Non-negligible rate of needle tract seeding after endoscopic ultrasound-guided fine-needle aspiration for patients undergoing distal pancreatectomy for pancreatic cancer

Updated techniques and evidence for endoscopic ultrasound-guided tissue acquisition from solid pancreatic lesions

Endoscopic ultrasound-guided tissue acquisition (EUS-TA), including fine-needle aspiration (EUS-FNA) and fine-needle biopsy (EUS-FNB), has revolutionized specimen collection from intra-abdominal organs, especially the pancreas. Advances in personalized medicine and more precise treatment have increased demands to collect specimens with higher cell counts, while preserving tissue structure, leading to the development of EUS-FNB needles. EUS-FNB has generally replaced EUS-FNA as the procedure of choice for EUS-TA of pancreatic cancer. Various techniques have been tested for their ability to enhance the diagnostic performance of EUS-TA, including multiple methods of sampling at the time of puncture, on-site specimen evaluation, and specimen processing. In addition, advances in next-generation sequencing have made comprehensive genomic profiling of EUS-TA samples feasible in routine clinical practice. The present review describes updates in EUS-TA sampling techniques of pancreatic lesions, as well as methods for their evaluation.

Diagnosis of pancreatic malignancies using an overnight-stored pancreatic juice cell block specimen

BACKGROUND AND AIMS

Pancreatic juice cytology is useful for diagnosing pancreatic duct strictures and cystic lesions. However, some cases cannot be diagnosed using cytology. This study aimed to evaluate the utility of the overnight-stored pancreatic juice cell block (CB) method for diagnosing pancreatic disease.

METHODS

This retrospective study included 32 patients who presented with pancreatic duct strictures or cystic lesions between 2018 and 2024. The sensitivity, specificity, and accuracy of the CB method and single/multiple pancreatic juice cytology were compared to evaluate the utility of the CB.

RESULT

An endoscopic nasopancreatic drainage tube was placed in the main pancreatic duct, and pancreatic juice was collected to create a CB specimen. The median amount of pancreatic juice collected was 180(30-200) mL, and the median number of cytological examinations was three(2-8). Of the 32 cases, 13 were malignant, and 19 were benign (non-malignant). The sensitivity was significantly higher for the CB method (62 %) than for single cytology(15 %, P = 0.0414), and there was no significant difference between CB and multiple cytology(54 %, P = 1.0). The specificity and accuracy were not significantly different between the CB method and single or multiple cytology. When multiple cytology and CB were combined, sensitivity improved to 77 %. The pathological findings of the CB specimens were similar to the surgical specimens, including immunohistochemistry.

CONCLUSION

The overnight-stored pancreatic juice CB method was more effective than single cytology, with similar sensitivities to multiple cytology and can also be used for immunohistochemistry. The pancreatic juice CB method is useful for pancreatic juice assessment.

The role of endoscopic ultrasound in the detection of pancreatic lesions in high-risk individuals

Individuals at high risk of developing pancreatic ductal adenocarcinoma are eligible for surveillance within research programs. These programs employ periodic imaging in the form of magnetic resonance imaging/magnetic resonance cholangiopancreatography or endoscopic ultrasound for the detection of early cancer or high-grade precursor lesions. This narrative review discusses the role of endoscopic ultrasound within these surveillance programs. It details its overall strengths and limitations, yield, burden on patients, and how it compares to magnetic resonance imaging. Finally, recommendations are given when and how to incorporate endoscopic ultrasound in the surveillance of high-risk individuals.

Impact of endoscopic ultrasound-guided tissue acquisition on prognosis and peritoneal lavage cytology in resectable or borderline resectable pancreatic ductal adenocarcinoma

OBJECTIVES

This study aimed to evaluate the clinical impact of preoperative endoscopic ultrasound-guided tissue acquisition (EUS-TA) on the prognosis and incidence of positive peritoneal lavage cytology (PLC) during laparotomy or staging laparoscopy in patients with resectable (R) or borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC).

METHODS

We retrospectively collected data from patients diagnosed with body and tail PDAC with/without EUS-TA at our hospital from January 2006 to December 2021.

RESULTS

To examine the effect of EUS-TA on prognosis, 153 patients (122 in the EUS-TA group, 31 in the non-EUS-TA group) were analyzed. There was no significant difference in overall survival between the EUS-TA and non-EUS-TA groups after PDAC resection (P = 0.777). In univariate and multivariate analysis, preoperative EUS-TA was not identified as an independent factor related to overall survival after pancreatectomy [hazard ratio 0.96, 95 % confidence interval (CI) 0.54-1.70, P = 0.897]. Next, to examine the direct influence of EUS-TA on the results of PLC, 114 patients (83 in the EUS-TA group and 31 in the non-EUS-TA group) were analyzed. Preoperative EUS-TA was not statistically associated with positive PLC (odds ratio 0.73, 95 % CI 0.25-2.20, P = 0.583). After propensity score matching, overall survival and positive PLC were the same in both groups.

CONCLUSIONS

EUS-TA had no negative impact on postoperative survival and PLC-positive rates in R/BR PDAC.

Endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: a comprehensive review

Advancements in diagnostic radiology have amplified the incorporation of these techniques into routine clinical practice. Concurrently, the frequency of incidentally identifying pancreatic cystic lesions (PCLs) has surged. PCLs encompass diverse categories contingent upon their origin. Among them, branch duct-intraductal papillary mucinous neoplasms (BD-IPMN) and mucinous cystic neoplasms (MCN) are categorized as mucinous cystic lesions that have malignant potential. Even solid neoplasms occasionally show cystic degeneration. Therefore, precise differential PCL diagnosis is crucial to optimize clinical management strategies and detect malignant transformations. Endoscopic ultrasound (EUS) affords comprehensive visualization of the pancreas with high-resolution ultrasound, complemented by fine-needle aspiration (FNA) under real-time EUS guidance, which is a minimally invasive procedure for obtaining pathological samples. This synergy has established EUS and EUS-FNA as vital procedures in the management of PCLs, enabling differentiation of PCLs. Cyst fluid analysis has played a pivotal role in deciding the optimal management strategy. The efficacy of cytological analysis is limited by scant cytologic material. The "string sign" test evaluates fluid viscosity, and its simplicity warrants initial consideration. Amylase and tumor markers, such as CEA, have been studied, but they yield varied sensitivity and specificity. Glucose and genetic mutations (KRAS, GNAS) exhibit promise, while comprehensive genomic profiling underscores genetic insights. Through-the-needle biopsy and needle-based confocal laser endomicroscopy also show high diagnostic yield. EUS-FNA, however, entails risks like infection and needle tract seeding, emphasizing the need for proper utilization. Pancreatic cyst fluid analysis augments diagnostic accuracy and informs clinical decisions, making it a valuable adjunct to imaging.

The history of endoscopic ultrasound-guided fine-needle aspiration: development and progress

Endoscopic ultrasonography (EUS) is an important diagnostic technique to accurately diagnose diseases originating from organs near the gastrointestinal tract. EUS-guided fine-needle aspiration (FNA) has improved the histopathological diagnosis. EUS-FNA has been further developed over a long period of 40 years. The history of the development of endosonographic scopes, ultrasonographic observation systems, puncture needles, and puncture methods will provide a springboard for future development.

Methods to increase the diagnostic efficiency of endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic lesions: An updated review

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a means to procure adequate specimens for histological and cytologic analysis. The ideal EUS-FNA should be safe, accurate, and have a high sample adequacy rate and low adverse events rate. In recent years, many guidelines and trials on EUS-FNA have been published. The purpose of this article is to provide an update on the influence of some of the main factors on the diagnostic efficiency of EUS-FNA as well as a rare but serious complication known as needle tract seeding.

Predicting Pathological Response to Preoperative Chemotherapy in Pancreatic Ductal Adenocarcinoma Using Post-Chemotherapy Computed Tomography Radiomics

INTRODUCTION

Assessing the response to preoperative treatment in pancreatic cancer provides valuable information for guiding subsequent treatment strategies. The present study aims to develop and validate a computed tomography (CT) radiomics-based machine learning (ML) model for predicting pathological response (PR) to preoperative chemotherapy in pancreatic ductal adenocarcinoma (PDAC).

METHODS

Retrospective data were analyzed from 86 PDAC patients undergoing neoadjuvant or conversion chemotherapy followed by surgical resection from January 2018 to May 2023. The cohort was randomly divided into training (70%, n = 60) and testing (30%, n = 26) sets. Favorable PR was defined as Evans grade IIb or greater. Radiomic features were extracted from post-chemotherapy CT images, and dimensionality reduction was performed using the least absolute shrinkage and selection operator (LASSO) logistic regression. Four ML classifiers (Light Gradient Boosting Machine (LGBM), Random Forest, AdaBoost, and Quadratic Discriminant Analysis) were evaluated for predicting a favorable PR. Model performance was primarily assessed using the area under the receiver operating characteristic curve (AUC), Brier score, and decision curve analysis.

RESULTS

Forty-one (47.7%) patients had a favorable PR. LASSO analysis on the training set identified five radiomic features. The LGBM model demonstrated the best performance, with a training AUC of 0.902 and a testing AUC of 0.923. It also exhibited the lowest Brier scores, both in training (0.136) and testing (0.135). Decision curve analysis further confirmed its clinical potential.

CONCLUSION

The CT radiomics-based ML model exhibited promising performance in predicting PR in PDAC after neoadjuvant/conversion chemotherapy. This suggests clinical utility in optimizing surgical candidates and timing of surgery, leading to personalized treatment strategies.

Role of Endoscopic Ultrasound in Diagnosis of Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is the most common (90%) type of solid pancreatic neoplasm. Due to its late presentation and poor survival rate, early diagnosis and timely treatment is of utmost importance for better clinical outcomes. Endoscopic ultrasound provides high-resolution images of the pancreas and has excellent sensitivity in the diagnosis of even small (<2 cm) pancreatic lesions. Apart from imaging, it also has an advantage of tissue acquisition (EUS fine-needle aspiration, FNA; or fine-needle biopsy, FNB) for definitive diagnoses. EUS-guided tissue acquisition plays a crucial role in genomic and molecular studies, which in today's era of personalized medicine, are likely to become important components of PDAC management. With the use of better needle designs and technical advancements, EUS has now become an indispensable tool in the management of PDAC. Lastly, artificial intelligence for the detection of pancreatic lesions and newer automated needles for tissue acquisition will obviate observer dependency in the near future, resulting in the wider dissemination and adoption of this technology for improved outcomes in patients with PDAC.

Cysts or necrotic components in pancreatic ductal adenocarcinoma is associated with the risk of EUS-FNA/B complications including needle tract seeding

BACKGROUND

EUS-FNA/B for pancreatic ductal adenocarcinoma (PDAC) is generally considered to be safe; however, while the incidence is low, there are occurrences of complications. Among these complications, there are serious ones like needle tract seeding (NTS), and it is not known than which types of tumors have the risks of EUS-FNA/B complications. This study aimed to evaluate the risk of EUS-FNA/B complications in patients with PDAC, focusing on morphological features.

METHODS

Overall, 442 patients who underwent EUS-FNA/B for solid pancreatic masses between January 2018 and May 2022 in four institutions were retrospectively surveyed. Finally, 361 patients histopathologically diagnosed with PDAC were analyzed. Among these patients, 79 tumors with cysts or necrotic components were compared with 282 tumors without cysts or necrotic components. The incidence and risk of EUS-FNA/B complications including NTS were evaluated.

RESULTS

There were 9 (2.4 %) of total EUS-FNA/B complications and 3 (0.8 %) of NTS. The incidence of total complication rate and NTS in tumors with cysts or necrotic components were significantly higher than in those without cysts or necrotic components (total complication 6.3 % vs. 1.4 %, p = 0.026, NTS 3.7 % vs. 0 %, p = 0.01). The transgastric route of puncture (OR: 93.3, 95 % CI: 3.81-2284.23) and the existence of cysts or necrotic components (OR: 7.3, 95 % CI: 1.47-36.19) were risk factors for EUS-FNA/B complications identified by the multivariate analysis.

CONCLUSIONS

We should pay attention to the risks of EUS-FNA/B complications, including NTS, when the tumor has cysts or necrotic components.

Is the radiomics-clinical combined model helpful in distinguishing between pancreatic cancer and mass-forming pancreatitis?

PURPOSE

To develop CT-based radiomics models for distinguishing between resectable PDAC and mass-forming pancreatitis (MFP) and to provide a non-invasive tool for cases of equivocal imaging findings with EUS-FNA needed.

METHODS

A total of 201 patients with resectable PDAC and 54 patients with MFP were included. Development cohort: patients without preoperative EUS-FNA (175 PDAC cases, 38 MFP cases); validation cohort: patients with EUS-FNA (26 PDAC cases, 16 MFP cases). Two radiomic signatures (LASSOscore, PCAscore) were developed based on the LASSO model and principal component analysis. LASSOCli and PCACli prediction models were established by combining clinical features with CT radiomic features. ROC analysis and decision curve analysis (DCA) were performed to evaluate the utility of the model versus EUS-FNA in the validation cohort.

RESULTS

In the validation cohort, the radiomic signatures (LASSOscore, PCAscore) were both effective in distinguishing between resectable PDAC and MFP (AUC_LASSO = 0.743, 95% CI: 0.590-0.896; AUC_PCA = 0.788, 95% CI: 0.639-0.938) and improved the diagnostic accuracy of the baseline onlyCli model (AUC_onlyCli = 0.760, 95% CI: 0.614-0.960) after combination with variables including age, CA19-9, and the double-duct sign (AUC_PCACli = 0.880, 95% CI: 0.776-0.983; AUC_LASSOCli = 0.825, 95% CI: 0.694-0.955). The PCACli model showed comparable performance to FNA (AUC_FNA = 0.810, 95% CI: 0.685-0.935). In DCA, the net benefit of the PCACli model was superior to that of EUS-FNA, avoiding biopsies in 70 per 1000 patients at a risk threshold of 35%.

CONCLUSIONS

The PCACli model showed comparable performance with EUS-FNA in discriminating resectable PDAC from MFP.

Pancreatic Cancer Cells May Adhere to the External Surface of the Puncture Needle After Endoscopic Ultrasound-Guided Fine-Needle Aspiration

OBJECTIVE

We prospectively investigated whether cells derived from pancreatic cancers adhered to the puncture needle's external surface after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and whether wiping the needle with alcohol swabs removed residual cancer cells.

METHODS

The participants were 100 consecutive patients who underwent EUS-FNA for suspected pancreatic ductal adenocarcinoma. In the first pass of EUS-FNA, we prepared aspiration and lavage cytological diagnosis materials from the lumen and external surface of the puncture needle, respectively. This was repeated in the second pass, although the needle's external surface was wiped with an alcohol swab.

RESULTS

The positivity rates of aspiration cytological diagnosis for the first and second passes were 67% and 72%, respectively. The positivity rates of lavage cytological diagnosis of the needle's external surface on the first and second passes were 20% and 3%, respectively. Wiping the needle's external surface with alcohol swabs significantly reduced the proportion of cancer cells detected ( P < 0.001). The accuracy rate based on all the collected specimens was 90%. There were no EUS-FNA-related adverse events.

CONCLUSION

Pancreatic cancer cells may adhere to the puncture needle's external surface after EUS-FNA. Wiping the needle with alcohol swabs after each puncture effectively removes residual cancer cells.

Case of needle tract seeding during preoperative neoadjuvant chemotherapy for resectable pancreatic cancer

Reports of needle tract seeding (NTS) as a complication of endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) have been increasing. To date, most of the reported cases of NTS have been diagnosed during the postoperative follow‐up period. Herein, we report a case of NTS that occurred during preoperative neoadjuvant chemotherapy after EUS‐FNA for resectable pancreatic cancer. The patient underwent transgastric EUS‐FNA for a pancreatic tail tumor. He was diagnosed as having resectable pancreatic cancer and received preoperative neoadjuvant chemotherapy. After completion of the chemotherapy, computed tomography showed a thick‐walled cyst‐like structure appearing between the pancreas and the gastric wall. Combined resection revealed adenocarcinoma invasion into the cyst‐like structure. Based on the clinical course, and surgical and pathological findings, the condition was diagnosed as NTS. It is thus crucial that after EUS‐FNA, a detailed review of the imaging findings be conducted in the preoperative period. If adhesions between the stomach and the pancreas are observed after transgastric EUS‐FNA, combined resection of the gastric wall should be considered.

Comprehensive review on endoscopic ultrasound-guided tissue acquisition techniques for solid pancreatic tumor

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030, a high mortality rate considering the number of cases. Surgery and chemotherapy are the main treatment options, but they are burdensome for patients. A clear histological diagnosis is needed to determine a treatment plan, and endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding. With the development of personalized medicine and precision treatment, there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure, leading to the development of the fine-needle biopsy (FNB) needle. EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration (FNA) as the procedure of choice for EUS-TA of pancreatic cancer. However, EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions, so it is important clinicians are familiar with both. Given these recent dev-elopments, we present an up-to-date review of the role of EUS-TA in pancreatic cancer. Particularly, technical aspects, such as needle caliber, negative pressure, and puncture methods, for obtaining an adequate specimen in EUS-TA are discussed.

Next-Generation Sequencing Analysis of Pancreatic Cancer Using Residual Liquid Cytology Specimens from Endoscopic Ultrasound—Guided Fine-Needle Biopsy: A Prospective Comparative Study with Tissue Specimens

This study evaluated the feasibility and clinical utility of liquid-based cytology (LBC) specimens via endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) for next-generation sequencing (NGS) of pancreatic cancer (PC). We prospectively evaluated the performance of DNA extraction and NGS using EUS-FNB samples obtained from PC. Thirty-three consecutive patients with PC who underwent EUS-FNB at our hospital were enrolled. DNA samples were obtained from 96.8% of the patients. When stratified with a variant allele frequency (VAF) > 10% tumor burden, the NGS success rate was 76.7% (n = 23) in formalin-fixed paraffin-embedded (FFPE), 83.3% (n = 25) in LBC, and 76.7% (n = 23) in frozen samples. The overall NGS success rate was 86.7% (n = 26) using FFPE, LBC, or frozen samples. The detection rates for the main mutated genes were as follows: 86.7% for KRAS, 73.3% for TP53, 66.7% for CDKN2A, 36.7% for SMAD4, and 16.7% for ARID1A. LBC had the highest median value of VAF (23.5%) for KRAS and TP53. PC mutation analysis using NGS was successfully performed using LBC compared with FFPE and frozen samples. This approach provides an alternative and affordable source of molecular testing materials.

A case of needle tract seeding that seemed to be caused by endoscopic ultrasound-guided fine-needle aspiration

A 66-year-old man underwent a single endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) session and distal pancreatectomy for the pancreatic body adenocarcinoma measuring 12 mm in diameter. At 3 years after surgery, we diagnosed needle tract seeding (NTS) and performed total gastrectomy. NTS can occur with small tumors or after a single session of EUS-FNA.

Gastric intramural metastasis caused by needle tract seeding after preoperative fine needle aspiration for pancreatic body cancer subsequently resected by total pancreatectomy: a case report and literature review

BACKGROUND

Recently, there has been an increase in the number of reports of needle tract seeding (NTS) of tumor cells after a biopsy as one of the adverse events related to endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). In most of the previously reported cases of NTS in pancreatic cancer, distal pancreatectomy was performed as the initial surgery, following which metachronous metastasis was discovered in the gastric wall, whose localization matched the puncture route of the EUS-FNA. We report a case of early metastasis from pancreatic cancer in the gastric wall, which was postulated to be caused by NTS. Our patient underwent a total pancreatectomy (TP), and the NTS was resected synchronously.

CASE PRESENTATION

A 70-year-old woman with a diagnosis of pancreatic head-body-tail cancer presented to our department for surgery. Transgastric EUS-FNA and biopsy established the histological diagnosis in her case. We administered neoadjuvant chemotherapy (NAC) to the patient and performed a TP. Histopathological and immunohistochemical examination subsequently confirmed the diagnosis of pT3N1aM1 pancreatic adenocarcinoma and its gastric metastasis, which was caused by NTS. It is postulated that the tumor cells of NTS had progressed to develop the metastatic lesion in the gastric wall during the NAC period. This was also resected during the initial surgery. The patient developed an early postoperative recurrence in the peritoneum 8 months after the surgery.

CONCLUSION

In pancreatic head cancer cases, the puncture route is often included in the resection area of radical surgery, and NTS is seldom considered as a potential clinical problem. However, NTS can progress rapidly and may be associated with early recurrence of malignancy. Therefore, when transgastrointestinal puncture is performed for the diagnosis of pancreatic cancer, the treatment strategy should be established considering the potential development of NTS.

Current Status of the Diagnosis of Early-Stage Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) can be treated with surgery, chemotherapy, and radiotherapy. Despite medical progress in each field in recent years, it is still insufficient for managing PDAC, and at present, the only curative treatment is surgery. A typical pancreatic cancer is relatively easy to diagnose with imaging. However, it is often not recommended for surgical treatment at the time of diagnosis due to metastatic spread beyond the pancreas. Even if it is operable, it often recurs during postoperative follow-up. In the case of PDAC with a diameter of 10 mm or less, the 5-year survival rate is as good as 80% or more, and the best index for curative treatment is tumor size. The early detection of pancreatic cancer with a diameter of less than 10 mm or carcinoma in situ is critical. Here, we provide an overview of the current status of diagnostic imaging features and genetic tests for the accurate diagnosis of early-stage PDAC.

Negligible procedure-related dissemination risk of mucosal incision-assisted biopsy for gastrointestinal stromal tumors versus endoscopic ultrasound-guided fine-needle aspiration/biopsy

BACKGROUND

Mucosal incision-assisted biopsy (MIAB) is a valuable alternative to endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNAB) for sampling gastric subepithelial lesions (SELs). This study aimed to evaluate the potential risk of dissemination and impact on postoperative prognosis associated with MIAB, which has not yet been investigated.

METHODS

Study 1: A prospective observational study was conducted to examine the presence or absence and growth rate of tumor cells in gastric juice before and after the procedure in patients with SELs who underwent MIAB (n = 25) or EUS-FNAB (n = 22) between September 2018 and August 2021. Study 2: A retrospective study was conducted to examine the impact of MIAB on postoperative prognosis in 107 patients with gastrointestinal stromal tumors diagnosed using MIAB (n = 39) or EUS-FNAB (n = 68) who underwent surgery between January 2001 and July 2020.

RESULTS

In study 1, although no tumor cells were observed in gastric juice in MIAB before the procedure, they were observed in 64% of patients after obtaining samples (P < 0.001). In contrast, no tumor cells were observed in the gastric juice in EUS-FNAB before and after the procedure. In study 2, there was no significant difference in 5-year disease-free survival between MIAB (100%) and EUS-FNAB (97.1%) (P = 0.27).

CONCLUSION

MIAB is safe, with little impact on postoperative prognosis, although the procedure releases some tumor cells after damaging the SEL's pseudocapsule.

Needle-Tract Seeding of Pancreatic Cancer after EUS-FNA: A Systematic Review of Case Reports and Discussion of Management

Needle-tract seeding (NTS) has been sporadically reported as complication of Endoscopic Ultrasound (EUS)-guided aspiration (FNA) in pancreatic adenocarcinoma (PDAC). However, the evidence of its treatment and outcome is sparse. Adhering to PRISMA guidelines, we conducted a systematic review of EUS-FNA NTS cases of PDAC and analyzed their management and outcome. Up to September 2022, the search query retrieved forty-five cases plus an unpublished case from our center, for a total of forty-six; 43.6% were male, with a mean age of 68.6 years. Thirty-four patients (87.1%) underwent an initial surgical resection, with only 44.1% and 5.9% undergoing adjuvant and neoadjuvant chemotherapy, respectively, and 5.9% undergoing both. The NTS nodule was mostly located in the posterior gastric wall, developing at a median of 19 months after primary resection; 82.4% underwent surgical resection of the seeding, while for 17.6%, palliative chemotherapy treatment. Follow-up after NTS diagnosis and treatment was reported for only twenty-three patients: when NTS was treated with surgery, the median overall survival was 26.5 months compared to 15.5 if treated with radio/chemotherapy. NTS after EUS-FNA of PDAC occurs late and might be treated aggressively with good results. Interestingly, only a low number of patients developing NTS underwent chemotherapy for the primary cancer, suggesting its possible protective role.

Curative surgery for primary squamous cell carcinoma of the liver: a rare case study

Primary squamous cell carcinoma (SCC) of the liver is an extremely rare disease with a very poor prognosis. An 83-year-old woman was referred to our hospital with left abdominal pain. Laboratory data showed mildly elevated C-reactive protein and biliary enzymes. The tumor markers carcinoembryonic antigen, alpha-fetoprotein, and carbohydrate antigen 19-9 were within normal ranges. Contrast-enhanced computed tomography revealed a 60 mm-sized low-density mass with poor contrast enhancement located in the lateral segment of the liver. The tumor showed low signal on T₁-weighted magnetic resonance imaging (MRI) and high signal on T₂-weighted MRI. The cytology of bile juice showed no malignant findings. Endoscopic ultrasound-guided fine-needle aspiration biopsy was performed, which was suggestive of primary hepatic SCC. Tumor markers cytokeratin 19 fragment (CYFRA) and SCC-related antigen were elevated, at 25.2 ng/mL and 14.7 ng/mL, respectively. Left lobectomy and hilar lymph node dissection were performed. One month after surgery, the tumor marker values showed a marked decrease of 1.8 ng/mL for CYFRA and 0.3 ng/dL for SCC-related antigen. The patient has been without recurrence for more than one and half year postoperatively. SCC-related antigen and CYFRA were markedly decreased after tumor resection in this case, which may suggest their utility as tumor markers for SCC of liver origin.

Diagnostic yield of liquid-based cytology in serial pancreatic juice aspiration cytological examination

Objectives

Serial pancreatic juice aspiration cytological examination (SPACE) via endoscopic retrograde cholangiopancreatography is a useful diagnostic method for early‐stage pancreatic cancer, such as carcinoma in situ that are difficult to diagnose by endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA). However, the diagnostic accuracy of SPACE is low, which is attributed to problems regarding specimen treatment. Hence, we evaluated the diagnostic efficacy of liquid‐based cytology (LBC) in pancreatic juice cytology for pancreatic cancer.

Methods

We retrospectively analyzed 24 patients with suspected pancreatic cancer that was difficult to diagnose by endoscopic ultrasound‐guided fine needle aspiration who underwent SPACE using LBC between April 2017 and April 2021.

Results

The most common reason for performing SPACE was localized stenosis of the main pancreatic duct without a mass. Eleven patients were diagnosed with malignancy after surgical resection, nine of whom had pancreatic ductal adenocarcinoma. Ten patients were diagnosed as benign after a follow‐up of more than 1 year. The nine cases of malignancy were diagnosed before surgical resection by SPACE using LBC, with a sensitivity of 81.8% and specificity of 100%. The overall diagnostic accuracy was 91.7%. A total of 152 LBC examinations were performed via SPACE, with an adequate sample collection rate of 88.9%. No adverse events, including acute pancreatitis, occurred after endoscopic retrograde cholangiopancreatography.

Conclusion

SPACE with LBC offers good diagnostic efficacy in patients with pancreatic cancer that is difficult to diagnose by endoscopic ultrasound‐guided fine needle aspiration.

Needle Tract Seeding after Endoscopic Ultrasound Tissue Acquisition of Pancreatic Lesions: A Systematic Review and Meta-Analysis

There is limited evidence on the incidence of needle tract seeding (NTS) in patients undergoing endoscopic ultrasound (EUS) tissue acquisition (TA) of pancreatic lesions. This meta-analysis aimed to assess the incidence of NTS after EUS-TA. With a search of the literature up until April 2022, we identified 10 studies (13,238 patients) assessing NTS incidences in patients undergoing EUS-TA. The primary outcome was NTS incidence. The secondary outcome was a comparison in terms of peritoneal carcinomatosis incidence between patients who underwent EUS-TA and non-sampled patients. Results were expressed as pooled rates or odds ratio (OR) and 95% confidence intervals (CI). The pooled rate of NTS was 0.3% (95% CI 0.2-0.4%), with no evidence of heterogeneity (I2 = 0%). Subgroup analysis based on the type of sampled lesion confirmed this finding both in patients with pancreatic adenocarcinoma (0.4%, 0.2-0.6%) and in patients with cystic pancreatic lesions (0.3%, 0.1-0.5%). No difference in terms of metachronous peritoneal dissemination was observed between patients who underwent EUS-TA and non-sampled patients (OR 1.02, 0.72-1.46; p = 0.31), with evidence of low heterogeneity (I2 = 16%). Rates of NTS after EUS-TA are very low; therefore, EUS-TA could be safely performed in a pre-operative setting.

Multidisciplinary Approach to Indeterminate Biliary Strictures

Biliary strictures that remain unclassified after cross-sectional imaging and endoscopic retrograde cholangiopancreatography-based tissue sampling are defined as indeterminate biliary strictures (IDBS). A substantial proportion of biliary strictures fall into this category due to low sensitivity of brush cytology and intraductal biopsy. Over last few decades, several modalities have emerged for the evaluation of IDBS. Of these, cholangioscopy and endosonography are the frontrunners and have cemented their place for the evaluation of IDBS. Both of these modalities are widely available, and therefore, biliary strictures that remain uncharacterized after their utilization represent IDBS in the current era.

Isolated Gastric Metastases of Pancreatic Ductal Adenocarcinoma following Radical Resection—Impact of Endosonography-Guided Fine Needle Aspiration Tract Seeding

Background: Endosonography-guided fine needle aspiration biopsy (EUS-FNA)-associated metachronous gastric seeding metastases (GSM) of pancreatic ductal adenocarcinoma (PDAC) represent a serious condition with insufficient evidence. Methods: Retrospective analysis of PDAC resections with a curative-intent, proven pathological diagnosis of PDAC, preoperative EUS-FNA and post-resection follow-up of at least 60 months. The systematic literature search of published data was used for the GSM growth evaluation using Pearson correlation and the linear regression analyses. Results: The inclusion criteria met 59/134 cases, 16 (27%) had retained needle tract (15 following distal pancreatectomy, 1 following pylorus-sparing head resection). In total, 3/16 cases (19%) developed identical solitary GSM (10–26th month following primary surgery) and were radically resected. A total of 30 published cases of PDAC GSM following EUS-FNA were identified. Lesion was resected in 20 distal pancreatectomy cases with complete information in 14 cases. A correlation between the metastasis size and time (r = 0.612) was proven. The regression coefficient b = 0.72 expresses the growth of 0.72 mm per month. Conclusions: The GSM represent a preventable and curable condition. A remarkably high number of GSM following EUS-FNA was identified, leading to follow-up recommendation of EUS-FNA sampled patients. Multimodal management (gastric resection, adjuvant chemotherapy) may prolong survival.

Endoscopic ultrasonography as additional preoperative workup is valuable in half of the patients with a pancreatic body or tail lesion

BACKGROUND

The management of pancreatic body and tail lesions is underexposed. It remains unclear whether endoscopic ultrasonography (EUS) increases the accuracy of the preoperative workup. This study assessed the diagnostic value and safety of EUS in addition to cross-sectional imaging in a surgical cohort of patients with pancreatic body or tail lesions.

METHODS

A multicenter retrospective cohort study was performed of patients who underwent distal pancreatectomy from 2010 to 2017. The composite primary outcome was the additional value of EUS, defined as: (a) EUS confirmed an uncertain diagnosis on cross-sectional imaging, (b) EUS was correct in case of discrepancy with cross-sectional imaging, or (c) EUS provided tissue diagnosis for neoadjuvant treatment. Furthermore, serious adverse events and needle tract seeding were assessed.

RESULTS

In total, 181 patients were included, of whom 123 (68%) underwent EUS besides cross-sectional imaging. Postoperative pathology was heterogeneous: 91 was malignant, 49 premalignant, 41 benign. Most lesions were solid (n = 117). EUS had additional value in 59/123 (48%) patients; 27/50 (54%) of cystic and 32/73 (44%) of solid lesions. No serious adverse event or needle tract seeding following EUS occurred.

CONCLUSION

EUS had additional value besides cross-sectional imaging in half of the patients and showed low associated risks.

Needle tract seeding after endoscopic ultrasound-guided tissue acquisition of pancreatic tumors: A nationwide survey in Japan

OBJECTIVES

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) plays a crucial role in the diagnosis of pancreatic tumors. The present study aimed to investigate the current status of needle tract seeding (NTS) after EUS-TA of pancreatic tumors based on a nationwide survey in Japan.

METHODS

Patients who underwent surgical resection of primary pancreatic tumors after EUS-TA performed between April 2010 and March 2018 were surveyed. The incidence rates of NTS were determined, and compared in patients with pancreatic ductal adenocarcinomas (PDACs) and other tumors, and in patients who underwent transgastric and transduodenal EUS-TA of PDACs. The detailed features and prognosis of patients with NTS were also assessed.

RESULTS

A total of 12,109 patients underwent surgical resection of primary pancreatic tumors after EUS-TA. The overall incidence rate of NTS was 0.330%, and the NTS rate was significantly higher in patients with PDAC than in those with other tumors (0.409% vs. 0.071%, P=0.004). NTS was observed in 0.857% of patients who underwent transgastric EUS-TA, but in none of those who underwent transduodenal EUS-TA. Of the patients with NTS of PDACs, the median time from EUS-TA to occurrence of NTS and median patient survival were 19.3 and 44.7 months, respectively, with 97.4% of NTS located in the gastric wall and 65.8% of NTS resected. The patient survival was significantly longer in patients who underwent NTS resection than in those without NTS resection (P=0.037).

CONCLUSIONS

NTS appeared only after transgastric not after transduodenal EUS-TA. Careful follow-up provides an opportunity to remove localized NTS lesions by gastrectomy.

Optimal indication of endoscopic retrograde pancreatography-based cytology in the preoperative pathological diagnosis of pancreatic ductal adenocarcinoma

BACKGROUND

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is extremely useful for pathological diagnosis of pancreatic ductal adenocarcinoma (PDAC); however, puncturing is difficult in some cases, and there is a risk of needle tract seeding. This study evaluated the indications for endoscopic retrograde pancreatography-based (ERP)-based cytology for the preoperative diagnosis of PDAC.

METHODS

This study included 267 patients with PDAC who underwent preoperative ERP. The diagnostic performance of ERP-based cytology for PDAC was evaluated based on the sample collection method (pancreatic juice cytology [PJC] during ERP, brush cytology, PJC via endoscopic nasopancreatic drainage [ENPD] catheter), lesion site (pancreatic head, body/tail), and lesion size (≤10 mm, 10-20 mm, >20 mm), and compared with the diagnostic performance of EUS-FNA.

RESULTS

The overall sensitivity of ERP-based cytology was 54.9%; sensitivity by the sampling method was 34.7% for PJC during ERP, 65.8% for brush cytology, and 30.8% for PJC via an ENPD catheter. The sensitivity of EUS-FNA was 85.3%. Brush cytology and PJC via an ENPD catheter were performed more often in pancreatic body/tail lesions than in head lesions (P = 0.016 and P < 0.001, respectively), and the overall sensitivity of ERP-based cytology was better for body/tail lesions (63.2% vs. 49.0%, P = 0.025). The sensitivities of ERP-based cytology and EUS-FNA in diagnosing PDAC ≤10 mm were 92.3% and 33.3%, respectively. Post-ERP pancreatitis was observed in 22 patients (8.2%) and significantly less common with ENPD catheters (P = 0.002).

CONCLUSIONS

ERP-based cytology may be considered the first choice for pathological diagnosis of PDAC ≤10 mm and in the pancreatic body/tail.

Endoscopic ultrasonography‐guided tissue acquisition for small solid pancreatic lesions: Does the size matter?

Endoscopic ultrasonography‐guided tissue acquisition (EUS‐TA) is now an established technique to obtain the pathological diagnosis of solid pancreatic lesions (SPLs), but the diagnosis of small SPLS by EUS‐TA can still be difficult. We conducted a literature review and a meta‐analysis on the diagnostic yield of EUS‐TA according to the tumor size. In a meta‐analysis of 33 studies with 6883 cases, a pooled odds ratio (OR) of sensitivity was significantly higher in SPLs of >20 mm (OR 1.64, p = 0.02) and in SPLs of >10 mm (OR 3.05, p = 0.01), but not in SPLs of >30 mm (OR 1.18, p = 0.46). The meta‐analysis of accuracy also showed a similar trend: OR of 1.59 in SPLs of >20 mm (p < 0.01) and OR of 3.27 in SPLs of >10 mm (p < 0.01) and OR of 1.03 in SPLs of >30 mm (p = 0.87). The use of a 25‐gauge needle tended to improve sensitivity in small SPLs, though not statistically significant: OR of 1.25 and 2.82 in studies with and without a 25‐gauge needle (p = 0.08). The use of fine needle biopsy needles, slow pull method, and rapid on‐site evaluation did not significantly improve sensitivity in small SPLs. EUS‐TA for small SPLs, especially neuroendocrine neoplasms, is reported to have a high risk of adverse events. In summary, the diagnostic yield and safety of EUS‐TA for small (<20 mm) SPLs still needs improvement, and the best needle and technique for small SPLs should be further investigated.

The Utility of Endoscopic-Ultrasonography-Guided Tissue Acquisition for Solid Pancreatic Lesions

Endoscopic-ultrasonography-guided tissue acquisition (EUS-TA) has been widely performed for the definitive diagnosis of solid pancreatic lesions (SPLs). As the puncture needles, puncture techniques, and sample processing methods have improved, EUS-TA has shown higher diagnostic yields and safety. Recently, several therapeutic target genomic biomarkers have been clarified in pancreatic ductal carcinoma (PDAC). Although only a small proportion of patients with PDAC can benefit from precision medicine based on gene mutations at present, precision medicine will also be further developed for SPLs as more therapeutic target genomic biomarkers are identified. Advances in next-generation sequencing (NGS) techniques enable the examination of multiple genetic mutations in limited tissue samples. EUS-TA is also useful for NGS and will play a more important role in determining treatment strategies. In this review, we describe the utility of EUS-TA for SPLs.

Multicenter prospective study of the efficacy of stereomicroscopic on-site evaluation in endoscopic ultrasound-guided tissue acquisition in patients with pancreatic cancer

OBJECTIVE

In sample isolation processing by stereomicroscopy (SIPS), a technique used to assess the quality of specimens collected during endoscopic ultrasound (EUS)-guided tissue acquisition (EUS-TA), the cutoff value of stereomicroscopically visible white core (SVWC) (≥11 mm) indicates high diagnostic sensitivity. However, the procedure of SIPS is complicated and time-consuming. Therefore, we devised the stereomicroscopic on-site evaluation (SOSE), a new rapid assessment method that is simpler than SIPS and only determines if the SVWC cutoff value is attained. We aimed to examine the usefulness of SOSE in a multicenter, prospective setting.

METHODS

Seventy patients from multiple institutions with solid pancreatic masses suspected to be pancreatic cancer were included. EUS-TA was performed using a 22-gauge Franseen needle. SVWCs were measured on-site using stereomicroscopy. The primary outcome was the sensitivity of SVWC cutoff value in EUS-TA with SOSE.

RESULTS

The total number of punctures was 214 and SOSE was performed on 150 punctures. The SVWC cutoff value collection rate was 100% per lesion, with 80% in the first pass, 79% in the second pass, and 78% per puncture in all passes. The median time taken to determine the SVWC cutoff value for SOSE was 47 s. The sensitivity of the SVWC cutoff value was 93.2% for histology and 96.6% for cytology + histology. The per-lesion accuracy of pathological diagnosis reached the highest level (98.6%) at the second puncture.

CONCLUSIONS

SOSE showed high diagnostic sensitivity and may be a new rapid assessment method for the diagnosis of malignant pancreatic cancer using EUS-TA.

Establishment of organoids using residual samples from saline flushes during endoscopic ultrasound-guided fine-needle aspiration in patients with pancreatic cancer

Background and study aims  In patients with pancreatic cancer (PC), patient-derived organoid cultures can be useful tools for personalized drug selection and preclinical evaluation of novel therapies. To establish a less invasive method of creating organoids from a patient's tumor, we examined whether PC organoids can be established using residual samples from saline flushes (RSSFs) during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Methods  Five patients with PC who underwent EUS-FNA were enrolled in a prospective study conducted at our institution. RSSFs obtained during EUS-FNA procedures were collected. An organoid culture was considered as established when ≥ 5 passages were successful. Organoid-derived xenografts were created using established organoids. Results  EUS-FNA was performed using a 22- or 25-gauge lancet needle without complications. Patient-derived organoids were successfully established in four patients (80.0 %) with the complete medium and medium for the selection of KRAS mutants. Organoid-derived xenografts were successfully created and histologically similar to EUS-FNA samples. Conclusions  Patient-derived PC organoids were successfully established using EUS-FNA RSSFs, which are produced as a byproduct of standard manipulations, but are usually not used for diagnosis. This method can be applied to all patients with PC, without additional invasive procedures, and can contribute to the development of personalized medicine and molecular research.

Predictive factors of operability after neoadjuvant chemotherapy in resectable or borderline resectable pancreatic cancer: a single-center retrospective study

BACKGROUND/AIMS

Recently neoadjuvant chemotherapy (NAC) for pancreatic cancer has been shown to be superior to upfront surgery, but it remains a matter of debate for resectable cases. In clinical practice, some resectable cases may become unresectable after NAC. This study aimed to reveal the outcomes after NAC and to clarify the characteristics of unresected cases.

METHODS

The medical records of 142 patients who underwent NAC between 2016 and 2020 were retrospectively reviewed. Patient characteristics, effectiveness of NAC, and outcomes were compared between the surgical group and non-surgical group (NSG). Furthermore, the risk of recurrence limited to in the patients who received NAC with gemcitabine plus nab-paclitaxel, which were mostly administered in this cohort, following R0/R1 resection was assessed.

RESULTS

The overall and R0 resection rates after NAC were 89.1% and 79.7%, respectively. The neutrophil to lymphocyte ratio (NLR) > 2.78 (p = 0.0120) and anatomical borderline resectable pancreatic cancer (p = 0.0044) revealed a statistically significantly correlation with the NSG. On the other hand, NAC week < 8 (p = 0.0285), radiological response, stable disease or progression disease (p = 0.0212), and pathological stage > IIA (P = 0.0003) were significantly associated with recurrence. The tumor response rate was approximately 26.1%, and three patients with ≥ 30% reduction of primary tumor lost excision opportunities because of metastasis, interstitial pneumonia, and vascular invasion.

CONCLUSIONS

This study shows incomplete tumor shrinkage benefits, but pre-NAC NLR is a predictive factor for predicting operability after NAC. The NLR can be easily calculated by normal blood test, and can be considered as a suitable marker of operability.

Clinical dilemma of endoscopic ultrasound-guided fine needle aspiration for resectable pancreatic body and tail cancer

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a first-line procedure for definitive tissue diagnosis of pancreatic cancer because of its high accuracy and low complication rate. The overall sensitivity of EUS-FNA for the diagnosis of pancreatic cancer is approximately 90%; however, its diagnostic ability for small lesions (<10 mm) remains limited. Although EUS-FNA is a relatively safe procedure, with an overall morbidity of ≤2%, it should be noted that needle tract seeding (NTS) can occur after EUS-FNA, which may affect the patient prognosis negatively. In patients with resected pancreatic tumors, preoperative EUS-FNA is not associated with an increased risk of postoperative recurrence. However, NTS after EUS-FNA for resectable pancreatic body and tail cancer has been highlighted recently, particularly by Japanese endoscopists. Thus, the use of preoperative EUS-FNA for the diagnosis of resectable pancreatic body and tail cancer has become a clinical dilemma that challenges gastroenterologists and must be carefully considered on a case-by-case basis by weighing the benefits and risks. This review summarizes the pros and cons of performing EUS-FNA in patients with resectable pancreatic body and tail cancer and provides valuable insight for gastroenterologists treating pancreatic cancer.

Adverse events of endoscopic ultrasound-guided fine-needle aspiration for histologic diagnosis in Japanese tertiary centers: Multicenter retrospective study

BACKGROUND AND AIMS

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is used for the histopathological diagnosis of any type of gastrointestinal disease. Few adverse events are experienced with this procedure; however, the actual rate of adverse events remains unclear. This study aimed to clarify the current status of cases that experienced adverse events related to the EUS-FNA procedure used for histopathologic diagnoses.

METHODS

A retrospective analysis of cases with EUS-FNA-related adverse events in Japanese tertiary centers was conducted by assessing the following clinical data: basic case information, FNA technique, type of procedural adverse events, and prognosis.

RESULTS

Of the 13,566 EUS-FNA cases overall, the total number of cases in which adverse events related to EUS-FNA occurred was 234. The incidence of EUS-FNA-related adverse events was ~1.7%. Bleeding and pancreatitis cases accounted for ~49.1% and 26.5% of all adverse events, respectively. Bleeding was the most common adverse event with only seven cases requiring blood transfusion. In cases with neuroendocrine tumors, pancreatitis was the most frequent adverse event. Needle tract seeding because of EUS-FNA was observed during the follow-up period in only ~0.1% of cases with pancreatic cancer. There was no mortality because of adverse events caused by EUS-FNA.

CONCLUSIONS

This study revealed that the adverse events-related EUS-FNA for histopathologic diagnoses were not severe conditions, and had low incidence.

Biliary Strictures and Cholangiocarcinoma - Untangling a Diagnostic Conundrum

Cholangiocarcinoma is an uncommon and highly aggressive biliary tract malignancy with few manifestations until late disease stages. Diagnosis is currently achieved through a combination of clinical, biochemical, radiological and histological techniques. A number of reported cancer biomarkers have the potential to be incorporated into diagnostic pathways, but all lack sufficient sensitivity and specificity limiting their possible use in screening and early diagnosis. The limitations of standard serum markers such as CA19-9, CA125 and CEA have driven researchers to identify multiple novel biomarkers, yet their clinical translation has been slow with a general requirement for further validation in larger patient cohorts. We review recent advances in the diagnostic pathway for suspected CCA as well as emerging diagnostic biomarkers for early detection, with a particular focus on non-invasive approaches.

Evaluation of preoperative diagnostic methods for resectable pancreatic cancer: a diagnostic capability and impact on the prognosis of endoscopic ultrasound-guided fine needle aspiration

BACKGROUND

A pathological diagnosis of pancreatic cancer should be performed as much as possible to determine the appropriate treatment strategy, but priorities and algorithms for diagnostic methods have not yet been established. In recent years, the endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become the primary method of collecting tissues from pancreatic disease, but the effect of EUS-FNA on surgical results and prognosis has not been clarified.

AIMS

To evaluate the diagnostic ability of EUS-FNA and its effect on the preoperative diagnosis, surgical outcome, and prognosis of pancreatic cancer.

METHODS

Between January 2005 and June 2017, 293 patients who underwent surgical resection for pancreatic cancer were retrospectively evaluated. The outcomes of interest were the diagnostic ability of EUS-FNA and its influence on the surgical results and prognosis.

RESULTS

The diagnostic sensitivity of EUS-FNA was 94.4%, which was significantly higher than that of endoscopic retrograde cholangiopancreatography (ERCP) (45.5%) (p < 0.001). The adverse event rate in ERCP was 10.2%, which was significantly higher than EUS-FNA (1.3%) (p = 0.001). Patients were divided into FNA group (N = 160) and non-FNA group (N = 133) for each preoperative diagnostic method. In the study of surgical curability R0 between the two groups, there was no significant difference in FNA group (65.0% [104/160]) and non-FNA group (64.7% [86/133], p = 1.000). In the prognostic study, 256 patients with curative R0 or R1 had a recurrence rate was 54.3% (70/129) in the FNA group and 57.4% (73/127) in the non-FNA group. Moreover peritoneal dissemination occurred in 34.3% (24/70) in the FNA group and in 21.9% (16/73) in the non-FNA group, neither of which showed a significant difference. The median survival times of the FNA and non-FNA groups were 955 days and 799 days, respectively, and there was no significant difference between the two groups (log-rank p = 0.735). In the Cox proportional hazards model, factors influencing prognosis, staging, curability, and adjuvant chemotherapy were the dominant factors, but the preoperative diagnostic method (EUS-FNA) itself was not.

CONCLUSIONS

EUS-FNA is a safe procedure with a high diagnostic ability for the preoperative examination of pancreatic cancer. It was considered the first choice without the influence of surgical curability, postoperative recurrence, peritoneal dissemination and prognosis.

Pancreatic cancer in 2021: What you need to know to win

Pancreatic cancer is one of the solid tumors with the worst prognosis. Five-year survival rate is less than 10%. Surgical resection is the only potentially curative treatment, but the tumor is often diagnosed at an advanced stage of the disease and surgery could be performed in a very limited number of patients. Moreover, surgery is still associated with high post-operative morbidity, while other therapies still offer very disappointing results. This article reviews every aspect of pancreatic cancer, focusing on the elements that can improve prognosis. It was written with the aim of describing everything you need to know in 2021 in order to face this difficult challenge.

Advanced Endoscopic Techniques for the Diagnosis of Pancreatic Cancer and Management of Biliary and GastricOutlet Obstruction

Following high-quality imaging studies for staging, endoscopic ultrasound examination fine needle aspiration/biopsy is the preferred modality for tissue diagnosis of pancreatic cancer. Endoscopic retrograde cholangiopancreatography with metal stent placement is used for palliation of malignant biliary obstruction. Metal stents can be placed in patients with resectable pancreatic cancer in whom surgery is going to be delayed. For palliation of gastric outlet obstruction, endoscopic enteral stenting is often selected because of its less invasiveness. Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction or gastrojejunostomy for gastric outlet obstruction are emerging less invasive techniques as compared with palliative surgery.

[Clinical and Technical Guideline for Endoscopic Ultrasound-guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy]

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in eight categories intended to help physicians make evidence- based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.

Automatic Segmentation of Pancreatic Tumors Using Deep Learning on a Video Image of Contrast-Enhanced Endoscopic Ultrasound

Background: Contrast-enhanced endoscopic ultrasound (CE-EUS) is useful for the differentiation of pancreatic tumors. Using deep learning for the segmentation and classification of pancreatic tumors might further improve the diagnostic capability of CE-EUS. Aims: The aim of this study was to evaluate the capability of deep learning for the automatic segmentation of pancreatic tumors on CE-EUS video images and possible factors affecting the automatic segmentation. Methods: This retrospective study included 100 patients who underwent CE-EUS for pancreatic tumors. The CE-EUS video images were converted from the originals to 90-s segments with six frames per second. Manual segmentation of pancreatic tumors from B-mode images was performed as ground truth. Automatic segmentation was performed using U-Net with 100 epochs and was evaluated with 4-fold cross-validation. The degree of respiratory movement (RM) and tumor boundary (TB) were divided into 3-degree intervals in each patient and evaluated as possible factors affecting the segmentation. The concordance rate was calculated using the intersection over union (IoU). Results: The median IoU of all cases was 0.77. The median IoUs in TB-1 (clear around), TB-2, and TB-3 (unclear more than half) were 0.80, 0.76, and 0.69, respectively. The IoU for TB-1 was significantly higher than that of TB-3 (p < 0.01). However, there was no significant difference between the degrees of RM. Conclusions: Automatic segmentation of pancreatic tumors using U-Net on CE-EUS video images showed a decent concordance rate. The concordance rate was lowered by an unclear TB but was not affected by RM.

Utility of contrast-enhanced harmonic endoscopic ultrasonography for predicting the prognosis of pancreatic neuroendocrine neoplasms

BACKGROUND AND AIMS

Pancreatic neuroendocrine neoplasms (PanNENs), including Grade 1 (G1) or G2 tumors, can have a poor prognosis. This study investigated the value of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for predicting the prognosis of PanNENs.

METHODS

This single-center, retrospective study included 47 consecutive patients who underwent CH-EUS and were diagnosed with PanNEN by surgical resection or EUS-guided fine needle aspiration between December 2011 and February 2016. Patients were divided into aggressive and non-aggressive groups according to the degree of clinical malignancy. CH-EUS was assessed regarding its capacity for diagnosing aggressive PanNEN, the correspondence between contrast patterns and pathological features, and its ability to predict the prognosis of PanNEN.

RESULTS

There were 19 cases of aggressive PanNEN and 28 cases of non-aggressive PanNEN. The aggressive group included three G1, four G2, three G3 tumors, three mixed neuroendocrine non-neuroendocrine neoplasms, and six neuroendocrine carcinomas. CH-EUS was superior to contrast-enhanced computed tomography for the diagnosis of aggressive PanNEN (P < 0.001): hypo-enhancement on CH-EUS was an indicator of aggressive PanNEN, with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 94.7%, 100%, 100%, 96.6%, and 97.9%, respectively. Among G1/G2 PanNENs, cases with hypo-enhancement on CH-EUS had a poorer prognosis than those with hyper/iso-enhancement (P = 0.0009). Assessment of 36 resected specimens showed that hypo-enhancement on CH-EUS was associated with smaller and fewer vessels and greater degree of fibrosis.

CONCLUSION

Contrast-enhanced harmonic endoscopic ultrasonography may be useful for predicting the prognosis of PanNENs.

Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE)

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a task force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in eight categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice. (Gut Liver 2021;15:-374)

Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE)

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in 8 categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.

Type 1 Autoimmune Pancreatitis Extending along the Main Pancreatic Duct: IgG4-related Pancreatic Periductitis

We herein report a unique form of autoimmune pancreatitis (AIP) spreading along the main pancreatic duct (MPD). A 70-year-old man was referred for a small lesion at the pancreatic neck, accompanying an adjacent cyst and dilated upstream MPD. Four years earlier, health checkup images had shown a pancreatic cyst but no mass lesion. Endoscopic ultrasonography showed a contrast-enhanced, tumorous lesion, mainly occupying the MPD. With a preoperative diagnosis of ductal neoplasms mainly spreading in the MPD, Whipple's resection was performed. The resected specimens showed MPD periductitis with IgG4-related pathology, indicating type 1 AIP. Clinicians should practice caution concerning the various AIP forms.

Clinical Analysis of Early-Stage Pancreatic Cancer and Proposal for a New Diagnostic Algorithm: A Multicenter Observational Study

Early diagnosis of pancreatic ductal adenocarcinoma (PDAC) is challenging but essential for improving its poor prognosis. We established a multicenter study to clarify the clinicopathological features, and to propose new algorithm for early diagnosis of PDAC. Ninety-six patients with stage 0 and IA PDAC were enrolled from 13 high-volume centers. Overall, 70% of the patients were asymptomatic. The serum pancreatic enzyme levels were abnormal in half of the patients. The sensitivity of endoscopic ultrasonography (EUS) for detecting small PDAC was superior to computed tomography and magnetic resonance imaging (MRI) (82%, 58%, and 38%, respectively). Indirect imaging findings were useful to detect early-stage PDAC; especially, main pancreatic duct stenosis on MRI had the highest positive rate of 86% in stage 0 patients. For preoperative pathological diagnosis, the sensitivity of endoscopic retrograde cholangiopancreatography (ERCP)-associated pancreatic juice cytology was 84%. Among the stage IA patients, EUS-guided fine-needle aspiration revealed adenocarcinoma in 93% patients. For early diagnosis of PDAC, it is essential to identify asymptomatic patients and ensure close examinations of indirect imaging findings and standardization of preoperative pathological diagnosis. Therefore, a new diagnostic algorithm based on tumor size and imaging findings should be developed.