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 lymphadenectomy 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 EUSFNA.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.     

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy for pancreatic masses,subepithelial lesions,and lymph nodes

Endoscopic ultrasound tissue acquisition, in the form of both fine needle aspiration (EUS-FNA) and fine needle biopsy (EUS-FNB), is utilized for pancreatic mass lesions, subepithelial lesions, and lymph node biopsy. Both procedures are safe and yield high diagnostic value. Despite its high diagnostic yield, EUS-FNA has potential limitations associated with cytological aspirations, including inability to determine histologic architecture, and a small quantitative sample for further immunohistochemical staining. EUS-FNB, with its larger core biopsy needle, was designed to overcome these potential limitations. However, it remains unclear which technique should be used and for which lesions. Comparative trials are plagued by heterogeneity at every stage of comparison; including variable needles used, and different definitions of endpoints, which therefore limit generalizability. Thus, we present a review of prospective trials, systematic reviews, and meta-analyses on studies examining EUS-FNA vs EUS-FNB. Prospective comparative trials of EUS-FNA vs EUS-FNB primarily focus on pancreatic mass lesions, and yield conflicting results in terms of demonstrating the superiority of one method. However, consistent among trials is the potential for diagnosis with fewer passes, and a larger quantity of sample achieved for next generation sequencing. With regard to subepithelial lesions and lymph node biopsy, fewer prospective trials exist, and larger prospective studies are necessary. Based on the available literature, we would recommend EUS-FNB for peri-hepatic lymph nodes.     

EUS-guided reverse bevel fine-needle biopsy sampling and open tip fine-needle aspiration in solid pancreatic lesions – a prospective,comparative study

Objectives: Different diagnostic entities can present as solid pancreatic lesions (SPL). This study aimed to explore the utility of endoscopic ultrasound-guided reverse bevel fine-needle biopsy sampling (EUS-FNB) in SPLs.

Material and methods: In 2012–2015, consecutive patients with SPLs were prospectively included in a tertiary center setting and subjected to dual needle sampling with a 22 gauge reverse bevel biopsy needle and a conventional 25 gauge open tip aspiration needle (EUS-FNA). The outcome measures were the diagnostic accuracy of sampling, calculated for each modality separately and for the modalities combined (EUS-FNA?+?FNB), and the adverse event rate related to sampling.

Results: In 68 unique study subjects, the most common diagnostic entities were pancreatic neuroendocrine tumor, PNET, (34%), pancreatic ductal adenocarcinoma, PDAC, (32%), pancreatitis (15%) and metastasis (6%). The overall diagnostic accuracy of EUS-FNB was not significantly different from that of EUS-FNA, (69% vs. 78%, p?=?.31). EUS-FNA?+?FNB, compared with EUS-FNA alone, had a higher sensitivity for tumors other than PDAC (89% vs. 69%, p?=?.02) but not for PDACs (95% vs. 85%, p?=?.5). No adverse event was recorded after the study dual-needle sampling procedures.

Conclusions: Endoscopic ultrasound-guided tissue acquisition performed with a 22 gauge reverse bevel biopsy needle is safe but not superior to conventional fine-needle aspiration performed with a 25 gauge open tip needle in diagnosing solid pancreatic lesions. However, the performance of both these modalities may facilitate the diagnostic work-up in selected patients, such as cases suspicious for pancreatic neuroendocrine tumors and metastases. NCT02360839.     

Comprehensive review on endoscopic ultrasound-guided tissue acquisition techniques for solid pancreatic tumor

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030, a high mortality rate considering the number of cases. Surgery and chemotherapy are the main treatment options, but they are burdensome for patients. A clear histological diagnosis is needed to determine a treatment plan, and endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding. With the development of personalized medicine and precision treatment, there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure, leading to the development of the fine-needle biopsy (FNB) needle. EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration (FNA) as the procedure of choice for EUS-TA of pancreatic cancer. However, EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions, so it is important clinicians are familiar with both. Given these recent dev-elopments, we present an up-to-date review of the role of EUS-TA in pancreatic cancer. Particularly, technical aspects, such as needle caliber, negative pressure, and puncture methods, for obtaining an adequate specimen in EUS-TA are discussed.     

Rescue Endoscopic Ultrasound (EUS)-Guided Trucut Biopsy Following Suboptimal EUS-Guided Fine Needle Aspiration for Mediastinal Lesions

Background/Aims

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and Trucut biopsy (TCB) are sensitive techniques for diagnosing mediastinal lesions, but it is unclear how either one or both should be used to obtain a pathologic diagnosis. The objective of our study was to evaluate whether EUS-TCB impacts the diagnosis of mediastinal lesions after the initial on-site review of EUS-FNA specimen suggests a suboptimal result.

Methods

We enrolled consecutive patients with mediastinal lesions who underwent EUS-TCB during the same procedure if the initial EUS-FNA demonstrated an inadequate FNA sample or suggested that histopathology was required for diagnosis. Diagnostic accuracies between procedures were compared as the main outcome.

Results

Twenty-seven patients (14 men; median age, 56 years; range, 19 to 82 years) underwent EUS-FNA and EUS-TCB to evaluate a mediastinal lymphadenopathy or mass (n=17), to determine the cancer stage (n=3) or to exclude tumor recurrence or metastasis (n=7). The overall diagnostic accuracies of EUS-FNA and EUS-TCB were 78% and 67%, respectively (p=0.375). The combined diagnostic accuracy of EUS-FNA plus EUS-TCB was 82%. In six patients with nondiagnostic EUS-FNA, EUS-TCB provided a final diagnosis in one patient (17%).

Conclusions

In the current series of patients with mediastinal masses or adenopathy, the administration of EUS-TCB following suboptimal results for the on-site cytology review did not increase the diagnostic yield.     

Role of endoscopic ultrasound in the molecular diagnosis of pancreatic cancer

Pancreatic ductal adenocarcinoma remains one of the most deadly types of tumor. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe, cost-effective, and accurate technique for evaluating and staging pancreatic tumors. However, EUS-FNA may be inconclusive or doubtful in up to 20% of cases. This review underlines the clinical interest of the molecular analysis of samples obtained by EUS-FNA in assessing diagnosis or prognosis of pancreatic cancer, especially in locally advanced tumors. On EUS-FNA materials DNA, mRNA and miRNA can be extracted, amplified, quantified and subjected to methylation assay. Kras mutation assay, improves diagnosis of pancreatic cancer. When facing to clinical and radiological presentations of pseudo-tumorous chronic pancreatitis, wild-type Kras is evocative of benignity. Conversely, in front of a pancreatic mass suspected of malignancy, a mutated Kras is highly evocative of pancreatic adenocarcinoma. This strategy can reduce false-negative diagnoses, avoids the delay of making decisions and reduces loss of surgical resectability. Similar approaches are conducted using analysis of miRNA expression as well as Mucin or markers of invasion (S100P, S100A6, PLAT or PLAU). Beyond the diagnosis approach, the prediction of response to treatment can be also investigated form biomarkers expression within EUS-FNA materials.     

Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications

Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.     

Endoscopic mediastinal staging of lung cancer

The advent of endoscopic ultrasound-guided sampling procedures such as endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has lead to significant advances in the mediastinal diagnosis and staging of lung cancer. These endoscopic techniques can be performed in the outpatient setting under conscious sedation and local anesthesia, in contrast to the surgical standard, mediastinoscopy (MS), which requires operating theatre time and general anesthesia. Proponents of mediastinoscopy have always emphasized the advantages of mediastinoscopy, namely its sensitivity even with a low prevalence of mediastinal metastases and its low false negative rate. Newer endoscopic techniques such as EBUS-TBNA are showing sensitivities exceeding that of mediastinoscopy, even in the setting of an equally low prevalence of mediastinal metastases. However, endoscopic techniques have double the false negative rate of mediastinoscopy. As the tracheobronchial route and esophageal route provide almost complete access to mediastinal lymph nodes, these endoscopic techniques are complementary rather than competing. When used in combination, it is possible mediastinoscopy may be superseded. The challenge however, is how best to select the appropriate endoscopic procedures to accurately stage lung cancer in the most cost-effective manner.     

Resected tumor seeding in stomach wall due to endoscopic ultrasonography-guided fine needle aspiration of pancreatic adenocarcinoma

Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is a useful and relatively safe tool for the diagnosis and staging of pancreatic cancer. However, there have recently been several reports of tumor seeding after EUS-FNA of adenocarcinomas. A 78-year-old man was admitted to our hospital due to upper gastric pain. Examinations revealed a 20 mm mass in the pancreatic body, for which EUS-FNA was performed. The cytology of the lesion was adenocarcinoma, and the stage of the cancer was T3N0M0. The patient underwent surgery with curative intent, followed by adjuvant chemotherapy with S-1. An enlarging gastric submucosal tumor was found on gastroscopy at 28 mo after surgery accompanied by a rising level of CA19-9. Biopsy result was adenocarcinoma, consistent with a pancreatic primary tumor. Tumor seeding after EUS-FNA was strongly suspected. The patient underwent surgical resection of the gastric tumor with curative intent. The pathological result of the resected gastric specimen was adenocarcinoma with a perfectly matched mucin special stain result with the previously resected pancreatic cancer. This is the first case report of tumor seeding after EUS-FNA which was surgically resected and inspected pathologically.     

内镜超声引导下细针穿刺活检术对腹腔占位病灶的诊断价值

目的探讨内镜超声引导下细针穿刺活检术(EUS-FNA)对腹腔占位病灶的诊断价值和安全性。方法收集2009-05～2011-06因腹腔占位行EUS-FNA的患者19例,回顾性分析EUS-FNS病理的阳性率及EUS-FNA与手术后病理的符合率。结果 19例患者穿刺病理结果,腺癌11例,假性乳头状瘤1例,胰腺导管内乳头状黏液瘤(IPMT)1例,炎性改变6例,穿刺检查阳性率为68.4%。其中7例行手术治疗,术后病理与穿刺标本病理或细胞学结果符合6例,符合率为86.0%。本组19例患者EUS-FNA术后无出血、穿孔、感染及急性胰腺炎等并发症。结论 EUS-FNA是一项准确而安全有效的技术,对腹腔占位病灶尤其是胰腺肿瘤的定性诊断及进一步治疗方案的确定具有重要的临床价值。     

Improved diagnostic yield of endoscopic ultrasound-fine needle biopsy with histology specimen processing

BACKGROUND Endoscopic ultrasound-guided fine needle biopsy(EUS-FNB) has emerged as a safe, efficacious alternative to fine needle aspiration(FNA) for tissue acquisition. EUS-FNB is reported to have higher diagnostic yield while preserving specimen tissue architecture. However, data on the optimal method of EUS-FNB specimen processing is limited.AIM To evaluate EUS-FNB with specimen processing as histology vs EUS-FNA cytology with regards to diagnostic yield and specimen adequacy.METHODS All EUS-FNA and EUS-FNB performed at our institution from July 1, 2016, to January 31, 2018, were retrospectively analyzed. We collected data on demographics, EUS findings, pathology, clinical outcomes, and procedural complications in two periods, July 2016 through March 2017, and April 2017 through January 2018, with predominant use of FNB in the second data collection time period. FNA specimens were processed as cytology with cell block technique and reviewed by a cytopathologist; FNB specimens were fixed in formalin, processed for histopathologic analysis and immunohistochemical staining, and reviewed by an anatomic pathologist. Final diagnosis was based on surgical pathology when available, repeat biopsy or imaging, and length of clinical follow up.RESULTS One hundred six EUS-FNA and EUS-FNB procedures were performed. FNA alone was performed in 17 patients; in 56 patients, FNB alone was done; and in 33 patients, both FNA and FNB were performed. For all indications, diagnostic yield was 47.1%(8/17) in FNA alone cases, 85.7%(48/56) in FNB alone cases, and 84.8%(28/33) in cases where both FNA and FNB were performed(P = 0.0039). Specimens were adequate for pathologic evaluation in 52.9%(9/17) of FNA alone cases, in 89.3%(50/56) of FNB alone cases, and 84.8%(28/33) in cases where FNA with FNB were performed(P = 0.0049). Tissue could not be aspirated for cytology in 10.0%(5/50) of cases where FNA was done, while in 3.4%(3/89) of FNB cases, tissue could not be obtained for histology. In patients who underwent FNA with FNB, there was a statistically significant difference in both specimen adequacy(P = 0.0455) and diagnostic yield(P = 0.0455) between the FNA and FNB specimens(processed correspondingly as cytology or histology).CONCLUSION EUS-FNB has a higher diagnostic yield and specimen adequacy than EUS-FNA. In our experience, specimen processing as histology may have contributed to the overall increased diagnostic yield of EUS-FNB.     

Gastrointestinal stromal tumor of the stomach: How to manage?

Gastrointestinal stromal tumor (GIST) is one of the most common malignant mesenchymal tumors of the stomach. Prognosis of this disease is related to tumor size and mitotic activity and early diagnosis is the only way to improve it. Diagnosis of GIST always requires histological and immunohistochemical confirmation as no imaging modalities can diagnose it conclusively. Endoscopic forceps biopsy results are frequently negative. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a technique which allows tissue samples to be obtained with minimal risks and is accurate in the diagnosis of GIST. From the point of view of the endoscopist, aggressive use of EUS-FNA is the only promising way to allow early diagnosis and early treatment of this disease.     

超声内镜引导细针穿刺抽吸术在常规内镜活检诊断不明确 的胃肠道病变中的应用价值

目的 评价超声内镜引导细针穿刺抽吸术（EUS-FNA）在常规内镜活检诊断不明确的胃肠道病变中的应用价值。 方法 回顾性分析65例常规内镜活检诊断不明确的胃肠道病变且在我院行EUS-FNA的患者的诊断结果和随访情况,以手术病理和随访结果为最终诊断,评估EUS-FNA对此类病变的诊断价值。结果 本研究中男性患者41例,女性24例,中位年龄60岁。普通内镜下以弥漫浸润型病变最为多见（56.9%）,其次为黏膜下隆起型病变（21.7%）。54例（83.1%）患者诊断为肿瘤性病变,非肿瘤性病变11例（83.1%）。EUS-FNA总的诊断敏感度、特异度及准确性为76.8%（95%CI: 65.7%-87.8%）、100%（95%CI: 66.4%-100%）、及80.0%（95%CI: 70.3%-89.7%）。亚组分析显示EUS-FNA在弥漫浸润型病变中的诊断敏感度、特异度及准确性分别为70.6%（95%CI: 55.3%-85.9%）、100%（95%CI: 29.2%-100%）及73.0%（95%CI: 58.7%-87.3%）;在黏膜下隆起型病变中的诊断敏感度、特异度及准确性分别为68.8%（95%CI: 46.0%-91.5%）、100%（95%CI: 2.5%-100%）及70.6%（95%CI: 44.0%-89.7%）。结论 EUS-FNA对常规内镜活检诊断不明确的胃肠道病变具有中等强度的诊断价值,可作为此类病变在常规内镜活检无法确诊后的备选方案,但仍需结合其他手段或技术改进以进一步提高EUS-FNA的诊断效能。     

Role of preoperative endoscopic ultrasound-guided fine-needle tattooing of a pancreatic head insulinoma

Although insulinomas are rare, they are the most com-mon pancreatic neuroendocrine tumor, with an inci-dence of four cases per million population. Insulinomas are generally benign indolent intrapancreatic tumors. Surgical resection remains the main option for treat-ment. However, up to 67% of a pancreatic head insu-linomas are nonpalpable, thus surgical resection of the nonplapable insulinoma in this area could become prob-lematic resulting in prolonged surgical time, increased risk of pancreatic duct injury and need for pancreati-coduodenectomy. Endoscopic ultrasound-guided fine- needle tattooing(EUS-FNT), has been shown to have a crucial role for localization of pancreatic body and tail lesions, facilitating laparoscopic distal pancreatectomyand helping surgeons identify the location of the tumor. EUS-FNT might have a role for preoperative localiza-tion of pancreatic head insulinomas which are likely to be nonpalpable. We report a case of preoperative EUS-FNT for localization of a nonplapable pancreatic head insulinoma. This report demonstrates that EUS-FNT of pancreatic head insulinomas may facilitate surgical resection, reduce operative time and decrease surgical complications.     

Pancreatic paraganglioma diagnosed by endoscopic ultrasound-guided fine needle aspiration: A case report and review of literature

BACKGROUNDPancreatic paragangliomas (PPGL) are rare benign neuroendocrine neoplasms but malignancy can occur. PPGL are often misdiagnosed as pancreatic neuroendocrine tumor or pancreatic adenocarcinoma.CASE SUMMARYWe reviewed 47 case reports of PPGL published in PubMed to date. Fifteen patients (15/47) with PPGL underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Only six (6/15) were correctly diagnosed as PPGL. All patients with PPGL underwent surgical resection except three (one patient surgery was aborted because of hypertensive crisis, two patients had metastasis or involvement of major vessels). Our patient remained on close surveillance as she was asymptomatic.CONCLUSIONAccurate preoperative diagnosis of PPGL can be safely achieved by EUS-FNA with immunohistochemistry. Multidisciplinary team approach should be considered to bring the optimal results in the management of PPGL.     

Severe Bleeding and Perforation Are Rare Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration for Pancreatic Masses: An Analysis of 3,090 Patients from 212 Hospitals

Background/Aims

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is useful for the pathological diagnosis of pancreatic masses, but patients are susceptible to severe bleeding and perforation. Because the incidence and severity of these complications have not been fully evaluated.

Methods

We aimed to evaluate severe bleeding and perforation after EUS-FNA for pancreatic masses using large-scale data derived from a Japanese nationwide administrative database.

Results

In total, 3,090 consecutive patients from 212 low- to high-volume hospitals were analyzed. Severe bleeding requiring transfusion or endoscopic treatment occurred in seven patients (0.23%), and no perforation was observed. No patient mortality was recorded within 30 days of EUS-FNA. The rate of severe bleeding in low-volume hospitals was significantly higher than that in medium- and high-volume hospitals (0.48% vs 0.10%, p=0.045).

Conclusions

Severe bleeding and perforation following EUS-FNA for pancreatic masses are rare, and the procedure is safe.     

Clinical impact of endoscopic ultrasonography on the management of neuroendocrine tumors: lights and shadows

The incidence of gastroenteropancreatic neuroendocrine neoplasms has increased in the recent decades.An extensive bibliographical search was performed in PubMed to identify guidelines and primary literature (retrospective and prospective studies, systematic reviews, case series) published mostly between year 1997 and June 2017, using both medical subject heading (MeSH) terms and free-language keywords about the accuracy and diagnostic and therapeutic role of endoscopic ultrasound in the context of gastro-entero-pancreatic neuroendocrine neoplasms.Endoscopic ultrasound is the modality of choice for diagnosing pancreatic neuroendocrine neoplasms and for the locoregional staging of gastric, duodenal, pancreatic and rectal neuroendocrine neoplasms; in particular, in the setting of pancreatic neuroendocrine neoplasms it has demonstrated higher accuracy in tumor detection than other imaging modalities.Furthermore, the possibility of tattooing pancreatic lesions by endoscopic ultrasound fine needle aspiration may help surgeons to locate the tumor and avoid any demolition surgery. Finally, endoscopic ultrasound-guided therapies have been proposed and used in several studies for patients unsuitable for surgery, with good results on the control of symptoms and the reduction of tumor burden.     

内镜超声引导下细针抽吸术获取胰腺癌组织构建体外三维类器官模型的前瞻性临床研究

目的 探讨通过内镜超声引导下细针抽吸术（EUS-FNA）获取胰腺癌组织构建体外三维类器官（organoid）模型的可行性。方法 自2017年6月至2018年1月前瞻性纳入发现胰腺占位并行EUS-FNA诊断的患者9例,术中使用COOK公司22 G穿刺针穿刺获取病灶组织构建体外类器官模型,并持续观察其体外生长状态。结果 9例患者EUS-FNA穿刺的胰腺病灶组织标本,其中5例体外类器官模型构建成功。这5例组织标本经组织病理学诊断均证实为胰腺癌。随着传代次数增加,类器官的生长速度相应加快,对类器官进行HE染色显示类器官与其来源的人胰腺病灶组织病理形态大致相似。结论 通过EUS-FNA穿刺获取人胰腺病灶组织,可以成功构建体外三维类器官模型。胰腺癌类器官模型的建立为临床上胰腺肿瘤患者精准治疗策略的制定提供了绝佳的模型。     

Comparison of 22-gauge aspiration needle with 22-gauge biopsy needle in endoscopic ultrasonography-guided subepithelial tumor sampling

Abstract

Objective. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (EUS-FNA) may facilitate tissue sampling for histopathological diagnosis of subepithelial tumors (SETs) in the gastrointestinal (GI) tract. However, immunohistochemistry is not always feasible using EUS-FNA samples due to the low quality of specimens often obtained by aspiration. This study aimed to compare the use of 22-gauge (G) EUS-guided fine-needle biopsy (EUS-FNB) with 22G EUS-FNA for core sampling used for histopathological examination, including immunohistochemistry, in patients with GI SETs. Methods. Twenty-eight patients with GI SETs ≥2 cm in size were prospectively enrolled at five university hospitals in Korea between January and June 2013. They were randomized to undergo either EUS-FNB or EUS-FNA. Results. A total of 22 patients was finally analyzed in this study: 10 and 12 patients underwent EUS-FNA and EUS-FNB, respectively. Compared to the EUS-FNA group, the EUS-FNB group had a significantly lower median number of needle passes to obtain macroscopically optimal core samples (4 vs. 2, p = 0.025); higher yield rates of macroscopically and histologically optimal core samples with three needle passes (30% vs. 92%, p = 0.006; 20% vs. 75%, p = 0.010, respectively); and a higher diagnostic sufficiency rate (20% vs. 75%, p = 0.010). No technical difficulties were encountered in either group. Conclusions. This study shows that EUS-FNB has a better ability to obtain histological core samples and a higher diagnostic sufficiency rate than EUS-FNA and that EUS-FNB is a feasible, safe, and preferable modality for adequate core sampling for histopathological diagnosis of GI SETs.     

Comparative study of diagnostic value of cytologic sampling by endoscopic ultrasonography-guided fine-needle aspiration and that by endoscopic retrograde pancreatography for the management of pancreatic mass without biliary stricture

BACKGROUND: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) can now provide a cytopathological diagnosis of underlying pancreatic malignancy with higher success rates than endoscopic retrograde pancreatography (ERP). To determine the significance of EUS-FNA for the diagnosis of pancreatic mass without biliary stricture, the value of cytopathological diagnosis obtained by EUS-FNA was retrospectively compared with that by ERP, and the complications associated with these procedures evaluated. METHODS: Eighty-three patients who were suspected to have a pancreatic mass (excluding a cystic mass), without biliary stricture on conventional ultrasound and/or computed tomography were enrolled. The EUS-FNA biopsy was performed in 53 patients and cytology utilizing ERP was performed in 30 patients. RESULTS: The sampling rate of adequate specimen was 100% in both groups. In the EUS-FNA group, the overall results for the available samples were sensitivity 92.9% and accuracy 94.3%. In contrast, in the ERCP group, the overall results were sensitivity 33.3% and accuracy 46.7%. There was a significant difference between the two groups (P < 0.01). With regard to complications, there was a significant difference (P < 0.01) in the frequency of post-procedure pancreatitis between the EUS-FNA group and ERP group (0%, 0/53 vs 33.3%, 10/30, respectively). CONCLUSION: Endoscopic ultrasonography-guided fine-needle aspiration is safer and more accurate for the cytopathological diagnosis of suspected pancreatic masses without a biliary stricture as compared with cytology during ERP. Endoscopic ultrasonography with FNA should be considered a preferred test (prior to attempting endoscopic retrograde cholangiopancreatography) when a cytological diagnosis of a pancreatic mass is required, especially when there is no biliary obstruction, or when emergent decompression of an obstructed biliary tree is not considered clinically necessary due to lack of signs and symptoms of cholangitis.