Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB): past, present, and future

Pancreatic Metastases from Renal Cell Carcinoma Showing Atypical Imaging Findings

A 59-year-old man receiving sunitinib chemotherapy for postoperative recurrence of renal cell carcinoma (RCC) metastases was found to have multiple metastases on contrast-enhanced computed tomography (CECT). CECT revealed a typical hyperdense enhanced nodule in the arterial phase of the stomach and head and tail of the pancreas. However, in the uncinate process of the pancreas, CECT revealed an atypical image and a hypodense enhanced nodule in each phase. Both lesions were finally pathologically diagnosed as clear cell carcinoma. Treatment-modified pancreatic metastases from RCC may present with nonspecific images; therefore, caution is required when deciding on treatment strategies.

Clinicopathological study of surgically treated non-neoplastic diseases of the pancreas with special reference to autoimmune pancreatitis

PURPOSE

After the popularization of serum immunoglobulin G4 (IgG4) measurement and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in our institute, surgical resection for non-neoplastic diseases of the pancreas became less common. Although the incidence of such false-positive cases was clarified in the 10-year period after the introduction of these measures (2009-2018), these data were not compared with the 30 years before 2009 (1979-2008). This study was performed to determine the percentage of autoimmune pancreatitis (AIP) that was included during the latter period and how the numbers of false-positive cases differed between the two periods.

METHODS

From 1979 to 2008, 51 patients had clinical suspicion of pancreatic carcinoma (false-positive disease). Among these 51 patients, 32 non-alcoholic patients who had tumor-forming chronic pancreatitis (TFCP) were clinically, histologically, and immunohistochemically compared with 11 patients who had TFCP during the latter 10-year period.

RESULTS

Retrospective IgG4 immunostaining of false-positive TFCP revealed 14 (35.0%) cases of AIP in the former 30 years versus 5 (45.5%) in the latter 10 years. There were 40 (5.9%) cases of TFCP among 675 patients in the former 30 years and 11 (0.9%) among 1289 patients in the latter 10 years.

CONCLUSIONS

When the TFCP ratio of pancreatic resections and the AIP ratio of false-positive TFCPs were compared between the two periods, the TFCP ratio was 5.9% versus 0.9% and the AIP ratio was 35.0% versus 45.5%, respectively. It can thus be speculated that IgG4 measurement and EUS-FNA are absolutely imperative for the diagnosis of TFCP.

Endoscopic ultrasound-guided tissue acquisition for splenic lesions: A systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND AND AIMS

At present, it is difficult and risky to diagnose splenic lesions by conventional needle biopsy using computed tomography (CT) or ultrasound (US). Endoscopic ultrasound (EUS)-guided tissue acquisition is increasingly being used as a new technique to determine the tissue diagnosis of splenic lesions. Therefore, our goal was to determine the efficacy and safety of EUS-guided tissue acquisition for splenic lesions.

METHODS

We performed a systematic review and meta-analysis to evaluate the pooled sensitivity and specificity of EUS-guided tissue acquisition for the diagnosis of splenic lesions using Metadisc. The Quality Assessment of Diagnostic Accuracy Studies Questionnaire, a quality assessment tool, was used to scrutinize the quality of the studies.

RESULTS

Six eligible studies between January 2000 and June 2022 were identified, and a total number of 62 patients (aged range from 19 to 84) were enrolled. One patient was excluded because of insufficient specimens. The pooled sensitivity and specificity of included studies were 0.85 [95% confidence interval (CI), 0.73-0.93] and 0.77 (95% CI, 0.46-0.95), respectively. The pooled positive likelihood ratio (LR) was 2.38 (95% CI, 1.24-4.57), the pooled negative LR was 0.31 (95% CI, 0.17-0.55), the pooled diagnostic odds ratio (DOR) was 8.67 (95% CI, 2.80-26.82), the area under the summary receiver operating characteristic (SROC) curve was 0.8100 (Standard Error 0.0813).

CONCLUSION

EUS-guided tissue acquisition is a safe technique with high sensitivity in the diagnosis of splenic lesions. However, because of the small sample sizes, more studies with more cases are needed to further validate these results.

A Bibliometric Analysis of Publications on Endoscopic Ultrasound

Background

Over the past 40 years, endoscopic ultrasound (EUS) has become a safe and effective tool for both diagnostic and therapeutic applications. A growing number of articles have been published annually. We aimed to explore global scientific outputs and hotspots of EUS published by different countries, organizations, and authors.

Methods

The global literature regarding EUS during the 1900–2020 period was identified from the Web of Science (WOS) Core database. “Bibliometrix” and software VOSviewer were applied to perform bibliometric analysis.

Results

The annual growth rate of publications from 1980 to 2020 was around 16% and the number of EUS-related articles had experienced a sudden increase in the last decade. Bhutani MS was the most productive author over the past years, with 94 publications. Hawes RH had the highest number of citations, with 6,034 citations. The United States and institutions from United States dominated the EUS research. Among the journals, GASTROINTESTINAL ENDOSCOPY published the highest number of articles, followed by ENDOSCOPY. The majority of top 10 frequently cited references were cited more than 200 times. Carcinoma, diagnosis, fine-needle-aspiration, cytology, and pancreatitis were the important keywords in co-occurrence analysis of keywords. Recent studies focused more on tissue acquisition, size of the needle, lumen-apposing metal stent, and fine-needle- biopsy.

Conclusion

Research on EUS has significantly increased in the last decade globally and it will continue to increase. Active collaboration among different authors and countries was observed in the EUS field. Tissue acquisition, size of the needle, apposing metal stent, and fine-needle-biopsy might be the latest research frontiers and should receive more attention.

Advances in gastrointestinal surgical endoscopy

Surgeons have a role in observing, detect abnormalities, disease, and other deficiencies in function which could be treated. Diagnosing and treating back days were challenging for many reasons. However, technology's innovation enhances surgeons' ability to treat their patients. The term endoscopy refers to the Greek prefix endo- ("within") and the verb skopein ("to view or observe"). Endoscopy is practical both in the diagnosis and treatment of various pathologies. Technological advances, especially in endoscopy, gradually progress and discover many possibilities which allow rapid advancement. Endoscopy development aims to assess human orifice that has not been inspected, probed, and examined over the centuries. Endoscopy over these decades is improving, which led to new problem solving using advanced technological approaches. Thus, a surgeon can solve any issues from examination, diagnosis, and treatment using progressive endoscopy evolution. This review delivers a brief history of advances in surgical endoscopy and describes current endoscopy development.

Diagnostic Process Using Endoscopy for Biliary Strictures: A Narrative Review

The diagnostic process for biliary strictures remains challenging in some cases. A broad differential diagnosis exists for indeterminate biliary strictures, including benign or malignant lesions. The diagnosis of indeterminate biliary strictures requires a combination of physical examination, laboratory testing, imaging modalities, and endoscopic procedures. Despite the progress of less invasive imaging modalities such as transabdominal ultrasonography, computed tomography, and magnetic resonance imaging, endoscopy plays an essential role in the accurate diagnosis, including the histological diagnosis. Imaging findings and brush cytology and/or forceps biopsy under fluoroscopic guidance with endoscopic retrograde cholangiopancreatography (ERCP) are widely used as the gold standard for the diagnosis of biliary strictures. However, ERCP cannot provide an intraluminal view of the biliary lesion, and its outcomes are not satisfactory. Recently, peroral cholangioscopy, confocal laser endomicroscopy, endoscopic ultrasound (EUS), and EUS-guided fine-needle aspiration have been reported as useful for indeterminate biliary strictures. Appropriate endoscopic modalities need to be selected according to the patient's condition, the lesion, and the expertise of the endoscopist. The aim of this review article is to discuss the diagnostic process for indeterminate biliary strictures using endoscopy.

Endoscopic Ultrasound-guided Fine Needle Aspiration for the Diagnosis of Duodenal Stenosis Due to Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) initially presents with hematuria and hydronephrosis. We report a case of UTUC presenting with initial findings of duodenal stenosis before the appearance of hydronephrosis. A 59-year-old man presented with upper abdominal symptoms on his initial visit. Esophagogastroduodenoscopy (EGD) revealed circumferential stenosis at the descending part of the duodenum. However, the underlying cause of duodenal stenosis was unknown as repeated histopathological examinations of endoscopic biopsy specimens showed no specific findings. We then performed endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of the thickened duodenal wall, and successfully diagnosed duodenal metastasis of UTUC. EUS-FNA is an effective diagnostic method in cases in which the cause of duodenal stenosis is unknown.

Peritoneal dissemination of pancreatic cancer caused by endoscopic ultrasound-guided fine needle aspiration: A case report and literature review

BACKGROUND

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a biopsy technique widely used to diagnose pancreatic tumors because of its high sensitivity and specificity. Although needle-tract seeding caused by EUS-FNA has been recently reported, dissemination of pancreatic cancer cells is generally considered to be a rare complication that does not affect patient prognosis. However, the frequency of dissemination and needle-tract seeding appears to have been underestimated. We present a case of peritoneal dissemination of pancreatic cancer due to preoperative EUS-FNA.

CASE SUMMARY

An 81-year-old man was referred to the Department of Surgery of our hospital in Japan owing to the detection of a pancreatic mass on computed tomography during medical screening. Trans-gastric EUS-FNA revealed that the mass was an adenocarcinoma; hence laparoscopic distal pancreatectomy with lympha-denectomy was performed. No intraoperative peritoneal dissemination and liver metastasis were visually detected, and pelvic lavage cytology was negative for carcinoma cells. The postoperative surgical specimen was negative for carcinoma cells at the dissected margin and the cut end margin; however, pathological findings revealed adenocarcinoma cells on the peritoneal surface proximal to the needle puncture site, and the cells were suspected to be disseminated via EUS- FNA. Hence, the patient received adjuvant therapy with S-1 (tegafur, gimeracil, and oteracil potassium); however, computed tomography performed 5 mo after surgery revealed liver metastasis and cancerous peritonitis. The patient received palliative therapy and died 8 mo after the operation.

CONCLUSION

The indications of EUS-FNA should be carefully considered to avoid iatrogenic dissemination, especially for cancers in the pancreatic body or tail.

Detecting Early Pancreatic Cancer: Current Problems and Future Prospects

The number of patients with pancreatic cancer (PC) is currently increasing in both Korea and Japan. The 5-year survival rate of patients with PC 13.0%; however, resection with minimal invasion (tumor size: ≤10 mm) increases the 5-year survival rate to 80%. For this reason, early detection is essential, but most patients with early-stage PC are asymptomatic. Early detection of PC has been reported to require screening of high-risk individuals (HRIs), such as those with a family history of PC, inherited cancer syndromes, intraductal papillary mucinous neoplasm, or chronic pancreatitis. Studies on screening of these HRIs have confirmed a significantly better prognosis among patients with PC who were screened than for patients with PC who were not screened. However, to date in Japan, most patients with early-stage PC diagnosed in routine clinics were not diagnosed during annual health checks or by surveillance; rather, PC was detected in these patients by incidental findings during examinations for other diseases. We need to increase the precision of the PC screening and diagnostic processes by introducing new technologies, and we need to pay greater attention to incidental clinical findings.

Evaluation of Local Recurrence of Pancreatic Cancer by KRAS Mutation Analysis Using Washes from Endoscopic Ultrasound-Guided Fine-Needle Aspiration

BACKGROUND AND AIMS

The sensitivity of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosing the recurrence of pancreatic cancer is usually low because of difficulties in obtaining adequate samples for pathological examinations. We evaluated the efficacy of highly sensitive KRAS mutation analysis using EUS-FNA washes to detect cancer recurrence.

METHODS

Nineteen consecutive patients with suspected pancreatic cancer recurrence after surgical resection were enrolled. All underwent EUS-FNA, and samples were obtained for pathological examination. After the first session, the inside of the FNA needle was washed with saline for DNA extraction. KRAS mutations were examined using digital droplet PCR (dPCR).

RESULTS

The median needle puncture number used to obtain adequate pathological samples was two (range 1-6). In ten patients pathologically diagnosed with malignant pancreatic cancer, nine patients tested positive for a KRAS mutation. All patients who were not diagnosed with a malignant pancreatic cancer tested negative for a KRAS mutation. About half of surgically resected primary cancers (9/19) showed double KRAS mutations (G12V and G12D); however, all but one wash sample showed a single KRAS mutation, G12D. After including one patient who showed a malignant recurrence during follow-up, the sensitivities of a pathological diagnosis and KRAS analysis to detect recurrence were 90.9% and 81.8%, respectively.

CONCLUSIONS

KRAS mutation analysis of needle wash samples using dPCR is a new methodology for the diagnosis of the local recurrence of pancreatic cancer. The diagnostic ability of dPCR with a one-time needle wash sample was comparable to a pathological diagnosis with multiple samplings.

Comparison of liquid-based cytology with conventional smear cytology for EUS-guided FNA of solid pancreatic masses: a prospective randomized noninferiority study

BACKGROUND AND AIMS

There are limited data on the efficacy of liquid-based cytology (LBC) for EUS-guided FNA specimens. We aimed to evaluate the diagnostic efficacy of LBC for solid pancreatic neoplasms compared with conventional smears (CSs).

METHODS

In this randomized, crossover, noninferiority trial, we randomly assigned (1:1) patients with suspected pancreatic cancer to the LBC group or the CS group. Aspirates from the first needle pass were processed by one method, aspirates from the second pass by the other method, and specimens from the last pass were processed as core biopsy samples. The primary endpoint was the diagnostic efficacy of each method, with the final diagnosis as the gold standard. A noninferiority margin of -10% was assumed.

RESULTS

Of 170 randomized patients, 165 were classified as malignant and 5 as benign. Unsatisfactory samples were less frequent in the LBC group (1.78%) compared with the CS group (5.33%). The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of LBC versus CS were 88.0% versus 83.8% (P = .276), 87.7% versus 83.2% (P = .256), 100% versus 100% (P = .999), 100% versus 100% (P = .999), and 16.7% versus 16.1% (P = .953), respectively. A bloody background was significantly more frequent in the CS group (CS, 85.2%; LBC, 1.8%; P < .001), whereas the nuclear features were similar for both groups.

CONCLUSIONS

The diagnostic usefulness of LBC was comparable with that of CS. The cytomorphologic features did not differ significantly between the 2 methods, and the reduced bloody backgrounds allowed better visibility in the LBC method. (Clinical trial registration number: NCT03606148.).

Safety and efficacy of endoscopic ultrasound-guided fine needle aspiration for pancreatic masses: A prospective multicenter study

OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions has high diagnostic yield. However, few prospective multicenter studies have been performed. We performed a prospective cohort study to evaluate the efficacy and safety of EUS-FNA for diagnosis of solid pancreatic lesions.

METHODS

This prospective cohort study involved five hospitals in Japan. The primary outcome was sensitivity of EUS-FNA for diagnosing malignant lesions. We also evaluated parameters of diagnostic sufficiency and the safety of EUS-FNA.

RESULTS

In total, 246 patients were enrolled. The absolute values of the parameters evaluated showed no significant differences; however, the percentage changes in the white blood cell counts and C-reactive protein levels after examination were significantly higher, and the percentage change in hemoglobin concentrations was significantly lower. The minor and major complication rates at the time of puncture, 24 h, 7 days and 28 days were 4.1%, 2.8%, 1.6%, and 0.0%, respectively. The true complication rate was 1.2%. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 97.2%, 88.0%, 96.2%, 100%, and 81.4%, respectively.

CONCLUSIONS

EUS-FNA for solid pancreatic lesions has high diagnostic yield and is safe, consistent with previously studies.

Isolated pancreatic metastasis from malignant melanoma: a case report and literature review

Isolated pancreatic metastasis from malignant melanoma is rare. Pancreatic metastasis is difficult to diagnose in patients with unknown primary malignant melanoma. Endoscopic ultrasound-guided fine-needle aspiration plays an important role in confirming the diagnosis. A 67-year-old woman was referred to our institution because of a mass in her pancreas. Computed tomography and magnetic resonance imaging revealed a 35-mm mass localized on the pancreatic tail, with low attenuation, surrounded by a high-attenuation rim. Endoscopic ultrasonography revealed a hypoechoic mass with central anechoic areas. Endoscopic ultrasound-guided fine-needle aspiration of the mass was performed, and the pathological diagnosis was malignant melanoma. Intense fluorodeoxyglucose uptake was observed in the pancreatic tail on positron emission tomography-computed tomography. No other malignant melanoma was found. Distal pancreatectomy was performed. Six months postoperatively, positron emission tomography-computed tomography revealed high uptake in the left nasal cavity, and biopsy revealed the mass to be a malignant melanoma, indicating that the primary site of the malignant melanoma was the left nasal cavity and that the pancreatic mass and peritoneal lesion were metastases. The patient had survived > 2 years after the distal pancreatectomy. Pancreatic resection of isolated pancreatic metastasis can possibly prolong survival; however, metastatic melanoma usually has poor prognosis.

Surveillance of Individuals with a Family History of Pancreatic Cancer and Inherited Cancer Syndromes: A Strategy for Detecting Early Pancreatic Cancers

A family history of pancreatic cancer (PC) is a risk factor of PC, and risk levels increase as affected families grow in number and/or develop PC at younger ages. Familial pancreatic cancer (FPC) is defined as a client having at least two PC cases in a first degree relatives. In the narrow sense, FPC does not include some inherited cancer syndromes that are known to increase the risks of PC, such as Peutz-Jeghers syndrome (PJS), hereditary pancreatitis (HP), hereditary breast ovarian cancer syndrome (HBOC), and so on. FPC accounts for 5%-10% of total PC diagnoses and is marked by several features in genetic, epidemiological, and clinicopathological findings that are similar to or distinct from conventional PC. Recent advances in genetic medicine have led to an increased ability to identify germline variants of cancer-associated genes. To date, high-risk individuals (HRIs) in many developed countries, including FPC kindreds and inherited cancer syndromes, are screened clinically to detect and treat early-stage PC. This article highlights the concept of FPC and the most recent data on its detection.

Push vs pull method for endoscopic ultrasound-guided fine needle aspiration of pancreatic head lesions: Propensity score matching analysis

AIM

To evaluate the efficacy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic head cancer when pushing (push method) or pulling the echoendoscope (pull method).

METHODS

Overall, 566 pancreatic cancer patients had their first EUS-FNA between February 2001 and December 2017. Among them, 201 who underwent EUS-FNA for pancreatic head lesions were included in this study. EUS-FNA was performed by the push method in 85 patients, the pull method in 101 patients and both the push and pull methods in 15 patients. After propensity score matching (age, sex, tumor diameter, and FNA needle), 85 patients each were stratified into the push and pull groups. Patient characteristics and EUS-FNA-related factors were compared between the two groups.

RESULTS

Patient characteristics were not significantly different between the two groups. The distance to lesion was significantly longer in the push group than in the pull group (13.9 ± 4.9 mm vs 7.0 ± 4.9 mm, P < 0.01). The push method was a significant factor influencing the distance to lesion (≥ median 10 mm) (P < 0.01). Additionally, tumor diameter ≥ 25 mm (OR = 1.91, 95%CI: 1.02-3.58, P = 0.043) and the push method (OR = 1.91, 95%CI: 1.03-3.55, P = 0.04) were significant factors contributing to the histological diagnosis of malignancy.

CONCLUSION

The pull method shortened the distance between the endoscope and the lesion and facilitated EUS-FNA of pancreatic head cancer. The push method contributed to the histological diagnosis of pancreatic head cancer using EUS-FNA specimens.

Pancreatic intraepithelial neoplasia in heterotopic pancreas: incidentally diagnosed on endoscopic mucosal resection of a duodenal polyp

Heterotopic pancreas is the presence of pancreatic tissue outside its normal location. It can develop similar pathological conditions that develop in the normal pancreas, including adenocarcinoma and its precursor lesions. Due to the rarity of the condition, the diagnosis can be challenging, and treatment is not well established. ​We present a 47-year-old female patient referred for endoscopic resection of a 2 cm polyp in the second part of her duodenum. Complete endoscopic mucosal resection (EMR) was performed, with pathology revealing low-grade pancreatic intraepithelial neoplasia (PanIN) in heterotopic pancreatic tissue. To the best of our knowledge, this is the first case of heterotopic pancreas with low-grade PanIN in the duodenum to be incidentally diagnosed and treated with EMR.

KRAS mutation analysis of washing fluid from endoscopic ultrasound-guided fine needle aspiration improves cytologic diagnosis of pancreatic ductal adenocarcinoma

EUS-FNA becomes one of the most important diagnostic modalities for PDACs. However, acquired tissue specimens were sometimes insufficient to make a definite cytological diagnosis. On the other hand, KRAS mutation is the most frequently acquired genetic alteration found more than 90% of PDACs. To investigate the way to improve diagnostic accuracy for PDACs using both cytological examination and KRAS mutation analysis would be a great help. Therefore, the aims of this study were to evaluate usefulness of conventional cytological examination combined with KRAS mutation analysis with modified PCR technology to improve the sensitivity and the accuracy. We enrolled 43 patients with solid pancreatic masses and 86 EUS-FNA specimens were obtained. During the EUS-FNA, the needle catheter was flushed with 2 cc of saline and the washed fluid was collected for KRAS mutation analysis for the first 2 passes; PNAClamp™ KRAS Mutation Detection Kit. There were 46 specimens from the 23 PDACs and 40 specimens from the 20 other pancreatic diseases. The sensitivity, specificity and accuracy were as follows; conventional cytopathologic examination: 63%, 100% and 80%; combination of cytopathologic examination and K-ras mutation analysis: 87%, 100% and 93%. Furthermore, KRAS mutation was detected 11 out of 17 PDAC samples whose cytopathology results were inconclusive. KRAS mutation analysis with PNAClamp™ technique using washing fluid from EUS-FNA along with cytological examination may not only improve the diagnostic accuracy of PDACs, but also establish the platform using genetic analysis which would be helpful as diagnostic modality for PDACs.

Endoscopic Ultrasonography-Guided Fine Needle Aspiration Can Be Used to Rule Out Malignancy in Autoimmune Pancreatitis Patients

OBJECTIVES

The aim of this study was to review the suitability of endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) for ruling out malignancy in autoimmune pancreatitis patients.

METHODS

We retrospectively reviewed 40 autoimmune pancreatitis patients (type 1:37 patients; type 2: two patients; possible autoimmune pancreatitis: one patient) who received EUS-FNA. Among the 40 autoimmune pancreatitis patients, 34 were not histopathologically diagnosed with autoimmune pancreatitis by EUS-FNA, and they were followed up for more than 6 months in our hospital. Moreover, 14 pancreatic cancer patients who were not diagnosed by EUS-FNA were selected as a control group. These 14 patients constituted 3.9% of the 360 pancreatic cancer patients who received EUS-FNA. We evaluated the prognoses of the 34 autoimmune pancreatitis patients and the clinical differences between these 34 autoimmune pancreatitis patients and the 14 pancreatic cancer patients.

RESULTS

All 34 autoimmune pancreatitis patients showed reduced pancreatic swelling. The main pancreatic duct dilation ( > 3 mm), the diameter of the main pancreatic duct, the capsule-like rim sign, and serum CA19-9 levels were significantly different between the autoimmune pancreatitis and pancreatic cancer patients (2.9% versus 69.2%, P < .01; 1.7 ± 1.6 mm versus 6.8 ± 5.0 mm, P < .01; 79.4% versus 0%, P < .01; 41.4 ± 79.0 U/mL versus 2079.1 ± 275.3 U/mL, P = .02).

CONCLUSIONS

Almost all pancreatic cancers can be diagnosed by EUS-FNA. Furthermore, other clinical characteristics of pancreatic cancer undiagnosed by EUS-FNA were different from autoimmune pancreatitis undiagnosed by EUS-FNA. Endoscopic ultrasonography-guided FNA can be used to rule out malignancy in autoimmune pancreatitis patients.

Prospective evaluation of digital single-operator cholangioscope for diagnostic and therapeutic procedures (with videos)

BACKGROUND AND AIM

Recently, the digital single-operator cholangioscope (SPY-DS) has become available. This system may allow diagnosis by direct visualization and allow performance of various therapeutic procedures. The aim of the present study was to prospectively evaluate the clinical utility of DSOCS for diagnostic and therapeutic procedures for biliary disease.

METHODS

Technical success was defined as successful visualization of target lesions in the biliary tract and carrying out forceps biopsy as a diagnostic procedure, and successfully carrying out treatment such as guidewire insertion for the area of interest, electrohydraulic lithotripsy (EHL), or migrated stent removal. Also, the present study aimed at investigating diagnostic yield of the cholangioscopic findings and biopsy specimens.

RESULTS

A total of 55 consecutive patients were prospectively enrolled in this study; a diagnostic procedure was done in 33 patients, and a therapeutic procedure was done in 22 patients. Overall accuracy of visual findings was 93%, with a sensitivity of 83%, a specificity of 89%, positive predictive value (PPV) of 83%, and negative predictive value (NPV) of 100%. However, the overall accuracy of forceps biopsy was 89%, with a sensitivity, specificity, and PPV of 100%, and NPV of 90%. Overall technical success rate of therapeutic procedures such as selective guidewire insertion, EHL or migrated stent removal was 91% (20/22). Finally, adverse events were seen in two cases in the diagnostic group, but were not seen in the therapeutic group.

CONCLUSION

Although additional cases and a randomized, controlled study with another cholangioscope are needed, diagnostic and therapeutic procedures using SPY-DS appear to be feasible and safe.

Benign esophageal schwannoma: a brief overview and our experience with this rare tumor

Background

Benign esophageal tumors are uncommon, comprising approximately 2% of esophageal tumors. Esophageal schwannomas constitute an even rarer entity, with few cases reported in the literature.

Case presentation

We present a 66-year-old male who was referred for dysphagia. A computed tomography scan showed a well-demarcated, enhancing, and homogenous esophageal tumor measuring 50 mm. The tumor was hypermetabolic on positron emission tomography, and an endoscopic ultrasound-guided fine needle aspiration demonstrated the presence of benign spindle cells. We performed an uncomplicated, simple, tumor enucleation through a cervical approach. Histology revealed spindle-shaped cells in a fasciculated, disarrayed pattern. Immunohistochemistry demonstrated positive staining for S-100 protein and negative staining for KIT, CD34, desmin, and α-smooth muscle actin. These findings were consistent with a benign esophageal schwannoma.

Conclusions

We report our experience with esophageal schwannoma, a rare but benign diagnosis of the esophagus.

Two cases of resectable pancreatic cancer diagnosed by open surgical biopsy after endoscopic ultrasound fine-needle aspiration failed to yield diagnosis: case reports

Background

Tumor biopsy for histological diagnosis is required preoperatively and before initiating chemotherapy or radiation therapy for patients with pancreatic cancer (Cancer of the Pancreas: Clinical Practice Guidelines, European Society for Medical Oncology). Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is widely applied to obtain tissue samples for histological examination. However, in some cases, EUS-FNA cannot be performed safely or tissue samples are insufficient to establish a definitive diagnosis. We present two cases of pancreatic cancer diagnosed by open surgical biopsy after EUS-FNA failed to yield a diagnosis.

Case presentation

Case 1 was a 50-year-old man. Computed tomography showed a hypovascular lesion in the uncus of the pancreas. Although EUS-FNA was conducted twice, we could not collect enough quantity of tissue samples to establish a definitive diagnosis. Open surgical biopsy revealed adenocarcinoma, and the patient underwent preoperative chemoradiation therapy followed by curative operation. Case 2 was a 68-year-old man. Computed tomography showed a hypovascular tumor in the uncus of the pancreas. EUS revealed a 14-mm hypoechoic lesion, but we could not perform EUS-FNA because the superior mesenteric vein was located in the puncture line. Open surgical biopsy revealed adenocarcinoma, and the patient underwent preoperative chemoradiation therapy followed by pancreaticoduodenectomy.

Conclusions

EUS-FNA is the first choice in the diagnostic modalities of pancreatic neoplasm, but open surgical biopsy is an effective diagnostic method if EUS-FNA is unsuccessful.

Meta-Analysis for Cyto-Pathological Outcomes in Endoscopic Ultrasonography-Guided Fine-Needle Aspiration With and Without the Stylet

BACKGROUND

Theoretically, use of the stylet during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) will prevent the tip of the needle from being blocked and the sample from being contaminated, improving the quality and diagnostic yield of specimens.

AIM

This meta-analysis aimed to evaluate any benefit from the use of a stylet during EUS-FNA.

METHODS

MEDLINE, EMBASE, WEB of SCIENCE, and the Cochrane Central Register of Controlled Trials were searched for articles published through October 2015. A fixed-effects model was used to calculate the pooled effects when there is no heterogeneity and a random-effects model was used in situations with significant heterogeneity.

RESULTS

Five prospective randomized controlled studies and two retrospective studies of a total of 5491 specimens (2504 specimens in the S+ group and 2987 specimens in the S- group) were included in this study. The pooled analysis demonstrated no significant differences in the adequate sample rate between the S+ group (2135/2504, 85.26 %) and S- group (2609/2987, 87.35 %) [odds ratio 0.94 (95 % confidence interval 0.79-1.11), p = 0.45]. Furthermore, the rate of cellularity > 50 %, the contamination rate, and the blood contamination rate were not significantly superior in the S+ group when compared with the S- group.

CONCLUSIONS

Whether the use of a stylet improves the proportion of adequate specimens or quality of the specimen is questionable. Our results suggest that the use of a stylet dose not guarantee any advantage during EUS-guided tissue sampling.

Human Equilibrative Nucleoside Transporter 1 Expression in Endoscopic Ultrasonography-Guided Fine-Needle Aspiration Biopsy Samples Is a Strong Predictor of Clinical Response and Survival in the Patients With Pancreatic Ductal Adenocarcinoma Undergoing Gemcitabine-Based Chemoradiotherapy

OBJECTIVES

This study aimed to clarify whether pretreatment human equilibrative nucleoside transporter (hENT1) expressions in endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNAB) specimens obtained from resectable, borderline resectable, and locally advanced unresectable pancreatic ductal adenocarcinoma (PDAC) are concordant with those in the resected specimen after gemcitabine-based chemoradiotherapy (Gem-CRT) and to validate the utility of hENT1 expression using EUS-FNAB samples as a prognostic marker.

METHODS

We evaluated the relationship between hENT1 expressions assessed by immunohistochemical staining and clinical outcomes in 51 of 76 patients with PDAC who were diagnosed by EUS-FNAB and received preoperative Gem-CRT.

RESULTS

The concordance rate of hENT1 expressions was 89.2% (K = 0.681). Median survival time (month) in the 51 whole patients and 37 patients with resection was significantly longer in hENT1 positive than in hENT1 negative: 25.0 and 30.0 versus 9.0 and 9.0, respectively. A multivariate analysis confirmed that hENT1 expression was an independent prognostic factor in both whole patients and those with resection. Regardless of T3 and T4, hENT1-positive patients with resection had significantly better prognosis than hENT1-negative patients, whose prognosis was similar to those without resection.

CONCLUSIONS

The assessment of hENT1 expression using EUS-FNAB samples before Gem-CRT provides important information on patients with PDAC who can benefit from curative-intent resection.

EUS-guided FNA for biliary disease as first-line modality to obtain histological evidence

BACKGROUND

Few reports have described endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for biliary lesions. In addition, adverse events were not completely examined in previous reports, due to the inclusion of cases in which biliary stents had already been placed. The present study aimed to investigate the diagnostic yield and adverse events of EUS-FNA for biliary lesions as the first-line diagnostic modality for consecutive prospectively registered patients.

METHODS

Inclusion criteria were as follows: (1) patients with suspected cholangiocarcinoma (CCA) based on computed tomography or other imaging modalities; (2) patients who had not previously undergone endoscopic retrograde cholangiopancreatography or EUS-FNA; (3) absence of surgically altered anatomy, such as Roux-en-Y anastomosis or duodenal obstruction caused by tumor invasion, through which an endoscope could not pass; and (4) provision of written informed consent to all procedures associated with the study.

RESULTS

A total of 47 consecutive patients with suspected CCA were registered to this study. Sensitivity and accuracy were 89% and 87%, respectively. On multivariate analysis, puncture site was the only factor associated with reduced diagnostic yield (hazard ration, 6.879; 95% confidence interval, 1.172-40.374; P = 0.033). Remarkably, no adverse events such as bleeding or bile leakage were associated with EUS-FNA in any of the 47 patients.

CONCLUSIONS

Our results suggest that EUS-FNA can be safely performed for biliary disease without biliary stenting. Furthermore, this procedure may warrant use as the first-line diagnostic method, although our results need to be validated in future prospective studies.

Maximum Standard Uptake Value as a Clinical Biomarker for Detecting Loss of SMAD4 Expression and Early Systemic Tumor Recurrence in Resected Left-Sided Pancreatic Cancer

This study investigated the oncologic impact of loss of SMAD4 expression in resected left-sided pancreatic cancer and its correlation with tumor metabolism.From 2005 to 2011, the medical records of patients who underwent radical distal pancreatectomy for resectable pancreatic cancer were retrospectively reviewed. Formalin-fixed, paraffin embedded tissue from 32 patients was investigated. Clinicopathological characteristics, immunostaining of SMAD4, and positron emission tomography-based parameters were analyzed in relation to oncologic outcomes.Thirteen patients were women and 19 were men, with a mean age of 63 ± 9.4 years. Mean resected tumor size was 3.3 ± 1.5 cm. Ten patients (31.3%) showed loss of SMAD4 expression. No significant clinicopathological differences were noted according to SMAD4 expression (P > 0.05); however, patients with loss of SMAD4 showed significantly poorer disease-free survival (mean 57.4 months vs mean 17.6 months, P = 0.006). As a cut-off value, a SUVmax of 4.5 was found to be predictive of loss of SMAD4 with a sensitivity of 75% and a specificity of 84.6%. In logistic regression analysis, SUVmax>4.5 was found to infer a 16-fold higher risk for loss of SMAD4 in resected left-sided pancreatic cancers (Exp[β] = 16.5, P = 0.012, 95% confidence interval: 1.832-148.606).Loss of SMAD4 is associated with poor oncologic outcomes. SUVmax can predict loss of SMAD4 in resected left-sided pancreatic cancer. SUVmax may be a clinical biomarker for detecting loss of SMAD4 expression and predicting early systemic metastasis.

Endoscopic ultrasound-guided fine needle core biopsy for the diagnosis of pancreatic malignant lesions: a systematic review and Meta-Analysis

Endoscopic ultrasound-guided fine needle core biopsy (EUS-FNB) has been used as an effective method of diagnosing pancreatic malignant lesions. It has the advantage of providing well preserved tissue for histologic grading and subsequent molecular biological analysis. In order to estimate the diagnostic accuracy of EUS-FNB for pancreatic malignant lesions, studies assessing EUS-FNB to diagnose solid pancreatic masses were selected via Medline. Sixteen articles published between 2005 and 2015, covering 828 patients, met the inclusion criteria. The summary estimates for EUS-FNB differentiating malignant from benign solid pancreatic masses were: sensitivity 0.84 (95% confidence interval (CI), 0.82–0.87); specificity 0.98 (95% CI, 0.93–1.00); positive likelihood ratio 8.0 (95% CI 4.5–14.4); negative likelihood ratio 0.17 (95% CI 0.10–0.26); and DOR 64 (95% CI 30.4–134.8). The area under the sROC curve was 0.96. Subgroup analysis did not identify other factors that could substantially affect the diagnostic accuracy, such as the study design, location of study, number of centers, location of lesion, whether or not a cytopathologist was present, and so on. EUS-FNB is a reliable diagnostic tool for solid pancreatic masses and should be especially considered for pathology where histologic morphology is preferred for diagnosis.

Endoscopic ultrasonography guided-fine needle aspiration for the diagnosis of solid pancreaticobiliary lesions: Clinical aspects to improve the diagnosis

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been applied to pancreaticobiliary lesions since the 1990s and is in widespread use throughout the world today. We used this method to confirm the pathological evidence of the pancreaticobiliary lesions and to perform suitable therapies. Complications of EUS-FNA are quite rare, but some of them are severe. Operators should master conventional EUS observation and experience a minimum of 20-30 cases of supervised EUS-FNA on non-pancreatic and pancreatic lesions before attempting solo EUS-FNA. Studies conducted on pancreaticobiliary EUS-FNA have focused on selection of suitable instruments (e.g., needle selection) and sampling techniques (e.g., fanning method, suction level, with or without a stylet, optimum number of passes). Today, the diagnostic ability of EUS-FNA is still improving; the detection of pancreatic cancer (PC) currently has a sensitivity of 90%-95% and specificity of 95%-100%. In addition to PC, a variety of rare pancreatic tumors can be discriminated by conducting immunohistochemistry on the FNA materials. A flexible, large caliber needle has been used to obtain a large piece of tissue, which can provide sufficient histological information to be helpful in classifying benign pancreatic lesions. EUS-FNA can supply high diagnostic yields even for biliary lesions or peri-pancreaticobiliary lymph nodes. This review focuses on the clinical aspects of EUS-FNA in the pancreaticobiliary field, with the aim of providing information that can enable more accurate and efficient diagnosis.

Endoscopic ultrasound elastography: Current status and future perspectives

Elastography is a new ultrasound modality that provides images and measurements related to tissue stiffness. Endoscopic ultrasound (EUS) has played an important role in the diagnosis and management of numerous abdominal and mediastinal diseases. Elastography by means of EUS examination can assess the elasticity of tumors in the proximity of the digestive tract that are hard to reach with conventional transcutaneous ultrasound probes, such as pancreatic masses and mediastinal or abdominal lymph nodes, thus improving the diagnostic yield of the procedure. Results from previous studies have promised benefits for EUS elastography in the differential diagnosis of lymph nodes, as well as for assessing masses with pancreatic or gastrointestinal (GI) tract locations. It is important to mention that EUS elastography is not considered a modality that can replace biopsy. However, it may be a useful adjunct, improving the accuracy of EUS-fine needle aspiration biopsy (EUS-FNAB) by selecting the most suspicious area to be targeted. Even more, it may be useful for guiding further clinical management when EUS-FNAB is negative or inconclusive. In the present paper we will discuss the current knowledge of EUS elastography, including the technical aspects, along with its applications in the differential diagnosis between benign and malignant solid pancreatic masses and lymph nodes, as well as its aid in the differentiation between normal pancreatic tissues and chronic pancreatitis. Moreover, the emergent indication and future perspectives are summarized, such as the benefit of EUS elastography in EUS-guided fine needle aspiration biopsy, and its uses for characterization of lesions in liver, biliary tract, adrenal glands and GI tract.

Effect of a stylet on a histological specimen in EUS-guided fine-needle tissue acquisition by using 22-gauge needles: a multicenter, prospective, randomized, controlled trial

BACKGROUND

EUS-guided FNA (EUS-FNA) has become the most efficacious way to obtain specimens from a solid lesion adjacent to the GI tract. Previous reports regarding the use of a stylet during EUS-FNA were all based on cytological diagnosis and have showed no significant superiority in terms of diagnostic yield.

OBJECTIVE

To clarify the noninferiority of EUS-FNA without a stylet (S-) compared with EUS-FNA with a stylet (S+) on histological assessment.

DESIGN

A prospective, single-blind, randomized, controlled crossover study.

SETTING

Five tertiary referral centers in Japan.

PATIENTS

Patients referred for EUS-FNA of a solid lesion.

INTERVENTION

EUS-FNA S+ and S- in a total of 4 alternate passes with randomization to S+ first or S- first.

MAIN OUTCOME MEASUREMENTS

The primary endpoint was the acquisition rate of an appropriate and sufficient specimen for histological assessment. The secondary endpoints were cellularity, contamination, bloodiness, diagnostic ability, and diagnostic accuracy.

RESULTS

We enrolled 107 patients (110 lesions) and analyzed 220 specimens each in the S+ and S- groups. The acquisition rate of appropriate and sufficient specimens in the S+ group was 121 of 220 (55.0%) and 122 of 220 (55.5%) in the S- group. The difference in the acquisition rate of the specimen (S- minus S+) based on the generalized estimating equation was 0.42% (95% confidence interval, -6.72% to 7.56%), which was less than 10% of the prespecified noninferiority margin of this study. With regard to cellularity, contamination, bloodiness score, diagnostic ability, and diagnostic accuracy, there were no significant differences between both groups. There were no dropouts in the study.

LIMITATIONS

A variety of target lesions, multiple pathologists, lack of an assessment of intraobserver and interobserver variability, and a single-blind study for the pathologists.

CONCLUSION

EUS-FNA S- is noninferior to EUS-FNA S+ on histological assessment. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000008695.).

Can endoscopic ultrasound-guided fine needle aspiration offer clinical benefit for thick-walled gallbladders?

BACKGROUND

No previous studies have compared cytology obtained under endoscopic transpapillary gallbladder drainage (ETGD) and EUS-guided fine needle aspiration (EUS-FNA) for thick-walled gallbladders.

AIM

The present study investigated the diagnostic yield of bile cytology under ETGD and EUS-FNA for gallbladder tumors.

METHODS

A total of 69 patients were diagnosed as having gallbladder wall thickening. Among these patients, 28 patients were diagnosed by clinical follow-up, solely by imaging such as computed tomography or by histological examination of surgical specimens. The remaining 41 patients underwent ETGD and/or EUS-FNA. In these 41 patients, the clinical data collected included gender, age, diameter of gallbladder wall, site of gallbladder wall thickening, final diagnosis, adverse events, and diagnostic yield of ETGD and EUS-FNA.

RESULTS

Cyto-histological diagnosis with EUS-FNA was higher than that with ETGD, with a sensitivity of 100 versus 71%, specificity of 100 versus 94%, and accuracy of 100 versus 88%, respectively, in the two groups. In addition, the sampling adequacy of EUS-FNA was 100%. Adverse events were seen in five patients in the ETGD group (mild pancreatitis), although no adverse events were seen in the EUS-FNA group (P = 0.08).

CONCLUSION

Our results suggest that EUS-FNA can be safely performed for the diagnosis of gallbladder lesions. Further, this procedure may be the diagnostic method of choice over cytology of bile juice obtained via ETGD to obtain histological evidence of gallbladder cancer.

Can elastography replace fine needle aspiration?

Endoscopic ultrasound (EUS) is one of the best diagnostic methods for diseases of the digestive tract and surrounding organs. Whereas EUS-guided fine needle aspiration (FNA) has been very useful for providing histological confirmation for previously hard to reach lesions, elastography is aiming to obtain a “virtual biopsy” by assessing differences in elasticity between the normal and pathological – usually malignant – tissue. A question that arises is whether EUS-elastography has reached a stage where it might successfully supplant the use of EUS-FNA in some of its clinical indications. The main indications of EUS-guided FNA are listed in this article and published data on the usage of elastography in these settings is reviewed for each one. In some of the indications, a plethora of studies have been published, notably for the evaluation of solid pancreatic masses and lymph nodes, while in others there is little relevant data (submucosal masses, left liver lesions, left adrenal masses), or elastography simply is not suitable as a diagnostic means (cystic lesions). Our conclusion is that elastography is not yet ready to replace EUS-FNA in its indications, but should complement it in various settings, especially for the assessment of lymph nodes. It can only be considered an alternative on a case-by-case basis, in situations where FNA is regarded as a contraindication. Furthermore, it could be used in conjunction with other imaging techniques, such as contrast-enhanced EUS, in order to further improve the accuracy of non-invasive EUS assessment, possibly making the case for a more limited or targeted use of EUS-FNA in selected cases.

Can endoscopic ultrasound-guided fine needle aspiration offer clinical benefit for tumors of the ampulla of vater? -an initial study

Objective:

No previous studies have described endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) only for intra-ampullary lesions of the papilla of Vater. We aimed to examine whether EUS-FNA can be used to diagnose such lesions.

Methods:

This study included a subset of 10 consecutive patients in whom EUS-FNA targeted the ampulla of Vater. All the patients underwent biopsy and/or brushing cytology under endoscopic retrograde cholangiopancreatography (ERCP) prior to EUS-FNA. The final diagnosis was based on pathological examinations of specimens obtained by surgical resection or clinical follow-up more than 1 year in case of evidence of benign lesions.

Results:

Tissues from the ampulla of Vater could be obtained by EUS-FNA for all 10 patients. The final diagnosis was papillitis (n = 7) and intra-ampullary carcinoma (n = 3). Carcinoma of the ampulla of Vater showed neither exposure on the duodenal mucosal surface nor invasion to the pancreas. The diagnostic accuracy of surface biopsy with duodenoscopy, and intra-ampullary biopsy and/or brush cytology with ERCP and/or intra-ampullary biopsy after endoscopic sphincterotomy (EST) in distinguishing between benign and malignancy was 70%. The diagnostic accuracy of EUS-FNA was 100%. No complications associated with EUS-FNA were encountered in this study.

Conclusion:

EUS-FNA for ampulla of Vater may be safely and accurately performed, and should be considered as a diagnostic modality before EST.

Evaluation of endoscopic cytological diagnosis of unresectable pancreatic cancer prior to and after the introduction of endoscopic ultrasound-guided fine-needle aspiration

With the advances in the multidisciplinary treatment of pancreatic cancer (PC) over the last few years, it is crucial to obtain a histopathological diagnosis prior to treatment. Histopathological diagnosis for unresectable PC is currently performed with endoscopic retrograde cholangiopancreatography (ERCP) in combination with endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). We retrospectively assessed the results of these two methods and investigated diagnostic performance according to the location of the lesion and the complications. This study was conducted on a series of 263 consecutive cases of unresectable PC diagnosed with endoscopic cytology. Up to 2006, ERCP-guided cytology (group A) was performed as the first choice for the diagnosis of PC. EUS-FNA was introduced in 2007 and became the first choice thereafter (group B), except in cases with obstructive jaundice, in which ERCP-guided cytology during endoscopic biliary stenting (EBS) remains the first choice. There were statistically significant differences in the overall cancer-positive rate between groups A and B (60.4 vs. 75.3%, P=0.01). The cancer-positive rate in the pancreatic body and tail was significantly higher in group B (59.5 vs. 83.3%, P=0.005), whereas there were no significant differences regarding cancer of the pancreatic head. The complication rate was 4.95% in group A and 3.09% in group B (P=0.448). The endoscopic cytology cancer-positive rate in unresectable PC cases was increased as a result of the introduction of EUS-FNA. In conclusion, we recommend performing EUS-FNA in combination with ERCP-guided cytology in cases with a lesion in the pancreatic head that requires EBS.

BCL10 as a useful marker for pancreatic acinar cell carcinoma, especially using endoscopic ultrasound cytology specimens

Acinar cell carcinomas (ACCs) of the pancreas are characterized by the histological and immunohistochemical features of acinar cell differentiation. Recently, BCL10, originally identified as a recurrent t(1;14)(p22;q32) translocation in MALT B-cell lymphoma, was found to be immunohistochemically positive in some solid tumors, including ACC. To evaluate its diagnostic efficacy, we performed BCL10 immunohistochemistry and evaluated molecular markers correlated to pancreatic tumor lineages (neuroendocrine markers and a mutation analysis of KRAS and GNAS) using samples from 126 pancreatic tumors (17 ACCs, 24 pancreatic ductal adenocarcinomas, 4 adenosquamous carcinomas, 9 intraductal papillary mucinous neoplasms, 10 mucinous cystic neoplasms, 44 neuroendocrine tumors, 9 serous cystic tumors and 10 solid-pseudopapillary neoplasms). BCL10 was exclusively expressed in normal acini. In pancreatic tumors, 14 of 17 (82%) ACCs and 2 of 4 (50%) adenosquamous carcinomas were positive, while the other subtypes were almost negative. We subsequently examined the diagnostic utility of BCL10 in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) specimens using 57 pancreatic tumors. BLC10 correctly identified ACCs (9/13) and adenosquamous carcinomas (2/4) but none of the other subtypes (n = 41). Therefore, we suggested that BCL10 expression is a useful marker for acinar cell differentiation, particularly in the diagnosis of EUS-FNA specimens.

Prospective randomized controlled study comparing cell block method and conventional smear method for bile cytology

BACKGROUND AND AIM

There is a paucity of data on the cell block (CB) method for bile cytology. We compared the diagnostic efficacy of the CB method with that of conventional smear cytology for bile obtained by endoscopic retrograde cholangiopancreatography (ERCP) in a randomized controlled trial manner.

METHODS

A total of 137 patients with biliary tract lesions suspicious of malignancy who had undergone bile collection under ERCP were recruited to this study. After sampling, the bile was randomized to the CB method (n = 69) or to smear cytology (n = 68). CB sections were prepared using the sodium alginate method and subjected to hematoxylin-eosin, Alcian blue-periodic acid-Schiff stain, and immunohistochemical stains. Both Papanicolaou and Giemsa stains were used for smear cytology.

RESULTS

The final diagnosis was malignancy in 94 patients: bile duct cancer, 42; pancreatic head cancer, 34; gallbladder cancer, 16; and ampullary cancer, two. The diagnostic accuracy of the CB method and that of smear cytology were 64% and 53%, respectively (P = 0.20). The sensitivity of the CB method (53%) was significantly better than that of smear cytology (28%; P = 0.014). Their respective sensitivities were 80% and 31% (P = 0.002) for bile duct cancer, 20% and 15% (P = 1.0) for pancreatic head cancer, and 30% and 67% (P = 0.30) for gallbladder cancer.

CONCLUSION

The CB method for bile cytology showed a higher diagnostic yield than smear cytology. Its diagnostic sensitivity was satisfactory in cases of bile duct cancer.

Diagnostic yield of endoscopic retrograde cholangiography and of EUS-guided fine needle aspiration sampling in gallbladder carcinomas. J Hepatobiliary Pancreat Sci. 2012;19:650-655. [PMID: 22127498 DOI: 10.1007/s00534-011-0482-6]

BACKGROUND

Obtaining histological evidence of gallbladder carcinoma (GBC) is difficult due to its extraductal nature, and pathological confirmation remains challenging. We compared the diagnostic value and safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with endoscopic retrograde cholangiography (ERC) in patients with suspected GBC.

PATIENTS

Eighty-three patients with GBC were evaluated. Prior to definitive management, pathological evidence of GBC was obtained through either ERC cytopathologic sampling (n = 33), EUS-FNA (n = 24) or both (n = 26).

RESULTS

Among the 83 patients, 59 (71.0%) with biliary obstruction were sampled using ERC with 47.4% (28/59) sensitivity. In 19 of the remaining 31 cases, EUS-FNA sampling had 100% diagnostic sensitivity. Likewise, 50 (60.2%) of the 83 patients with suspected GBC underwent EUS-FNA of regional lymph nodes or the gallbladder (GB) mass itself with 94.8% sensitivity. The overall diagnostic sensitivity rates of ERC and EUS-FNA were 47.4 and 96%, respectively (P < 0.001). Post-procedural complications were seen in 6.7% of the ERC group (4/59, all were mild pancreatitis), and in none of the EUS-FNA group (P = 0.10).

CONCLUSIONS

Gallbladder carcinoma sampling using ERC and EUS-FNA should be incorporated into the diagnostic workup of GB lesions as complementary tools, and EUS-FNA should be applied in the setting of failed or not indicated ERC.

Prognostic value of K-ras mutation status and subtypes in endoscopic ultrasound-guided fine-needle aspiration specimens from patients with unresectable pancreatic cancer

BACKGROUND

Although recent reports indicate that K-ras mutation status is a biomarker that acts as a prognostic factor, only a few analyses of K-ras mutation subtypes have been published. In addition, there are no reports that analyze overall survival and prognostic factors according to K-ras mutation status and subtypes in only unresectable pancreatic cancer (PC) determined from tissues obtained by endoscopic ultrasound-guided fine-needle aspiration.

METHODS

We retrospectively analyzed 242 patients who were diagnosed as having unresectable PC with available histological diagnosis. Clinical data collected included sex, age, Eastern Cooperative Oncology Group performance status, carbohydrate antigen (CA) 19-9, primary tumor location, stage (local or metastatic) according to TNM staging, first-line chemotherapy, K-ras mutation status and subtypes (G12D, G12V, and G12R), and overall survival. We analyzed the negative prognostic factors for reduced overall survival in unresectable PC patients using these data.

RESULTS

From multivariate analysis, CA19-9 ≥1000 U/ml (hazard ratio [HR] 1.78, 95 % confidence interval [CI] 1.28-2.46, P < 0.01), metastatic stage (HR 2.26, 95 % CI 1.58-3.24, P < 0.01), and mutant-K-ras (HR 1.76, 95 % CI 1.03-3.01, P = 0.04) were negative prognostic factors, indicating a reduced survival. Among the patients who had K-ras mutation subtypes, CA19-9 ≥1000 U/ml (HR 1.65, 95 % CI 1.12-2.37, P < 0.01), metastatic stage (HR 2.12, 95 % CI 1.44-3.14, P < 0.01), and the presence of the G12D or G12R mutations (HR 1.60, 95 % CI 1.11-2.28) were negative prognostic factors for overall survival.

CONCLUSIONS

K-ras mutation status and subtypes may be associated with survival duration in pancreatic cancer patients.

Molecular Biologic Approach to the Diagnosis of Pancreatic Carcinoma Using Specimens Obtained by EUS-Guided Fine Needle Aspiration

We review the utility of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), a rapid, safe, cost-effective, and accurate diagnostic modality for evaluating pancreatic tumors. EUS-FNA is currently used for the diagnosis and staging of pancreatic tumors. The sensitivity of EUS-FNA for pancreatic malignancy ranges from 75% to 94%, and its specificity approaches 100% in most studies. However, EUS-FNA has some limitations in the diagnosis of well-differentiated or early-stage cancers. Recent evidence suggests that molecular biological analysis using specimens obtained by EUS-FNA improves diagnostic sensitivity and specificity, especially in borderline cytological cases. It was also reported that additional information regarding patient response to chemotherapy, surgical resectability, time to metastasis, and overall survival was acquired from the genetic analysis of specimens obtained by EUS-FNA. Other studies have revealed that the analysis of KRAS, MUC, p53, p16, S100P, SMAD4, and microRNAs is helpful in making the diagnosis of pancreatic carcinoma. In this paper, we describe the present state of genetic diagnostic techniques for use with EUS-FNA samples in pancreatic diseases. We also discuss the role of molecular biological analyses for the diagnosis of pancreatic carcinoma.

Endoscopic ultrasound-guided fine needle aspiration in the differentiation of type 1 and type 2 autoimmune pancreatitis

AIM: To investigate the usefulness of endoscopic ultra-sound-guided fine needle aspiration (EUS-FNA) in the differentiation of autoimmune pancreatitis (AIP).

METHODS: We retrospectively reviewed 47 of 56 AIP patients who underwent EUS-FNA and met the Asian diagnostic criteria. On 47 EUS-FNA specimens, we evaluated the presence of adequate material and characteristic features of lymphoplasmacytic sclerosing pancreatitis (LPSP) and idiopathic duct-centric pancreatitis (IDCP) mentioned in the International Consensus Diagnostic Criteria and examined if these findings make a contribution to the differential diagnosis of type 1 and type 2 AIP. A disposable 22-gauge needle was used for EUS-FNA.

RESULTS: Adequate specimens including pancreatic tissue for differentiating AIP from cancer were obtained from 43 of 47 patients who underwent EUS-FNA. EUS-FNA was performed from the pancreatic head in 21 cases, which is known to be technically difficult when performed by core biopsy; there was no significant difference in the results compared with pancreatic body-tail. Nine of 47 patients met level 1 findings of LPSP and 5 patients met level 2 findings of LPSP. No one met level 1 findings of IDCP, but 3 patients met level 2 findings of IDCP. Of 10 seronegative cases, 2 cases were diagnosed with “definitive type 1 AIP”, and 3 cases were diagnosed with “probable type 2 AIP” when considering both the level 2 histological findings and response to steroids.

CONCLUSION: EUS-FNA is useful in the differentiation of type 1 and type 2 AIP, particularly in seronegative cases.

Prospective randomized controlled study comparing cell block method and conventional smear method for pancreatic juice cytology

AIM

  To elucidate the diagnostic efficacy of the cell block (CB) method by comparing it with that of conventional smear cytology for pancreatic juice obtained by endoscopic retrograde cholangiopancreatography (ERCP) in a randomized controlled trial fashion.

METHODS

  A total of 170 patients with pancreatic lesions suspicious of being malignant who underwent pancreatic juice collection without giving secretin under ERCP were enrolled in this study. After sampling, the pancreatic juice was randomized to the CB method (n = 85) or to smear cytology (n = 85). CB sections were subjected to hematoxylin-eosin, periodic acid Schiff-Alcian blue, and immunohistochemical stains. Both Papanicolaou stain and Giemsa stain were used for smear cytology.

RESULTS

  The final diagnosis was malignancy in 54 patients: pancreatic cancer, 45; intraductal papillary-mucinous carcinoma, six; and endocrine tumor, three. The number of patients with a cytological borderline malignancy in the CB group (3.5%) was significantly smaller than that in the smear group (27.1%) (P < 0.001). The diagnostic accuracy of the CB method and that of smear cytology were 76.5% (65/85) and 74.1% (63/85), respectively (P = 0.72), and their respective sensitivities were 50% (14/28) and 38.5% (10/26) (P = 0.39). The sensitivity of the CB method (88.9%) was better than that of smear cytology (42.9%) for invasive ductal carcinoma in the pancreas head (P = 0.048).

CONCLUSIONS

  The CB method using immunostaining for pancreatic juice cytology showed a much lower rate of equivocal borderline malignancy and a tendency for a higher diagnostic yield compared with smear cytology. Its diagnostic sensitivity, however, was not satisfactory except for pancreatic-head cancer.

Clinical impact of K-ras mutation analysis in EUS-guided FNA specimens from pancreatic masses

BACKGROUND

EUS-guided FNA (EUS-FNA) is considered optimal for differentially diagnosing pancreatic masses. However, the sensitivity of EUS-FNA ranges from 65% to 95%, respectively, which requires improvement.

OBJECTIVE

To evaluate clinical impact of K-ras mutation analysis in EUS-FNA specimens from pancreatic masses.

DESIGN

Prospective registration, single-center study.

SETTING

Tertiary referral center.

PATIENTS

This study involved 394 consecutive patients with pancreatic masses (307 pancreatic ductal adenocarcinomas [PDACs], 47 pancreatic inflammatory lesions, and 40 other types of tumors) who underwent EUS-FNA and analysis of K-ras mutations.

INTERVENTION

EUS-FNA, Cycleave polymerase chain reaction.

MAIN OUTCOME MEASUREMENTS

Improvement of the diagnostic accuracy by K-ras mutation analysis; absence of K-ras mutations in non-PDAC masses.

RESULTS

K-ras mutations were detected in 266 of 307 PDAC aspirates (87%) and in 3 of 87 non-PDAC masses (3%). K-ras mutations were detected in 18 of 39 patients (46%) who remained cytohistopathologically undiagnosed. The sensitivity, specificity, positive and negative predictive values, and accuracy of cytohistopathological and K-ras mutation analyses alone were 87%, 100%, 100%, 54%, and 89%, respectively, and, when combined, were 93%, 100%, 100%, 68%, and 94%, respectively. Adding K-ras mutation analysis to standard cytohistopathological assessment increased the sensitivity and accuracy of EUS-FNA by 6% (P < .001) and 5% (P < .001), respectively.

LIMITATIONS

Single-center study.

CONCLUSIONS

K-ras mutation analysis may be helpful in patients with suspected PDAC yet inconclusive EUS-FNA findings. K-ras mutations were extremely rare in pancreatic inflammation and other pancreatic tumors.

Endoscopic ultrasonography-guided fine needle aspiration biopsy using 22-gauge needle in diagnosis of autoimmune pancreatitis

BACKGROUNDS

The effectiveness of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has not been fully evaluated in the diagnosis of autoimmune pancreatitis (AIP).

AIM

To evaluate the effectiveness of EUS-FNA using 22-gauge needles in the diagnosis of AIP.

METHODS

EUS-FNA was examined in 85 patients with pancreatic mass, including 64 patients with pancreatic cancer and 21 patients with AIP. We investigated ability of EUS-FNA using 22-gauge needle for the differential diagnosis between AIP and pancreatic cancer. We also compared the factors concerning FNA procedures (number of needle passes, size of lesion, device, and amount of obtained pancreatic tissue) between two diseases.

RESULTS

Tissues obtained from 21 patients with AIP, although none of them demonstrated histology suspicious for malignancy, did not show histological evidence definitive for AIP. The amount of obtained pancreatic tissue was almost equal between two diseases in each pancreatic location. Sensitivity, specificity, overall accuracy, and negative predictive value of histological diagnosis of pancreatic cancer were 92.2%, 100%, 94.1%, and 80.8%, respectively.

CONCLUSION

EUS-FNA using 22-gauge needle distinguished benign from malignant pancreatic mass with >90% of accuracy, regardless of the location. Hence, it was helpful for the clinical diagnosis of AIP, however not providing satisfactory samples for the histological diagnosis of AIP.

Influence of on-site cytopathology evaluation on the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solid pancreatic masses

OBJECTIVES

The aim of this study was to evaluate the influence of on-site cytopathological evaluation on the diagnostic yield of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for the differential diagnosis of solid pancreatic masses in an unselected series of consecutive patients.

METHODS

Patients undergoing EUS-guided FNA of solid pancreatic lesions over a 2-year study period were included. Samples were either evaluated on site by a cytopathologist or processed by the endoscopist and sent to the pathology department for evaluation. Diagnostic accuracy for malignancy, number of needle passes, adequate-specimen collection rate, cytological diagnosis, and final diagnosis, and complication rate according to the presence or absence of on-site cytopathologist were evaluated.

RESULTS

A total of 182 patients were included. An on-site cytopathologist was available in 95 cases (52.2%). There was no difference between groups in terms of age, sex, location, and size of the lesions. A significantly higher number of needle passes was performed when an on-site cytopathologist was not available (3.5±1.0 vs. 2.0±0.7; P<0.001). The presence of an on-site cytopathologist was associated with a significantly lower number of inadequate samples (1.0 vs. 12.6%, P=0.002), and a significantly higher diagnostic sensitivity (96.2 vs. 78.2%; P=0.002) and overall accuracy (96.8 vs. 86.2%; P=0.013) for malignancy. Three patients developed complications (two acute pancreatitis, one local bleeding), all of them belonging to the group without on-site cytopathology.

CONCLUSIONS

On-site cytopathological evaluation improves the diagnostic yield of EUS-guided FNA for the cytological diagnosis of solid pancreatic masses. This is associated with a significantly lower number of inadequate samples and a lower number of needle passes.

Role of endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration in diagnosing metastasis to the pancreas: a tertiary center experience

BACKGROUND

Metastasis to the pancreas (MP) is a rare entity that is difficult to identify by imaging alone. Few reports have described endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (FNA) findings. Herein, we try to describe the EUS and EUS-FNA characteristics of MP.

METHODS

This retrospective study compared 28 patients with MP (13 males; mean age: 60.1 ± 12.6 years) and 60 control patients (30 males; 62.7 ± 11.5 years) with pancreatic ductal adenocarcinoma (PDAC). All lesions were characterized by EUS, and MP was diagnosed by EUS-FNA (n = 16), surgery (n = 6) or both (n = 6).

RESULTS

Multivariate logistic regression revealed that the presence of regular borders (p = 0.004; OR: 8.81, 95% CI: 1.97-39.4), the absence of retention cysts (p = 0.045; OR: 12.5, 95% CI: 1.06-147.0), and the absence of main pancreatic duct (MPD) dilation (p = 0.003; OR: 8.18, 95% CI: 2.04-32.8) were predictors of MP rather than PDAC. The EUS-FNA sampling adequacy was 95.4% (21/22), and the correct diagnosis was obtained in 95.2% (20/21) of cases when K-ras mutation analysis and/or immunostaining were added.

CONCLUSION

The presence of regular borders, the absence of retention cysts and the presence of nondilated MPD on EUS indicate MP rather than PDAC. This diagnosis can be accurately confirmed by EUS-FNA with immunostaining and/or K-ras analysis.