Impact of cytopathologist expert on diagnosis and treatment of pancreatic lesions in current clinical practice. A series of 106 endoscopic ultrasound-guided fine needle aspirations

Pancreaticobiliary Cytology Practice in 2021: Results of a College of American Pathologists Survey

CONTEXT.—

The College of American Pathologists (CAP) surveys provide national benchmarks of pathology practice.

OBJECTIVE.—

To investigate pancreaticobiliary cytology practice in domestic and international laboratories in 2021.

DESIGN.—

We analyzed data from the CAP Pancreaticobiliary Cytology Practice Supplemental Questionnaire that was distributed to laboratories participating in the 2021 CAP Nongynecologic Cytopathology Education Program.

RESULTS.—

Ninety-three percent (567 of 612) of respondent laboratories routinely evaluated pancreaticobiliary cytology specimens. Biliary brushing (85%) was the most common pancreaticobiliary cytology specimen evaluated, followed by pancreatic fine-needle aspiration (79%). The most used sampling methods reported by 235 laboratories were 22-gauge needle for fine-needle aspiration (62%) and SharkCore needle for fine-needle biopsy (27%). Cell block was the most used slide preparation method (76%), followed by liquid-based cytology (59%) for pancreatic cystic lesions. Up to 95% (303 of 320) of laboratories performed rapid on-site evaluation (ROSE) on pancreatic solid lesions, while 56% (180 of 320) performed ROSE for cystic lesions. Thirty-six percent (193 of 530) of laboratories used the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology in 2021. Among all institution types, significant differences in specimen volume, specimen type, ROSE practice, and case sign-out were identified. Additionally, significant differences in specimen type, slide preparation, and ROSE practice were found.

CONCLUSIONS.—

This is the first survey from the CAP to investigate pancreaticobiliary cytology practice. The findings reveal significant differences among institution types and between domestic and international laboratories. These data provide a baseline for future studies in a variety of practice settings.

Endoscopic Ultrasound in Cancer Staging

The authors review the role of endoscopic ultrasound (EUS) in the staging of cancers throughout the gastrointestinal tract. EUS offers an advantage over cross-sectional imaging in locoregional tumor staging but is less sensitive in identifying distant metastasis. The addition of FNA increases diagnostic accuracy and provides a tissue diagnosis. EUS combined with cross-sectional imaging is important in accurately staging GI tumors and thereby reducing unnecessary procedures and health care costs.

Atypical cells in fine needle aspiration biopsies of pancreas: Causes, work-up, and recommendations for management

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a sensitive and specific method for diagnosing cancer in solid pancreatic masses. However, some cases receive indeterminate atypical diagnoses, which creates management dilemmas. In the 2014 Papanicolaou Society of Cytopathology (PSC) standardized guidelines for pancreatobiliary cytology, specimens in the "Atypical" category show a spectrum of architectural and/or cellular changes beyond normal or reactive, but, quantitatively or qualitatively, insufficient for classification as neoplastic (benign/other), suspicious or positive for malignancy. Implementation of the PSC system decreased atypical diagnoses, particularly for cystic lesions, and redistributed many cases into benign and neoplastic categories. Because no set cytologic criteria exist for the "Atypical" category there is wide variability in its use, and its frequency ranges from 0%-16% (mean 6%). It consists of a heterogeneous mix of cases that occur because of preanalytic, lesion-specific (low cellularity, necrosis, cystic, reactive and premalignant changes), to pathologist-dependent factors (experience, expertise, training and institutional case volume). Outcomes of atypical diagnoses in solid pancreatic masses range from benign to premalignant and malignant and include reactive atypia in pancreatitis, well differentiated adenocarcinoma, and non-ductal malignancies. The associated risk of malignancy (ROM) ranges from 28%-100%, with an overall intermediate ROM in large-scale studies. Cytopathologists and institutions should monitor and keep their personal and/or laboratory's atypical rates low by judiciously using rapid onsite evaluation, ancillary studies, consensus or expert review, as well as correlation with clinical and radiologic findings. Early repeat EUS-FNA is indicated for unresolved cases.

Variation of cytopathologists' use of the indeterminate diagnostic categories "atypical" and "suspicious for malignancy" in the cytologic diagnosis of solid pancreatic lesions on endoscopic ultrasound-guided fine-needle aspirates

Indeterminate cytologic diagnoses in endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) of solid pancreatic lesions include the diagnostic categories "atypical" (ATY) and "suspicious for malignancy" (SUSP), which are used at variable rates and are associated with variable underlying risk of malignancy. The aim of this study was to determine individual cytopathologists' rates of indeterminate diagnoses in EUS-FNA of solid pancreatic lesions and their relationship to cytopathologists' experience and volume of pancreatic EUS-FNA examined, as well as the potential impact of departmental consensus review on indeterminate diagnoses.

DESIGN

The diagnostic rates of ATY and SUSP and their underlying risk of malignancy were calculated for six cytopathologists who diagnosed 1,114 of 1,225 EUS-FNA of solid pancreatic lesions from 1/1/2001 to 9/15/2014, and were then compared for the periods before and after the implementation of departmental consensus review during 2009.

RESULTS

The six cytopathologists diagnosed 10% of cases as indeterminate; 82 (7.4%) as "atypical" and 29 (2.6%) as "suspicious". The individual cytopathologists' indeterminate diagnosis rates varied twofold (6.67-12.80%) and did not correlate with their experience, total or annual volume of EUS-FNAs. Of the 56/99 (56.57%) cases with follow-up, the underlying rate of malignancy was 47% (35/75; for "atypical" and 87.5% (21/24); for "suspicious"). The underlying rates of malignancy were 33-67% for "atypical" and 80-100% for "suspicious" diagnoses made by individual cytopathologists. The rate of indeterminate diagnoses decreased from 11.55 to 7.88% after the implementation of departmental consensus review.

CONCLUSION

Individual cytopathologists' rates of indeterminate diagnoses and their significance vary; however, consensus review is helpful in reducing these rates. Diagn. Cytopathol. 2017;45:3-13. © 2016 Wiley Periodicals, Inc.

Specialized clinical cytology may improve the results of EUS (endoscopic ultrasound)-guided fine-needle aspiration (FNA) from pancreatic tumors

BACKGROUND AND STUDY AIMS

A variety of factors (needle type, needle passes, tumor location, cytological assessment, etc.) may influence the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) from pancreatic tumors. Whereas most published studies report a diagnostic accuracy of > 80 % for EUS-FNAC, the results in routine settings are often considerably lower. This retrospective study aimed to define the effect of switching microscopic assessment from a standard pathology department to a highly specialized institute of cytology.

PATIENTS AND METHODS

A total of 63 patients underwent EUS-FNAC of solid or semisolid pancreatic masses. Specimens of the first consecutive 20 cases (Phase 1) were assessed by the local department of pathology. Then in Phase 2, involving another 43 subsequent cases, a specialized cytology laboratory examined all aspirates. All EUS-FNACs were performed in the same manner, using a 22-gauge needle. After cytological evaluation, all patients either underwent surgery or were followed up for at least 6 months.

RESULTS

Of the tumors, 56 were solid and 7 semisolid; the mean size was 30 mm. Sensitivity (sens.), specificity (spec.), positive predictive value (PPV), and negative predictive value (NPV) of EUS-FNAC were 38.5 % (95 %CI [confidence interval] 13.9 - 68.4 %), 100 % (59.0 - 100 %), 100 % (47.8 - 100 %), and 46.7 % (21.3 - 73.4 %) during Phase 1 versus 91.4 % (95 %CI 76.9 - 98.2 %), 100 % (63.1 - 100 %), 100 % (89.1 - 100 %), and 72.7 % (39.0 - 94.0 %) during Phase 2.

CONCLUSION

These results emphasize the considerable impact of a dedicated cytological evaluation on the results of EUS-FNAC.

Contrast-enhanced harmonic endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of solid pancreatic lesions: a retrospective study

BACKGROUND

The negative predictive value of endoscopic ultrasonography-guided fine needle aspiration for the diagnosis of solid pancreatic lesions remains low, and the biopsy specimens are sometimes inadequate for appropriate pathological diagnosis.

AIMS

To evaluate the usefulness of a novel method of contrast-enhanced harmonic endoscopic ultrasonography-guided fine-needle aspiration for the differential diagnosis and adequate sampling of solid pancreatic lesions.

METHODS

Patients with a diagnosis of solid pancreatic lesions who underwent fine-needle aspiration guided by contrast-enhanced harmonic endoscopic ultrasonography or by endoscopic ultrasonography from October 2010 to July 2013 were retrospectively identified and classified into the CH-EUS or EUS group, respectively. Surgical pathology and/or follow-up results were defined as the final diagnosis. Operating characteristics and adequacy of biopsy specimens by fine-needle aspiration were compared between the two groups.

RESULTS

Operating characteristics for contrast-enhanced harmonic endoscopic ultrasonography-guided fine-needle aspiration in solid pancreatic lesions were as follows: area under the curve = 0.908, sensitivity = 81.6%, specificity = 100%, positive predictive value = 100%, negative predictive value = 74.1%, and accuracy = 87.9%. The percentage of adequate biopsy specimens in the CH-EUS group (96.6%) was greater than that in the EUS group (86.7%).

CONCLUSION

Simultaneous contrast-enhanced harmonic endoscopic ultrasonography during fine-needle aspiration is useful for improving the diagnostic yield and adequate sampling of solid pancreatic lesions.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Significance of the diagnostic categories "atypical" and "suspicious for malignancy" in the cytologic diagnosis of solid pancreatic masses

Endoscopic ultrasound guided (EUS) fine-needle aspiration (FNA) investigation of solid pancreatic lesions has been shown to have good sensitivity and specificity. Many lesions can be definitely classified as benign or malignant but some can only be cytologically classified as "atypical" or "suspicious for malignancy". Risk for malignancy in these indeterminate categories has not been well categorized. The cytology records of four University Medical centers were searched for all EUS guided FNAs of solid pancreatic lesions. All cases with a diagnosis of "atypical", or "suspicious for malignancy" were selected for analysis when histologic biopsy or over 18 months clinical follow-up was available. Two hundred and ninety-two cases with a diagnosis of "atypical" or "suspicious for malignancy" and adequate follow-up were obtained from the combined data of the four institutions. The percentage malignant for the categories "atypical" and "suspicious for malignancy" were 79.2 and 96.3%, respectively. If the category "atypical" was classified as benign and "suspicious for malignancy" was classified as malignant, the resulting positive predictive value was 96.3 (95% CI: 92.6-98.5) and the negative predictive value 20.8 (95% CI: 13.4-30.0). The categories of "atypical" and "suspicious for malignancy" stratify risk for malignancy in a fashion, which may aid in patient counseling and selection of follow-up protocols. Classification of "suspicious for malignancy" as malignant optimizes diagnostic sensitivity and specificity.

How can an endosonographer assess for diagnostic sufficiency and options for handling the endoscopic ultrasound-guided fine-needle aspiration specimen and ancillary studies

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become well established as a minimally invasive technique in diagnosing and staging various gastrointestinal, pancreaticobiliary, and retroperitoneal malignancies. The diagnostic accuracy of this procedure is significantly enhanced by the presence of on-site cytopathology. However, in many EUS centers, cytopathology is not readily available for on-site evaluation. This article is intended to assist the independent endosonographer in the assessment of diagnostic sufficiency and in specimen handling.

Malignancy risk associated with diagnostic categories defined by the Papanicolaou Society of Cytopathology pancreaticobiliary guidelines

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently the predominant method for obtaining a preoperative tissue diagnosis for pancreatic lesions suspicious for malignancy. The diagnostic sensitivity and specificity of EUS-FNA are well documented, but malignancy risk associated with the diagnostic categories proposed by the Papanicolaou Society of Cytopathology is poorly defined.

METHODS

The records of the Departments of Pathology at Duke University and the University of Utah were searched for all cases of EUS-FNA performed for the investigation of pancreatic lesions. All cases with follow-up surgical diagnosis or greater than 3 years of clinical follow-up were selected. Cytologic diagnostic categories were "nondiagnostic," "benign," "atypical (not otherwise specified)," "suspicious for malignancy," "neoplasm," and "malignant." Correlation of cytologic diagnosis with surgical and/or clinical follow-up was made and risk of malignancy calculated for each category.

RESULTS

Three hundred seventeen EUS-FNAs with adequate surgical or clinical follow-up were obtained. Risk of malignancy for nondiagnostic specimens was 21%;, benign specimens, 13%; atypical cases, 74%; suspicious for malignancy, 82%; the neoplasm category, 14%; and the malignant category, 97%

CONCLUSIONS

The cytologic categories proposed by the Papanicolaou Society of Cytopathology demonstrate an increasing risk for malignancy extending from benign to malignant. Aspirates designated benign have the lowest risk of malignancy (13%) and aspirates designated malignant the highest (97%). The proposed categorization scheme stratifies risk for malignancy giving useful information to clinicians treating patients with pancreatic lesions.

Role of repeated endoscopic ultrasound-guided fine needle aspiration for inconclusive initial cytology result

For tissue diagnosis of suspected pancreatic cancer, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the procedure of choice with high safety and accuracy profiles. However, about 10% of cytologic findings of EUS-FNA are inconclusive. In that situation, careful observation, surgical exploration, or alternative diagnostic tools such as bile duct brushing with endoscopic retrograde cholangiopancreatography or computed tomography-guided biopsy can be considered. However, some concerns and/or risks of these options render repeat EUS-FNA a reasonable choice. Repeated EUS-FNA may impose substantial clinical impact with low risk.

Endoscopic ultrasonography for pancreatic cancer: current and future perspectives

A suspected pancreatic lesion can be a difficult challenge for the clinician. In the last years we have witnessed tumultuous technological improvements of the radiological and nuclear medicine imaging. Taking this into account, we will try to delineate the new role of endoscopic ultrasound (EUS) in pancreatic imaging and to place it in a shareable diagnostic and staging algorithm of pancreatic cancer (PC). To date the most accurate imaging techniques for the PC remain contrast-enhanced computed tomography (CT) and EUS. The latter has the highest accuracy in detecting small lesions, in assessing tumor size and lymph nodes involvement, but helical CT or an up-to-date magnetic resonance imaging (MRI) must be the first choice in patients with a suspected pancreatic lesion. After this first step there is place for EUS as a second diagnostic level in several cases: negative results on CT/MRI scans and persistent strong clinical suspicion of PC, doubtful results on CT/MRI scans or need for cyto-histological confirmation. In the near future there will be great opportunities for the development of diagnostic and therapeutic EUS and pancreatic pathology could be the best testing bench.

Rapid on-site evaluation increases endoscopic ultrasound-guided fine-needle aspiration adequacy for pancreatic lesions

BACKGROUND

Rapid on-site evaluation (ROSE) has the potential to improve adequacy rates and affect other outcomes; however, there have been few comparative studies to assess the impact of ROSE in the setting of ultrasound-guided endoscopic fine-needle aspiration cytology for pancreatic lesions.

AIMS

To determine whether ROSE improves adequacy rates of endoscopic fine-needle aspiration cytology for pancreatic lesions.

METHODS

Systematic review and meta-analysis of studies reporting a head-to-head comparison of adequacy or diagnostic accuracy (with ROSE vs. without ROSE) at a single site.

RESULTS

ROSE was associated with a statistically significant (p < 0.001) improvement in the adequacy rate (average 10 %, 95 % CI: 5-24 %). The impact of ROSE depends on the per-pass adequacy rate without ROSE. ROSE had no impact on diagnostic yield (p < 0.76).

CONCLUSIONS

ROSE is associated with an improvement in adequacy rates when implemented at sites where the per-case adequacy rate without ROSE is low (<90 %). It is unclear whether the type of assessor (pathologist vs. non-pathologist) has a significant impact on the success rate of ROSE. ROSE has no impact on diagnostic yield. Studies should employ head-to-head comparisons of cohorts with and without ROSE at a single location.

Accuracy of endoscopic ultrasound-guided fine needle aspiration cytology on the differentiation of malignant and benign pancreatic cystic lesions: a single-center experience

OBJECTIVES

The aim was to compare the use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in cytology and the biochemical analysis of cyst fluid, together with the size of the lesion in the differentiation between benign and malignant pancreatic cystic lesions.

METHODS

Data of patients who underwent EUS-FNA for pancreatic cystic lesions in our center from January 2006 to October 2010 were retrospectively analyzed. The diagnostic accuracy of EUS-FNA was determined.

RESULTS

Of the 56 patients, 37 (66.1%) had evaluable cytology for diagnosis and sufficient cyst fluid was available for biochemical analysis in 58.9% (33/56) of the patients. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-FNA for detecting malignancy were 63%, 100%, 100% and 85%, respectively. EUS-FNA was the most accurate diagnostic method for differentiating malignant and benign pancreatic cystic lesions (88%). Cyst fluid carcinoembryonic antigen (CEA) > 365 ng/mL had a sensitivity of 100% for the detection of malignant cystic lesions.

CONCLUSIONS

Although the rate of insufficient cyst fluid aspiration is high, the combination of cytological evaluation and CEA analysis of cyst fluid obtained by EUS-FNA is accurate in differentiating malignant cystic lesions from benign ones. Safe techniques are essential to improve the yield of cyst fluid aspiration by EUS.

EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis

BACKGROUND

Preoperative diagnosis of solid pancreatic lesions remains challenging despite advancement in imaging technologies. EUS has the benefit of being a minimally invasive, well-tolerated procedure, although results are operator-dependent. The addition of FNA (EUS-guided FNA) provides samples for cytopathologic analysis, a major advantage over other imaging techniques.

OBJECTIVE

To determine the diagnostic accuracy of EUS-FNA for pancreatic cancer.

DESIGN

This is a meta-analysis of published studies assessing the diagnostic capability of EUS-FNA. Relevant studies were identified via MEDLINE and were included if they used a reference standard of definitive surgical histology or clinical follow-up of at least 6 months.

MAIN OUTCOME MEASUREMENTS

Data from selected studies were analyzed by using test accuracy meta-analysis software, providing a pooled value for sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve. Cytology results were classified as inadequate, benign, atypical, suspicious, or malignant. Predefined subgroup analysis was performed.

RESULTS

Thirty-three studies published between 1997 and 2009 were included, with a total number of 4984 patients. The pooled sensitivity for malignant cytology was 85% (95% confidence interval [CI], 84-86), and pooled specificity was 98% (95% CI, 0.97-0.99). If atypical and suspicious cytology results were included to determine true neoplasms, the sensitivity increased to 91% (95% CI, 90-92); however, the specificity was reduced to 94% (95% CI, 93-96). The diagnostic accuracy of EUS-FNA was enhanced in prospective, multicenter studies.

LIMITATION

Publication bias was not a significant determinant of pooled accuracy.

CONCLUSION

This meta-analysis demonstrates that EUS-FNA is a highly accurate diagnostic test for solid neoplasms of the pancreas and should be considered when algorithms for investigating solid pancreatic lesions are being planned.

Efficacy of endoscopic ultrasound guided fine needle aspiration in patients with solid pancreatic neoplasms

BACKGROUND/AIM

Endosonography is a distinct method for evaluating the structural lesions of the gastrointestinal (GI) tract, particularly the pancreatobilliary region. This procedure has made a fundamental change in the diagnosis of pancreatic mass lesion through providing fine needle aspiration. This study aims at evaluating the results and efficacy of endoscopic ultrasound fine needle aspiration (EUS-FNA) in patients with pancreatic solid mass.

PATIENTS AND METHODS

The present study is an observational, prospective case series nature, evaluated patients with pancreatic solid mass referred to Imam Khomeini educational hospital in Tehran for a duration of one year since November 2010. In order to determine the false negative cases, the patients were followed-up from 6 to 12 months.

RESULTS

EUS-FNA was conducted on all 53 patients without any complication. The majority of patients included in the study were males (68%) and 81% of patients had a mass in the head of pancreas. The result of cytopathology revealed 36 adenocarcinomas (68%), 7 other malignancies (13%), benign lesions (6%) and 7 non-diagnostic cases (13%). The frequency of non-diagnostic results was significantly high in masses smaller than 3 cm (6 vs. 1, P < 0.002). Patients with non-diagnostic result were younger than those with malignant cytopathology (52 ± 7.5 vs. 66 ± 7.5 years, P < 0.001).. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of this procedure concerning Adenocarcinoma were 88%, 100%, 100%, 70% and 90%, respectively.

CONCLUSION

EUS - FNA is an effective and safe procedure in histopathologic diagnosis of pancreatic tumors. This procedure is useful in all pancreatic mass cases including resectable and non-resectable ones.

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

BACKGROUND AND AIM

We report our single-centre experience with endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of solid pancreatic lesions with regard to clinical utility, diagnostic accuracy and safety.

METHODS

We prospectively reviewed data on 100 consecutive EUS-FNA procedures performed in 93 patients (54 men, mean age 60.6 +/- 12.9 years) for evaluation of solid pancreatic lesions. Final diagnosis was based on a composite standard: histologic evidence at surgery, or non-equivocal malignant cytology on FNA and follow-up. The operating characteristics of EUS-FNA were determined.

RESULTS

The location of the lesions was pancreatic head in 73% of cases, the body in 20% and the tail in 7%. Mean lesion size was 35.1 +/- 12.9 mm. The final diagnosis revealed malignancy in 87 cases, including adenocarcinomas (80.5%), neuroendocrine tumours (11.5%), lymphomas (3.4%) and other types (4.6%). The FNA findings were: 82% interpreted as malignant cytology, 1% as suspicious for neoplasia, 1% as atypical, 7% as benign process and 9% as non-diagnostic. No false-positive results were observed. There was a false-negative rate of 5%. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 94.3%, 100%, 100%, 72.2% and 95%, respectively. In 23 (88.5%) of 26 aspirated lymph nodes malignancy was found. Minor complications occurred in two patients.

CONCLUSIONS

Our experience confirms that EUS-FNA in patients with suspected solid pancreatic lesions is safe and has a high diagnostic accuracy. This technique should be considered the preferred test when a cytological diagnosis of a pancreatic mass lesion is required.

Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer

Early diagnosis of pancreatic cancer remains a difficult task, and multiple imaging tests have been proposed over the years. The aim of this review is to describe the current role of endoscopic ultrasound (EUS) for the diagnosis and staging of patients with pancreatic cancer. A detailed search of MEDLINE between 1980 and 2007 was performed using the following keywords: pancreatic cancer, endoscopic ultrasound, diagnosis, and staging. References of the selected articles were also browsed and consulted. Despite progress made with other imaging methods, EUS is still considered to be superior for the detection of clinically suspected lesions, especially if the results of other cross-sectional imaging modalities are equivocal. The major advantage of EUS is the high negative predictive value that approaches 100%, indicating that the absence of a focal mass reliably excludes pancreatic cancer. The introduction of EUS-guided fine needle aspiration allows a preoperative diagnosis in patients with resectable cancer, as well as a confirmation of diagnosis before chemoradiotherapy for those that are not. This comprehensive review highlighted the diagnostic capabilities of EUS including the newest refinements such as contrast-enhanced EUS, EUS elastography, and 3-dimensional EUS. The place of EUS-guided biopsy is also emphasized, including the addition of molecular marker techniques.

Immunostaining as an adjunct to cytology for diagnosis of pancreatic adenocarcinoma

BACKGROUND & AIMS

Serial analysis of gene expression has helped identify several proteins that are expressed differentially in pancreatic cancer and are highly sensitive and specific for pancreatic adenocarcinoma. We evaluated if the diagnostic accuracy of pancreatic cancer from endoscopic ultrasound (EUS)-fine-needle aspiration (FNA) can be improved by combined evaluation of cytology and immunostaining with these markers.

METHODS

This study involved the use of archived specimens from patients treated at Saint Louis University Hospital from 2002 to 2006. We identified 5 protein markers that appeared most promising from published literature. We sequentially evaluated immunostaining with these markers in (1) surgical resection specimens, (2) cell blocks from EUS-FNA, and (3) direct smears of EUS-FN aspirates. Finally, we performed a combined evaluation of cytology and immunostaining in direct smears that were difficult to interpret and required a second consultative cytologic opinion.

RESULTS

In resection specimens, the majority of pancreatic adenocarcinomas expressed all 5 markers but fascin, maspin, and carcinoembryonic antigen-related cell adhesion molecule 6 also were expressed abnormally in normal pancreata and in chronic pancreatitis. Further evaluation therefore was limited to the other 2 markers: mesothelin and 14-3-3sigma. It was feasible and useful to perform immunostaining in cell blocks and direct smear for diagnosing pancreatic cancer. In cases requiring a second cytologic consultation, a combined evaluation of cytologic morphology and immunostaining had 90% accuracy for a pancreatic adenocarcinoma diagnosis.

CONCLUSIONS

In conclusion, immunostaining with newer protein markers is feasible in EUS-FNA specimens and can assist cytopathologists in diagnosing pancreatic cancer. Among the currently available protein immunomarkers, a combination of mesothelin and 14-3-3sigma seems most promising, but needs to be validated in prospective studies before routine clinical use.

Prospective pilot evaluation of a new needle prototype for endoscopic ultrasonography-guided fine-needle aspiration: comparison of cytology and histology yield

OBJECTIVES

Endoscopic ultrasonography (EUS) with the adjunct of EUS-guided fine needle aspiration has become an important diagnostic modality in gastroenterologic oncology. EUS-guided fine needle aspiration mainly relies on cytology; data are scarce that compare cytology and histology. While testing a 22-gauge prototype needle, we prospectively compared the yield for both.

METHODS

Forty-two consecutive patients (27 male, 15 female; mean age 59.2 years, range: 17-90 years) were included. In each patient we aimed to make two needle passes, and if the material acquired appeared insufficient macroscopically (no in-room cytopathology was available), further passes were done. The material was sent for cytological and histological assessment.

RESULTS

A median number of two passes (range: 2-3) were uneventfully performed for pancreatic lesions (n=30), mediastinal and other lymph nodes/masses (n=8) and various other lesions (n=4) and yielded adequate material for cytology, histology or at least one of the two investigations in 62, 67 and 74% of patients, respectively. No false positive results were found (specificity 100%). Sensitivities were 58.6 and 65.5%, respectively, for cytology and histology alone; combined assessment increased sensitivity to 79.3%. When adjusted values were calculated, based only on those cases with adequate material, sensitivity was 89.5% for cytology and 85.7% for histology, and increased to 100% with combined assessment.

CONCLUSION

The new needle achieves sensitivities similar to those previously reported with no significant differences in sensitivity between cytology and histology. More effective tissue acquisition methods must be sought to improve overall results.

CT-guided core needle biopsy in the diagnosis of pancreatic diseases with an automated biopsy gun

PURPOSE

To evaluate the safety and diagnostic accuracy of computed tomographic (CT)-guided core needle biopsy (CNB) in the diagnosis of pancreatic diseases by using an automated biopsy gun with a cutting-type needle.

MATERIALS AND METHODS

From January 2000 to January 2006, CT-guided CNB was performed in 80 patients suspected of having pancreatic diseases in the absence of liver metastasis. Biopsies were performed with an 18-20-gauge cutting needle driven by a spring-loaded biopsy gun. Histologic reports and medical records of all patients were retrospectively reviewed. An institutional review board exemption was obtained to perform this retrospective study.

RESULTS

All patients tolerated the biopsies well, with no serious complications. Three patients had mild abdominal pain after the procedure, and a limited abdominal CT scan did not reveal any marked abnormality. Two patients had an elevated serum amylase level, which returned to normal within 2 weeks. A definitive diagnosis and accurate histologic diagnosis were obtained for 69 patients, for a successful diagnosis rate of 86%. Surgical sampling was performed in 11 patients with neoplasms and nondiagnostic core-needle biopsies. Only 50% of patients with well-differentiated adenocarcinomas were definitely diagnosed with CT-guided CNB.

CONCLUSIONS

CT-guided CNB with an automated biopsy gun is a safe and effective method for obtaining tissue for the histologic evaluation of pancreatic diseases. However, CT-guided CNB requires further development for the accurate diagnosis of well-differentiated adenocarcinomas.

Endoscopic ultrasound-guided fine needle aspiration cytology of the pancreas: a morphological and multimodal approach to the diagnosis of solid and cystic mass lesions

Cytological evaluation of pancreatic masses and cysts is the preferred pre-operative diagnostic modality and is increasingly being performed by endoscopic ultrasound. This review focuses on the multimodal approach at the Massachusetts General Hospital that utilizes clinical, cytological, radiological and ancillary studies in rendering a final cytological diagnosis.

[Endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic neoplasms: utility and limitations]

Endoscopic ultrasound-guided fine-needle aspiration has become an important method for the diagnosis of pancreatic cystic lesions. The collection, endoscopic handling and lab processing of the material must be optimally performed to avoid diagnostic pitfalls. The wide cytological spectrum of cystic pancreatic neoplasms is described especially for the diagnosis of serous cystadenoma and mucinous neoplasms in order to distinguish them from gastrointestinal contaminants. Knowledge of the clinical history, sonographic findings and even the aspirated fluid gross appearance are essential in helping the cytopathologist reach an accurate diagnosis.

Endoscopic ultrasound-guided fine needle aspiration biopsy: equipment and technique

Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA) is currently performed on a routine basis at many endoscopic centers and it is evident that this procedure has a major impact on the therapeutic management of patients by obtaining a definite tissue diagnosis from lesions outlined by endosonography. The reported yield of EUS-FNA is about 90-95%, with an overall sensitivity and specificity of 90% and 100%, respectively. Moreover, even minute lesions down to a size of 5 mm may be imaged and consequently biopsied. This Review describes the technique of EUS-FNA in detail, based on a literature review and the authors' extensive experience with this method. The endoscopes and needle systems available on the market are presented in detail. The biopsy procedure is carefully explained, as well as the preparation of the cytology smears. Finally, the limitations and complications of the procedure are reviewed in brief, stressing the low rate of complications (below 1-2%), most of them being minor and self-limiting. Currently endosonography has strengthened its position as a diagnostic and staging method, especially after establishing the method of FNA biopsy. Thus, EUS-FNA is very useful to establish an initial tissue diagnosis of malignancy, but also to accurately stage the patients preoperatively, influencing the decision-making process and reducing the morbidity and mortality that accompanies inappropriate surgical interventions in patients with advanced cancer.