Primary leiomyosarcoma of the pancreas with metastasis to the spleen

Video 1EUS evaluation of the pancreas and the spleen.

Comparing Needles and Methods of Endoscopic Ultrasound-Guided Fine-Needle Biopsy to Optimize Specimen Quality and Diagnostic Accuracy for Patients With Pancreatic Masses in a Randomized Trial

BACKGROUND & AIMS

Given the lack of procedure standardization, findings vary from analyses of pancreatic tissues collected by endoscopic ultrasound-guided fine-needle biopsy. It is not clear which needle and technique yield the best specimen for analysis. We compared the specimen quality and accuracy of diagnoses made from samples collected by fine-needle biopsy needles using different collection techniques.

METHODS

Patients found to have pancreatic masses during imaging (n = 129) were assigned randomly to groups from whom pancreatic tissue samples were collected by reverse-bevel, Menghini-tip, franseen, or fork-tip needles. A second randomization determined the technical sequence of biopsies in each patient (suction, no suction, and stylet retraction). Two independent pathologists, blinded to the type of needle and sampling technique, analyzed all the samples. Final diagnoses of malignancy were made based on surgical resection, death from cancer progression, or findings from radiology or clinical follow-up evaluations (reference standard). The primary objective was to compare the cellularity of the samples collected, defined as the proportion of core tissue in the biopsy sample. Secondary objectives were to compare the accuracy of diagnoses made from biopsy samples and identify factors associated with high cellularity.

RESULTS

One-hundred and nine patients had a final diagnosis of malignancy (84.5%) and 20 patients had benign disease (15.5%). Samples collected by fork-tip or franseen needles had significantly higher cellularity than samples collected by reverse-bevels or Menghini-tip needles (P < .001). Neoplasias were identified with greater than 90% accuracy using samples collected by fork-tip or franseen needles (P < .001 compared with other needles). On multivariable regression analysis, use of franseen needles (odds ratio [OR], 4.42; 95% CI, 2.58-7.58; P < .001) or fork-tip needles (OR, 3.86; 95% CI, 2.24-6.64; P < .001), stylet retraction (OR, 2.13; 95% CI, 1.21-3.72; P = .008), no suction (OR, 2.74; 95% CI, 1.57-4.80; P < .001), and pancreatic mass larger than 3 cm (OR, 1.92; 95% CI, 1.21-3.05; P = .005) were associated with high cellularity of the sample.

CONCLUSIONS

In patients with suspected pancreatic cancer, samples with the highest degree of cellularity in a single biopsy, resulting in a diagnostic accuracy of 90% of higher, were collected by fine-needle biopsy using the franseen or fork-tip needle. Clinicaltrials.gov no: NCT04085055.

In memoriam: Fine-needle aspiration, birth: Fine-needle biopsy: The changing trend in endoscopic ultrasound-guided tissue acquisition

BACKGROUND AND AIM

Fine-needle aspiration (FNA) cytology has been the preferred technique for procuring tissue at endoscopic ultrasound (EUS) procedures for the past 25 years. To overcome some of the limitations of FNA cytology, fine-needle biopsy (FNB) has been recently developed to yield histological tissue. Main objective was to compare the diagnostic yield of FNB compared to FNA for both onsite and offsite specimen assessment.

METHODS

A retrospective study was conducted at a single tertiary referral center to evaluate the outcomes of FNA and FNB over a 4-year period. EUS-guided tissue sampling was carried out using 22- or 25-G FNA needles from 2014 to 2015, and 22-G FNB needle was used from 2016 to 2017.

RESULTS

Of 3020 patients undergoing EUS-guided sampling of solid mass lesions (pancreatic masses 71.3%, other lesions 28.7%), FNA was carried out in 68.9% and FNB in 31.1%. Median number of passes required for diagnostic adequacy on rapid onsite evaluation was significantly lower for FNB compared to FNA (1 [IQR: 1-2] vs 2 [IQR 1-3], P < 0.001). Diagnostic yield on cell block was also significantly superior with FNB compared to FNA (92.3 vs 71.1%, P < 0.001). The superior performance of FNB over FNA was observed for both pancreatic (P < 0.001) and non-pancreatic lesions (P < 0.001).

CONCLUSION

Given these promising findings, in the future, EUS-guided FNB will likely be the preferred technique for sampling of solid mass lesions.

Not Your Usual Suspect: Clear Cell Renal Cell Carcinoma Presenting as Ulcerative Esophagitis

Renal cell carcinoma (RCC) has the propensity to hematogenously metastasize to the lung, bone, or liver, however, metastasis to the esophagus is exceedingly rare. We report a case of ulcerative esophagitis secondary to recurrent metastatic renal cell cancer status post remote nephrectomy.

An 82-year-old Caucasian male presented with dark tarry stools for two days, progressive dysphagia to solid food for several weeks and unintentional weight loss. His past medical history was significant for hypertension, diverticulosis and right-sided renal cell cancer for which he underwent nephrectomy 13 years ago. Physical examination was unremarkable. Laboratory data showed hemoglobin of 12.5 g/dL, with normal platelet count and an international normalized ratio (INR). His stools were positive for occult blood. Esophagogastroduodenoscopy (EGD) revealed a fragile mid esophageal mass and antral erosive gastritis which were both biopsied. Colonoscopy showed diverticulosis without stigmata of active gastrointestinal (GI) bleed. CT scan (computed tomography) of the chest showed a solid esophageal mass in the lower esophagus as well as a right upper lobe lung mass for which CT-guided needle biopsy was obtained. The histopathology revealed metastatic renal cell cancer of clear cell subtype. The patient was started on palliative radiotherapy. On completion of radiotherapy two months later, his dysphagia had resolved. The patient is currently on chemotherapy with Sunitinib.

Metastatic involvement of esophagus is relatively uncommon and is reported in 6% of patients with metastatic lung, breast and prostate cancer. Esophageal metastasis of clear cell RCC is very rare and so far only seven cases have been reported.

Diagnosis is confirmed by endoscopy, imaging and histopathology. Treatment options include surgical or endoscopic resection for a solitary metastatic lesion. If the tumor is unresectable, multidisciplinary treatment including radiation and chemotherapy is indicated.

Endosonographer-driven dynamic telecytopathology of pancreatic lesions-a pilot study

INTRODUCTION

Telecytopathology for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been shown to be an alternative to rapid on-site evaluation (ROSE). Gastroenterologists (endosonographers) performing EUS-FNA can be trained to evaluate a specimen for adequacy. This study examined the ability of an endosonographer with focused cytopathologic training to assess the adequacy of pancreatic FNA specimens and transmit diagnostic images to a remotely located cytopathologist as compared to an experienced cytotechnologist.

MATERIALS AND METHODS

This was a retrospective study of consecutive pancreatic lesions sampled by EUS-FNA reviewed by an endosonographer and a cytotechnologist. The participants were assessed based on their ability to (1) determine adequacy, (2) locate and transmit representative cell groups, (3) provide a preliminary diagnosis, and (4) provide concordance with actual diagnosis.

RESULTS

105 consecutive cases of EUS-FNA of the pancreas were analyzed, including: adenocarcinoma (n = 39), cyst (n = 17), neuroendocrine neoplasia (n = 7), pancreatitis (n = 14), benign pancreas (n = 9), other neoplasms (n = 6), suspicious/atypical (n = 3), and nondiagnostic (n = 10). The cytotechnologist demonstrated superiority in accuracy 92.7% versus 70% (P = 0.003) and subcategorization 95.0% versus 76% (P = 0.007). There was no difference in "broad" categorization (benign/malignant) between the endosonographer and cytotechnologist, 98% and 98.2% (P = 0.946), respectively. Also, there was no difference with regard to adequacy assessment (P = 0.29). A steady learning curve for the endosonographer was demonstrated in their cytologic assessment (P = 0.041). The endosonographer was shown to be able to remotely transmit diagnostic images to a pathologist.

CONCLUSION

An endosonographer with limited training can examine for specimen adequacy, transmit images, and demonstrate representative cell groups. Larger studies are required though preliminary results are encouraging.

Falling under the umbrella cells: A single institutional experience and literature review of urothelial carcinoma presenting as a primary pancreatic mass on endoscopic ultrasound-guided fine-needle aspiration

Metastases to the pancreas are much less common than primary pancreatic lesions, and there are few reports in the literature of metastatic urothelial carcinoma (UC) found in the pancreas. We report two cases of metastatic UC mimicking a primary pancreatic lesion. Two female patients, aged 48 and 83 years, presented with isolated pancreatic lesions causing obstructive jaundice suspicious for pancreatic adenocarcinoma and underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with rapid on-site evaluation (ROSE). On cytopathology, the lesions were found to be UC, confirmed with immunohistochemical (IHC) staining. UC rarely metastasizes to the pancreas, and diagnosis through EUS-FNA can be challenging. However, the utilization of ROSE, dedicated cell block passes, and IHC have proved to be effective in obtaining this unusual pancreatic diagnosis by EUS-FNA.

Endoscopic ultrasound.guided fine-needle tissue acquisition – A review and update of literature

Ever since the first endoscopic ultrasound-guided fine needle aspiration (FNA) was done in 1992, the procedure has evolved to become an indispensable tool for tissue acquisition in patients with gastrointestinal tumors and periluminal lesions. With the growing evidence of neoadjuvant therapy and research into intratumoral therapy, the need to obtain tissue diagnosis for tumors is quite apparent. This review provides an overall perspective to the endosonographer on various issues that are a key for best practices in FNA, in addition to being an update for practicing experienced endosonographers.

[Life-threatening opioid overdose. Decoding the physician pin code of a patient-controlled anesthesia pump by patients]

Patient-controlled analgesia (PCA) is an established standard therapy for providing postoperative analgesia. To avoid possible abuse by patients each PCA pump is secured by a pin code that should be neither known nor accessible to patients. The two case reports described illustrate how manipulation of a PCA pump led to massive opioid abuse by the patients who decoded the pin code for unlimited additional doses. One patient developed withdrawal symptoms after switching the therapy and, as a consequence even had to be admitted to the intensive care unit (ICU). Easy access to the PCA pump codes on the internet for the patients and the impossibility of changing the pin codes by the medical staff played an important role in these two cases.

Lack of seasonal variation in flow-mediated dilatation of the brachial artery in women with primary Raynaud's phenomenon and healthy controls

BACKGROUND

The aim of this study was to examine endothelium function and seasonal variations of endothelium function in women with primary Raynaud's phenomenon (RP) and healthy controls.

PATIENTS AND METHODS

After a fast of at least 8 hours we studied 21 patients with primary RP (mean age 31.1 years, mean duration of RP 9.1 years) and 22 controls (mean age 27.8 years) by use of high resolution brachial artery sonography in winter (December/January 2000) and summer (July/August 2001). To exclude circadian variations all examinations were performed in the late afternoon only. All subjects were non-smokers. Confounding factors like serum glucose, HbAlc, and lipid concentrations were analyzed immediately before the investigations. Nicotine contamination was randomly analyzed in hair samples in 8 subjects of each study group. Flow mediated dilatation (FMD%) and nitroglycerin induced dilatation (NID%) were calculated by putting the basal vessel diameter as 100%.

RESULTS

Basal, flow-mediated, and nitroglycerin-induced absolute diameters of the brachial artery did not differ significantly between the study groups (p = 0.85). The test conditions (basal, postocclusive, nitroglycerin-induced) always let to the same vessel response in winter and summer (p = 0.61) and there was no significant influence between these test conditions and the study groups (p = 0.07). Compared to patients FMD% was slightly reduced in controls in summer (p = 0.09). Analysis of variance excluded a significant relation between study group and season (p = 0.43). For NID% too, no statistically significant differences were found.

CONCLUSIONS

We were not able to show impaired or seasonally variant flow-mediated or nitroglycerin-induced dilatation of the brachial artery in patients with primary RP. Our results argue against the presence of a more generalized endothelium dysfunction detectable with high resolution ultrasound of the brachial artery in patients with primary RP.