Endoscopic ultrasound-guided fine needle aspiration of the pancreas: cytomorphological evaluation with emphasis on adequacy assessment, diagnostic criteria and contamination from the gastrointestinal tract

Sensitivity of endoscopic ultrasound-guided fine-needle aspiration cytology and biopsy for a diagnosis of pancreatic ductal adenocarcinoma: A comparative analysis

The utility of endoscopic ultrasound fine-needle aspiration cytology (EUS-FNAC) or endoscopic ultrasound fine-needle aspiration biopsy (EUS-FNAB) for diagnosis of small and large pancreatic ductal adenocarcinomas (PDACs) remains in question. We addressed this by analyzing 97 definitively diagnosed cases of PDAC, for which both EUS-FNAC and EUS-FNAB had been performed. We subclassified the 97 solid masses into small (n = 35) or large (n = 62) according to the maximum tumor diameter (<24 mm or ≥24 mm) and compared the diagnostic sensitivity (truly positive rate) of EUS-FNAC and of EUS-FNAB for small and large masses. Diagnostic sensitivity of EUS-FNAC did not differ between large and small masses (79.0% vs. 60.0%; p = 0.0763). However, the diagnostic sensitivity of EUS-FNAB was significantly higher for large masses (85.5% vs. 62.9%; p = 0.0213). Accurate EUS-FNAC-based diagnosis appeared to depend on the degree of cytological atypia of cancer cells, which was not associated with quantity of cancer cells. The accuracy of EUS-FNAB-based diagnosis appeared to depend on cancer cell viability in large masses and cancer volume in small masses. Based on the advantages or disadvantages in each modality, both modalities play an important role in the qualitative diagnosis of PDAC as a complementary procedure.

Background features in the cytology of pancreatic neoplasms

Cytology is a useful method for diagnosing pancreatic neoplasms. Although endoscopic ultrasound‐guided fine‐needle aspiration has recently become the mainstream method for the diagnosis of pancreatic neoplasms, pancreatic juice and pancreatic duct brushing cytology continue to be useful diagnostic methods for the investigation of pancreatic neoplasms. Diagnoses using pancreatic cytology are primarily based on the features related to tumor cells; however, evaluation of the background features provides important information that could further aid the diagnosis. Pancreatic neoplasms show various histological types, each of which is associated with its own characteristic background features. The necrotic background, desmoplastic stroma, and presence of cancer‐associated fibroblasts are background features of pancreatic ductal adenocarcinoma, a mucinous background is associated with intraductal papillary mucinous neoplasms and mucinous cystic neoplasms, and hyaline globules are observed in solid pseudopapillary neoplasms. However, some background features are associated with more than one histological type of pancreatic neoplasm, highlighting the importance to base a diagnosis on the results of a comprehensive analysis of not only the background features but also the tumor cells. Here, we provide a review of the key background cytological features of pancreatic neoplasms, which can serve as a guide to improve diagnosis and research.

The diagnostic performance of combined conventional cytology with smears and cell block preparation obtained from endoscopic ultrasound-guided fine needle aspiration for intra-abdominal mass lesions

BACKGROUND/AIM

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the primary method for tissue acquisition of intra-abdominal masses. However, the main limitation of cytology alone is the lack of tissue architecture and inadequate samples. This study aimed to evaluate the diagnostic performance of combined conventional cytology and cell block preparation obtained from EUS-FNA of intra-abdominal masses without Rapid On-site Evaluation (ROSE).

METHODS

Cytologic smears and cell block slides of 166 patients undergoing EUS-FNA during 2010-2015 were reviewed by an experienced cytopathologist blinded to clinical data.

RESULTS

125 patients had neoplastic lesions. Pancreatic adenocarcinoma was the most common etiology (35.5%), followed by lymph node metastasis (27.7%). The mean mass size was 2.5±1.3 cm. The mean number of passes was 1.9±1.28. Tissue adequacy for conventional cytology and cell block preparation was 78.9% and 78.1%, respectively. Factors associated with tissue adequacy were assessed. For cytology, lesions of > 2.1 cm, masses in the pancreatic body or tail, malignancy, and pancreatic cancer were positively associated with adequate cellularity. For cell block preparation, lesions of > 3 cm and malignancy were associated with increased tissue adequacy. The conventional cytology alone had a sensitivity of 68.5%, a specificity of 95.7%, and an area under the receiver operating characteristics (AUROC) of 0.821. The cell block preparation alone had a sensitivity of 65.4%, a specificity of 96%, and an AUROC of 0.807. The combined conventional cytology and cell block preparation performed significantly better than either method alone (p<0.05), as demonstrated by an increased AUROC of 0.853. Furthermore, cell block detected malignancy in 9.3% of cases where the cytologic smears failed to identify malignant cells.

CONCLUSIONS

The combined conventional cytology and cell block preparation increased the diagnostic accuracy of EUS-FNA compared to either method alone. This approach should be implemented in routine practice, especially where ROSE is unavailable.

A Radiomics Nomogram for the Preoperative Prediction of Lymph Node Metastasis in Pancreatic Ductal Adenocarcinoma

Purpose

To construct and verify a CT-based multidimensional nomogram for the evaluation of lymph node (LN) status in pancreatic ductal adenocarcinoma (PDAC).

Materials and Methods

We retrospectively assessed data from 172 patients with clinicopathologically confirmed PDAC surgically resected between February 2014 and November 2016. Patients were assigned to either a training cohort (n = 121) or a validation cohort (n = 51). We acquired radiomics features from the preoperative venous phase (VP) CT images. The maximum relevance–minimum redundancy (mRMR) algorithm and the least absolute shrinkage and selection operator (LASSO) methods were used to select the optimal features. We used multivariable logistic regression to construct a combined radiomics model for visualization in the form of a nomogram. Performance of the nomogram was evaluated by the receiver operating characteristic (ROC) curve approach, calibration testing, and analysis of clinical usefulness.

Results

A Rad score consisting of 10 LN status-related radiomics features was found to be significantly associated with the actual LN status (P < 0.01). A nomogram that consisted of Rad scores, CT-reported parenchymal atrophy, and CT-reported LN status performed well in terms of predictive power in the training cohort (area under the curve, 0.92), and this was confirmed in the validation cohort (area under the curve, 0.95). The nomogram also performed well in the calibration test and decision curve analysis, demonstrating its potential clinical value.

Conclusion

A multidimensional radiomics nomogram consisting of Rad scores, CT-reported parenchymal atrophy, and CT-reported LN status may contribute to the non-invasive evaluation of LN status in PDAC patients.

Endoscopic Ultrasound-Guided Fine-Needle Aspiration Microhistology in Asymptomatic and Symptomatic Pancreatic Cystic Lesions

OBJECTIVE

This study aimed to analyze the usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) microhistology to detect malignancy in pancreatic cystic lesions (PCLs).

METHODS

Patients with PCLs were identified and submitted to EUS-FNA from January 2010 to January 2017. The percentage of samples suitable for diagnostic classification by microhistology and the positive and negative likelihood ratios to detect malignancy in asymptomatic (APC) and symptomatic (SPC) PCLs were determined.

RESULTS

Endoscopic ultrasound-guided fine-needle aspiration was performed in 510 patients. The resulting material was processed by microhistology and useful for diagnosis in 432 (84.2%). Clinical characteristics of APC (341) and SPC (169) revealed that APC patients were younger (P = 0.004) and had smaller PCLs (23 vs 35 mm; P < 0.001). In APC, we found more preneoplastic (38.7% vs 30.2%; P = 0.0016) and a lower number of malignant PCLs (8.2% vs 24.3%; P < 0.001). In APC and SPC, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of microhistology to detect malignancy were 71.4%, 99.7%, 95.2%, 97.5%, and 97.4% (k = 0.80) and 58.5%, 96.9%, 85.7%, 87.9%, and 87.6%, respectively.

CONCLUSIONS

Endoscopic ultrasound-guided fine-needle aspiration was technically feasible. Microhistology was especially useful to detect neoplastic or malignant PCLs in APC patients.

Endoscopic ultrasonography and small-bowel endoscopy: Present and future

Over the last decade, impressive technological advances have occurred in ultrasonography and small-bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device-assisted enteroscopy have quickly become the reference standard for the diagnosis of small-bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up-to-date overview of the latest advances in endoscopic ultrasonography and small-bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.

Indeterminate diagnoses in EUS-guided FNA of the pancreas: analysis of cytologist and clinician perceptions, cytologic features, and clinical outcomes

INTRODUCTION

Indeterminate "atypical" or "suspicious for malignancy" diagnoses in the evaluation of pancreatic fine-needle aspiration (FNA) specimens can present challenges in the clinical management of patients with pancreatic masses. A main goal of this study was to identify, via survey, potential differences in perception between cytologists and clinicians with regard to the implications of, and factors contributing to, indeterminate diagnoses. We also evaluated clinical practice at our institution as it relates to such diagnoses and identified clinicopathologic features associated with indeterminate diagnoses, which allowed for correlation with survey results.

MATERIALS AND METHODS

Online surveys were sent to cytologists and clinicians to gather information on the respondents' experiences with pancreatic endoscopic ultrasound-guided FNA and their perceptions about the indeterminate diagnostic categories. Cytological specimens and patient medical records were reviewed to collect data on specimen acquisition, cytological features, tumor characteristics, and patient management.

RESULTS

Survey responses revealed that cytologists and clinicians held similar perceptions of the clinical impact of the indeterminate categories but had dissimilar ideas on the factors contributing to these diagnoses. Statistically significant associations were identified between indeterminate diagnoses and the following variables: number of passes performed; adequacy on rapid on-site evaluation; repeat FNA procedures; lesions with cystic changes; and well-differentiated tumor cytomorphology.

CONCLUSIONS

Awareness of the perceptions of cytologists and clinicians about, as well as the clinical features and cytologic variables associated with, "indeterminate" cases has the potential to improve patient care.

Pancreatic Cytology

The diagnostic approach to pancreaticobiliary disease requires a multidisciplinary team in which the cytopathologist plays a crucial role. Fine-needle aspiration, obtained by endoscopic ultrasound, is the diagnostic test of choice for pancreatic lesions. Preoperative clinical management depends on many factors, many of which rely on accurate cytologic assessment. Pancreaticobiliary cytology is wrought with diagnostic pitfalls. Clinical history, imaging studies, cytology samples, and ancillary tests, including immunohistochemistry, biochemical analysis, and genetic sequencing, are integral to forming a complete diagnosis and guiding optimal patient management. This article reviews clinical aspects and the diagnostic work-up of commonly encountered diagnostic entities within the field of pancreatic cytology.

Staging pancreatic carcinoma by computed tomography

Pancreatic carcinoma is becoming more common in our environment; the mortality rate for this tumor has barely changed over the last 20 years. Early diagnosis and accurate staging are crucial to ensure an appropriate therapeutic approach, which should aim to improve survival in patients in whom complete resection is possible and to minimize surgical morbidity and mortality in those with a high risk of residual disease after the intervention. Various imaging techniques are used for tumor staging: multidetector computed tomography (CT), magnetic resonance imaging, positron emission tomography (PET)-CT, endoscopic ultrasound, and diagnostic laparoscopy. Currently, multidetector CT is the technique of choice for the study of pancreatic tumors; thus, this article aims to review the state of the art in staging adenocarcinoma of the pancreas, focusing mainly on the applications and limitations of this technique.

The Role of Endoscopic Ultrasound in the Diagnosis of Autoimmune Pancreatitis

Autoimmune pancreatitis (AIP) is increasingly being recognized due to improved understanding of the disease and its criteria for diagnosis. The classic type 1 AIP can be diagnosed on clinical data, but type 2 AIP requires histologic confirmation. Current criteria incorporate cross-sectional imaging and endoscopic retrograde cholangiopancreatography in the diagnosis of AIP. However, endoscopic ultrasound (EUS) will likely have an increasing role in the diagnosis through its characteristic imaging, image-enhancing techniques, and its ability to acquire tissue through either fine needle aspiration or biopsy. This article will review the diagnostic challenges of AIP and the current role of EUS.

Computer-assisted cytologic diagnosis in pancreatic FNA: An application of neural networks to image analysis

BACKGROUND

Fine-needle aspiration (FNA) biopsy is an accurate method for the diagnosis of solid pancreatic masses. However, a significant number of cases still pose a diagnostic challenge. The authors have attempted to design a computer model to aid in the diagnosis of these biopsies.

METHODS

Images were captured of cell clusters on ThinPrep slides from 75 pancreatic FNA cases (20 malignant, 24 benign, and 31 atypical). A K-means clustering algorithm was used to segment the cell clusters into separable regions of interest before extracting features similar to those used for cytomorphologic assessment. A multilayer perceptron neural network (MNN) was trained and then tested for its ability to distinguish benign from malignant cases.

RESULTS

A total of 277 images of cell clusters were obtained. K-means clustering identified 68,301 possible regions of interest overall. Features such as contour, perimeter, and area were found to be significantly different between malignant and benign images (P <.05). The MNN was 100% accurate for benign and malignant categories. The model's predictions from the atypical data set were 77% accurate.

CONCLUSIONS

The results of the current study demonstrate that computer models can be used successfully to distinguish benign from malignant pancreatic cytology. The fact that the model can categorize atypical cases into benign or malignant with 77% accuracy highlights the great potential of this technology. Although further study is warranted to validate its clinical applications in pancreatic and perhaps other areas of cytology as well, the potential for improved patient outcomes using MNN for image analysis in pathology is significant. Cancer Cytopathol 2017;125:926-33. © 2017 American Cancer Society.

Imaging modalities for characterising focal pancreatic lesions

BACKGROUND

Increasing numbers of incidental pancreatic lesions are being detected each year. Accurate characterisation of pancreatic lesions into benign, precancerous, and cancer masses is crucial in deciding whether to use treatment or surveillance. Distinguishing benign lesions from precancerous and cancerous lesions can prevent patients from undergoing unnecessary major surgery. Despite the importance of accurately classifying pancreatic lesions, there is no clear algorithm for management of focal pancreatic lesions.

OBJECTIVES

To determine and compare the diagnostic accuracy of various imaging modalities in detecting cancerous and precancerous lesions in people with focal pancreatic lesions.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, and Science Citation Index until 19 July 2016. We searched the references of included studies to identify further studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We planned to include studies reporting cross-sectional information on the index test (CT (computed tomography), MRI (magnetic resonance imaging), PET (positron emission tomography), EUS (endoscopic ultrasound), EUS elastography, and EUS-guided biopsy or FNA (fine-needle aspiration)) and reference standard (confirmation of the nature of the lesion was obtained by histopathological examination of the entire lesion by surgical excision, or histopathological examination for confirmation of precancer or cancer by biopsy and clinical follow-up of at least six months in people with negative index tests) in people with pancreatic lesions irrespective of language or publication status or whether the data were collected prospectively or retrospectively.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the references to identify relevant studies and extracted the data. We planned to use the bivariate analysis to calculate the summary sensitivity and specificity with their 95% confidence intervals and the hierarchical summary receiver operating characteristic (HSROC) to compare the tests and assess heterogeneity, but used simpler models (such as univariate random-effects model and univariate fixed-effect model) for combining studies when appropriate because of the sparse data. We were unable to compare the diagnostic performance of the tests using formal statistical methods because of sparse data.

MAIN RESULTS

We included 54 studies involving a total of 3,196 participants evaluating the diagnostic accuracy of various index tests. In these 54 studies, eight different target conditions were identified with different final diagnoses constituting benign, precancerous, and cancerous lesions. None of the studies was of high methodological quality. None of the comparisons in which single studies were included was of sufficiently high methodological quality to warrant highlighting of the results. For differentiation of cancerous lesions from benign or precancerous lesions, we identified only one study per index test. The second analysis, of studies differentiating cancerous versus benign lesions, provided three tests in which meta-analysis could be performed. The sensitivities and specificities for diagnosing cancer were: EUS-FNA: sensitivity 0.79 (95% confidence interval (CI) 0.07 to 1.00), specificity 1.00 (95% CI 0.91 to 1.00); EUS: sensitivity 0.95 (95% CI 0.84 to 0.99), specificity 0.53 (95% CI 0.31 to 0.74); PET: sensitivity 0.92 (95% CI 0.80 to 0.97), specificity 0.65 (95% CI 0.39 to 0.84). The third analysis, of studies differentiating precancerous or cancerous lesions from benign lesions, only provided one test (EUS-FNA) in which meta-analysis was performed. EUS-FNA had moderate sensitivity for diagnosing precancerous or cancerous lesions (sensitivity 0.73 (95% CI 0.01 to 1.00) and high specificity 0.94 (95% CI 0.15 to 1.00), the extremely wide confidence intervals reflecting the heterogeneity between the studies). The fourth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (dysplasia) provided three tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing invasive carcinoma were: CT: sensitivity 0.72 (95% CI 0.50 to 0.87), specificity 0.92 (95% CI 0.81 to 0.97); EUS: sensitivity 0.78 (95% CI 0.44 to 0.94), specificity 0.91 (95% CI 0.61 to 0.98); EUS-FNA: sensitivity 0.66 (95% CI 0.03 to 0.99), specificity 0.92 (95% CI 0.73 to 0.98). The fifth analysis, of studies differentiating cancerous (high-grade dysplasia or invasive carcinoma) versus precancerous (low- or intermediate-grade dysplasia) provided six tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing cancer (high-grade dysplasia or invasive carcinoma) were: CT: sensitivity 0.87 (95% CI 0.00 to 1.00), specificity 0.96 (95% CI 0.00 to 1.00); EUS: sensitivity 0.86 (95% CI 0.74 to 0.92), specificity 0.91 (95% CI 0.83 to 0.96); EUS-FNA: sensitivity 0.47 (95% CI 0.24 to 0.70), specificity 0.91 (95% CI 0.32 to 1.00); EUS-FNA carcinoembryonic antigen 200 ng/mL: sensitivity 0.58 (95% CI 0.28 to 0.83), specificity 0.51 (95% CI 0.19 to 0.81); MRI: sensitivity 0.69 (95% CI 0.44 to 0.86), specificity 0.93 (95% CI 0.43 to 1.00); PET: sensitivity 0.90 (95% CI 0.79 to 0.96), specificity 0.94 (95% CI 0.81 to 0.99). The sixth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (low-grade dysplasia) provided no tests in which meta-analysis was performed. The seventh analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) provided two tests in which meta-analysis was performed. The sensitivity and specificity for diagnosing cancer were: CT: sensitivity 0.83 (95% CI 0.68 to 0.92), specificity 0.83 (95% CI 0.64 to 0.93) and MRI: sensitivity 0.80 (95% CI 0.58 to 0.92), specificity 0.81 (95% CI 0.53 to 0.95), respectively. The eighth analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) or benign lesions provided no test in which meta-analysis was performed.There were no major alterations in the subgroup analysis of cystic pancreatic focal lesions (42 studies; 2086 participants). None of the included studies evaluated EUS elastography or sequential testing.

AUTHORS' CONCLUSIONS

We were unable to arrive at any firm conclusions because of the differences in the way that study authors classified focal pancreatic lesions into cancerous, precancerous, and benign lesions; the inclusion of few studies with wide confidence intervals for each comparison; poor methodological quality in the studies; and heterogeneity in the estimates within comparisons.

High-resolution endoscopic ultrasound imaging and the number of needle passages are significant factors predicting high yield of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid masses without an on-site cytopathologist

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the accurate diagnostic method for pancreatic masses and its accuracy is affected by various FNA methods and EUS equipment. Therefore, we aimed to elucidate the instrumental and methodologic factors for determining the diagnostic yield of EUS-FNA for pancreatic solid masses without an on-site cytopathology evaluation.We retrospectively reviewed the medical records of 260 patients (265 pancreatic solid masses) who underwent EUS-FNA. We compared historical conventional EUS groups with high-resolution imaging devices and finally analyzed various factors affecting EUS-FNA accuracy.In total, 265 pancreatic solid masses of 260 patients were included in this study. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of EUS-FNA for pancreatic solid masses without on-site cytopathology evaluation were 83.4%, 81.8%, 100.0%, 100.0%, and 34.3%, respectively. In comparison with conventional image group, high-resolution image group showed the increased accuracy, sensitivity and specificity of EUS-FNA (71.3% vs 92.7%, 68.9% vs 91.9%, and 100% vs 100%, respectively). On the multivariate analysis with various instrumental and methodologic factors, high-resolution imaging (P = 0.040, odds ratio = 3.28) and 3 or more needle passes (P = 0.039, odds ratio = 2.41) were important factors affecting diagnostic yield of pancreatic solid masses.High-resolution imaging and 3 or more passes were the most significant factors influencing diagnostic yield of EUS-FNA in patients with pancreatic solid masses without an on-site cytopathologist.

Pancreatic Cytopathology

Pancreatic cytopathology, particularly through the use of endoscopic ultrasound-guided fine-needle aspiration (FNA), has excellent specificity and sensitivity for the diagnosis of pancreatic lesions. Such diagnoses can help guide preoperative management of patients, provide prognostic information, and confirm diagnoses in patients who are not surgical candidates. Furthermore, FNA can be used to obtain cyst fluid for ancillary tests that can improve the diagnosis of cystic lesions. In this article, we describe the cytomorphological features and differential diagnoses of the most commonly encountered pancreatic lesions on FNA.

Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? (with video)

BACKGROUND AND AIMS

Tissue diagnosis, regardless of technique or endoscope used, can be challenging in patients with indeterminate biliary strictures (IDBSs). This exploratory study evaluated the utility and role of rapid onsite evaluation of touch imprint cytology (ROSE-TIC) when single-operator cholangioscopy (SOC)-guided biopsies of IDBSs are performed.

METHODS

Patients with IDBSs were evaluated by intraprocedural ROSE-TIC during SOC-guided biopsy procedures. Final diagnosis was established by long-term patient follow-up in conjunction with off-site findings or surgical histology. The main outcome measure was to evaluate the utility of ROSE-TIC by determination of its operating characteristics and comparison with off-site histologic assessment.

RESULTS

Of 31 patients with IDBSs, tissue diagnosis was indeterminate at prior ERCP-guided brush and/or biopsy in 14, prior EUS-guided FNA (EUS-FNA) in 6, and a mass could not be identified at EUS in 11. The mean number of biopsies performed was 3.3 (range 1-8), and diagnostic interpretation by ROSE-TIC was diagnostic and/or suspicious for carcinoma in 15, benign in 13, atypical-reactive in 2, and bile duct intraductal papillary mucinous neoplasm in 1. Final diagnosis by surgical histology (n = 4), death by disease (n = 10), and patient follow-up (n = 17) showed that the overall sensitivity of ROSE-TIC for diagnosing malignancy was 100%, specificity 88.9%, positive predictive value 86.7%, negative predictive value 100%, and diagnostic accuracy 93.5%.

CONCLUSIONS

Preliminary data suggest that the diagnostic outcomes of SOC-guided biopsies in IDBSs can be significantly improved by using ROSE-TIC. This technique also may benefit centers that rely mainly on fluoroscopy-guided intraductal biopsies.

Endoscopic ultrasound-guided fine needle aspiration biopsy of pancreatic lesions. An 8-year analysis of single institution material focusing on efficacy and learning progress

OBJECTIVE

To evaluate the efficacy and the learning curve of the endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) diagnostics of pancreatic lesions over 8 years (2007-2014).

MATERIAL AND METHODS

EUS-FNAB using a Linear Echoendoscope Olympus was performed in 531 patients, mostly without rapid on-site evaluation (ROSE). Smears plus cytoblock sections were used routinely. Immunocytochemistry was utilised as indicated.

RESULTS

The average, satisfactory sampling rate increased from the 61.2% in the first 3-year period to 72.9% in the last 3-year period (P = 0.008). The availability of the material for cytoblocks increased from 36.4% in the first period to 75.3% in the last period (P = 0.017). The efficacy of cytoblocks increased from 39.6% to 46.2% (P = 0.086). Comparing the first and last 3-year periods, the indication for immunocytochemistry did not rise substantially (5.2% and 8.5% respectively), but the predictive value of immunocytochemistry rose from 56.3% to 100.0% (P = 0.001). The most frequent diagnostic result was malignancy confirmation - both primary (41.2%) and metastatic (2.1%). In cases with representative samples and follow-up information, the specificity, sensitivity, positive predictive value and accuracy were high from the beginning. The negative predictive value decreased slightly in the last 3-year period.

CONCLUSION

The pancreatic EUS-FNAB without ROSE represents a suboptimal arrangement conditioned with our staff/time/location reality. Nevertheless, within the last 3 years of our activity, nearly three-quarters of patients profit from the diagnostic contribution of this procedure.

Diagnostic utility of arborizing stromal meshwork fragments in mucinous tumors

INTRODUCTION

Arborizing stromal meshwork fragments (ASMFs) have been proposed as a useful clue to differentiate mucin associated with mucinous adenocarcinoma from contaminating mucus during endobronchial ultrasound-guided transbronchial needle aspiration. Our aim was to retrospectively review cytology cases with mucinous material to determine the utility of ASMFs in diagnosing mucinous tumors.

MATERIAL AND METHODS

Diff-Quik stained smears from archival cytology cases (N = 40) were reviewed, including adenocarcinomas with mucinous features, cystic mucinous neoplasms, and control cases with mucin contamination. Specimens were procured by image-guided fine needle aspiration (FNA) (16 cases), endoscopic ultrasound-guided FNA (22 cases), pathologist-performed FNA (1 case), and fluid drainage (1 case). All cases were reviewed for ASMFs, which were defined as metachromatic, spidery extensions with frayed edges within a background of mucinous material.

RESULTS

ASMFs were identified in 4 (10% of cases, 14% of adenocarcinomas) cases of metastatic gastrointestinal mucinous adenocarcinomas in various locations (liver, lymph node, lung, and bone), but absent in mucin contamination. ASMFs in Diff-Quik stained smears were magenta-colored and corresponded to intervening stroma between dissecting mucin in the tumor. Nonarborizing desmoplastic stroma, inspissated mucus, cartilage fragments, transgressing vessels in renal cell carcinoma, and mucus-like material in pancreatic pseudocysts can morphologically mimic ASMFs.

CONCLUSION

These data show that ASMFs may be encountered in some (14%) cases of adenocarcinoma with mucinous differentiation. When present, ASMFs can be diagnostically helpful to differentiate adenocarcinoma with mucinous features from contaminating mucus, if reliably distinguished from mimics. Diagn. Cytopathol. 2016;44:805-810. © 2016 Wiley Periodicals, Inc.

Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Lesions: A Systematic Review of Technical and Procedural Variables

Endoscopic ultrasound (EUS)-guided tissue acquisition has emerged over the last decade as an invaluable diagnostic tool in approaching the different pancreatic lesions. Given the safety and minimal invasiveness of this approach combined with the high diagnostic yield, it became the standard of care when dealing with different pancreatic pathologies. However, some variables regarding this procedure remain not fully understood. These can influence the diagnostic yield of the procedure and include the presence of the on-site cytopathologist, the type and size of the needle used as well as obtaining aspiration versus core biopsy, the number of passes and the sampling technique, and the role of suction and stylet use among others. We performed a comprehensive literature search using PubMed, Google Scholar, and Embase for studies that assessed these variables. Eligible studies were analyzed using several parameters such as technique and procedure, with the aim of reviewing results from an evidence-based standpoint.

Eliminating the Residual Negative Pressure in the Endoscopic Ultrasound Aspirating Needle Enhances Cytology Yield of Pancreas Masses

BACKGROUND

Prior to withdrawing the EUS-FNA needle from the lesion, the stopcock of the suction syringe is closed to reduce contamination. Residual negative pressure (RNP) may persist in the needle despite closing the stopcock.

AIMS

To determine whether neutralizing RNP before withdrawing the needle will improve the cytology yield.

METHODS

Bench-top testing was done to confirm the presence of RNP followed by a prospective, randomized, cross-over study on patients with pancreas mass. Ten milliliters of suction was applied to the FNA needle. Before withdrawing the needle from the lesion, the stopcock was closed. Based on randomization, the first pass was done with the stopcock either attached to the needle (S+) or disconnected (S-) to allow air to enter and neutralize RNP and accordingly the second pass was crossed over to S+ or S-. On-site cytopathologist was blinded to S+/S-.

RESULTS

Bench tests confirmed the presence of RNP which was successfully neutralized by disconnecting the syringe (S-) from the needle. Sixty patients were enrolled, 120 samples analyzed. S+ samples showed significantly greater GI tract contamination compared to S- samples (16.7 vs. 6.7%, p = 0.03). Of the 53 patients confirmed to have pancreas adenocarcinoma, FNA using S- approach was positive in 49 (93%) compared to 40 using the S+ approach (76%, p = 0.02).

CONCLUSIONS

Despite closing the stopcock of the suction syringe, RNP is present in the FNA needle. Neutralizing RNP prior to withdrawing the needle from the target lesion significantly decreased GI tract contamination of the sample thereby improving the FNA cytology yield.

CLINICAL TRIALS REGISTRATION NUMBER

NCT01995474.

Cell-block procedure in endoscopic ultrasound-guided-fine-needle-aspiration of gastrointestinal solid neoplastic lesions

In the present review we have analyzed the clinical applications of endoscopic ultrasound-guided-fine-needle-aspiration (EUS-FNA) and the methodological aspects obtained by cell-block procedure (CBP) in the diagnostic approach to the gastrointestinal neoplastic pathology. CBP showed numerous advantages in comparison to the cytologic routine smears; in particular, better preservation of cell architecture, achievement of routine haematoxylin-eosin staining equivalent to histological slides and possibility to perform immunohistochemistry or molecular analyses represented the most evident reasons to choose this method. Moreover, by this approach, the differential diagnosis of solid gastrointestinal neoplasias may be more easily achieved and the background of contaminant non-neoplastic gastrointestinal avoided. Finally, biological samples collected by EUS-FNA CBP-assisted should be investigated in order to identify and quantify further potential molecular markers.

Endoscopic ultrasound-guided fine-needle aspiration cytology in pancreaticobiliary carcinomas: diagnostic efficacy of cell-block immunocytochemistry

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration cytology was demonstrated to be a useful tool for the diagnosis and staging of pancreaticobiliary neoplastic lesions. Nonetheless, the diagnostic value of this procedure may be limited by low cellularity of the specimen, contamination of intestinal cells and unfeasibility of ancillary immunocytochemical procedures. The present study was to evaluate its usefulness in the diagnosis of neoplastic lesions.

METHODS

A series of 46 pancreaticobiliary carcinomas with available cell block preparations was submitted to immunocytochemistry against cytokeratins, carcinoembryonic antigen, E-cadherin, CD10 and p53. The sensitivity, specificity, positive and negative predictive values of the cytological smear in the discrimination of malignant lesions were calculated and compared with those of cell block preparation with the immunocytochemical stains against p53 and CD10.

RESULTS

According to our findings, the use of cell block preparations together with immunostains against p53 and CD10 allowed to discriminate malignant versus benign specimens with higher sensitivity than the only cytological examination. In detail, CD10 immunostaining was of significant help for the discrimination between cytological contaminants, such as benign gastrointestinal cells, and the neoplastic elements of pancreaticobiliary well differentiated adenocarcinomas. Also, intense nuclear immunoreactivity for p53 was encountered in about 2/3 of the cases and identified pancreatic malignancy with high sensitivity.

CONCLUSIONS

We suggest that immunocytochemistry against both CD10 and p53 could be applied case by case, mainly to differentiate gastrointestinal and pancreatic benign cellular contaminants showing hyperplasia or reactive changes from differentiated pancreaticobiliary adenocarcinomas.

CD10 is useful to identify gastrointestinal contamination in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology from pancreatic ductal adenocarcinoma

OBJECTIVE

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology is an effective tool to diagnose pancreatic ductal adenocarcinoma (PDA). Standard morphological criteria are usually reliable. When contaminating gastrointestinal (GI) epithelial cells are prevalent among neoplastic cells, these can be highlighted by carcinoembryonic antigen (CEA) staining. CD10 is a cell-surface metallopeptidase normally expressed by the GI epithelial apical border, whose expression is decreased or lost in PDA. We included CD10 in a panel, together with CEA, to discriminate the GI contaminant cells from PDA cells on cell blocks.

METHODS

Eight cases of EUS-FNA of PDA, featuring both contaminating GI cells and neoplastic cells, whose corresponding cell blocks were available for immunostaining, were selected. CD10 and CEA were stained on cell blocks by standard methods.

RESULTS

CD10 strongly labelled only the GI cells, with a well-defined apical membrane signal; conversely, GI cells did not show CEA staining; benign duodenal cells were faintly labelled in only one case. Malignant cells were positive for CEA and negative for CD10, with the exception of one case with labelled neoplastic cells with weak diffuse cytoplasmic positivity. CD10 apical membrane staining was a feature only seen in benign GI cells.

CONCLUSIONS

As a loss of CD10 is a consistent feature of PDA, this marker can be useful, together with CEA, to aid the cytopathologist to identify neoplastic cells in a background rich in GI contaminant cells.

Specialized clinical cytology may improve the results of EUS (endoscopic ultrasound)-guided fine-needle aspiration (FNA) from pancreatic tumors

BACKGROUND AND STUDY AIMS

A variety of factors (needle type, needle passes, tumor location, cytological assessment, etc.) may influence the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) from pancreatic tumors. Whereas most published studies report a diagnostic accuracy of > 80 % for EUS-FNAC, the results in routine settings are often considerably lower. This retrospective study aimed to define the effect of switching microscopic assessment from a standard pathology department to a highly specialized institute of cytology.

PATIENTS AND METHODS

A total of 63 patients underwent EUS-FNAC of solid or semisolid pancreatic masses. Specimens of the first consecutive 20 cases (Phase 1) were assessed by the local department of pathology. Then in Phase 2, involving another 43 subsequent cases, a specialized cytology laboratory examined all aspirates. All EUS-FNACs were performed in the same manner, using a 22-gauge needle. After cytological evaluation, all patients either underwent surgery or were followed up for at least 6 months.

RESULTS

Of the tumors, 56 were solid and 7 semisolid; the mean size was 30 mm. Sensitivity (sens.), specificity (spec.), positive predictive value (PPV), and negative predictive value (NPV) of EUS-FNAC were 38.5 % (95 %CI [confidence interval] 13.9 - 68.4 %), 100 % (59.0 - 100 %), 100 % (47.8 - 100 %), and 46.7 % (21.3 - 73.4 %) during Phase 1 versus 91.4 % (95 %CI 76.9 - 98.2 %), 100 % (63.1 - 100 %), 100 % (89.1 - 100 %), and 72.7 % (39.0 - 94.0 %) during Phase 2.

CONCLUSION

These results emphasize the considerable impact of a dedicated cytological evaluation on the results of EUS-FNAC.

Diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology of pancreatic lesions

BACKGROUND

Endoscopic ultrasound-guided fine needle aspiration cytology (EUS-FNAC) is currently the most commonly used procedure for obtaining cytologic specimens of the pancreas. It is accurate, minimally invasive, safe and cost-effective. However, there is discrepancy between cytological and surgical diagnoses. This study was aimed at evaluating the diagnostic accuracy of EUS-FNAC of the pancreas.

METHODS

We performed a retrospective review of 191 cases of pancreatic lesions initially diagnosed by EUS-FNAC with subsequent histological diagnosis between 2010 and 2012 in the Department of Pathology, Seoul National University Hospital. Cytologic and surgical diagnoses were categorized into five groups: negative, benign, atypical, malignant, and insufficient for diagnosis. Subsequently, 167 cases with satisfactory yield in both surgical and cytology specimens were statistically analyzed to determine correlations with diagnosis.

RESULTS

In comparison to surgical diagnoses, cytologic diagnoses were true-positive in 103 cases (61.7%), true-negative in 28 cases (16.8%), false-positive in 9 cases (5.4%), and false-negative in 27 cases (16.1%). The diagnostic accuracy was 78.4%, sensitivity was 79.2%, and specificity was 75.7%. The positive predictive value was 92.0%, and negative predictive value was 50.9%.

CONCLUSIONS

EUS-FNAC has high accuracy, sensitivity, specificity and positive predictive value. Overcoming the limitations of EUS-FNAC will make it a useful and reliable diagnostic tool for accurate evaluation of pancreatic lesions.

Endoscopic ultrasound-guided pancreatic fine-needle aspiration: potential pitfalls in one institution's experience of 1212 procedures

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has emerged as the diagnostic modality of choice for mass lesions in the pancreas. The objective of the current study was to determine the accuracy and pitfalls of EUS-FNA in the diagnosis of pancreatic lesions in cases that involved follow-up surgical resection.

METHODS

Cases of EUS-FNA of pancreatic lesions performed from 2007 to mid-2012 for which subsequent surgical resection was performed were retrieved from the department's database. The accuracy of the cytologic diagnosis was assessed using the histological diagnosis as the gold standard. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. "Neoplastic," "suspicious," and "malignant" were classified as a positive cytologic diagnosis. In one calculation method, "atypical" was also included as a positive cytologic diagnosis whereas in another it was not considered to be a positive cytological result. The cases with a cytologic-histological discrepancy were reviewed to identify sources of errors.

RESULTS

A total of 1212 cases from 1104 patients (518 women and 586 men; age range, 18-94 years [average age, 63.5 years]) were identified. Cytologic diagnoses included 52 unsatisfactory, 224 benign, 129 atypical, 140 neoplasm, 35 suspicious, and 632 malignant diagnoses. Of these cases, 397 patients had histological follow-up information available. The sensitivity, specificity, positive predictive value, and negative predictive value were 83.2%, 85.9%, 95.9%, and 56.1%, respectively, with atypical cases excluded from the analysis. When atypical cases were included as a positive cytologic diagnosis, the sensitivity, specificity, positive predictive value, and negative predictive value were 86.7%, 67.9%, 90.7%, and 58.5%, respectively, and were 73.7%, 87.7%, 95.6%, and 48.0%, respectively, when atypical cases were included as a negative cytologic diagnosis. The major difficulty in EUS-FNA cytology was to differentiate pancreatic mucinous neoplasms from contaminants of gastric mucosa. Other pitfalls included differentiating mucinous neoplasm from extensive pancreatic intraepithelial neoplasia, and endocrine tumor from nesidioblastosis versus acinar cell carcinoma or intrapancreatic spleen.

CONCLUSIONS

EUS-FNA is a valuable tool for the diagnosis of pancreatic lesions, especially solid malignant tumors. Cytologic-radiological correlation is essential in differentiating pancreatic mucinous neoplasms from gastric mucosa, because the former usually are found to have characteristic features on imaging. Pathologists should be aware of the pitfalls in the cytologic diagnosis of pancreatic lesions that may significantly change the clinical management of the patients.

Diagnostic efficacy of cell block immunohistochemistry, smear cytology, and liquid-based cytology in endoscopic ultrasound-guided fine-needle aspiration of pancreatic lesions: a single-institution experience

Background

The diagnostic efficiency of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology varies widely depending on the treatment method of the specimens. The present study aimed to evaluate the diagnostic efficacy of cell block (CB) immunohistochemistry, smear cytology (SC), and liquid-based cytology (LBC) in patients with pancreatic lesions without consulting an on-site cytopathologist.

Methods

This study prospectively enrolled 72 patients with pancreatic lesions. The EUS-FNA specimens were examined by SC, LBC, and CB immunohistochemistry. The diagnostic efficacy of the 3 methods was then compared. Patients’ final diagnosis was confirmed by surgical resection specimens, diagnostic imaging, and clinical follow-up.

Results

Our results included 60 malignant and 12 benign pancreatic lesions. The diagnostic sensitivity (90%), negative predictive value (66.7%), and accuracy (91.7%) of CB immunohistochemistry were significantly higher than those of SC (70.0%, 30.0%, and 75.0%, respectively) and LBC (73.3%, 31.6%, and 77.8%, respectively) (all P<0.05). The combination of CB and SC, or CB and LBC, did not significantly increase the efficacy compared to CB immunohistochemistry alone.

Conclusion

Our findings suggest that in the absence of an on-site cytopathologist, CB immunohistochemistry on EUS-FNA specimens offers a higher diagnostic efficacy in patients with pancreatic lesions than does SC and LBC.

Endoscopic ultrasound-guided fine-needle aspiration of the pancreas: a retrospective study of 1000 cases

INTRODUCTION

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has emerged as a superior method for the diagnosis of pancreatic tumors. Very few large studies have been published. We retrospectively examined 1000 cases to determine the sensitivity and specificity of EUS-guided FNA for solid and cystic lesions.

MATERIALS AND METHODS

EUS-guided FNA was performed in 1000 patients. Air-dried aspirates were reviewed immediately to ensure adequacy, and ethanol-fixed aspirates were reviewed the following day. The rendered diagnoses were placed into various categories and compared to subsequent histologic and clinical follow-up data.

RESULTS

Of the 1000 cases, 579 were solid lesions. The FNA diagnoses of the solid lesions were benign (B) 229 (39.5%), atypia (A) 22 (3.8%), suspicious (S) 27 (4.7%), malignant (M) 260 (44.9%), tumor (T) 1 (0.2%), and nondiagnostic (ND) 40 (6.9%). The sensitivity, specificity, positive predictive value, and negative predictive value for solid lesions were 97%, 97%, 99%, and 94%, respectively. There were 421 cystic lesions. The FNAs of the cystic lesions were classified as follows: B 342 (81.2%), A 5 (1.2%), S 4 (1%), M 7 (1.7%), T 46 (10.9%), and ND 17 (4.0%). The sensitivity, specificity, positive predictive value, and negative predictive value to identify mucinous tumors and malignancy for cystic lesions were 46%, 98%, 94%, and 87%, respectively.

CONCLUSIONS

At our institution, EUS-guided FNA of solid pancreatic lesions is both sensitive and specific for the diagnosis of both primary and metastatic tumors. For cystic lesions, FNA is not as sensitive, but its specificity remains high.

A triple approach for diagnostic assessment of endoscopic ultrasound-guided fine needle aspiration in pancreatic solid masses and lymph nodes

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) has been becoming the standard tool for acquiring pancreatic lesion tissue. However, a single cytologic or histologic evaluation is not satisfactory for diagnosis. In this study, we evaluated the diagnostic yield of EUS-FNA for pancreatic solid masses and intra-abdominal lymph nodes using a triple approach.

METHODS

This study included patients undergoing evaluation for a solid pancreatic mass (n = 59) or intra-abdominal lymph nodes (n = 16) using EUS-FNA with a 22- or 25-gauge (G) needle, respectively. The specimens from each pass were analyzed by on-site cytology using Diff-Quick stain, cytology using Papanicolaou stain, and histology with immunohistochemical (IHC) staining.

RESULTS

A total of 75 patients (49 males; mean age; 63.7 years) were included. The median number of needle pass for diagnosis of malignancy was 2.0, and there was no technical failure. The diagnostic accuracies with on-site cytology, cytology using Papanicolaou staining, and histology were 70.7, 80.0, and 80.0 %, respectively. The diagnostic accuracy using a triple approach was significantly greater than cytology using Papanicolaou staining alone (94.7 vs. 80.0 %; p = 0.007). In patients with malignant lesions, cytology identified 12 of 71 (16.9 %) malignant lesions that were not diagnosed by histology using IHC, and histology identified six (8.5 %) malignant lesions that were not diagnosed by cytology.

CONCLUSION

On-site cytopathologic evaluation combined with cytologic and histologic analysis with IHC stain for one-pass specimen is considered to be able to increase the overall accuracy of EUS-FNA in pancreatic solid masses and lymph nodes.

Impact of rapid on-site evaluation on the adequacy of endoscopic-ultrasound guided fine-needle aspiration of solid pancreatic lesions: a systematic review and meta-analysis

BACKGROUND

Rapid on-site evaluation (ROSE) has the potential to improve adequacy rates for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solid pancreatic lesions, but its impact is context-dependent. No studies exist that summarize the relationship between ROSE, number of needle passes, and resulting adequacy rates.

AIMS

To analyze data from previous studies to establish if ROSE is associated with improved adequacy rates; to evaluate the relationship between ROSE, number of needle passes, and the resulting adequacy rates of EUS-FNA for solid pancreatic lesions.

METHODS

Systematic review and meta-analysis of studies reporting the adequacy rates for EUS-FNA of solid pancreatic lesions.

RESULTS

The search produced 3822 original studies, of which 70 studies met our inclusion criteria. The overall average adequacy rate was 96.2% (95% confidence interval: 95.5, 96.9). ROSE was associated with a statistically significant improvement of up to 3.5% in adequacy rates. There was heterogeneity in adequacy rates across all subgroups. No association between the assessor type and adequacy rates was found. Studies with ROSE have high per-case adequacy and a relatively high number of needle passes in contrast to non-ROSE studies. ROSE is an effect modifier of the relationship between number of needle passes and adequacy.

CONCLUSIONS

ROSE is associated with up to 3.5% improvement in adequacy rates for EUS-FNA of solid pancreatic lesions. ROSE assessor type has no impact on adequacy rates. ROSE is an effect modifier on the relationship between needle passes and per-case adequacy for EUS-FNA of solid pancreatic lesions.

Ancillary Studies, Including Immunohistochemistry and Molecular Studies, in Pancreatic Cytology

Fine-needle aspiration biopsy of the pancreas is indicated for sampling of solid and cystic masses. Preoperative cytologic diagnosis of pancreatic ductal adenocarcinoma and cystic lesions on cytology can be problematic, and ancillary studies may help confirm diagnosis. Ancillary studies in pancreatic cytology include special stains, immunohistochemistry, mutational analyses of specific genes, cyst fluid analysis of tumor markers and enzymes, and, in some instances, flow cytometry. Proteomics, microRNA sequencing, and whole-exome gene sequencing have been used to illustrate the progression of pancreatic neoplasms and identify key diagnostic markers. This article summarizes recent literature on ancillary studies in pancreatic fine-needle aspiration samples.

Malignancy risk associated with diagnostic categories defined by the Papanicolaou Society of Cytopathology pancreaticobiliary guidelines

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently the predominant method for obtaining a preoperative tissue diagnosis for pancreatic lesions suspicious for malignancy. The diagnostic sensitivity and specificity of EUS-FNA are well documented, but malignancy risk associated with the diagnostic categories proposed by the Papanicolaou Society of Cytopathology is poorly defined.

METHODS

The records of the Departments of Pathology at Duke University and the University of Utah were searched for all cases of EUS-FNA performed for the investigation of pancreatic lesions. All cases with follow-up surgical diagnosis or greater than 3 years of clinical follow-up were selected. Cytologic diagnostic categories were "nondiagnostic," "benign," "atypical (not otherwise specified)," "suspicious for malignancy," "neoplasm," and "malignant." Correlation of cytologic diagnosis with surgical and/or clinical follow-up was made and risk of malignancy calculated for each category.

RESULTS

Three hundred seventeen EUS-FNAs with adequate surgical or clinical follow-up were obtained. Risk of malignancy for nondiagnostic specimens was 21%;, benign specimens, 13%; atypical cases, 74%; suspicious for malignancy, 82%; the neoplasm category, 14%; and the malignant category, 97%

CONCLUSIONS

The cytologic categories proposed by the Papanicolaou Society of Cytopathology demonstrate an increasing risk for malignancy extending from benign to malignant. Aspirates designated benign have the lowest risk of malignancy (13%) and aspirates designated malignant the highest (97%). The proposed categorization scheme stratifies risk for malignancy giving useful information to clinicians treating patients with pancreatic lesions.

Technical Advances in Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition for Pancreatic Cancers: How Can We Get the Best Results with EUS-Guided Fine Needle Aspiration?

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.

Diagnostic ability and factors affecting accuracy of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid lesions: Japanese large single center experience

BACKGROUND

Several studies have investigated the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic lesions, but they have included only limited patient populations. This study aimed to clarify the diagnostic accuracy of EUS-FNA in a large number of pancreatic lesions, and to describe the factors that influence it.

METHODS

From March 1997 to May 2010, 944 consecutive patients who had undergone EUS-FNA for pancreatic solid lesions were evaluated retrospectively. Factors affecting EUS-FNA accuracy were then analyzed.

RESULTS

A total of 996 solid pancreatic lesions were sampled by EUS-FNA. The overall sampling adequacy and diagnostic accuracy of these lesions were 99.3 % (989/996) and 91.8 % (918/996), respectively. The sensitivity and specificity for differentiating malignant from benign lesions were 91.5 % (793/867) and 97.7 % (126/129), respectively. The diagnostic performance was significantly higher when both cytological and cell-block examinations were carried out than with only cytological examination. In multivariate analysis, final diagnosis, location of lesion, lesion size, availability of on-site cytopathological evaluation, and experience of EUS-FNA procedure were independent factors affecting the accuracy of EUS-FNA. On-site cytopathological evaluation and lesion size were found to be the most weighted factors affecting diagnostic accuracy.

CONCLUSIONS

EUS-FNA for pancreatic solid lesions yielded a high accuracy and low complication rate. Both cytological and cell-block preparations and on-site cytopathological evaluation contributed to improve the accuracy. The diagnostic ability of EUS-FNA was less for smaller lesions, and repeated procedures may be needed if malignancy is suspected.

Clinical next-generation sequencing successfully applied to fine-needle aspirations of pulmonary and pancreatic neoplasms

BACKGROUND

Next-generation sequencing was performed on pulmonary and pancreatic fine-needle aspirations (FNAs) and on paired FNAs and resected primary tumors from the same patient.

METHODS

DNA was isolated in formalin-fixed, paraffin-embedded cell blocks from 16 pulmonary FNAs, 23 pancreatic FNAs, and 5 resected pancreatic primary tumors. Next-generation sequencing was performed for 4561 exons of 287 cancer-related genes and for 47 introns of 19 genes on indexed, adaptor-ligated, hybridization-captured libraries using a proprietary sequencing system (the Illumina HiSeq 2000).

RESULTS

Genomic profiles were generated successfully from 16 of 16 (100%) pulmonary FNAs, which included 14 nonsmall cell lung cancers (NSCLCs) and 2 small cell lung cancers (SCLCs). The NSCLC group included 6 adenocarcinomas, 5 squamous cell carcinomas, and 3 NSCLCs not otherwise specified. Genomic profiles were successfully obtained from 23 of 23 (100%) pancreatic FNAs and from 5 of 5 (100%) matched pancreatic primary tumors, which included 17 ductal adenocarcinomas, 3 mucinous adenocarcinomas, 2 adenocarcinomas NOS, and 1 neuroendocrine tumor. Eighty-one genomic alterations were identified in the 16 pulmonary FNAs (average, 5.1 genomic alterations per patient); and the most common genomic alterations were TP53, RB1, SOX2, PIK3CA, and KRAS. Eighty-seven genomic alterations were identified in the 23 pancreatic tumor FNAs (average, 3.8 genomic alterations per patient); and the most common genomic alterations were KRAS, TP53, CDKN2A/B, SMAD4, and PTEN. Among the pancreatic tumors, there was 100% concordance of 20 genomic alterations that were identified in 5 patient-matched FNA and surgical primary tumor pairs.

CONCLUSIONS

The authors were able to perform next-generation sequencing reliably on FNAs of pulmonary and pancreatic tumors, and the genomic alterations discovered correlated well with those identified in matched resected pancreatic tumors.

Histology combined with cytology by endoscopic ultrasound-guided fine needle aspiration for the diagnosis of solid pancreatic mass and intra-abdominal lymphadenopathy

Background/Aims

Small core biopsy samples can occasionally be obtained with conventional endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Although most studies have focused on the cytological analysis of specimens, data regarding histological assessment is scarce. The aim of this study was to determine whether core biopsies by conventional EUS-FNA could increase the accuracy of EUS-guided sampling when combined with cytology in the absence of an on-site cytopathologist.

Methods

In the 95 consecutive patients (98 lesions) undergoing EUS-FNA of solid pancreatic masses and intra-abdominal lymphadenopathy, tissue coils from the needle were harvested for histology, and residual tissue was examined by cytology.

Results

Adequate samples were obtained by EUS-FNA cytology, histology, and combined cytology-histology in 91.8%, 65.3%, and 94.8% of patients, respectively. From the pancreas (n=67), adequate samples for histology were obtained by EUS-FNA in 68.7% of cases, compared with 58.0% from non-pancreatic cases (n=31), respectively (p>0.05). The overall sensitivity and accuracy of EUS-FNA was 78.0% and 81.6% for cytology alone, 63.4% and 69.4% for histology alone, and 84.1% and 86.7% for combined cytology-histology, respectively.

Conclusions

Combined cytology and histology analysis for diagnosing pancreatic masses and intra-abdominal lymphadenopathy may increase the diagnostic yield of conventional EUS-FNA without on-site cytology.

The presence of a cytopathologist increases the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology for pancreatic adenocarcinoma: a meta-analysis

OBJECTIVE

A meta-analysis has not been previously performed to evaluate critically the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solely pancreatic ductal adenocarcinoma and address factors that have an impact on variability of accuracy. The aim of this study was to determine whether the presence of a cytopathologist, variability of the reference standard and other sources of heterogeneity significantly impacts diagnostic accuracy.

METHODS

We conducted a comprehensive search to identify studies, in which the pooled sensitivity, specificity, likelihood ratios for a positive or negative test (LR+, LR-) and summary receiver-operating curves (SROC) could be determined for EUS-FNA of the pancreas for ductal adenocarcinoma using clinical follow-up, and/or surgical biopsy or excision as the reference standard.

RESULTS

We included 34 distinct studies (3644 patients) in which EUS-FNA for a solid pancreatic mass was evaluated. The pooled sensitivity and specificity for EUS-FNA for pancreatic ductal adenocarcinoma was 88.6% [95% confidence interval (CI): 87.2-89.9] and 99.3% (95% CI: 98.7-99.7), respectively. The LR+ and LR- were 33.46 (95% CI: 20.76-53.91) and 0.11 (95% CI: 0.08-0.16), respectively. The meta-regression model showed rapid on-site evaluation (ROSE) (P = 0.001) remained a significant determinant of EUS-FNA accuracy after correcting for study population number and reference standard.

CONCLUSION

EUS-FNA is an effective modality for diagnosing pancreatic ductal adencarcinoma in solid pancreatic lesions, with an increased diagnostic accuracy when using on-site cytopathology evaluation.

The role of cytology in the preoperative assessment and management of patients with pancreaticobiliary tract neoplasms

OBJECTIVE

Endoscopic ultrasound-guided fine-needle aspiration and bile duct brushings are utilized in the cytologic evaluation of solid and cystic pancreaticobiliary tract lesions. We sought to determine the diagnostic accuracy of cytology.

METHODS

Five hundred seventy-nine pancreatic resections with 727 corresponding cytology specimens were identified from 1997 to 2012. Histologic diagnoses included benign, carcinoma, pancreatic endocrine neoplasm (PEN), nonepithelial neoplasms, cystic neoplasms, and ampullary adenomas. Standard interpretative categories-nondiagnostic, negative, atypical, suspicious, and positive--were utilized for preoperative cytology specimens.

RESULTS

For solid masses, the sensitivity and specificity of positive fine-needle aspiration (FNA) cytology for detecting carcinoma were 74 and 100 %, respectively. FNAs performed better than brushings (sensitivity, 40 %; specificity, 98 %) in detecting carcinomas. Similar findings were seen for PENs and nonepithelial neoplasms. For cystic lesions, the sensitivity of FNA for predicting malignancy was lower (24 %) with a specificity of 97 %. Sequentially combining suspicious and atypical categories with the positive category resulted in increases in sensitivity and decreases in specificity for all cases except for cystic lesions.

CONCLUSIONS

Cytology adds to the assessment of solid masses, but its utility in cystic lesions is less clear. Consideration of a suspicious cytologic interpretation as a positive diagnosis for triaging patients to surgery is supported by our study.

Diagnostic yield of malignancy during EUS-guided FNA of solid lesions with and without a stylet: a prospective, single blind, randomized, controlled trial

BACKGROUND

Use of a stylet during EUS-guided FNA (EUS-FNA) is believed to improve the quality and diagnostic yield of specimens.

OBJECTIVE

To compare samples obtained by EUS-FNA with (S+) and without (S-) a stylet for diagnostic yield of malignancy and cytological characteristics.

DESIGN

Randomized, controlled trial.

SETTING

Tertiary referral center.

PATIENTS

Consecutive patients referred for EUS-FNA of solid lesions.

INTERVENTION

EUS-FNA; the number of passes was determined by lesion site (6 pancreas/others and 4 lymph nodes).

MAIN OUTCOME MEASUREMENTS

Diagnostic yield of malignancy and degree of cellularity, specimen adequacy, contamination, and amount of blood.

RESULTS

One hundred patients were prospectively enrolled in this randomized, controlled trial and the sites of EUS-FNA were the pancreas, 58; lymph node, 25; and other, 17. The overall diagnosis was malignancy in 56, benign in 30, suspicious/atypical in 7, and inadequate specimen in 7 lesions. There were 550 passes made (275 with a stylet and 275 without a stylet). Interim analysis demonstrated no difference in the diagnostic yield of malignancy (94 passes with a stylet [34.2%] vs 110 without a stylet [40%], P = .2) and in the proportion of inadequate specimens (57 with a stylet [20.7%] vs 64 without a stylet [23.3%], P = .2). There was no difference with regard to cellularity (P = .83), contamination (P = .31), number of cells (P = .25), and amount of blood (P = .6). Similar results were noted in a subgroup analysis based on lesion site. Applying the rules of futility, the study was terminated.

LIMITATIONS

Subjectivity in cytopathologists' assessment, endosonographer not blinded.

CONCLUSIONS

There was no difference in the diagnostic yield of malignancy or proportion of inadequate specimens between passes with and without a stylet. These results suggest that the use of a stylet does not confer any advantage during EUS-FNA.

Imaging of pancreatic adenocarcinoma: update on staging/resectability

Because of the evolution of treatment strategies staging criteria for pancreatic cancer now emphasize arterial involvement for determining unresectable disease. Preoperative therapy may improve the likelihood of margin negative resections of borderline resectable tumors. Cross-sectional imaging is crucial for correctly staging patients. Magnetic resonance (MR) imaging and computed tomography (CT) are probably comparable, with MR imaging probably offering an advantage for identifying liver metastases. Positron emission tomography/CT and endoscopic ultrasound may be helpful for problem solving. Clear and concise reporting of imaging findings is important. Several national organizations are developing templates to standardize the reporting of imaging findings.

Dynamic telecytopathology for on-site preliminary diagnosis of endoscopic ultrasound-guided fine needle aspiration of pancreatic masses

We evaluated dynamic telecytopathology for on-site-evaluation of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) samples of the pancreas. Realtime images of stained cytology smears were assessed by a cytopathologist while communicating with the on-site operator by telephone. A total of 55 consecutive cases was assessed; preliminary diagnoses of benign, atypical/suspicious and positive for malignancy were 69%, 7% and 24%. We also reviewed 55 consecutive cases of EUS-guided FNA of pancreas which had had conventional microscopic on-site evaluation prior to the introduction of telecytopathology. Preliminary diagnoses of benign, atypical/suspicious and positive for malignancy were 60%, 9% and 31%. The overall concordance between the preliminary and final diagnosis was 84% for telecytopathology and 87% for conventional microscopy. Neuroendocrine neoplasms and well-differentiated adenocarcinoma were diagnostically challenging for both telecytopathology and conventional microscopy. Telecytopathology was similar in accuracy of preliminary diagnosis to conventional microscopy during EUS-FNA of pancreas.

Z-axis video for cytology database is a useful tool for the case presentation prior to the cytology training workshop

We have built a database on the Internet managing z-axis video for cytology (Zavic), and report on a new style of case discussion supported by the Zavic database. Z-axis video for cytology is a movie file derived from the video recording of a microscopic field with changes in the focus. We used it for the case presentation of EUS-FNA of pancreatic lesions on the Internet prior to a training workshop. The attendees were asked to observe the Zavic and to make diagnoses of 20 cases before the workshop. Fourteen attendees also observed lesions under a microscope on that day, and the results were compared with those of Zavic observation. The evaluation of the Zavic database (DB) was surveyed by a questionnaire. The average number of accurate diagnoses by 46 Zavic observers was 10.8. These accuracies for those who observed both the Zavic and glass slides were 11.57 and 11.43, respectively, for the videos and slides. Compared with Zavic observation alone, the diagnoses with glass slide observation were shifted to a correct diagnosis in two cases, but were shifted to an incorrect diagnosis in two cases. Approximately 60% of Zavic observers replied in the questionnaire that the movies on Zavic DB started to play within 3-4 seconds after clicking the play button. We successfully carried out the new style of case discussion supported by the Zavic DB. It was evaluated favorably by many attendees, who were psychologically still dependent on the glass slide observation.

Cytology of the Pancreas: A Practical Review for Cytopathologists

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

Diagnosis of deep-seated lymphomas by endoscopic ultrasound-guided fine needle aspiration combined with flow cytometry

OBJECTIVE

Although endoscopic ultrasound combined with fine needle aspiration (EUS-FNA) is rapidly becoming the preferred diagnostic approach for the sampling and diagnosis of gastrointestinal and mediastinal malignancies, there are limited data as to its use in the diagnosis of lymphoproliferative disorders. Therefore, we carried out a retrospective evaluation of the performance of EUS-guided FNA combined with flow cytometry (FC) as a tool to improve overall sensitivity and specificity in the diagnosis of lymphoma.

METHODS

Of 1560 patients having EUS-guided FNA during the period of the study, a total of 56 patients were evaluated by cytology with FC after EUS-FNA. There was adequate material to perform FC analysis for all but one case.

RESULTS

EUS-FNA-FC gave a diagnosis of lymphoma in 11 cases and of reactive lymphadenopathy in 20. A specific histological type was defined by FC alone in eight cases. The remaining cases were diagnosed later by cytology and cell block sections: 13 carcinomas, nine granulomatous lymphadenopathies and one mediastinal extramedullary haematopoiesis. One case was considered only suspicious for lymphoma on cytology and FC but was not confirmed on molecular analysis and one had insufficient material for FC.

CONCLUSIONS

Our results show that a combination of EUS-FNA-FC is a feasible and highly accurate method, which may be used for the diagnosis and subtyping of deep-seated lymphoma, providing a significant improvement to cytomorphology alone both for diagnosis and treatment planning, as long as immunocytochemistry is available for non-lymphoma cases.