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Notohara K, Nakamura K. Tissue processing of endoscopic ultrasound-guided fine-needle aspiration specimens from solid pancreatic lesions. J Med Ultrason (2001) 2024; 51:261-274. [PMID: 38051462 DOI: 10.1007/s10396-023-01387-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/04/2023] [Indexed: 12/07/2023]
Abstract
Now that tissue cores can be obtained using fine-needle biopsy (FNB) needles, the ways tissues are handled for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are changing. Direct smear, touch smear of core tissues, and centrifugation have been used for cytological examinations, and liquid-based cytology (LBC), which allows immunostaining and genetic tests that use residual samples, is emerging as an alternative. We emphasize that liquid cytology (Cytospin™ cytology and LBC) is still important, because it enables the diagnosis of pancreatic ductal adenocarcinoma (PDAC) when cancerous cells are scarce in specimens. Cell blocks are being replaced by core tissues obtained via FNB needles. Recent reports indicate that rapid on-site evaluation (ROSE) is not necessary when FNB needles are used, and macroscopic on-site evaluation is used to evaluate specimen adequacy. Macroscopic findings of specimens are helpful in the diagnostic workup and for clarifying specimen-handling methods. In addition to the red strings and white cores observed in PDAC, mixed red and white strings, gray tissues, and gelatinous tissues are observed. Gray (necrotic) tissues and gelatinous (mucus) tissues are more suitable than histology for cell block or cytological processing. Tumor cells in neuroendocrine tumors (NETs) are numerous in red strings but cannot be observed macroscopically. ROSE might thus be necessary for lesions that may be NETs. Core tissues can be used for genetic tests, such as those used for KRAS mutations and comprehensive genomic profiling. Cytological materials, including slides and LBC specimens, can also be genetic test materials.
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Affiliation(s)
- Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan.
| | - Kaori Nakamura
- Pathological Laboratory, Division of Medical Technology, Kurashiki Central Hospital, Kurashiki, Japan
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2
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Hikichi T, Hashimoto M, Yanagita T, Kato T, Nakamura J. Endoscopic ultrasound-guided fine-needle aspiration for gastrointestinal subepithelial lesions. J Med Ultrason (2001) 2024; 51:195-207. [PMID: 37490244 DOI: 10.1007/s10396-023-01342-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/15/2023] [Indexed: 07/26/2023]
Abstract
Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the first-choice procedure for obtaining pathological tissue samples from gastrointestinal (GI) subepithelial lesions (SELs). However, its diagnostic accuracy is lower than that for pancreatic masses owing to puncture difficulty and the need for immunostaining for definitive diagnosis. The advent of fine-needle biopsy needles, which have become well known in recent years, improves the diagnostic accuracy of EUS-FNA for GI SELs. The forward-viewing echoendoscope and rapid on-site evaluation (ROSE) have also helped to improve diagnostic accuracy. Furthermore, in facilities where ROSE is not available, endosonographers perform a macroscopic on-site evaluation. With these procedural innovations, EUS-FNA is now performed aggressively even for SELs smaller than 20 mm. The incidence of procedure-related adverse events such as bleeding and infection is low, and thus, EUS-FNA can be safely performed to diagnose SELs.
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Affiliation(s)
- Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Minami Hashimoto
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Takumi Yanagita
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Tsunetaka Kato
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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Iwashita T, Uemura S, Ryuichi T, Senju A, Iwata S, Ohashi Y, Shimizu M. Advances and efficacy in specimen handling for endoscopic ultrasound-guided fine needle aspiration and biopsy: A comprehensive review. DEN OPEN 2024; 4:e350. [PMID: 38495467 PMCID: PMC10941515 DOI: 10.1002/deo2.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 02/19/2024] [Accepted: 02/23/2024] [Indexed: 03/19/2024]
Abstract
Endoscopic ultrasound-guided fine needle aspiration and biopsy have significantly evolved since they offer a minimally invasive approach for obtaining pathological specimens from lesions adjacent to or within the intestine. This paper reviews advancements in endoscopic ultrasound-guided fine needle aspiration and biopsy techniques and devices, emphasizing the importance of handling specimens for diagnostic accuracy. Innovations of fine needle biopsy needles with features like side holes and Franseen shapes have enhanced histological sampling capabilities. Techniques for specimen handling, including rapid on-site evaluation and macroscopic on-site evaluation, play pivotal roles in assessing sample adequacy, thereby influencing diagnostic outcomes. The utility of artificial intelligence in augmenting rapid on-site evaluation and macroscopic on-site evaluation, although still in experimental stages, presents a promising avenue for improving procedural efficiency and diagnostic precision. The choice of specimen handling technique is dependent on various factors including endoscopist preference, procedure objectives, and available resources, underscoring the need for a comprehensive understanding of each method's characteristics to optimize diagnostic efficacy and procedural safety.
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Affiliation(s)
- Takuji Iwashita
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Shinya Uemura
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Tezuka Ryuichi
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Akihiko Senju
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Shota Iwata
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Yosuke Ohashi
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Masahito Shimizu
- First Department of Internal MedicineGifu University HospitalGifuJapan
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4
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Ishigaki K, Nakai Y, Endo G, Kurihara K, Ishida K, Tange S, Fukuda R, Takaoka S, Tokito Y, Suzuki Y, Oyama H, Kanai S, Suzuki T, Sato T, Hakuta R, Saito T, Hamada T, Takahara N, Shinozaki‐Ushiku A, Fujishiro M. Feasibility of comprehensive genomic profiling using endoscopic ultrasound-guided tissue acquisition with a 22-gauge Franseen needle. DEN OPEN 2024; 4:e365. [PMID: 38628502 PMCID: PMC11019146 DOI: 10.1002/deo2.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/25/2024] [Accepted: 03/31/2024] [Indexed: 04/19/2024]
Abstract
Aim Comprehensive genomic profiling (CGP) test for solid tumors is now increasingly utilized in clinical practice, especially in pancreatobiliary cancer, and specimens obtained by endoscopic ultrasound-guided tissue acquisition (EUS-TA) are often submitted for tissue-based CGP test. In this study, we evaluated the feasibility of EUS-TA using a 22-gauge Franseen needle for the CGP test. Methods Consecutive patients with solid tumors who underwent EUS-TA using a 22-gauge Franseen needle, and whose tissue samples were pre-checked for suitability for CGP test, were included in this single-center, retrospective analysis. The success rates of appropriate sample collection for CGP evaluated by pathologists (1st quality control) and CGP test (2nd quality control) were evaluated. In addition, The EUS-TA slides were evaluated for the tissue area and tumor area content, using the image software. Results A total of 50 cases, with 78% of pancreatic cancer, were included in the analysis. A median of 3 passes of EUS-TA were performed with an adverse event rate of 4%. The success rates for 1st and 2nd quality control for CGP tests were 86% and 76%, respectively. The image analyses suggested EUS-TA specimen did not always fulfill CGP test criteria, with 18% of tissue area ≥16 mm2 and 38% of tumor area content ≥20%, even in cases with successful CGP tests. The suction method yielded a significantly larger amount of DNA but without a significant difference in the multivariate analysis. Conclusions The present study demonstrated the feasibility of EUS-TA using a 22-gauge Franseen needle for CGP test.
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Affiliation(s)
- Kazunaga Ishigaki
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
- Department of ChemotherapyThe University of Tokyo HospitalTokyoJapan
| | - Yousuke Nakai
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
- Department of Endoscopy and Endoscopic SurgeryThe University of Tokyo HospitalTokyoJapan
| | - Go Endo
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Kohei Kurihara
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Kota Ishida
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Shuichi Tange
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Rintaro Fukuda
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Shinya Takaoka
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Yurie Tokito
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Yukari Suzuki
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Hiroki Oyama
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Sachiko Kanai
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Tatsunori Suzuki
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Tatsuya Sato
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Ryunosuke Hakuta
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Tomotaka Saito
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Tsuyoshi Hamada
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Naminatsu Takahara
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | | | - Mitsuhiro Fujishiro
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
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5
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Chong CCN, Pittayanon R, Pausawasdi N, Bhatia V, Okuno N, Tang RSY, Cheng TY, Kuo YT, Oh D, Song TJ, Kim TH, Hara K, Chan AWH, Leung HHW, Yang A, Jin Z, Xu C, Lakhtakia S, Wang HP, Seo DW, Teoh AYB, Ho LKY, Kida M. Consensus statements on endoscopic ultrasound-guided tissue acquisition. Guidelines from the Asian Endoscopic Ultrasound Group. Dig Endosc 2024. [PMID: 38433315 DOI: 10.1111/den.14768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 01/23/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES This consensus was developed by the Asian EUS Group (AEG), who aimed to formulate a set of practice guidelines addressing various aspects of endoscopic ultrasound-guided tissue acquisition (EUS-TA). METHODS The AEG initiated the development of consensus statements and formed an expert panel comprising surgeons, gastroenterologists, and pathologists. Three online consensus meetings were conducted to consolidate the statements and votes. The statements were presented and discussed in the first two consensus meetings and revised according to comments. Final voting was conducted at a third consensus meeting. The Grading of Recommendations, Assessment, Development, and Evaluation system was adopted to define the strength of the recommendations and quality of evidence. RESULTS A total of 20 clinical questions and statements regarding EUS-TA were formulated. The committee recommended that fine-needle biopsy (FNB) needles be preferred over conventional fine-needle aspiration (FNA) needles for EUS-TA of subepithelial lesions. For solid pancreatic masses, rapid on-site evaluation is not routinely recommended when FNB needles are used. For dedicated FNB needles, fork-tip and Franseen-tip needles have essentially equivalent performance. CONCLUSION This consensus provides guidance for EUS-TA, thereby enhancing the quality of EUS-TA.
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Affiliation(s)
- Charing Ching-Ning Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Siriraj Endoscopy Center, Mahidol University, Bangkok, Thailand
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center, Aichi, Japan
| | - Raymond Shing-Yan Tang
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Institute of Digestive Diseases, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Tsu-Yao Cheng
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Ting Kuo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Dongwook Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae Jun Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae Hyeon Kim
- Department of Internal Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center, Aichi, Japan
| | - Anthony Wing-Hung Chan
- Department of Anatomical and Cellular Pathology, Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Howard Ho Wai Leung
- Department of Anatomical and Cellular Pathology, Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Aiming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Can Xu
- Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Hsiu-Po Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Dong-Wan Seo
- Department of Internal Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Anthony Yuen-Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lawrence Khek-Yu Ho
- Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Hospital, National University Health System, Singapore City, Singapore
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University School of Medicine, Kanagawa, Japan
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6
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Tanisaka Y, Mizuide M, Fujita A, Jinushi R, Shiomi R, Shin T, Sugimoto K, Tashima T, Mashimo Y, Ryozawa S. 22-gauge Co-Cr versus stainless-steel Franseen needles for endoscopic ultrasound-guided tissue acquisition in patients with solid pancreatic lesions. Clin Endosc 2024; 57:237-245. [PMID: 38273220 PMCID: PMC10984738 DOI: 10.5946/ce.2023.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/21/2023] [Accepted: 03/29/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND/AIMS Endoscopic ultrasound-guided tissue acquisition (EUS-TA) using Franseen needles is reportedly useful for its high diagnostic yield. This study compared the diagnostic yield and puncturing ability of EUS-TA using 22-gauge cobalt-chromium (CO-Cr) needles with those of stainless-steel Franseen needles in patients with solid pancreatic lesions. METHODS Outcomes were compared between the 22-gauge Co-Cr Franseen needle (December 2019 to November 2020; group C) and stainless-steel needle (November 2020 to May 2022; group S). RESULTS A total of 155 patients (group C, 75; group S, 80) were eligible. The diagnostic accuracy was 92.0% in group C and 96.3% in group S with no significant intergroup differences (p=0.32). The rate of change in the operator (from training fellows to experts) was 20.0% (15/75) in group C and 7.5% (6/80) in group S. Stainless-steel Franseen needles showed less inter-operator difference than Co-Cr needles (p=0.03). CONCLUSION Both Co-Cr and stainless-steel Franseen needles showed high diagnostic ability. Stainless-steel Franseen needles are soft and flexible; therefore, the range of puncture angles can be widely adjusted, making them suitable for training fellows to complete the procedure.
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Affiliation(s)
- Yuki Tanisaka
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Masafumi Mizuide
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Akashi Fujita
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Ryuhei Jinushi
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Rie Shiomi
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Takahiro Shin
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Kei Sugimoto
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tomoaki Tashima
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yumi Mashimo
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
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de Jong M, van Delft F, Roozen C, van Geenen EJ, Bisseling T, Siersema P, Bruno M. Nonsteroidal anti-inflammatory drugs before endoscopic ultrasound guided tissue acquisition to reduce the incidence of post procedural pancreatitis. World J Gastroenterol 2024; 30:811-816. [PMID: 38516233 PMCID: PMC10950633 DOI: 10.3748/wjg.v30.i8.811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/22/2023] [Accepted: 01/22/2024] [Indexed: 02/26/2024] Open
Abstract
Endoscopic ultrasound (EUS) with fine needle aspiration or fine needle biopsy is the gold standard for sampling tissue to diagnose pancreatic cancer and autoimmune pancreatitis or to analyze cyst fluid. The most common reported adverse event of fine needle aspiration and/or fine needle biopsy is acute pancreatitis, which is likely induced by the same pathophysiological mechanisms as after endoscopic retrograde cholangiopancreatography (ERCP). According to the current European Society of Gastrointestinal Endoscopy guideline, nonsteroidal anti-inflammatory drugs are administered prior to ERCP as a scientifically proven treatment to reduce post-ERCP pancreatitis incidence rate. A single suppository of diclofenac or indomethacin prior to EUS guided tissue acquisition (TA) is harmless in healthy adults. Since it is associated with low costs and, most important, may prevent a dreadsome complication, we strongly recommend the administration of 100 mg diclofenac rectally prior to EUS-TA. We will explain this recommendation in more detail in this review as well as the risk and pathophysiology of post-EUS TA pancreatitis.
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Affiliation(s)
- Mike de Jong
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen 6525 GA, Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen 6525 GA, Netherlands
| | - Christine Roozen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen 6525 GA, Netherlands
| | - Erwin-Jan van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen 6525 GA, Netherlands
| | - Tanya Bisseling
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen 6525 GA, Netherlands
| | - Peter Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen 6525 GA, Netherlands
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam 3015 GD, Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam 3015 GD, Netherlands
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Conti Bellocchi MC, Bernuzzi M, Brillo A, Bernardoni L, Amodio A, De Pretis N, Frulloni L, Gabbrielli A, Crinò SF. EUS-FNA versus EUS-FNB in Pancreatic Solid Lesions ≤ 15 mm. Diagnostics (Basel) 2024; 14:427. [PMID: 38396466 PMCID: PMC10888305 DOI: 10.3390/diagnostics14040427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
A small tumor size may impact the diagnostic performance of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for diagnosing solid pancreatic lesions (SPLs). We aimed to compare the diagnostic yield of EUS-guided fine-needle aspiration (FNA) and biopsy (FNB) in SPLs with a diameter ≤ 15 mm. Consecutive patients who underwent EUS-TA for SPLs ≤ 15 mm between January 2015 and December 2022 in a tertiary referral center were retrospectively evaluated. The primary endpoint was diagnostic accuracy. The final diagnosis was based on surgical pathology or disease evolution after a minimum follow-up of 6 months. Inadequate samples were all considered false negatives for the study. Secondary outcomes included sample adequacy, factors impacting accuracy, and safety. We included 368 patients (52.4% male; mean age: 60.2 years) who underwent FNA in 72 cases and FNB in 296. The mean size of SPLs was 11.9 ± 2.6 mm. More than three passes were performed in 5.7% and 61.5% of patients in the FNB and FNA groups, respectively (p < 0.0001). FNB outperformed FNA in terms of diagnostic accuracy (89.8% vs. 79.1%, p = 0.013) and sample adequacy (95.9% vs. 86.1%, p < 0.001). On multivariate analysis, using FNA (OR: 2.10, 95% CI: 1.07-4.48) and a final diagnosis (OR: 3.56, 95% CI: 1.82-6.94) of benign conditions negatively impacted accuracy. Overall, the adverse event rate was 0.8%, including one pancreatitis in the FNA group and one pancreatitis and one bleeding in the FNB group, all mild and conservatively managed. EUS-TA for SPLs ≤ 15 mm has a high diagnostic yield and safety. This study suggests the superiority of FNB over FNA, with better performance even with fewer passes performed.
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Affiliation(s)
- Maria Cristina Conti Bellocchi
- Diagnostic and Interventional Endoscopy of the Pancreas, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (L.B.); (S.F.C.)
| | - Micol Bernuzzi
- Department of Medicine, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy (A.B.); (A.A.); (N.D.P.); (L.F.)
| | - Alessandro Brillo
- Department of Medicine, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy (A.B.); (A.A.); (N.D.P.); (L.F.)
| | - Laura Bernardoni
- Diagnostic and Interventional Endoscopy of the Pancreas, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (L.B.); (S.F.C.)
| | - Antonio Amodio
- Department of Medicine, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy (A.B.); (A.A.); (N.D.P.); (L.F.)
| | - Nicolò De Pretis
- Department of Medicine, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy (A.B.); (A.A.); (N.D.P.); (L.F.)
| | - Luca Frulloni
- Department of Medicine, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy (A.B.); (A.A.); (N.D.P.); (L.F.)
| | - Armando Gabbrielli
- Diagnostic and Interventional Endoscopy of the Pancreas, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (L.B.); (S.F.C.)
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of the Pancreas, Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (L.B.); (S.F.C.)
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9
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Nakatani S, Okuwaki K, Watanabe M, Imaizumi H, Iwai T, Matsumoto T, Hasegawa R, Masutani H, Kurosu T, Tamaki A, Ishizaki J, Ishizaki A, Kida M, Kusano C. Stereomicroscopic on-site evaluation in endoscopic ultrasound-guided tissue acquisition of upper gastrointestinal subepithelial lesions. Clin Endosc 2024; 57:89-95. [PMID: 37070203 PMCID: PMC10834295 DOI: 10.5946/ce.2022.288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND/AIMS In stereomicroscopic sample isolation processing, the cutoff value (≥4 mm) of stereomicroscopically visible white cores indicates high diagnostic sensitivity. We aimed to evaluate endoscopic ultrasound-guided tissue acquisition (EUS-TA) using a simplified stereomicroscopic on-site evaluation of upper gastrointestinal subepithelial lesions (SELs). METHODS In this multicenter prospective trial, we performed EUS-TA using a 22-gauge Franseen needle in 34 participants with SELs derived from the upper gastrointestinal muscularis propria, requiring pathological diagnosis. The presence of stereomicroscopically visible white core (SVWC) in each specimen was assessed using stereomicroscopic on-site evaluation. The primary outcome was EUS-TA's diagnostic sensitivity with stereomicroscopic on-site evaluation based on the SVWC cutoff value (≥4 mm) for malignant upper gastrointestinal SELs. RESULTS The total number of punctures was 68; 61 specimens (89.7%) contained stereomicroscopically visible white cores ≥4 mm in size. The final diagnoses were gastrointestinal stromal tumor, leiomyoma, and schwannoma in 76.5%, 14.7%, and 8.8% of the cases, respectively. The sensitivity of EUS-TA with stereomicroscopic on-site evaluation based on the SVWC cutoff value for malignant SELs was 100%. The per-lesion accuracy of histological diagnosis reached the highest level (100%) at the second puncture. CONCLUSION Stereomicroscopic on-site evaluation showed high diagnostic sensitivity and could be a new method for diagnosing upper gastrointestinal SELs using EUS-TA.
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Affiliation(s)
- Seigo Nakatani
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
- Department of Gastroenterology, Isehara Kyodo Hospital, Isehara, Japan
| | - Kosuke Okuwaki
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masafumi Watanabe
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroshi Imaizumi
- Department of Gastroenterology, Japan Community Health Care Organization Sagamino Hospital, Sagamihara, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takaaki Matsumoto
- Department of Gastroenterology, Isehara Kyodo Hospital, Isehara, Japan
| | - Rikiya Hasegawa
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hironori Masutani
- Department of Gastroenterology, Japan Community Health Care Organization Sagamino Hospital, Sagamihara, Japan
| | - Takahiro Kurosu
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Akihiro Tamaki
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Junro Ishizaki
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ayana Ishizaki
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Chika Kusano
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
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10
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Cho YK. What method can we choose if rapid on-site evaluation is not available for the endoscopic ultrasound-guided tissue acquisition of upper gastrointestinal subepithelial lesions? Clin Endosc 2024; 57:53-55. [PMID: 38302249 PMCID: PMC10834289 DOI: 10.5946/ce.2023.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 02/03/2024] Open
Affiliation(s)
- Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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11
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Nakamura K, Notohara K, Nishizaki R, Ishida E, Sato M, Kodera A, Itakura J, Mizuno M. Macroscopic qualitative evaluation of solid pancreatic lesion specimens from endoscopic ultrasound-guided fine needle aspiration/biopsies. Pancreatology 2023; 23:1028-1035. [PMID: 37839924 DOI: 10.1016/j.pan.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/30/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES To pathologically clarify the macroscopic features of endoscopic ultrasound-guided fine needle aspiration/biopsy (EUS-FNA/B) specimens in representative pancreatic diseases and establish tissue-handling standards based on the macroscopic findings. METHODS We gathered EUS-FNA/B specimens of cases at our institution with the final diagnoses of pancreatic ductal adenocarcinoma (PDAC, n = 172), neuroendocrine tumor (NET, n = 19), and chronic inflammatory lesion (CIL, n = 24) including autoimmune pancreatitis. We classified the specimens' macroscopic features in five categories (red strings, mixed-red-and-white strings, white cores, gray tissues, gelatinous tissues) and compared the specimens' features on cytological and histological slides. RESULTS All five macroscopic categories were observed in variable combinations in the PDACs; red strings and white cores predominated in the NETs and CILs. White cores represented neoplastic (PDAC, NET) or lesion (CIL) tissues. Mixed-red-and-white strings were unique to PDACs and contained cancerous cells. Neoplastic cells were numerous in red strings in NETs but not the other groups. Gray and gelatinous tissues represented necrosis and mucin, respectively, and the former were almost exclusively observed in PDACs. Red strings, mixed-red-and-white strings, and white cores were suitable for histological examination, whereas gray and gelatinous tissues were suitable for cytological examination. The white cores, mixed-red-and-white strings, and gelatinous tissues may be composed of non-neoplastic tissues such as contaminated gastrointestinal epithelium. In seven PDACs, although white cores were obtained, a histological diagnosis was not established. CONCLUSIONS Macroscopic evaluations of EUS-FNA/B can enable the identification of specimen components and a possible diagnosis. They also contribute to the selection of the optimal tissue-handling methods.
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Affiliation(s)
- Kaori Nakamura
- Pathological Laboratory, Division of Medical Technology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Ryoji Nishizaki
- Pathological Laboratory, Division of Medical Technology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Etsuji Ishida
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Midori Sato
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Akemi Kodera
- Pathological Laboratory, Division of Medical Technology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Junya Itakura
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Motowo Mizuno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Kurashiki, Japan
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12
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Milluzzo SM, Olivari N, Rossi G, Bianchi D, Liserre B, Graffeo M, Lovera M, Correale L, Hassan C, Spada C. Rapid on-site evaluation improves the sensitivity of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions irrespective of technique: A single-centre experience. Cytopathology 2023; 34:318-324. [PMID: 37186418 DOI: 10.1111/cyt.13237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 02/20/2023] [Accepted: 03/30/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the first-line technique for the sampling of pancreatic lesions. Many factors can influence the diagnostic performance of this procedure, including the use of rapid on-site evaluation (ROSE). The primary aim of this study was to compare the adequacy, diagnostic yield, accuracy, sensitivity and specificity of EUS-FNA for solid pancreatic lesions before and after the introduction of ROSE. METHODS This retrospective single-centre study evaluated all consecutive patients who underwent EUS-FNA for suspicious, solid pancreatic masses from April 2012 to March 2015. We compared the findings of EUS-FNA procedures performed during the first and second years following the adoption of ROSE ("ROSE1" and "ROSE2", respectively) to those performed the year before ROSE introduction (the "pre-ROSE" group). RESULTS Ninety-one consecutive patients with a total of 93 pancreatic lesions were enrolled. For the pre-ROSE, ROSE1 and ROSE2 groups, the adequacy rates were 96.2%, 96.6% and 100%, the diagnostic yield values were 76.9%, 89.7% and 92.1% and accuracy values were 69.2%, 86.2% and 89.5% (p = NS). Sensitivity for malignancy improved from 63.7% in the pre-ROSE group to 91.7% and 91.2% in the post-ROSE groups (p < 0.05). Specificity for malignancy was 100% in all groups. CONCLUSIONS ROSE can improve the diagnostic performance of EUS-FNA for solid pancreatic lesions, although only sensitivity reached statistical significance.
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Affiliation(s)
| | - Nicola Olivari
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy
| | - Giulio Rossi
- Pathology Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Denise Bianchi
- Pathology Unit, Fondazione Poliambulanza, Brescia, Italy
| | | | - Massimo Graffeo
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy
| | - Mauro Lovera
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy
| | - Loredana Correale
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Cesare Hassan
- Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Cristiano Spada
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy
- Department of Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS -Università Cattolica del Sacro Cuore, Rome, Italy
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13
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Guan C, Wu M, Ye J, Liu Z, Mao Z, Lu C, Zhang J. Macroscopic on‑site quality evaluation of biopsy specimens to improve the diagnostic accuracy of endoscopic ultrasound‑guided fine needle aspiration using a 22‑gauge needle for solid lesions: A single‑center retrospective study. Exp Ther Med 2023; 26:338. [PMID: 37383379 PMCID: PMC10294598 DOI: 10.3892/etm.2023.12037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/03/2023] [Indexed: 06/30/2023] Open
Abstract
The present study aimed to evaluate the clinical value of macroscopic on-site evaluation (MOSE) of solid masses by endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) using a standard 22-gauge needle and to explore the cut-off length of macroscopic visible core (MVC) required to obtain an accurate histopathological diagnosis. In total, 119 patients who satisfied the inclusion and exclusion criteria and underwent EUS-FNA were divided into conventional FNA and FNA combined with MOSE groups. In the MOSE group, the presence of MVC was examined and its total length measured, after which the pathological results of FNA were compared with the final diagnosis. The diagnostic sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of FNA in the two groups were calculated and the effect of MOSE on the FNA result was analyzed. The MOSE group had a higher diagnostic sensitivity (75.0% vs. 89.8%; P=0.038) and accuracy (74.5% vs. 90.6%; P=0.026). MVC was observed in 98.4% (63/64) of patients in the MOSE group. The median length of MVC was 15 mm. The optimal cut-off length of MVC for obtaining an accurate histological diagnosis was 13 mm, with a sensitivity of 90.2%. No statistically significant significance was observed in the specificity, PPV and NPV between the groups. Thus, MOSE helps to improve the diagnostic ability of FNA for solid masses and may be a useful alternative to assess the adequacy of puncture specimens in units where rapid on-site evaluation cannot be performed.
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Affiliation(s)
- Chengqi Guan
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Mengyu Wu
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
- Department of Gastroenterology, Maanshan People's Hospital, Manashan, Anhui 243000, P.R. China
| | - Jingxin Ye
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Zhaoxiu Liu
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Zhenbiao Mao
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Cuihua Lu
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Jianfeng Zhang
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
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14
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Lin R, Sheng LP, Han CQ, Guo XW, Wei RG, Ling X, Ding Z. Application of artificial intelligence to digital-rapid on-site cytopathology evaluation during endoscopic ultrasound-guided fine needle aspiration: A proof-of-concept study. J Gastroenterol Hepatol 2023; 38:883-887. [PMID: 36409289 DOI: 10.1111/jgh.16073] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/06/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND During endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), cytopathology with rapid on-site evaluation (ROSE) can improve diagnostic yield and accuracy. However, ROSE is unavailable in most Asian and European institutions because of the shortage of cytopathologists. Therefore, developing computer-assisted diagnostic tools to replace manual ROSE is crucial. Herein, we reported the validation of an artificial intelligence (AI)-based model (ROSE-AI model) to substitute manual ROSE during EUS-FNA. METHODS A total of 467 digitized images from Diff-Quik (D&F)-stained EUS-FNA slides were divided into training (3642 tiles from 367 images) and internal validation (916 tiles from 100 images) datasets. The ROSE-AI model was trained and validated using training and internal validation datasets, respectively. The specificity was emphasized while developing the model. Then, we evaluated the AI model on a 693-image external dataset. We assessed the performance of the AI model to detect cancer cells (CCs) regarding the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS The ROSE-AI model achieved an accuracy of 83.4% in the internal validation dataset and 88.7% in the external test dataset. The sensitivity and PPV were 79.1% and 71.7% in internal validation dataset and 78.0% and 60.7% in external test dataset, respectively. CONCLUSION We provided a proof of concept that AI can be used to replace manual ROSE during EUS-FNA. The ROSE-AI model can address the shortage of cytopathologists and make ROSE available in more institutes.
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Affiliation(s)
- Rong Lin
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Li-Ping Sheng
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Gastroenterology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Chao-Qun Han
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xian-Wen Guo
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Rong-Gan Wei
- Department of Pathology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, Guangxi Zhuang Autonomous Region, China
| | - Xin Ling
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhen Ding
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
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15
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Keswani RN, Duloy A, Nieto JM, Panganamamula K, Murad MH, Bazerbachi F, Shaukat A, Elmunzer BJ, Day LW. Interventions to improve the performance of ERCP and EUS quality indicators. Gastrointest Endosc 2023; 97:825-838. [PMID: 36967249 DOI: 10.1016/j.gie.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/11/2022] [Indexed: 04/21/2023]
Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna Duloy
- Division of Gastroenterology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jose M Nieto
- Digestive Disease Consultants, Jacksonville, Florida, USA
| | - Kashyap Panganamamula
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, Minnesota, USA
| | - Aasma Shaukat
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, New York, New York, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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16
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Comparison between Target Sample Check Illuminator and White Light Observation in Discriminating the Presence of Target Specimen for Endoscopic Ultrasound-Guided Fine Needle Aspiration Sample. J Clin Med 2023; 12:jcm12062139. [PMID: 36983143 PMCID: PMC10051683 DOI: 10.3390/jcm12062139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/11/2023] Open
Abstract
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an essential endoscopic tissue sampling method for diagnosing pancreatobiliary diseases; however, determining the presence of target specimens mixed in the blood by conventional observation is challenging due to the small size of the obtained sample. This study investigated the usefulness of a target sample check illuminator (TSCI) that emits a specific wavelength of light to determine the presence of target specimens. Twenty-seven patients who underwent EUS-FNA at our hospital were included. Conventional white light observation was performed for the collected samples, followed by TSCI; six people evaluated the presence of the target specimen on a 5-point scale. The target specimen discrimination score using TSCI (median: 5) was significantly higher than that using conventional white light observation (median: 1) (p < 0.001). No significant difference was observed in the discrimination score between the evaluator (novice vs. expert, p = 0.162) and puncture needle (22G vs. 25G, p = 0.196). The discriminability of TSCI in the samples obtained using EUS-FNA was significantly higher than that of conventional observation. TSCI does not depend on the evaluator or puncture needle for the identification of the target specimen; hence, it can provide a good pathological specimen and may contribute to the improvement of the diagnostic ability.
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17
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Comparison between three types of needles for endoscopic ultrasound-guided tissue acquisition of pancreatic solid masses: a multicenter observational study. Sci Rep 2023; 13:3677. [PMID: 36871105 PMCID: PMC9985625 DOI: 10.1038/s41598-023-30920-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
It is debatable which needle has clear superiority of diagnostic performance in endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) of solid pancreatic masses. This study aimed to compare the performance of three needles and determine the variables that affect diagnostic accuracy. From March 2014 to May 2020, 746 patients with solid pancreatic masses who underwent EUS-FNB using three types of needles (Franseen needle, Menghini-tip needle, and Reverse-bevel needle) were retrospectively reviewed. Multivariate analysis using a logistic regression model was used to identify factors related to diagnostic accuracy. There were significant differences between the groups regarding the procurement rate of the histologic and optimal quality cores (Franseen vs. Menghini-tip vs. Reverse-bevel: 98.0% [192/196] vs. 85.8% [97/113] vs. 91.9% [331/360], P < 0.001 and 95.4% [187/196] vs. 65.5% [74/113] vs. 88.3% [318/360], P < 0.001, respectively). The sensitivity and accuracy using histologic samples were 95.03% and 95.92% for Franseen, 82.67% and 88.50% for Menghini-tip, and 82.61% and 85.56% for Reverse-bevel needles, respectively. In direct comparison between the needles using histologic samples, the Franseen needle showed significantly superior accuracy than the Menghini-tip (P = 0.018) and Reverse-bevel needles (P < 0.001). Multivariate analysis indicated that tumor size ≥ 2 cm (odds ratio [OR] 5.36, 95% confidence interval [CI] 3.40-8.47, P < 0.001) and fanning technique (OR 1.70, 95% CI 1.00-2.86, P = 0.047) were significantly associated with an accurate diagnosis. EUS-FNB using the Franseen needle enables the acquisition of a larger and more adequate histologic core tissue and achieves an accurate histological diagnosis when using the fanning technique.
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18
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ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. Am J Gastroenterol 2023; 118:405-426. [PMID: 36863037 DOI: 10.14309/ajg.0000000000002190] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/13/2022] [Indexed: 03/04/2023]
Abstract
A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.
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19
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Mohan BP, Madhu D, Reddy N, Chara BS, Khan SR, Garg G, Kassab LL, Muthusamy AK, Singh A, Chandan S, Facciorusso A, Mangiavillano B, Repici A, Adler DG. Diagnostic accuracy of EUS-guided fine-needle biopsy sampling by macroscopic on-site evaluation: a systematic review and meta-analysis. Gastrointest Endosc 2022; 96:909-917.e11. [PMID: 35932815 DOI: 10.1016/j.gie.2022.07.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Assessment of EUS-guided fine-needle tissue acquisition by macroscopic on-site evaluation (MOSE) is gathering attention. Studies report good diagnostic parameters with MOSE; however, the overall data are limited. We conducted this systematic review and meta-analysis to report on the pooled diagnostic assessment parameters of EUS-guided tissue acquisition by MOSE using fine-needle biopsy sampling (FNB). METHODS Multiple databases were searched (from inception to December 2021), and studies that reported on the diagnostic assessment of EUS-guided tissue acquisition by MOSE were selected. Pooled diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were calculated by standard meta-analysis methods following the random-effects model. Heterogeneity was assessed by I2 statistics. RESULTS Fourteen studies were included in the analysis, and 1508 lesions were biopsy sampled in 1489 patients undergoing EUS-guided tissue acquisition. MOSE definition included a visible core of tissue with opacity and "wormlike" features of adequate size and length (≥4 mm). The pooled accuracy of FNA and/or FNB specimens in yielding a pathologic diagnosis by MOSE was 91.3% (95% confidence interval [CI], 88.6-93.3; I2 = 66%), pooled sensitivity was 91.5% (95% CI, 88.6-93.6; I2 = 66%), pooled specificity was 98.9% (95% CI, 96.6-99.7; I2 = 80%), pooled positive predictive value was 98.8% (95% CI, 97.4-99.5; I2 = 33%), and pooled negative predictive value was 55.5% (95% CI, 46.9-63.9; I2 = 95%). Subgroup analyses by newer-generation FNB needles demonstrated similar pooled rates, with minimal adverse events (2.5%; 95% CI, 1.5-3.9; I2 = 21%). CONCLUSIONS Excellent pooled diagnostic accuracy parameters were demonstrated in EUS-guided tissue acquisition by FNB using the MOSE method.
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Affiliation(s)
- Babu P Mohan
- Department of Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, Utah, USA
| | - Deepak Madhu
- Department of Gastroenterology, Caritas Hospital, Kottayam, Kerala, India
| | - Nitin Reddy
- Department of Internal Medicine, PSG Institute of Medical Science, Coimbatore, Tamil Nadu, India
| | - Beatriz Sordi Chara
- Department of Medicine, University of Joinville, Joinville, Santa Catarina, Brazil
| | - Shahab R Khan
- Department of Internal Medicine, Brigham's & Children Hospital, Harvard University, Boston, Massachusetts, USA
| | - Gauri Garg
- Department of Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, Utah, USA
| | - Lena L Kassab
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Arun Kumar Muthusamy
- Department of Gastroenterology, Cedar Valley Medical Specialists, Waterloo, Iowa, USA
| | - Achintya Singh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Saurabh Chandan
- Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA
| | | | - Benedetto Mangiavillano
- Department of Gastroenterology, Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Humanitas University, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center, Milan, Italy
| | - Douglas G Adler
- Department of Gastroenterology, Center for Advanced Therapeutic Endoscopy, Denver, Colorado, USA
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20
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Facciorusso A, Gkolfakis P, Tziatzios G, Ramai D, Papanikolaou IS, Triantafyllou K, Lisotti A, Fusaroli P, Mangiavillano B, Chandan S, Mohan BP, Crinò SF. Comparison between EUS-guided fine-needle biopsy with or without rapid on-site evaluation for tissue sampling of solid pancreatic lesions: A systematic review and meta-analysis. Endosc Ultrasound 2022; 11:458-465. [PMID: 36537383 PMCID: PMC9921973 DOI: 10.4103/eus-d-22-00026] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The benefit of rapid on-site evaluation (ROSE) on the diagnostic accuracy of EUS-guided fine-needle biopsy (EUS-FNB) in patients with pancreatic masses is still matter of debate. Aim of our meta-analysis is to compare the diagnostic outcomes of these two tissue acquisition strategies. Computerized bibliographic search on the main databases was performed through December 2021 and 8 studies were identified (2147 patients). The primary outcome was sample adequacy. Pooled effects were calculated using a random-effects model by means of DerSimonian and Laird test and summary estimates were expressed in terms of odds ratio (OR) or mean difference and 95% confidence Interval (CI). There was no difference in terms of baseline variables between the two groups. Pooled sample adequacy was 95.5% (95% CI 93.2%-97.8%) and 88.9% (83.4%-94.5%) in the EUS-FNB + ROSE and EUS-FNB groups, respectively (OR = 2.05, 0.94-4.49; P = 0.07). Diagnostic accuracy resulted significantly superior in the EUS-FNB + ROSE group (OR = 2.49, 1.08-5.73; P = 0.03), particularly when the analysis was restricted to reverse bevel needle (OR = 3.24, 1.19-8.82, P = 0.02), whereas no statistical difference was observed when newer end-cutting needles were used (OR = 0.71, 0.29-3.61, P = 0.56). Diagnostic sensitivity was not significantly different between the two groups (OR = 1.94, 0.84-4.49; P = 0.12), whereas pooled specificity was 100% with both approaches. The number of needle passes needed to obtain diagnostic samples was not significantly different (mean difference 0.07,-0.22 to 0.37; P = 0.62). Our meta-analysis stands for a non-superiority of EUS-FNB + ROSE over EUS-FNB with newer end-cutting needles, whereas ROSE could have still a role when reverse bevel needles are used.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy,Address for correspondence Dr. Antonio Facciorusso, Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia. AOU Ospedali Riuniti, Viale Pinto, 1, 71100 Foggia, Italy. E-mail:
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, Athens, Greece
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT, USA
| | - Ioannis S. Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, Athens, Greece
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
| | | | - Saurabh Chandan
- Gastroenterology Unit, CHI Health Creighton University Medical Center, Omaha, NE, USA
| | - Babu P Mohan
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT, USA
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
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21
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Ramai D, Adler DG. EUS-FNA for solid lesions: An idea whose time has passed? Endosc Ultrasound 2022; 11:429-431. [PMID: 36537382 PMCID: PMC9921979 DOI: 10.4103/eus-d-22-00121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Daryl Ramai
- Department of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Porter Adventist Hospital/PEAK Gastroenterology, Denver, Colorado, USA,Address for correspondence Dr. Douglas G Adler, Center for Advanced Therapeutic Endoscopy, Porter Adventist Hospital, Centura Health Denver, Colorado, USA. E-mail:
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22
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Yeung MCF, Shek TWH. KRAS Mutation Testing on Endoscopic Ultrasound-Guided Fine-Needle Aspiration Samples Improves the Diagnostic Accuracy of Pancreatic Cancer. Pancreas 2022; 51:1365-1371. [PMID: 37099780 DOI: 10.1097/mpa.0000000000002193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology was one of the investigations for pancreatic masses. While the specificity approached 100%, its sensitivity remained low because of high rate of indeterminate and false-negative results. Meanwhile, KRAS gene was frequently mutated in up to 90% of pancreatic ductal adenocarcinoma and its precursor lesions. This study aimed to determine whether KRAS mutation analysis could improve the diagnostic sensitivity in EUS-FNA samples for pancreatic adenocarcinoma. METHODS The EUS-FNA samples from patients with a pancreatic mass obtained between January 2016 and December 2017 were reviewed retrospectively. The cytology results were classified as malignant, suspicious for malignancy, atypical, negative for malignancy, and nondiagnostic. KRAS mutation testing was performed using polymerase chain reaction followed by Sanger sequencing. RESULTS A total of 126 EUS-FNA specimens were reviewed. The overall sensitivity and specificity by cytology alone were 29% and 100%, respectively. When KRAS mutation testing was performed in cases with indeterminate and negative cytology, the sensitivity increased to 74.2%, and the specificity remained at 100%. CONCLUSIONS KRAS mutation analysis, especially when performed in cytologically indeterminate cases, improves the diagnostic accuracy for pancreatic ductal adenocarcinoma. This may reduce the need to repeat invasive EUS-FNA for diagnosis.
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Affiliation(s)
- Maximus C F Yeung
- From the Department of Pathology, Queen Mary Hospital and The University of Hong Kong, Hong Kong
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23
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Technical Performance, Overall Accuracy and Complications of EUS-Guided Interventional Procedures: A Dynamic Landscape. Diagnostics (Basel) 2022; 12:diagnostics12071641. [PMID: 35885546 PMCID: PMC9324484 DOI: 10.3390/diagnostics12071641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/01/2022] [Accepted: 07/03/2022] [Indexed: 11/16/2022] Open
Abstract
Endoscopic ultrasound (EUS) gained wide acceptance as the diagnostic and minimally invasive therapeutic approach for intra-luminal and extraluminal gastrointestinal, as well as various non-gastrointestinal lesions. Since its introduction, EUS has undergone substantial technological advances. This multi-centric study is a retrospective analysis of a prospectively maintained database of patients who underwent EUS for the evaluation of lesions located within the gastrointestinal tract and the proximal organs. It aimed to extensively assess in dynamic the dual-center EUS experience over the course of the past 20 years. Hence, we performed a population study and an overall assessment of the EUS procedures. The performance of EUS-FNA/FNB in diagnosing pancreatic neoplasms was evaluated. We also investigated the contribution of associating contrast-enhanced ultrasound imaging (CE-EUS) with EUS-FNA/FNB for differentiating solid pancreatic lesions or cystic pancreatic lesions. A total of 2935 patients undergoing EUS between 2002–2021 were included, out of which 1880 were diagnostic EUS and 1052 EUS-FNA/FNB (80% FNA and 20% FNB). Therapeutic procedures performed included endoscopic transmural drainage of pancreatic fluid collections, celiac plexus block and neurolysis, while diagnostic EUS-like CE-EUS (20%) and real-time elastography (12%) were also conducted. Most complications occurred during the first 7 days after EUS-FNA/FNB or pseudocyst drainage. EUS and the additional tools have high technical success rates and low rates of complications. The EUS methods are safe, cost effective and indispensable for the diagnostic or therapeutic management in gastroenterological everyday practice.
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24
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Gkolfakis P, Crinò SF, Tziatzios G, Ramai D, Papaefthymiou A, Papanikolaou IS, Triantafyllou K, Arvanitakis M, Lisotti A, Fusaroli P, Mangiavillano B, Carrara S, Repici A, Hassan C, Facciorusso A. Comparative diagnostic performance of end-cutting fine-needle biopsy needles for EUS tissue sampling of solid pancreatic masses: a network meta-analysis. Gastrointest Endosc 2022; 95:1067-1077.e15. [PMID: 35124072 DOI: 10.1016/j.gie.2022.01.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/21/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Evidence is limited on the comparative diagnostic performance of newer end-cutting fine-needle biopsy (FNB) needles for tissue sampling of pancreatic masses. We performed a systematic review with network meta-analysis to compare the diagnostic accuracy of available FNB needles for sampling of solid pancreatic lesions. METHODS A systematic literature review (Medline and Cochrane Database) was conducted for studies evaluating the accuracy of newer FNB needles in adults undergoing EUS-guided sampling of solid pancreatic masses. The primary outcome was diagnostic accuracy. Secondary outcomes were sample adequacy, diagnostic sensitivity, specificity, and adverse event rate. We performed pairwise and network meta-analyses and appraised the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation methodology. RESULTS Overall, 16 RCTs (1934 patients) were identified. On network meta-analysis, Franseen needles (Acquire; Boston Scientific, Marlborough, Mass, USA) significantly outperformed reverse-bevel needles (risk ratio [RR], 1.21 [95% confidence interval {CI}, 1.05-1.40] for accuracy and 1.31 [95% CI, 1.05-1.22] for adequacy) and FNA needles (RR, 1.21 [95% CI, 1.01-1.25] for accuracy and 1.07 [95% CI, 1.02-1.13] for adequacy). Likewise, the Fork-tip needle (SharkCore; Medtronic, Dublin, Ireland) was significantly superior to the reverse-bevel needle (RR, 1.17 [95% CI, 1.03-1.33] for accuracy and 1.09 [95% CI, 1.02-1.16] for adequacy) and to the FNA needle (RR, 1.09 [95% CI, 1.01-1.19] for accuracy and 1.03 [95% CI, 1.01-1.07] for adequacy). Other comparisons did not achieve statistical significance. As a consequence, Franseen (surface under the cumulative ranking score, .89 for accuracy and .94 for adequacy) and Fork-tip needles (surface under the cumulative ranking score, .76 for accuracy and .73 for adequacy) ranked as the 2 highest-performing FNB needles. When considering different needle sizes, 25-gauge Franseen and 25-gauge Fork-tip needles were not superior to 22-gauge reverse-bevel needles (RR, 1.18 [95% CI, .96-1.46] and 1.04 [95% CI, .62-1.52]). None of the tested needles was significantly superior to the other FNB devices or to FNA needles when rapid onsite cytologic evaluation was available. CONCLUSIONS Franseen and Fork-tip needles, particularly 22-gauge size, showed the highest performance for tissue sampling of pancreatic masses, with low confidence in estimates.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Daryl Ramai
- Department of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah, USA
| | | | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | | | - Silvia Carrara
- IRCCS Humanitas Research Hospital, Endoscopic Unit, Department of Gastroenterology, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessandro Repici
- IRCCS Humanitas Research Hospital, Endoscopic Unit, Department of Gastroenterology, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Cesare Hassan
- IRCCS Humanitas Research Hospital, Endoscopic Unit, Department of Gastroenterology, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Antonio Facciorusso
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy; Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
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25
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Zhang S, Zhou Y, Tang D, Ni M, Zheng J, Xu G, Peng C, Shen S, Zhan Q, Wang X, Hu D, Li WJ, Wang L, Lv Y, Zou X. A deep learning-based segmentation system for rapid onsite cytologic pathology evaluation of pancreatic masses: A retrospective, multicenter, diagnostic study. EBioMedicine 2022; 80:104022. [PMID: 35512608 PMCID: PMC9079232 DOI: 10.1016/j.ebiom.2022.104022] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background We aimed to develop a deep learning-based segmentation system for rapid on-site cytopathology evaluation (ROSE) to improve the diagnostic efficiency of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy. Methods A retrospective, multicenter, diagnostic study was conducted using 5345 cytopathological slide images from 194 patients who underwent EUS-FNA. These patients were from Nanjing Drum Tower Hospital (109 patients), Wuxi People's Hospital (30 patients), Wuxi Second People's Hospital (25 patients), and The Second Affiliated Hospital of Soochow University (30 patients). A deep convolutional neural network (DCNN) system was developed to segment cell clusters and identify cancer cell clusters with cytopathological slide images. Internal testing, external testing, subgroup analysis, and human–machine competition were used to evaluate the performance of the system. Findings The DCNN system segmented stained cells from the background in cytopathological slides with an F1-score of 0·929 and 0·899–0·938 in internal and external testing, respectively. For cancer identification, the DCNN system identified images containing cancer clusters with AUCs of 0·958 and 0·948–0·976 in internal and external testing, respectively. The generalizable and robust performance of the DCNN system was validated in sensitivity analysis (AUC > 0·900) and was superior to that of trained endoscopists and comparable to cytopathologists on our testing datasets. Interpretation The DCNN system is feasible and robust for identifying sample adequacy and pancreatic cancer cell clusters. Prospective studies are warranted to evaluate the clinical significance of the system. Funding Jiangsu Natural Science Foundation; Nanjing Medical Science and Technology Development Funding; National Natural Science Foundation of China.
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Affiliation(s)
- Song Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210008, China; Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China
| | - Yangfan Zhou
- National Institute of Healthcare Data Science at Nanjing University, Nanjing, Jiangsu 210008, China; National Key Laboratory for Novel Software Technology, Department of Computer Science and Technology, Nanjing University, Nanjing, Jiangsu 210008, China
| | - Dehua Tang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China
| | - Muhan Ni
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China
| | - Jinyu Zheng
- Department of Pathology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China
| | - Guifang Xu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210008, China; Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China
| | - Chunyan Peng
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210008, China; Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China
| | - Shanshan Shen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210008, China; Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China
| | - Qiang Zhan
- Department of Gastroenterology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Xiaoyun Wang
- Department of Gastroenterology, Wuxi Second People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214002, China
| | - Duanmin Hu
- Department of Gastroenterology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215004, China
| | - Wu-Jun Li
- National Institute of Healthcare Data Science at Nanjing University, Nanjing, Jiangsu 210008, China; National Key Laboratory for Novel Software Technology, Department of Computer Science and Technology, Nanjing University, Nanjing, Jiangsu 210008, China; Center for Medical Big Data, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China.
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210008, China; Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China.
| | - Ying Lv
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210008, China; Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China.
| | - Xiaoping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210008, China; Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, China.
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Zakaria A, Al-Share B, Klapman JB, Dam A. The Role of Endoscopic Ultrasonography in the Diagnosis and Staging of Pancreatic Cancer. Cancers (Basel) 2022; 14:1373. [PMID: 35326524 PMCID: PMC8946253 DOI: 10.3390/cancers14061373] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the fourth leading cause of cancer-related death and the second gastrointestinal cancer-related death in the United States. Early detection and accurate diagnosis and staging of pancreatic cancer are paramount in guiding treatment plans, as surgical resection can provide the only potential cure for this disease. The overall prognosis of pancreatic cancer is poor even in patients with resectable disease. The 5-year survival after surgical resection is ~10% in node-positive disease compared to ~30% in node-negative disease. The advancement of imaging studies and the multidisciplinary approach involving radiologists, gastroenterologists, advanced endoscopists, medical, radiation, and surgical oncologists have a major impact on the management of pancreatic cancer. Endoscopic ultrasonography is essential in the diagnosis by obtaining tissue (FNA or FNB) and in the loco-regional staging of the disease. The advancement in EUS techniques has made this modality a critical adjunct in the management process of pancreatic cancer. In this review article, we provide an overall description of the role of endoscopic ultrasonography in the diagnosis and staging of pancreatic cancer.
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Affiliation(s)
- Ali Zakaria
- Department of Gastroenterology-Advanced Endoscopy, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA; (J.B.K.); (A.D.)
| | - Bayan Al-Share
- Department of Hematology and Oncology, Karmanos Cancer Center, Wayne State University, Detroit, MI 48201, USA;
| | - Jason B. Klapman
- Department of Gastroenterology-Advanced Endoscopy, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA; (J.B.K.); (A.D.)
| | - Aamir Dam
- Department of Gastroenterology-Advanced Endoscopy, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA; (J.B.K.); (A.D.)
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27
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Watanabe M, Okuwaki K, Kida M, Imaizumi H, Matsumoto T, Iwai T, Hasegawa R, Masutani H, Kurosu T, Minato N, Tamaki A, Ishizaki J, Kusano C. Multicenter prospective study of the efficacy of stereomicroscopic on-site evaluation in endoscopic ultrasound-guided tissue acquisition in patients with pancreatic cancer. Pancreatology 2022; 22:311-316. [PMID: 34969602 DOI: 10.1016/j.pan.2021.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Masafumi Watanabe
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Kosuke Okuwaki
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hiroshi Imaizumi
- Department of Gastroenterology, Japan Community Health Care Organization Sagamino Hospital, 1-2-30 Huchinobe, Chuou, Sagamihara, Kanagawa, 252-0206, Japan
| | - Takaaki Matsumoto
- Department of Gastroenterology, Isehara Kyodo Hospital, 345 Tanaka, Isehara, Kanagawa, 259-1187, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Rikiya Hasegawa
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hironori Masutani
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan; Department of Gastroenterology, Japan Community Health Care Organization Sagamino Hospital, 1-2-30 Huchinobe, Chuou, Sagamihara, Kanagawa, 252-0206, Japan
| | - Takahiro Kurosu
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Naoki Minato
- Department of Gastroenterology, Isehara Kyodo Hospital, 345 Tanaka, Isehara, Kanagawa, 259-1187, Japan
| | - Akihiro Tamaki
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan; Department of Gastroenterology, Isehara Kyodo Hospital, 345 Tanaka, Isehara, Kanagawa, 259-1187, Japan
| | - Junro Ishizaki
- Department of Gastroenterology, Japan Community Health Care Organization Sagamino Hospital, 1-2-30 Huchinobe, Chuou, Sagamihara, Kanagawa, 252-0206, Japan
| | - Chika Kusano
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
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28
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Coronel M, Lee JH, Coronel E. Endoscopic Ultrasound for the Diagnosis and Staging of Biliary Malignancy. Clin Liver Dis 2022; 26:115-125. [PMID: 34802657 DOI: 10.1016/j.cld.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cholangiocarcinoma (CCA) is the most common neoplasm of the biliary tract. The biological behavior and prognosis of CCA vary depending on the tumor's location in the biliary tree, dictating a different diagnostic, and treatment approach. Establishing a diagnosis of CCA remains a challenge and up to 20% of biliary strictures can yield indeterminate results, despite extensive evaluation. Endoscopic ultrasound (EUS) has become an effective diagnostic tool, as it provides high-quality images of the bile duct and allows for the sampling of strictures in the same plane of view. In this chapter, we explore the utility of EUS as a diagnostic and staging tool for biliary cancers.
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Affiliation(s)
- Martin Coronel
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
| | - Emmanuel Coronel
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA.
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29
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Liao H, Sheridan T, Cosar E, Owens C, Zuo T, Wang X, Akalin A, Kandil D, Dresser K, Fogarty K, Bellve K, Baer C, Fischer A. Deconvolution Microscopy: A Platform for Rapid On-Site Evaluation (ROSE) of Fine Needle Aspiration (FNA) Specimens that Enables Recovery of the Sample. Cytopathology 2022; 33:312-320. [PMID: 35102620 PMCID: PMC9305921 DOI: 10.1111/cyt.13106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/03/2022] [Accepted: 01/22/2022] [Indexed: 12/01/2022]
Abstract
CONTEXT Rapid on-site evaluation (ROSE) optimizes the performance of cytology, but requires skilled handling, and smearing can make the material unavailable for some ancillary tests. There is a need to facilitate ROSE without sacrificing part of the sample. OBJECTIVE We evaluated the image quality of inexpensive deconvolution fluorescence microscopy for optically sectioning non-smeared FNA tissue fragments. DESIGN A portion of residual material from 14 FNA samples was stained for 3 minutes in Hoechst 33342 and SyproTM Red to label DNA and protein respectively, transferred to an imaging chamber, and imaged at 200X or 400X magnification at 1 micron intervals using a GE DeltaVision inverted fluorescence microscope. A deconvolution algorithm was applied to remove out of plane signal, and resulting images were inverted and pseudocolored to resemble an H&E section. Five cytopathologists blindly diagnosed 2 to 4 representative image stacks per case (total 70 evaluations), and later compared them to conventional epifluorescent images. RESULTS Accurate definitive diagnoses were rendered in 45 of 70 (64%) total evaluations; equivocal diagnoses (atypical or suspicious) were made in 21 of 70 (30%). There were two false positive and two false negative "definite" diagnoses in three cases (4/70; 6%). Cytopathologists preferred deconvolved images compared to raw images (p< 0.01). The imaged fragments were recovered and prepared into a ThinPrep or cell block without discernable alteration. CONCLUSIONS Deconvolution improves image quality of FNA fragments compared to epifluorescence, often allowing definitive diagnosis while enabling the ROSE material to be subsequently triaged.
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Affiliation(s)
| | | | - Ediz Cosar
- University of Massachusetts Medical School
| | | | - Tao Zuo
- University of Massachusetts Medical School
| | | | - Ali Akalin
- University of Massachusetts Medical School
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Gawande A, Mukewar S, Daswani R, Bhaware B, Mukewar S. Recent Endoscopic Ultrasound-Related Publications With Potential to Influence Clinical Practice. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1741107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
AbstractThe field of endoscopic ultrasound (EUS) has evolved significantly over the last two decades from being a tool of only diagnostic purpose to tissue acquisition and now therapeutic potential. There have been several important publications in the field of EUS in the last few years, which had a major impact in the clinical management of various gastrointestinal disorders. In this review, we discuss four such articles that in our opinion will significantly impact the role of EUS in treating various conditions. The first article is a randomized controlled trial comparing EUS-guided gall bladder drainage with percutaneous gall bladder drainage for high-risk acute cholecystitis. The second article is a randomized controlled trial comparing EUS versus minimally invasive surgery for necrotizing pancreatitis. The third article is a novel human study of EUS-guided portal pressure measurement in patients with portal hypertension. The last article is also a randomized controlled trial evaluating the role of rapid on-site evaluation for EUS-guided fine needle biopsy in solid pancreatic lesions.
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Affiliation(s)
- Atul Gawande
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Shrikant Mukewar
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Ravi Daswani
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Bhushan Bhaware
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Saurabh Mukewar
- Department of Gastroenterology, Midas Multispeciality Hospital, Nagpur, Maharashtra, India
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Li SY, Gao L, Zhang PP, Su XJ, Kong XY, Wang KX, Jin ZD. Endosonographers performing on-site evaluation of solid pancreatic specimens for EUS-guided biopsy: A formal training method and learning curves. Endosc Ultrasound 2021; 10:463-471. [PMID: 34975043 PMCID: PMC8785675 DOI: 10.4103/eus-d-21-00088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objectives: This study aimed to examine the effects of a training program combining formal cytological curriculum and practical assessments on endosonographers and to determine how many operations were needed for training through learning curves. Methods: A formal cytological curriculum was implemented in November 2019 for four endosonographers. The competency of endosonographers before and after the curriculum was judged by quantitative scores. From December 2019 to October 2020, trainees independently examined the adequacy and atypia grade of pancreatic specimens acquired by EUS-guided-fine-needle biopsy based on specific atypical grading criteria. The accuracy of the adequacy and atypia assessment of each trainee was calculated, and learning curves were drawn to evaluate the improvement. Results: The median posttraining score improved by 87% from 49 to 91.5 out of 100. Ninety patients were enrolled in the practical assessments. The accuracy for specimen adequacy and atypia assessment of each trainee was 91.7%, 92.8%, 91.0%, and 89.3% and 80.0%, 82.1%, 81.0%, and 78.9%. The learning curves of each trainee showed a steady and significant improvement, and ninety cases were sufficient for satisfactory adequacy assessment. Conclusions: Basic knowledge of on-site cytopathologic evaluation can be gained through standardized and systematic training. Practical assessments showed that, at the completion of ninety cases, trained endosonographers reached a satisfactory level of recognizing specimen adequacy, but continue practice was needed for atypia assessment.
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Affiliation(s)
- Shi-Yu Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Li Gao
- Department of Pathology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Ping-Ping Zhang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Xiao-Ju Su
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Xiang-Yu Kong
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Kai-Xuan Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
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Ishigaki K, Nakai Y, Sasahira N, Sugimori K, Kitamura K, Iwai T, Matsubara S, Shimura K, Itoi T, Ryozawa S, Ushio J, Doi S, Imazu H, Maetani I, Isayama H. A prospective multicenter study of endoscopic ultrasound-guided fine needle biopsy using a 22-gauge Franseen needle for pancreatic solid lesions. J Gastroenterol Hepatol 2021; 36:2754-2761. [PMID: 33939863 DOI: 10.1111/jgh.15534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/04/2021] [Accepted: 04/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM While encouraging data of endoscopic ultrasound (EUS)-guided fine-needle biopsy (EUS-FNB) using a 22-gauge Franseen needle have been reported, large-scale data of per pass and quantitative analyses are still lacking. METHODS This was a multicenter prospective study of EUS-FNB using the 22-gauge Franseen needle for a pancreatic solid lesion. Cytological and histological analyses per pass were evaluated and semi-quantitative analyses were performed on core tissue and blood contamination. Primary end-point was diagnostic accuracy per session. Prognostic factors were analyzed for diagnostic accuracy, sensitivity, core tissue, and blood contamination. RESULTS A total of 629 passes were performed in 244 cases at 14 centers between 2018 and 2019. The median tumor size was 29 mm, and the puncture was transduodenal in 43%. The median pass number was 2. Diagnostic accuracy per session, at a first pass, and per pass were 93%, 90%, and 88%. In 198 cases with pancreatic cancer, diagnostic sensitivity per session, at a first pass, and per pass were 94%, 89%, and 89%. The rates of core tissue score of 4 and blood contamination score of 3 were 50% and 47%. The adverse event rate was 1.6%. In the multivariate analysis, tumor size ≤20 mm (odds ratio [OR] of 0.46, P = 0.03), transduodenal puncture (OR of 0.53, P = 0.04), and suction (OR of 0.16, P = 0.01) were associated with lower diagnostic accuracy. CONCLUSIONS The EUS-FNB using the 22-gauge Franseen needle for pancreatic solid lesions showed high per pass and overall diagnostic accuracy.
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Affiliation(s)
- Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - Kazuya Sugimori
- Gastroentelogical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Katsuya Kitamura
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
- Division of Gastroenterology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Kenji Shimura
- Department of Gastroenterology, Asahi General Hospital, Chiba, Japan
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Jun Ushio
- Department of Gastroenterology, Jichi Medical University Hospital, Tochigi, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Hiroo Imazu
- Department of Gastroenterology, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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33
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Crinò SF, Di Mitri R, Nguyen NQ, Tarantino I, de Nucci G, Deprez PH, Carrara S, Kitano M, Shami VM, Fernández-Esparrach G, Poley JW, Baldaque-Silva F, Itoi T, Manfrin E, Bernardoni L, Gabbrielli A, Conte E, Unti E, Naidu J, Ruszkiewicz A, Amata M, Liotta R, Manes G, Di Nuovo F, Borbath I, Komuta M, Lamonaca L, Rahal D, Hatamaru K, Itonaga M, Rizzatti G, Costamagna G, Inzani F, Curatolo M, Strand DS, Wang AY, Ginès À, Sendino O, Signoretti M, van Driel LMJW, Dolapcsiev K, Matsunami Y, van der Merwe S, van Malenstein H, Locatelli F, Correale L, Scarpa A, Larghi A. Endoscopic Ultrasound-guided Fine-needle Biopsy With or Without Rapid On-site Evaluation for Diagnosis of Solid Pancreatic Lesions: A Randomized Controlled Non-Inferiority Trial. Gastroenterology 2021; 161:899-909.e5. [PMID: 34116031 DOI: 10.1053/j.gastro.2021.06.005] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The benefit of rapid on-site evaluation (ROSE) on the diagnostic accuracy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) has never been evaluated in a randomized study. This trial aimed to test the hypothesis that in solid pancreatic lesions (SPLs), diagnostic accuracy of EUS-FNB without ROSE was not inferior to that of EUS-FNB with ROSE. METHODS A noninferiority study (noninferiority margin, 5%) was conducted at 14 centers in 8 countries. Patients with SPLs requiring tissue sampling were randomly assigned (1:1) to undergo EUS-FNB with or without ROSE using new-generation FNB needles. The touch-imprint cytology technique was used to perform ROSE. The primary endpoint was diagnostic accuracy, and secondary endpoints were safety, tissue core procurement, specimen quality, and sampling procedural time. RESULTS Eight hundred patients were randomized over an 18-month period, and 771 were analyzed (385 with ROSE and 386 without). Comparable diagnostic accuracies were obtained in both arms (96.4% with ROSE and 97.4% without ROSE, P = .396). Noninferiority of EUS-FNB without ROSE was confirmed with an absolute risk difference of 1.0% (1-sided 90% confidence interval, -1.1% to 3.1%; noninferiority P < .001). Safety and sample quality of histologic specimens were similar in both groups. A significantly higher tissue core rate was obtained by EUS-FNB without ROSE (70.7% vs. 78.0%, P = .021), with a significantly shorter mean sampling procedural time (17.9 ± 8.8 vs 11.7 ± 6.0 minutes, P < .0001). CONCLUSIONS EUS-FNB demonstrated high diagnostic accuracy in evaluating SPLs independently on execution of ROSE. When new-generation FNB needles are used, ROSE should not be routinely recommended. (ClinicalTrial.gov number NCT03322592.).
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Affiliation(s)
- Stefano Francesco Crinò
- Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy.
| | - Roberto Di Mitri
- Gastroenterology and Endoscopy Unit, ARNAS Civico Di Cristina Benfratelli Hospital, Palermo, Italy
| | - Nam Q Nguyen
- Department of Gastroenterology, Royal Adelaide Hospital, South Australia
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Germana de Nucci
- Department of Gastroenterology, Rho and Garbagnate Milanese Hospital, ASST Rhodense, Milano, Italy
| | - Pierre H Deprez
- Department of Gastroenterology and Hepatology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Silvia Carrara
- Department of Gastroenterology, Endoscopic Unit, Humanitas Clinical and Research Center- IRCCS, Rozzano (MI), Italy
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Gloria Fernández-Esparrach
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Francisco Baldaque-Silva
- Department of Upper GI Diseases, Unit of Gastrointestinal Endoscopy, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku, Tokyo, Japan
| | - Erminia Manfrin
- Department of Diagnostics and Public Health, Section of Pathology, G.B. Rossi University Hospital, Verona, Italy
| | - Laura Bernardoni
- Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Armando Gabbrielli
- Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Elisabetta Conte
- Gastroenterology and Endoscopy Unit, ARNAS Civico Di Cristina Benfratelli Hospital, Palermo, Italy
| | - Elettra Unti
- Pathology Unit, ARNAS Civico Di Cristina Benfratelli Hospital, Palermo, Italy
| | - Jeevinesh Naidu
- Department of Gastroenterology, Royal Adelaide Hospital, South Australia
| | | | - Michele Amata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Rosa Liotta
- Pathology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS - ISMETT), Palermo, Italy
| | - Gianpiero Manes
- Department of Gastroenterology, Rho and Garbagnate Milanese Hospital, ASST Rhodense, Milano, Italy
| | - Franca Di Nuovo
- Pathology Unit, ASST Rhodense, Garbagnate Milanese (MI), Italy
| | - Ivan Borbath
- Department of Gastroenterology and Hepatology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Mina Komuta
- Department of Pathology, School of Medicine, Keio University, Tokyo, Japan; Department of Pathology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Laura Lamonaca
- Department of Gastroenterology, Endoscopic Unit, Humanitas Clinical and Research Center- IRCCS, Rozzano (MI), Italy
| | - Daoud Rahal
- Department of Pathology, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Keiichi Hatamaru
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Itonaga
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Frediano Inzani
- Pathology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Mariangela Curatolo
- Pathology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Àngels Ginès
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Oriol Sendino
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Marianna Signoretti
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Lydi M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Karoly Dolapcsiev
- Department of Pathology, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku, Tokyo, Japan
| | - Schalk van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Belgium
| | - Hannah van Malenstein
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Belgium
| | - Francesca Locatelli
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, G.B. Rossi University Hospital, Verona, Italy
| | - Loredana Correale
- Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, G.B. Rossi University Hospital, Verona, Italy; ARC-Net Research Centre, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
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Ashida R, Kitano M. Advances in the evaluation of sample adequacy during endoscopic ultrasound-guided tissue acquisition. Dig Endosc 2021; 33:927-928. [PMID: 34397146 DOI: 10.1111/den.14093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Reiko Ashida
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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35
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Mohan AA, Vallonthaiel AG, Nambiar A, Ariyannur P, Joy RA, Thelakkattusserry SK, Vikkath N, Joseph T, Mehta A, Perathur A. EGFR analysis on scrapings from cytology smears in lung carcinoma, an effective alternative to testing on trucut biopsies. Diagn Cytopathol 2021; 49:1155-1163. [PMID: 34432954 DOI: 10.1002/dc.24856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/07/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Lung carcinomas are a leading cause of cancer morbidity and mortality. Many cases present at an advanced stage of disease where definitive treatment by surgical resection is not feasible. Molecular testing using materials derived from minimally invasive procedures aid in targeted therapy with least iatrogenic burden to the patient. METHODS Cases diagnosed as non-small cell lung carcinoma (NSCLC) on cytology were included in the study. Scrapings from the smears with adequate tumor cell load were submitted for molecular testing. The DNA was extracted and quantified. Mutations in exons 18, 19, 20, and 21 of the EGFR gene were detected using Sanger sequencing. DNA quantity and EGFR mutation status on equal number of consecutive trucut biopsy specimens were also analyzed. RESULTS Seventy cases of NSCLC tested for EGFR mutation had a median DNA concentration of 40.2 ng/μl and 31% cases showed mutation. Majority of mutations (14/21, 66.66%) were identified in exon 19. Among 70 trucut biopsy samples, DNA concentration was 41.42 ng/μl and 30% cases showed mutation. No significant difference was seen in DNA quantity and EGFR mutation between cytology smears and trucut biopsies. CONCLUSION EGFR testing on cytology smears provides adequate DNA yield with minimal invasiveness and is equally effective as biopsies. Testing on samples like pleural effusion allows for concomitant diagnosis, staging, and molecular testing in one procedure. Tests done on the smears rather than on cell block or trucut biopsies ensures superior quality DNA from the tumor cells as they are unexposed to cross linking formalin fixative.
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Affiliation(s)
- Anish A Mohan
- Department of Pathology, Amrita Institute of Medical Sciences, Kochi, India
| | | | - Ajit Nambiar
- Department of Pathology, Amrita Institute of Medical Sciences, Kochi, India
| | - Prasanth Ariyannur
- Molecular Oncology Laboratory, Amrita Institute of Medical Sciences, Kochi, India
| | - Reenu Anne Joy
- Molecular Oncology Laboratory, Amrita Institute of Medical Sciences, Kochi, India
| | | | - Narendranath Vikkath
- Molecular Oncology Laboratory, Amrita Institute of Medical Sciences, Kochi, India
| | - Tinku Joseph
- Department of Pulmonary Medicine, Amrita Institute of Medical Sciences, Kochi, India
| | - Asmita Mehta
- Department of Pulmonary Medicine, Amrita Institute of Medical Sciences, Kochi, India
| | - Arvind Perathur
- Department of Pulmonary Medicine, Amrita Institute of Medical Sciences, Kochi, India
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36
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Chung MJ, Park SW, Kim SH, Cho CM, Choi JH, Choi EK, Lee TH, Cho E, Lee JK, Song TJ, Lee JM, Son JH, Park JS, Oh CH, Park DA, Byeon JS, Lee ST, Kim HG, Chun HJ, Choi HS, Park CG, Cho JY. [Clinical and Technical Guideline for Endoscopic Ultrasound-guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 78:73-93. [PMID: 34446631 DOI: 10.4166/kjg.2021.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Moon Jae Chung
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Se Woo Park
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwasung, Korea
| | - Seong-Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | - Chang Min Cho
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun-Ho Choi
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Eun Kwang Choi
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Eunae Cho
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Medical Center, Dongguk University College of Medicine, Goyang, Korea
| | - Tae Jun Song
- Department of Internal Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Jae Min Lee
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jun Hyuk Son
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jin Suk Park
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine,Incheon, Korea
| | - Chi Hyuk Oh
- Department of Internal Medicine, KyungHee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Dong-Ah Park
- Division of Healthcare Technology Assessment Research, Office of Health Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Internal Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Soo Teik Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | - Ho Gak Kim
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Ho Soon Choi
- Department of Internal Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Korea
| | - Chan Guk Park
- Department of Internal Medicine, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
| | - Joo Young Cho
- Department of Internal Medicine, Cha University Bundang Medical Center, Cha University, Seongnam, Korea
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Diagnostic Value of EUS-Guided Fine-Needle Aspiration Biopsy for Gastric Linitis Plastica with Negative Endoscopic Biopsy. J Clin Med 2021; 10:jcm10163716. [PMID: 34442011 PMCID: PMC8397167 DOI: 10.3390/jcm10163716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/21/2022] Open
Abstract
Due to the tendency of gastric linitis plastica (GLP) to cause extensive submucosal infiltration, a superficial endoscopic biopsy sometimes yields no evidence of malignancy, hindering definite diagnosis. The present study was a single-center retrospective analysis of 54 consecutive patients diagnosed with GLP between 2016 and 2020 to evaluate EUS-guided fine-needle aspiration (EUS-FNA) biopsy outcomes in patients with negative endoscopic biopsy findings. A pathological GLP diagnosis was achieved by endoscopic biopsy in 40 patients (74.1%). EUS-FNA biopsy with a 22-gauge needle was performed in 13 of the remaining 14 patients, and GLP diagnosis was confirmed in 10 patients, with a median of three needle passes. The remaining four patients were laparoscopically diagnosed with GLP. The diagnostic ability of EUS-FNA biopsy for GLP was 76.9%, and EUS-FNA biopsy contributed to GLP diagnosis in 18.5% (10/54) of all cases. None of the 13 patients exhibited EUS-FNA biopsy-related adverse events. Univariable and multivariable analyses revealed an absence of superficial ulcerations as a predictor of false-negative endoscopic biopsy findings in patients with GLP. These results suggest EUS-FNA biopsy as a minimally invasive and safe alternative diagnostic modality for GLP in cases where conventional endoscopic biopsy fails to verify malignancy, although prospective studies with larger cohorts are warranted to confirm these findings.
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HooKim K, Reid MD. Atypical cells in fine needle aspiration biopsies of pancreas: Causes, work-up, and recommendations for management. Diagn Cytopathol 2021; 50:196-207. [PMID: 34378874 DOI: 10.1002/dc.24848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Kim HooKim
- Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michelle D Reid
- Department of Pathology, Emory University Hospital, Atlanta, Georgia, USA
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Ginès A, Fusaroli P, Sendino O, Seicean A, Gimeno-Garcia AZ, Gratacós-Ginès J, Araujo IK, Rodríguez-Carunchio L, Alós S, Lisotti A, Cominardi A, Montenegro A, Fernández-Esparrach G. Performance of a new flexible 19 G EUS needle in pancreatic solid lesions located in the head and uncinate process: A prospective multicenter study. Endosc Int Open 2021; 9:E1269-E1275. [PMID: 34447875 PMCID: PMC8383085 DOI: 10.1055/a-1480-0428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/22/2021] [Indexed: 12/30/2022] Open
Abstract
Background and study aims The poor flexibility of large-bore EUS needles often leads to technical failure when sampling from the duodenum. The aim of this study was to evaluate the technical and diagnostic performances of a new Menghini tip 19G nitinol EUS needle for sampling pancreatic solid lesions in the head and uncinate process. Patients and methods This was a European prospective multicenter single-arm study. A maximum of four passes were allowed. In case of failure, different needles were permitted. Results We included 75 patients (51 % males) with lesions in the head (n = 68; 91 %) and uncinate process (n = 7; 9 %) (mean size: 33 ± 12 mm; number of passes: 1.8 ± 0.9). Technical success was seen in 71 of 75 (94.7 %). Diagnostic rates were 89.3 % (67/75) and 94.4 % (67/71) in the intention-to-treat (ITT) and per-protocol (PP) analysis, respectively. In the eight cases with failure, diagnosis was obtained with another needle (n = 4), from another lesion (n = 3) or with follow-up (n = 1). A histological sample was obtained in 64 patients (ITT 85.3 % and PP 90 %) and immunohistochemistry was successfully performed in 13 of 15 lesions in which it was required. No differences between rapid on-site evaluation (ROSE) and non-ROSE groups were observed regarding diagnostic success (87.5 % vs 91 %, P = 0.582) and diagnosis at the first pass (70 % vs 81 %, P = 0.289). Number of passes was lower in the ROSE group (1.4 + 0.9 vs 2.2 + 0.7, P < 0.001). One adverse event was recorded (1.3 %) consisting in a duodenal perforation after a single session EUS-ERCP. Conclusions The new nitinol Menghini tip 19G EUS needle showed high technical diagnostic success in safely sampling solid lesions in the head and uncinate process of the pancreas.
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Affiliation(s)
- Angels Ginès
- Hospital Clinic de Barcelona – Endoscopy Unit, Barcelona. University of Barcelona, Spain,CIBEREHD Barcelona, Spain,IDIBAPS – Medicina, Barcelona, Spain
| | - Pietro Fusaroli
- Hospital of Imola – GI Unit, University of Bologna, Imola, Italy
| | - Oriol Sendino
- Hospital Clinic de Barcelona – Endoscopy Unit, Barcelona. University of Barcelona, Spain,CIBEREHD Barcelona, Spain,IDIBAPS – Medicina, Barcelona, Spain
| | - Andrada Seicean
- University of Medicine and Pharmacy – Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Antonio Z. Gimeno-Garcia
- Hospital Universitario de de Sta Cruz de Tenerife – Service of Gastroenterology, Tenerife, Spain
| | - Jordi Gratacós-Ginès
- Hospital Clinic de Barcelona – Endoscopy Unit, Barcelona. University of Barcelona, Spain
| | - Isis K. Araujo
- Hospital Clinic de Barcelona – Endoscopy Unit, Barcelona. University of Barcelona, Spain,IDIBAPS – Medicina, Barcelona, Spain
| | - Leonardo Rodríguez-Carunchio
- Hospital Clinic de Barcelona – Pathology Department, University of Vic – Central University of Catalonia (UVic-UCC), Barcelona, Spain
| | - Silvia Alós
- Hospital Clinic de Barcelona – Pathology Department, University of Vic – Central University of Catalonia (UVic-UCC), Barcelona, Spain
| | - Andrea Lisotti
- Hospital of Imola – GI Unit, University of Bologna, Imola, Italy
| | - Anna Cominardi
- Hospital of Imola – GI Unit, University of Bologna, Imola, Italy
| | - Andrea Montenegro
- Hospital Clinic de Barcelona – Endoscopy Unit, Barcelona. University of Barcelona, Spain
| | - Glòria Fernández-Esparrach
- Hospital Clinic de Barcelona – Endoscopy Unit, Barcelona. University of Barcelona, Spain,CIBEREHD Barcelona, Spain,IDIBAPS – Medicina, Barcelona, Spain
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Nebel JA, Soldan M, Dumonceau JM, de Souza Carvalho CE, Chagas VLA, de Assis PG, Lapa E Silva JR, Rezende GFDM. Rapid On-Site Evaluation by Endosonographer of Endoscopic Ultrasound Fine-Needle Aspiration of Solid Pancreatic Lesions: A Randomized Controlled Trial. Pancreas 2021; 50:815-821. [PMID: 34347723 DOI: 10.1097/mpa.0000000000001846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Rapid on-site evaluation (ROSE) by cytopathologists during endoscopic ultrasound-fine-needle aspiration (EUS-FNA) of solid pancreatic lesions (SPLs) improves adequacy and diagnostic accuracy while reducing the number of needle passes. We evaluated the usefulness of ROSE performed by the endosonographer. METHODS Patients with an SPL were randomly assigned to EUS-FNA with ROSE or non-ROSE. Procedure duration, number of needle passes, specimen adequacy, and adverse event rates were compared. RESULTS Sixty-five patients were enrolled (33 in the ROSE vs 32 in the non-ROSE group). Both groups were similar in terms of age, sex, size, and location of the lesion. Specimen adequacy rates were high and similar between groups. Mean (standard deviation) procedure duration was shorter in the ROSE versus non-ROSE group (30.0 [11.3] vs 37.0 [7.2] minutes, P < 0.005), as well as the mean (standard deviation) number of needle passes (2.6 [0.8] vs 3.5 [0.8], P < 0.005). Accuracy parameters as sensitivity and accuracy of ROSE by the endosonographer for malignancy were 93% and 88%, respectively. CONCLUSIONS After specific training, the endosonographer can accurately evaluate samples during EUS-FNA of SPL, allowing for a shorter procedure duration and a lower number of needle passes.
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Affiliation(s)
- João Autran Nebel
- From the Gastroenterology Service, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Monica Soldan
- From the Gastroenterology Service, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | - José Roberto Lapa E Silva
- Department of Internal Medicine, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Guilherme Ferreira da Motta Rezende
- Department of Internal Medicine, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Effectiveness of EUS-Guided Fine-Needle Biopsy versus EUS-Guided Fine-Needle Aspiration: A Retrospective Analysis. Diagnostics (Basel) 2021; 11:diagnostics11060965. [PMID: 34071881 PMCID: PMC8228011 DOI: 10.3390/diagnostics11060965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023] Open
Abstract
Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic tumors and subepithelial lesions (SEL) of the gastrointestinal tract are effective for histological diagnosis. There are also reports that tissue sampling is possible with a smaller number of punctures by EUS-guided fine-needle biopsy (EUS-FNB). In this study, we retrospectively compared the diagnostic abilities of EUS-FNA and EUS-FNB. We examined 130 patients who underwent EUS-FNA/EUS-FNB for pancreatic tumors and SEL from July 2018 to January 2021. None of the cases underwent rapid on-site evaluation. There were 94 and 36 cases in the EUS-FNA and EUS-FNB groups, respectively. The median tumor size in the EUS-FNB group was 30 mm, which was significantly larger than the EUS-FNA group (p = 0.02). In addition, transgastric puncture was significantly more common in the EUS-FNB group (p = 0.01). The EUS-FNA and EUS-FNB groups had a sensitivity of 82.9% and 91.7% and an accuracy rate of 85.1% and 91.7%, respectively. However, both procedures had a comparable diagnostic ability.
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42
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Chung MJ, Park SW, Kim SH, Cho CM, Choi JH, Choi EK, Lee TH, Cho E, Lee JK, Song TJ, Lee JM, Son JH, Park JS, Oh CH, Park DA, Byeon JS, Lee ST, Kim HG, Chun HJ, Choi HS, Park CG, Cho JY. Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE). Gut Liver 2021; 15:354-374. [PMID: 33767027 PMCID: PMC8129669 DOI: 10.5009/gnl20302] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/13/2020] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
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)
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Affiliation(s)
- Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University College of Medicine, Hwaseong, Korea
| | - Seong-Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Chang Min Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun-Ho Choi
- Division of Gastroenterology, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Eun Kwang Choi
- Division of Gastroenterology, Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Jun Kyu Lee
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Min Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jun Hyuk Son
- Division of Gastroenterology, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Jin Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Chi Hyuk Oh
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Dong-Ah Park
- Division of Healthcare Technology Assessment Research, Office of Health Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jeong-Sik Byeon
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo Teik Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Division of Gastroenterology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ho Soon Choi
- Division of Gastroenterology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Chan Guk Park
- Division of Gastroenterology, Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, Cha University College of Medicine, Seongnam, Korea
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Del Vecchio Blanco G, Palmieri G, Giannarelli D, Formica V, Portarena I, Nardecchia A, Troncone E, Benassi M, Giudice E, Anselmo A, Tisone G, Roselli M, Monteleone G, Paoluzi OA. Factors influencing diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pancreatic and biliary tumors. Scand J Gastroenterol 2021; 56:498-504. [PMID: 33539716 DOI: 10.1080/00365521.2021.1880628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is influenced by several factors, primarily operator expertise. Formal training in EUS-FNA, as suggested by the European Society of Gastrointestinal Endoscopy and the American Society for Gastrointestinal Endoscopy guidelines, is not always available and is often expensive and time-consuming. In this study we evaluate factors influencing the diagnostic accuracy of pancreatic EUS-FNA. METHODS In a retrospective study, 557 consecutive EUS-FNAs were evaluated. Several variables relating to the procedures were considered to calculate the EUS-FNA performance over eight years. RESULTS A total of 308 out of 557 EUS-FNAs were selected. Overall sensitivity of EUS-FNA was 66% (95% CI: 60.8-71.8), specificity 100%, and diagnostic accuracy 69% (95% CI: 64.0-74.4). An increase in diagnostic accuracy was observed to >90% using a new fine-needle biopsy (FNB) needle and in the case of simultaneous sampling of primary and metastatic lesions. Diagnostic accuracy >80% was observed after 250 procedures, in the absence of rapid on-site cytopathological examination (ROSE). Multivariate logistic regression analysis confirmed that the FNB needle, operator skill, and double EUS-FNA sampling are associated with high diagnostic accuracy. CONCLUSIONS The learning curve for EUS-FNA may be longer and a considerable number of procedures are needed to achieve high diagnostic accuracy in the absence of ROSE. However, the use of FNB needles and the simultaneous sampling of primary and metastatic lesions can rapidly improve the diagnostic accuracy of the procedure.
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Affiliation(s)
| | - Giampiero Palmieri
- Anatomic Pathology Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Diana Giannarelli
- Biostatistical Unit, Regina Elena Institute-Hospital Physiotherapy Institutes, Rome, Italy
| | | | | | | | - Edoardo Troncone
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Michela Benassi
- Radiotherapy Unit, Department of Oncohematology, University of Rome Tor Vergata, Rome, Italy
| | - Emilia Giudice
- Radiotherapy Unit, Department of Oncohematology, University of Rome Tor Vergata, Rome, Italy
| | - Alessandro Anselmo
- Transplant Surgery Unit, Department of Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Tisone
- Transplant Surgery Unit, Department of Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Mario Roselli
- Oncology Unit, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Monteleone
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Omero Alessandro Paoluzi
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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Ang TL, Wang LM. The evolving role of EUS-guided tissue acquisition. J Dig Dis 2021; 22:204-213. [PMID: 33611846 DOI: 10.1111/1751-2980.12976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022]
Abstract
The introduction of endoscopic ultrasound-guided fine-needle aspiration into clinical practice was a pivotal moment for diagnostic gastrointestinal endoscopy. It facilitates the ease of tissue acquisition from previously inaccessible sites. The performance characteristics of cytological diagnosis are excellent. However, there remain areas of inadequacies. These include procedural inefficiencies such as the need for rapid on-site cytological evaluation or macroscopic on-site evaluation, the crucial role of histology for diagnosis in specific conditions, the issue of sampling errors and the need for repeat procedures, and the shift towards personalized medicine, which requires histology, immunohistochemical studies, and molecular analysis. The original Trucut biopsy needle had been cumbersome to use, but the recent introduction of newer-generation biopsy needles has transformed the landscape, such that there is now a greater focus on tissue acquisition for histological assessment. Concomitant technological advances of endoscopic ultrasound processors enabled higher-resolution imaging, and facilitated image enhancement using contrast harmonic endoscopic ultrasound and endoscopic ultrasound elastography. These techniques can be used as an adjunct to guide tissue acquisition in challenging situations. There is ongoing research on the use of artificial intelligence to complement diagnostic endoscopic ultrasound and the early data are promising. Artificial intelligence may be especially important to guide clinical decision-making if biopsy results are nondiagnostic.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital; Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lai Mun Wang
- Department of Laboratory Medicine, Section of Pathology, Changi General Hospital; Pathology Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
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Delconte G, Cavalcoli F, Magarotto A, Centonze G, Bezzio C, Cattaneo L, Rausa E, Kelly ME, Bonitta G, Milione M, Enzo M. Does ProCore Fine-Needle Biopsy Really Improve the Clinical Outcome of Endoscopic Ultrasound-Guided Sampling of Pancreatic Masses? Dig Dis 2021; 40:78-84. [PMID: 33780932 DOI: 10.1159/000516177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fine-needle biopsy (FNB) has been suggested to provide better histological samples as compared to endoscopic ultrasound fine-needle aspiration (EUS-FNA). However, studies comparing EUS-FNA and EUS-FNB for pancreatic lesions reported contrasting results. The aim of this study was to compare the clinical performance of EUS-FNA versus EUS-FNB with the ProCore needle for the investigation of pancreatic lesions. METHODS We reviewed all patients undergoing EUS for the investigation of pancreatic lesions from August 2012 to September 2018. From August 2012 to January 2015, all procedures were performed with standard needles, whereas from February 2015 to September 2018, the use of ProCore needles had been introduced. Data on diagnostic accuracy, number of needle passes, and/or adverse events were collected. RESULTS Three hundred twenty-four patients were retrospectively evaluated: 190 (58.6%) underwent EUS-FNA and 134 (41.4%) EUS-FNB. Both EUS-FNA and EUS-FNB showed high diagnostic accuracy for malignancy (94% [95% CI: 89-97%] vs. 94% [95% CI: 89-98%]). Notably, there were no differences between EUS-FNA and EUS-FNB in terms of sensitivity, specificity, positive and negative likelihood ratio, histological core tissue retrieval, adverse events, or number of needle passes. However, subgroup analysis noted a higher diagnostic accuracy for 25G EUS-FNB as compared to 25G EUS-FNA (85.7 vs. 55.5%; *p = 0.023). CONCLUSION EUS-FNB with the ProCore needle is safe and feasible in pancreatic lesions. The ProCore needle did not provide any advantage in terms of diagnostic accuracy, sensitivity, specificity, positive and/or negative likelihood ratio, or acquisition of the core specimen; therefore, its routine application is not supported.
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Affiliation(s)
- Gabriele Delconte
- Diagnostic and Therapeutic Endoscopy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Federica Cavalcoli
- Diagnostic and Therapeutic Endoscopy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Andrea Magarotto
- Diagnostic and Therapeutic Endoscopy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Giovanni Centonze
- First Pathology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Cristina Bezzio
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Rho, Italy
| | - Laura Cattaneo
- First Pathology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Emanuele Rausa
- General, Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Gianluca Bonitta
- Diagnostic and Therapeutic Endoscopy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Massimo Milione
- First Pathology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Masci Enzo
- Diagnostic and Therapeutic Endoscopy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Chung MJ, Park SW, Kim SH, Cho CM, Choi JH, Choi EK, Lee TH, Cho E, Lee JK, Song TJ, Lee JM, Son JH, Park JS, Oh CH, Park DA, Byeon JS, Lee ST, Kim HG, Chun HJ, Choi HS, Park CG, Cho JY. Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE). Clin Endosc 2021; 54:161-181. [PMID: 33767027 PMCID: PMC8039738 DOI: 10.5946/ce.2021.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/27/2021] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University College of Medicine, Hwaseong, Korea
| | - Seong-Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Chang Min Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun-Ho Choi
- Division of Gastroenterology, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Eun Kwang Choi
- Division of Gastroenterology, Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Jun Kyu Lee
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Ulsan University College of Medicine, Seoul, Korea
| | - Jae Min Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jun Hyuk Son
- Division of Gastroenterology, Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea
| | - Jin Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Chi Hyuk Oh
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Dong-Ah Park
- Division of Healthcare Technology Assessment Research, Office of Health Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jeong-Sik Byeon
- Division of Gastroenterology, Department of Internal Medicine, Ulsan University College of Medicine, Seoul, Korea
| | - Soo Teik Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Division of Gastroenterology, Department of Internal Medicine, Catholic University of Daegu College of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ho Soon Choi
- Division of Gastroenterology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Chan Guk Park
- Division of Gastroenterology, Department of Internal Medicine, Chosun University College of Medicine, Korea, Gwangju, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, Cha University College of Medicine, Seongnam, Korea
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Chandan S, Mohan BP, Khan SR, Ofosu A, Dhaliwal AS, Shah AR, Bhogal N, Mashiana HS, Mashiana SS, Kassab LL, Ponnada S, Facciorusso A, Bhat I, Singh S, Witt BL, Adler DG. Comparison of EUS-guided conventional smear and liquid-based cytology in pancreatic lesions: A systematic review and meta-analysis. Endosc Int Open 2020; 8:E1611-E1622. [PMID: 33140017 PMCID: PMC7581473 DOI: 10.1055/a-1240-0027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) has limitations of inadequate sampling and false-negative results for malignancy. It has been performed using conventional smear (CS) cytology with rapid on-site evaluation (ROSE) with reasonable diagnostic accuracy. An alternative to ROSE is liquid-based cytology (LBC). Commonly used LBC techniques include precipitation-based (SurePath™) and filtration-based (ThinPrep ® , CellPrep ® ). Data regarding the diagnostic efficacy of LBC compared with CS are limited. Methods Multiple databases were searched through March 2020 to identify studies reporting diagnostic yield of EUS-guided CS and LBC in pancreatic lesions. Pooled diagnostic odds and rates of performance for the cytologic diagnoses of benign, suspicious, and malignant lesions were calculated. Diagnostic efficacy was evaluated by pooled rates of accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results Nine studies with a total of 1308 patients were included in our final analysis. Pooled diagnostic odds of CS cytology were 1.69 (CI 1.02-2.79) and 0.39 (CI 0.19-0.8) for malignant lesions when compared to filtration-based and precipitation-based LBC techniques, respectively. For CS, precipitation-based and filtration-based LBC, pooled diagnostic accuracy was 79.7 %, 85.2 %, 77.3 %, sensitivity was 79.2 %, 83.6 %, 68.3 %, and specificity was 99.4 %, 99.5 %, 99.5 %, respectively. Conclusions The precipitation-based LBC technique (SurePath™) had superior diagnostic odds for malignant pancreatic lesions compared with CS cytology in the absence of ROSE. It showed superior accuracy and sensitivity, but comparable specificity and PPV. Diagnostic odds of CS cytology in the absence of ROSE were superior to the filtration-based LBC technique (ThinPrep ® , Cellprep ® ) for diagnosing malignant pancreatic lesions.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahab R. Khan
- Section of Gastroenterology, Rush University Medical Center, Chicago, Illinois, USA
| | - Andrew Ofosu
- Division of Gastroenterology & Hepatology, Stanford University, Stanford, California, United States
| | - Amaninder S. Dhaliwal
- Division of Digestive Diseases & Nutrition, University of South Florida, Tampa, Florida, USA
| | - Aun R. Shah
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Neil Bhogal
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Harmeet S. Mashiana
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Simran S. Mashiana
- Pathology & Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Lena L. Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh Ponnada
- Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Ishfaq Bhat
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shailender Singh
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Benjamin L. Witt
- Cytopathology Section, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS-FNA) with Image Enhancement. Diagnostics (Basel) 2020; 10:diagnostics10110888. [PMID: 33143258 PMCID: PMC7692599 DOI: 10.3390/diagnostics10110888] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/20/2020] [Accepted: 10/29/2020] [Indexed: 02/08/2023] Open
Abstract
Although endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is useful in the differential diagnosis of solid pancreatic lesions, lymph nodes, and liver lesions, inadequate sampling may result in an incorrect pathological diagnosis. The accuracy of EUS for the evaluation of pancreatobiliary lesions may be increased by image enhancement technologies, including contrast-enhanced harmonic (CH)-EUS and EUS-elastography. These methods can provide information that complement EUS-FNA for the diagnosis and staging of pancreatobiliary cancer, and can help to identify the EUS-FNA target, reducing the requirement for repeat FNA.
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Stathopoulos P, Pehl A, Breitling LP, Bauer C, Grote T, Gress TM, Denkert C, Denzer UW. Endoscopic ultrasound-fine needle biopsies of pancreatic lesions: Prospective study of histology quality using Franseen needle. World J Gastroenterol 2020; 26:5693-5704. [PMID: 33088162 PMCID: PMC7545386 DOI: 10.3748/wjg.v26.i37.5693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/21/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The introduction of fine needle biopsies (FNB) to clinical practice presents a changing trend towards histology in the endoscopic ultrasound-guided tissue acquisition (EUS-TA).
AIM To evaluate the clinical performance of a new FNB needle, the 22-gauge (22G) Franseen needle, when sampling pancreatic solid lesions.
METHODS Consecutive patients with an indication for EUS-TA for the assessment of pancreatic solid lesions were included in this prospective, single-center, single-arm trial. Each patient underwent a puncture of the lesion two times using the 22G Franseen needle and the obtained samples were directly placed into formalin for histological analysis. The primary study endpoint was the rate of high-quality obtained specimen. Secondary endpoints included the length and diameter of the core specimen, the diagnostic accuracy and the complication rate.
RESULTS From June 2017 to December 2018, forty patients with pancreatic solid lesions (22 females; mean age 67.2 years) were enrolled. Tissue acquisition was achieved in all cases. High-quality histology, rated with Payne score 3, was obtained in 37/40 cases (92.5%) after two needle passes. The mean size of the acquired histological core tissue was 1.54 mm × 0.39 mm. The diagnostic accuracy for the correct diagnosis was 85% (34/40). Only one adverse event was occurred, consisting of a self-limiting bleeding in the puncture site.
CONCLUSION The 22G Franseen needle achieved according to our standardized protocol a high rate of histological core procurement, and a high diagnostic accuracy, with one minor adverse event reported.
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Affiliation(s)
- Petros Stathopoulos
- Division of Endoscopy, Department of Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Marburg, Marburg 35043, Hessen, Germany
| | - Anika Pehl
- Institute of pathology, University Hospital Marburg, Marburg 35043, Hessen, Germany
| | - Lutz Philipp Breitling
- Division of Endoscopy, Department of Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Marburg, Marburg 35043, Hessen, Germany
| | - Christian Bauer
- Division of Endoscopy, Department of Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Marburg, Marburg 35043, Hessen, Germany
| | - Tobias Grote
- Division of Endoscopy, Department of Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Marburg, Marburg 35043, Hessen, Germany
| | - Thomas Mathias Gress
- Division of Endoscopy, Department of Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Marburg, Marburg 35043, Hessen, Germany
| | - Carsten Denkert
- Institute of pathology, University Hospital Marburg, Marburg 35043, Hessen, Germany
| | - Ulrike Walburga Denzer
- Division of Endoscopy, Department of Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Marburg, Marburg 35043, Hessen, Germany
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50
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Chong CCN, Lakhtakia S, Nguyen N, Hara K, Chan WK, Puri R, Almadi MA, Ang TL, Kwek A, Yasuda I, Doi S, Kida M, Wang HP, Cheng TY, Jiang Q, Yang A, Chan AWH, Chan S, Tang R, Iwashita T, Teoh AYB. Endoscopic ultrasound-guided tissue acquisition with or without macroscopic on-site evaluation: randomized controlled trial. Endoscopy 2020; 52:856-863. [PMID: 32498098 DOI: 10.1055/a-1172-6027] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The use of macroscopic on-site evaluation (MOSE) to estimate the adequacy of a specimen for histological diagnosis during endoscopic ultrasound (EUS)-guided fine-needle tissue acquisition (FNTA) has recently been advocated. This study aimed to evaluate the diagnostic yield of MOSE compared with conventional EUS-FNTA without rapid on-site evaluation (ROSE). METHODS This was an international, multicenter, prospective, randomized controlled study. After providing informed consent, consecutive adult patients referred for EUS-FNTA for solid lesions larger than 2 cm were randomized to a MOSE arm or to a conventional arm without ROSE. A designated cytopathologist from each center performed all cytopathological examinations for that center and was blinded to the randomization results. The primary outcome measure was the diagnostic yield, and the secondary outcomes included sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, and the rate of procedure-related complications. RESULTS 244 patients (122 conventional, 122 MOSE) were enrolled during the study period. No significant differences between the two arms were found in procedure time or rate of procedure-related adverse events. The diagnostic yield for the MOSE technique (92.6 %) was similar to that for the conventional technique (89.3 %; P = 0.37), with significantly fewer passes made (median: conventional 3, MOSE 2; P < 0.001). CONCLUSIONS EUS-FNTA with the MOSE technique provided a similar diagnostic yield to conventional EUS-FNTA technique in the absence of ROSE but with fewer passes. This technique can be used when ROSE is not available.
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Affiliation(s)
- Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nam Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Wah Kheong Chan
- Department of Medicine, Faculty of Medicine, University of Malaya Medical Center, University of Malaya, Kuala Lumpur, Malaysia
| | - Rajesh Puri
- Department of Gastroenterology and Hepatology, Medanta, The Medicity, Gurgaon, India
| | - Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Tsu-Yao Cheng
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Qingwei Jiang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Aiming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Anthony W H Chan
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Shannon Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Raymond Tang
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Anthony Y B Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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