Prospective cohort study comparing transient EUS guided elastography to EUS-FNA for the diagnosis of solid pancreatic mass lesions

BackgroundSemiquantitative EUS-elastography has been introduced to distinguish between malignant and benign pancreatic lesions. This study investigated whether semiquantitative EUS-guided transient real time elastography increases the diagnostic accuracy for solid pancreatic lesions compared to EUS-FNA.Patients and methodsThis single centre prospective cohort study included all patients with solitary pancreatic lesions on EUS during one year. Patients underwent EUS-FNA and semiquantitative EUS-elastography during the same session. EUS and elastography results were compared with final diagnosis which was made on the basis of tissue samples and long-term outcome.Results91 patients were recruited of which 68 had pancreatic malignancy, 17 showed benign disease and 6 had cystic lesions and were excluded from further analysis. Strain ratios from malignant lesions were significantly higher (24.00; 8.01–43.94 95% CI vs 44.00; 32.42–55.00 95% CI) and ROC analysis indicated optimal cut-off of 24.82 with resulting sensitivity, specificity and accuracy of 77%, 65% and 73% respectively. B-mode EUS and EUS-FNA had an accuracy for the correct diagnosis of malignant lesions of 87% and 85%. When lowering the cut-off strain ratio for elastography to 10 the sensitivity rose to 96% with specificity of 43% and accuracy of 84%, resulting in the least accurate EUS-based method. This was confirmed by pairwise comparison.ConclusionSemiquantitative EUS-elastography does not add substantial value to the EUS-based assessment of solid pancreatic lesions when compared to B-mode imaging.     

Accuracy of preoperative workup in a prospective series of surgically resected cystic pancreatic lesions

Abstract

Background. Magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) are considered useful techniques in the evaluation of pancreatic cysts. Aim of this study was to prospectively compare the diagnostic value of these techniques. Methods. This study included consecutive patients who underwent MRI, EUS, and EUS-FNA for a pancreatic cyst that was eventually resected surgically. Observers scored for cyst characteristics, a distinction between mucinous and non-mucinous cysts and a suspicion of malignancy. The interobserver agreement between MRI and EUS was calculated. Results. A total of 32 patients were included. Sensitivity for diagnosing a mucinous cyst was 78% for EUS versus 91% for MRI. Sensitivity for detecting malignancy was 25% (1/4) and 50% (2/4) for EUS and MRI respectively. Sensitivity of EUS-FNA for diagnosing a mucinous cyst (positive cytology and/or CEA >192 ng/ml) was 61%. Sensitivity for detecting malignancy (positive cytology) was 1/4 (25%). Interobserver agreement between MRI and EUS for the features was poor to fair. Conclusion. MRI and EUS are comparable techniques for the morphological characterization of pancreatic cysts. Combined sensitivity of EUS and MRI was higher than the sensitivity of one of the techniques alone. For diagnosing a mucinous cyst, FNA findings showed a low sensitivity, but a high specificity.     

Yield of endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography for solid pancreatic neoplasms

Objective: Both endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) cytology may provide tissue diagnoses in solid pancreatic neoplasms. However, there are scant data comparing these two methods. This study aims at retrospectively comparing EUS-FNA and ERCP tissue sampling and ability of cytopathological diagnosis in solid pancreatic neoplasms and to determine usefulness and adverse events of combining both procedures. Material and methods: Two hundred and thirty four patients suspected to have solid pancreatic mass on abdominal ultrasound and/or computed tomography (CT) were enrolled. EUS-FNA (group A), ERCP cytology (group B) and combined procedures (Group C) performed in 105, 91 and 38 cases, respectively. Results: Sensitivity, specificity and accuracy were 98.9%, 93.3% and 98.1% for group A, and 72.1%, 60% and 71.4% for group B. Those for group C were all 100%. Sensitivity for malignancy in the pancreas head was 100% for group A and 82.4% for group B, and in the pancreas body and tail, 97.6% for group A and 57.1% for group B. EUS-FNA was more sensitive than ERCP cytology in diagnosing malignant pancreatic neoplasms 21–30?mm in size (p?=?0.0068), 31–40?mm (p?=?0.028) and?≥41?mm (p?Conclusions: EUS-FNA is superior to ERCP cytology for diagnosis of solid pancreatic neoplasms. Although combination of both procedures provide efficient tissue diagnosis and with a minimal adverse events rate, a prospective study including larger number of patients is required.     

Accuracy of EUS and CEH EUS for the diagnosis of pancreatic tumours

Abstract

Objectives: The main objective is to compare the accuracy of EUS and CEH EUS for the diagnosis of pancreatic cancer (PC). The secondary objective is to evaluate the accuracy of EUS FNA and to determine to what extent EUS and CEH EUS findings are affected by endosonographer subjectivity.

Methods: A prospective single-centre study was conducted in patients with pancreatic lesions detected on CT. The patients were examined by EUS, CEH EUS and EUS FNA. The obtained results were compared with the final diagnosis that was based on cytology and further clinical findings and on histopathological findings from subjects who underwent surgery. A second reading of the EUS and CEH EUS images was performed by the endosonographer, who was blinded to clinical data of patients.

Results: We examined 116 patients, 73 had a final diagnosis of PC, 14 had NETs and 20 had other tumours. The sensitivity, specificity, NPV, PPV, and accuracy of EUS for diagnosis of PC were 83.1, 62.5, 83.1, 70.7 and 78.6%, for CEH EUS 94.5, 61.7, 84.1, 84 and 84.1% and for EUS FNA 87.6, 91.2, 95.5, 77.5 and 88.8, respectively. The inter-observer agreement for EUS marker of PC was good (κ?=?0.75), and that for CEH EUS was average (κ?=?0.59 for arterial phase and κ?=?0.68 for washout in venous phase).

Conclusion: CEH EUS is a non-invasive method that allows more accurate identification of PC than EUS. The subjectivity of CEH EUS evaluation is worse than that of EUS but acceptable.     

Diagnostic value of EUS elastography in differentiation of benign and malignant solid pancreatic masses: A meta-analysis

Background/AimsEUS elastography is a novel technique that can be used for distinguishing benign from malignant lymph nodes and focal pancreatic masses. However, the studies pertaining to EUS elastography for differential diagnosis of solid pancreatic masses have reported widely varied sensitivities and specificities. A meta-analysis of all relevant articles was performed to estimate the overall diagnostic accuracy of EUS elastography for differentiating benign and malignant solid pancreatic masses.MethodsThe literatures were identified by searching in PubMed and Embase databases. Two reviewers independently extracted the information from the literatures for constructing 2 × 2 table. A random-effect model or a fixed-effect model was used to estimate the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. A summary receiver operating characteristic curve (SROC) also was constructed. Meta-regression and subgroup analysis were used to explore the sources of heterogeneity.Results13 studies including a total of 1042 patients with solid pancreatic masses were selected for meta-analysis. The pooled sensitivity and specificity of EUS elastography for differentiating benign and malignant solid pancreatic masses were 95% (95% confidence interval [CI], 93%–96%), 69% (95% CI, 63%–75%), respectively. The area under SROC (AUC) was 0.8695. Two significant variables were associated with heterogeneity: color pattern and blinding.ConclusionAs a less invasive modality, EUS elastography is a promising method for differentiating benign and malignant solid pancreatic masses with a high sensitivity, and it can prove to be a valuable supplement to EUS-FNA.     

Determination of qualitative telomerase activity as an adjunct to the diagnosis of pancreatic adenocarcinoma by EUS-guided fine-needle aspiration

BACKGROUND: Telomerase activity is up-regulated in pancreatic cancer. Hence, measurement of telomerase activity in pancreatic needle-biopsy specimens could assist in establishing a positive diagnosis in specimens that are inadequate for cytology. OBJECTIVE: To determine the sensitivity and specificity of telomerase activity for neoplasia in a series of EUS-guided fine-needle aspirate (EUS-FNA) biopsies of pancreatic mass lesions. DESIGN: Prospective, consecutive, non-randomized cohort. SETTING: Academic hospital, tertiary referral center. PATIENTS: Seventy-one patients with a pancreatic mass diagnosed by cross-sectional imaging. INTERVENTIONS: EUS-FNA of 52 solid and 18 cystic pancreatic lesions. MAIN OUTCOME MEASUREMENTS: (1) Cytologic diagnosis; (2) tissue telomerase activity by semi-quantitative polymerase chain reaction; (3) patient demographics; (4) clinical outcomes. RESULTS: Cytology results were positive for adenocarcinoma in 40 patients with a solid pancreatic mass; of these, telomerase activity was detected in 31. There were no telomerase false-positive results. Telomerase results were positive in 6 of the 7 patients (86%) who had negative cytology results and who eventually were found to have biopsy-proven adenocarcinoma. The sensitivity and specificity of telomerase activity for detecting pancreatic adenocarcinoma in solid masses was 79% (95% CI, 64%-89%) and 100% (95% CI, 55%-100%). LIMITATIONS: Extremely high sensitivity and specificity of EUS-FNA cytology in solid lesions minimized the incremental benefit of telomerase. CONCLUSIONS: Telomerase activity can be measured readily in specimens obtained at EUS-FNA and accurately predicts malignancy. Used in combination with cytology, telomerase increased the sensitivity from 85% to 98% while maintaining the specificity at 100%. Lesions with negative cytology result and positive telomerase activity should be evaluated aggressively to exclude malignancy.     

Sensitivity of CT,MRI, and EUS-FNA/B in the preoperative workup of histologically proven left-sided pancreatic lesions

Background and objectivesLeft-sided pancreatic lesions are often treated surgically. Accurate diagnostic work-up is therefore essential to prevent futile major abdominal surgery. Large series focusing specifically on the preoperative work-up of left-sided pancreatic lesions are lacking. This surgical cohort analysis describes the sensitivity of CT, MRI, and EUS-FNA/B in the diagnostic work-up of left-sided pancreatic lesions.MethodsWe performed a post-hoc analysis of patients who underwent surgery for a left-sided pancreatic lesion between April 2010 and August 2017 and participated in the randomized CPR trial. Primary outcome was the sensitivity of CT, MRI, and EUS-FNA/B. Sensitivity was determined as the most likely diagnosis of each modality compared with the postoperative histopathological diagnosis. Additionally, the change in sensitivity of EUS versus EUS-FNA/B (i.e., cyst fluid analysis, and/or tissue acquisition) was measured.ResultsOverall, 181 patients were included (benign: 23%, premalignant: 27%, malignant: 50%). Most patients had solid lesions (65%). Preoperative imaging included CT (86%), MRI (41%), EUS (68%). Overall, CT and EUS-FNA/B reached a sensitivity of both 71%, compared with 66% for MRI. When EUS was combined with FNA/B, sensitivity rose from 64% to 71%. For solid lesions, CT reached the highest sensitivity (75%) when compared with MRI (70%) and EUS-FNA/B (69%). For cystic lesions, EUS-FNA/B reached the highest sensitivity (75%) when compared with CT and MRI (both 62%).ConclusionsCT is the most sensitive diagnostic modality for solid and EUS-FNA/B for cystic left-sided pancreatic lesions. EUS-FNA/B was associated with an increased sensitivity when compared to EUS alone.     

EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results

BACKGROUND: Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult. OBJECTIVE: To report our experience with EUS-guided FNA (EUS-FNA) of PBSs following negative or unsuccessful results with brush cytology during ERCP. DESIGN: Retrospective cohort study. SETTING: Single, tertiary referral hospital in Indianapolis, Indiana. PATIENTS: Consecutive subjects from January 2001 to November 2004 who underwent EUS-FNA of a PBS documented by ERCP. INTERVENTIONS: EUS-FNA of PBS. MAIN OUTCOME MEASURES: Performance of EUS-FNA, with the final diagnosis determined by surgical pathology study or the results of EUS-FNA and follow-up. RESULTS: A total of 291 biliary strictures undergoing EUS were identified. Of these, 26 (9%) had PBSs and 2 were excluded. EUS-FNA was not attempted in 1 because no mass was visualized. The second had a PBS seen on magnetic resonance cholangiopancreatography, but no ERCP was performed. Twenty-four patients (14 men; mean age, 68 years) underwent EUS-FNA of a PBS following ERCP brush cytology studies that were either negative/nondiagnostic (20) or unable to be performed (4). EUS visualized a mass in 23 (96%) patients, including 13 in whom previous imaging detected no lesion. EUS-FNA (median, 4 passes; range, 1-11) demonstrated malignancy in 17 of 24 (71%) patients with findings showing adenocarcinoma (15), lymphoma (2), atypical cytology (3), or benign cells (4). No complications were noted. Pathology results from 8 of 24 (33%) patients who underwent surgery showed hilar cholangiocarcinoma (6), gallbladder cancer (1), and a benign, inflammatory stricture (1). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 77% (95% confidence interval [CI], 54%-92%), 100% (95% CI, 15%-100%), 100% (95% CI, 83%-100%), 29% (95% CI, 4%-71%), and 79% (95% CI, 58%-93%), respectively. LIMITATIONS: Histopathologic correlation of EUS-FNA findings was limited to 8 of 24 (33%) patients who underwent surgery. CONCLUSIONS: EUS-FNA is a sensitive method for the diagnosis of PBSs following negative results or unsuccessful ERCP brush cytology. The low negative predictive value does not permit reliable exclusion of malignancy following a negative biopsy.     

Endoscopic ultrasound guided fine needle aspiration of solid pancreatic lesions: Performance and outcomes

Background and Aim:  We report our single-centre experience with endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of solid pancreatic lesions with regard to clinical utility, diagnostic accuracy and safety.
Methods:  We prospectively reviewed data on 100 consecutive EUS-FNA procedures performed in 93 patients (54 men, mean age 60.6 ± 12.9 years) for evaluation of solid pancreatic lesions. Final diagnosis was based on a composite standard: histologic evidence at surgery, or non-equivocal malignant cytology on FNA and follow-up. The operating characteristics of EUS-FNA were determined.
Results:  The location of the lesions was pancreatic head in 73% of cases, the body in 20% and the tail in 7%. Mean lesion size was 35.1 ± 12.9 mm. The final diagnosis revealed malignancy in 87 cases, including adenocarcinomas (80.5%), neuroendocrine tumours (11.5%), lymphomas (3.4%) and other types (4.6%). The FNA findings were: 82% interpreted as malignant cytology, 1% as suspicious for neoplasia, 1% as atypical, 7% as benign process and 9% as non-diagnostic. No false-positive results were observed. There was a false-negative rate of 5%. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 94.3%, 100%, 100%, 72.2% and 95%, respectively. In 23 (88.5%) of 26 aspirated lymph nodes malignancy was found. Minor complications occurred in two patients.
Conclusions:  Our experience confirms that EUS-FNA in patients with suspected solid pancreatic lesions is safe and has a high diagnostic accuracy. This technique should be considered the preferred test when a cytological diagnosis of a pancreatic mass lesion is required.     

EUS-guided FNA diagnostic yield of malignancy in solid pancreatic masses: a benchmark for quality performance measurement

BACKGROUND: The diagnostic yield of EUS-guided FNA (EUS-FNA) of solid pancreatic masses is a potential benchmark for EUS-FNA quality, because the majority of EUS-FNA of solid pancreatic masses should be diagnostic for malignancy. OBJECTIVES: To determine the cytologic diagnostic rate of malignancy in EUS-FNA of solid pancreatic masses and to determine if variability exists among endoscopists and centers. DESIGN: Multicenter retrospective study. PATIENTS: EUS centers provided cytology reports for all EUS-FNAs of solid, noncystic, >or=10-mm-diameter, solid pancreatic masses during a 1-year period. MAIN OUTCOME MEASUREMENT: Cytology diagnostic of pancreatic malignancy. RESULTS: A total of 1075 patients underwent EUS-FNA at 21 centers (81% academic) with 41 endoscopists. The median number of EUS-FNA of solid pancreatic masses performed during the year per center was 46 (range, 4-177) and per endoscopist was 19 (range, 1-97). The mean mass dimensions were 32 x 27 mm, with 73% located in the head. The mean number of passes was 3.5. Of the centers, 90% used immediate cytologic evaluation. The overall diagnostic rate of malignancy was 71%, 95% confidence interval 0.69%-0.74%, with 5% suspicious for malignancy, 6% atypical cells, and 18% negative for malignancy. The median diagnostic rate per center was 78% (range, 39%-93%; 1st quartile, 61%) and per endoscopist was 75% (range, 0%-100%; 1st quartile, 52%). LIMITATIONS: Retrospective study, participation bias, and varying chronic pancreatitis prevalence. CONCLUSIONS: (1) EUS-FNA cytology was diagnostic of malignancy in 71% of solid pancreatic masses and (2) endoscopists with a final cytologic diagnosis rate of malignancy for EUS-FNA of solid masses that was less than 52% were in the lowest quartile and should evaluate reasons for their low yield.     

High-Risk Characteristics Associated with Advanced Pancreatic Cystic Lesions: Results from a Retrospective Surgical Cohort

Background and Aim

The management of pancreatic cystic lesions (PCLs) remains controversial. We performed a retrospective study to determine characteristics associated with advanced PCLs (A-PCLs) and whether these characteristics vary in different pathological types of PCLs. The additional diagnostic value of endoscopic ultrasound (EUS) was also evaluated.

Methods

Patients who underwent surgical resection for an identified PCLs by imaging modalities were included. A logistic regression model was developed to identify significant characteristics for A-PCLs. EUS data was assessed separately.

Results

Three hundred and fifty-three patients were included, and 125 patients (35.4%) were A-PCLs. The presence of main pancreatic duct (MPD) diameter ≥?10 mm (odds ratio [OR], 11.7; 95% confidence interval [CI], 1.53–89.2; P?=?0.018), mural nodules?≥?5 mm (OR, 11.67; 95% CI, 2.3–59.05; P?=?0.003), solid components within cysts (OR, 30.87; 95% CI, 7.23–131.7; P?<?0.0001) and high serum CA19-9 levels (OR, 1.006; 95% CI, 1.001–1.011; P?=?0.02) were independently associated with the presence of A-PCLs. The presence of septa was independently associated with the presence of non-A-PCLs (OR, 0.147; 95% CI, 0.04–0.6; P?=?0.008). Males who had a history of tobacco abuse (P?<?0.0001) and had a greatly dilated MPD (P?<?0.0001) were more common in advanced intraductal papillary mucinous neoplasms (IPMC) patients. Solid pseudopapillary neoplasm (SPT) often occurred in young women (P?<?0.0001), mostly asymptomatically (P?<?0.0001) and with lower serum CA19-9 levels (P?<?0.0001). In the 124 patients who underwent EUS-guided fine-needle aspiration (EUS-FNA), five additional characteristics (4 mural nodules and 1 MPD involvement) were identified by EUS imaging and 17 patients were identified with abnormal cytological results (13 atypical cells and 4 suspicious for malignancy cells) by EUS-FNA.

Conclusion

On the basis of a retrospective study with large sample size, the presence of MPD?≥?10 mm, mural nodules, solid components, and high serum CA19-9 levels were independently associated with the presence of A-PCLs. The high-risk characteristics may vary across different types of A-PCLs. EUS and EUS-FNA could provide additional diagnostic information for PCLs.

     

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.     

Efficacy of endoscopic ultrasonography and endoscopic ultrasonography-guided fine-needle aspiration for the diagnosis and grading of pancreatic neuroendocrine tumors

Background and aim: Pancreatic neuroendocrine tumors (pNETs) are histologically categorized according to the WHO 2010 classification by their mitotic index or Ki-67 index as G1, G2, or G3. The present study examined the efficacy of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis and grading of pNET. Methods: We retrospectively reviewed 61 pNETs in 51 patients who underwent EUS between January 2007 and June 2014. All lesions were pathologically diagnosed by surgical resection or EUS-FNA. We evaluated the detection rates of EUS for pNET and sensitivity of EUS-FNA, and compared the Ki-67 index between EUS-FNA samples and surgical specimens. EUS findings were compared between G1 and G2/G3 tumors. Results: EUS showed significantly higher sensitivity (96.7%) for identifying pNET than CT (85.2%), MRI (70.2%), and ultrasonography (75.5%). The sensitivity of EUS-FNA for the diagnosis of pNET was 89.2%. The concordance rate of WHO classification between EUS-FNA and surgical specimens was 69.2% (9/13). The concordance rate was relatively high (87.5%, 5/6) in tumors?<20?mm but lower (57.1%; 4/7) in tumors?≥20?mm. Regarding EUS findings, G2/G3 tumors were more likely to be large (>20?mm), heterogeneous, and have main pancreatic duct (MPD) obstruction than G1 tumors. Multivariate analysis showed large diameter and MPD obstruction were significantly associated with G2/G3 tumors. Conclusions: EUS and EUS-FNA are highly sensitive and accurate diagnostic methods for pNET. Characteristic EUS findings such as large tumor size and MPD obstruction are suggestive of G2/G3 tumors and would be helpful for grading pNETs.     

Effect of dedicated and supervised training on achieving competence in EUS-FNA of solid pancreatic lesions

Abstract

Background and Aim. The diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been suggested as a benchmark of quality performance in EUS. However, there is paucity of data on the training requirement for competency in EUS-FNA of the pancreas. KO commenced the service without prior formal training in EUS-FNA. A formally trained colleague (MN) who underwent a fellowship in the same unit was appointed to a substantive post in 2007. The aims of the study were to assess if a dedicated training program in pancreaticobiliary (PB) EUS-FNA of solid lesions: (1) produced better results at the outset of independent practice than produced at the initiation of service without formal training and (2) produced results comparable with those of an experienced endosonographer. Material and methods. This is a retrospective review comparing the first 80 consecutive cases at the onset of practice of operator KO1 (2003/2004) and MN (2007/2008) as well as consecutive cases of operator KO2 (2007/2008) in the same time frame as the initial cases of operator MN. Results. There was a significant difference in EUS-FNA sensitivity for pancreatic malignancy between operator KO1 (56%) and operator MN (77%) p < 0.05. There was no significant difference in test performance between operator KO2 (82%) and MN (77%) (p > 0.05). Conclusion. Our data show that formal training in PB EUS produces test performance at the outset of independent practice that is comparable with an experienced endosonographer, in line with the published standards for EUS-FNA of the pancreas and significantly better than that achieved without training.     

Rendimiento diagnóstico de la punción mediante ultrasonografía endoscópica de las lesiones quísticas del páncreas

IntroductionDespite advances in imaging techniques, in many cases they are insufficient to establish the diagnosis of pancreatic cystic lesions (PCL). There are few publications in our setting that evaluate the combination of several methods obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The aim of the study was to evaluate the overall utility of EUS-FNA in the diagnosis of PCL.Material and methodsRetrospective study based on a database updated prospectively of a cohort of patients referred for EUS-FNA due to PCL detected in an imaging test. The sensitivity, specificity and diagnostic yield of carcinoembryonic antigen (CEA), cytology and viscosity were studied to detect mucinous lesions.ResultsFrom November 2013 to April 2018, 122 EUS were performed for PCL. EUS-FNA was performed in 94/122 (77%) and 21/122 (17.2%) patients were operated on. We included 33/122 patients who had diagnostic confirmation by histology, imaging (serous cyst with typical pattern) or clinical evolution. The study of the ROC curve determined the cutoff point ≥419 ng/ml to differentiate mucinous/non-mucinous cystic lesions. The diagnostic yield of CEA was 87.5% (21/24), cytology 81.8% (27/33) and viscosity 84.4% (27/32). The three parameters in combination obtained the best result (30/33, 90.9%).ConclusionThe combination of CEA analysis, cytology and viscosity of pancreatic fluid obtained by EUS-FNA increases the performance in the diagnosis of mucinous pancreatic cystic lesions, with it being greater than 90%.     

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.     

Age and cystic size are associated with clinical impact of endoscopic ultrasonography-guided fine-needle aspiration on the management of pancreatic cystic neoplasms

Objectives: The clinical impact of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) in managing pancreatic cystic neoplasms (PCNs) remains controversial. The aim of this study was to identify which patients with PCNs would benefit from EUS-FNA.

Methods: A retrospective study was performed on patients with PCNs who underwent EUS-FNA between January 2009 and June 2018. A discordant or a consistent diagnosis after EUS-FNA was analyzed and was correlated with the clinical demographic data and cystic features. Predictors of the change in the diagnosis after EUS-FNA were analyzed.

Results: One hundred eighty-eight cases of PCNs were analyzed. EUS-FNA changed the diagnosis in 45.7% of all patients with PCNs and 54.5% patients with presumed branch ductal type intraductal papillary mucinous neoplasm (BD-IPMN) and impacted the recommendation in 35.6% of patients with PCNs and 50.5% patients with BD-IPMN. Patients with a discordant diagnosis after EUS-FNA were younger in age (54.8?±?12.6 vs. 61.2?±?14.2; p=.037) and had a cyst size larger than 3?cm than patients with a consistent diagnosis after EUS-FNA. The only worrisome feature (WF) that differed between patients with a discordant and a consistent diagnosis after EUS-FNA was the main pancreatic duct (MPD) between 5 and 9?mm (p=.013). In multivariate analysis, a cyst size >3?cm and age were independent predictors of diagnostic changes after EUS-FNA (OR: 5.33, 95% CI: 1.79–15.88, p?=?.003; OR: 0.96, 95% CI: 0.93–0.99, p = .031).

Conclusions: EUS-FNA made a significant change in the management of nearly half of the patients with PCNs, especially in younger patients and in patients with a cyst size larger than 3?cm.     

Diagnostic yield of EUS-FNA-based cytology distinguishing malignant and benign IPMNs: A systematic review and meta-analysis

ObjectivesDifferential diagnosis of malignant and benign intraductal papillary mucinous neoplasms (IPMNs) is essential to determine the optimal treatment. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently used to diagnose pancreatic cystic lesions worldwide, but few studies have focused on the diagnostic yield to distinguish malignant and benign IPMNs. Therefore, we aim to systematically review the diagnostic yield of EUS-FNA-based cytology to distinguish malignant and benign IPMNs.MethodsRelevant studies with a reference standard of definitive surgical histology which published between 2002 and 2012 were identified via MEDLINE and SCOPUS. Malignant IPMNs included invasive adenocarcinoma, carcinoma in situ, and high-grade dysplasia.ResultsFour studies with 96 patients were included in this meta-analysis. For diagnostic yield of EUS-FNA-based cytology distinguishing malignant and benign IPMNs, the pooled sensitivity and specificity were 64.8% (95% CI, 0.44–0.82) and 90.6% (95% CI, 0.81–0.96), respectively. Similarly, the positive likelihood ratio and negative likelihood ratio were 6.35 (95% CI, 2.95–13.68) and 0.43 (95% CI, 0.14–1.34), respectively. Malignant IPMNs were observed in 20.8% (20/96) of patients in EUS-FNA studies.ConclusionsEUS-FNA-based cytology has good specificity but poor sensitivity in differentiating benign from malignant IPMNs. Newer techniques or markers are needed to improve diagnostic yield.     

Surveillance of high-risk individuals for pancreatic cancer with EUS and MRI: A meta-analysis

Background/objectivesConsensus guidelines recommend surveillance of high-risk individuals (HRIs) for pancreatic cancer (PC) using endoscopic ultrasonography (EUS) and/or magnetic resonance imaging (MRI). This study aims to assess the yield of PC surveillance programs of HRIs and compare the detection of high-grade dysplasia or T1N0M0 adenocarcinoma by EUS and MRI.MethodsThe MEDLINE and Embase (Ovid) databases were searched for prospective studies published up to April 11, 2019 using EUS and/or MRI to screen HRIs for PC. Baseline detection of focal pancreatic abnormalities, cystic lesions, solid lesions, high-grade dysplasia or T1N0M0 adenocarcinoma, and all pancreatic adenocarcinoma were recorded. Weighted pooled proportions of outcomes detected were compared between EUS and MRI using random effects modeling.ResultsA total of 1097 studies were reviewed and 24 were included, representing 2112 HRIs who underwent imaging. The weighted pooled proportion of focal pancreatic abnormalities detected by baseline EUS (0.34, 95% CI 0.30–0.37) was significantly higher (p = 0.006) than by MRI (0.31, 95% CI 0.28–0.33). There were no significant differences between EUS and MRI in detection of other outcomes. The overall weighted pooled proportion of patients with high-grade dysplasia or T1N0M0 adenocarcinoma detected at baseline (regardless of imaging modality) was 0.0090 (95% CI 0.0022–0.016), corresponding to a number-needed-to-screen (NNS) of 111 patients to detect one high-grade dysplasia or T1N0M0 adenocarcinoma.ConclusionsSurveillance programs are successful in detecting high-risk precursor lesions. No differences between EUS and MRI were noted in the detection of high-grade dysplasia or T1N0M0 adenocarcinoma, supporting the use of either imaging modality.     

Comparison of 22-gauge standard fine needle versus core biopsy needle for endoscopic ultrasound-guided sampling of suspected pancreatic cancer: a randomized crossover trial

Background: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is effective for tissue diagnosis of pancreatic mass. To improve diagnostic yield and drawbacks, 22-gauge (G) core biopsy (FNB) needle has been developed. This study aims to compare 22G FNA and FNB needles for EUS-guided sampling of suspected pancreatic cancer.

Methods: This is a randomized controlled crossover trial. A total of 60 patients with suspected unresectable pancreatic cancer referred for EUS-guided sampling were randomly assigned to two groups. Both groups had 22G FNA and FNB needles performed in a randomized order. The primary endpoint was the cytological, histological and overall diagnostic accuracy of pancreatic cancer.

Results: FNA and FNB needles reported similar level of diagnostic accuracy (FNA needle 95% vs. FNB needle 93.3%; p?=?.564), and it was not statistically different. However, cytological cellularity was significantly higher in the FNB needles compared to FNA needles (odds ratio 2.75, 95% confidence interval (CI)). There were no procedure-related complications in both needles.

Conclusions: The diagnostic accuracy of EUS-guided sampling for pancreatic cancer using 22G FNA is comparable to FNB needles. The cytological quality of specimen is better in the FNB needle.