigate the diagnostic efficacy of EUS-FNA with LBC in patients with pancreatic mass lesions during the learning curve for EUS-FNA.

METHODS

In this study, we retrospectively enrolled 222 patients with pancreatic mass lesions who were diagnosed using EUS-FNA with LBC between 2011 and 2016. The diagnostic yields for EUS-FNA with LBC for pancreatic mass lesions were evaluated.

RESULTS

The diagnostic sensitivity, specificity, and accuracy for malignancy were found to be 93.9%, 95.1%, and 94.1%, respectively.

CONCLUSIONS

This study suggests that EUS-FNA with LBC for specimens provides good diagnostic efficacy in patients with pancreatic mass lesions even during the learning curve for EUS-FNA.