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

Transitioning to Combined EBUS EUS-B FNA for Experienced EBUS Bronchoscopist

Endobronchial ultrasound (EBUS) combined with trans-esophageal endoscopic ultrasound bronchoscope guided fine need aspirate (EUS-B FNA) of mediastinal lymph nodes is an established procedure for diagnosis. The main barrier to a combined EBUS EUS-B FNA approach is availability of trained and accredited pulmonologist who can perform procedure safely and confidently. To address this gap, we undertook a training program for experienced EBUS bronchoscopists to train, learn, and incorporate combined EBUS EUS-B FNA into their procedural practice. Thirty-two patients were selected based on CT and or PET findings. Four experienced bronchoscopists participated by reading through learning material, observing 5 cases before performing EUS-B FNA under direct supervision. Forty-one lymph nodes and 6 non-nodal lesions were sampled. EUSAT assessment was performed by supervisor. Learning curves were derived from assessment scores. We observed that learning curve tends to plateau when participant can perform 3 or more consecutive cases with EUSAT score above 50. There were no complications. Our experience suggests that there is relative ease in transition to combined EBUS EUS-B TBNA procedures for mediastinal lymphadenopathy and lung cancer diagnosis and staging for experienced bronchoscopist using a program which incorporates direct supervision, EUSAT assessment, and extension of EUS B FNA training into daily real-world practice.

Diagnosis and staging of lung cancer with the use of one single echoendoscope in both the trachea and the esophagus: A practical guide

Accurate staging of non-small cell lung cancer (NSCLC) is crucial for allocation to surgical, medical or multimodal treatment. EUS and endobronchial ultrasound (EBUS) have gained ground in the diagnosis and staging of lung cancer in addition to radiological imaging (e.g., computed tomography, fluoroscopy, and magnetic resonance imaging), nuclear medicine techniques (e.g. positron emission tomography, PET), combined techniques (e.g., fluorodesoxyglucosepositron emission tomography scanning), and sonographic imaging including conventional transcutaneous mediastinal and lung ultrasound. By using one single echoendoscope in both the trachea and the esophagus, surgical staging procedures (e.g. mediastinoscopy and video assisted thoracoscopy) can be avoided in a considerable proportion of patients with NSCLC.

Current Status of Needles in the Optimization of Endoscopic Ultrasound-Guided Procedures

Endoscopic ultrasound (EUS) is among the most important tools for the evaluation of gastrointestinal tumors and affected areas around the gastrointestinal tract. It enables the acquisition of material from abnormal lesions via the gastrointestinal wall for tissue confirmation via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA has played a vital role in oncological care and has become the standard method for tissue sampling. The choice of needle type is an important factor determining tissue acquisition and has been evaluated by many researchers. New needles are introduced into the market almost every year, and opinions vary regarding proper needle selection. While there are diverse opinions but no definitive recommendations about the use of one particular device, fine-needle biopsy needles may provide detailed information on a tissue’s architecture based on greater sample yields. This permits additional analyses, including genetic sequencing and phenotyping, thereby enabling the provision of more personalized treatment plans. Furthermore, other EUS-guided procedures have been developed, including interventional EUS and through-the-needle devices. Given the continued attempts to improve the diagnostic ability and therapeutic techniques, we review in detail the available types of puncture needles to provide guidance on the selection of the appropriate needle types.

Inflammation and DNA methylation coregulate the CtBP-PCAF-c-MYC transcriptional complex to activate the expression of a long non-coding RNA CASC2 in acute pancreatitis

Long non-coding RNAs (lncRNAs) are emerging as important regulators involved in the pathogenesis of many diseases. However, it is still unknown if they contribute to the occurrence of acute pancreatitis (AP). Here, we identified a lncRNA CASC2 (Cancer Susceptibility Candidate 2) was significantly upregulated in the pancreatic tissues from AP patients. Knockdown or overexpression of CASC2 in vitro could specifically repress or induce the expression of two proinflammatory cytokines including IL6 (Interleukin 6) and IL17, respectively. Changing the expression levels of several transcription factors that were predicted to bind to the promoter of CASC2, we found c-MYC could specifically regulate the expression of CASC2. Using immunoprecipitation, mass spectrometry, and co-immunoprecipitation assays, we proved that c-MYC assembled a transcriptional complex with PCAF (p300/CBP-associated Factor) and CtBP1/2 (C-terminal Binding Protein 1 and 2), terming as the CtBP-PCAF-c-MYC (CPM) complex. Further investigation revealed that CtBPs were amplified in the pancreatic tissues from AP patients and they functioned as coactivators to induce the expression of CASC2 and thus led to the upregulation of IL6 and IL17. Moreover, we identified that decreased DNA methylation levels in the promoters of CtBPs and inflammatory stimuli coactivated the expression of CtBPs. Collectively, we identified a new signaling pathway in which DNA methylation and inflammatory stimuli coregulate the CPM complex to activate CASC2 expression, whose induction further activates the expression of IL6 and IL17, eventually aggravating inflammation response and causing the pathology of AP.

Magnetically Actuated Soft Capsule Endoscope for Fine-Needle Biopsy

Wireless capsule endoscopes have revolutionized diagnostic procedures in the gastrointestinal (GI) tract by minimizing discomfort and trauma. Biopsy procedures, which are often necessary for a confirmed diagnosis of an illness, have been incorporated recently into robotic capsule endoscopes to improve their diagnostic functionality beyond only imaging. However, capsule robots to date have only been able to acquire biopsy samples of superficial tissues of the GI tract, which could generate false-negative diagnostic results if the diseased tissue is under the surface of the GI tract. To improve their diagnostic accuracy for submucosal tumors/diseases, we propose a magnetically actuated soft robotic capsule robot, which takes biopsy samples in a deep tissue of a stomach using the fine-needle biopsy technique. We present the design, control, and human-machine interfacing methods for the fine-needle biopsy capsule robot. Ex vivo experiments in a porcine stomach show 85% yield for the biopsy of phantom tumors located underneath the first layers of the stomach wall.

Cyst Fluid Biosignature to Predict Intraductal Papillary Mucinous Neoplasms of the Pancreas with High Malignant Potential

BACKGROUND

Current standard-of-care technologies, such as imaging and cyst fluid analysis, are unable to consistently distinguish intraductal papillary mucinous neoplasms (IPMNs) of the pancreas at high risk of pancreatic cancer from low-risk IPMNs. The objective was to create a single-platform assay to identify IPMNs that are at high risk for malignant progression.

STUDY DESIGN

Building on the Verona International Consensus Conference branch duct IPMN biomarker review, additional protein, cytokine, mucin, DNA, and microRNA cyst fluid targets were identified for creation of a quantitative polymerase chain reaction-based assay. This included messenger RNA markers: ERBB2, GNAS, interleukin 1β, KRAS, MUCs1, 2, 4, 5AC, 7, prostaglandin E2R, PTGER2, prostaglandin E synthase 2, prostaglandin E synthase 1, TP63; microRNA targets: miRs 101, 106b, 10a, 142, 155, 17, 18a, 21, 217, 24, 30a, 342, 532, 92a, and 99b; and GNAS and KRAS mutational analysis. A multi-institutional international collaborative contributed IPMN cyst fluid samples to validate this platform. Cyst fluid gene expression levels were normalized, z-transformed, and used in classification and regression analysis by a support vector machine training algorithm.

RESULTS

From cyst fluids of 59 IPMN patients, principal component analysis confirmed no institutional bias/clustering. Lasso (least absolute shrinkage and selection operator)-penalized logistic regression with binary classification and 5-fold cross-validation used area under the curve as the evaluation criterion to create the optimal signature to discriminate IPMNs as low risk (low/moderate dysplasia) or high risk (high-grade dysplasia/invasive cancer). The most predictive signature was achieved with interleukin 1β, MUC4, and prostaglandin E synthase 2 to accurately discriminate high-risk cysts from low-risk cysts with an area under the curve of up to 0.86 (p = 0.002).

CONCLUSIONS

We have identified a single-platform polymerase chain reaction-based assay of cyst fluid to accurately predict IPMNs with high malignant potential for additional studies.

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

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

MicroRNAs for Detection of Pancreatic Neoplasia: Biomarker Discovery by Next-generation Sequencing and Validation in 2 Independent Cohorts

Supplemental Digital Content is available in the text

Objective:

The aim of our study was to analyze the miRNome of pancreatic ductal adenocarcinoma (PDAC) and its preneoplastic lesion intraductal papillary mucinous neoplasm (IPMN), to find new microRNA (miRNA)-based biomarkers for early detection of pancreatic neoplasia.

Objective:

Effective early detection methods for PDAC are needed. miRNAs are good biomarker candidates.

Methods:

Pancreatic tissues (n = 165) were obtained from patients with PDAC, IPMN, or from control individuals (C), from Hospital Clínic of Barcelona. Biomarker discovery was done using next-generation sequencing in a discovery set of 18 surgical samples (11 PDAC, 4 IPMN, 3 C). MiRNA validation was carried out by quantitative reverse transcriptase PCR in 2 different set of samples. Set 1—52 surgical samples (24 PDAC, 7 IPMN, 6 chronic pancreatitis, 15 C), and set 2—95 endoscopic ultrasound-guided fine-needle aspirations (60 PDAC, 9 IPMN, 26 C).

Results:

In all, 607 and 396 miRNAs were significantly deregulated in PDAC and IPMN versus C. Of them, 40 miRNAs commonly overexpressed in both PDAC and IPMN were selected for further validation. Among them, significant up-regulation of 31 and 30 miRNAs was confirmed by quantitative reverse transcriptase PCR in samples from set 1 and set 2, respectively.

Conclusions:

miRNome analysis shows that PDAC and IPMN have differential miRNA profiles with respect to C, with a large number of deregulated miRNAs shared by both neoplastic lesions. Indeed, we have identified and validated 30 miRNAs whose expression is significantly increased in PDAC and IPMN lesions. The feasibility of detecting these miRNAs in endoscopic ultrasound-guided fine-needle aspiration samples makes them good biomarker candidates for early detection of pancreatic cancer.

Endoscopic ultrasound-guided radiofrequency ablation of the pancreas: An experimental study with pathological correlation

Background:

The treatment of pancreatic cancer represents a major objective in clinical research, as it still remains the fourth leading cause of cancer deaths among men and women, with approximately 6% of all cancer-related deaths.

Materials and Methods:

We studied the assessment of an endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) probe through a 19G needle in order to achieve a desirable necrosis area in the pancreas. Radiofrequency ablation of the head of the pancreas was performed on 10 Yorkshire pigs with a weight between 25 kg and 35 kg and a length of 40-70 cm. Using an EUS-guided RFA experimental probe, we ablated an area of 2-3 cm width. The biological samples were harvested after 3 days and 5 days and necropsy was performed 1 week after the procedure.

Results:

All pigs showed no significant change regarding their behavior and no signs of complication was encountered. Blood analysis revealed increased values of amylase, alkaline phosphatase, and gamma-glutamyl transpeptidase on the 3rd day but a decrease on the 5th day. After necropsy and isolation of the pancreas, the ablated area was easily found, describing a solid necrosis. The pathological examination revealed a coagulative necrosis area with minimal invasion and inflammatory tissue at about 2 cm surrounding the lesion.

Conclusion:

EUS-RFA is a feasible technique and might represent a promising therapy for the future treatment of pancreatic cancer. However, further studies are necessary to investigate EUS-guided RFA as an option for palliation in pancreatic cancer until it can be successfully used in human patients.

Cell-block procedure in endoscopic ultrasound-guided-fine-needle-aspiration of gastrointestinal solid neoplastic lesions

In the present review we have analyzed the clinical applications of endoscopic ultrasound-guided-fine-needle-aspiration (EUS-FNA) and the methodological aspects obtained by cell-block procedure (CBP) in the diagnostic approach to the gastrointestinal neoplastic pathology. CBP showed numerous advantages in comparison to the cytologic routine smears; in particular, better preservation of cell architecture, achievement of routine haematoxylin-eosin staining equivalent to histological slides and possibility to perform immunohistochemistry or molecular analyses represented the most evident reasons to choose this method. Moreover, by this approach, the differential diagnosis of solid gastrointestinal neoplasias may be more easily achieved and the background of contaminant non-neoplastic gastrointestinal avoided. Finally, biological samples collected by EUS-FNA CBP-assisted should be investigated in order to identify and quantify further potential molecular markers.

Current role of non-anesthesiologist administered propofol sedation in advanced interventional endoscopy

Complex and lengthy endoscopic examinations like endoscopic ultrasonography and/or endoscopic retrograde cholangiopancreatography benefit from deep sedation, due to an enhanced quality of examinations, reduced discomfort and anxiety of patients, as well as increased satisfaction for both the patients and medical personnel. Current guidelines support the use of propofol sedation, which has the same rate of adverse effects as traditional sedation with benzodiazepines and/or opioids, but decreases the procedural and recovery time. Non-anesthesiologist administered propofol sedation has become an option in most of the countries, due to limited anesthesiology resources and the increasing evidence from prospective studies and meta-analyses that the procedure is safe with a similar rate of adverse events with traditional sedation. The advantages include a high quality of endoscopic examination, improved satisfaction for patients and doctors, as well as decreased recovery and discharge time. Despite the advantages of non-anesthesiologist administered propofol, there is still a continuous debate related to the successful generalization of the procedures.

A prospective randomized study of the difference in diagnostic yield between endoscopic ultrasound-guided fine-needle aspiration (EUSFNA) needles with and without a side port in pancreatic masses

BACKGROUND AND STUDY AIMS

Two 22G needles with similar designs, apart from the absence (A) or presence of a side port (B), are available for endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). The side port was designed to increase diagnostic yield but this advantage was unproven. This study evaluated the difference in diagnostic yield between both needles in pancreatic masses.

PATIENTS AND METHODS

This was a prospective multicenter randomized cross-over study. Patients with pancreatic masses were randomized to one needle for the first two passes, followed by the other for the next two passes. A pathologist blinded to the needle assessed each puncture for cellularity and morphology. The diagnostic yield between both needles was compared.

RESULTS

In total, 30 patients were recruited (mean lesion size: 3.5 cm, range: 1.2 - 6.3). Comparison of cellularity adequacy: first pass: A vs. B: 26/30 vs. 24/30 (P = 0.488): 2nd pass: A vs. B: 25/30 vs. 26/30 (P = 0.718). Comparison of diagnostic accuracy: first pass: A vs. B: 22/30 vs. 23/30 (P = 0.766); after two passes: A vs. B: 26/30 vs. 26/30 (P = 1.0). When all four passes were assessed, adequate cellularity was obtained in 29/30 and the correct diagnosis was obtained in 28/30 patients. There were no procedural complications.

CONCLUSIONS

There was no significant difference in diagnostic yield between EUSFNA needles with or without a side port for pancreatic masses.

STUDY REGISTRATION

NCT02092519.

How to learn and to perform endoscopic ultrasound and endobronchial ultrasound for lung cancer staging: A structured guide and review

The learning of transesophageal ultrasound guided fine needle aspiration (FNA) (endoscopic ultrasound-FNA), and endobronchial ultrasound guided transbronchial needle aspiration (endosonography) should be based on the following steps: Acquiring theoretical knowledge, training on simulators, and supervised performance on patients. Each step should be completed by passing a validated exam before proceeding to the next step. This approach will assure basic competency on all levels, and testing also facilitates learning and improves retention. Competence in endosonography can be based on a systematic an easy principle consisting of 2 times six anatomical landmarks.

Endoscopic ultrasound-guided fine needle aspiration: from the past to the future

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a technique which allows the study of cells obtained through aspiration in different locations near the gastrointestinal tract. EUS-FNA is used to acquire tissue from mucosal/submucosal tumors, as well as peri-intestinal structures including lymph nodes, pancreas, adrenal gland, gallbladder, bile duct, liver, kidney, lung, etc. The pancreas and lymph nodes are still the most common organs targeted in EUS-FNA. The overall accuracy of EUS is superior to computed tomography scan and magnetic resonance imaging for detecting pancreatic lesions. In most cases it is possible to avoid unnecessary surgical interventions in advanced pancreatic cancer, and EUS is considered the preferred method for loco-regional staging of pancreatic cancer. FNA improved the sensitivity and specificity compared to EUS imaging alone in detection of malignant lymph nodes. The negative predictive value of EUS-FNA is relatively low. The presence of a cytopathologist during EUS-FNA improves the diagnostic yield, decreasing unsatisfactory samples or need for additional passes, and consequently the procedural time. The size of the needle is another factor that could modify the diagnostic accuracy of EUS-FNA. Even though the EUS-FNA technique started in early nineteen's, there are many remarkable progresses culminating nowadays with the discovery and performance of needle-based confocal laser endomicroscopy. Last, but not least, identification and quantification of potential molecular markers for pancreatic cancer on cellular samples obtained by EUS-FNA could be a promising approach for the diagnosis of solid pancreatic masses.

Techniques for cytologic sampling of pancreatic and bile duct lesions: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreatobiliary cytology, including indications for endoscopic ultrasound guided fine-needle aspiration biopsy, techniques of the endoscopic retrograde cholangiopancreatography, terminology and nomenclature of pancreatobiliary disease, ancillary testing, and postbiopsy management. All documents are based on the expertise of the authors, a review of literature, discussions of the draft document at several national and international meetings over an 18 month period and synthesis of online comments of the draft document on the Papanicolaou Society of Cytopathology website [www.papsociety.org]. This document presents the results of these discussions regarding the use of sampling techniques in the cytological diagnosis of biliary and pancreatic lesions. This document summarizes the current state of the art for techniques in acquiring cytology specimens from the biliary tree as well as solid and cystic lesions of the pancreas.

Guidelines for pancreaticobiliary cytology from the Papanicolaou Society of Cytopathology: A review

The newest installment on state-of-the-art standards of practice in cytopathology from the Papanicolaou Society of Cytopathology (PSC) focuses on the pancreaticobiliary system. Similar to the National Cancer Institute recommendations for aspiration cytology of the thyroid, the PSC guidelines for pancreaticobiliary cytology addresses indications, techniques, terminology and nomenclature, ancillary studies, and postprocedure management. Each committee was composed of a multidisciplinary group of experts in diagnosing, managing, and treating patients with pancreaticobiliary disease. Draft documents were posted on an interactive Web-based forum hosted by the PSC Web site (www.papsociety.org) and the topics of terminology, ancillary testing, and management were presented at national and international meetings over an 18-month period for discussion and feedback from practicing pathologists around the world. This review provides a synopsis of these guidelines.

Malignant pleural mesothelioma metastatic to the submandibular salivary gland, simulating glandular hypertrophy, diagnosed by fine-needle aspiration biopsy: a case report and literature review

Background

Malignant mesothelioma is a rare neoplasm that generally develops in the pleural or peritoneal cavity. Distant metastases are common; it rarely metastatizes to the head and neck region.

Case presentation

A 54-year-old white man, a non-smoker, was treated with chemotherapy, surgery and radiation for a malignant pleural mesothelioma. Seven months after the last treatment, he developed a right submandibular enlargement: clinical examination, ultrasound and computerized tomography scans revealed a salivary gland hypertrophy. Anti-inflammatory and antibiotic treatment was then started, without improvement. An ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) showed atypical mesothelial cells with nuclear enlargement and increased chromatin representation. Immunocytochemistry showed positivity for calretinin and WT-1.

A diagnosis of right submandibular salivary gland involvement from mesothelioma was established, allowing an adequate treatment.

Conclusion

We report a very rare site of metastasis from malignant pleural mesothelioma. We suggest that US-guided FNAB is a useful, quick, and cheap procedure for a definite diagnosis.

Use of ancillary techniques in improving the yield of samples obtained at endoscopic ultrasound-guided fine needle aspiration of thoracic and abdominal lymph nodes

OBJECTIVES

Thoracic and abdominal lymph nodes may be enlarged in a variety of disorders. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a well-established technique for sampling such nodes, but samples obtained are small, which may make definitive diagnosis difficult. We conducted a retrospective review to determine the contribution of ancillary techniques, such as special histochemistry (SHC), immunohistochemistry (IHC) and flow cytometry, in increasing the diagnostic yield of EUS-FNA carried out at our institution.

STUDY DESIGN

Between November 2005 and December 2012, 278 patients underwent EUS-FNA of enlarged thoracic and abdominal nodes at our institution. All specimens obtained were subjected to rapid on-site evaluation. Data were reviewed in all patients requiring ancillary techniques for definitive diagnosis.

RESULTS

Ancillary techniques were performed in 111 of 278 cases. IHC was performed in 24, flow cytometry in 3 and SHC staining in 84. IHC and SHC aided in reaching a definitive diagnosis in 19 of 24 and 3 cases, respectively. Flow cytometry led to a definitive diagnosis in 3 cases. A total of 80 cases were also submitted to culture for tuberculosis with 6 positive for Mycobacterium tuberculosis.

CONCLUSIONS

Ancillary studies in EUS-FNA of thoracic and abdominal lymph nodes can significantly improve the yield of EUS-FNA.

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.

Multicenter randomized controlled trial comparing the performance of 22 gauge versus 25 gauge EUS-FNA needles in solid masses

BACKGROUND AND AIMS

Few randomized studies have assessed the clinical performance of 25-gauge (25G) needles compared with 22-gauge (22G) needles during endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy of intra-abdominal lesions. We aimed to compare the diagnostic yield, as well as performance characteristics of 22G versus 25G EUS biopsy needles by determining their diagnostic capabilities, the number of needle passes as well as cellularity of aspirated tissue specimen.

METHODS

The study is a prospective, randomized, multicenter study. Patients were referred between January 2009 and January 2010 for diagnostic EUS including EUS-guided FNA of different lesions adjacent to the upper GI tract. All patients were randomized to EUS-FNA performed with either a 22G or 25G aspiration needle.

RESULTS

EUS-FNA was performed in 135 patients (62 patients with a 22G needle). Sensitivity and specificity of the 22G needle was 94.1% and 95.8%, respectively, and for the 25G needle 94.1% and 100%, respectively. Investigators reported better visualization and performance for the 22G needle compared to the 25G (p < 0.0001). The number of tissue slides obtained was higher for the 22G needle during the second and third needle passes (p < 0.05). We did not observe significant differences between the number and preservation status of obtained cells (p > 0.05).

CONCLUSIONS

A significant difference was found between the two types of needles in terms of reduced visualization of the 25G needle and suboptimal performance rating. However, this did not impact on overall results since both needles were equally successful in terms of a high diagnostic yield and overall accuracy.

Accuracy and Quality Assessment of EUS-FNA: A Single-Center Large Cohort of Biopsies

Introduction. Thorough quality control (QC) study with systemic monitoring and evaluation is crucial to optimizing the effectiveness of EUS-FNA. Methods. Retrospective analysis was composed of investigating consecutive patient files that underwent EUS-FNA. QC specifically focused on diagnostic accuracy, impacts on preexisting diagnoses, and case management. Results. 268 patient files were evaluated. EUS-FNA cytology helped establish accurate diagnoses in 92.54% (248/268) of patients. Sensitivity, specificity, PPV, NPV, and accuracy were 83%, 100%, 100%, 91.6%, and 94%, respectively. The most common biopsy site was the pancreas (68%). The most accurate location for EUS-FNA was the esophagus, 13/13 (100%), followed by the pancreas (89.6%). EUS-FNA was least informative for abdominal lymph nodes (70.5%). After FNA and followup, eight false negatives for tumors were found (3%), while 7.5% of samples still lacked a definitive diagnosis. Discussion. QC suggests that the diagnostic accuracy of EUS-FNA might be improved further by (1) taking more FNA passes from suspected lesions, (2) optimizing needle selection (3) having an experienced echo-endoscopist available during the learning curve, and (4) having a cytologist present during the procedure. QC also identified remediable reporting errors. In conclusion, QC study is valuable in identifying weaknesses and thereby augmenting the effectiveness of EUS-FNA.

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 an artificial neural network-based approach to endoscopic ultrasound elastography in diagnosis of focal pancreatic masses

BACKGROUND & AIMS

By using strain assessment, real-time endoscopic ultrasound (EUS) elastography provides additional information about a lesion's characteristics in the pancreas. We assessed the accuracy of real-time EUS elastography in focal pancreatic lesions using computer-aided diagnosis by artificial neural network analysis.

METHODS

We performed a prospective, blinded, multicentric study at of 258 patients (774 recordings from EUS elastography) who were diagnosed with chronic pancreatitis (n = 47) or pancreatic adenocarcinoma (n = 211) from 13 tertiary academic medical centers in Europe (the European EUS Elastography Multicentric Study Group). We used postprocessing software analysis to compute individual frames of elastography movies recorded by retrieving hue histogram data from a dynamic sequence of EUS elastography into a numeric matrix. The data then were analyzed in an extended neural network analysis, to automatically differentiate benign from malignant patterns.

RESULTS

The neural computing approach had 91.14% training accuracy (95% confidence interval [CI], 89.87%-92.42%) and 84.27% testing accuracy (95% CI, 83.09%-85.44%). These results were obtained using the 10-fold cross-validation technique. The statistical analysis of the classification process showed a sensitivity of 87.59%, a specificity of 82.94%, a positive predictive value of 96.25%, and a negative predictive value of 57.22%. Moreover, the corresponding area under the receiver operating characteristic curve was 0.94 (95% CI, 0.91%-0.97%), which was significantly higher than the values obtained by simple mean hue histogram analysis, for which the area under the receiver operating characteristic was 0.85.

CONCLUSIONS

Use of the artificial intelligence methodology via artificial neural networks supports the medical decision process, providing fast and accurate diagnoses.

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

Background. The utility of repeat EUS in patients with suspicion for pancreatic cancer after non-diagnostic EUS-FNA study is not well established. Aim. Determine the accuracy of repeat EUS-FNA in patients with suspected pancreatic cancer and prior non-diagnostic EUS-FNA. Methods. Retrospective cohort study. Results. From 2002 to 2008 in our institution 28 patients underwent repeat EUS-FNA for suspected pancreatic cancer. Initial EUS showed a pancreatic mass in 24 (85.71%), no mass in 3 (10.71%) and possible mass in 1 (3.58%). FNA was performed and was negative for malignancy in all patients. Repeat EUS showed pancreatic mass in 27 patients (96.42%) and no mass in 1 (3.58%). FNA was performed in all patients and cytology was positive for malignancy in 6 (21.43%). Out of the 28 patients, 17 (60.71%) were eventually confirmed to have cancer. Overall repeat EUS-FNA correctly determined the true final status in 17 out of 28 patients providing sensitivity for the diagnosis of cancer of 35% (95% CI 14%–62%), specificity 100% (95% CI 72%–100%), and overall accuracy of 61%, (95% CI 28%–72%). Conclusion. Repeat EUS-FNA provides reasonable accuracy and may be worthwhile in patients with suspected pancreatic cancer who had had prior negative EUS-FNA.

Fine-needle aspiration biopsies for gene expression ratio-based diagnostic and prognostic tests in malignant pleural mesothelioma

PURPOSE

Malignant pleural mesothelioma (MPM) is an aggressive disease associated with median survival between 9 and 12 months. The correct diagnosis of MPM is sometimes challenging and usually requires solid tissue biopsies rather than fine-needle aspiration biopsies (FNA). We postulated that the accuracy of FNA-based diagnosis might be improved by the addition of molecular tests using a gene expression ratio-based algorithm and that prognostic tests could be similarly performed.

EXPERIMENTAL DESIGN

Two MPM and 2 lung cancer cell lines were used to establish the minimal quantity of RNA required to perform the gene ratio test. On the basis of these results, 276 ex vivo FNA biopsies from 63 MPM patients and 250 ex vivo FNA samples from 92 lung cancer patients were analyzed using previously described diagnostic and prognostic tests based on gene expression ratios.

RESULTS

We found that the sensitivity of the diagnostic test for MPM was 100% [95% confidence interval (CI): 95%-100%] and the specificity in primary lung adenocarcinoma was 90% (95% CI: 81%-95%). The FNA-based prognostic classification was concordant among 76% (95% CI: 65%-87%) of patients with the risk assignment in a subset of the matched surgical specimens previously analyzed by the prognostic test.

CONCLUSIONS

Sufficient RNA can be extracted from most FNA biopsies to perform gene expression molecular tests. In particular, we show that the gene expression ratio algorithms performed well when applied to diagnosis and prognosis in MPM. This study provides support for the development of additional RNA molecular tests that may enhance the utility of FNA in the management of other solid cancers.

A prospective comparison of EUS-guided FNA using 25-gauge and 22-gauge needles

BACKGROUND AND AIMS

There are limited data on the differences in diagnostic yield between 25-gauge and 22-gauge EUS-FNA needles. This prospective study compared the difference in diagnostic yield between a 22-gauge and a 25-gauge needle when performing EUS-FNA.

METHODS

Forty-three patients with intraluminal or extraluminal mass lesions and/or lymphadenopathy were enrolled prospectively. EUS-FNA was performed for each mass lesion using both 25- and 22-gauge needles. The differences in accuracy rate, scoring of needle visibility, ease of puncture and quantity of obtained specimen were evaluated.

RESULTS

The overall accuracy of 22- and 25-gauge needle was similar at 81% and 76% respectively (N.S). Likewise the visibility scores of both needles were also similar. Overall the quantity of specimen obtained higher with the 22-gauge needle (score: 1.64 vs. P < .001). However the 25-gauge needle was significantly superior to the 22-gauge needle in terms of ease of puncture (score: 1.9 vs. 1.29, P < .001) and in the quantity of specimen in the context of pancreatic mass EUS-FNA (score: 1.8 vs. 1.58, P < .05).

CONCLUSION

The 22-gauge and 25-gauge needles have similar overall diagnostic yield. The 25-gauge needle appeared superior in the subset of patients with hard lesions and pancreatic masses.

Endoscopic gastric submucosal transplantation of islets (ENDO-STI): technique and initial results in diabetic pigs

The results of transplantation of human donor islets into the portal vein (PV) in patients with diabetes are encouraging. However, there are complications, for example, hemorrhage, thrombosis and an immediate loss of islets through the 'instant blood-mediated inflammatory reaction' (IBMIR). The gastric submucosal space (GSMS) offers potential advantages. Islets were isolated from adult pigs. Recipient pigs were made diabetic by streptozotocin. Donor islets were injected into the GSMS through a laparotomy (Group 1A, n = 4) or endoscopically (Group 1B, n = 8) or into the PV through a laparotomy (Group 2, n = 3). The pigs were followed for a maximum of 28 days. Monitoring of C-peptide in Group 1 indicated that there was minimal immediate loss of islets whereas in Group 2 there was considerable loss from IBMIR. In Group 1, there were significant reductions in mean blood glucose and mean exogenous insulin requirement between pretransplantation and 20 days posttransplantation. In Group 2, there was no significant reduction in either parameter. Insulin-positive cells were seen in the GSMS in Group 1, but not in the liver in Group 2. Endoscopic gastric submucosal transplantation of islets (ENDO-STI) offers a minimally invasive and quick approach to islet transplantation, avoids IBMIR and warrants further exploration.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA): experience of an academic centre in the USA

OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has become widely accepted as an effective modality for obtaining tissue for primary diagnosis and staging. We have been using EUS-FNA since July 2001 and herein we summarize our experience over a 5-year period.

METHODS

A computer-based search for in-house EUS-FNA was performed in the pathology database from July 2001 to October 2006. To calculate the sensitivity, specificity and accuracy of EUS-FNA, the cytology diagnosis was compared with the surgical follow-up.

RESULTS

A total of 951 EUS-FNAs were performed during the study period and included 279 pancreatic solid lesions, 186 pancreatic cyst lesions, 249 lymph node aspirations, 111 gastrointestinal (GI) tract submucosal lesions, and 126 miscellaneous lesions. EUS-FNA had a very high sensitivity and accuracy for solid pancreatic lesions (94.7 and 97.7%, respectively), low sensitivity and accuracy but high specificity (47, 64.8 and 95%, respectively) for cystic lesions. Cyst fluid carcinoembryonic (CEA) levels were significantly higher in mucinous neoplasms than non-neoplastic cysts. EUS-FNA also had very high sensitivity and specificity for detecting metastatic carcinoma in lymph nodes (95 and 100%, respectively). GI submucosal spindle cell tumours were further classified with immunohistochemical stains performed either on a cell block or a core biopsy obtained via EUS guidance.

CONCLUSIONS

EUS-FNA has a very high sensitivity and accuracy for pancreatic solid lesions, but the sensitivity for cystic lesions is generally low. Cyst fluid chemical analysis for CEA is helpful, but the overlap between mucinous neoplasm and non-neoplastic cysts is significant. Recognizing GI contamination is important and immunohistochemical stains are useful for GI submucosal spindle cell lesions.

MicroRNAs in plasma of pancreatic ductal adenocarcinoma patients as novel blood-based biomarkers of disease

Development of minimally invasive biomarker assays for early detection and effective clinical management of pancreatic cancer is urgently needed to reduce high morbidity and mortality associated with this malignancy. We hypothesized that if aberrantly expressing microRNAs (miRNA) in pancreatic adenocarcinoma tissues are detected in blood plasma, then plasma profiling of these miRNAs might serve as a minimally invasive early detection biomarker assay for this malignancy. By using a modified protocol to isolate and quantify plasma miRNAs from heparin-treated blood, we show that miRNA profiling in plasma can differentiate pancreatic adenocarcinoma patients from healthy controls. We have profiled four miRNAs, miR-21, miR-210, miR-155, and miR-196a, all implicated in the development of pancreatic cancer with either proven or predicted target genes involved in critical cancer-associated cellular pathways. Of these, miR-155 has recently been identified as a candidate biomarker of early pancreatic neoplasia, whereas elevated expression of miR196a has been shown to parallel progression of disease. The results revealed a sensitivity of 64% and a specificity of 89% with the analyses of plasma levels for this panel of four miRNAs. The area under the receiver operating characteristic curve were estimated at 0.82 and 0.78 without and with leave-one-out cross-validation scheme, respectively. These observations, although a "proof of principle" finding at this time, show the feasibility of developing plasma miRNA profiling as a sensitive and specific blood-based biomarker assay for pancreatic cancer that has the potential of translation to the clinic with additional improvements in the future.

Randomized controlled trial of endoscopic ultrasound-guided fine-needle sampling with or without suction for better cytological diagnosis

OBJECTIVE

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a highly accurate method to obtain specific diagnosis in various diseases. The optimal method of EUS-guided sampling of material for pathologic diagnosis has not been clearly established. The aim of our study was to compare two different techniques of EUS-guided sampling of solid masses, using either non-suction or suction with a 10-ml syringe.

MATERIAL AND METHODS

Patients assessed during a 6-month period were randomized to three passes of EUS-guided sampling with suction (26 patients) or non-suction (26 patients). The samples were characterized for cellularity and bloodiness, with a final cytology diagnosis established blindly. The final diagnosis was reached either by EUS-FNA if malignancy was definite, or by surgery and/or clinical follow-up of a minimum of 6 months in the cases of non-specific benign lesions.

RESULTS

EUS-guided fine-needle sampling with suction of solid masses increased the number of pathology slides (17.8+/-7.1 slides for suction as compared with 10.2+/-5.5 for non-suction, p=0.0001), without increasing the overall bloodiness of each sample. Sensitivity and the negative predictive values were higher when suction was applied, as compared to the non-suction group (85.7% as compared with 66.7%, p=0.05).

CONCLUSIONS

This prospective randomized study showed that EUS-guided fine-needle sampling of solid masses using suction yields a higher number of slides without increasing bloodiness. Although, the proportion of target cells was relatively similar between the suction and non-suction sampling techniques, the sensitivity and negative predictive values of the procedure were significantly higher when suction was added.

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.

Neural network analysis of dynamic sequences of EUS elastography used for the differential diagnosis of chronic pancreatitis and pancreatic cancer

BACKGROUND

EUS elastography is a newly developed imaging procedure that characterizes the differences of hardness and strain between diseased and normal tissue.

OBJECTIVE

To assess the accuracy of real-time EUS elastography in pancreatic lesions.

DESIGN

Cross-sectional feasibility study.

PATIENTS

The study group included, in total, 68 patients with normal pancreas (N = 22), chronic pancreatitis (N = 11), pancreatic adenocarcinoma (N = 32), and pancreatic neuroendocrine tumors (N = 3). A subgroup analysis of 43 cases with focal pancreatic masses was also performed.

INTERVENTIONS

A postprocessing software analysis was used to examine the EUS elastography movies by calculating hue histograms of each individual image, data that were further subjected to an extended neural network analysis to differentiate benign from malignant patterns.

MAIN OUTCOME MEASUREMENTS

To differentiate normal pancreas, chronic pancreatitis, pancreatic cancer, and neuroendocrine tumors.

RESULTS

Based on a cutoff of 175 for the mean hue histogram values recorded on the region of interest, the sensitivity, specificity, and accuracy of differentiation of benign and malignant masses were 91.4%, 87.9%, and 89.7%, respectively. The positive and negative predictive values were 88.9% and 90.6%, respectively. Multilayer perceptron neural networks with both one and two hidden layers of neurons (3-layer perceptron and 4-layer perceptron) were trained to learn how to classify cases as benign or malignant, and yielded an excellent testing performance of 95% on average, together with a high training performance that equaled 97% on average.

LIMITATION

A lack of the surgical standard in all cases.

CONCLUSIONS

EUS elastography is a promising method that allows characterization and differentiation of normal pancreas, chronic pancreatitis, and pancreatic cancer. The currently developed methodology, based on artificial neural network processing of EUS elastography digitalized movies, enabled an optimal prediction of the types of pancreatic lesions. Future multicentric, randomized studies with adequate power will have to establish the clinical impact of this procedure for the differential diagnosis of focal pancreatic masses.

Analysis of microRNAs in pancreatic fine-needle aspirates can classify benign and malignant tissues

BACKGROUND

MicroRNAs (miRNAs) are RNA molecules that are involved in the regulation of many cellular processes, including those related to human cancers. The aim of this study was to determine, as a proof of principle, whether specific candidate miRNAs could be detected in fine-needle aspirate (FNA) biopsies of pancreatic ductal adenocarcinoma (PDAC) and could accurately differentiate malignant from benign pancreatic tissues.

METHODS

We used TaqMan(R) assays to quantify miRNA levels in FNA samples collected in RNARetain (n = 16) and compared the results with a training set consisting of frozen macrodissected pancreatic samples (n = 20).

RESULTS

Quantitative reverse-transcription PCR analysis confirmed that miRNA levels are affected in PDAC FNAs and correlate well with the changes observed in the training set of frozen pancreatic samples. Analysis of the amounts produced for a few specific miRNAs enabled identification of PDAC samples. The combination of miR-196a and miR-217 biomarkers further improved the ability to distinguish between healthy tissue, PDAC, and chronic pancreatitis in the training set (P = 8.2 x 10(-10)), as well as segregate PDAC FNA samples from other FNA samples (P = 1.1 x 10(-5)). Furthermore, we showed that miR-196a production is likely specific to PDAC cells and that its incidence paralleled the progression of PDAC.

CONCLUSIONS

To the best of our knowledge, this study is the first to evaluate the diagnostic potential of miRNAs in a clinical setting and has shown that miRNA analysis of pancreatic FNA biopsy samples can aid in the pathologic evaluation of suspicious cases and may provide a new strategy for improving the diagnosis of pancreatic diseases.

A correlation study on diagnostic endoscopic ultrasound-guided fine-needle aspiration of lymph nodes with histological and clinical diagnoses, the UCLA Medical Center experience

Endoscopic ultrasound guided (EUS) FNA procedure has two aspects, the endoscopic sampling and the FNA interpretation. The two aspects of the procedure are performed in two different disciplines; gastroenterology (EUS) and pathology (FNA). The aim of this study was to evaluate the concordance, sensitivity, specificity, positive predictive (PPV), and negative predictive values (NPV).Sixty-one EUS-FNA procedures of the lymph nodes were analyzed by correlating the FNA results with histological or clinical diagnoses. The lymph nodes were divided in five groups; mediastinal, gastrohepatic, peripancreatic, portal, and perirectal.The study showed a concordance of 92% in mediastinal, 80% in gastrohepatic, 81% in peripancreatic, 95% in portal, and 100% in perirectal lymph nodes with an overall sensitivity of 84%, specificity of 92%, PPV of 88%, and NPV of 89%. In conclusion, EUS-FNA offers an invaluable approach for diagnostic examination of the internal lymph nodes where percutaneous FNA is either difficult or impossible. impossible.