EUS-guided FNA in the diagnosis of pancreatic neuroendocrine tumors before surgery

BACKGROUND: The use of EUS for precise preoperative evaluation of pancreatic neuroendocrine tumors is well established; up to 80% of insulinomas can be localized. However, the EUS appearance of pancreatic neuroendocrine tumors can be similar to that of benign peripancreatic lymph nodes. The aim of this study was to evaluate the role of EUS-guided FNA in this setting. METHODS: Thirty patients (18 women, 12 men) with 33 pancreatic/peripancreatic lesions confirmed by surgery underwent EUS-guided FNA between February 1997 and September 2002. Transabdominal US and CT were obtained in all patients before EUS. The diagnosis of pancreatic neuroendocrine tumor was established based on morphologic appearance and immunohistochemical staining of cytologic and surgical specimens. RESULTS: EUS detected 32 of the 33 (96.9%) lesions (mean diameter 20 mm, range 5-97 mm). There was one complication (abdominal pain). For the 30 patients, the following diagnoses were made: functioning pancreatic neuroendocrine tumor (16 patients), non-functioning pancreatic neuroendocrine tumor (7), peripancreatic lymph node (5), inflammatory intrapancreatic nodule (1), and peripancreatic splenosis (1). Sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-guided FNA were 82.6%, 85.7%, 95%, 60%, and 83.3%, respectively. There was one false-positive diagnosis by EUS-guided FNA and 4 false-negative diagnoses. In two of the latter cases, EUS-guided FNA was unsuccessful. CONCLUSIONS: EUS-guided FNA is accurate and safe for the diagnosis of pancreatic neuroendocrine tumor and may have a role in determining management strategy.     

Detection and tumor staging of malignancy in cystic, intraductal, and solid tumors of the pancreas by EUS

BACKGROUND: EUS can provide detailed imaging of pancreatic malignancies and direct fine needle aspiration (FNA) of pancreatic masses. The ability of EUS to detect and stage malignancy in cystic and intraductal lesions has not been investigated. Our aim was to determine the sensitivity and specificity of EUS imaging and FNA in detecting and staging of malignancy in solid, cystic, and intraductal lesions of the pancreas. METHODS: The records of 96 patients (46 solid, 26 cystic, 24 intraductal lesions) who underwent EUS followed by surgical exploration over a 3-year period were reviewed. The accuracy of EUS for detecting and staging malignancy was calculated based on the results of surgery and histology. RESULTS: EUS-guided FNA provided evidence of malignancy in solid, cystic, and ductal lesions with sensitivities of 59.5%, 50%, and 60%, respectively. The accuracy of staging by EUS was significantly less for intraductal lesions (47%), compared with cystic (100%) and solid lesions (85%) (p < 0. 05). CONCLUSIONS: EUS can be used to detect malignancy in cystic and intraductal tumors of the pancreas.     

内镜超声引导细针穿刺对胰腺癌的诊断价值

目的了解内镜超声(EUS)引导细针穿刺(FNA)对胰腺癌的临床价值及安全性。方法选择临床诊断或临床及影像学疑诊胰腺癌患者共21例,男13例,女8例,平均年龄(59.8±15.3)岁。EUS发现病变后,在实时超声引导下用超声穿刺针行FNA,对3例无法手术的胰腺癌患者行FNA同时,以无水乙醇阻滞腹腔神经丛治疗癌痛。结果B超共检出胰腺占位16例(16/21),未检出的5例中3例经CT检出,CT共检出胰腺占位19例;EUS检出全部21例胰腺占位,5例位于胰体尾,16例位于胰头。18例患者EUS-FNA获满意标本,17例诊断为胰腺癌,1例诊断为慢性胰腺炎,胰腺癌诊断敏感性为85.0%、特异性为100.0%、准确度为85.7%。3例行无水乙醇阻滞后疼痛减轻。术后发生轻度胰腺炎1例、发热1例。结论EUS能有效检出胰腺占位,结合FNA可提高诊断的特异性及准确性。     

Optimal number of EUS-guided fine needle passes needed to obtain a correct diagnosis

BACKGROUND: The immediate assistance of a cytologist during EUS-guided FNA is not universal. The optimal number of fine needle passes during EUS-guided FNA has not been determined in a prospective study. The aim of this study was to determine the optimal number of passes required to obtain a correct diagnosis. METHODS: Seven or more passes were made with a fine needle into a variety of lesions during EUS-guided FNA. Adequacy of the aspirate, diagnosis, and a "certainty score" were recorded after each pass and interpreted sequentially by a cytopathologist. Surgical histopathology and 1-year clinical follow-up were used as reference standards. The percentage of correctly diagnosed cases was calculated and stratified according to organ, disease group, and EUS characteristics of the lesion. RESULTS: Lesions from 95 patients were categorized into the following locations: pancreas, lymph node, and miscellaneous. The sensitivity and specificity for 7 passes from the pancreas and miscellaneous lesion groups were, respectively, 83% and 100%. The sensitivity and specificity for 5 passes from the lymph node group were, respectively, 77% and 100%. CONCLUSIONS: During EUS-guided FNA, at least 7 passes with a fine needle into pancreatic and miscellaneous lesions, and 5 passes into lymph nodes are needed to ensure a high degree of certainty for making a correct diagnosis.     

Differential diagnosis of pancreatic cancer and focal pancreatitis by using EUS-guided FNA

BACKGROUND: Despite advances in diagnostic imaging techniques, the differentiation between pancreatic cancer and focal pancreatitis remains difficult. This study evaluated the effectiveness of EUS-guided FNA in the differential diagnosis between pancreatic cancer and focal pancreatitis, with particular reference to detection of the K-ras point mutation. METHODS: The study included 62 consecutive patients with pancreatic ductal cancer and 15 patients with focal pancreatitis demonstrated as a pancreatic mass lesion by EUS. RESULTS: Sensitivity, specificity, overall accuracy, positive predictive value, and negative predictive value of cytopathologic diagnosis were 82%, 100%, 86%, 100%, and 58%, respectively. Sensitivity, specificity, overall accuracy, positive predictive value, and negative predictive value of histopathologic diagnosis were 44%, 100%, 55%, 100%, and 32%, respectively. The K-ras point mutation was found in 74% of pancreatic cancers and 0% of focal pancreatitis lesions. No complication of EUS-guided FNA was observed. CONCLUSIONS: EUS-guided FNA is useful for the differential diagnosis of pancreatic mass lesions caused by pancreatic cancer and focal pancreatitis. Analysis for the K-ras point mutation in specimens obtained by EUS-guided FNA may enhance diagnostic accuracy in indeterminate cases.     

Frequency and significance of acute intracystic hemorrhage during EUS-FNA of cystic lesions of the pancreas

BACKGROUND: Complications from EUS-guided FNA of cystic lesions of the pancreas are infrequent. Although several studies have evaluated infectious complications of EUS-guided FNA in this setting, the frequency and the clinical significance of intracystic hemorrhage have not been determined. This study assessed the frequency of acute intracystic hemorrhage during EUS-guided FNA of pancreatic cystic lesions. The characteristic EUS appearance is described. METHODS: EUS-guided FNA of pancreatic cyst lesions was performed in 50 patients (July 2000 to June 2003). Patients were followed prospectively for the development of complications. OBSERVATIONS: Acute intracystic hemorrhage occurred during EUS-guided FNA at the site of aspiration in 3 patients (6%: 95% confidence interval [1.3%, 16.6%]). Endosonographically, the bleeding manifested as a small hyperechoic area at the puncture site that progressed gradually over a few minutes to involve the majority of the cyst cavity. EUS-guided FNA was terminated when bleeding was observed. One patient was asymptomatic, but two patients experienced abdominal pain transiently. All patients were treated with a short course of orally administered antibiotics and were observed as outpatients. Clinical history and laboratory parameters did not predict which patients were at risk for intracystic hemorrhage. CONCLUSIONS: Acute intracystic hemorrhage is a rare complication of EUS-guided FNA; it has a characteristic EUS appearance. Recognition of this event is important, because it permits termination of the procedure and thereby minimizes the potential for more serious bleeding.     

Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration

Background:  Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is increasingly being used in the staging algorithm for pancreatic carcinoma. This allows for a tissue diagnosis, which was previously difficult to obtain. The aim of this study is to assess the utility of EUS–FNA in establishing the diagnosis of solid pancreatic mass lesions in an Australian population.
Methods:  A retrospective review of the EUS databases of St Vincent's Hospital Melbourne and Western Hospital, Melbourne from November 2002 to May 2006 was undertaken. The focus was on patients with a solid pancreatic mass who underwent EUS–FNA. Surgical pathology or long-term follow up was used to identify false-positive or false-negative results.
Results:  EUS was undertaken to investigate a solid pancreatic or distal common bile duct mass lesion in 155 patients. Seventy-two of these underwent EUS-guided FNA. Mean age was 68 years. A positive tissue diagnosis of malignancy could be made in 55 (76%). Nine (13%) had benign histology, with 8 (11%) having inadequate tissue obtained from FNA. A later tissue diagnosis of carcinoma was made in eight of those with either benign or inadequate histology, although in all cases there were EUS features diagnostic of malignancy, with FNA limited by technical difficulties. The overall utility of EUS–FNA showed a sensitivity of 87%, specificity 100%, positive predictive value 100%, negative predictive value 52% and overall accuracy 89%.
Conclusion:  EUS–FNA gives a high return for histological diagnosis of solid pancreatic mass lesions and should be part of the standard management algorithm for pancreatic carcinoma.     

ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study

BACKGROUND: The accuracy of ERCP-based brush cytology or forceps biopsy for tissue diagnosis is relatively low (usually not exceeding 70%). By contrast, reported accuracy rates for EUS-guided FNA of pancreatobiliary masses are over 80%. This prospective study compared these two modalities for the first time in the diagnosis of indeterminate biliary strictures and pancreatic tumors. METHODS: Fifty consecutive patients (29 men, 21 women; mean age 62.1 years) with obstructive jaundice in whom a tissue diagnosis was required were included. During ERCP, intraductal specimens were obtained with a forceps and with two different types of brush (conventional and spiral suction) in random order. During EUS, only visible mass lesions or localized bile duct wall thickening were aspirated (22-gauge needle), with at least two passes yielding material sufficient for assessment. A cytopathologist was not present in the procedure room to evaluate specimen adequacy. The reference methods were surgery, other biopsy results, follow-up until death, or the conclusion of the study (mean follow-up 20 months). RESULTS: The final diagnoses were malignancy, 28 (16 pancreatic, 12 biliary), and benign biliary stricture, 22. Sensitivity and specificity for ERCP-guided biopsy were 36% and 100%, respectively; for ERCP-guided cytology (when using conventional and spiral suction brushes), 46% and 100%, respectively; and for EUS-guided FNA, 43% and 100%, respectively. If the punctured lesions are considered (n=28) alone, the sensitivity of EUS-guided FNA was 75%. In general, sensitivity was better for ERCP-based techniques in the subgroup biliary tumor (ERCP 75% vs. EUS 25%), whereas EUS-guided biopsy was superior for pancreatic mass (EUS 60% vs. ERCP 38%). CONCLUSIONS: For biliary strictures, combined ERCP- and EUS-guided tissue acquisition seems to be the best approach to tissue diagnosis. From a clinical standpoint, it appears reasonable, when a tissue diagnosis is required, to start with ERCP if biliary malignancy is suspected and with EUS when a pancreatic tumor is thought to be the cause of a biliary stricture.     

The utility and the safety of EUS-guided FNA in the evaluation of duplication cysts

BACKGROUND: Diagnosis of a foregut duplication cyst is of great clinical impact. A definitive diagnosis of a foregut duplication cyst can avert the need for major thoracic surgery in the otherwise asymptomatic individual. This study sought to evaluate the safety and the utility of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of foregut duplication cysts. METHODS: Over a period of 4 years, 4771 patients underwent EUS for various indications at two EUS referral centers. EUS findings were consistent with a mediastinal cyst in 30 cases. EUS-FNA was performed in 22 patients. A definitive diagnosis was established based on cytology, surgical pathology, and/or clinical follow-up. FNA was done with 22-gauge needles and antibiotic prophylaxis. RESULTS: The appearance of cyst contents on EUS ranged from completely anechoic (23 cases) to hypoechoic (7 cases). Hypoechoic cystic lesions contained echogenic foci. All anechoic lesions were confirmed as benign duplication cysts based on cytology, pathology, and clinical follow-up. Hypoechoic cystic lesions were confirmed to be benign duplication cysts in 4 cases. Three cases proved to be malignant or granulomatous necrotizing lymph nodes. No periprocedural complications occurred. CONCLUSIONS: Variation exists in the EUS appearance of benign mediastinal cysts. EUS-FNA of mediastinal cysts with smaller-gauge needles, and antibiotic prophylaxis appears safe and can provide a definitive diagnosis in atypical mediastinal cystic lesions.     

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of pancreatic cysts by combined cytopathology and cystic content analysis

Recent advances in imaging technology have resulted in an increase in incidental discoveries of pancreatic cystic lesions. Pancreatic cysts comprise a wide variety of lesions and include non-neoplastic cysts and neoplastic cysts. Because some pancreatic cysts have more of a malignant potential than others, it is absolutely essential that an accurate diagnosis is rendered so that effective care can be given to each patient. In many centers, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has emerged as the modality of choice that enables one to distinguish between mucinous and non-mucinous lesion, diagnose malignancy and collect cyst fluid for further diagnostic studies, such as pancreatic enzyme levels, molecular analysis and other tumor biomarkers. The current review will focus on EUS-guided FNA and the cytological diagnosis for pancreatic cysts.     

Endoscopic ultrasound in clinical practice

Endoscopic ultrasonography (EUS) is an accurate technique for the diagnosis and staging of benign and malignant lesions in the gastrointestinal tract and the mediastinum. EUS overcomes the limitations of other imaging diagnostic methods and gives the possibility to obtain tissue for histologic diagnosis (EUS guided FNA). The most useful indications of EUS are differentiation of submucosal tumors, staging for neoplasia, examination of the pancreato-biliary system and therapeutics. EUS can distinguish extrinsic compressions from intramural lesions and defines their nature (solid, cystic or vascular) and origin. EUS is useful for local staging of esophageal, gastric, duodenal, and rectal cancer using the TNM (tumor, node, metastases) system, as well as for diagnosing and staging of pancreatic lesions. The addition of EUS-guided FNA has improved the ability to detect malignant lymph node invasion. EUS is also highly sensitive for the diagnosis of choledocholithiasis, avoiding unnecessary danger of diagnostic ERCP. New therapeutic indications of EUS include drainage of pancreatic pseudocysts and abscesses and celiac plexus block and neurolysis. EUS has become an indispensable diagnostic method in gastroenterological everyday practice and should be part of most endoscopy units.     

Diagnosis of an aneurysm masquerading as a pancreatic-cyst lesion at EUS

BACKGROUND: EUS-guided FNA is commonly performed for evaluating pancreatic-cyst lesions. However, not all such lesions are true cystic neoplasms of the pancreas. OBJECTIVE: Determine the frequency at which aneurysms mimicking cysts are encountered during EUS evaluation of the pancreas. STUDY DESIGN: Observational study. SETTING: Tertiary referral center. PATIENTS: Consecutive patients found to have pancreatic cyst lesions at EUS. INTERVENTIONS: Patients with a cyst lesion in the pancreas that was suspicious for an aneurysm at EUS underwent abdominal CT imaging for a definitive diagnosis. MAIN OUTCOME MEASURES: To determine the frequency at which aneurysms are encountered during EUS while evaluating pancreatic-cyst lesions and to describe the EUS characteristics of an underlying aneurysm. RESULTS: Four of 413 lesions (0.97%, 95% confidence interval 0.26%-2.5%) that appeared as pancreatic cysts at EUS were diagnosed to be aneurysms: 2 were splenic artery aneurysms, 1 was an aneurysm of the gastroduodenal artery, and another was an infrarenal aortic aneurysm. The aneurysms had a characteristic donut-like appearance at EUS: a thick outer wall with a central anechoic area. LIMITATIONS: Observational study; small sample size. CONCLUSIONS: Aneurysms can masquerade as pancreatic-cystic lesions. Awareness of this entity is important because an inadvertent FNA during EUS may potentially lead to serious complications.     

Endoscopic ultrasound‐guided fine‐needle aspiration when combined with positron emission tomography improves specificity and overall diagnostic accuracy in unexplained mediastinal lymphadenopathy and staging of non‐small‐cell lung cancer

Background: The aim of this study was to assess the incremental value of endoscopic ultrasound (EUS)‐guided fine‐needle aspiration (FNA) to positron emission tomography (PET) in the diagnosis of unexplained mediastinal lymphadenopathy and staging of non‐small‐cell lung cancer (NSCLC). Methods: Patients who had both EUS‐guided FNA and PET were retrospectively identified from an EUS database at a tertiary hospital. All EUS‐guided FNA were carried out by one endoscopist between August 2002 and April 2005, either for the diagnosis of unexplained mediastinal lymphadenopathy or for the staging of NSCLC. Results of PET and EUS were compared with histology. A true histological positive result was defined as histological involvement in either surgery (mediastinoscopy or resection) or EUS‐guided FNA. A true histological negative result was defined as negative involvement at surgery (mediastinoscopy or resection). Results: Forty‐nine patients who had both PET scanning and EUS‐guided FNA for diagnosis of unexplained mediastinal lymphadenopathy or staging of NSCLC were identified. Of these, 33 (73% males, n = 24, age range = 44–78 years, mean = 62 years) had surgical confirmation of mediastinal lymph node pathology. In these patients, PET alone showed sensitivity, 95%; specificity, 90%; positive predictive value, 87%; negative predictive value, 90% and accuracy, 88%; whereas the addition of EUS‐guided FNA increased the overall specificity and positive predictive value to 100%, with an overall accuracy of 97%. Conclusions: This study suggests that EUS‐guided FNA complements PET by improving the overall specificity and thereby the accuracy for diagnosis of unexplained mediastinal lymphadenopathy. It provides a minimally invasive technique to assess the mediastinum in patients with NSCLC and is particularly valuable in cases in which PET findings are equivocal.     

Role of endoscopic ultrasound in the diagnosis of patients with solid pancreatic masses

Endoscopic ultrasound (EUS) is the most sensitive imaging procedure for the detection of small solid pancreatic masses and is accurate in determining vascular invasion of the portal venous system. Even compared to the new CT techniques, EUS provides excellent results in preoperative staging of solid pancreatic tumors. Compared to helical CT techniques, EUS is less accurate in detecting tumor involvement of the superior mesenteric artery. EUS staging and EUS-guided FNA can be performed in a single-step procedure, to establish the diagnosis of cancer. There is no known negative impact of tumor cell seeding due to EUS-guided fine needle aspiration (FNA). Without FNA, EUS and additional methods are not able to reliably distinguish between inflammatory and malignant masses.     

EUS-FNA of recurrent postoperative extraluminal and metastatic malignancy

BACKGROUND: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described. METHODS: A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence. RESULTS: Twenty-one patients underwent EUS-guided FNA of 21 lesions (19 masses, 2 lymph nodes) because of a suspicion of recurrent malignancy based on CT (n = 17) or EUS (n = 4) findings. Median time from the initial diagnosis to recurrence was 26 months (range 5-276 months). Lesions were located in the pancreas (9 patients), mediastinum (7), liver (3), perigastric region (1), and liver hilum (1). EUS-guided FNA (mean number of needle passes, 4.5; range 2-8) obtained diagnostic material for recurrent malignancy in all patients as follows: esophageal (6 patients), renal cell (6), pancreatic (2), breast (2), colon (2), bile duct (1), Ewing's sarcoma (1), and lung (1) cancer. No complication was encountered. Transgastric EUS-guided FNA (4 patients), distal, or transesophageal EUS-FNA (2) proximal to a surgical anastomosis was required to confirm recurrence in all 6 patients with esophageal cancer. The initial cytologic diagnosis of recurrent malignancy was made by EUS in 20 of 21 (95%) patients. One patient with recurrent breast cancer had CT-guided FNA of a right lung mass preceding EUS-guided FNA of an AP window lymph node. CONCLUSIONS: EUS-guided FNA can detect and safely diagnose recurrent malignancy in the mediastinum, retroperitoneum, and liver. When possible, correlation between EUS-guided FNA cytology and original tumor histopathology/cytology, or the use of immunostaining to confirm the diagnosis, is recommended.     

EUS findings in patients with autoimmune pancreatitis

BACKGROUND: Autoimmune pancreatitis is an increasingly recognized benign condition with a presentation similar to pancreatic neoplasia but responds to corticosteroid therapy. Clinical features, ERCP, and CT findings have been described. This study assessed the EUS and EUS-guided FNA features of proven autoimmune pancreatitis. METHODS: The diagnosis of autoimmune pancreatitis was based on examination of surgical resection specimens or typical clinical findings (elevated immunoglobulin G level, no evidence of malignancy, characteristic non-EUS imaging studies, and clinical improvement, especially in response to treatment with a corticosteroid). RESULTS: Presenting manifestations in 14 patients included obstructive jaundice, abdominal pain, and weight loss. Ten patients underwent surgery (including exploratory surgery). Six were successfully treated with corticosteroid. EUS revealed diffuse hypoechoic pancreatic enlargement (8/14) or a focal irregular hypoechoic mass (6/14). Features of chronic pancreatitis were not noted. EUS-guided FNA of the pancreas was suggestive of chronic inflammatory pancreatitis in 9 of 12 patients. Celiac and peripancreatic lymphadenopathy (up to 3 cm in diameter) was present in 6 patients. EUS-guided FNA of lymph nodes (3/4) did not reveal evidence of malignancy. Vascular involvement was noted in 3 patients. CONCLUSIONS: The EUS features of autoimmune pancreatitis are easily mistaken for malignancy. However, a diffusely hypoechoic, enlarged pancreas, together with chronic inflammatory cells in aspirated cytologic specimens, is supportive of the diagnosis of autoimmune pancreatitis. When combined with clinical data, EUS and EUS-guided FNA may support a diagnosis of autoimmune pancreatitis, may warrant a trial of corticosteroid, and thereby may prevent unnecessary surgery.     

Percutaneous ultrasound and endoscopic ultrasound-guided biopsy of solid pancreatic lesions: An analysis of 1074 lesions

Backgrounds: Percutaneous ultrasound (US) and endoscopic ultrasound (EUS)-guided pancreatic biopsies are widely accepted in the diagnosis of pancreatic diseases. Studies comparing the diagnostic performance of US- and EUS-guided pancreatic biopsies are lacking. This study aimed to evaluate and compare the diagnostic yields of US- and EUS-guided pancreatic biopsies and identify the risk factors for inconclusive biopsies. Methods: Of the 1074 solid pancreatic lesions diagnosed from January 2017 to February 2021 in our center, 275 underwent EUS-guided fine needle aspiration (EUS-FNA), and 799 underwent US-guided core needle biopsy (US-CNB/FNA). The outcomes were inconclusive pathological biopsy, diagnostic accuracy and the need for repeat biopsy. All of the included factors and diagnostic performances of both US-CNB/FNA and EUS-FNA were compared, and the independent predictors for the study outcomes were identified. Results: The diagnostic accuracy was 89.8% for EUS-FNA and 95.2% for US-CNB/FNA ( P = 0.001). Biopsy under EUS guidance [odds ratio (OR) = 1.808, 95% confidence interval (CI): 1.083-3.019; P = 0.024], lesion size < 2 cm (OR = 2.069, 95% CI: 1.145-3.737; P = 0.016), hypoechoic appearance (OR = 0.274, 95% CI: 0.097-0.775; P = 0.015) and non-pancreatic ductal adenocarcinoma carcinoma (PDAC) diagnosis (OR = 2.637, 95% CI: 1.563-4.449; P < 0.001) were identified as factors associated with inconclusive pathological biopsy. Hypoechoic appearance (OR = 0.236, 95% CI: 0.064-0.869; P = 0.030), lesions in the uncinate process of the pancreas (OR = 3.506, 95% CI: 1.831-6.713; P < 0.001) and non-PDAC diagnosis (OR = 2.622, 95% CI: 1.278-5.377; P = 0.009) were independent predictors for repeat biopsy. Biopsy under EUS guidance (OR = 2.024, 95% CI: 1.195-3.429; P = 0.009), lesions in the uncinate process of the pancreas (OR = 1.776, 95% CI: 1.014-3.108; P = 0.044) and hypoechoic appearance (OR = 0.127, 95% CI: 0.047-0.347; P < 0.001) were associated with diagnostic accuracy. Conclusions: Both percutaneous US- and EUS-guided biopsies of solid pancreatic lesions are safe and effective; though the diagnostic accuracy of EUS-FNA is inferior to US-CNB/FNA. A tailored pancreatic biopsy should be considered a part of the management algorithm for the diagnosis of solid pancreatic disease.     

Rapid on-site evaluation of endoscopic-ultrasound-guided fine-needle aspiration diagnosis of pancreatic masses

Endoscopic ultrasound (EUS) has become an essential tool for the study of pancreatic diseases. Specifically, EUS plays a pivotal role evaluating patients with a known or suspected pancreatic mass. In this setting, differential diagnosis remains a clinical challenge. EUS-guided fine-needle aspiration (FNA) and fine-needle biopsy (FNB) have been proven to be safe and useful tools in this setting. EUS-guided FNA and FNB, by obtaining cytological and/or histological samples, are able to diagnose pancreatic lesions with high sensitivity and specificity. In this context, several methodological features, trying to increase the diagnostic yield of EUS-guided FNA and FNB, have been evaluated. In this review, we focus on the role of rapid on-site evaluation (ROSE). From data reported in the literature, ROSE may increase diagnostic yield of EUS-FNA specimens by 10%-30%, and thus, diagnostic accuracy. However, we should point out that many recent studies have reported adequacy rates of > 90% without ROSE, indicating that, perhaps, at high-volume centers, ROSE may not be indispensable to achieve excellent results. The use of ROSE can be considered important during the learning curve of EUS-FNA, and also in hospital with diagnostic accuracy rates < 90%.     

Endosonographically controlled fine needle aspiration cytology--indications and results in routine diagnosis]

The usefulness and clinical utility of routine EUS-guided fine needle aspiration cytology (FNA) in the diagnosis of lesions adjacent to the upper gastrointestinal tract was prospectively studied. METHODS: EUS/FNA was performed in 122 patients for 125 lesions: Mediastinal lymph nodes (n = 56), pancreatic lesions (n = 45), paragastric masses (n = 12), submucosal tumors (n = 4) and small hepatic lesions (n = 2) were successfully punctured for cytological diagnosis. RESULTS: Adequate material was gained in 119 out of 125 punctures (95%). Overall sensitivity, specifity, positive and negative predictive value were 90%, 98%, 98% and 89%. Results of EUS/FNA in mediastinal lymph nodes were superior (95%, 100%, 100%, 90%) to those in pancreatic lesions (80%, 100%, 100%, 80%). In paragastric masses sensitivity was 100% whereas specifity was only 67%--due to one false-positive result. Out of four submucosal tumors diagnosis was revealed in three. Two liver metastasis were successfully punctured. 35 out of 56 mediastinal nodes showed malignancy. 27 metastases of lung-, three of gastric-, two of renal cancer and three Non-Hodgkins's lymphoma were diagnosed. The cytological results of 45 pancreatic lesions showed cancer in 19 and chronic inflammation in 21, two abscesses and three benign cysts. There were no complications. 37 patients were treated on outpatient's basis. CONCLUSIONS: EUS-guided FNA is an accurate and safe technique to sample cytology from lesions adjacent to the wall of the upper gastrointestinal tract. New indications may be established for the diagnosis of lung cancer or metastases of other spreading out into the mediastinum or the celiac axis.     

Role of endoscopic ultrasonography in the diagnosis and treatment of cystic tumors of the pancreas

Endoscopic ultrasound (EUS) allows high resolution imaging of the pancreas. EUS is a very useful technique for evaluating morphological features of a cystic tumors of the pancreas. These features include thick wall type, tumor protruding type, thick septal type, microcystic type, thin septal type and simple type. Malignant cystic lesions may present as a hypoechoic cystic/solid mass or as a complex cyst and are frequently associated with a dilated main pancreatic duct. There is some overlap between EUS appearances of non-neoplastic and neoplastic cystic pancreatic lesions. EUS guided FNA of cystic pancreatic lesions can play an important role in the differential diagnosis of these lesions and deciding about the need for surgery by evaluating cytology and tumor markers such as CEA in cyst fluid. There is some emerging data on EUS guided treatment of cystic pancreatic tumors by injection of alcohol.