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

Preoperative treatment response prediction for pancreatic cancer by multiple microRNAs in plasma exosomes: Optimization using machine learning and network analysis

BACKGROUND/OBJECTIVES

MicroRNAs (miRNAs) are involved in chemosensitivity through their biological activities in various malignancies, including pancreatic cancer (PC). However, single-miRNA models offer limited predictability of treatment response. We investigated whether a multiple-miRNA prediction model optimized via machine learning could improve treatment response prediction.

METHODS

A total of 20 and 66 patients who underwent curative resection for PC after gemcitabine-based preoperative treatment were included in the discovery and validation cohorts, respectively. Patients were classified according to their response to preoperative treatment. In the discovery cohort, miRNA microarray and machine learning were used to identify candidate miRNAs (in peripheral plasma exosomes obtained before treatment) associated with treatment response. In the validation cohort, miRNA expression was analyzed using quantitative reverse transcription polymerase chain reaction to validate its ability to predict treatment response.

RESULTS

In the discovery cohort, six and three miRNAs were associated with good and poor responders, respectively. The combination of these miRNAs significantly improved predictive accuracy compared with using each single miRNA, with area under the curve (AUC) values increasing from 0.485 to 0.672 to 0.909 for good responders and from 0.475 to 0.606 to 0.788 for poor responders. In the validation cohort, improved predictive performance of the miRNA combination over single-miRNA prediction models was confirmed, with AUC values increasing from 0.461 to 0.669 to 0.777 for good responders and from 0.501 to 0.556 to 0.685 for poor responders.

CONCLUSIONS

Peripheral blood miRNA profiles using an optimized combination of miRNAs may provide a more advanced prediction model for preoperative treatment response in PC.

miR-6855-5p Enhances Radioresistance and Promotes Migration of Pancreatic Cancer by Inducing Epithelial-Mesenchymal Transition via Suppressing FOXA1: Potential of Plasma Exosomal miR-6855-5p as an Indicator of Radiosensitivity in Patients with Pancreatic Cancer

BACKGROUND

Whether radiation should be added to neoadjuvant treatment remains controversial, and liquid biopsy has not been reported to predict radioresistance in pancreatic cancer (PC). We aimed to identify microRNAs (miRNAs) governing radioresistance in PC by utilizing peripheral plasma exosome samples and to verify their usefulness as biomarkers.

METHODS

miRNA microarray analysis was conducted using pretreatment peripheral plasma exosomes from 10 patients with PC receiving neoadjuvant chemoradiotherapy (NACRT) in the discovery cohort. Patients were categorized into two groups (good and poor responders) based on treatment responses, and candidate miRNAs exhibiting differential expression between the two groups were identified. The radiosensitivity of PC cells was examined after miR-6855-5p overexpression. Next-generation sequencing (NGS) and TargetScan were used to explore the mechanisms of radioresistance. We investigated the correlation between miR-6855-5p expression levels in the pretreatment peripheral plasma exosomes of 28 patients in the validation cohort and the response to NACRT.

RESULTS

miR-6855-5p expression was higher in poor responders than in good responders. miR-6855-5p induces radioresistance in PC cells. NGS showed that epithelial-mesenchymal transition (EMT) was involved in miR-6855-5p-related radioresistance. Forkhead box protein A1 (FOXA1) was identified as a direct target of miR-6855-5p using NGS and TargetScan. Clinical examination of samples from the validation cohort revealed a tendency for patients with higher expression of miR-6855-5p in peripheral plasma exosomes to exhibit increased radioresistance (r = -0.5964).

CONCLUSIONS

miR-6855-5p regulates the radioresistance of PC by inducing EMT via suppressing FOXA1, and miR-6855-5p in peripheral plasma exosomes may be a biomarker for radioresistance of PC.

Comparison of the diagnostic yield of rapid versus non-rapid onsite evaluation in endoscopic ultrasound-guided fine-needle aspiration cytology of solid pancreatic lesions

Background

The role of rapid on-site evaluation (ROSE) for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic lesions is debatable. In this study, we aimed to compare the diagnostic yield of ROSE vs. non-ROSE in solid pancreatic lesions.

Methods

This retrospective single-center study included patients undergoing EUS-FNA of solid pancreatic lesions from 2019-2021. Patients with cystic lesions, those undergoing fine-needle core biopsy, those undergoing repeat procedures, and patients with non-diagnostic smears with less than 6-month follow up were excluded. The diagnostic yield, need for repeat procedures and number of passes required with and without ROSE were analyzed in these patients.

Results

Of the 111 patients included, 56 underwent ROSE. The majority of lesions were malignant in both groups (79.6% ROSE vs. 75% non-ROSE). The diagnostic yield was 96.4% in the ROSE group and 94.5% in the non-ROSE group. Repeat samples were needed in 1 ROSE and 2 non-ROSE patients. The median number of passes made was significantly fewer in the ROSE group (3.5, interquartile range - 3,4) compared with the non-ROSE group (4, interquartile range - 3,5) P=0.01. However, the frequency of procedure-related complications was similar in both groups.

Conclusion

The utilization of ROSE during EUS-FNA of solid pancreatic lesions does not affect the diagnostic yield or the need for repeat samples, but reduces the number of passes needed for acquiring samples.

Reporting Pancreatic FNAC using the Papanicolaou System: Still a Diagnostic Challenge

Introduction

The Papanicolaou Society of Cytopathology System for reporting Pancreaticobiliary Cytology (PSCPC) is a reliable method to classify pancreatic fine needle aspiration cytology (FNAC) smears. However, it is not without practical problems which can diminish the diagnostic accuracy of the cytological diagnosis.

Aims and Objectives

To determine the diagnostic pitfalls while reporting cytomorphology of pancreatic lesions according to PSCPC on correlating FNAC findings with histopathology.

Materials and Methods

Retrospective analysis of pancreatic FNAC smears received in the Department of Pathology of our tertiary care institute over a period of 2 years was done. The cytological diagnoses were classified according to the Papanicolaou Society of Cytopathology system of reporting pancreaticobiliary cytology and correlated with histopathology. The reasons of cyto-histological discordance were analyzed.

Results

Out of 50 cases in which both FNAC and biopsy of pancreatic lesions were done, 34 cases were positive/malignant (Category VI), eight cases were suspicious for malignancy (Category V), three cases were neoplastic (Category IV), two cases were atypical (Category III), two cases were negative for malignancy (Category II), and one case was non-diagnostic (Category I). Out of 50 cases, histopathology was non-diagnostic due to inadequate material in six cases. The cytological diagnoses were compared with histopathology in the remaining 44 cases. Categories III, IV V, and VI were considered as positive for neoplastic pathology. The sensitivity of FNAC to predict neoplastic pathology was 97.5%, while the specificity was 25%. The positive predictive value was 92.9%. Two cases reported as atypical (Category III) turned out to be adenocarcinoma on histopathology. One case reported as neuroendocrine tumor and two cases reported as adenocarcinoma on cytology displayed features of chronic pancreatitis on histology. One case reported as neoplastic mucinous cyst (Category IV) turned out to be adenocarcinoma on histology (limited concordance).

Conclusion

The cytopathologist needs to be wary of the potential pitfalls to improve the diagnostic accuracy of FNACs.

Grading pancreatic adenocarcinomas on fine needle aspiration cytology. The outstanding issues

OBJECTIVE

The three-tier grading scheme described in "The Papanicolaou Society of Cytopathology (PSC) System for reporting Pancreaticobiliary Cytopathology" (TPSCRPBC) which remained unchanged following the WHO Reporting System for Pancreaticobiliary Cytopathology (WRPBC) was evaluated on pancreatic adenocarcinomas (PACs) reported on endoscopic ultrasound-guided fine needle aspiration cytology (EUS-FNAC).

METHODS

The Papanicolaou and May Grunwald Giemsa-stained smears from 116 cases of PACs were graded using the three-tier grading scheme laid down by TPSCRPBC/WRPBC. Cases exhibiting multiple grades were assigned primary, secondary and tertiary grades. Each case was assigned a grade score, either by adding the primary and secondary grades, by adding the primary and tertiary grades when the tertiary grade was 3 or by doubling the grade when only one grade existed. Necrosis was estimated semi-quantitatively. The inter-observer reproducibility in grading was evaluated using Kappa and Kendall's tau-c. Correlations between the various grades, the stage of the tumour and the amount of necrosis were assessed using Spearman rho and Kendall's tau-b.

RESULTS

31.89% of cases showed one grade, and 68.11% showed at least two grades. 16.38% showed three grades. The two commonest grade scores were 3 and 5. The inter-observer reproducibility for grading and grade scoring was satisfactory. A positive correlation was noted between the grades and the amount of necrosis. No significant correlation was found between the grades, grade scores and the stage of the tumours.

CONCLUSIONS

The TPSCRPBC/WRPBC grading scheme can be suitably applied to PACs with good inter-observer reproducibility. Cases often show multiple grades in the same tumour.

Diagnosing and monitoring pancreatic cancer through cell-free DNA methylation: progress and prospects

Pancreatic cancer is one of the most challenging cancers due to its high mortality rates. Considering the late diagnosis and the limited survival benefit with current treatment options, it becomes imperative to optimize early detection, prognosis and prediction of treatment response. To address these challenges, significant research efforts have been undertaken in recent years to develop liquid-biopsy-based biomarkers for pancreatic cancer. In particular, an increasing number of studies point to cell-free DNA (cfDNA) methylation analysis as a promising non-invasive approach for the discovery and validation of epigenetic biomarkers with diagnostic or prognostic potential. In this review we provide an update on recent advancements in the field of cfDNA methylation analysis in pancreatic cancer. We discuss the relevance of DNA methylation in the context of pancreatic cancer, recent cfDNA methylation research, its clinical utility, and future directions for integrating cfDNA methylation analysis into routine clinical practice.

Comparison of Endoscopic Ultrasound-Guided Fine-Needle Aspiration with Fine-Needle Biopsy for Solid Gastrointestinal Lesions: A Randomized Crossover Single-Center study

Background/Aims The purpose of this study was to compare the results of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) and fine-needle biopsy (FNB) performed at the same site in a single session in the same patient.

Methods Consecutive patients with solid gastrointestinal lesions referred for EUS evaluation underwent EUS-FNA and FNB using 22G needles with three and two passes, respectively, in the same session. Patients were randomized to one group having EUS-FNA first followed by EUS-FNB, while other group had EUS-FNB first followed by EUS-FNA.

Results Total 50 patients (31 male) of mean age 56.58 ± 14.2 years and mean lesion size of 2.6 (±2) cm were included. The Kappa agreement for final diagnosis for FNA and FNB was 0.841 and 0.61, respectively. The sensitivity and specificity of FNA versus FNB were 85.19 versus 62.96% and 100 versus 100%, respectively, in comparison with final diagnosis.

Conclusion Both EUS-FNA and FNB are equally safe when compared between the two techniques simultaneously in same lesion. EUS-FNA is better than FNB in terms of sensitivity, diagnostic accuracy, and tissue yield for solid GI lesion. However, the specificity and positive predictive value were equally good for both the modalities.

Single Cell RNA Sequencing: A New Frontier in Pancreatic Ductal Adenocarcinoma

Simple Summary

Pancreatic cancer has a very low survival rate for several reasons. One of those is primarily due to the difficulty in diagnosing it at an early stage. For this reason, it is important to refine our understanding of this disease to guide the development of new diagnostic and therapeutic modalities to combat this fatal illness. Here we attempt to provide a review of current progress in utilizing single-cell RNA sequencing (scRNA-seq) techniques in the molecular profiling of pancreatic ductal adenocarcinoma.

Abstract

Pancreatic ductal adenocarcinoma is a malignancy with a high mortality rate. It exhibits significant heterogeneity in metabolic pathways which are associated with its progression. In this review, we discuss the role of single cell RNA sequencing in unraveling the metabolic and clinical features of these highly malignant tumors.

Phenotypic profiling of pancreatic ductal adenocarcinoma plasma-derived small extracellular vesicles for cancer diagnosis and cancer stage prediction: a proof-of-concept study

Circulating pancreatic ductal adenocarcinoma (PDAC) derived small extracellular vesicles (sEVs) are nano-sized membranous vesicles secreted from PDAC cells and released into surrounding body fluids, such as blood. The use of plasma-derived sEVs for cancer diagnosis is particularly appealing in biomedical research because the sEVs reflect some key features (e.g. genetic and phenotypic status) related to the organs from which they originate. For example, the surface membrane proteins and their expression level on sEVs were reported to be related to the presence and progression of PDAC. However, difficulty in sEVs isolation and lack of ultrasensitive assays for simultaneous analysis of multiple protein biomarkers on patient plasma-derived sEVs hinder their application in the clinic. In our previous study, we have demonstrated the application of magnetic beads (MBs) and surface-enhanced Raman scattering (SERS) assay for phenotypic analysis of cancer cells-derived sEVs using different cell lines. To further demonstrate the clinical application of the proposed assay, we have profiled the sEVs' phenotypes (relative expression of biomarker Glypican 1, EpCAM and CD44V6) of healthy donors and PDAC patients to enable simultaneous detection of multiple surface membrane proteins on plasma-derived sEVs. We discovered that the PDAC sEVs' phenotype signatures had high accuracy for PDAC diagnosis (100%) and showed strong correlation with cancer stages, which were further validated by the imaging techniques (e.g. computerized tomography and magnetic resonance imaging) and also the correlation of cancer stages with CA19-9 (gold standard biomarker) and the sEVs' phenotype signatures. The present proof-of-concept study thus provides an initial investigation of using the proposed SERS assay for PDAC diagnosis and early cancer stage prediction in the clinic.

The impact of preoperative EUS-FNA for distal resectable pancreatic cancer: Is it really effective enough to take risks?

BACKGROUND AND AIMS

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is frequently used for the preoperative histologic diagnosis of pancreatic cancer. However, debate continues regarding the clinical merits of preoperative EUS-FNA for the management of resectable pancreatic cancer. We aimed to evaluate the benefits and safety of preoperative EUS-FNA for resectable distal pancreatic cancer.

METHODS

The medical records of 304 consecutive patients with suspected distal pancreatic cancer who underwent EUS-FNA were retrospectively reviewed to evaluate the clinical benefits of preoperative EUS-FNA. We also reviewed the medical records of 528 patients diagnosed with distal pancreatic cancer who underwent distal pancreatectomy with or without EUS-FNA. The recurrence rates and cancer-free survival periods of patients who did or did not undergo preoperative EUS-FNA were compared.

RESULTS

The diagnostic accuracy of preoperative EUS-FNA was high (sensitivity, 87.5%; specificity, 100%; positive predictive value 100%; accuracy, 90.7%; negative predictive value, 73.8%). Among patients, 26.7% (79/304) avoided surgery based on the preoperative EUS-FNA findings. Of the 528 patients who underwent distal pancreatectomy, 193 patients received EUS-FNA and 335 did not. During follow-up (median 21.7 months), the recurrence rate was similar in the two groups (EUS-FNA, 72.7%; non-EUS-FNA, 75%; P = 0.58). The median cancer-free survival was also similar (P = 0.58); however, gastric wall recurrence was only encountered in the patients with EUS-FNA (n = 2).

CONCLUSION

Preoperative EUS-FNA is not associated with increased risks of cancer-specific or overall survival. However, clinicians must consider the potential risks of needle tract seeding, and care should be taken when selecting patients.

Predicting Factors for Pancreatic Malignancy with Computed Tomography and Endoscopic Ultrasonography in Chronic Pancreatitis

Diagnosing pancreatic malignancy is challenging, especially in patients with chronic pancreatitis (CP). Endoscopic ultrasonography (EUS) is a promising diagnostic procedure for discriminating between malignancy and CP. We aimed to investigate the predictive factors and reliability of computed tomography (CT) and EUS for differentiating pancreatic mass lesions and the diagnostic accuracy of EUS-FNA or FNB in patients with CP. Forty patients with CP, receiving CT and EUS-FNA or FNB for pancreatic mass lesion evaluation, were enrolled in the study. Patients’ data, CT and EUS characteristics, image-based diagnosis, cytopathology, and final diagnosis were recorded. EUS was superior to CT in terms of diagnostic accuracy (92.5% vs. 82.5%, p = 0.02). Both CT and EUS showed significant predictive factors (all p < 0.05) with the tumor image hypoattenuation pattern or vessel invasion on CT and pancreatic duct dilatation, or distal pancreatic atrophy on EUS. EUS imaging is a reliable modality for evaluating pancreatic lesions, even with a CP background. The EUS image has a higher diagnostic accuracy than CT. Predicting factors, including hypoechoic pattern, pancreatic duct dilatation, and distal pancreas atrophy, may help to differentiate benign or malignant in patients with CP.

Role of Pathologist in the Era of Image-Guided and EUS-Guided Aspirations: A 10-Year Study at a Single Tertiary Care Oncology Institute in North India

BACKGROUND

With improved and readily accessible imaging techniques, the shift in fine-needle aspiration cytology (FNAC) from palpation-guided FNA (PGFNA) to image-guided FNA (IGFNA) and endoscopic ultrasound-guided FNA (EUS-FNA) became evident in last few decades. The present study evaluates the impact of IGFNA and EUS-FNA on the practice of cytopathology at our 300-bedded oncology institute.

STUDY DESIGN

A 10-year audit of three aspiration modalities PGFNA, IGFNA, and EUS-FNA was done. The number of aspirates, inadequacy rates, new patient registration numbers, and tissue biopsy numbers were compared.

RESULTS

A total of 29,610 FNAC were evaluated against a total 141,333 new patient registrations over a period of 10 years. The new cancer patient registration over last 10 years showed a 56% increase, with a comparable increase of 60% in diagnostic biopsies; whereas, the number of FNAC increased by only 6%. This reduction in the number of aspirates was mainly due to fall in the number of PGFNA to 18% of all procedures in the year of 2019 from a high of 44% in 2011. Further, PGFNA showed a reduction by 50% over 3 years. The inadequacy rates of PGFNA increased to 9.1% (in 2019) from 1.6% (in 2012). The IGFNA constituted 46%-60% of procedures, with inadequacy varying from 8.5% to 12.1% over years. The EUS-FNAC gradually increased from 3% to 22% from 2013, and the inadequacy rates were variable overtime showing parallelism with the use of rapid on-site adequacy evaluation (ROSE) by the endoscopist. Inadequacy rates ranged from 7.1% (2013) to 2.6% (2016), 7.7% (2017), and 5.4% (2019).

CONCLUSION

The utility of ROSE and diminishing role of pathologist is highlighted in our study. Judicious ROSE improves diagnostic accuracy, decreases the rate of missed diagnosis and the repetition of procedures. The study sheds light on the ever-increasing lacuna in the training of pathologists for blind as well as in image-guided FNAC. Further, it enumerates the factors leading to the underutilization of ROSE, its undisputed advantages, operator variations in procedure, smear preparation, and screening.

Magnetic Resonance Imaging Radiomics-Based Nomogram From Primary Tumor for Pretreatment Prediction of Peripancreatic Lymph Node Metastasis in Pancreatic Ductal Adenocarcinoma: A Multicenter Study

BACKGROUND

Determining the absence or presence of peripancreatic lymph nodal metastasis (PLNM) is important to the pathologic staging, prognostication, and guidance of treatment in pancreatic ductal adenocarcinoma (PDAC) patients. Computed tomography and MRI had a poor sensitivity and diagnostic accuracy in the assessment of PLNM.

PURPOSES

To develop and validate a 3 T MRI primary tumor radiomics-based nomogram from multicenter datasets for pretreatment prediction of the PLNM in PDAC patients.

STUDY TYPE

Retrospective.

SUBJECTS

A total of 251 patients (156 men and 95 women; mean age, 60.85 ± 8.23 years) with histologically confirmed pancreatic ductal adenocarcinoma from three hospitals.

FIELD STRENGTH AND SEQUENCES

A 3.0 T and fat-suppressed T1-weighted imaging.

ASSESSMENT

Quantitative imaging features were extracted from fat-suppressed T1-weighted (FS T1WI) images at the arterial phase.

STATISTICAL TESTS

Normally distributed data were compared by using t-tests, while the Mann-Whitney U test was used to evaluate non-normally distributed data. The diagnostic performances of the preoperative and postoperative nomograms were assessed in the external validation cohort with the area under receiver operating characteristics curve (AUC), calibration curve, and decision curve analysis (DCA). AUCs were compared with the De Long test. A p value below 0.05 was considered to be statistically significant.

RESULTS

The AUCs of magnetic resonance imaging (MRI) Rad-score were 0.868 (95% confidence level [CI]: 0.613-0.852) and 0.772 (95% CI: 0.659-0.879) in the training and internal validation cohort, respectively. The preoperative and postoperative nomograms could accurately predict PLNM in the training cohort (AUC = 0.909 and 0.851) and were validated in both the internal and external cohorts (AUC = 0.835 and 0.805, 0.808 and 0.733, respectively). DCA indicated that the two novel nomograms are of similar clinical usefulness.

DATA CONCLUSION

Pre-/postoperative nomograms and the constructed radiomics signature from primary tumor based on FS T1WI of arterial phase could serve as a potential tool to predict PLNM in patients with PDAC. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 2.

Cytologic Categorization with Risk Stratification of Endoscopic Ultrasound-Guided Fine Needle Aspiration from Pancreatic Lesions Based on Guidelines of the Papanicolaou Society of Cytopathology: 12-Year Tertiary Care Experience

BACKGROUND AND AIMS: Pancreatic malignancy is an important cause of cancer mortality worldwide. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) plays a crucial role in the pre-operative diagnosis of pancreatic lesions. In this study, we have analyzed the cytological spectrum of pancreatic lesions in the Indian population over 12 years, categorized them according to the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology (PSCPC), and assessed the risk of malignancy (ROM) for each of the categories. METHODS: A computerized data search from January 2008 to December 2019 revealed 581 pancreatic EUS-FNA samples, among which surgical follow-up was available for 73 cases. All cytological specimens were reviewed and prospectively classified into one of the six diagnostic categories proposed by the PSCPC. Subsequently, a cytohistological correlation was performed and the ROM was calculated for each category. RESULTS: The cytologic diagnoses included 50 nondiagnostic (category I), 175 negative for malignancy (category II), 19 atypical (category III), 27 neoplastic:benign (category IVA), 30 neoplastic:other (category IVB), 26 suspicious (category V), and 254 malignant (category VI) cases. ROM for non-diagnostic aspirates, nonneoplastic benign specimens, atypical cases, neoplastic:benign, neoplastic:other, suspicious for malignancy, and the malignant category was 16.7%, 7.1%, 33.3%, 0.0%, 20.0%, 100%, and 78.6%, respectively. CONCLUSION: We document an increased risk of malignancy from category I to category VI of the PSCPC. The malignancy risk for category VI (malignant) was statistically significant in our study but was lower in comparison to the values reported by other authors. Nonetheless, such an approach would establish transparent communication between the pathologist and the clinician, as well as aid the clinician in decision making, particularly in intermediate categories.

Endoscopic Ultrasound-Guided Fine Needle Aspiration Cytology of Pancreatic Adenocarcinomas Revisited. A Detailed Cytological Analysis

Background

Early detection of pancreatic adenocarcinomas is essential for improving survival. In this regard, endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) has established itself as the method of choice for its ability to target lesions smaller than those which could be targeted by the traditional imaging methods like transabdominal ultrasound. Identifying these tumors correctly on FNA may be challenging because pancreatic adenocarcinomas may show a wide range of morphological features and the presence of contaminants from the gastrointestinal tract may show up as potential pitfalls. This study presents detailed cytomorphological analyses of 59 cases reported as pancreatic adenocarcinomas on smears and cell blocks. The clinical and histopathology follow-up data wherever available have also been presented.

Materials and Methods

EUS-FNAC smears and cell blocks from cases reported as pancreatic adenocarcinomas were retrospectively evaluated with individual assessments of a range of features related to cellularity, cellular arrangement, cytoplasmic qualities, and nuclear features. Aspirates from peripancreatic lymph nodes, histopathology sections, and clinical records were reviewed wherever available.

Results

Nonneoplastic cells like pancreatic ductal cells and acinar cells, duodenal, and gastric epithelia were detected along with neoplastic cells showing a wide range of variations in different cytomorphological characters. Often, a mixture of features was noted in the same case. Cell block preparations served as useful adjuncts since they made it possible to render unequivocal diagnoses of malignancies in cases where smears were hypocellular.

Conclusion

The study creates a useful knowledge base of cytomorphological features of pancreatic adenocarcinomas.

Reshaping preoperative treatment of pancreatic cancer in the era of precision medicine

This review summarises the recent evidence on preoperative therapeutic strategies in pancreatic cancer and discusses the rationale for an imminent need for a personalised therapeutic approach in non-metastatic disease. The molecular diversity of pancreatic cancer and its influence on prognosis and treatment response, combined with the failure of 'all-comer' treatments to significantly impact on patient outcomes, requires a paradigm shift towards a genomic-driven approach. This is particularly important in the preoperative, potentially curable setting, where a personalised treatment allocation has the substantial potential to reduce pancreatic cancer mortality.

Molecular Subtyping and Precision Medicine for Pancreatic Cancer

Substantial progress in recent years has dramatically increased our knowledge of the molecular basis of cancer, revealing new potential therapeutic targets and paving the way for effective personalised medicine for the treatment of many tumour types. However, pancreatic cancer has been lagging behind in this success and continues to be one of the most lethal solid malignancies. Its molecular heterogeneity and the unselected design of the majority of clinical trials to date can in part explain the reason for our failure to make a significant change in the survival outcomes for patients with pancreatic cancer. A changing paradigm in drug development is required to validate the new molecular taxonomy and to rapidly translate preclinical discovery into clinical trials. Here, we review the molecular subtyping of pancreatic cancer, the challenges in identifying effective treatment regimens according to defined low-prevalence molecular subgroups and we illustrate a new model of translational therapeutic development that was established in the U.K. (Precision-Panc) as a potentially effective solution to improve outcomes for patients with pancreatic cancer.

The applicability of Papanicolaou Society of Cytopathology system on reporting endoscopic ultrasound-guided fine needle aspiration cytology specimens of pancreatic lesions in situations with limited availability of ancillary tests. Experience at a single laboratory

INTRODUCTION

The Papanicolaou Society of Cytopathology (PSC) system of reporting pancreatobiliary cytology is a standardised reporting nomenclature that uses a six-tiered scheme of diagnostic categories utilising routine microscopy and ancillary tests such as biochemical and molecular analysis of cyst fluids and immunochemistry. The objective of this study was to determine the applicability of the PSC system on endoscopic ultrasound-guided fine needle aspiration cytology samples reported at the cytopathology laboratory, Mubarak Al Kabeer Hospital, in Kuwait with special emphasis on situations with limited availability of ancillary tests.

METHODS

In total, 132 cases of endoscopic ultrasound-guided fine needle aspiration cytology samples from pancreatic lesions were categorised according to PSC system guidelines after examining the glass slides and reviewing the clinical, imaging and ancillary test findings. These review diagnoses were compared with the diagnoses rendered during initial reporting. Correlation with histopathology reports was done wherever available.

RESULTS

In 23 (17.42%) of 132 cases, re-categorisation was necessary between initial and reviewed diagnoses. In 16 cases, re-categorisations were because of non-analogous categories between initial and reviewed diagnosis. In the remaining seven, they were due to identification of newer cytomorphological and imaging findings or because of issues arising from unavailability of sufficient material for ancillary investigations.

CONCLUSION

All cases could be categorised using the PSC system with a moderate number of re-categorisations between initial and reviewed diagnoses. In certain circumstances, limited availability of ancillary tests, resulted in non-diagnostic categories whereas in other such circumstances, diagnostic categories could be assigned with certain conceptual modifications to the PSC guidelines.

Circulating Cell-Free DNA-Based Liquid Biopsy Markers for the Non-Invasive Prognosis and Monitoring of Metastatic Pancreatic Cancer

Liquid biopsy may assist in the management of cancer patients, which can be particularly applicable in pancreatic ductal adenocarcinoma (PDAC). In this study, we investigated the utility of circulating cell-free DNA (cfDNA)-based markers as prognostic tools in metastatic PDAC. Plasma was obtained from 61 metastatic PDAC patients, and cfDNA levels and fragmentation were determined. BEAMing technique was used for quantitative determination of RAS mutation allele fraction (MAF) in cfDNA. We found that the prognosis was more accurately predicted by RAS mutation detection in plasma than in tissue. RAS mutation status in plasma was a strong independent prognostic factor for both overall survival (OS) and progression-free survival (PFS). Moreover, RAS MAF in cfDNA was also an independent risk factor for poor OS, and was strongly associated with primary tumours in the body/tail of the pancreas and liver metastases. Higher cfDNA levels and fragmentation were also associated with poorer OS and shorter PFS, body/tail tumors, and hepatic metastases, whereas cfDNA fragmentation positively correlated with RAS MAF. Remarkably, the combination of CA19-9 with MAF, cfDNA levels and fragmentation improved the prognostic stratification of patients. Furthermore, dynamics of RAS MAF better correlated with patients’ outcome than standard CA19-9 marker. In conclusion, our study supports the use of cfDNA-based liquid biopsy markers as clinical tools for the non-invasive prognosis and monitoring of metastatic PDAC patients.

Evaluation of Pancreatic Lesions With Endoscopic Ultrasound and Fine Needle Aspiration

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

Comparison between Conventional Smear and Liquid-Based Preparation in Endoscopic Ultrasonography-Fine Needle Aspiration Cytology of Pancreatic Lesions

The present study aimed to compare the diagnostic accuracy between conventional smear (CS) and liquid-based preparation (LBP) in endoscopic ultrasonography-fine needle aspiration cytology (EUS-FNAC) of pancreatic lesions. Using 31 eligible studies, the diagnostic accuracy of cytologic examination in CS and LBP was evaluated through a conventional meta-analysis and diagnostic test accuracy review. Overall concordance rates were 82.8% (95% confidence interval [CI], 79.8–85.5%) and 94.0% (95% CI, 84.4–97.8%) in CS and LBP, respectively. CS with rapid on-site evaluation (ROSE) showed a higher concordance rate than CS without ROSE. In CS, the pooled sensitivity and specificity were 89.8% (95% CI, 85.2–93.1%) and 95.0% (95% CI, 90.0–97.6%), respectively. The diagnostic odds ratio (OR) and area under curve (AUC) of the summary receiver operating characteristic (SROC) curve were 90.32 (95% CI, 43.85–147.11) and 0.945, respectively. In LBP, the pooled sensitivity and specificity were 80.9% (95% CI, 69.7–88.7%) and 99.9% (95% CI, 1.5–100.0%), respectively. The diagnostic OR and AUC of the SROC curve were 57.21 (95% CI, 23.61–138.64) and 0.939, respectively. Higher concordance rates were found in CS with ROSE and LBP in EUS-FNAC of pancreatic lesions. Regardless of the cytologic preparation method, EUS-FNAC is a useful and accurate diagnostic tool for pancreatic lesions.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

This was a retrospective study.

Diagnostic value of various liquid biopsy methods for pancreatic cancer: A systematic review and meta-analysis

BACKGROUND

Liquid biopsy is a novel method for cancer diagnosis, which has been applied in lung and breast cancers, demonstrating high diagnostic value. However, clinical value of it in pancreatic cancer (PC) remains to be verified. The aim of this meta-analysis was to evaluate overall diagnostic value of various liquid biopsy methods (circulating tumor DNA, circulating tumor cells and exosomes) in detecting PC.

METHODS

We comprehensively searched relevant studies in PubMed, Medline, Embase, and Web of Science without time limitation according to PRISMA. Data necessary for reconstructing a 2 × 2 table was calculated from the original articles. The methodological quality of included studies was evaluated by QUADAS-2. Statistical analysis including was performed by the software Meta-Disc version 1.4, and STATA 14.2.

RESULTS

A total of 19 studies including 1872 individuals were included in this meta-analysis. In which, 7 were studies about ctDNA, 7 were on CTCs and 6 were about exosomes (Sefrioui D, studied diagnostic accuracy of both ctDNA and CTCs, with no common patients in these 2 groups). The pooled sensitivity estimates for ctDNA, CTCs and exosomes in detecting PC with their 95% confidential intervals (95% CI) were 0.64 (95%CI 0.58-0.70), 0.74 (95%CI 0.68-0.79) and 0.93 (95%CI 0.90-0.95), respectively. The pooled specificity estimates were 0.92(95%CI 0.88-0.95), 0.83 (95%CI 0.78-0.88) and 0.92 (95%CI 0.88-0.95), respectively. The area under curve (AUC) of the sROC for ctDNA, CTCs and exosomes in detecting PC were 0.9478, 0.8166, and 0.9819, respectively. The overall sensitivity, specificity and AUC of the sROC curve for overall liquid biopsy in detecting PC were 0.80 (95%CI 0.77-0.82), 0.89 (95%CI 0.87-0.91) and 0.9478, respectively.

CONCLUSION

This meta-analysis confirmed that liquid biopsy had high diagnostic value in detecting PC. In ctDNA, CTCs and exosomes these 3 subgroups, exosomes showed highest sensitivity and specificity.

Endoscopic ultrasound guided fine-needle aspiration vs core needle biopsy for solid pancreatic lesions: Comparison of diagnostic accuracy and procedural efficiency

BACKGROUND

Endoscopic ultrasound (EUS) guided core needle biopsies (CNB) are increasingly being performed to diagnose solid pancreatic lesions. However, studies have been conflicting in terms of CNB improving diagnostic accuracy and procedural efficiency vs fine-needle aspiration (FNA), which this study aims to elucidate.

METHODS

Data were prospectively collected on consecutive patients with solid pancreatic or peripancreatic lesions at a single tertiary care center from November 2015 to November 2016 that underwent either FNA or CNB. Patient demographics, characteristics of lesions, diagnostic accuracy, final and follow-up pathology, use of rapid on-site evaluation (ROSE), complications, and procedure variables were obtained.

RESULTS

A total of 75 FNA and 48 CNB were performed; of these, 13 patients had both. Mean passes were lower with CNB compared to FNA (2.4 vs 2.9, P = .02). Use of ROSE was higher for FNA (97.3% vs 68.1%, P = .001). Mean procedure time was shorter with CNB (34.1 minutes vs 51.2 minutes, P = .02) and diagnostic accuracy was similar (89.2% vs 89.4%, P = .98). There was no difference in diagnostic accuracy when ROSE was performed for CNB vs not performed (93.5% vs 85.7%, P = .58). Additionally, diagnostic accuracy of combined FNA and CNB procedures was 92.3%, which was comparable to FNA (P = .73) or CNB (P = .52) alone.

CONCLUSION

FNA and CNB had comparable safety and diagnostic accuracy. Use of CNB resulted in less number of passes and shorter procedure time as compared to FNA. Moreover, diagnostic accuracy for CNB with or without ROSE was similar.

Liquid Biopsy as Surrogate for Tissue for Molecular Profiling in Pancreatic Cancer: A Meta-Analysis Towards Precision Medicine

Liquid biopsy (LB) is a non-invasive approach representing a promising tool for new precision medicine strategies for cancer treatment. However, a comprehensive analysis of its reliability for pancreatic cancer (PC) is lacking. To this aim, we performed the first meta-analysis on this topic. We calculated the pooled sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratio, and diagnostic odds ratio (DOR). A summary receiver operating characteristic curve (SROC) and area under curve (AUC) were used to evaluate the overall accuracy. We finally assessed the concordance rate of all mutations detected by multi-genes panels. Fourteen eligible studies involving 369 patients were included. The overall pooled sensitivity and specificity were 0.70 and 0.86, respectively. The LR+ was 3.85, the LR- was 0.34 and DOR was 15.84. The SROC curve with an AUC of 0.88 indicated a relatively high accuracy of LB for molecular characterization of PC. The concordance rate of all mutations detected by multi-genes panels was 31.9%. LB can serve as surrogate for tissue in the molecular profiling of PC, because of its relatively high sensitivity, specificity and accuracy. It represents a unique opportunity to be further explored towards its introduction in clinical practice and for developing new precision medicine approaches against PC.

Risk of malignancy in the categories of the Papanicolaou Society of Cytopathology system for reporting pancreaticobiliary cytology

BACKGROUND

Management of pancreatic lesions depends on the risk of malignancy, which is primarily determined from the cytologic and radiologic evaluation findings. The Papanicolaou Society of Cytopathology (PSC) published a classification system for reporting pancreaticobiliary cytology. However, the "neoplastic: other" category can be further stratified by high-grade atypia (HGA). Studies on the risk of malignancy using the PSC system have been limited.

MATERIALS AND METHODS

All patients who had undergone endoscopic ultrasound-guided fine-needle aspiration (FNA) for a pancreatic lesion at Massachusetts General Hospital from January 2016 to December 2016 were prospectively classified. The clinical, radiographic, and endoscopic findings, cytologic and histologic diagnoses, and follow-up data from 334 FNA biopsies from 322 patients were reviewed. The neoplastic: other category was subclassified as low-grade atypia or HGA. The absolute risk of malignancy was determined by the histologic outcome or follow-up of ≥6 months.

RESULTS

The absolute risk of malignancy was 7.7% for the nondiagnostic category; 1.0% for negative; 28.0% for atypical; 0.0% for neoplastic: benign; 30.3% for neoplastic: other; 90.0% for neoplastic: other with HGA; 100% for suspicious; and 100% for positive. When the neoplastic: other with HGA, suspicious, and positive cytologic diagnoses were considered positive, the sensitivity, specificity, positive predictive value, and negative predictive value for pancreatic FNA biopsy was 92.2%, 98.8%, 98.3%, and 94.3%, respectively.

CONCLUSIONS

Categories of the PSC system each carry an implied absolute risk of malignancy, increasing from the negative to positive categories. The presence of HGA identifies lesions at the greatest risk of malignancy in the neoplastic: other category, and its inclusion with suspicious and positive as positive diagnoses optimizes the diagnostic performance of identifying high-risk lesions that warrant surgical excision.

Preoperative EUS-guided FNA: effects on peritoneal recurrence and survival in patients with pancreatic cancer

BACKGROUND AND AIMS

EUS-guided FNA (EUS-FNA) is an accurate and relatively safe tissue confirmation method for pancreatic cancer. However, there is concern that this procedure may spread tumor cells along the needle track or within the peritoneum. We aimed to estimate the effect of preoperative EUS-FNA on the risk of peritoneal recurrence and long-term outcomes in resected pancreatic cancer.

METHODS

We retrospectively reviewed records of patients diagnosed with pancreatic cancer who had undergone curative resection between 2009 and 2013 to investigate the overall survival, cancer-free survival, and peritoneal recurrence. Peritoneal recurrence was diagnosed based on image findings or cytology-confirmed ascites.

RESULTS

Of 411 patients, 90 underwent preoperative EUS-FNA (EUS-FNA group), whereas 321 did not (non-EUS-FNA group). The median length of follow-up was 16.2 months (range, 2-46). Peritoneal recurrence occurred in 131 patients: 30% (27/90) in the EUS-FNA group versus 32% (104/321) in the non-EUS-FNA group (P = .66). Cancer-free survival or overall survival was not significantly different between the 2 groups: median overall survival of 25.3 months in the EUS-FNA group versus 23.7 months in the non-EUS-FNA group (P = .36) and median cancer-free survival of 12.7 months in the EUS-FNA group versus 11.6 months in the non-EUS-FNA group (P = .38).

CONCLUSIONS

Preoperative EUS-FNA for pancreatic cancer was not associated with an increased rate of peritoneal recurrence or mortality. Therefore, EUS-FNA is an accurate and safe method to obtain suspicious pancreatic mass tissue.

It is necessary to exam bottom and top slide smears of EUS-FNA for pancreatic cancer

BACKGROUND

Despite many reports on the diagnostic yield of cytology from endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), inter-slide differences are unknown. This prospective study aimed to compare diagnostic yield and cellular characteristics of bottom slides (BS) and top slides (TS) from EUS-FNA cytology performed without an on-site cytopathologist.

METHODS

In patients with suspected pancreatic cancer on previous imaging explorations, a single endoscopist performed EUS-FNA and obtained 2 sets of cytology slide (8 BS and 8 TS), 1 cellblock slide, and 1 biopsy slide. Both slide sets were randomly assigned. A cytopathologist with more than 10 years of expertise in pancreatic cytopathology blindly inspected and compared two slide sets.

RESULTS

In total, 73 specimens [42 head (57.5%), 16 body (21.9%), and 15 tail (20.5%)] were acquired for final analysis. Seventy-one cases were finally diagnosed with pancreatic cancer. The sensitivity and specificity of BS were 80.3% and 100.0%; and of TS 78.9% and 100.0%, respectively. In analyzing inter-slide difference, 66 cases (90.4%) showed consistent results between BS and TS. However, seven (9.6%) were positive only in one slide sets (4 BS and 3 TS). The proportions of specimens more than moderate and high cellularity were 75.3% and 60.3% in both slide sets (P> 0.99), and the proportion of artifact-free sets were 50.7%, and 52.1% for the BS and TS, respectively (P= 0.869).

CONCLUSIONS

Although BS and TS exhibited highly consistent diagnostic yields in cytologic smears from EUS-FNA, the proportion of inter-slide discordance is clinically considerable. Both slide sets need to be examined if there is no on-site cytopathologist.

Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at centre and endoscopist level: 1 Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90%); 2 antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95%); 3 bile duct cannulation rate (key performance measure, at least 90%); 4 tissue sampling during EUS (key performance measure, at least 85%); 5 appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95%); 6 bile duct stone extraction (key performance measure, at least 90%); 7 post-ERCP pancreatitis (key performance measure, less than 10%); and 8 adequate documentation of EUS landmarks (minor performance measure, at least 90%). This present list of quality performance measures for ERCP and EUS recommended by the ESGE should not be considered to be exhaustive; it might be extended in future to address further clinical and scientific issues.

Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2: Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3: Bile duct cannulation rate (key performance measure, at least 90 %); 4: Tissue sampling during EUS (key performance measure, at least 85 %); 5: Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6: Bile duct stone extraction (key performance measure, at least 90 %); 7: Post-ERCP pancreatitis (key performance measure, less than 10 %). 8: Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.

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.

Percutaneous ultrasound-guided core needle biopsy of solid pancreatic masses: Results in 250 patients

BACKGROUND

To determine the diagnostic accuracy and complications of percutaneous sonographic (US)-guided core needle-needle biopsy in the diagnosis of solid pancreatic masses.

METHODS

Cases of US-guided percutaneous core needle biopsy of solid pancreatic masses performed in our department between July 2009 and June 2015 were analyzed retrospectively. The demographic data, lesions' size and location, pathology results, accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and complications of the biopsies were determined.

RESULTS

A total of 250 patients (150 males, 100 females; age range, 16-88 years; mean age, 64.3 ± 12.1 years) were included in the study. The overall diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of all 250 biopsies were 94.8%, 94.3%, 97.2%, 99.5%, and 75%, respectively, and changed to 98.4%, 99%, 94.7%, 99%, and 94.7%, respectively, after the biopsy was repeated in 12 patients. Four (1.6%) major complications, including a pseudoaneurysm of the gastroduodenal artery, and three cases of acute pancreatitis, and one (0.4%) minor complication (a vaso-vagal syncope), were observed. There was no biopsy-related death.

CONCLUSIONS

US-guided percutaneous core needle biopsy is a safe and highly effective method with acceptable complication rates in the diagnosis of solid pancreatic masses. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:470-473, 2016.

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.