Diagnostic impact of color Doppler ultrasound-guided core biopsy on fine-needle aspiration of anterior mediastinal masses

Although lymphoma and thymoma are common etiologies of anterior mediastinal masses (AMMs), smaller percentages and numbers of patients with these diseases have been enrolled in previous ultrasound-guided biopsy studies. To date, there has been no study of color Doppler sonographic features to support the differentiation of AMMs. For this retrospective cohort study, a search of the database of the China Medical University Hospital using the clinical coding "ultrasound-guided biopsy" was conducted for the period December 2003 to February 2013. We selected patients diagnosed with AMMs (not cysts) using radiographic records. This search yielded a list of 80 cases. Real-time ultrasound-guided core needle biopsy (CNB) was performed in all but 5 patients without a sufficient safety range. In 89% (67/75) of these ultrasound-guided CNB cases, the diagnostic accuracy achieved subclassification. Fine-needle aspiration cytology achieved subclassification in only 10% of cases. On color Doppler sonography, 71% of lymphomas were characterized as "rich vascular with central/crisscross collocations" and 29% as "avascular or localized/scattered peripheral vessels." However, decreased proportions of "rich vascular with central/crisscross collocations" were found in lung cancer (4% [1/23], odds ratio = 0.018, 95% confidence interval: 0.002-0.154, p < 0.001) and thymoma/thymic carcinoma (25% [4/16]; odds ratio = 0.133, 95% confidence interval: 0.035-0.514, p = 0.003) compared with the lymphoma group. We conclude that the vessels in lymphoma AMMs have specific patterns on color Doppler sonography. Ultrasound-guided CNB of AMMs had an accuracy of ≤ 89% in diagnosis and subclassification. Fine-needle aspiration cytology itself cannot aid in the diagnosis. Color Doppler sonographic evaluation of AMMs followed by real-time CNB is a more efficient method.

Clinical features and management of pancreatic solid pseudopapillary tumor

Solid pseudopapillary tumor (SPT) is a rare pancreatic tumor with low malignant potential. Between February 2006 and May 2013, six patients were affected by SPT. Two patients were male and four were female. Median age of the patients was 31.5 years (range, 13 to 47 years). One patient was preoperatively diagnosed by an endoscopic ultrasound-guided fine-needle aspiration biopsy. Pancreaticoduodenectomy was performed in two and distal pancreatectomy was done in four. One operation of those was laparoscopic distal pancreatectomy. In this series, recurrence or distant metastasis was not reported and successful outcome was achieved in all patients. In conclusion, whereas diagnosis of SPT is difficult, it can be diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy preoperatively. It should be treated by surgery, and laparoscopic operation can be considered.

Clinical value of endobronchial ultrasound findings for predicting nodal metastasis in patients with suspected lymphadenopathy: a prospective study

We evaluated whether sonographic findings can provide additional diagnostic yield in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), and can more accurately predict nodal metastasis than chest computed tomography (CT) or positron emission tomography (PET)/CT scans. EBUS-TBNA was performed in 146 prospectively recruited patients with suspected thoracic lymph node involvement on chest CT and PET/CT from June 2012 to January 2013. Diagnostic yields of EBUS finding categories as a prediction model for metastasis were evaluated and compared with findings of chest CT, PET/CT, and EBUS-TBNA. In total, 172 lymph nodes were included in the analysis: of them, 120 were malignant and 52 were benign. The following four EBUS findings were predictive of metastasis: nodal size ≥10 mm, round shape, heterogeneous echogenicity, and absence of central hilar structure. A single EBUS finding did not have sufficient diagnostic yield; however, when the lymph node had any one of the predictive factors on EBUS, the diagnostic yields for metastasis were higher than for chest CT and PET/CT, with a sensitivity of 99.1% and negative predictive value of 83.3%. When any one of predictive factors is observed on EBUS, subsequent TBNA should be considered, which may provide a higher diagnostic yield than chest CT or PET/CT.

High and low negative pressure suction techniques in EUS-guided fine-needle tissue acquisition by using 25-gauge needles: a multicenter, prospective, randomized, controlled trial

BACKGROUND

EUS-guided FNA (EUS-FNA) has a high diagnostic accuracy for pancreatic diseases. However, although most reports have typically focused on cytology, histological tissue quality has rarely been investigated. The effectiveness of EUS-FNA combined with high negative pressure (HNP) suction was recently indicated for tissue acquisition, but has not thus far been tested in a prospective, randomized clinical trial.

OBJECTIVE

To evaluate the adequacy of EUS-FNA with HNP for the histological diagnosis of pancreatic lesions by using 25-gauge needles.

DESIGN

Prospective, single-blind, randomized, controlled crossover trial.

SETTING

Seven tertiary referral centers.

PATIENTS

Patients referred for EUS-FNA of pancreatic solid lesions. From July 2011 to April 2012, 90 patients underwent EUS-FNA of pancreatic solid masses by using normal negative pressure (NNP) and HNP with 2 respective passes. The order of the passes was randomized, and the sample adequacy, quality, and histology were evaluated by a single expert pathologist.

INTERVENTION

EUS-FNA by using NNP and HNP.

MAIN OUTCOME MEASUREMENTS

The adequacy of tissue acquisition and the accuracy of histological diagnoses made by using the EUS-FNA technique with HNP.

RESULTS

We found that 72.2% (65/90) and 90% (81/90) of the specimens obtained using NNP and HNP, respectively, were adequate for histological diagnosis (P = .0003, McNemar test). For 73.3% (66/90) and 82.2% (74/90) of the specimens obtained by using NNP and HNP, respectively, an accurate diagnosis was achieved (P = .06, McNemar test). Pancreatitis developed in 1 patient after this procedure, which subsided with conservative therapy.

LIMITATIONS

This was a single-blinded, crossover study.

CONCLUSION

Biopsy procedures that combine the EUS-FNA with HNP techniques are superior to EUS-FNA with NNP procedures for tissue acquisition. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000005939.).

Endoscopic ultrasound guided fine needle aspiration and useful ancillary methods

The role of endoscopic ultrasound (EUS) in evaluating pancreatic pathology has been well documented from the beginning of its clinical use. High spatial resolution and the close proximity to the evaluated organs within the mediastinum and abdominal cavity allow detection of small focal lesions and precise tissue acquisition from suspected lesions within the reach of this method. Fine needle aspiration (FNA) is considered of additional value to EUS and is performed to obtain tissue diagnosis. Tissue acquisition from suspected lesions for cytological or histological analysis allows, not only the differentiation between malignant and non-malignant lesions, but, in most cases, also the accurate distinction between the various types of malignant lesions. It is well documented that the best results are achieved only if an adequate sample is obtained for further analysis, if the material is processed in an appropriate way, and if adequate ancillary methods are performed. This is a multi-step process and could be quite a challenge in some cases. In this article, we discuss the technical aspects of tissue acquisition by EUS-guided-FNA (EUS-FNA), as well as the role of an on-site cytopathologist, various means of specimen processing, and the selection of the appropriate ancillary method for providing an accurate tissue diagnosis and maximizing the yield of this method. The main goal of this review is to alert endosonographers, not only to the different possibilities of tissue acquisition, namely EUS-FNA, but also to bring to their attention the importance of proper sample processing in the evaluation of various lesions in the gastrointestinal tract and other accessible organs. All aspects of tissue acquisition (needles, suction, use of stylet, complications, etc.) have been well discussed lately. Adequate tissue samples enable comprehensive diagnoses, which answer the main clinical questions, thus enabling targeted therapy.

Endoscopic ultrasound-guided fine-needle biopsy of small solid pancreatic lesions using a 22-gauge needle with side fenestration

BACKGROUND

Early detection of small pancreatic cancer is important because expected survival is markedly better for tumors ≤ 2 cm. A new endoscopic ultrasound-(EUS) guided biopsy needle with side fenestration has been recently developed to enable fine-needle biopsy (FNB) under EUS guidance. The aim of this study was to evaluate the outcome of EUS-FNB using a 22-gauge ProCore needle in solid pancreatic lesions ≤ 2 cm, in terms of diagnostic accuracy and yield.

METHODS

From January 2011 to December 2012, all consecutive EUS-guided tissue sampling of small pancreatic lesions (≤ 2 cm) were performed using 22-gauge ProCore needles; the data of these patients were analyzed retrospectively.

RESULTS

Sixty-eight patients with a mean age of 65.7 years were included. The mean lesion size was 16.5 mm (range 5-20). None of the patients developed complications. On pathological examination, the tissue retrieved was judged adequate in 58 out of 68 cases (85.3 %) and the presence of a tissue core was recorded in 36 out of 68 cases (52.9 %). The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 80, 100, 100, 40, and 82 %, respectively.

CONCLUSION

Our results suggested that EUS-FNB of small pancreatic lesions using a 22-gauge ProCore needle is effective and safe, and supports our hypothesis that EUS-FNB is highly useful in establishing the nature of small pancreatic lesions.

Incremental value of cell block preparations over conventional smears alone in the evaluation of EUS-FNA for pancreatic masses

BACKGROUND/AIMS

The effectiveness of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been established for a definite pathological diagnosis of pancreatic solid masses. We investigated the usefulness of cell block preparations in EUS-FNA, by evaluating the added value of cell block preparations over conventional smears alone.

METHODOLOGY

Between March 2011 and June 2013, 61 patients were retrospectively evaluated who underwent EUS-FNA for pancreatic solid masses. Diagnostic values for diagnosing pancreatic malignancy were compared for a combination of the conventional smear and cell block (CSCB) and the conventional smear alone (CS).

RESULTS

The addition of the cell block technique increased the sensitivity of conventional smear for diagnosing the pancreatic malignancy from 79% (CS) to 90% (CSCB, p=0.0313) and the accuracy from 81% to 91% (p=0.0313). The specificity and positive predictive value were 100% in both methods. The negative predictive value was increased from 33% (CS) to 50% (CSCB), but this difference was not statistically significant (p=0.0833).

CONCLUSION

The addition of the cell block method after a conventional smear may increase the sensitivity and negative predictive value for diagnosing the pancreatic malignancy in patients with pancreatic masses who undergo EUS-FNA. Further study may be warranted to determine whether the cell block method can replace the conventional smear.

Diagnostic efficacy of cell block immunohistochemistry, smear cytology, and liquid-based cytology in endoscopic ultrasound-guided fine-needle aspiration of pancreatic lesions: a single-institution experience

Background

The diagnostic efficiency of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology varies widely depending on the treatment method of the specimens. The present study aimed to evaluate the diagnostic efficacy of cell block (CB) immunohistochemistry, smear cytology (SC), and liquid-based cytology (LBC) in patients with pancreatic lesions without consulting an on-site cytopathologist.

Methods

This study prospectively enrolled 72 patients with pancreatic lesions. The EUS-FNA specimens were examined by SC, LBC, and CB immunohistochemistry. The diagnostic efficacy of the 3 methods was then compared. Patients’ final diagnosis was confirmed by surgical resection specimens, diagnostic imaging, and clinical follow-up.

Results

Our results included 60 malignant and 12 benign pancreatic lesions. The diagnostic sensitivity (90%), negative predictive value (66.7%), and accuracy (91.7%) of CB immunohistochemistry were significantly higher than those of SC (70.0%, 30.0%, and 75.0%, respectively) and LBC (73.3%, 31.6%, and 77.8%, respectively) (all P<0.05). The combination of CB and SC, or CB and LBC, did not significantly increase the efficacy compared to CB immunohistochemistry alone.

Conclusion

Our findings suggest that in the absence of an on-site cytopathologist, CB immunohistochemistry on EUS-FNA specimens offers a higher diagnostic efficacy in patients with pancreatic lesions than does SC and LBC.

Genomic characterisation of small cell lung cancer patient-derived xenografts generated from endobronchial ultrasound-guided transbronchial needle aspiration specimens

Patient-derived xenograft (PDX) models generated from surgical specimens are gaining popularity as preclinical models of cancer. However, establishment of PDX lines from small cell lung cancer (SCLC) patients is difficult due to very limited amount of available biopsy material. We asked whether SCLC cells obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) could generate PDX lines that maintained the phenotypic and genetic characteristics of the primary tumor. Following successful EBUS-TBNA sampling for diagnostic purposes, we obtained an extra sample for cytologic analysis and implantation into the flanks of immunodeficient mice. Animals were monitored for engraftment for up to 6 months. Histopathologic and immunohistochemical analysis, and targeted next-generation re-sequencing, were then performed in both the primary sample and the derivative PDX line. A total of 12 patients were enrolled in the study. EBUS-TBNA aspirates yielded large numbers of viable tumor cells sufficient to inject between 18,750 and 1,487,000 cells per flank, and to yield microgram quantities of high-quality DNA. Of these, samples from 10 patients generated xenografts (engraftment rate 83%) with a mean latency of 104 days (range 63–188). All but one maintained a typical SCLC phenotype that closely matched the original sample. Identical mutations that are characteristic of SCLC were identified in both the primary sample and xenograft line. EBUS-TBNA has the potential to be a powerful tool in the development of new targeting strategies for SCLC patients by providing large numbers of viable tumor cells suitable for both xenografting and complex genomic analysis.

Ultrasound-guided fine needle aspiration cytology as an addendum to sentinel lymph node biopsy can perfect the staging strategy in melanoma patients

BACKGROUND

Ultrasound guided fine needle aspiration cytology (US-guided FNAC) can identify microscopic involvement of lymph nodes as in breast cancer and avoid surgical sentinel node (SN). Its utility in melanoma patients is controversial and subject of this study.

METHODS

Between 2001 and 2010 over 1000 stage I/II consecutive melanoma patients prospectively underwent US-FNAC prior to SN biopsy. All patients underwent lymphoscintigraphy prior to US-FNAC. The Berlin US morphology criteria: Peripheral perfusion (PP), loss of central echoes (LCE) and balloon shaped (BS) were registered. FNAC was performed in case of presence of any of these factors. SN tumour burden was measured according to the Rotterdam criteria. All patients underwent SN or lymph node dissection (LND) in case of positive FNAC.

FINDINGS

Mean/median Breslow thickness was 2.58/1.57 mm. Mean/median follow-up was 56/53 months (1-132). SN positivity rate was 21%. US-FNAC Sensitivity was 71% (US only) and 51% (US-FNAC). Sensitivity of US-FNAC was highest for T4 (76%) and ulcerated melanomas (63%). PP, LCE and BS had sensitivity of 69%, 24% and 24% respectively. Sensitivity of US-FNAC increased with increasing SN tumour burden. PP was an early sign of metastasis (58% in <0.1mm metastases). Threshold size of a metastasis for FNAC was 0.3mm. Five-year survival correlated to US-FNAC status (95% in negative and 59% in positive).

INTERPRETATION

Ultrasound guided FNAC (US-FNAC) according to the Berlin morphology criteria could correctly identify at least half of all tumour positive sentinel nodes, prior to the surgical SN procedure. Peripheral perfusion is an early sign of metastasis, which is very sensitive, but with lower positive predictive value (PPV). It is responsible for the sensitivity of the procedure. Balloon shape is a sign of advanced metastases, with lower sensitivity, but high PPV. US-FNAC sensitivity correlated with increasing T-stage, ulceration of the primary and increasing SN tumour burden. US-FNAC status accurately predicts survival.

Effectiveness and complications of ultrasound guided fine needle aspiration for primary liver cancer in a Chinese population with serum α-fetoprotein levels ≤200 ng/ml--a study based on 4,312 patients

BACKGROUND

Hepatocellular carcinoma (HCC) can be diagnosed by noninvasive approaches with serum α-fetoprotein (AFP) levels >200 ng/ml and/or a radiological imaging study of tumor mass >2 cm in patients with chronic liver disease. Percutaneous fine needle aspiration (FNA) under ultrasound (US) guidance has a diagnostic specificity of 95% and is superior to radiological imaging studies.

AIM

The aim of this study is to elucidate the effectiveness and complications of fine needle aspiration in a Chinese population with primary liver cancer and AFP levels ≤200 ng/ml.

MATERIALS AND METHODS

A retrospective study was conducted over a period of 28 years. This selection period included patients with a suspected diagnosis of primary liver cancer whose AFP levels were ≤200 ng/ml and who underwent US-FNA. This data was then analyzed with cytomorphological features correlating with medical history, radiological imaging, AFP, and follow-up information.

RESULTS

Of the 1,929 cases with AFP ≤200 mg/ml, 1,756 underwent FNA. Of these, 1,590 cases were determined malignant and the remaining 166 were determined benign. Further, 1,478 malignant cases were diagnosed by FNA alone, and of these, 1,138 were diagnosed as PLC. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the diagnoses were 92.96%, 100%, 100%, 59.71%, and 93.62% respectively. There was no significant difference in the sensitivity, specificity, PPV and NPV between the subgroups with tumor size<2 cm and ≥2 cm. Major complications included implantation metastasis and hemorrhage.

CONCLUSION

Patients with PLC, especially those who present with an AFP ≤200 ng/ml, should undergo FNA. If negative results are obtained by FNA, it still could be HCC and repeated FNA procedure may be needed if highly suspicious of HCC on imaging study. The superiority of FNA in overall accuracy may outweigh its potential complications, such like hemorrhage and implantation metastasis.

[Prostate biopsy. Update for indication, procedure, and future developments]

Transrectal ultrasound-guided prostate biopsy is considered the gold standard in the primary investigation of a suspicious prostate-related finding. The procedure can be carried out with ten probes or more on the lateral side of the prostate, after administering antibiotic prophylaxis and applying local anesthesia. The indication for a biopsy depends on the results of the digitorectal examination, on the serum prostate-specific antigen level, on the individual patient's wish and on his comorbidities. Whether multiparametric imaging should be used before or during the course of a primary or repeated biopsy in order to identify suspicious prostate lesions is the subject of current investigations. Extended biopsy protocols require further clinical investigations before they can become the new standard in the diagnostic work-up. This review delivers an update on the indication for, and technique of, prostate biopsies.

Comparison of 12- and 16-core prostate biopsy in japanese patients with serum prostate-specific antigen level of 4.0-20.0 ng/mL

PURPOSE

In the present study, we compared 12- with 16-core biopsy in patients with prostate- specific antigen (PSA) levels of 4.0-20.0 ng/mL.

MATERIALS AND METHODS

Between 2003 and 2010, 332 patients whose serum PSA level was between 4.0 and 20.0 ng/mL underwent initial transrectal ultrasound (TRUS)-guided needle biopsy. Of those patients, 195 underwent 12-core biopsy and 137 underwent 16-core biopsy.

RESULTS

In the 12-core prostate biopsy group, 66 (33.8%) patients were found to have prostate cancer. On the other hand, in the 16-core prostate biopsy group of 137 patients, 61 (44.5%) were found to have prostate cancer. Among all patients, the prostate cancer detection rate was slightly higher in the 16-core biopsy group than in the 12-core biopsy group. Moreover, in patients with prostate volume > 30 mL or PSA density (PSAD) < 0.2, the prostate cancer detection rate was significantly higher in the 16-core biopsy group than in the 12-core biopsy group. There was no significant difference in pathological tumor grade, indolent cancer probability, or biopsy complication rate between the two groups.

CONCLUSION

In order to detect prostate cancer, 16-core prostate biopsy is safe and feasible for Japanese patients with serum PSA level of 4.0-20.0 ng/mL.

Utility of endoscopic ultrasound (EUS)-guided fine-needle aspiration for peri-arterial soft tissue cuffs without identifiable pancreas mass on CT and EUS: a prospective comparative study

Pancreatic cancer may present as a peri-arterial soft tissue cuff (PSTC) around the superior mesenteric artery or celiac axis without an identifiable pancreatic mass. We evaluated the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with a PSTC without definite pancreas involvement and those with a typical pancreatic mass. The patients who underwent EUS-FNA of a PSTC without pancreatic involvement were prospectively enrolled. The patients who underwent EUS-FNA for a pancreatic mass were recruited as a control group. A total of 224 patients underwent 247 EUS-FNAs. Among the 13 patients with a PSTC, 11 were positive for malignancy as determined by EUS-FNA, with 5 diagnosed after the first session and 6 after the second session. The diagnostic yield of PSTCs by EUS-FNA was significantly lower than that for typical pancreatic masses (65% vs. 87%, p = 0.02). An on-site cytopathologist and repeated EUS-FNA are recommended to improve the diagnostic accuracy of this disease entity.

[Diagnostic bronchoscopy]

Endoscopic technology has developed markedly with endobronchial ultrasonography (EBUS) having become dramatically widespread over the past 10 years. EBUS-guided transbronchial needle aspiration (EBUS-TBNA) has become an important modality for the mediastinal staging of lung cancer as well as mediastinoscopy. The combination of EBUS with a guide sheath( EBUS-GS) and virtual navigation systems, such as Bf-NAVI, LungPoint, superDimension/Bronchus system, is useful for diagnosis of small peripheral pulmonary lesions. Moreover, the ability to observe lesions has increased using picture enhancement developed by new methods such as autofluorescence imaging( AFI), narrow band imaging (NBI), and FUJI intelligent color enhancement( FICE). However, these modalities have limited value in detection of lung cancer and preneoplastic lesions. In recent years, the indications for AFI have widened and it can be now used for evaluation of tumor extension. Knowledge of these new technologies is certainly useful to allow their routine clinical use by respiratory surgeons. We will review these new technologies in this paper.

High-quality endoscopic ultrasound-guided fine needle aspiration tissue acquisition

Endoscopic ultrasound-guided fine needle aspiration is a multistep procedure that involves proper clinical indication, correct selection of needles, adapting evidence-based techniques such as the fanning maneuver and not routinely using suction or the stylet for tissue sampling, and establishing reliable cytopathology support. Integrating cytopathology in the training curriculum and developing a more flexible platform of needles and echoendoscopes are likely to further advance the field of endosonography. This review aims to summarize the technical issues that are key to performing high-quality endoscopic ultrasound-guided fine needle aspiration.

[The first experience in using elastography in combination with endobronchial ultrasonography for mediastinal pathology: Preliminary assessment of feasibility and comparison of characteristics via different approaches]

OBJECTIVE

To preliminarily assess the feasibility of elastography in endobronchial ultrasonography and to compare characteristics via different accesses.

MATERIAL AND METHODS

The investigation enrolled 3 patients (malignant, benign mediastinal adenopathy, paratracheal tumor). Elastography was carried out using a Pentax EB-1970UK echobronchoscope with a Hitachi Noblus ultrasound scanner. All the patients underwent fine-needle aspiration biopsy of mediastinal and pulmonary lymph nodes/masses with 22G needles (Cook, Medi-Globe). Sequential study of the same group of lymph nodes through different approaches through the esophagus and trachea was conducted, and its characteristics were compared in one patient.

RESULTS

A total of 8 lymph nodes and one paratracheal mass (Group 4L-7-4R-2R) were assessed in three patients. Reproducible images acceptable for visual assessment were obtained in all cases. The wall of the trachea and bronchi had no significant negative impact on the quality of an obtained image. Both malignant lesion of lymph nodes and paratracheal mass was accompanied by decreased tissue elasticity in the area of interest. Assessment of the same benign lymph node through different approaches revealed a clear discordance between elastographic findings with a drastic decrease in elasticity values via an endobronchial approach.

CONCLUSION

Endobronchial ultrasonography elastography is technically feasible. The wall of the trachea and bronchi has no significant impact on the quality of an obtained image; elastographic data are reproducible during re-measurements. Comparison of elastographic characteristics through different approaches suggests that there is a tendency to overestimate data on lymph node density during endobronchial examination versus a transesophageal approach. Thus, the direct transfer of the accumulated data and patterns of elastographic diagnosis to an endobronchial approach is impossible and likely to require a revision of criteria to estimate malignancy-associated changes during its application.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of small cell lung cancer

BACKGROUND

Massive lymphadenopathy and direct mediastinal invasion are well-recognized phenomena in patients with small cell lung cancer (SCLC). The aim of this study was to assess the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of SCLC.

METHODS

We retrospectively reviewed the records of 780 patients who underwent EBUS-TBNA at our institution from March 2004 to June 2012. Of these, 101 had a final diagnosis of SCLC. Excluding 3 patients with known SCLC who underwent EBUS-TBNA for staging purposes and including 2 patients who underwent EBUS-TBNA twice for the diagnosis of recurrence after achieving complete response by chemoradiation therapy during the study period, a total of 100 EBUS-TBNA procedures in 98 patients were analyzed.

RESULTS

Other diagnostic tests prior to the initial EBUS-TBNA had failed to yield a diagnosis in 41 patients. The overall diagnostic yield of EBUS-TBNA for SCLC was 97% (97 of 100). Rapid on-site cytologic evaluation (ROSE) was performed at the operator's discretion in 77 procedures. ROSE did not have any impact on diagnostic yield (99% with ROSE vs. 90% without ROSE, p=0.1), but the use of ROSE was associated with fewer lesions (mean 1.1 with ROSE vs. 1.6 without ROSE, p<0.01) or aspirates (mean 2.3 with ROSE vs. 4.0 without ROSE, p<0.01).

CONCLUSIONS

EBUS-TBNA provided a high diagnostic yield in SCLC with or without ROSE. EBUS-TBNA can be recommended for patients suspected to have SCLC, even if other diagnostic tests have failed.

Influence of the safety and diagnostic accuracy of preoperative endoscopic ultrasound-guided fine-needle aspiration for resectable pancreatic cancer on clinical performance

AIM: To evaluate the safety and diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in a cohort of pancreatic cancer patients.

METHODS: Of 213 patients with pancreatic cancer evaluated between April 2007 and August 2011, 82 were thought to have resectable pancreatic cancer on the basis of cross-sectional imaging findings. Of these, 54 underwent EUS-FNA before surgery (FNA+ group) and 28 underwent surgery without preoperative EUS-FNA (FNA- group).

RESULTS: All 54 lesions were visible on EUS, and all 54 attempts at FNA were technically successful. The diagnostic accuracy according to cytology and histology findings was 98.1% (53/54) and 77.8% (42/54), respectively, and the total accuracy was 98.1% (53/54). One patient developed mild pancreatitis after EUS-FNA but was successfully treated by conservative therapy. No severe complications occurred after EUS-FNA. In the FNA+ and FNA- groups, the median relapse-free survival (RFS) was 742 and 265 d, respectively (P = 0.0099), and the median overall survival (OS) was 1042 and 557 d, respectively (P = 0.0071). RFS and OS were therefore not inferior in the FNA+ group. These data indicate that the use of EUS-FNA did not influence RFS or OS, nor did it increase the risk of peritoneal recurrence.

CONCLUSION: In patients with resectable pancreatic cancer, preoperative EUS-FNA is a safe and accurate diagnostic method.

Gastric glomus tumor diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy: report of a case

A glomus tumor of the stomach is rare. It is difficult to diagnose the tumor before surgery by only endoscopic biopsy and radiography, and there is no established method of diagnosis before surgical treatment. Esophagogastroduodenoscopy (EGD) on a 50-year-old Japanese woman revealed a 10 mm submucosal tumor in the anterior wall of the gastric angle. Follow-up EGD revealed an increase in the size of the tumor to 15mm. Endoscopic ultrasonography (EUS) demonstrated a 15mm subepithelial hypoechoic solid tumor with continuity to the proper muscle layer. Histologic diagnosis by endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) was glomus tumor. The tumor was treated by laparoscopic local resection. The histologic diagnosis of the resected tumor was similar to the preoperative EUS-FNA results. EUS-FNA would appear to be an effective histologic test for early diagnosis of gastric glomus tumor.

Phase grouping-based needle segmentation in 3-D trans-rectal ultrasound-guided prostate trans-perineal therapy

A robust and efficient needle segmentation method used to localize and track the needle in 3-D trans-rectal ultrasound (TRUS)-guided prostate therapy is proposed. The algorithmic procedure begins by cropping the 3-D US image containing a needle; then all voxels in the cropped 3-D image are grouped into different line support regions (LSRs) based on the outer product of the adjacent voxels' gradient vector. Two different needle axis extraction methods in the candidate LSR are presented: least-squares fitting and 3-D randomized Hough transform. Subsequent local optimization refines the position of the needle axis. Finally, the needle endpoint is localized by finding an intensity drop along the needle axis. The proposed methods were validated with 3-D TRUS tissue-mimicking agar phantom images, chicken breast phantom images and patient images obtained during prostate cryotherapy. The results of the in vivo test indicate that our method can localize the needle accurately and robustly with a needle endpoint localization accuracy <1.43 mm and detection accuracy >84%, which are favorable for 3-D TRUS-guided prostate trans-perineal therapy.

Clinical factors associated with accuracy of EUS-FNA for pancreatic or peripancreatic solid mass without on-site cytopathologists

BACKGROUND AND AIMS

Endoscopic ultrasound-guided fine needle aspiration (EUSFNA) is a safe and effective technique for tissue diagnosis in patients with pancreatic or peripancreatic solid masses. However, the procedure is difficult to accomplish without an on-site cytopathologist. The aims of this study were to examine the outcomes of EUS-FNA for pancreatic or peripancreatic solid masses without an on-site cytopathologist and to determine the factors associated with diagnostic accuracy.

METHODS

From December 2005 to November 2011, 230 patients with pancreatic or peripancreatic solid masses had 240 EUS-FNAs performed without an on-site cytopathologist. The medical records of the 230 patients from a single tertiary center were retrospectively reviewed.

RESULTS

Among the 230 patients who underwent EUS-FNA, 201 patients (88%) had malignancy, which included 171 adenocarcinomas (74%). Assuming that the cytopathological malignancy was positive or suspicious for malignant cells with cytology, the accuracy without an on-site cytopathologist was 67.9%. However, the accuracy increased from 40.0% for the first 30 cases (from 2006 to 2008) to 83.3% for the last 30 cases (in 2011) and was constantly over 80.0% starting from the sixth octile onwards for every 30 cases (in 2011). From the analysis of factors associated with the accuracy of the diagnosis using logistic regression analysis, the number of needle passes and the experience of endosonographer were statistically associated with the diagnostic accuracy.

CONCLUSIONS

In the case of performing EUS-FNA for pancreatic or peripancreatic solid masses without an on-site cytopathologist, the experience of the endosonographer, and the number of needle passes were associated with the diagnostic accuracy.

Impact of rapid on-site evaluation on the adequacy of endoscopic-ultrasound guided fine-needle aspiration of solid pancreatic lesions: a systematic review and meta-analysis

BACKGROUND

Rapid on-site evaluation (ROSE) has the potential to improve adequacy rates for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solid pancreatic lesions, but its impact is context-dependent. No studies exist that summarize the relationship between ROSE, number of needle passes, and resulting adequacy rates.

AIMS

To analyze data from previous studies to establish if ROSE is associated with improved adequacy rates; to evaluate the relationship between ROSE, number of needle passes, and the resulting adequacy rates of EUS-FNA for solid pancreatic lesions.

METHODS

Systematic review and meta-analysis of studies reporting the adequacy rates for EUS-FNA of solid pancreatic lesions.

RESULTS

The search produced 3822 original studies, of which 70 studies met our inclusion criteria. The overall average adequacy rate was 96.2% (95% confidence interval: 95.5, 96.9). ROSE was associated with a statistically significant improvement of up to 3.5% in adequacy rates. There was heterogeneity in adequacy rates across all subgroups. No association between the assessor type and adequacy rates was found. Studies with ROSE have high per-case adequacy and a relatively high number of needle passes in contrast to non-ROSE studies. ROSE is an effect modifier of the relationship between number of needle passes and adequacy.

CONCLUSIONS

ROSE is associated with up to 3.5% improvement in adequacy rates for EUS-FNA of solid pancreatic lesions. ROSE assessor type has no impact on adequacy rates. ROSE is an effect modifier on the relationship between needle passes and per-case adequacy for EUS-FNA of solid pancreatic lesions.