Onsite cytopathology evaluation and ancillary studies beneficial in EUS-FNA of pancreatic, mediastinal, intra-abdominal, and submucosal lesions

Fine-Needle Aspiration Biopsy of Adrenal Gland Lesions: The Roles of Image Guidance, Rapid On-Site Evaluation and Additional Tissue Sampling

OBJECTIVE

An accurate fine-needle aspiration (FNA) diagnosis of adrenal lesions may be challenging. This study was to investigate roles of imaging guidance, rapid on-site evaluation (ROSE) and additional tissue sampling in FNA diagnosis of adrenal lesions.

METHODS

Adrenal FNA cases were retrieved from pathology archive. Patients' demographics, lesion size and location, imaging guidance methods, cytologic diagnoses and histopathologic diagnoses were reviewed and analysed.

RESULTS

The study cohort included 72 cases of left (86%) and right (14%) adrenal lesions. Endoscopic ultrasound (EUS) and computed tomography (CT) were used in 47 (65%) and 25 (35%) cases, respectively. Left adrenal lesions were sampled mostly by EUS-FNA (73%), whereas right adrenal lesions by CT-guided FNA (80%). There were no differences between the EUS-FNA and CT-FNA groups in terms of non-diagnostic rate and cytologic diagnostic categories. The non-diagnostic rate and cytologic diagnostic categories were the same between ROSE and non-ROSE groups. In a subset of 18 cases with concurrent core tissue biopsy, a definite diagnosis was rendered in all biopsy cases including three cases with a non-diagnostic or indeterminate cytology diagnosis.

CONCLUSION

Our study demonstrates that FNA has great efficacy for evaluation of adrenal lesions, either via EUS or CT guidance. Incorporation of ROSE evaluation into FNA procedure does not directly affect the performance of FNA biopsy but may help direct additional tissue sampling to salvage the cases with a non-diagnostic or indeterminate cytology diagnosis, increasing diagnostic yield.

Giant Intraabdominal Lymphangioma in a Pediatric Patient-A Challenging Diagnosis

Introduction: Intra-abdominal cystic formations represent heterogeneous pathologies with varied localization and clinical manifestation. The first challenge of a giant intra-abdominal cystic lesion is identifying the organ of origin. The clinical presentation of intra-abdominal cystic lesions varies from acute manifestations to non-specific symptoms or accidental discovery. Case presentation: A 2-year-old girl presents to the emergency unit with a fever of 38.5 Celsius, loss of appetite, and apathy. The investigations showed a gigantic intra-abdominal mass whose organ belonging could not be specified. Postoperatively, a giant mesenteric lymphangioma was evident, which was completely excised. Discussion: Giant cystic formations modify the anatomical reports and become space-replacing formations, and the starting point is even more challenging to assess preoperatively. Nevertheless, the careful evaluation of the characteristics of the formation, the effect on the adjacent organs, the age of the patient, and the clinical picture can provide elements of differential diagnosis. The stated purpose of this work is to systematize intra-abdominal lesions according to the organ of origin and to make the preoperative diagnosis of an intra-abdominal cystic lesion in the pediatric patient easy to perform starting from the presented case.

The Driver Role of Pathologists in Endocrine Oncology: What Clinicians Seek in Pathology Reports

Endocrine neoplasia represents an increasingly broad spectrum of disorders. Endocrine neoplasms range from incidental findings to potentially lethal malignancies. In this paper, we cover the impact of pathology in the interpretation of the clinic-pathological, genetic, and radiographic features underpinning these neoplasms. We highlight the critical role of multidisciplinary interactions in structuring a rational diagnostic and efficient therapeutic plan and emphasize the role of histopathological input in decision-making. In this context, standardized pathology reporting and second opinion endocrine pathology review represent relevant tools to improve the overall diagnostic workup of patients affected by endocrine tumors in every specific scenario. In fact, although a relevant proportion of cases may be correctly identified based on clinical presentation and biochemical/imaging investigations, a subset of cases presents with atypical findings that may lead to an inappropriate diagnosis and treatment plan based on a wrong pathological diagnosis if all pieces of the puzzle are not correctly considered. Pathologists have a responsibility to actively guide clinicians before and during surgical procedures to prevent unnecessary interventions. In all areas of endocrine pathology, pathologists must understand the complexity of tissue preservation and assay sensitivities and specificities to ensure the optimal quality and interpretation of diagnostic material. Finally, pathologists are central actors in tumor tissue biobanking, which is an expanding field in oncology that should be promoted while adhering to strict ethical and methodological standards.

EUS-guided FNAC in intra-abdominal lesions: Technique of tissue acquisition, ancillary testing, pearls and perils, and prospects

Endoscopic ultrasound enables visualization of lesions within and in the vicinity of the gastrointestinal tract. Endoscopic ultrasound guided fine needle aspiration cytology (EUS-FNAC) helps in targeting various luminal and extraluminal lesions both diagnostically and therapeutically. Various intra-abdominal organs amenable to EUS-FNA include the gastrointestinal tract (GIT), pancreas, kidney, adrenal gland, liver, bile duct, gallbladder, spleen, and lymph nodes. EUS-FNAC is mostly done for pancreatic and intra-abdominal lymph nodal lesions. In the present review, we have discussed various aspects of EUS-FNAC.

Fine-needle aspiration cytology for the diagnosis of plasma cell neoplasms in the head and neck region: A systematic analysis of the literature

BACKGROUND

Cytopathologic analysis is feasible and provides detailed morphological characterisation of head and neck lesions.

AIMS

To integrate the available data published on fine-needle aspiration cytology (FNAC) used for the diagnosis of plasma cell neoplasms (PCN) of the head and neck region.

MATERIALS AND METHODS

Searches on PubMed, Web of Science, Embase, and Scopus were performed to compile data from case reports/case series published in English. The Joanna Briggs Institute tool was used for the critical appraisal of studies.

RESULTS

A total of 82 studies comprising 102 patients were included in this review. There was a predilection for men (68.6%) (male/female ratio: 2.1:1). Individuals in their 50s (29.4%), 60s (22.5%), and 70s (22.5%) were more often affected. The thyroid gland (26.2%) was the main anatomical location, followed by scalp (15.5%), neck/cervical region (15.5%), jaws (13.6%), and major salivary glands (13.6%). For FNAC analysis, a smear was employed in 41 (40.6%) cases and a cell block was used in four (3.9%). In 56 (55.4%) reports, no cytological methods were available. Morphologically, 34 (56.7%) cases had a diagnosis of PCN with agreement between cytopathology and histopathology. The rate of wrong diagnoses when using cytology was 27.5%. Immunophenotyping was performed in 49 (48%) of the cases. The 69-month disease-free survival rate was 60.2%, while the 27-month overall survival rate was 64.1%.

CONCLUSION

This study reinforces that FNAC can be an ancillary tool in the first step towards the diagnosis of PCN of the head and neck region, especially when applying a cell block for cytological analysis.

T, Manikandan A, Ravichandar S. Petals of rose: Application of rapid on-site evaluation in bronchoscopy

In present day scenario, procedures that are minimally invasive like FNAs and Core needle biopsies are on the rise. Rapid on-site evaluation (ROSE) is a laboratory service that assesses the cytomorphologic features from FNA smears or biopsy contact imprints in the biopsy room and can provide on the spot input and suggestions for the clinician through immediate cytological examination of the biopsy sample. ROSE also allows for a preliminary diagnosis, allowing for the requirement of additional material for ancillary studies. We are presenting two cases which highlights the merits of ROSE in cytological diagnosis.   In the first case, a thirty four year old male patient came with complaints of productive cough, breathlessness and fever. Bronchoscopic needle aspiration and biopsy was done with Rapid Onsite Evaluation. ROSE revealed two non-caseating epithelioid granulomas on the 4th pass. Bronchoscopic lymph node biopsy was non- contributory. With other clinical and biochemical parameters, diagnosis of Sarcoidosis was made. This case study underscores the significance of ROSE in arriving at the diagnosis.   In the other case, a fifty seven year old male patient came to hospital with productive cough and breathlessness (MMRC grade II). CT chest revealed features suggestive of bronchogenic carcinoma. ROSE was performed along with bronchial brush cytology in which presence of atypical cells with increased nuclear cytoplasmic ratio, nuclear hyperchromatism and nuclear molding was noted. On histopathological examination, it was diagnosed as a case of non-small cell carcinoma of lung – poorly differentiated type. This case proves the advantage of ROSE in avoiding repeated invasive procedures for the patient.

Clinical application of endoscopic ultrasonography in evaluation of colorectal and peri-colorectal lesions

BACKGROUND

Endoscopic ultrasonography (EUS) has the functions of both endoscopy and ultrasound. Due to the complex anatomical structure of the intestine, there are few studies on EUS in colorectal lesions.

AIM

To explore the clinical application value of EUS in the diagnosis of colorectal and peri-colorectal lesions.

METHODS

We retrospectively analyzed the examination results of 95 patients detected by endoscopic miniprobe sonography (MPS) and linear EUS from September 2018 to July 2021, which were then compared to postoperative pathology. The kappa test was used in statistical analysis.

RESULTS

Using postoperative pathology as the golden standard, the accuracy of linear EUS in diagnosing the depth of rectal cancer invasion (T stage) was 73.9% (17/23 cases), including T1 (2/4 cases), T2 (4/6 cases), T3 (6/7 cases) , and T4 (5/ 5 cases) stages. The accuracy of linear EUS in diagnosing regional lymph node metastasis (N stage) was 91.3% (21/23 cases), including N0 (14/15 cases) and N1 (7/8 cases) stages. The consistency was high (kappa value = 0.782, P < 0.01). During preoperative evaluation of colorectal adenoma or early cancer before endoscopic submucosal dissection (ESD), the accuracy of MPS in diagnosing the depth of tumor invasion was 87.1% (27/31 cases), and the consistency was moderate (kappa value = 0.665, P < 0.01). The accuracy of MPS in diagnosing the origin and type of colorectal submucosal lesions was 95.5% (21/22 cases), and the consistency was high (kappa value = 0.919, P < 0.01). The accuracy of endoscopic ultrasonography-guided fine-needle aspiration in determining rectal and peri-rectal lesions was 70.0% (7/10 cases), and the consistency was moderate (kappa value = 0.565, P < 0.01).

CONCLUSION

According to the specific location and size of colorectal and peri-colorectal lesions, selective use of the MPS and linear EUS is of great value with regard to T/N staging of rectal cancer, preoperative evaluation of ESD, determination of the characteristics of colorectal-submucosal bulging lesions, and acquisition of lesion tissue of rectal and peri-rectal lesions.

Tumor Location in the Head/Uncinate Process and Presence of Fibrosis Impair the Adequacy of Endoscopic Ultrasound-Guided Tissue Acquisition of Solid Pancreatic Tumors

Simple Summary

Endoscopic ultrasound-guided tissue acquisition is the most accurate method to diagnose pancreatic tumors; nevertheless, this technique does not always bring adequate diagnostic accuracy. This study aimed to identify which factors can impair its adequacy. Pancreatic cytological and histological aspirates were retrospectively assessed according to two scores for grading the adequacy and the fibrosis of the specimens. The performance of the biopsies was lower when the tumor was located in the head/uncinate process of the pancreas, probably due to the higher fibrosis that we found in these sites. The specimens were less adequate also when <3 needle passes were performed and when the cell block was not done. We demonstrated the benefit to assess the presence of fibrosis in the specimens because it increased the risk of false negative results.

Abstract

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) of solid pancreatic tumors shows optimal specificity despite fair sensitivity, with an overall suboptimal diagnostic yield. We aim to quantify the adequacy and accuracy of EUS-TA and assess predictive factors for success, focusing on the presence and degree of specimen fibrosis. All consecutive EUS-TA procedures were retrieved, and the specimens were graded for sample adequacy and fibrosis. The results were evaluated according to patients’ and tumor characteristics and the EUS-TA technique. In total, 407 patients (59% male, 70 [63–77] year old) were included; sample adequacy and diagnostic accuracy were 90.2% and 94.7%, respectively. Fibrosis was significantly more represented in tumors located in the head/uncinate process (p = 0.001). Tumor location in the head/uncinate (OR 0.37 [0.14–0.99]), number of needle passes ≥ 3 (OR 4.53 [2.22–9.28]), and the use of cell block (OR 8.82 [3.23–23.8]) were independently related to adequacy. Severe fibrosis was independently related to false negative results (OR 8.37 [2.33–30.0]). Pancreatic tumors located in the head/uncinate process showed higher fibrosis, resulting in EUS-TA with lower sample adequacy and diagnostic accuracy. We maintain that three or more needle passes and cell block should be done to increase the diagnostic yield.

The Value of Cellblock in Diagnosing Pancreatic Lymphomas

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the diagnostic tool of choice for pancreatic solid mass lesions. Pancreatic lymphomas represent an infrequent and challenging cytologic diagnosis. Our aim was to determine the diagnostic value of cellblock (CB) in the diagnosis of pancreatic lymphomas.

METHODS

We retrieved pancreatic EUS-FNAs performed over 10-years from our institution's database. We correlated the cytologic and CB diagnosis with the histologic diagnosis as a gold standard.

RESULTS

We found 5 cases (2 women and 3 men; age range, 37-66 years [average age, 52 years]) of pancreatic lymphomas with histologic follow-up biopsies. They included 1 case of T-cell lymphoma (TCL), 1 case of plasma cell neoplasm (multiple myeloma [MM]), 1 case of diffuse large B-cell lymphoma (DLBCL), 1 case of classic Hodgkin lymphoma (HL), and 1 case of high-grade B-cell lymphoma (HGBCL). Cytologically, the cases of HL and DLBCL were suspected, the cases of TCL and MM were confused with undifferentiated carcinoma and neuroendocrine carcinoma, and the case of HGBCL was inconclusive. CB samples were of value in highlighting the morphologic details of lymphomas and allowed confirmation, proper classification, and grading of the lymphomas using immunohistochemistry that matched tissue biopsies.

CONCLUSIONS

EUS-FNA smears with CBs are helpful diagnostic tools, differentiating lymphomas from other malignancies and from nonneoplastic lymphocyte-rich lesions. CBs allow proper classification and grading of cases of pancreatic lymphomas.

EUS-FNA, ancillary studies and their clinical utility in patients with mediastinal, pancreatic, and other abdominal lesions

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an important modality to obtain tissue diagnosis from mediastinal, pancreatic, and intra-abdominal lesions in close proximity to the pulmonary and gastrointestinal tract. It is considered to be a relatively safe, rapid, and minimally invasive technique with low complication rates.

AIMS

To determine the diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and outcome of EUS-FNA, with histological correlation where applicable.

METHODS

Data of all 1059 consecutive patients who underwent EUS-FNA from 1 January 2005 to 31 December 2017 at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore was reviewed in this retrospective study. The major sites that were targeted for EUS-FNA were pancreatic (423), mediastinal (376), and other abdominal lesions (260).

RESULTS

The average number of passes per patient was 2.22. Rapid on-site evaluation (ROSE) was adequate in 969 patients (91.4%). Concordance between ROSE and final cytology was 99.5%. Follow-up was available in 810 patients (76.4%). The overall diagnostic yield was 94.3%. Ancillary studies, including immunohistochemical stains and flow cytometry, helped to increase the diagnostic yield from 78.1% to 94.3%. The overall sensitivity, specificity, PPV, NPV, and diagnostic accuracy for EUS-FNA were 94.8%, 98.6%, 99.9%, 65.5%, and 95.1%, respectively. Seven of 1059 patients (0.6%) developed complications.

CONCLUSION

EUS-FNA is a very sensitive and specific diagnostic tool with a minimal complication rate. Ancillary studies helped to increase the sensitivity, as well as the diagnostic yield.

This 'Rose' Has no Thorns-Diagnostic Utility of 'Rapid On-Site Evaluation' (ROSE) in Fine Needle Aspiration Cytology

Fine needle aspiration (FNA) cytology is a basic diagnostic technique used to investigate superficial and deep swellings. Rapid on-site evaluation (ROSE) using toluidine blue (TB) is easily available, cheap, cost-effective, can be used both for testing adequacy and giving provisional diagnosis. To evaluate the role of ROSE using toluidine blue staining in arriving at a diagnosis in comparison to routine stains. A total of 1500 cases of FNA of palpable swellings from sites like salivary gland, breast, thyroid, lymph node, and soft tissue lesions [non-image guided] during a 9-month period were studied. All the cases were evaluated by ROSE using toluidine blue stain and routine Giemsa/PAP staining. The results were compared in each case. Only 2% cases proved inadequate on TB, Giemsa and PAP combination, commonest site of inadequacy being lymph node. Adequate sample was obtained within two passes in 92.5% cases. The turn-around time (TAT) was 1 day in 96.4% of cases. The average time for making a provisional diagnosis on TB was 3 minutes. There was 99.2% concordance between TB and final cyto-diagnosis. Validity parameters: sensitivity 98%, specificity 100%, positive predictive value 100%, negative predictive value 99.8%, efficacy 99.2% and false negative 1.94%. ROSE using toluidine blue is a reliable means of demonstrating sample adequacy, for making a provisional diagnosis and guiding collection of diagnostic material for microbiology, immunocytochemistry (ICC), cell block and molecular testing etc. The technique is easy enough for general laboratories to incorporate into their routine practice. ROSE can be called as the "frozen section of cytology".

It is necessary to exam bottom and top slide smears of EUS-FNA for pancreatic cancer

BACKGROUND

Despite many reports on the diagnostic yield of cytology from endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), inter-slide differences are unknown. This prospective study aimed to compare diagnostic yield and cellular characteristics of bottom slides (BS) and top slides (TS) from EUS-FNA cytology performed without an on-site cytopathologist.

METHODS

In patients with suspected pancreatic cancer on previous imaging explorations, a single endoscopist performed EUS-FNA and obtained 2 sets of cytology slide (8 BS and 8 TS), 1 cellblock slide, and 1 biopsy slide. Both slide sets were randomly assigned. A cytopathologist with more than 10 years of expertise in pancreatic cytopathology blindly inspected and compared two slide sets.

RESULTS

In total, 73 specimens [42 head (57.5%), 16 body (21.9%), and 15 tail (20.5%)] were acquired for final analysis. Seventy-one cases were finally diagnosed with pancreatic cancer. The sensitivity and specificity of BS were 80.3% and 100.0%; and of TS 78.9% and 100.0%, respectively. In analyzing inter-slide difference, 66 cases (90.4%) showed consistent results between BS and TS. However, seven (9.6%) were positive only in one slide sets (4 BS and 3 TS). The proportions of specimens more than moderate and high cellularity were 75.3% and 60.3% in both slide sets (P> 0.99), and the proportion of artifact-free sets were 50.7%, and 52.1% for the BS and TS, respectively (P= 0.869).

CONCLUSIONS

Although BS and TS exhibited highly consistent diagnostic yields in cytologic smears from EUS-FNA, the proportion of inter-slide discordance is clinically considerable. Both slide sets need to be examined if there is no on-site cytopathologist.

A quarter century of EUS-FNA: Progress, milestones, and future directions

Tissue acquisition using EUS has considerably evolved since the first EUS-FNA was reported 25 years ago. Its introduction was an important breakthrough in the endoscopic field. EUS-FNA has now become a part of the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of the organs in its proximity, including lung diseases. This review aims to present the history of EUS-FNA development and to provide a perspective on the recent developments in procedural techniques and needle technologies that have significantly extended the role of EUS and its clinical applications. There is a bright future ahead for EUS-FNA in the years to come as extensive research is conducted in this field and various technologies are continuously implemented into clinical practice.

Pathological and Molecular Aspects to Improve Endoscopic Ultrasonography-Guided Fine-Needle Aspiration From Solid Pancreatic Lesions

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been applied to pancreatic lesions since the 1990s, and its use is now widespread. Improvements in endoscopic devices and sampling techniques have resulted in excellent diagnostic ability for solid pancreatic lesions. However, clinical improvements alone are not responsible for it; pathological aspects have also played important roles. Rapid on-site evaluation minimizes endoscopic procedures, although its value at improving the diagnostic ratio is still debated. Diagnostic efficacy differs by sample preparations (direct smear, cytospin, liquid-based cytology, cell block, and biopsy) and by staining methods (Papanicoloau, Diff-Quik, hematoxylin-eosin, and Giemsa). Several immunocytochemistry protocols aid in diagnosing epithelial components with cytological atypia and in differentiating various tumor types. One cytopathology diagnostic system is telecytology, which uses transmitted digital images and enables real-time diagnosis of EUS-FNA samples by expert cytologists at remote locations. However, EUS-FNA samples are useful for more than just diagnoses, as molecular analysis of these samples allows the identification of prognostic markers, such as genetic alterations in K-ras and EGFR. Expression of drug-metabolizing enzymes, human equilibrative nucleoside transporter 1, correlates with the response to gemcitabine-based chemotherapy. These pathology efforts have enhanced the diagnostic efficacy of EUS-FNA, thereby leading to better outcomes for patients with pancreatic diseases.

Endoscopic ultrasound-guided fine-needle aspiration and cytology for differentiating benign from malignant lymph nodes

BACKGROUND AND STUDY AIMS

Intra-abdominal and mediastinal lymphadenopathy are often difficult to diagnose, particularly in the absence of a primary lesion. Endosonography (EUS)-guided fine-needle aspiration and cytology (FNAC) has provided an easy and safe access to these lymph nodes, sparing the use of invasive and costly interventions. The main aim of this study is to assess the specificity, sensitivity, and predictive value of EUS-guided FNAC in the diagnosis of benign and malignant lymph nodes. In addition, the study aims to determine significant EUS features that could help in predicting lymph node malignancy.

PATIENTS AND METHODS

This prospective study included 142 patients with intra-abdominal or intrathoracic lymphadenopathy who were referred for EUS-guided FNAC because of inaccessibility by other imaging modalities. Ninety (63.3%) patients were found to have malignant lymph nodes, and 52 (36.6%) had lymphadenopathy of benign nature.

RESULTS

EUS-guided FNAC had a sensitivity and specificity of 92% and 100% respectively. It had positive and negative predictive values of 100% and 88% for malignancy, respectively. By logistic regression analysis, EUS features and shortest diameter were found to be potential predictors of malignancy with p-value of <0.0001.

CONCLUSION

EUS-guided FNAC is a powerful modality in the diagnosis of benign and malignant lymph nodes. Additional complementary EUS features could be added to this technique for definitive diagnosis.

Imaging modalities for characterising focal pancreatic lesions

BACKGROUND

Increasing numbers of incidental pancreatic lesions are being detected each year. Accurate characterisation of pancreatic lesions into benign, precancerous, and cancer masses is crucial in deciding whether to use treatment or surveillance. Distinguishing benign lesions from precancerous and cancerous lesions can prevent patients from undergoing unnecessary major surgery. Despite the importance of accurately classifying pancreatic lesions, there is no clear algorithm for management of focal pancreatic lesions.

OBJECTIVES

To determine and compare the diagnostic accuracy of various imaging modalities in detecting cancerous and precancerous lesions in people with focal pancreatic lesions.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, and Science Citation Index until 19 July 2016. We searched the references of included studies to identify further studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We planned to include studies reporting cross-sectional information on the index test (CT (computed tomography), MRI (magnetic resonance imaging), PET (positron emission tomography), EUS (endoscopic ultrasound), EUS elastography, and EUS-guided biopsy or FNA (fine-needle aspiration)) and reference standard (confirmation of the nature of the lesion was obtained by histopathological examination of the entire lesion by surgical excision, or histopathological examination for confirmation of precancer or cancer by biopsy and clinical follow-up of at least six months in people with negative index tests) in people with pancreatic lesions irrespective of language or publication status or whether the data were collected prospectively or retrospectively.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the references to identify relevant studies and extracted the data. We planned to use the bivariate analysis to calculate the summary sensitivity and specificity with their 95% confidence intervals and the hierarchical summary receiver operating characteristic (HSROC) to compare the tests and assess heterogeneity, but used simpler models (such as univariate random-effects model and univariate fixed-effect model) for combining studies when appropriate because of the sparse data. We were unable to compare the diagnostic performance of the tests using formal statistical methods because of sparse data.

MAIN RESULTS

We included 54 studies involving a total of 3,196 participants evaluating the diagnostic accuracy of various index tests. In these 54 studies, eight different target conditions were identified with different final diagnoses constituting benign, precancerous, and cancerous lesions. None of the studies was of high methodological quality. None of the comparisons in which single studies were included was of sufficiently high methodological quality to warrant highlighting of the results. For differentiation of cancerous lesions from benign or precancerous lesions, we identified only one study per index test. The second analysis, of studies differentiating cancerous versus benign lesions, provided three tests in which meta-analysis could be performed. The sensitivities and specificities for diagnosing cancer were: EUS-FNA: sensitivity 0.79 (95% confidence interval (CI) 0.07 to 1.00), specificity 1.00 (95% CI 0.91 to 1.00); EUS: sensitivity 0.95 (95% CI 0.84 to 0.99), specificity 0.53 (95% CI 0.31 to 0.74); PET: sensitivity 0.92 (95% CI 0.80 to 0.97), specificity 0.65 (95% CI 0.39 to 0.84). The third analysis, of studies differentiating precancerous or cancerous lesions from benign lesions, only provided one test (EUS-FNA) in which meta-analysis was performed. EUS-FNA had moderate sensitivity for diagnosing precancerous or cancerous lesions (sensitivity 0.73 (95% CI 0.01 to 1.00) and high specificity 0.94 (95% CI 0.15 to 1.00), the extremely wide confidence intervals reflecting the heterogeneity between the studies). The fourth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (dysplasia) provided three tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing invasive carcinoma were: CT: sensitivity 0.72 (95% CI 0.50 to 0.87), specificity 0.92 (95% CI 0.81 to 0.97); EUS: sensitivity 0.78 (95% CI 0.44 to 0.94), specificity 0.91 (95% CI 0.61 to 0.98); EUS-FNA: sensitivity 0.66 (95% CI 0.03 to 0.99), specificity 0.92 (95% CI 0.73 to 0.98). The fifth analysis, of studies differentiating cancerous (high-grade dysplasia or invasive carcinoma) versus precancerous (low- or intermediate-grade dysplasia) provided six tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing cancer (high-grade dysplasia or invasive carcinoma) were: CT: sensitivity 0.87 (95% CI 0.00 to 1.00), specificity 0.96 (95% CI 0.00 to 1.00); EUS: sensitivity 0.86 (95% CI 0.74 to 0.92), specificity 0.91 (95% CI 0.83 to 0.96); EUS-FNA: sensitivity 0.47 (95% CI 0.24 to 0.70), specificity 0.91 (95% CI 0.32 to 1.00); EUS-FNA carcinoembryonic antigen 200 ng/mL: sensitivity 0.58 (95% CI 0.28 to 0.83), specificity 0.51 (95% CI 0.19 to 0.81); MRI: sensitivity 0.69 (95% CI 0.44 to 0.86), specificity 0.93 (95% CI 0.43 to 1.00); PET: sensitivity 0.90 (95% CI 0.79 to 0.96), specificity 0.94 (95% CI 0.81 to 0.99). The sixth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (low-grade dysplasia) provided no tests in which meta-analysis was performed. The seventh analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) provided two tests in which meta-analysis was performed. The sensitivity and specificity for diagnosing cancer were: CT: sensitivity 0.83 (95% CI 0.68 to 0.92), specificity 0.83 (95% CI 0.64 to 0.93) and MRI: sensitivity 0.80 (95% CI 0.58 to 0.92), specificity 0.81 (95% CI 0.53 to 0.95), respectively. The eighth analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) or benign lesions provided no test in which meta-analysis was performed.There were no major alterations in the subgroup analysis of cystic pancreatic focal lesions (42 studies; 2086 participants). None of the included studies evaluated EUS elastography or sequential testing.

AUTHORS' CONCLUSIONS

We were unable to arrive at any firm conclusions because of the differences in the way that study authors classified focal pancreatic lesions into cancerous, precancerous, and benign lesions; the inclusion of few studies with wide confidence intervals for each comparison; poor methodological quality in the studies; and heterogeneity in the estimates within comparisons.

Falling under the umbrella cells: A single institutional experience and literature review of urothelial carcinoma presenting as a primary pancreatic mass on endoscopic ultrasound-guided fine-needle aspiration

Metastases to the pancreas are much less common than primary pancreatic lesions, and there are few reports in the literature of metastatic urothelial carcinoma (UC) found in the pancreas. We report two cases of metastatic UC mimicking a primary pancreatic lesion. Two female patients, aged 48 and 83 years, presented with isolated pancreatic lesions causing obstructive jaundice suspicious for pancreatic adenocarcinoma and underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with rapid on-site evaluation (ROSE). On cytopathology, the lesions were found to be UC, confirmed with immunohistochemical (IHC) staining. UC rarely metastasizes to the pancreas, and diagnosis through EUS-FNA can be challenging. However, the utilization of ROSE, dedicated cell block passes, and IHC have proved to be effective in obtaining this unusual pancreatic diagnosis by EUS-FNA.

"Clinical" cytology for endoscopists: A practical guide

Clinical cytology was originally used by clinicians to provide rapid diagnosis. However, with advancing medical subspecialization, few clinicians interpret cytology themselves these days, for example, gynecologists, hematologists, urologists, and occasional gastroenterologist (mainly in Asian countries). Cytological assessment enjoyed a renaissance with the development of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). Subsequently, pathologists, most of them more experienced in histology, had to take over. Recently, it has been shown that in-room cytology can be easily performed by the endoscopist themselves for initial evaluation of the quality of the EUS-FNA specimen and an initial diagnosis distinguishing benign or malignant cells. Bringing cytology back to the clinician has some advantages but does not substitute the professional cytopathologist. This report has written to lower the threshold for the clinician to find his way back to the microscope, which may improve both their diagnostic yield and assessment of EUS-FNA sample quality.

EUS-guided FNA and FNB after on-site cytological evaluation in gastric subepithelial tumors

OBJECTIVE

Acquiring adequate tissue for immunohistochemical (IHC) analysis is important in the differential diagnosis of subepithelial tumors (SETs). In this study, we aimed to compare the diagnostic yield based on IHC analysis between endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and EUS-guided fine needle biopsy (EUS-FNB) after on-site cytological evaluation for cellularity in gastric SETs.

METHODS

In 22 patients with gastric SETs, EUS-guided tissue sampling was performed on the same SET in a randomized sequence, with EUS-FNA followed by EUS-FNB, or vice versa. After on-site cytological evaluation for cellularity, the cytological and histological examinations were performed.

RESULTS

There was a significant difference in the median number of needle passes to obtain adequate cellularity in the on-site cytological evaluation (2.0 for EUS-FNA vs 1.0 for EUS-FNB, P = 0.008). The proportion of adequate cellularity on the first needle pass was significantly higher in the EUS-FNB than in the EUS-FNA group (68.2% vs 31.8%, P = 0.034). However, diagnosis based on IHC examination was established in 15 (68.2%) and 18 (81.8%) cases by EUS-FNA and EUS-FNB, respectively (P = 0.488).

CONCLUSIONS

EUS-FNB decreases the number of needle passes to obtain adequate cellularity and yields a higher proportion of adequate cellularity during the first needle pass compared with EUS-FNA in gastric SETs. However, there was no significant difference in diagnostic yield with IHC stain between the two procedures after on-site cytological evaluation for adequate cellularity.

Endoscopic/Endobronchial Ultrasound-Guided Fine Needle Aspiration and Ancillary Techniques, Particularly Flow Cytometry, in Diagnosing Deep-Seated Lymphomas

Evaluation of deep-seated lymphomas by fine-needle aspiration (FNA) can be challenging due to their reduced accessibility. Controversy remains as to whether FNA and ancillary techniques can be used to diagnose deep-seated lymphomas reliably and sufficiently for clinical management. Most published studies are favorable that endobronchial ultrasound (EBUS)/endoscopic ultrasound (EUS)-FNA plays an important role in the diagnosis of deep-seated lymphomas. The addition of ancillary techniques, particularly flow cytometry, increases diagnostic yield. While subclassification is possible in a reasonable proportion of cases, the reported rates of successful subclassification are lower than those for lymphoma detection/diagnosis. The diagnostic limitation exists for Hodgkin's lymphoma, grading of follicular lymphoma, and some T-cell lymphomas. The role of FNA in deep-seated lymphomas is much better established for recurrent than primary disease. It remains unclear whether the use of large-sized-needle FNA or a combination of core needle biopsy and FNA improves subclassification. It is important for cytopathologists to have considerable understanding of the WHO lymphoma classification and develop a collaborative working relationship with hematopathologists and oncologists. As EUS/EBUS-FNA techniques advance and sophisticated molecular techniques such as next- generation sequencing become possible, the role of FNA in the diagnosis of deep-seated lymphomas will possibly increase.

Efforts to improve the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration for pancreatic tumors

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is widely used to obtain a definitive diagnosis of pancreatic tumors. Good results have been reported for its diagnostic accuracy, with high sensitivity and specificity of around 90%; however, technological developments and adaptations to improve it still further are currently underway. The endosonographic technique can be improved when several tips and tricks useful to overcome challenges of EUS-FNA are known. This review provides various techniques and equipment for improvement in the diagnostic accuracy in EUS-FNA.

Endoscopic Ultrasonography-Guided Biopsy for Differentiation of Benign and Malignant Pelvic Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Preoperative diagnosis of pelvic lesions remains challenging despite advances in imaging technologies. Endoscopic ultrasonography (EUS)-guided biopsy is an effective diagnostic modality for sampling the digestive tract and surrounding areas. However, a meta-analysis summarizing the diagnostic efficacy of EUS-guided biopsy for pelvic lesions has not been published.

AIMS

We aimed to evaluate the utility of EUS-guided biopsy in the diagnosis of pelvic lesions.

METHODS

Articles were identified via structured database search; only studies where pelvic lesions were confirmed by surgery or clinical follow-up were included. Data extracted were selected with strict criteria. A fixed-effects model was used to estimate the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). A summary receiver operating characteristic curve (SROC) was also constructed.

RESULTS

Ten studies containing a total of 246 patients were included. The pooled sensitivity of EUS-guided biopsy for differential diagnosis of pelvic masses was 0.89 (95% CI 0.83-0.94), and the specificity was 0.93 (95% CI 0.86-0.97). The area under the SROC was 0.9631. The combined PLR, NLR, and DOR were 11.75 (95% CI 5.90-23.43), 0.12 (95% CI 0.07-0.20), and 100.06 (95% CI 37.48-267.10) respectively. There is potential presence of publication bias in this meta-analysis.

CONCLUSIONS

Our meta-analysis shows that EUS-guided biopsy is a powerful tool for differentiating pelvic masses with a high sensitivity and specificity. Furthermore, it is a safe procedure with low rate of complication, although more high-quality prospective studies are required to be done.