Does onsite cytotechnology evaluation improve the accuracy of endoscopic ultrasound-guided fine-needle aspiration biopsy?

BACKGROUND:

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the preferred modality for the cytological diagnosis of various cancers. Onsite cytopathology interpretation is not available in most centres.

OBJECTIVE:

To assess whether the the adequacy of tissue sampling assessed by an onsite cytotechnologist improves the diagnostic accuracy of EUS-FNA.

METHODS:

The present study is a retrospective review of all patients undergoing solid mass EUS-FNA between September 2005 and August 2007. Patients in group I (September 2005 to August 2006) had cytology slides prepared by an endoscopy nurse. Patients in group II (September 2006 to August 2007) had cytology slides prepared, stained and assessed for adequacy of tissue sampling by a cytotechnologist in the endoscopy suite. The final cytopathological diagnosis (definitely positive, definitely negative or inconclusive) was compared between the two groups.

RESULTS:

A total of 49 EUS-FNA procedures were performed in 47 patients in group I and 60 EUS-FNA procedures in 55 patients in group II. Pancreatic masses were the most common target site in both groups. The total number of needle passes was 105 in group I (mean 2.14 passes per patient; range one to five needle passes) and 158 in group II (mean 2.63 passes per patient; range one to four needle passes). The difference in the number of needle passes was not statistically significant between groups. The final diagnosis was definite in 53% in group I compared with 77% in group II (P=0.01). The percentage of inconclusive diagnoses was 47% in group I and 23% in group II (P=0.001).

CONCLUSION:

Onsite cytotechnologist interpretation of adequacy of tissue sampling significantly improves the diagnostic yield of EUS-FNA. This appears to be independent of the total number of needle passes undertaken for tissue sampling.     

Does cytotechnician training influence the accuracy of EUS-guided fine-needle aspiration of pancreatic masses?

Background/aimThe presence of on-site cytopathologists improves the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic masses; however, on-site cytopathologists are not available to all endoscopic units. We hypothesized that experienced cytotechnicians can accurately assess whether an on-site pancreatic mass fine needle aspiration specimen is adequate. The aim of this study was to evaluate the effect of formal cytotechnician training on the diagnostic accuracy of EUS-FNA of pancreatic masses.MethodsSingle-centre, prospective study. The cytotechnician made an on-site assessment of specimen adequacy with immediate evaluation of smears over a 12-month period (pre-training period) then over another 12-month period (post-training period), with a year's intermediate training when the cytopathologist and the cytotechnician worked together in the room. The gold standard used to establish the final diagnosis was based on a non-equivocal fine needle aspiration biopsy reviewed by the same expert cytopathologist. The main outcome measurements were the cytotechnician diagnostic accuracy before and after the training period.ResultsA total of 107 patients were enrolled in the pre-training period. Cytotechnician in-room adequacy was 68.2% (73/107). The diagnostic accuracy was 74.8%. The adequacy for the blind-review pathologist was 93.4% (100/107), significantly higher (p = 0.008) than the cytotechnician's results. During the post-training period, 95 EUS-FNA were performed and reviewed. Cytotechnician in-room adequacy was 87.4% (83/95). The diagnostic accuracy was 90.5%. The adequacy for the blinded pathologist was 95.8% (91/95), not significantly different from the cytotechnician (p = 0.23).ConclusionsAn adequate training period with an expert pathologist significantly improves the cytotechnician skill in terms of judging adequacy and diagnostic accuracy.     

Rare pancreatic neoplasms: the utility of endoscopic ultrasound-guided fine-needle aspiration—a large single center study

Background  Tumors other than ductal adenocarcinomas constitute 10%–15% of all pancreatic tumors. We describe the performance and pitfalls of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosis of these rare pancreatic tumors and their characteristic cytopathological features. Methods  The records of 455 pancreatic fine-needle aspiration procedures done between March 1997 and August 2006 at Aichi Cancer Center, Nagoya, Japan, were reviewed. Besides cytology, aspirated material was routinely submitted in formalin for cell-block analysis. The reference standard for final diagnosis was surgical pathology from resected specimens. Results  Twenty-eight rare (nonductal adenocarcinomas) pancreatic tumors were identified. Overall, EUS-FNA with the results of cytology, cell-block processing, and immunohistochemistry could correctly diagnose the type of neoplasm in 19 (67.9%) cases. EUS-FNA could distinguish benign from malignant rare tumors with a sensitivity of 69.2%, a specificity of 100%, positive predictive value of 100%, negative predictive value of 79.0%, and accuracy of 85.7%. None of three malignant pancreatic endocrine neoplasms could be diagnosed as malignant. An adequate core tissue sample could be obtained in 21 cases (75.0%) and provide a histopathological diagnosis in 19 (67.9%) cases. EUS-FNA could change the presumptive diagnosis in 11 (39.3%) cases. Specific immunochemical studies were useful adjuncts to the diagnosis. No major or minor complication was noted in any patient. Conclusions  Pancreatic neoplasms other than ductal adenocarcinomas have diverse imaging and histopathological features. EUS-FNA is accurate and safe for their identification.     

Can endoscopic ultrasonography-guided fine-needle aspiration predict response to chemoradiation in non-small cell lung cancer? A pilot study

BACKGROUND: Accurate prediction of pathologic response to chemoradiation (CHEMO-XRT) has a significant impact on the treatment of patients with non-small cell lung cancer (NSCLC) and mediastinal lymph node (LN) metastasis (N2 disease). Objective: This pilot study evaluates the ability of EUS-FNA to predict pathologic response in LN following CHEMO-XRT in NSCLC patients with N2 disease. Patients and METHODS: Retrospective analysis of prospectively collected data on patients with NSCLC and biopsy-proven N2 disease who underwent restaging by EUS following CHEMO-XRT. At restaging, FNA was performed on the same LN, if present, or any other visible LN in the posterior mediastinum. Response to therapy (N0 disease) was defined by either absence of mediastinal LN or residual disease on FNA. Those staged N0 by EUS underwent tumor resection with complete LN dissection. RESULTS: Fourteen patients met the criteria for evaluation. Restaging by EUS suggested disease response in 7 patients and residual disease in 6; tissue yield was unsatisfactory in 1 patient. Eleven of 14 patients in whom mediastinal LN were seen at restaging by EUS underwent FNA: the aspirate was benign in 4, residual disease was found in 6, and an inadequate sample was obtained in 1 patient. In 3 patients no mediastinal LN were evident at EUS. Final diagnosis on the 7 patients in whom EUS suggested N0 disease was established at surgery: EUS was true negative in 6 and false negative in 1. Of the 6 patients with residual disease, 5 underwent palliative CHEMO-XRT and 1 underwent extended tumor resection. The patient in whom tissue sampling was inadequate was found to have residual disease at surgery. The diagnostic accuracy of EUS-FNA for predicting mediastinal response to preoperative CHEMO-XRT was 86%. CONCLUSIONS: EUS-FNA appears to qualify as an accurate, safe and minimally invasive diagnostic technique for restaging of mediastinal LN after CHEMO-XRT in NSCLC patients. Given this promising preliminary data, a prospective evaluation is justified.     

Endoscopic ultrasound-guided fine-needle aspiration cytology diagnosis of solid pseudopapillary tumor of the pancreas： A case report and literature review

We describe the clinical, imaging and cytopathological features of solid pseudopapillary tumor of the pancreas (SPTP) diagnosed by endoscopic ultrasound- guided (EUS-guided) fine-needle aspiration (FNA). A 17-year-old woman was admitted to our hospital with complaints of an unexplained episodic abdominal pain for 2 mo and a short history of hypertension in the endocrinology clinic. Clinical laboratory examinations revealed polycystic ovary syndrome, splenomegaly and low serum amylase and carcinoembryonic antigen (CEA) levels. Computed tomography (CT) analysis revealed a mass of the pancreatic tail with solid and cystic consistency. EUS confirmed the mass, both in body and tail of the pancreas, with distinct borders, which caused dilation of the peripheral part of the pancreatic duct (major diameter 3.7 mm). The patient underwent EUS-FNA. EUS-FNA cytology specimens consisted of single cells and aggregates of uniform malignant cells, forming microadenoid structures, branching, papillary clusters with delicate fibrovascular cores and nuclear overlapping. Naked capillaries were also seen. The nuclei of malignant cells were round or oval, eccentric with fine granular chromatin, small nucleoli and nuclear grooves in some of them. The malignant cells were periodic acid Schiff (PAS)-Alcian blue ( ) and immunocytochemically they were vimentin ( ), CA 19.9 ( ), synaptophysin ( ), chromogranin (-), neuro-specific enolase (-), a1- antitrypsin and a1-antichymotrypsin focal positive. Cytologic findings were strongly suggestive of SPTP. Biopsy confirmed the above cytologic diagnosis. EUS- guided FNA diagnosis of SPTP is accurate. EUS findings,cytomorphologic features and immunostains of cell block help distinguish SPTP from pancreatic endocrine tumors, acinar cell carcinoma and papillary mucinous carcinoma.     

Is the effect of fine-needle aspiration biopsy on the thyroid nodule volume important to evaluate the effectiveness of suppression therapy?

Fine-needle aspiration biopsy (FNAB) is recommended for the initial evaluation of thyroid nodule. If a benign cytology is obtained, suppression therapy with levothyroxine is the first choice in the management of nodular goiter with a follow-up of nodule size with ultrasonography, but the effects of FNAB have not been taken into consideration in this approach. We aimed at evaluating the effect of FNAB on thyroid volume and other ultrasonographic dimensions by measurement of these parameters before and immediately after the procedure, and in later periods, and to clarify the necessity of regarding the effects of FNAB on thyroid. Forty-six patients (34 females, 12 males; mean age: 36.3+/-10.7 yr) with solitary thyroid nodules were included in the study. The nodules were solid in ultrasonography, thyroid function tests were normal and results of FNAB were found as benign cytology. Thyroid hormone suppression therapy was not initiated. Ultrasonographic measurements were made before FNAB, repeated immediately after FNAB, and 1 month and 6 months later. There were no statistically significant changes in the mean thyroid nodule volume, nodule area and circumference of patients before, immediately after FNAB, 1 month and 6 months later. Size differences and individual variability at each time period were analyzed. These parameters changed by more than 10% in a great majority (69.5-78.2%) of patients, and more than 50% change was observed in 17.3-26.0% of patients. Changes in thyroid dimensions were bi-directional, both increment and decrement being noticed. It was thought that this is the reason why there was no significant change in mean nodule volume, area and circumference. Evaluating the difference in nodule volume according to ultrasonographic parameters obtained before FNAB may be misleading because of the individual change in these parameters with FNAB. It may be useful to evaluate the nodule size and volume closely after FNAB to make a true correspondence of these parameters in the long term.     

Role of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of solid pancreatic and peripancreatic lesions: is onsite cytopathology necessary?

Objectives:

The reported median diagnostic yield from endoscopic ultrasound (EUS) fine-needle aspiration (FNA) cytology is 78% (range 39–93%). The aim of this study is to describe a single-centre experience in the diagnostic work-up of solid pancreatic and peripancreatic masses without the benefit of an onsite cytopathologist.

Methods:

In a consecutive series of 429 EUS examinations performed over a 12-month period by a single operator, 108 were on non-cystic pancreatic or biliary lesions. Data were collected prospectively and the accuracy of FNA was assessed retrospectively using either surgery or repeat imaging as the benchmark in the presence or absence of malignancy.

Results:

Of the 108 FNAs, 102 (94%) were diagnostic, four were falsely negative (FN) and two were atypical and considered equivocal. There were 78 pancreatic lesions, of which 65 were true positives (TP), 11 true negatives (TN) and two FN, giving an overall accuracy of 97% (76/78). Of nine periampullary lesions, two were TP, six were TN and one was FN, giving an overall accuracy of 89% (8/9). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of EUS-FNA for pancreatic and periampullary lesions combined were 96%, 100%, 100% [95% confidence interval (CI) 95–100%], 85% (95% CI 62–97%) and 97%, respectively. There were 21 bile duct lesions, of which 10 were TP, eight TN, two atypical and one FN, giving an overall accuracy of 86% (18/21). The sensitivity, specificity, PPV, NPV and accuracy of EUS-FNA for biliary lesions were 91%, 100%, 100% (95% CI 69–100%), 91% (95% CI 59–100%) and 95%, respectively.

Conclusions:

The diagnostic accuracy of EUS-FNA for pancreatic lesions in our series was 97% and the PPV for the three subgroups of lesion type was 100%; these figures are comparable with the best rates reported in the literature, despite the absence of onsite cytopathology. These rates are potentially a direct result of high-volume practice, dedicated endosonography and cytopathology. These results show that it is possible to achieve high rates of accuracy in places where logistical issues make it impossible to maintain a cytopathologist in the endoscopy suite. In addition, our results contribute to the limited, collective global experience on the effectiveness of EUS-FNA in periampullary and biliary lesions.