The utility of repeat endoscopic ultrasound-guided fine needle aspiration for suspected pancreatic cancer. Gastroenterol Res Pract. 2010;2010:268290. [PMID: 21234311 PMCID: PMC3018632 DOI: 10.1155/2010/268290]

K-ras gene mutation analysis to diagnosis pancreatic adenocarcinoma from endoscopic ultrasound-guided tissue acquisition; a systematic review and meta-analysis

BACKGROUND

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has high sensitivity for the pathological diagnosis of pancreatic masses, but also a high false-negative rate. K-ras gene mutations occur in over 75 % of pancreatic ductal adenocarcinomas (PDAC), and this meta-analysis evaluated the utility of detecting K-ras gene mutations from EUS-TA specimens for the diagnosis of PDAC.

METHODS

Relevant studies in PubMed, the Cochrane Library, and Web of Science were systematically searched. Meta-analysis was performed on data from the selected studies using a bivariate model to provide pooled values of sensitivity, specificity, and their 95 % confidence intervals (CIs).

RESULTS

This meta-analysis included 1521 patients (from 10 eligible studies) who underwent EUS-TA with K-ras gene mutation analysis for diagnosis of pancreatic solid masses. The pooled estimates of sensitivity and specificity were 76.6 % (95 % CI, 70.9-81.5 %) and 97.0 % (95 % CI, 94.0-98.5 %), respectively, for pathological diagnosis, 75.9 % (95 % CI 69.5-81.4 %) and 95.3 % (95 % CI, 92.3-97.2 %) for K-ras gene mutation analysis, and 88.7 % (95 % CI 87.1-91.7 %) and 94.9 % (95 % CI, 91.5-97.0 %) for pathological diagnosis in combination with K-ras gene mutation analysis. The sensitivity for diagnosis of PDAC was significantly higher for pathological diagnosis in combination with K-ras gene mutation analysis than for pathological diagnosis or K-ras gene mutation analysis alone (both, p < 0.001). There was no difference in specificity between pathological diagnosis in combination with K-ras gene mutation analysis and both either (p = 0.234, 0.945, respectively).

CONCLUSIONS

K-ras gene mutation analysis in combination with to pathological diagnosis of EUS-TA increases the accuracy of differential diagnosis of PDAC.

Diagnostic Yield of Repeat Endoscopic Ultrasound-Guided Fine Needle Biopsy for Solid Pancreatic Lesions

PATIENTS AND METHODS

we performed a retrospective case-control study, including cases with repeat EUS FNB for a solid pancreatic lesion, matched on a 1:2 ratio on age, sex, tumor location and presence of chronic pancreatitis with cases diagnosed on the first EUS FNB.

RESULTS

thirty-four cases and 68 controls were included in the analysis. Diagnostic accuracies were 80% and 88% in the repeat and single EUS FNB groups, respectively (p = 0.824). The second EUS FNB had a sensitivity of 80%, a specificity of 75%, a positive predictive value of 96%, and a negative predictive value of 33%. Of the 34 patients in the repeat EUS FNB group, 25 (74%) had a positive diagnosis with the second EUS FNB, 4 (12%) after surgery due to a second negative EUS FNB, 4 (12%) during clinical follow-up, and 1 (3%) after a third EUS FNB. Of the 25 patients diagnosed on the repeat EUS FNB, 17 (68%) had pancreatic adenocarcinomas, 2 (8%) neuroendocrine tumors, 2 (8%) other autoimmune pancreatitis, 2 (8%) chronic pancreatitis nodules, 1 (4%) renal cancer metastasis, and 1 (4%) other malignant diagnostic. There were no complications reported after the second EUS FNB in this study.

CONCLUSION

repeat EUS FNB made a diagnosis in three fourths of patients with solid pancreatic lesions and a first negative EUS FNB, with 26% of benign lesions. This supports the repetition of EUS FNB sampling in this clinical situation.

Pancreatic cancer, autoimmune or chronic pancreatitis, beyond tissue diagnosis: Collateral imaging and clinical characteristics may differentiate them

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies and is developing into the 2^nd leading cause of cancer-related death. Often, the clinical and radiological presentation of PDAC may be mirrored by other inflammatory pancreatic masses, such as autoimmune pancreatitis (AIP) and mass-forming chronic pancreatitis (MFCP), making its diagnosis challenging. Differentiating AIP and MFCP from PDAC is vital due to significant therapeutic and prognostic implications. Current diagnostic criteria and tools allow the precise differentiation of benign from malignant masses; however, the diagnostic accuracy is imperfect. Major pancreatic resections have been performed in AIP cases under initial suspicion of PDAC after a diagnostic approach failed to provide an accurate diagnosis. It is not unusual that after a thorough diagnostic evaluation, the clinician is confronted with a pancreatic mass with uncertain diagnosis. In those cases, a re-evaluation must be entertained, preferably by an experienced multispecialty team including radiologists, pathologists, gastroenterologists, and surgeons, looking for disease-specific clinical, imaging, and histological hallmarks or collateral evidence that could favor a specific diagnosis. Our aim is to describe current diagnostic limitations that hinder our ability to reach an accurate diagnosis among AIP, PDAC, and MFCP and to highlight those disease-specific clinical, radiological, serological, and histological characteristics that could support the presence of any of these three disorders when facing a pancreatic mass with uncertain diagnosis after an initial diagnostic approach has been unsuccessful.

Repeat EUS-FNA of pancreatic masses after nondiagnostic or inconclusive results: systematic review and meta-analysis

BACKGROUND AND AIMS

EUS-guided FNA (EUS-FNA) is the criterion standard for the diagnosis of solid pancreatic lesions. Several studies assessed the role of repeat EUS-FNA (rEUS-FNA) after an inconclusive examination. Our aim was to evaluate the pooled diagnostic accuracy of rEUS-FNA after a nondiagnostic result.

METHODS

We conducted systematic research on electronic databases (Medline, PubMed, EMBASE) and a meta-analysis to obtain pooled sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio. A summary receiver operating characteristic curve was used to calculate area under the curve. Subgroup analysis was used to assess the role of rapid on-site evaluation (ROSE).

RESULTS

Twelve studies (505 patients) were included. Sensitivity was 77% (66%-86%), specificity 98% (78%-100%), and positive and negative predictive values 99% (98%-100%) and 61 (60%-63%), respectively. At 73% of disease prevalence (pretest probability), positive rEUS-FNA increased the disease probability to 99%, whereas a negative result decreased the disease probability to 39%. The sensitivity was 83% (64%-93%) and specificity 98% (80%-100%) when ROSE was available and 65% (57%-73%) and 94% (31%-100%) when not available. The number needed to diagnose was 1.2 (1.1-2.3) and 1.7 (1.4-8.3) in ROSE-positive and ROSE-negative cases, respectively. The number of correctly diagnosed cases increased from 6 (1-7) to 8 (4-9) of 10 patients without and with ROSE, respectively.

CONCLUSIONS

This study objectively substantiated the added value of rEUS-FNA for the diagnosis of solid pancreatic masses in cases of a previous nondiagnostic or inconclusive result. Moreover, our data suggested that ROSE may be beneficial in this setting, because it increased the proportion of definitive diagnoses.

Follow-up of indeterminate cytologic diagnoses of solid pancreatic lesions: atypia versus suspicious (one institution's experience)

INTRODUCTION

A comparison of the long-term risk of malignancy between indeterminate cytological diagnoses, namely, atypical versus suspicious for malignancy, from endoscopic ultrasound-guided (EUS) fine-needle aspiration (FNA) of a pancreatic mass has not been well characterized. The primary aim of this study was to compare the risk of malignancy between patients with such indeterminate diagnoses. Secondarily, we investigated whether serologic markers serve as predictors of risk of malignancy in the setting of indeterminate cytological diagnoses.

MATERIALS AND METHODS

We reviewed 484 cases of EUS-FNA on solid pancreatic lesions, performed at a single academic tertiary care center from 2004 to 2017. Patients with solid pancreas mass lesions who had atypical or suspicious final cytology were identified for further clinical outcome analysis.

RESULTS

Of the 484 patients with pancreas mass lesions, 53 (11%) were given an indeterminate final cytologic diagnosis, with 28 atypical and 25 suspicious for malignancy. Follow-up was completed for 22 and 20 patients from atypical and suspicious diagnoses, respectively. Of patients with follow-up, 15 (68%) and 18 (90%) had subsequent diagnoses of malignancy from atypical and suspicious groups, respectively. There was no statistical difference in predicting risk of malignancy between the two groups (P = 0.24). Serologic markers were available in 29 of 42 patients with follow-up. Serologic markers were elevated in 21 of 29 patients and all were subsequently diagnosed with malignancy. Elevated serologic markers correlated with future risk of malignancy (P = 0.0026).

CONCLUSION

The risk of subsequent malignancy is high for both atypical and suspicious pancreatic solid lesions but there exists no statistical difference between the two. Combined serologic markers with indeterminate cytology proved to be a good predictor of malignancy.

Team work and cytopathology molecular diagnosis of solid pancreatic lesions

Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second leading cause of cancer-associated death in the next decade or so. It is widely accepted that tumorigenesis is linked to specific alterations in key genes and pancreatic neoplasms are some of the best characterized at the genomic level. Recent whole-exome and whole-genome sequencing analyses confirmed that PDAC is frequently characterized by mutations in a set of four genes among others: KRAS, TP53, CDKN2A/p16, and SMAD4. Sequencing, for example, is the preferable technique available for detecting KRAS mutations, whereas in situ immunochemistry is the main approach for detecting TP53 gene alteration. Nevertheless, the diagnosis of PDAC is still a clinical challenge, involving adequate acquisition of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) and specific pathological assessment from tissue architecture to specific biomolecular tests. The aim of the present review is to provide a complete overview of the current knowledge of the biology of pancreatic cancer as detected by the latest biomolecular techniques and, moreover, to propose a paradigm for strict teamwork collaboration in order to improve the correct use of diagnostic sources.

Imaging modalities for characterising focal pancreatic lesions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Harmonic contrast-enhanced endoscopic ultrasound fine-needle aspiration: Fact or fiction?

The negative predictive value of endoscopic ultrasonography fine-needle aspiration is relatively low. To achieve the improvement of the diagnostic yield, the following were proposed: a higher number of passes, the presence of the rapid on-site cytopathologist evaluation, the fanning technique, or the repetition of the fine needle biopsy. Harmonic contrast-enhanced endosonography may better identify the targeted area in the lesions by avoiding the inside necrosis and the vessels of fibrosis, so it can guide the fine-needle aspiration. Both techniques are complementary, not competitive, and they can be done in the same session. The combined technique is simple, safe, and requires only a few minutes with minimal extra costs compared to standard fine-needle aspiration. It minimally increases the diagnostic rate, and it permits the decrease of the number of passes. However, we will know its real clinical impact only in the future and whether it will be incorporated into the lesion assessment process.

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

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Repeat Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Patients with Suspected Pancreatic Cancer: Diagnostic Yield and Associated Change in Access to Appropriate Care

Background. There is a high incidence of inconclusive cytopathology at initial EUS-FNA (endoscopic ultrasound-guided fine-needle aspiration) for suspected malignant pancreatic lesions. To obtain appropriate preoperative or palliative chemotherapy for pancreatic cancer, definitive cytopathology is often required. The utility of repeat EUS-FNA is not well established. Methods. A retrospective cohort study was conducted evaluating the yield of repeat EUS-FNA in determining a cytological diagnosis in patients who had undergone a prior EUS-FNA for diagnosis of suspected malignant pancreatic lesions with inconclusive cytopathology. The wait times to the second procedure and to decisions regarding therapy were calculated. Results. Overall, 45 repeat EUS-FNA procedures were performed over seven years for suspected malignant pancreatic lesions. Cytopathological class (I to IV) changed between first and second EUS-FNA in 32 patients (71%). Of 34 patients with an initially nonconclusive diagnosis, 20 had a conclusive diagnosis (59%) on repeat EUS-FNA. The cumulative yield after repeat EUS-FNA for definite pancreatic adenocarcinoma was 7 (16%). The median time interval between first and second EUS-FNA was 31 (7-175) days. Conclusions. A substantial number of patients had a definitive diagnosis of adenocarcinoma on repeat FNA and were, therefore, subsequently able to access appropriate care.

Repeat endoscopic ultrasound fine needle aspiration after a first negative procedure is useful in pancreatic lesions

Background and Objectives:

There is no consensus about the ideal method for diagnosis in patients who have already undergone endoscopic ultrasound fine needle aspiration (EUS-FNA), and the inconclusive material is often obtained. The aim was to evaluate the diagnostic yield of the second EUS-FNA of pancreatic lesions.

Materials and Methods:

A retrospective analysis of prospectively collected data of patients with EUS-FNA of pancreatic lesions is performed. All patients who underwent more than one EUS-FNA for the evaluation of suspected pancreatic cancer over a 7-year period were included in the analysis.

Results:

A total of 296 EUS-FNAs of the pancreas were performed in 257 patients. The diagnostic yield with the first EUS-FNA was 78.6% (202/257). Thirty-nine (13.3%) FNAs were repeated in 34 patients; 17 (50%) patients were women. The mean ± standard deviation (SD) age was 58.8 ± 16.1 years. The location of the lesions in the pancreatic gland, from which the second biopsies were taken, was head of the pancreas, n = 28 (82.4%), body of the pancreas, n = 3 (8.8%), and tail, n = 3 (8.8%). The mean ± SD of the size of the lesion was 36.3 ± 14.6 mm. The second EUS-FNA was more likely to be positive for diagnosis in patients with an “atypical“ histological result in the first EUS-FNA (odds ratio [OR]: 4.04; 95% confidence interval [CI]: 0.9–18.3), in contrast to patients with a first EUS-FNA reported as “normal” (OR: 0.21; 95% CI: 0.06–0.71). Overall, the diagnostic yield of the second EUS-FNA was 58.8% (20/34) with an increase to 86.3% overall (222/257).

Conclusion:

Repeat EUS-FNA in pancreatic lesions is necessary in patients with a negative first EUS-FNA because it improves the diagnostic yield.

Endoscopic ultrasound in the evaluation of pancreatic neoplasms-solid and cystic: A review

Pancreatic neoplasms have a wide range of pathology, from pancreatic adenocarcinoma to cystic mucinous neoplasms. Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) is a helpful diagnostic tool in the work-up of pancreatic neoplasms. Its utility in pancreatic malignancy is well known. Over the last two decades EUS-FNA has become a procedure of choice for diagnosis of pancreatic adenocarcinoma. EUS-FNA is highly sensitive and specific for solid lesions, with sensitivities as high as 80%-95% for pancreatic masses and specificity as high as 75%-100%. Multiple aspects of the procedure have been studied to optimize the rate of diagnosis with EUS-FNA including cytopathologist involvement, needle size, suctioning and experience of endoscopist. Onsite pathology is one of the most important elements in increasing diagnostic yield rate in EUS-FNA. EUS-FNA is valuable in diagnosing rare and atypical pancreatic neoplasms including neuroendocrine, lymphoma and metastatic disease. As more and more patients undergo cross sectional imaging, cystic lesions of the pancreas are becoming a more common occurrence and EUS-FNA of these lesions can be helpful for differentiation. This review covers the technical aspects of optimizing pancreatic neoplasm diagnosis rate, highlight rare pancreatic neoplasms and role of EUS-FNA, and also outline the important factors in diagnosis of cystic lesions by EUS-FNA.

Impact of inconclusive endoscopic ultrasound-guided fine-needle aspiration results in the management and outcome of patients with solid pancreatic masses

BACKGROUND AND AIM

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can be inconclusive in diagnosing solid pancreatic masses. The aim of the present study was to evaluate the impact of an inconclusive EUS-FNA in the management of patients with solid pancreatic masses.

METHODS

This is a retrospective analysis of a prospective database of patients with solid pancreatic masses referred for EUS-FNA between December 2011 and December 2013. Consecutive patients with inconclusive initial EUS-FNA were included. Demographic, clinical, procedural and outcome data were analyzed.

RESULTS

Over the study period, 387 patients underwent EUS-FNA of solid pancreatic masses, of which 38 patients had inconclusive cytology. Of the 38 patients, 18 were categorized as atypical, two were categorized as indeterminate or suspicious for malignancy, and 18 were categorized as benign process. Subsequently, 24 (63.2%) patients achieved cytopathological diagnosis by repeat EUS-FNA (8), transcutaneous FNA (4) and surgery (12). Repeat EUS-FNA were done a median of 13 days after the index examination and resulted in conclusive diagnosis in 72.7% of cases. Five patients undergoing surgery were confirmed to have benign lesions. In 14 (36.8%) patients not receiving a positive cytopathological diagnosis, 11 were eventually confirmed to be malignant based on clinical outcome and imaging evidence.

CONCLUSIONS

Inconclusive EUS-FNA could lead to unnecessary surgical procedures in patients with resectable solid pancreatic masses if no cytopathological diagnosis is obtained through either repeat or alternative diagnostic modalities. Repeat EUS-FNA provided a conclusive diagnosis in a majority of cases, and therefore should be strongly considered ahead of other modalities.

Neoplasia in chronic pancreatitis: how to maximize the yield of endoscopic ultrasound-guided fine needle aspiration

When performing endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), identifying neoplasia in the setting of chronic pancreatitis can be technically challenging. The morphology of an ill-defined mass on sonography, presence of calcifications or intervening collaterals, reverberation from a biliary stent, low yield of tissue procurement, and interpretative errors in cytopathology can result in both false-negative and false-positive results. Although these challenges cannot be completely eliminated, elastography or contrast-enhanced imaging can aid in differentiating an inflammatory mass from a neoplasm. Also, performing more passes of FNA, procuring core biopsy material, performing rapid onsite evaluation, conducting ancillary pathology studies, and even repeating the procedure on a different day can aid in improving the diagnostic performance of EUS-FNA. This review provides a concise update and offers practical tips to improving the diagnostic yield of EUS-FNA when sampling solid pancreatic mass lesions in the setting of chronic pancreatitis.

Predictors of malignancy in patients with suspicious or indeterminate cytology on pancreatic endoscopic ultrasound-guided fine-needle aspiration: a multivariate model

OBJECTIVE

The aim of this study was to evaluate predictors of malignancy in pancreatic lesions with suspicious or indeterminate endoscopic ultrasound fine-needle aspiration (EUS-FNA) cytology.

METHODS

Suspicious/indeterminate EUS-FNA cytology was identified from our database. Stable imaging, benign pathology, or survival for 12 months after EUS-FNA was considered benign. Diagnosis of malignancy was based on positive pathology, local invasion/metastasis on imaging, or death within 12 months from cancer-associated causes. Univariate analysis was performed to compare variables between benign and malignant lesions. Multivariate analysis (covariates: age [<70 or ≥70], appearance [solid/cystic], size [<20 or ≥20 mm], and serum CA19-9 [<40 or ≥40]) was performed using binary logistic regression.

RESULTS

There were 81 patients with suspicious or indeterminate cytology. Final diagnosis was cancer in 55 (67.9%) of 81 (adenocarcinoma in 40/81 [49.4%], "other neoplasms" in 15/81 [18.5%]) and benign in 26 (32.1%) of 81. Univariate analysis revealed a difference in age, lesion size, solid/cystic characteristics, and serum CA 19-9 between benign and malignant lesions. Only elevated serum CA 19-9 was independently associated with a diagnosis of malignancy on multivariate analysis.

CONCLUSIONS

Age, lesion size, and solid/cystic characteristics on EUS were not independently associated with cancer. Pancreatic lesions with suspicious/indeterminate cytology and elevated serum CA 19-9 should be considered as concerning for a malignant diagnosis.

Tips to overcome technical challenges in EUS-guided tissue acquisition

The diagnostic yield of EUS-FNA depends on several factors, such as the experience of the endosonographer, the characteristics of the lesion, the clinical status of the patient, the size and type of needles, the methods of specimen preparation, as well as cytopathologist expertise. The endosonographic technique can be improved when several tips and tricks useful to overcome challenges of FNA are known. Technical challenges of FNA are related to the characteristics of the lesion and its surroundings, sonographic imaging, and limitations related to the needle. Several tips and tricks necessary to overcome them are presented in this review.

The role of K-ras gene mutation analysis in EUS-guided FNA cytology specimens for the differential diagnosis of pancreatic solid masses: a meta-analysis of prospective studies

BACKGROUND

Differential diagnosis of pancreatic solid masses with EUS-guided FNA (EUS-FNA) is still challenging in about 15% of cases. Mutation of the K-ras gene is present in over 75% of pancreatic adenocarcinomas (PADC).

OBJECTIVE

To assess the accuracy of K-ras gene mutation analysis for diagnosing PADC.

DESIGN

We systematically searched the electronic databases for relevant studies published. Data from selected studies underwent meta-analysis by use of a bivariate model providing a pooled value for sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve.

SETTING

Meta-analysis of 8 prospective studies.

PATIENTS

Total of 931 patients undergoing EUS-FNA for diagnosis of pancreatic solid masses.

INTERVENTION

K-ras mutation analysis.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy of K-ras mutation analysis and of combined diagnostic strategy by using EUS-FNA and K-ras mutation analysis in the diagnosis of PADC.

RESULTS

The pooled sensitivity of EUS-FNA for the differential diagnosis of PADC was 80.6%, and the specificity was 97%. Estimated sensitivity and specificity were 76.8% and 93.3% for K-ras gene analysis, respectively, and 88.7% and 92% for combined EUS-FNA plus K-ras mutation analysis. Overall, K-ras mutation testing applied to cases that were inconclusive by EUS-FNA reduced the false-negative rate by 55.6%, with a false-positive rate of 10.7%. Not repeating EUS-FNA in cases in which mutation testing of the K-ras gene is inconclusive would reduce the repeat-biopsy rate from 12.5% to 6.8%.

LIMITATIONS

Small number of studies and between-study heterogeneity.

CONCLUSION

K-ras mutation analysis can be useful in the diagnostic work-up of pancreatic masses, in particular when tissue obtained by EUS-FNA is insufficient, and the diagnosis inconclusive.

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

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

Technical Advances in Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition for Pancreatic Cancers: How Can We Get the Best Results with EUS-Guided Fine Needle Aspiration?

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.

Endoscopic ultrasound guided fine needle aspiration for the diagnosis of pancreatic cystic neoplasms: a meta-analysis

BACKGROUND AND OBJECTIVES

Mucinous cystic neoplasms and intraductal papillary mucinous tumours have greater malignant potential than serous cystic neoplasms. EUS alone is inadequate for characterising these lesions but the addition of FNA may significantly improve diagnostic accuracy. The performance of EUS-FNA is highly variable in published studies.

AIM

To determine the diagnostic accuracy of EUS-FNA to differentiate mucinous versus non-mucinous cystic lesions with cyst fluid analysis for cytology and carcinoembryonic antigen (CEA) by performing a meta-analysis of published studies.

METHODS

Relevant studies were identified via structured database search and included if they used a reference standard of definitive surgical histology or clinical follow-up of at least 6 months. Data from selected studies were pooled to give summary sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio and Receiver Operating Characteristic (ROC) curve. Pre-defined subgroup analysis was performed.

RESULTS

Eighteen studies (published 2002-2011) were included, with a total of 1438 patients. For cytology, pooled sensitivity was 54(95%CI 49-59)% and specificity 93(90-95)%. The diagnostic odds ratio (DOR) was 13.3 (4.37-49.43), with I(2) of 77.1%. For CEA sensitivity was 63(59-67)% and specificity 88(83-91)%. The DOR was 10.76(6.29-18.41) with an I(2) of 25.4%. The diagnostic accuracy of EUS-FNA was enhanced in prospective studies and studies of <36 months duration. No impact of publication bias on our results was demonstrated.

CONCLUSIONS

Fine-needle aspiration has moderate sensitivity but high specificity for mucinous lesions. EUS-FNA, when used in conjunction with cross sectional imaging, is a useful diagnostic tool for the correct identification of mucinous cysts.

Factors affecting the diagnostic accuracy of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) for upper gastrointestinal submucosal or extraluminal solid mass lesions

AIM

A number of potential variables are associated with the diagnostic accuracy of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA). The aim of this study was to evaluate factors affecting the diagnostic accuracy of EUS-FNA for upper gastrointestinal submucosal or extraluminal solid lesions.

METHODS

Patients with such lesions who underwent EUS-FNA between January 2009 and December 2010 were studied retrospectively. Needles of 22, 25 and 19 gauge were used. The associations between the EUS-FNA results and factors such as mass location, mass size, needle size, number of needle passes, combined histologic-cytologic analysis and final diagnosis were analyzed.

RESULTS

A total of 170 EUS-FNA procedures were performed in 158 patients with upper gastrointestinal submucosal or extraluminal solid lesions. The overall accuracy of EUS-FNA was 86.5% (147/170). The diagnostic accuracy with three or more needle passes was higher than with less than 3.0 needle passes (90.0%, 108/120 vs 78.0%, 39/50; P < 0.05). Mass location, mass size, and final diagnosis were not associated with EUS-FNA accuracy. Combined cytologic-histologic analysis had significantly higher diagnostic accuracy than either cytologic or histologic analysis alone (P < 0.001). In a subgroup of 90 patients, both 22 and 25 gauge needles were used for EUS-FNA. The overall diagnostic accuracy was similar for 25 gauge needles and 22 gauge needles (80.0% vs 78.9% P = 1.000) in this subgroup.

CONCLUSION

Overall, 25 and 22 gauge needles have a similar diagnostic accuracy. Our results suggest that 3.0 or more needle passes and combined cytologic-histologic analysis enhance the diagnostic accuracy of EUS-FNA.

Best practices in endoscopic ultrasound-guided fine-needle aspiration

Over the past 2 decades, endoscopic ultrasound-guided fine-needle aspiration has evolved to become an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. The technique is useful for biopsy of mucosal and submucosal lesions in which prior endoscopic biopsies have been nondiagnostic; to sample peri-intestinal structures such as lymph nodes; and to sample masses in the pancreas, liver, adrenal glands, gallbladder, and bile duct. Also, with the advent of neoadjuvant therapies for diseases such as pancreatic cancer, most patients require a tissue diagnosis before initiating treatment. This review provides a perspective on technical issues that are key for best practices in endoscopic ultrasound-guided fine-needle aspiration.

How can we get the best results with endoscopic ultrasound-guided fine needle aspiration?

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has evolved to become an indispensable tool for tissue acquisition. While the overall diagnostic accuracy of EUS-FNA is greater than 90% for lung cancer staging, it is lower for pancreatic mass lesions. Several factors such as location of the tumor, disease characteristics and procedural techniques determine the outcomes of EUS-FNA. In this review we evaluate the various technical factors that are keys to attaining optimal procedural outcomes.

EUS-guided FNA of solid pancreas tumors

Although endoscopic ultrasonography (EUS) is considered superior to MRI and CT in detecting pancreatic masses, it is the ability to target and place a needle into suspicious lesions that has made EUS indispensible in the evaluation of patients with solid pancreatic tumors. Endoscopic ultrasound-guided-fine-needle aspiration (EUS-FNA) is an accurate and safe technique to confirm the diagnosis of pancreatic cancer. EUS-FNA is now the principal technique applied to obtain the diagnosis of malignancy. We have designed this article to address a number of the key technical aspects of EUS-FNA of solid pancreatic masses.