Value of repeat endoscopic ultrasound-guided fine needle aspiration for suspected pancreatic cancer

Background and Aims: Endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) is a safe and accurate technique for diagnosing pancreatic cancer. The value of repeat EUS‐FNA in patients with high clinical suspicion for pancreatic cancer after an inconclusive index study is unknown. Our aims were to determine the yield and success of repeat EUS‐FNA and the reasons for failure of initial EUS‐FNA. Methods: This was a retrospective analysis of prospectively collected data in a tertiary University based referral center for pancreatico‐biliary disorders. All patients who underwent more then one EUS‐FNA for evaluation of suspected pancreatic cancer over a five and a half year period were included in this analysis. Results: Of the 547 procedures performed on 517 patients, 24 (4.6%) patients underwent 51 repeat EUS‐FNA procedures. Initial EUS‐FNA was atypical/suspicious in 10 (41.6%), benign in 10 (41.6%), malignant in two (8.3%), and failed/indeterminate in two (8.3%) patients. Eight of 10 (80%) patients with atypical/suspicious findings at initial EUS‐FNA were diagnosed with malignancy on repeat EUS‐FNA. Of the 10 patients with benign findings at initial EUS‐FNA, repeat study diagnosed two (20%) with malignancy and the rest were confirmed benign on long‐term follow up (average 530 days, SD 369 days). Of the two patients with indeterminate findings at initial EUS‐FNA, repeat study diagnosed one patient with malignant disease and the other with benign disease that was confirmed by long‐term follow up. Of the two patients diagnosed with neoplastic disease at initial EUS‐FNA, repeat EUS‐FNA with immunostains downgraded both to chronic pancreatitis. Repeat EUS‐FNA facilitated determination of the true status of disease in 20 of 24 patients (accuracy 84%). Suspected reasons for failed initial EUS‐FNA were: coexisting pancreatitis (n = 10; 42%), technical difficulty due to scope positioning in uncinate lesion/sedation failure (n = 4; 16.7%), difficult cytology (partly cystic, extensive necrosis, well‐differentiated adenocarcinoma) (n = 4; 16.7%), presence of ascites or collaterals (n = 3; 12.5%), pathologist's interobserver variation (n = 2; 8.33%), and unknown reason in one patient. Conclusion: Repeat EUS‐FNA is warranted in patients with high clinical suspicion for pancreatic cancer despite indeterminate or negative findings at initial EUS‐FNA.