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Doi S, Adachi T, Watanabe A, Katsukura N, Tsujikawa T. Current perspectives on the diversification of endoscopic ultrasound-guided fine-needle aspiration and biopsy. J Med Ultrason (2001) 2024; 51:235-243. [PMID: 38108995 DOI: 10.1007/s10396-023-01393-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/23/2023] [Indexed: 12/19/2023]
Abstract
Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has undergone significant advancements since it was first reported in 1992. Initially focused on the pancreas, EUS-guided fine-needle aspiration (FNA) has now been extended to encompass all organs proximal to the gastrointestinal system. Recently, a novel fine-needle biopsy (FNB) needle with an end-cut tip was developed, allowing for the collection of specimens suitable for histological assessment, a feat hard to achieve with traditional needles. The FNB needle holds promise for applications in immunohistochemistry staining and genetics evaluation, and it has the potential to yield specimens of comparable quality to core needle biopsy during percutaneous puncture, especially for lesions beyond the pancreas, such as lymph nodes. This review focuses on the efficacy of EUS-FNA/FNB for extended target regions, specifically lymph nodes, spleen, adrenal gland, and ascites. The indications for EUS-FNA have greatly expanded beyond the pancreas over the years, and future improvements and innovations in puncture needles will allow for the collection of higher-quality specimens, which is expected to play a significant part in personalized cancer treatment.
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Affiliation(s)
- Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-Ku, Kawasaki, Kanagawa, 213-8507, Japan.
| | - Takako Adachi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-Ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Ayako Watanabe
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-Ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Nobuhiro Katsukura
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-Ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Takayuki Tsujikawa
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-Ku, Kawasaki, Kanagawa, 213-8507, Japan
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2
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Gopakumar H, Puli SR. Value of Endoscopic Ultrasound-Guided Through-the-Needle Biopsy in Pancreatic Cystic Lesions. A Systematic Review and Meta-Analysis. J Gastrointest Cancer 2024; 55:15-25. [PMID: 37341913 DOI: 10.1007/s12029-023-00949-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) has been used over the past few years to increase diagnostic accuracy for pancreatic cystic lesions (PCLs). However, many concerns remain regarding its widespread use. This systematic review and meta-analysis aimed to pool the data from high-quality studies to evaluate the utility of EUS-TTNB in diagnosing PCLs. METHODS Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the diagnostic performance of EUS-TTNB in the diagnosis of pancreatic cystic lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. RESULTS The initial search identified 635 studies, of which 35 relevant articles were reviewed. We extracted data from 11 studies that met the inclusion criterion, comprising a total of 575 patients. Mean patient age was 62.25 years ± 6.12 with females constituting 61.39% of the study population. Pooled sensitivity of EUS-TTNB in differentiating a PCL as neoplastic or non-neoplastic was 76.60% (95% CI = 72.60-80. 30). For the same indication, EUS TTNB had a pooled specificity of 98.90% (95% CI = 93.80-100.00). The positive likelihood ratio was 10.28 (95% CI = 4.77-22.15), and the negative likelihood ratio was 0.26 (95% CI = 0.22-0.31). The pooled diagnostic odds ratio for EUS-TTNB in diagnosing PCLs as malignant/pre-malignant vs. non-malignant was 41.34 (95% CI = 17.42-98.08). Pooled adverse event rates were 3.04% (95% CI = 1.83-4.54) for pancreatitis, 4.02% (95% CI = 2.61-5.72) for intra-cystic bleeding, 0.94% (95% CI = 0.33-1.86) for fever, and 1.73% (95% CI = 0.85-2.91) for other minor events. CONCLUSIONS EUS-TTNB has good sensitivity with excellent specificity in accurately classifying PCLs as neoplastic or non-neoplastic. Adding EUS-TTNB to EUS-FNA increases the accuracy of EUS-guided approach in diagnosing PCLs. However, it could significantly increase the risk of post-procedural pancreatitis.
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Affiliation(s)
- Harishankar Gopakumar
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, Peoria, IL, USA.
| | - Srinivas R Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, Peoria, IL, USA
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3
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Bueno A, Felipe-Silva A, Saieg M. Small biopsies for pancreatic lesions: Is there still room for fine needle aspiration? Cytopathology 2024; 35:70-77. [PMID: 37905686 DOI: 10.1111/cyt.13323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/08/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023]
Abstract
Pancreatic carcinoma is an aggressive tumour with increasing incidence in both sexes worldwide. Early detection is, therefore, essential for patient management. A recent advancement involves the utilization of larger, thicker gauge needles, which enable the collection of core-type biopsies (FNB). Here, we investigated the role of fine needle aspiration and cytopathology in the diagnostic workflow of pancreatic lesions. A search query was designed to search for articles in the PubMed database comparing FNA and FNB for biopsy of pancreatic lesions, and detailed data were extracted from selected studies. Statistical analyses were performed using the R package meta version 6.2. Twenty-one studies made the final cut for data extraction. Overall, median age was 64.3 years (±6.1; 47.6-71.5), male: female proportion 53.9 (±11.3; 27.6-67.4), lesion size 3.1 cm (±0.5; 1.9-4.2 cm) and percentage of malignant cases 78.3% (±26.8; 2.1-100). FNA and FNB diagnostic yield was 85.8% (±10.3; 70.0-100.0) and 89.2% (±7.7; 70.0-98.6), respectively. Average accuracy was 89.5% (±11.7; 63.0-100.0) for FNA and 90.8% (±7.1; 77.0-100.0) for FNB. Adverse effects rate was 1.0% (±1.3; 0-4.3) for FNA and 2.2% (±4.4; 0-16.1) for FNB. None of the selected variables had a significant statistical difference between both methods. FNA and FNB perform similarly for diagnostic material acquisition in pancreatic lesions. The best outcome comes from the association of both techniques, emphasizing the value of combining cytological and histological morphology for the most accurate analysis.
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Affiliation(s)
| | | | - Mauro Saieg
- Fleury Group, São Paulo, Brazil
- Santa Casa Medical School, São Paulo, Brazil
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4
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Vitali F, Zundler S, Jesper D, Wildner D, Strobel D, Frulloni L, Neurath MF. Diagnostic Endoscopic Ultrasound in Pancreatology: Focus on Normal Variants and Pancreatic Masses. Visc Med 2023; 39:121-130. [PMID: 37899794 PMCID: PMC10601528 DOI: 10.1159/000533432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/03/2023] [Indexed: 10/31/2023] Open
Abstract
Background Endoscopic ultrasound (EUS) is a main tool in gastroenterology for both diagnosis and exclusion of pancreatic pathology. It allows minimally invasive assessment of various diseases or anatomic variations affecting the pancreas also with the help of new Doppler technologies, elastography, contrast-enhanced imaging including post hoc image processing with quantification analyses, three-dimensional reconstruction, and artificial intelligence. EUS also allows interventional direct access to the pancreatic parenchyma and the retroperitoneal space, to the pancreatic duct, pancreatic masses, cysts, and vascular structures. Summary This review aimed to summarize new developments of EUS in the field of pancreatology. We highlight the role of EUS in evaluating pancreatic pathology by describing normal anatomic variants like pancreas divisum, pancreatic lipomatosis, pancreatic fibrosis in the elderly and characterizing pancreatic masses, both in the context of chronic pancreatitis and within healthy pancreatic parenchyma. EUS is considered the optimal imaging modality for pancreatic masses of uncertain dignity and allows both cytological diagnosis and histology, which is essential not only for neoplastic conditions but also for tailoring therapy for benign inflammatory conditions. Key Messages EUS plays an indispensable role in pancreatology and the development of new diagnostic and interventional approaches to the retroperitoneal space and the pancreas exponentially increased over the last years. The development of computer-aided diagnosis and artificial intelligence algorithms hold the potential to overcome the obstacles associated with interobserver variability and will most likely support decision-making in the management of pancreatic disease.
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Affiliation(s)
- Francesco Vitali
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Zundler
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Daniel Jesper
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Dane Wildner
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Deike Strobel
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Luca Frulloni
- Department of Medicine, Gastroenterology Unit, Pancreas Center, University of Verona, Verona, Italy
| | - Markus F. Neurath
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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Al-Taee AM, Taylor JR. Endoscopic Imaging of Pancreatic Cysts. Gastrointest Endosc Clin N Am 2023; 33:583-598. [PMID: 37245937 DOI: 10.1016/j.giec.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pancreatic cystic lesions (PCLs) have been diagnosed with increasing frequency likely due to the widespread use of cross-sectional imaging. A precise diagnosis of the PCL is important because it helps identify patients in need of surgical resection and those who can undergo surveillance imaging. A combination of clinical and imaging findings as well as cyst fluid markers can help classify PCLs and guide management. This review focuses on endoscopic imaging of PCLs including endoscopic and endosonographic features and fine needle aspiration. We then review the role of adjunct techniques, such as microforceps, contrast-enhanced endoscopic ultrasound, pancreatoscopy, and confocal laser endomicroscopy.
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Affiliation(s)
- Ahmad M Al-Taee
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Digestive Health Institute, 611 West Park Street, Urbana, IL 61801, USA.
| | - Jason R Taylor
- St Luke's Hospital, 224 South Woods Mill Road, Suite 410, Chesterfield, MO 63017, USA
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6
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Ahmed W, Mirzaali M, Young C, Sanni L, Everett S, Paranandi B, Huggett MT, On W. EUS-guided through the needle microbiopsy: a useful adjunct in the investigation of pancreatic cystic lesions. BMJ Open Gastroenterol 2023; 10:e001184. [PMID: 37399433 DOI: 10.1136/bmjgast-2023-001184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/21/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE Endoscopic ultrasound-guided through-the-needle microbiopsy (EUS-TTNB) forceps is a recent development that facilitates sampling of the walls of pancreatic cystic lesions (PCL) for histological analysis. We aimed to assess the impact of EUS-TTNB and its influence on patient management in a tertiary pancreas centre. DESIGN A prospective database of consecutive patients who underwent EUS-TTNB from March 2020 to August 2022 at a tertiary referral centre was retrospectively analysed. RESULTS Thirty-four patients (22 women) were identified. Technical success was achieved in all cases. Adequate specimens for histological diagnosis were obtained in 25 (74%) cases. Overall, EUS-TTNB led to a change in management in 24 (71%) cases. Sixteen (47%) patients were downstaged, with 5 (15%) discharged from surveillance. Eight (24%) were upstaged, with 5 (15%) referred for surgical resection. In the 10 (29%) cases without change in management, 7 (21%) had confirmation of diagnosis with no change in surveillance, and 3 (9%) had insufficient biopsies on EUS-TTNB. Two (6%) patients developed post-procedural pancreatitis, and 1 (3%) developed peri-procedural intracystic bleeding with no subsequent clinical sequelae. CONCLUSION EUS-TTNB permits histological confirmation of the nature of PCL, which can alter management outcomes. Care should be taken in patient selection and appropriately consented due to the adverse event rate.
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Affiliation(s)
- Wafaa Ahmed
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mikaeil Mirzaali
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Caroline Young
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Latifu Sanni
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon Everett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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7
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Facciorusso A, Kovacevic B, Yang D, Vilas-Boas F, Martínez-Moreno B, Stigliano S, Rizzatti G, Sacco M, Arevalo-Mora M, Villarreal-Sanchez L, Conti Bellocchi MC, Bernardoni L, Gabbrielli A, Barresi L, Gkolfakis P, Robles-Medranda C, De Angelis C, Larghi A, Di Matteo FM, Aparicio JR, Macedo G, Draganov PV, Vilmann P, Pecchia L, Repici A, Crinò SF. Predictors of adverse events after endoscopic ultrasound-guided through-the-needle biopsy of pancreatic cysts: a recursive partitioning analysis. Endoscopy 2022; 54:1158-1168. [PMID: 35451041 DOI: 10.1055/a-1831-5385] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS : Endoscopic ultrasound-guided through-the-needle biopsy (TTNB) of pancreatic cystic lesions (PCLs) is associated with a non-negligible risk for adverse events (AEs). We aimed to identify the hierarchic interaction among independent predictors for TTNB-related AEs and to generate a prognostic model using recursive partitioning analysis (RPA). PATIENTS AND METHODS : Multicenter retrospective analysis of 506 patients with PCLs who underwent TTNB. RPA of predictors for AEs was performed and the model was validated by means of bootstrap resampling. RESULTS : Mean cysts size was 36.7 mm. Most common diagnoses were intraductal papillary mucinous neoplasm (IPMN, 45 %), serous cystadenoma (18.8 %), and mucinous cystadenoma (12.8 %). Fifty-eight (11.5 %) AEs were observed. At multivariate analysis, age (odds ratio [OR] 1.32, 1.09-2.14; p = 0.05), number of TTNB passes (OR from 2.17, 1.32-4.34 to OR 3.16, 2.03-6.34 with the increase of the number of passes), complete aspiration of the cyst (OR 0.56, 0.31-0.95; p = 0.02), and diagnosis of IPMN (OR 4.16, 2.27-7.69; p < 0.001) were found to be independent predictors of AEs, as confirmed by logistic regression and random forest analyses. RPA identified three risk classes: high-risk (IPMN sampled with multiple microforceps passes, 28 % AEs rate), low-risk (1.4 % AE rate, including patients < 64 years with other-than-IPMN diagnosis sampled with ≤ 2 microforceps passes and with complete aspiration of the cyst) and middle-risk class (6.1 % AEs rate, including the remaining patients). CONCLUSION : TTNB should be selectively used in the evaluation of patients with IPMN. The present model could be applied during patient selection as to optimize the benefit/risk of TTNB.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical and Surgical Sciences, Section of Gastroenterology, University of Foggia, Foggia, Italy.,Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Bojan Kovacevic
- Division of Endoscopy, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Dennis Yang
- Center of Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Filipe Vilas-Boas
- Department of Gastroenterology, Centro Hospitalar e Universitário de São João-Porto, Porto, Portugal
| | - Belén Martínez-Moreno
- Unidad de Endoscopia. ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | - Serena Stigliano
- Operative Endoscopy Department, Campus Bio-Medico University Hospital, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Sacco
- Gastroenterology Division, AOU Cittá della Salute e della Scienza di Torino, Turin, Italy
| | | | | | - Maria Cristina Conti Bellocchi
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Laura Bernardoni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Claudio De Angelis
- Gastroenterology Division, AOU Cittá della Salute e della Scienza di Torino, Turin, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - José R Aparicio
- Unidad de Endoscopia. ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | - Guilherme Macedo
- Department of Gastroenterology, Centro Hospitalar e Universitário de São João-Porto, Porto, Portugal
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Peter Vilmann
- Division of Endoscopy, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | | | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
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Molecular Analysis of Pancreatic Cyst Fluid for the Management of Intraductal Papillary Mucinous Neoplasms. Diagnostics (Basel) 2022; 12:diagnostics12112573. [PMID: 36359417 PMCID: PMC9689264 DOI: 10.3390/diagnostics12112573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 12/03/2022] Open
Abstract
Pancreatic cancer is one of the most lethal human cancers. Early detection and diagnosis of precursor lesions for pancreatic malignancy is essential to improve the morbidity and mortality associated with this diagnosis. Of the cystic precursor lesions, branch duct intraductal papillary mucinous neoplasm (IPMN) is the most frequently identified lesion and has a wide range of malignant potential. Currently, Carcinogenic embryonic antigen (CEA) levels in the cyst fluid and cytology are the two most often utilized tools to diagnose these lesions; however, their diagnostic and risk stratification capabilities are somewhat limited. Within the last decade, the use of endoscopic ultrasound-guided fine-needle aspiration has opened the door for molecular analysis of cystic fluid as an option to enhance both the diagnosis and risk stratification of these lesions. The first step is to differentiate branch duct IPMNs from other lesions. KRAS and GNAS alterations have been shown to be accurate markers for this purpose. Following cyst type identification, mutational analysis, telomere fusion, microRNAs, long non-coding RNA, and DNA methylation have been identified as potential targets for stratifying malignant potential using the cystic fluid. In this review, we will examine the various targets of cyst fluid molecular analysis and their utility in the diagnosis and risk stratification of branch duct IPMNs.
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Pușcașu CI, Rimbaş M, Mateescu RB, Larghi A, Cauni V. Advances in the Diagnosis of Pancreatic Cystic Lesions. Diagnostics (Basel) 2022; 12:diagnostics12081779. [PMID: 35892490 PMCID: PMC9394320 DOI: 10.3390/diagnostics12081779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are a heterogenous group of lesions ranging from benign to malignant. There has been an increase in PCLs prevalence in recent years, mostly due to advances in imaging techniques, increased awareness of their existence and population aging. Reliable discrimination between neoplastic and non-neoplastic cystic lesions is paramount to ensuring adequate treatment and follow-up. Although conventional diagnostic techniques such as ultrasound (US), magnetic resonance imaging (MRI) and computer tomography (CT) can easily identify these lesions, assessing the risk of malignancy is limited. Endoscopic ultrasound (EUS) is superior to cross-sectional imaging in identifying potentially malignant lesions due to its high resolution and better imaging characteristics, and the advantage of allowing for cyst fluid sampling via fine-needle aspiration (FNA). More complex testing, such as cytological and histopathological analysis and biochemical and molecular testing of the aspirated fluid, can ensure an accurate diagnosis.
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Affiliation(s)
- Claudia Irina Pușcașu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
| | - Mihai Rimbaş
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
- Department of Internal Medicine, Carol Davila University of Medicine, 050474 Bucharest, Romania
- Correspondence: ; Tel.: +40-723-232-052
| | - Radu Bogdan Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
- Department of Internal Medicine, Carol Davila University of Medicine, 050474 Bucharest, Romania
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Victor Cauni
- Urology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania;
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10
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Cho SH, Song TJ, Seo DW, Oh D, Park DH, Lee SS, Lee SK, Kim MH. Efficacy and safety of EUS-guided through-the-needle microforceps biopsy sampling in categorizing the type of pancreatic cystic lesions. Gastrointest Endosc 2022; 95:299-309. [PMID: 34624305 DOI: 10.1016/j.gie.2021.09.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/24/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EUS-guided through-the-needle biopsy sampling (EUS-TTNB) using microbiopsy forceps is performed for the accurate diagnosis of pancreatic cystic lesions (PCLs). However, there are no standardized protocols for this procedure, and the amount of data on its efficacy is limited. Here, we evaluated the feasibility, efficacy, and safety of EUS-TTNB in categorizing the types of PCLs and identified the factors associated with diagnostic failure. METHODS The prospectively collected and maintained EUS-TTNB database at Asan Medical Center was reviewed to identify patients with PCLs who underwent EUS-TTNB between January 2019 and January 2021. The primary outcomes were technical success, diagnostic yield, and adverse events. Factors contributing to diagnostic failure and the discrepancies in the diagnosis made by conventional modalities (ie, EUS morphology, cross-sectional imaging, and cystic fluid analysis) were also evaluated. RESULTS Forty-five patients were analyzed. EUS-TTNB was successfully performed in all patients (technical success, 100%). Histologic diagnosis of PCLs was made in 37 patients (diagnostic yield, 82%). When comparing EUS-TTNB with a presumptive diagnosis, EUS-TTNB changed the diagnosis in 10 patients in terms of the categorization of the types of PCLs. The diagnostic yield was significantly higher in those who had 4 or more visible biopsy specimens per session (93%) than in those with fewer than 4 visible biopsy specimens per session (67%; P = .045). During follow-up, 3 patients (7%) experienced adverse events (2 acute pancreatitis, 1 intracystic bleeding), and no life-threatening adverse event occurred. CONCLUSIONS EUS-TTNB showed high technical feasibility, diagnostic yield, and good safety profile. EUS-TTNB may improve the categorization of the types of PCLs. Studies with standardized procedure protocols are needed to reduce the diagnostic failure for the types of PCLs.
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Affiliation(s)
- Sung Hyun Cho
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Tae Jun Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dongwook Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Do Hyun Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang Soo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sung Koo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Myung-Hwan Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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11
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Facciorusso A, Ramai D, Gkolfakis P, Shapiro A, Arvanitakis M, Lisotti A, Triantafyllou K, Fusaroli P, Papanikolaou IS, Crinò SF. Through-the-needle biopsy of pancreatic cystic lesions: current evidence and implications for clinical practice. Expert Rev Med Devices 2021; 18:1165-1174. [PMID: 34842023 DOI: 10.1080/17434440.2021.2012450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION There is increasing evidence to support the efficacy of endoscopic ultrasound (EUS)-guided through-the-needle biopsy (TTNB) technique as a means of sampling pancreatic cystic lesions (PCLs). Results provide evidence demonstrating the benefits of this procedure over standard EUS fine-needle aspiration (FNA), thus supporting a push for its widespread implementation in clinical practice. Though this technique has demonstrated advantages, achieving these advantages in clinical practice is contingent upon careful considerations to ensure safety and efficacy. AREAS COVERED The purpose of this review is to assess the level of evidence supporting the use of through-the-needle biopsy, revise its main technical and procedural characteristics, and to develop suggested guidelines outlining the safe assimilation of this device in clinical practice. EXPERT OPINION EUS-TTNB enables more definitive and accurate diagnosis of PCLs by providing higher-quality histological samples. However, EUS-TTNB is not appropriate for all PCLs. Selection of suitable patients as well as morphology and risk factors of the cystic lesion is a crucial component of achieving the described benefits of this procedure while minimizing risks of adverse effects. Subjects with weak or absent indications for this procedure are susceptible to a range of complications and may even result in fatality.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical and Surgical Sciences, Section of Gastroenterology, University of Foggia, Foggia, Italy.,Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT, USA
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cub Erasme Hospital, Université Libre de Bruxelles (Ulb), Brussels, Belgium
| | - Alexandra Shapiro
- Department of Medicine, St. George's University School of Medicine, True Blue, Grenada
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cub Erasme Hospital, Université Libre de Bruxelles (Ulb), Brussels, Belgium
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
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12
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Keane MG, Pereira SP. The Role of Confocal Endomicroscopy in the Diagnosis and Management of Pancreatic Cysts. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/20-00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Pancreatic cystic lesions are an increasingly common clinical finding. Current diagnostic techniques cannot reliably differentiate patients with high-risk lesions requiring surgical resection from those that can be safely surveyed or discharged. As a result, some patients may undergo unnecessary surgery with associated morbidity while others enter long-term surveillance with associated healthcare costs. Needle-based confocal laser endomicroscopy enables real time microscopic examination of the epithelial lining of a cyst wall at the time of a standard endoscopic ultrasound examination. The procedure is associated with low rates of adverse events, especially when the probe is loaded into the fine-needle aspiration needle before the procedure and examination times are limited. Needle-based confocal laser endomicroscopy has consistently been shown to have better diagnostic accuracy than cytology, which is often paucicellular and non-diagnostic in pancreatic cystic lesions. Studies have shown that diagnostic accuracy in needle-based confocal laser endomicroscopy is 84–95% in mucinous lesions and 39–99% in serous lesions. However, this technology is expensive and its place in diagnostic algorithms remains uncertain. Despite this, health economic analyses in certain health systems have been favourable, largely because of its potential to be able to discharge patients with benign lesions, such as serous cystic neoplasms, from long-term surveillance. Widespread adoption of this technology is unlikely but it has the potential to have an important role in indeterminate pancreatic cystic lesions.
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Affiliation(s)
- Margaret G Keane
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland, USA
| | - Stephen P Pereira
- Institute for Liver and Digestive Health, University College London, Royal Free Hospital Campus, UK
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13
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Cystic pancreatic lesions: MR imaging findings and management. Insights Imaging 2021; 12:115. [PMID: 34374885 PMCID: PMC8355307 DOI: 10.1186/s13244-021-01060-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/17/2021] [Indexed: 12/14/2022] Open
Abstract
Cystic pancreatic lesions (CPLs) are frequently casual findings in radiological examinations performed for other reasons in patients with unrelated symptoms. As they require different management according to their histological nature, differential diagnosis is essential. Radiologist plays a key role in the diagnosis and management of these lesions as imaging is able to correctly characterize most of them and thus address to a correct management. The first step for a correct characterization is to look for a communication between the CPLs and the main pancreatic duct, and then, it is essential to evaluate the morphology of the lesions. Age, sex and a history of previous pancreatic pathologies are important information to be used in the differential diagnosis. As some CPLs with different pathologic backgrounds can show the same morphological findings, differential diagnosis can be difficult, and thus, the final diagnosis can require other techniques, such as endoscopic ultrasound, endoscopic ultrasound-fine needle aspiration and endoscopic ultrasound-through the needle biopsy, and multidisciplinary management is important for a correct management.
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14
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Rift CV, Melchior LC, Scheie D, Hansen CP, Lund EL, Hasselby JP. Molecular heterogeneity of pancreatic intraductal papillary mucinous neoplasms and implications for novel endoscopic tissue sampling strategies. J Clin Pathol 2021; 75:jclinpath-2021-207598. [PMID: 34039665 DOI: 10.1136/jclinpath-2021-207598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
AIMS Intraductal papillary mucinous neoplasms (IPMNs) may be precursor lesions of pancreatic cancer. The path towards malignancy is associated with mutations in tumour suppressor-and oncogenes that may serve as biomarkers during diagnostic investigation. A novel micro forceps has made it possible to obtain biopsies from the cyst wall for analysis by next generation sequencing (NGS), providing an opportunity for early detection and intervention. However, the impact of spatial tumour heterogeneity on the representability of the biopsies has not been determined. The primary aim is to characterise the impact of molecular heterogeneity of the luminal cyst wall on tissue sampling strategies with small biopsies. METHODS We performed NGS and immunohistochemical phenotyping on 18 resected IPMNs with varying degrees of dysplasia and for a subset, concomitant carcinoma, using a commercially available NGS-panel of 51 oncogenes. We simulated endoscopic biopsies by performing punch biopsies (PBs) of the cyst wall from resected specimens. RESULTS In total, 127 NGS analyses were performed. Concomitant KRAS and GNAS was a common feature of the IPMNs. Mutations in KRAS and GNAS were associated with low-grade dysplasia whereas alterations in TP53, SMAD4, CDKN2A and PIK3CA were associated with high-grade dysplasia and/or carcinoma. The mutational analysis of the PBs from the cyst wall was compared with the whole lesion. No difference was detected between PBs and whole lesions when the cumulated mutational profile in increasing order of randomly performed PBs was compared. CONCLUSIONS Small IPMN biopsies from the cyst wall are adequate to yield a molecular diagnosis.
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Affiliation(s)
| | | | - David Scheie
- Department of Pathology, Rigshospitalet, Copenhagen, Denmark
| | | | - Eva Løbner Lund
- Department of Pathology, Rigshospitalet, Copenhagen, Denmark
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15
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Binda C, Dabizzi E, Sinagra E, Fornelli A, Saragoni L, Cennamo V, Anderloni A, Fabbri C. Micro-Biopsy Forceps in the Assessment of Peritoneal Carcinomatosis: A Possible New Indication? Clin Endosc 2021; 54:613-617. [PMID: 33765374 PMCID: PMC8357587 DOI: 10.5946/ce.2020.241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/19/2021] [Indexed: 12/15/2022] Open
Abstract
Peritoneal carcinomatosis (PC) is defined as a metastatic involvement of the peritoneum by several other primary sites and it is characterized by a marked worsening of prognosis, with limited treatment opportunities. Subsequently, PC should be ruled out before any invasive treatment is administered. A new through-the-needle micro-biopsy forceps (MF) was recently introduced that permits micro-histology cores. In this case series, we evaluated the feasibility of MF in the assessment of PC to complete patient diagnostic work-ups. Five consecutive patients referred for endoscopic ultrasound staging were sampled using MF. Sampling was feasible in all patients with a technical success of 100%. No adverse events were reported in any cases. This technique was feasible and safe with a technical success rate of 100%. It permitted sampling of peritoneal irregularity, obtained high-quality tissue fragments in all cases, and enabled an additional assessment, i.e., immunohistochemical staining.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì - Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Emanuele Dabizzi
- Gastroenterology and Interventional Endoscopy Unit, Ospedale Maggiore "C.A. Pizzardi", AUSL Bologna, Bologna, Italy
| | - Emanuele Sinagra
- Servizio di Endoscopia Digestiva, Fondazione Istituto G. Giglio di Cefalù, Cefalù (PA), Italy.,Section of Nutrition, Istituto Euromediterraneo di Scienze e Tecnologia (IEMEST), Palermo, Italy
| | - Adele Fornelli
- Pathology Unit, Ospedale Maggiore "C.A. Pizzardi", AUSL Bologna, Bologna, Italy
| | - Luca Saragoni
- Pathology Unit, Morgagni-Pierantoni Hospital, Forlì, AUSL Romagna, Forlì, Italy
| | - Vincenzo Cennamo
- Gastroenterology and Interventional Endoscopy Unit, Ospedale Maggiore "C.A. Pizzardi", AUSL Bologna, Bologna, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì - Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
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16
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Rift CV, Scheie D, Toxværd A, Kovacevic B, Klausen P, Vilmann P, Hansen CP, Lund EL, Hasselby JP. Diagnostic accuracy of EUS-guided through-the-needle-biopsies and simultaneously obtained fine needle aspiration for cytology from pancreatic cysts: A systematic review and meta-analysis. Pathol Res Pract 2021; 220:153368. [PMID: 33652239 DOI: 10.1016/j.prp.2021.153368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/21/2021] [Accepted: 01/25/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To address the diagnostic accuracy of endoscopic ultrasound guided through-the-needle-biopsies (TTNBs) and simultaneously obtained cytology samples from pancreatic cysts compared to the final histopathological diagnosis of the surgical specimen, and to give an overview of ancillary tests performed on TTNBs. METHODS A literature search was conducted in MEDLINE, Embase and Scopus. Studies were included in the meta-analysis, if they had data for TTNB, cytology and a surgical specimen of pancreatic cysts as reference standard. The assessment of the risk of bias and quality of the included studies was conducted using the modified QUADAS-2 tool. RESULTS Ten studies with 99 patients were included in the meta-analysis. Data regarding study design and clinicopathological features were extracted systematically. For TTNB, pooled sensitivity was 0.86 (95 % CI 0.62-0.96), specificity 0.95 (95 % CI 0.79-0.99) and area under the curve (AUC) 0.86 for the diagnosis of a mucinous cyst and pooled sensitivity was 0.78 (95 % CI 0.61-0.89), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.92 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.69 (95 % CI 0.50-0.83), specificity 0.47 (95 % CI 0.28-0.68) and AUC 0.49. For cytology performed simultaneously, pooled sensitivity was 0.46 (95 % CI 0.35-0.57), specificity 0.90 (95 % CI 0.46-0.99) and AUC 0.64 for the diagnosis of mucinous cysts, and pooled sensitivity was 0.38 (95 % CI 0.23-0.55), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.84 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.29 (95 % CI 0.21-0.39), specificity 0.45 (95 % CI 0.25-0.66) and AUC 0.30. Furthermore, immunohistochemical stains can be useful to establish the specific cyst subtype. CONCLUSIONS TTNBs have a higher sensitivity and specificity than cytology for the diagnosis of mucinous cyst and high- risk cysts of the pancreas.
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Affiliation(s)
- Charlotte Vestrup Rift
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark.
| | - David Scheie
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Anders Toxværd
- Department of Pathology, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, DK 2730, Herlev, Denmark
| | - Bojan Kovacevic
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, DK 2730, Herlev, Denmark
| | - Pia Klausen
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, DK 2730, Herlev, Denmark
| | - Peter Vilmann
- Gastroenterology Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, DK 2730, Herlev, Denmark
| | - Carsten Palnæs Hansen
- Department of Surgery, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Eva Løbner Lund
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Jane Preuss Hasselby
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
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17
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Abstract
Pancreatic cystic neoplasms (PCNs) are being detected increasingly frequently due to the widespread use of high-resolution abdominal imaging modalities. Some subtypes of PCNs have the potential for malignant transformation. Therefore, accurate diagnosis of PCNs is crucial to determine whether surgical resection or surveillance is the best management strategy. However, the current cross-section imaging modalities are not accurate enough to enable definite diagnoses. In the last decade, EUS-based techniques have emerged, aiming to overcome the limitations of standard cross-section imaging modalities. These novel EUS-based techniques were primarily designed to acquire distinct images to make radiological diagnoses, collect cyst fluid to undergo biochemical or molecular analyses, and obtain tissue to conclude the pathological diagnoses. In this article, we present a comprehensive and critical review of these emerging EUS techniques for the diagnosis of PCNs, with emphasis being placed on the advantages, feasibilities, diagnostic performances, and limitations of these novel techniques.
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Affiliation(s)
- Liqi Sun
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Haojie Huang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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18
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Kovacevic B, Klausen P, Rift CV, Toxværd A, Grossjohann H, Karstensen JG, Brink L, Hassan H, Kalaitzakis E, Storkholm J, Hansen CP, Hasselby JP, Vilmann P. Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts. Endoscopy 2021; 53:44-52. [PMID: 32693411 DOI: 10.1055/a-1214-6043] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The limited data on the utility of endoscopic ultrasound (EUS)-guided through-the-needle biopsies (TTNBs) in patients with pancreatic cystic lesions (PCLs) originate mainly from retrospective studies. Our aim was to determine the clinical impact of TTNBs, their added diagnostic value, and the adverse event rate in a prospective setting. METHODS This was a prospective, single-center, open-label controlled study. Between February 2018 and August 2019, consecutive patients presenting with a PCL of 15 mm or more and referred for EUS were included. Primary outcome was a change in clinical management of PCLs following TTNB compared with cross-sectional imaging and cytology. Adverse events were defined according to the ASGE lexicon. RESULTS 101 patients were included. TTNBs led to a change in clinical management in 11.9 % of cases (n = 12). Of these, 10 had serous cysts and surveillance was discontinued, while one of the remaining two cases underwent surgery following diagnosis of a mucinous cystic neoplasm. The diagnostic yield of TTNBs for a specific cyst diagnosis was higher compared with FNA cytology (69.3 % vs. 20.8 %, respectively; P < 0.001). The adverse event rate was 9.9 % (n = 10; 95 % confidence interval 5.4 % - 17.3 %), with the most common event being acute pancreatitis (n = 9). Four of the observed adverse events were severe, including one fatal outcome. CONCLUSIONS TTNBs resulted in a change of clinical management in about one in every 10 patients; however, the associated adverse event risk was substantial. Further studies are warranted to elucidate in which subgroups of patients the clinical benefit outweighs the risks.
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Affiliation(s)
- Bojan Kovacevic
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Pia Klausen
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | | | - Anders Toxværd
- Department of Pathology, Herlev Hospital, Herlev, Denmark
| | - Hanne Grossjohann
- Department of Gastrointestinal Surgery, Rigshospitalet, Copenhagen, Denmark
| | - John Gásdal Karstensen
- Gastroenterology Unit, Pancreatitis Centre East, Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Brink
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Hazem Hassan
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | | | - Jan Storkholm
- Department of Gastrointestinal Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Peter Vilmann
- Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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19
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Balaban VD, Cazacu IM, Pinte L, Jinga M, Bhutani MS, Saftoiu A. EUS-through-the-needle microbiopsy forceps in pancreatic cystic lesions: A systematic review. Endosc Ultrasound 2021; 10:19-24. [PMID: 32611848 PMCID: PMC7980686 DOI: 10.4103/eus.eus_23_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are being increasingly encountered in clinical practice, and sometimes, they can represent a diagnostic challenge. Recently, a through-the-needle micro forceps biopsy (MFB) device was introduced in the endosonography practice to facilitate EUS-guided sampling of PCLs. The aim was to perform a systematic review of studies evaluating the technical aspects, safety, and efficacy of the EUS-guided MFB for PCLs. A literature search was performed in three major databases, PubMed, Embase, and Web of Science in September 2019 using the search terms: "through-the-needle," "biopsy forceps," "microforceps," "endoscopic ultrasound," and "endosonography." Case reports and case series with <10 patients were excluded from the analysis. Altogether nine studies reporting on 463 patients were included in our systematic review. The mean age of the patients was 68.3 years, with a slight female predominance (60.9%). Most of the cysts were located in the body/tail of the pancreas (61.2%), with an overall mean size of 33 mm. The technical success of EUS-guided MFB was reported in 98.5%. The tissue acquisition yield reported was 88.2%, and the diagnostic accuracy was 68.6%. Adverse events were reported in 9.7%. EUS-guided MFB is technically feasible, safe, and has a high diagnostic accuracy for PCLs.
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Affiliation(s)
- Vasile Daniel Balaban
- Internal Medicine and Gastroenterology Clinic, "Carol Davila" University of Medicine and Pharmacy, Craiova; Department of Gastroenterology, "Dr. Carol Davila" Central Military Emergency University Hospital, Bucharest, Romania
| | - Irina M Cazacu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania; Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Larisa Pinte
- Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Clinic, "Carol Davila" University of Medicine and Pharmacy, Craiova; Department of Gastroenterology, "Dr. Carol Davila" Central Military Emergency University Hospital, Bucharest, Romania
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Adrian Saftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
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20
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Kovacevic B, Antonelli G, Klausen P, Hassan C, Larghi A, Vilmann P, Karstensen JG. EUS-guided biopsy versus confocal laser endomicroscopy in patients with pancreatic cystic lesions: A systematic review and meta-analysis. Endosc Ultrasound 2021; 10:270-279. [PMID: 34290168 PMCID: PMC8411554 DOI: 10.4103/eus-d-20-00172] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives: Pancreatic cystic lesions (PCLs) are frequent incidental findings on cross-sectional imaging and represent a diagnostic challenge as different kinds of PCLs harbor a dissimilar risk of malignancy. Two diagnostic tools have recently been developed and introduced: through-the-needle biopsy (TTNB) and needle-based confocal laser endomicroscopy (nCLE). The aim of this meta-analysis was to compare the diagnostic yield and performance, as well as the safety profile of the two methods. Methods: This meta-analysis was performed in accordance with the PRISMA statement. Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies with five or more patients undergoing either endoscopic ultrasound (EUS)-TTNB or EUS-nCLE for a PCL. Reviews, case reports, editorials, conference abstracts, and studies on exclusively solid pancreatic lesions were excluded. Outcomes of interest were diagnostic yield and performance, safety, and technical success. Results: Twenty studies with 1023 patients were included in the meta-analysis. Pooled diagnostic yield of EUS-nCLE was higher compared to EUS-TTNB (85% vs. 74%, P < 0.0001), while diagnostic performance was high and comparable for both methods (pooled sensitivity: 80% vs. 86% and pooled specificity: 80% vs. 83% for TTNB and nCLE, respectively, P > 0.05). Pooled estimate of total adverse event (AE) rate was 5% in the TTNB group and 3% in the nCLE group, P = 0.302. Technical success rates were high and comparable (94% and 99% for EUS-TTNB and nCLE, respectively; P = 0.07). Conclusion: EUS-TTNB and EUS-nCLE have a similar safety profile with a relatively low number of AEs. Technical success, sensitivity, and specificity are comparable; however, EUS-nCLE seems to have a slightly higher diagnostic yield.
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Affiliation(s)
- Bojan Kovacevic
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Giulio Antonelli
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Pia Klausen
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - John Gásdal Karstensen
- Gastro Unit, Pancreatitis Centre East, Hvidovre Hospital, Hvidovre; Department of Clinical Medicine, University of Copenhagen, København, Denmark
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21
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Kovacevic B, Hansen MC, Kristensen TS, Karstensen JG, Klausen P, Storkholm J, Hansen CP, Vilmann P. Diagnostic performance of current guidelines and postoperative outcome following surgical treatment of cystic pancreatic lesions - a 10-year single center experience. Scand J Gastroenterol 2020; 55:1447-1453. [PMID: 33147090 DOI: 10.1080/00365521.2020.1841283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Pancreatic cystic lesions (PCLs) are diagnostically challenging and there are currently several different guidelines. The aim of this study was to compare diagnostic performance of the most widely utilized International Association of Pancreatology (IAP) guidelines and the recent evidence-based European guidelines and to report on postoperative outcomes following surgical treatment of PCLs. METHODS This is a retrospective single-center study of patients undergoing surgery due to a PCL between 2010 and 2019. Primary outcome was a comparison of diagnostic performance between IAP and European guidelines, measured in area under the receiver operating characteristic curve (AUC). Other outcomes included diagnostic performance of different risk features, 30-day postoperative mortality and major morbidity, final diagnosis, and overall survival. RESULTS We identified 137 patients, three of whom did not undergo curative surgery due to metastatic disease. Overall, there was no difference in the performance of the two guidelines with AUC values ranging from 0.572-0.610 and 0.607-0.621 for IAP and European guidelines respectively. Postoperative 30-day mortality and major morbidity were 0% (95% CI 0.0-2.7%) and 37.3% (95% CI 29.1-46.1%), respectively. More than half of the resected lesions (52.6%) were low-grade dysplastic or non-neoplastic. CONCLUSIONS Overall, the IAP and the European guidelines performed equally, although European guidelines had a slightly higher mean specificity. Pancreatic surgery is associated with high major morbidity, and there is a need for new diagnostic tools and strategies in order to decrease the amount of overtreatment in patients with PCL.
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Affiliation(s)
- Bojan Kovacevic
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | | | | | - John Gásdal Karstensen
- Gastro Unit, Pancreatitis Centre East, Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Pia Klausen
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Jan Storkholm
- Department of Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Tacelli M, Celsa C, Magro B, Barchiesi M, Barresi L, Capurso G, Arcidiacono PG, Cammà C, Crinò SF. Diagnostic performance of endoscopic ultrasound through-the-needle microforceps biopsy of pancreatic cystic lesions: Systematic review with meta-analysis. Dig Endosc 2020; 32:1018-1030. [PMID: 31912580 DOI: 10.1111/den.13626] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/24/2019] [Accepted: 01/06/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Endoscopic ultrasound through-the-needle biopsy (EUS-TTNB) is a useful tool for differential diagnosis among pancreatic cystic lesions (PCLs). Cystic fluid cytology (CFC) is recommended by guidelines, but its diagnostic accuracy is about 50%. The aim of this meta-analysis is to assess the clinical impact of EUS-TTNB in terms of technical success (TS), histological accuracy (HA) and diagnostic yield (DY). METHODS Original studies in English language on EUS-TTNB were searched in MEDLINE and EMBASE until October 2019. Diagnostic accuracy of EUS-TTNB for identification of mucinous PCLs was calculated using individual diagnostic data of patients who underwent CFC and surgery. RESULTS Nine studies, including 454 patients who underwent EUS-TTNB, met the inclusion criteria for the meta-analysis. TS and HA of EUS-TTNB were, respectively, 98.5% (95% Confidence Interval [CI] 97.3%-99.6%) and 86.7% (95%CI 80.1-93.4). DY was 69.5% (95%CI 59.2-79.7) for EUS-TTNB and 28.7% (95%CI 15.7-41.6) for CFC. Heterogeneity persisted significantly high in most of subgroup analyses. In the multivariate meta-regression, cyst size was independently associated with higher DY. Sensitivity and specificity for mucinous PCLs were 88.6 and 94.7% for EUS-TTNB, and 40 and 100% for CFC. Adverse events rate was 8.6% (95%CI 4.0-13.1). CONCLUSIONS This meta-analysis shows that EUS-TTNB is a feasible technique that allows a high rate of adequate specimens to be obtained for histology; in about two-thirds of patients a specific histotype diagnosis could be assessed. The number of adverse events is slightly higher respect to standard EUS-FNA, but complications are very rarely severe.
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Affiliation(s)
- Matteo Tacelli
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Bianca Magro
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Marco Barchiesi
- Department of Internal Medicine, ASST FBF-Sacco, Milan, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Gabriele Capurso
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Calogero Cammà
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
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McCarty T, Rustagi T. Endoscopic ultrasound-guided through-the-needle microforceps biopsy improves diagnostic yield for pancreatic cystic lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1280-E1290. [PMID: 33015329 PMCID: PMC7508652 DOI: 10.1055/a-1194-4085] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/09/2020] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Given variable diagnostic yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for pancreatic cystic lesions (PCLs), a through-the-needle (TTN) microforceps biopsy device passed through a 19-gauge FNA needle has been devised to improve tissue sampling. This was a systematic review and meta-analysis to evaluate the feasibility, diagnostic yield, and safety of EUS-guided TTN microforceps biopsy for diagnosis of PCLs. Methods Individualized searches were developed in accordance with PRISMA and MOOSE guidelines. This was a cumulative meta-analysis performed by calculating pooled proportions with rates estimated using random effects models. Measured outcomes included pooled technical success, diagnostic yield, accuracy, and procedure-associated adverse events (AEs) as well as comparison to conventional FNA. Results Eleven studies (n = 518 patients; mean age 64.13 ± 5.83 years; 58.19 % female) were included. Mean PCL size was 33.39 ± 3.72 mm with the pancreatic head/uncinate (35.50 %) being the most common location. A mean of 2.47 ± 0.92 forceps passes were performed with a mean of 2.79 ± 0.81 microbiopsies obtained per lesion. Pooled technical success was 97.12 % (95 % CI, 93.73-98.71; I 2 = 34.49) with a diagnostic yield of 79.60 % (95 % CI, 72.62-85.16; I 2 = 56.00), and accuracy of 82.76 % [(95 % CI, 77.80-86.80; I 2 = 0.00). The pooled serious adverse event rate was 1.08 % (95 % CI, 0.43-2.69; I 2 = 0.00). Compared to conventional FNA, TTN microforceps biopsy resulted in significant improvement in diagnostic yield [OR 4.79 (95 % CI: 1.52-15.06; P = 0.007)] and diagnostic accuracy [OR 8.69 (95 % CI, 1.12-67.12; P = 0.038)], respectively. Conclusions EUS-guided TTN microforceps biopsy appears to be safe and effective for diagnosis of PCLs with improvement in diagnostic yield and accuracy when compared to FNA alone.
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Affiliation(s)
- Thomas McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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24
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Guzmán-Calderón E, Martinez-Moreno B, Casellas JA, de Madaria E, Aparicio JR. Endoscopic ultrasound-guided, through-the-needle forceps biopsy for diagnosis of pancreatic cystic lesions: a systematic review. Endosc Int Open 2020; 8:E1123-E1133. [PMID: 32904862 PMCID: PMC7458739 DOI: 10.1055/a-1149-1647] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Pancreatic cystic lesions (PCL), are a heterogeneous group of cystic lesions. Some patients with PCLs have a significantly higher overall risk of pancreatic cancer and the only test that can differentiate benign and malignnat PCL is fine-needle aspiration plus cytological analysis, but its sensitivity is very low. Through-the-needle direct intracystic biopsy is a technique that allows acquisition of targeted tissue from PCLs and it may improve the diagnostic yield for them. The aim of this study was to review articles about endoscopic ultrasound (EUS)-guided through-the-needle intracystic biopsy for targeted tissue acquisition and diagnosis of PCLs. Methods A systematic review of computerized bibliographic databases was carried out for studies of EUS-guided through-the-needle forceps biopsy (EUS-TTNB) of PCLs. The percentages and their 95 % confidence intervals (CIs) were calculated for all the considered endpoints (technical success, adequate specimens, adverse events (AEs), and overall diagnosis). Results Overall, eight studies with a total of 423 patients were identified. Pooled technical success was 95.6 % of the cases (399/423), (95 % CI, 93.2 %-97.3 %). Technical failure rate was 5.1 % (24 cases). Frequency of adequate specimens was 82.2 %, (95 % CI, 78.5 %-85.8 %). Adverse events were reported in seven of the eight studies. Forty-two total adverse events were reported (10.1 %) (95 % CI, 7.3 %-13.6 %). The overall ability to provide a specific diagnosis with EUS-TTNB for diagnosis of pancreatic cystic lesions was 74.6 % (313 cases), (95 % CI: 70.2 %-78.7 %). The most frequent diagnoses found with EUS-TTNB were mucinous cystic neoplasms (MCN) in 96 cases (30.6 %), IPMN in 80 cases (25.5 %), and serous cystoadenoma neoplasm (SCN) in 48 cases (15.3 %). Conclusions Through-the-needle forceps biopsy appears to be effective and safe, with few AE for diagnosis of pancreatic cystic lesions. This technique had acceptable rates of technical and clinical success and an excellent safety profile. TTNB is associated with a high tissue acquisition yield and provided additional diagnostic yield for mucinous pancreatic lesions. TTNB may be a useful adjunctive tool for EUS-guided assessment of PCLs.
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Affiliation(s)
- Edson Guzmán-Calderón
- Gastroenterology Unit of Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru,Universidad Peruana de Ciencias Aplicadas (UPC), Alicante, Spain
| | | | - Juan A. Casellas
- Gastroenterology Unit oh Hospital General Universitario de Alicante, Alicante, Spain
| | - Enrique de Madaria
- Gastroenterology Unit oh Hospital General Universitario de Alicante, Alicante, Spain
| | - José Ramón Aparicio
- Gastroenterology Unit oh Hospital General Universitario de Alicante, Alicante, Spain
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25
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Rift CV, Kovacevic B, Toxværd A, Klausen P, Hansen CP, Vilmann P, Hasselby JP. EUS-guided through-the-needle biopsy sampling of pancreatic cystic lesions: a pathologist's guide for the endoscopist. Gastrointest Endosc 2020; 92:252-258. [PMID: 32334016 DOI: 10.1016/j.gie.2020.04.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/15/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Charlotte Vestrup Rift
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bojan Kovacevic
- Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Anders Toxværd
- Department of Pathology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Pia Klausen
- Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Carsten Palnæs Hansen
- Department of Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Vilmann
- Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Jane Preuss Hasselby
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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26
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Current Status of Needles in the Optimization of Endoscopic Ultrasound-Guided Procedures. Diagnostics (Basel) 2020; 10:diagnostics10070463. [PMID: 32650628 PMCID: PMC7400280 DOI: 10.3390/diagnostics10070463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/05/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
Endoscopic ultrasound (EUS) is among the most important tools for the evaluation of gastrointestinal tumors and affected areas around the gastrointestinal tract. It enables the acquisition of material from abnormal lesions via the gastrointestinal wall for tissue confirmation via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA has played a vital role in oncological care and has become the standard method for tissue sampling. The choice of needle type is an important factor determining tissue acquisition and has been evaluated by many researchers. New needles are introduced into the market almost every year, and opinions vary regarding proper needle selection. While there are diverse opinions but no definitive recommendations about the use of one particular device, fine-needle biopsy needles may provide detailed information on a tissue’s architecture based on greater sample yields. This permits additional analyses, including genetic sequencing and phenotyping, thereby enabling the provision of more personalized treatment plans. Furthermore, other EUS-guided procedures have been developed, including interventional EUS and through-the-needle devices. Given the continued attempts to improve the diagnostic ability and therapeutic techniques, we review in detail the available types of puncture needles to provide guidance on the selection of the appropriate needle types.
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27
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Facciorusso A, Wani S. Response. Gastrointest Endosc 2020; 92:238. [PMID: 32586563 DOI: 10.1016/j.gie.2020.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
Affiliation(s)
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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28
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Vilas-Boas F, Costa-Moreira P, Moutinho-Ribeiro P, Martins D, Lopes J, Macedo G. Through-the-needle biopsy sampling may allow preoperative intraductal papillary mucinous neoplasia subtyping. Gastrointest Endosc 2020; 92:235-236. [PMID: 32586560 DOI: 10.1016/j.gie.2020.02.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/24/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Filipe Vilas-Boas
- Department of Gastroenterology, Faculty of Medicine, Porto WGO Training Center, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Pedro Costa-Moreira
- Department of Gastroenterology, Faculty of Medicine, Porto WGO Training Center, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Pedro Moutinho-Ribeiro
- Department of Gastroenterology, Faculty of Medicine, Porto WGO Training Center, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Diana Martins
- Department of Pathology, Faculty of Medicine, Porto WGO Training Center, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Joanne Lopes
- Department of Pathology, Faculty of Medicine, Porto WGO Training Center, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology, Faculty of Medicine, Porto WGO Training Center, Centro Hospitalar e Universitário de São João, Porto, Portugal
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29
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Tacelli M, Celsa C, Arcidiacono PG, Crinò SF. Through-the-needle biopsy of pancreatic cystic lesions: stronger evidences of higher diagnostic yield compared with cytology. Gastrointest Endosc 2020; 92:237-238. [PMID: 32586562 DOI: 10.1016/j.gie.2020.02.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Matteo Tacelli
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza, University of Palermo, Palermo, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS Milan
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
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30
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Westerveld DR, Ponniah SA, Draganov PV, Yang D. Diagnostic yield of EUS-guided through-the-needle microforceps biopsy versus EUS-FNA of pancreatic cystic lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E656-E667. [PMID: 32355885 PMCID: PMC7164999 DOI: 10.1055/a-1119-6543] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/15/2020] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Accurate diagnosis and risk stratification of pancreatic cysts (PCs) is challenging. The aim of this study was to perform a systematic review and meta-analysis to assess the feasibility, safety, and diagnostic yield of endoscopic ultrasound-guided through-the-needle biopsy (TTNB) versus fine-needle aspiration (FNA) in PCs. Methods Comprehensive search of databases (PubMed, EMBASE, Cochrane, Web of Science) for relevant studies on TTNB of PCs (from inception to June 2019). The primary outcome was to compare the pooled diagnostic yield and concordance rate with surgical pathology of TTNB histology and FNA cytology of PCs. The secondary outcome was to estimate the safety profile of TTNB. Results: Eight studies (426 patients) were included. The diagnostic yield was significantly higher with TTNB over FNA for a specific cyst type (OR: 9.4; 95 % CI: [5.7-15.4]; I 2 = 48) or a mucinous cyst (MC) (OR: 3.9; 95 % CI: [2.0-7.4], I 2 = 72 %). The concordance rate with surgical pathology was significantly higher with TTNB over FNA for a specific cyst type (OR: 13.5; 95 % CI: [3.5-52.3]; I 2 = 48), for a MC (OR: 8.9; 95 % [CI: 1.9-40.8]; I 2 = 29), and for MC histologic severity (OR: 10.4; 95 % CI: [2.9-36.9]; I 2 = 0). The pooled sensitivity and specificity of TTNB for MCs were 90.1 % (95 % CI: [78.4-97.6]; I 2 = 36.5 %) and 94 % (95 % CI: [81.5-99.7]; I 2 = 0), respectively. The pooled adverse event rate was 7.0 % (95 % CI: [2.3-14.1]; I 2 = 82.9). Conclusions TTNB is safe, has a high sensitivity and specificity for MCs and may be superior to FNA cytology in risk-stratifying MCs and providing a specific cyst diagnosis.
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Affiliation(s)
- Donevan R. Westerveld
- Department of Internal Medicine, University of Florida, Gainesville, Florida, United States
| | - Sandeep A. Ponniah
- Department of Internal Medicine, University of Florida, Gainesville, Florida, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
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31
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Krishna SG, Hart PA, Malli A, Kruger AJ, McCarthy ST, El-Dika S, Walker JP, Dillhoff ME, Manilchuk A, Schmidt CR, Pawlik TM, Porter K, Arnold CA, Cruz-Monserrate Z, Conwell DL. Endoscopic Ultrasound-Guided Confocal Laser Endomicroscopy Increases Accuracy of Differentiation of Pancreatic Cystic Lesions. Clin Gastroenterol Hepatol 2020; 18:432-440.e6. [PMID: 31220640 DOI: 10.1016/j.cgh.2019.06.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/18/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Imaging patterns from endoscopic ultrasound (EUS)-guided needle-based confocal laser endomicroscopy (nCLE) have been associated with specific pancreatic cystic lesions (PCLs). We compared the accuracy of EUS with nCLE in differentiating mucinous from nonmucinous PCLs with that of measurement of carcinoembryonic antigen (CEA) and cytology analysis. METHODS We performed a prospective study of 144 consecutive patients with a suspected PCL (≥20 mm) who underwent EUS with fine-needle aspiration of pancreatic cysts from June 2015 through December 2018 at a single center; 65 patients underwent surgical resection. Surgical samples were analyzed by histology (reference standard). During EUS, the needle with the miniprobe was placed in the cyst, which was analyzed by nCLE. Fluid was aspirated and analyzed for level of CEA and by cytology. We compared the accuracy of nCLE in differentiating mucinous from nonmucinous lesions with that of measurement of CEA and cytology analysis. RESULTS The mean size of dominant cysts was 36.4 ± 15.7 mm and the mean duration of nCLE imaging was 7.3 ± 2.8 min. Among the 65 subjects with surgically resected cysts analyzed histologically, 86.1% had at least 1 worrisome feature based on the 2012 Fukuoka criteria. Measurement of CEA and cytology analysis identified mucinous PCLs with 74% sensitivity, 61% specificity, and 71% accuracy. EUS with nCLE identified mucinous PCLs with 98% sensitivity, 94% specificity, and 97% accuracy. nCLE was more accurate in classifying mucinous vs nonmucinous cysts than the standard method (P < .001). The overall incidence of postprocedure acute pancreatitis was 3.5% (5 of 144); all episodes were mild, based on the revised Atlanta criteria. CONCLUSIONS In a prospective study, we found that analysis of cysts by nCLE identified mucinous cysts with greater accuracy than measurement of CEA and cytology analysis. EUS with nCLE can be used to differentiate mucinous from nonmucinous PCLs. ClincialTrials.gov no: NCT02516488.
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Affiliation(s)
- Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio.
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Ahmad Malli
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Andrew J Kruger
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Sean T McCarthy
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Samer El-Dika
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Jon P Walker
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Mary E Dillhoff
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Andrei Manilchuk
- Department of General Surgery, The Ohio State University, Columbus, Ohio
| | - Carl R Schmidt
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Christina A Arnold
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
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32
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Tian G, Ye Z, Zhao Q, Jiang T. Complication incidence of EUS-guided pancreas biopsy: A systematic review and meta-analysis of 11 thousand population from 78 cohort studies. Asian J Surg 2020; 43:1049-1055. [PMID: 31974051 DOI: 10.1016/j.asjsur.2019.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/26/2019] [Accepted: 12/18/2019] [Indexed: 01/10/2023] Open
Abstract
A systematic review and meta-analysis were performed to estimate the incidence of possible complications following EUS-guided pancreas biopsy. Pancreatic cancer has a very poor prognosis with a high fatality rate. Early diagnosis is important to improve the prognosis of pancreatic cancer. We searched Pubmed, Embase, Web of Science, and Scopus databases for studies published from inception to Augest, 2018. Meta-analysis were conducted with random-effect models and heterogeneity was calculated with the Q, I2 and τ2 statistics. We enrolled 78 studies from 71 articles in the meta-analysis, comprising 11,652 patients. Pooled data showed that the whole complication incidences were low 0.210 × 10-4(95%CI -0.648 × 10-4, 1.068 × 10-4). And they were in bleeding 0.002 × 10-4 (95%CI -0.092 × 10-4, 0.097 × 10-4), pancreatitis 0.002 (95%CI -0.082 × 10-4, 0.086 × 10-4), abdominal pain 0 (95%CI -0.037 × 10-4, 0.038 × 10-4), fever 0 (95%CI -0.032 × 10-4, 0. 032 × 10-4), infection 0 (95%CI -0.030 × 10-4, 0.031 × 10-4), duodenal perforation 0 (95%CI -0.033 × 10-4, 0.034 × 10-4), pancreatic fistula 0 (95%CI -0.029 × 10-4, 0.029 × 10-4), abscess 0 (95%CI -0.029 × 10-4, 0.029 × 10-4) and sepsis 0 (95%CI -0.029 × 10-4, 0.030 × 10-4). Subgroup analysis based on the tumor size, site, needle type and tumor style also showed robust results. The pooled data showed EUS-guided pancreas biopsy could be a safe approach for the diagnosis of pancreatic lesions. More large-scale studies will be necessary to confirm the findings across different population.
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Affiliation(s)
- Guo Tian
- Department of Ultrasound Medicine, The First Afliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Zhengdu Ye
- Department of Ultrasound Medicine, The First Afliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiyu Zhao
- Department of Ultrasound Medicine, The First Afliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tian'an Jiang
- Department of Ultrasound Medicine, The First Afliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China.
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33
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Kovacevic B, Kalaitzakis E, Klausen P, Brink L, Hassan H, Karstensen JG, Vilmann P. EUS-guided through-the-needle microbiopsy of pancreatic cysts: Technical aspects (with video). Endosc Ultrasound 2020; 9:220-224. [PMID: 32611847 PMCID: PMC7529000 DOI: 10.4103/eus.eus_12_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cystic lesions are frequently encountered and diagnostically challenging as some of the cysts may have malignant potential (mucinous) while others are completely benign (serous). EUS-guided through-the-needle biopsy (EUS-TTNB) of the cyst wall has recently been introduced as an alternative to cyst fluid cytology. Several studies have shown that microbiopsies outperform cytology in terms of distinction between mucinous and nonmucinous lesions, but also in determining the specific cyst diagnosis. However, little is known about the technical aspects of tissue sampling with TTNB. Herein, we summarize our experience with the procedure in a tertiary referral center and discuss indications, technical aspects, and safety of the procedure. Most adverse events (AEs) associated with the procedure are mild, but there is emerging evidence that the rate of postprocedural pancreatitis is higher compared to standard fine-needle aspiration. The added diagnostic yield should therefore be placed in perspective with an increased risk of AEs. Prospective studies are warranted to fully identify which patient groups could benefit from EUS-TTNB.
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Affiliation(s)
- Bojan Kovacevic
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - Evangelos Kalaitzakis
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - Pia Klausen
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - Lene Brink
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - Hazem Hassan
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
| | - John G Karstensen
- Gastroenterology Unit, Pancreatitis Centre East, Hvidovre Hospital, Department of Clinical Medicine, Copenhagen University, Hvidovre, Denmark
| | - Peter Vilmann
- Gastroenterology Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, Herlev, Denmark
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Uchida D, Kato H, Matsumoto K, Ishihara Y, Matsumi A, Saragai Y, Takada S, Yabe S, Muro S, Tomoda T, Horiguchi S, Okada H. Single-session esophagogastroduodenoscopy and endoscopic ultrasound using a forward-viewing radial scan ultrasonic endoscope. BMC Gastroenterol 2019; 19:220. [PMID: 31852458 PMCID: PMC6921396 DOI: 10.1186/s12876-019-1141-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/10/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Endoscopic ultrasound is useful for obtaining high-resolution images of pancreaticobiliary diseases, but is not readily available for physical checkups. In this study, we evaluated the safety and efficacy of single-session esophagogastroduodenoscopy and endoscopic ultrasound in the detection of upper-gastrointestinal and pancreaticobiliary diseases using a forward-viewing radial scan ultrasonic endoscope. METHODS A total of 148 patients who were scheduled for upper-gastrointestinal screening using an endoscope were prospectively included. All patients were examined by EUS in combination with EGD using a forward-viewing radial scan ultrasonic endoscope. The primary endpoint was the safety of the procedures. The secondary endpoints were the prevalence of diseases, the basal imaging capability of EUS, the procedure time, total dose of propofol, and the correlation between background factors and the prevalence of pancreatic disease. The imaging capability at each region was scored as 0 (invisible) to 2 (sufficient visualization to evaluate the organs). RESULTS Intraoperative hypotension occurred as an adverse event of intravenous anesthesia in one patient. There were 82 pancreaticobiliary findings and 165 upper-gastrointestinal findings (malignancy not included). Follicular lymphoma of the intra-abdominal lymph nodes was detected in one patient. The mean imaging scores of each section were 1.95 (pancreatic head and papilla), 2.0 (pancreatic body), 1.99 (pancreatic tail), and 1.89 (common bile duct and gallbladder). Age, history of diabetes mellitus, and smoking history were significantly associated with the prevalence of pancreatic diseases. CONCLUSION The simultaneous performance of EGD and EUS using a new ultrasonic endoscope is tolerable and safe for upper-gastrointestinal and pancreaticobiliary screening.
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Affiliation(s)
- Daisuke Uchida
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan. .,Center for Innovative Clinical Medicine, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Hironari Kato
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yuki Ishihara
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Akihiro Matsumi
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yosuke Saragai
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Saimon Takada
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shuntaro Yabe
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shinichiro Muro
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shigeru Horiguchi
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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Crinò SF, Bernardoni L, Brozzi L, Barresi L, Malleo G, Salvia R, Frulloni L, Sina S, Parisi A, Remo A, Larghi A, Gabbrielli A, Manfrin E. Association between macroscopically visible tissue samples and diagnostic accuracy of EUS-guided through-the-needle microforceps biopsy sampling of pancreatic cystic lesions. Gastrointest Endosc 2019; 90:933-943. [PMID: 31100310 DOI: 10.1016/j.gie.2019.05.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/06/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS EUS-guided through-the-needle biopsy (TTNB) sampling has been reported to improve diagnostic yield compared with cytology for the evaluation of pancreatic cystic lesions (PCLs). The number of macroscopically visible tissue samples needed to reach an adequate diagnosis is still unknown. METHODS This is a retrospective, single-center study on consecutive patients with PCLs with risk features (cyst >3 cm, thickened wall, cyst growth during follow-up, and mural nodules) who underwent TTNB sampling. The capability of differentiating mucinous versus nonmucinous cysts, ability to obtain a cyst-lining epithelium, definition of the grade of dysplasia, and specific diagnosis of cyst histotype were evaluated for 1, 2, or 3 TTNB macroscopically visible specimens. RESULTS Sixty-one patients were evaluated. A 100% histologic adequacy was reached by 2 samples (P = .05 versus 1). Compared with cytology, 1 TTNB specimen improved the possibility of defining cyst histotype (P < .0001), whereas 2 specimens increased all 4 diagnostic categories (P < .003). Two specimens also increased diagnostic yield compared with 1 sample (P < .085). The collection of a third sample did not improve the value of any diagnostic categories. A specific diagnosis was reached in 74% of patients with 2 histologic samples. The diagnostic reliability of TTNB sampling compared with surgical histology was 90%, with a 22.9% rate of adverse events. CONCLUSIONS Two TTNB macroscopically visible specimens reached 100% histologic adequacy and a specific diagnosis in 74% of patients. The collection of a third specimen did not add any additional information and should be avoided to possibly decrease the risk of adverse events.
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Affiliation(s)
- Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Laura Bernardoni
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Lorenzo Brozzi
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Frulloni
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Sokol Sina
- Department of Diagnostics and Public Health, G.B. Rossi University Hospital, Verona, Italy
| | - Alice Parisi
- Department of Diagnostics and Public Health, G.B. Rossi University Hospital, Verona, Italy
| | - Andrea Remo
- Department of Pathology, Mater Salutis Hospital, Legnago, Verona, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, IRCCS, Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | - Armando Gabbrielli
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Erminia Manfrin
- Department of Diagnostics and Public Health, G.B. Rossi University Hospital, Verona, Italy
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Skef W, McGrath K. Pancreatic cyst through-the-needle biopsy: two's the charm. Gastrointest Endosc 2019; 90:944-946. [PMID: 31759419 DOI: 10.1016/j.gie.2019.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Wasseem Skef
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kevin McGrath
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Hashimoto R, Lee JG, Chang KJ, Chehade NEH, Samarasena JB. Endoscopic ultrasound-through-the-needle biopsy in pancreatic cystic lesions: A large single center experience. World J Gastrointest Endosc 2019; 11:531-540. [PMID: 31798774 PMCID: PMC6875688 DOI: 10.4253/wjge.v11.i11.531] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 09/25/2019] [Accepted: 10/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Establishing a diagnosis of pancreatic cystic lesions (PCLs) preoperatively still remains challenging. Recently, endoscopic ultrasound (EUS)-through-the-needle biopsy (EUS-TTNB) using microforceps in PCLs has been made available.
AIM To assess the efficacy and safety of EUS-TTNB in the diagnosis of PCLs.
METHODS We retrospectively collected data of patients with PCLs who underwent both EUS-fine-needle aspiration (FNA) for cytology and EUS-TTNB at our institution since 2016. EUS-FNA for cytology was followed by EUS-TTNB in the same session. Evaluation of the cyst location, primary diagnosis, adverse events, and comparison between the cytologic fluid analyses and histopathology was performed. Technical success of EUS-TTNB was defined as visible tissue present after biopsy. Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis.
RESULTS A total of 56 patients (mean age 66.9 ± 11.7, 53.6% females) with PCLs were enrolled over the study period. The mean cyst size was 28.8 mm (12-85 mm). The EUS-TTNB procedure was technically successful in all patients (100%). The clinical success rate using EUS-TTNB was much higher than standard EUS-FNA, respectively 80.4% (45/56) vs 25% (14/56). Adverse events occurred in 2 patients (3.6%) who developed mild pancreatitis that resolved with medical therapy. Using TTNB specimens, 23 of 32 cases (71.9%) with intraductal papillary mucinous neoplasm were further differentiated into gastric type (19 patients) and pancreaticobiliary type (4 patients) based on immunochemical staining.
CONCLUSION EUS-TTNB for PCLs was technically feasible and had a favorable safety profile. Furthermore, the diagnostic yield for PCLs was much higher with EUS-TTNB than standard EUS-FNA cytology and fluid carcinoembryonic antigen. EUS-TTNB should be considered as an adjunct to EUS-FNA and cytologic analysis in the diagnosis and management of PCLs.
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Affiliation(s)
- Rintaro Hashimoto
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, Orange, CA 92868, United States
| | - John G Lee
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, Orange, CA 92868, United States
| | - Kenneth J Chang
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, Orange, CA 92868, United States
| | - Nabil El Hage Chehade
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, Orange, CA 92868, United States
| | - Jason B Samarasena
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, Orange, CA 92868, United States
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Larghi A, Manfrin E, Fabbri C, Crinò SF, Correale L, Chiarello G, Barresi L, Van Velthuysen ML, Poley JW, Rahal D, Carrara S, Inzani F, Fornelli A. Interobserver agreement among expert pathologists on through-the-needle microforceps biopsy samples for evaluation of pancreatic cystic lesions. Gastrointest Endosc 2019; 90:784-792.e4. [PMID: 31323232 DOI: 10.1016/j.gie.2019.07.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The recent development of microforceps for EUS through-the-needle biopsy (TTNB) sampling of the wall of pancreatic cystic lesions (PCLs) allows the collection of histologic specimens never handled and evaluated before by pathologists. We aimed to estimate the interobserver agreement among pathologists in evaluating such samples. METHODS TTNB specimen slides from 40 PCLs with worrisome features were retrieved and independently evaluated for specimen adequacy, presence of lining epithelium, grade of epithelial dysplasia, presence of ovarian type stroma, and specific diagnosis by 6 expert pathologists from 6 different tertiary care centers. The Gwet's AC1 was used to assess interobserver agreement. RESULTS An almost perfect agreement was observed for specimen adequacy (AC1, .82; 95% confidence interval [CI], .79-.98), presence of lesional epithelium (AC1, .90; 95% CI, .86-.92), epithelial dysplasia (AC1, .97; 95% CI, .95-.99), and ovarian-like stroma (AC1, .90; 95% CI, .86-.93). When considering all diagnoses separately, a moderate to substantial agreement was observed (AC1, .62; 95% CI, .57-.67), similarly to mucinous cysts versus serous adenoma versus other diagnoses (AC1, .65; 95% CI, .59-.70) and for mucinous cysts versus all other diagnoses (AC1,.74; 95% CI, .68-.84). The agreement for diagnosis of mucinous cystic neoplasm versus intraductal mucinous papillary neoplasm was almost perfect (AC1, .88; 95% CI, .81-.95). CONCLUSIONS Interobserver agreement between expert pathologists in the evaluation of TTNB samples from PCLs with worrisome features was close to perfection for all evaluated parameters, except definitive diagnosis. When mucinous cystic lesions were compared versus all other diagnoses, the agreement became substantial, thus indicating that TTNB specimens can provide important information for PCL management decisions.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Erminia Manfrin
- Department of Diagnostics and Public Health, G.B. Rossi University Hospital, Verona, Italy
| | - Carlo Fabbri
- Digestive Endoscopy and Gastroenterology, Azienda Unità Sanitaria Locale AUSL della Romagna, Ospedali di Forlì e Cesena, Cesena and Forli, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Loredana Correale
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Gaia Chiarello
- Pathology Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | | | - Jan Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Daoud Rahal
- Pathology Department, Humanitas Research Hospital, Milan, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Frediano Inzani
- Department of Pathology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Adele Fornelli
- Pathology Unit, Azienda USL Città di Bologna, Ospedale Maggiore, Bologna, Italy
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Abstract
PURPOSE OF REVIEW Pancreatic cystic lesions (PCLs) are increasingly identified on abdominal imaging. Given the malignant potential of certain cyst subtypes and the poor survival rates of pancreatic cancer, accurate diagnosis and appropriate management of these cysts are critical. RECENT FINDINGS Advances in endoscopic ultrasound (EUS)-guided diagnostics have increased the accuracy of differentiating PCLs. These include cyst fluid molecular analysis, EUS-guided needle-based confocal laser endomicroscopy, and EUS-guided through the needle microforceps biopsy. This review encapsulates recent advances in the endoscopic management of PCLs with a specific focus on EUS-guided diagnosis. SUMMARY It is important to accurately diagnose pancreatic cystic lesions with malignant potential where the definitive management is surgical resection. Misdiagnosis can result in inadvertent surgery of an otherwise benign lesion or malignant progression of a precancerous cyst. Moreover, pancreatic surgery is associated with significant morbidity and mortality. Recent advances in EUS-guided tissue acquisition, imaging, and molecular biomarkers have resulted in improved diagnostic accuracy of pancreatic cystic lesions. Future studies need to define efficient and accurate diagnostic algorithms for improved management of pancreatic cysts.
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Endoscopic Ultrasound for Early Diagnosis of Pancreatic Cancer. Diagnostics (Basel) 2019; 9:diagnostics9030081. [PMID: 31344904 PMCID: PMC6787710 DOI: 10.3390/diagnostics9030081] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/18/2019] [Accepted: 07/23/2019] [Indexed: 12/12/2022] Open
Abstract
Detection of small pancreatic cancers, which have a better prognosis than large cancers, is needed to reduce high mortality rates. Endoscopic ultrasound (EUS) is the most sensitive imaging modality for detecting pancreatic lesions. The high resolution of EUS makes it particularly useful for detecting small pancreatic lesions that may be missed by other imaging modalities. Therefore, EUS should be performed in patients with obstructive jaundice in whom computed tomography (CT) or magnetic resonance imaging (MRI) does not identify a definite pancreatic lesion. Interest in the use of EUS for screening individuals at high risk of pancreatic cancer, including those with intraductal papillary mucinous neoplasms (IPMNs) and familial pancreatic cancer is growing. Contrast-enhanced EUS can facilitate differential diagnosis of small solid pancreatic lesions as well as malignant cystic lesions. In addition, EUS-guided fine needle aspiration can provide samples of small pancreatic lesions. Thus, EUS and EUS-related techniques are essential for early diagnosis of pancreatic cancer.
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Mitselos IV, Karoumpalis I, Theopistos VI, Tzilves D, Christodoulou DK. Endoscopic ultrasonography in pancreatic diseases: advances in tissue acquisition. Endosc Int Open 2019; 7:E922-E930. [PMID: 31304238 PMCID: PMC6624111 DOI: 10.1055/a-0915-9594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/09/2019] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Ioannis V. Mitselos
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Ioannis Karoumpalis
- Department of Gastroenterology, General National Hospital of Athens “G. Gennimatas”, Athens, Greece
| | - Vasileios I. Theopistos
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Dimitrios Tzilves
- Department of Gastroenterology, General Hospital of Thessaloniki “Theageneion”,Thessaloniki, Greece
| | - Dimitrios K. Christodoulou
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece,Corresponding author Dimitrios K. Christodoulou, MD, PhD University Hospital of IoanninaFaculty of MedicineUniversity of IoanninaPO Box 1186Ioannina, 45110Greece+30 265 100 7016
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Yang D, Trindade AJ, Yachimski P, Benias P, Nieto J, Manvar A, Ho S, Esnakula A, Gamboa A, Sethi A, Gupte A, Khara HS, Diehl DL, El Chafic A, Shah J, Forsmark CE, Draganov PV. Histologic Analysis of Endoscopic Ultrasound-Guided Through the Needle Microforceps Biopsies Accurately Identifies Mucinous Pancreas Cysts. Clin Gastroenterol Hepatol 2019; 17:1587-1596. [PMID: 30471456 DOI: 10.1016/j.cgh.2018.11.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is a challenge to accurately assess pancreatic cystic lesions (PCLs) and determine their risk. We compared the yield of tissue acquired with endoscopic ultrasound (EUS)-guided microforceps (through the needle tissue biopsy [TTNB]) with that of samples collected by EUS-guided fine-needle-aspiration (EUS-FNA), and the accuracy of analyses of each sample type in the diagnosis of mucinous PCLs. METHODS We performed a prospective open-label study of 114 consecutive adults (56.1% women; mean age, 64.2 y) undergoing EUS-FNA evaluation of PCLs (mean size, 35 mm) at 7 centers, from June 20, 2016, through August 31, 2018. Samples were collected from each cyst by FNA and microforceps; samples collected by FNA were analyzed by cytology and samples collected by TTNB were analyzed by histology. Acquisition yield was defined as the percentage of specimens collected that were adequate for cytologic or histologic analysis. Diagnoses of mucinous cysts were made based on identification of pancreatic mucinous epithelium by cytology analysis of FNA samples or histologic analysis of TTNB samples. Surgical specimens were used as the reference standard when available. RESULTS The EUS-guided microforceps were successfully inserted into 97.4% (111 of 114) of PCLs. Tissue acquisition yield was significantly higher with TTNB (95 of 114; 83.3%) than FNA (43 of 114; 37.7%) (P < .001). Sixty-one PCLs were determined to be mucinous based on TTNB analysis (53.5%) vs 11 with FNA analysis (9.6%) (P < .001). Among PCLs categorized as equivocal, based on the level of carcinoembryonic antigen, TTNB analysis found 50% (41 of 82) to be mucinous and FNA analysis found 8.5% (7 of 82) to be mucinous (P < .001). Findings from analyses of samples collected by TTNB were 100% concordant with findings from histologic analysis of surgical specimens (14 of 14), whereas only 3 of 14 findings from analysis of samples collected by FNA were in agreement with findings from surgical specimens (21.4%) (P < .001). Four of 5 mucinous PCLs with advanced neoplasia (80%) were detected with TTNB compared with none with FNA (P = .04). Self-limited intracystic bleeding occurred in 7 patients (6.1%), and acute pancreatitis in 6 patients (5.3%). CONCLUSIONS In a multicenter prospective study of patients undergoing EUS-FNA for evaluation of PCLs, we found TTNB collection of tissues for histologic analysis to be safe and feasible, with an acquisition yield of 83.3%. Histologic analysis of samples collected by TTNB identified a larger proportion of mucinous PCLs compared with cytologic analysis of samples collected by FNA-even among samples categorized as equivocal, based on the level of carcinoembryonic antigen. More samples collected by TTNB than FNA were found to have advanced neoplasia. Clinicaltrials.gov no: NCT02979509.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida.
| | - Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Petros Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York
| | - Jose Nieto
- Borland-Groover Clinic, Jacksonville, Florida
| | - Amar Manvar
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sammy Ho
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ashwini Esnakula
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Anthony Gamboa
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University, Medical Center-New York Presbyterian Hospital, New York, New York
| | - Anand Gupte
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Harshit S Khara
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania
| | - David L Diehl
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania
| | - Abdul El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, Louisiana
| | - Janak Shah
- Division of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, Louisiana
| | - Christopher E Forsmark
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
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Barresi L, Tacelli M, Traina M. Endoscopic ultrasound through-the-needle biopsy diagnosis of a pancreatic lymphoepithelial cyst. Dig Endosc 2019; 31:210. [PMID: 30633828 DOI: 10.1111/den.13343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Matteo Tacelli
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy.,Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine (DI.BI.M.I.S.), University of Palermo, Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
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Barresi L, Tacelli M, Ligresti D, Traina M, Tarantino I. Tissue acquisition in pancreatic cystic lesions. Dig Liver Dis 2019; 51:286-292. [PMID: 30166219 DOI: 10.1016/j.dld.2018.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 02/06/2023]
Abstract
Despite the progress achieved by scientific research in recent years, pancreatic cystic lesions (PCLs) remain a challenging clinical problem. A significant percentage of benign PCLs are still wrongly sent to surgery, with all the related risks of a high number of surgery-related complications and mortality. Diagnosis of the type of PCL, and risk stratification for malignancy are essential for a correct management of these lesions. Several guidelines have identified some clinical and morphological aspects suggesting the need for more accurate exams. Endoscopic ultrasound fine needle aspiration (EUS-FNA) of cystic fluid for cytology is the advised method of tissue acquisition in several guidelines, and the most used technique around the world. However sensitivity and adequacy of this technique are limited by the low amount of cells dispersed in cystic fluid. Alternative techniques have been tested to target the cystic walls in an attempt to obtain microhistologic specimens in order to augment the probability of obtaining an adequate diagnostic sample. The aim of this review is to offer a critical overview of the existing literature on tissue acquisition in PCLs, and emphasize advantages and disadvantages of each technique, and unclear areas that need to be investigated with future research.
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Affiliation(s)
- Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy.
| | - Matteo Tacelli
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
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Abstract
Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.
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Affiliation(s)
- Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vipin Gupta
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Manfrin E, Perini C, Di Stefano S, Bernardoni L, Parisi A, Frulloni L, Sina S, Remo A, Gabbrielli A, Crinò SF. Pseudo solid-appearing pancreatic serous microcystic adenomas: Histologic diagnosis with the EUS core biopsy fork-tip needle. Endosc Ultrasound 2019; 8:334-341. [PMID: 30924447 PMCID: PMC6791108 DOI: 10.4103/eus.eus_11_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and Objectives: Despite rarely, serous cystic adenoma (SCA) can assume a pseudo-solid aspect mimicking other pancreatic neoplasm as neuroendocrine tumor. EUS-FNA cytology has low diagnostic accuracy due to the scant cellularity of the collected samples. Histological diagnosis is usually made after resection. Recently, end-cutting needles for EUS-fine-needle biopsy (EUS-FNB), which obtain tissue cores by penetrating the lesions, have been developed. We aimed to assess the capability of EUS-FNB with SharkCore™ needles in the preoperative diagnosis of serous cystic adenoma pseudo-solid-appearing on imaging (Sa-SCA). Materials and Methods: Between January 2016 and January 2018, data from consecutive adult patients, who were referred for EUS-FNB of a solid pancreatic lesion and were diagnosed with having SCA, were retrieved from a single-center institutional database. Results: Two patients were excluded because of microcystic aspect at EUS. Histological diagnosis of SCA was made by EUS-FNB in the remaining 7 patients (5 females; mean age of 62.5 years). Lesions (mean size of 19.8 mm) were hypervascular on cross-sectional imaging, slightly hyperdense magnetic resonance imaging with T2-weighted images can, and negative at 68Ga-somatostatin receptor positron emission tomography and 18fluoro-deoxyglucose positron emission tomography. EUS-FNB samples were judged adequate for a definitive diagnosis in all cases, achieving specimens suitable for histological evaluation and several ancillary stains. Histochemical positivity for periodic acid-Schiff (PAS) and PAS with diastase digestion was observed in 7/7 cases. Immunohistochemical positivity for α-inhibin (7/7), GLUT1 (6/6), MUC6 (5/5), and negativity for synaptophysin (7/7) and chromogranin A (2/2) favored SCA diagnosis. Conclusions: In the case of preoperative workup suspected for Sa-SCA, a “forward acquiring” needle could improve the rate of preoperative histological diagnosis.
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Affiliation(s)
- Erminia Manfrin
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Claudia Perini
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Serena Di Stefano
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Laura Bernardoni
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Alice Parisi
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Luca Frulloni
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Sokol Sina
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Andrea Remo
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Armando Gabbrielli
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
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48
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Kamata K, Kitano M. Endoscopic diagnosis of cystic lesions of the pancreas. Dig Endosc 2019; 31:5-15. [PMID: 30085364 DOI: 10.1111/den.13257] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/02/2018] [Indexed: 12/13/2022]
Abstract
Endoscopic methods are increasingly used in the diagnosis of cystic lesions of the pancreas. The two major endoscopic approaches are endoscopic ultrasonography (EUS) and transpapillary diagnosis. EUS-guided fine-needle aspiration cytology and EUS-guided fine needle-based confocal laser endomicroscopy have been used in the differential diagnosis of mucinous and non-mucinous pancreatic cysts. EUS is the most sensitive modality for detecting mural nodules (MN) in intraductal papillary mucinous neoplasms (IPMN). Contrast-enhanced harmonic EUS (CH-EUS), as an add-on to EUS, is useful for identifying and characterizing MN. Recent studies show that CH-EUS has a sensitivity of 60-100% and a specificity of 75-92.9% for diagnosing malignant cysts. Intraductal ultrasonography and peroral pancreatoscopy are especially useful for detecting MN and IPMN. A recent meta-analysis showed that cytological assessment of pancreatic juice using a transpapillary approach had a pooled sensitivity, specificity, and accuracy of 35.1%, 97.2%, and 92.9%, respectively, for diagnosing malignant IPMN. Further studies are warranted to determine the indications for each of these novel techniques in assessing cystic lesions of the pancreas.
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Affiliation(s)
- Ken Kamata
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University School of Medicine, Wakayama, Japan
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Abstract
Pancreatic cysts are common and are incidentally detected in up to 13.5% of individuals. Intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN) are precursors to pancreatic adenocarcinoma. Most will never develop into pancreatic cancer. Several types of pancreatic cysts have no malignant potential. Solid tumors can present as a pancreatic cysts. Guidelines recommend surveillance. Management includes differentiating IPMNs and MCNs from other types, identifying those at highest risk of harboring pancreatic cancer or high-grade dysplasia, and referral to a multidisciplinary group for evaluation and consideration of surgical resection.
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Affiliation(s)
- Olaya I Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, The Johns Hopkins Hospital, Sheikh Zayed Building, 1800 Orleans Street, Suite M2058, Baltimore, MD 21287, USA
| | - Anne Marie Lennon
- Medicine, Multidisciplinary Pancreatic Cyst Clinic, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Room 7125J, Baltimore, MD 21231, USA; Surgery, Multidisciplinary Pancreatic Cyst Clinic, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Room 7125J, Baltimore, MD 21231, USA; Oncology, Multidisciplinary Pancreatic Cyst Clinic, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Room 7125J, Baltimore, MD 21231, USA; Radiology, Multidisciplinary Pancreatic Cyst Clinic, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Room 7125J, Baltimore, MD 21231, USA.
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Yang D, Samarasena JB, Jamil LH, Chang KJ, Lee D, Ona MA, Lo SK, Gaddam S, Liu Q, Draganov PV. Endoscopic ultrasound-guided through-the-needle microforceps biopsy in the evaluation of pancreatic cystic lesions: a multicenter study. Endosc Int Open 2018; 6:E1423-E1430. [PMID: 30574535 PMCID: PMC6281441 DOI: 10.1055/a-0770-2700] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/24/2018] [Indexed: 12/16/2022] Open
Abstract
Background and study aims Accurate diagnosis and classification of pancreatic cysts (PCs) remains a challenge. The aims of this study were to: (1) evaluate the safety and technical success of a novel microforceps for EUS-guided through-the-needle biopsy (TTNB) of PCs; and (2) assess its diagnostic yield for mucinous PCs when compared to FNA cyst fluid analysis and cytology. Patients and methods This was a multicenter retrospective analysis of 47 patients who underwent EUS-FNA and TTNB for PCs between January 2014 and June 2017. Technical success was defined as acquisition of a specimen adequate for cytologic or histological evaluation. Cyst fluid carcinoembryonic antigen (CEA) was used to initially categorize cysts as non-mucinous (CEA < 192 ng/mL) or mucinous (CEA ≥ 192 ng/mL). Final diagnosis was based on identifiable mucinous pancreatic cystic epithelium on cytology, microforceps histology and/or surgical histology when available. Results Forty-seven patients with PCs (mean size 30.7 mm) were included. TTNB was successfully performed in 46 of 47 (97.9 %). Technical success was significantly lower with FNA (48.9 %) compared to TTNB (85.1 %) ( P < .001). For cysts with insufficient amount of fluid for CEA (n = 19) or CEA < 192 ng/mL, the cumulative incremental diagnostic yield of a mucinous PC was significantly higher with TTNB vs. FNA (52.6 % vs 18.4 %; P = .004). TTNB alone (34.4 %) diagnosed more mucinous PCs than either CEA ≥ 192 ng/mL alone (6.3 %) or when combined with FNA cytology (9.4 %). One episode of self-limited bleeding (2.1 %) and one of pancreatitis (2.1 %) occurred. Conclusions EUS-TTNB is safe and effective for evaluating PCs. TTNB may help increase the diagnostic yield of mucinous PCs.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States,Corresponding author Dennis Yang
1329 SW 16
th
Street, Room #5252
Gainesville, FL 32608United States+1-352-627-9002
| | - Jason B. Samarasena
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
| | - Laith H. Jamil
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Kenneth J. Chang
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
| | - David Lee
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
| | - Mel A. Ona
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
| | - Simon K. Lo
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Srinivas Gaddam
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Quin Liu
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
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