Accuracy and Quality Assessment of EUS-FNA: A Single-Center Large Cohort of Biopsies. Diagn Ther Endosc. 2012;2012:139563. [PMID: 23197929 PMCID: PMC3503321 DOI: 10.1155/2012/139563]

Classification of endoscopic ultrasound guided fine needle aspiration cytology of pancreatic space occupying lesions by Papanicolaou Society of Cytopathology System: A five year study

BACKGROUND

Majority of the pancreatic cancer patients present at an advanced stage and have poor 5 year survival rate. Thus, there is a need for early detection of pancreatic cancer with the initiation of the therapy.

MATERIALS & METHODS

This is a retrospective study including all the endoscopic ultrasound guided (EUS) guided pancreatic FNAs from 2016 to 2020. The aspirate smears were analyzed and classified according to The Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology (PSCPC).

RESULTS

A total of 245 EUS guided FNAs from pancreatic lesions were included. Cyto-histological correlation was done wherever available. Category I (non diagnostic) accounted for 40 cases (16%) cases, Category II (negative) comprised of 44 cases (18%); and Category III (Atypical) had 5 cases (2%). Category IV neoplastic-benign category included 3 cases of serous cystadenoma, while neoplastic-others category included pancreatic neuroendocrine tumors (n = 21), solid pseudo-papillary neoplasms (SPEN) (n = 12) and mucinous cystic neoplasms (n = 4). A total of 7 cases (2.8%) were reported in Category V (Suspicious). A diagnosis of adenocarcinoma (Category VI) was rendered in 105 cases (42.8%) cases. Rarer types included non Hodgkins lymphoma (n = 3) and one case of primary undifferentiated carcinoma with osteoclastic giant cells. Cyto-histological correlation in all categories was available in 58 cases with 8 false negative cases. Thus overall sensitivity of EUS guided FNAC was found to be 87.8% with a diagnostic yield of 83.6% while sensitivity in diagnosing adenocarcinoma was 96.9%.

CONCLUSION

The present study highlights the spectrum of EUS guided FNA of pancreatic lesions in a subset of North Indian population and classified them according to PSCPC. EUS guided FNAC is a sensitive investigation which plays a crucial role in confirming the diagnosis of pancreatic space occupying lesions (SOLs) in advanced stage.

Natural History of Asymptomatic Esophageal Subepithelial Tumors of 30 mm or Less in Size

BACKGROUND

No definite guidelines for the management of small esophageal subepithelial tumors (SETs) have been established, because there are limited data and studies on their natural history. We aimed to assess the natural history and propose optimal management strategies for small esophageal SETs.

METHODS

Patients diagnosed as esophageal SETs ≤ 30 mm in size between 2003 and 2017 using endoscopic ultrasound (EUS) with a minimal follow-up of 3 months were enrolled, and their esophagogastroduodenoscopy (EGD) and EUS were retrospectively reviewed.

RESULTS

Of 275 esophageal SETs in 262 patients, the initial size was < 10 mm, 10-20 mm, and 20-30 mm in 104 (37.8%), 105 (38.2%), and 66 (24.0%) lesions, respectively. Only 22 (8.0%) SETs showed significant changes in size and/or echogenicity and/or morphology at a median of 40 months (range, 4-120 months). Tissues of 6 SETs showing interval changes were obtained using EUS-guided fine needle aspiration biopsy; 1 was identified as a gastrointestinal stromal tumor (GIST) and was surgically resected, while the other 5 were leiomyomas and were regularly observed. Eight SETs showing interval changes were resected surgically or endoscopically without pathological confirmation; 1 was a GIST, 2 were granular cell tumors, and the other 5 were leiomyomas.

CONCLUSION

Regular follow-up with EGD or EUS may be necessary for esophageal SETs ≤ 30 mm in size considering that small portion of them has a possibility of malignant potential. When esophageal SETs ≤ 30 mm show significant interval changes, pathological confirmation may precede treatment to avoid unnecessary resection.

Analysis of Decreasing Adverse Events with Endoscopic Ultrasound in a New Advanced Endoscopy Program Over Time

OBJECTIVE

New innovations and increasing utility of endoscopic ultrasound (EUS) are associated with rare but serious risks. We investigate the rates and risk factors for post-procedural complications over a four-year period at a new advanced endoscopy program.

METHODS

We conducted a retrospective review of all adult patients who underwent upper EUS at an academic level-1 trauma center between April 2015 and November 2019. The primary outcome was the incidence of adverse events within 1 week of EUS. Secondary outcomes included emergency department visits and mortality within 30 days after EUS. Chi-square test, t test, and multivariable logistic regression were used to assess risk factors for post-procedural complications.

RESULTS

A total of 968 EUS procedures were performed on 864 patients (54% female; 79% Caucasian; mean age 61 years). The overall incidence of post-procedural adverse event with EUS was 5.6%. The probability of an adverse event decreased by an average of 22% per year (p =0.01, OR 0.78). The risk for adverse events were 3.3% acute pancreatitis, 1.9% clinically significant bleeding, 0.3% bacteremia, 0.2% perforation, and 2.4% 30-day mortality. The adverse event rate was highest among low volume proceduralists (p =0.04). The 30-day mortality was more than threefolds among patients who had an adverse event within 7 days after EUS.

CONCLUSION

The overall incidence of post-procedural adverse events at a new EUS program was 5.6%, with an average of 22% relative decrease in adverse events per year in the first 4 years.

Comparison of the reverse bevel versus Franseen type endoscopic ultrasound needle

BACKGROUND

Reverse bevel (RB) needle is widely used for endoscopic ultrasound fine needle biopsy (EUS-FNB). A 3-plane symmetrical needle with Franseen geometry (FG) has recently become available.

AIM

To compare the clinical efficacy of FG to that of RB needle.

METHODS

A retrospective cohort study of all adult patients who underwent EUS-FNB for solid and mixed lesions either with 22G RB needle or 22G FG needle between January 2016 and February 2019 was undertaken. All cytology slides were reviewed by an independent gastrointestinal cytopathologist blinded to the needle used and the initial cytology report. The primary and secondary outcomes were to assess the sample adequacy using Euro-cytology criteria and the number of cell clusters, respectively.

RESULTS

Two hundred and twenty six procedures were included in the study. RB needle was used in 128 procedures and FG needle in 98 procedures. The baseline characteristics of both groups were comparable. On multivariable analysis, FG needle (P = 0.02) and location of the lesion (P < 0.01) were independently associated with adequate tissue. Further, the use of FG needle (P = 0.04) and the size of the lesion (P = 0.02) were independently associated with acquisition of increased number of cell clusters.

CONCLUSION

FG needle is superior to RB needle in acquiring adequate tissue and attaining higher number of cell clusters for solid and mixed lesions.

EUS-guided FNA in Diagnosing Pancreatic Lesions: Strength and Cytological Spectrum

Introduction:

Early and accurate diagnosis is paramount for improving the therapeutic efficacy of pancreatic cancers. Endoscopic ultrasonography–fine needle aspiration (EUS-FNA) cytology has come up with the advantage of an early and accurate diagnosis of pancreatic cancers. This study was conducted to analyze the spectrum of pancreatic lesions cytology, and appraise the diagnostic accuracy of EUS-FNA cytology for pancreatic solid and cystic lesions.

Materials and Methods:

This retrospective study includes 288 EUS-guided pancreatic FNA cases. Clinical data, laboratory tests, cytopathology, histopathology, and imaging reports were retrieved. The final diagnosis was based on EUS-FNA cell block and/or pathology in surgical specimens, with immunohistochemistry support. The results of EUS-guided FNA were compared with the final diagnoses to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results:

Among 288 EUS-guided pancreatic FNA cases, 175 (62.0%) were malignant. The mean age was 57.8 ± 13.5 years and 50.1 ± 13.7 years, and the mean size of the lesion was 4.1 ± 1.8 cm and 2.2 ± 1.1 cm in malignant and benign groups, respectively. Sensitivity, specificity, PPV, and NPV of EUS-FNA cytology for solid malignant lesions were 98.3%, 95.1%, 98.3%, and 95.1%, and those for cystic lesions were 88%, 92.3%, 100%, and 100%. Diagnostic accuracy of EUS-FNA cytology for solid and cystic pancreatic lesions is 97.4% and 95.0%, respectively. In conclusion of the above; diagnosis of pancreatic solid and cystic malignancy can be assigned from a composite of the EUS-FNA cytology, cell block preparation and immunohistochemistry Diagnosis of pancreatic solid and cystic malignancy can be assigned from a composite of the EUS-FNA cytology, cell block preparation, and immunohistochemistry.

How to measure quality in endoscopic ultrasound

Quality is a key focus for gastrointestinal endoscopy and main international gastroenterology societies instituted specific task forces focused on this issue. Endoscopic ultrasound (EUS) represents one of the most fascinating fields to explore in gastrointestinal endoscopy due to its relatively limited availability out of high-volume centers. This leads to a particular need to define widely accepted quality indicators (QIs) and the ways to measure them. The current manuscript reviews these indicators in light of their impact on common clinical practice.

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.

Impact of endoscopic ultrasound quality assessment on improving endoscopic ultrasound reports and procedures

AIM: To evaluate the impact of endoscopic ultrasonography (EUS) quality assessment on EUS procedures by comparing the most recent 2013-2014 local EUS procedural reports against relevant corresponding data from a 2009 survey of EUS using standardized quality indicators (QIs).

METHODS: Per EUS exam, 27 QIs were assessed individually and by grouping pre-, intra-, and post-procedural parameters. The recorded QI frequencies from 200 reports (2013-2014) were compared to corresponding data of 100 reports from the quality control study of EUS in 2009. Data for QIs added after 2009 to professional guidelines (added after 2010) were also tabulated.

RESULTS: Significant differences (P-value < 0.05) were found for 13 of 20 of the relevant QIs examined. 4 of 5 pre-procedural QIs, 6 of 10 intra-procedural QIs, and 3 of 5 post-procedural QIs all demonstrated significant upgrading with a P-value < 0.05.

CONCLUSION: Significant improvements were demonstrated in QI adherence and thus EUS reporting and delivery quality when the 2013-2014 reports were compared to 2009 results. QI implementation facilitates effective high-quality EUS exams by ensuring comprehensive documentation while limiting error.

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

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

Diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology of pancreatic lesions

BACKGROUND

Endoscopic ultrasound-guided fine needle aspiration cytology (EUS-FNAC) is currently the most commonly used procedure for obtaining cytologic specimens of the pancreas. It is accurate, minimally invasive, safe and cost-effective. However, there is discrepancy between cytological and surgical diagnoses. This study was aimed at evaluating the diagnostic accuracy of EUS-FNAC of the pancreas.

METHODS

We performed a retrospective review of 191 cases of pancreatic lesions initially diagnosed by EUS-FNAC with subsequent histological diagnosis between 2010 and 2012 in the Department of Pathology, Seoul National University Hospital. Cytologic and surgical diagnoses were categorized into five groups: negative, benign, atypical, malignant, and insufficient for diagnosis. Subsequently, 167 cases with satisfactory yield in both surgical and cytology specimens were statistically analyzed to determine correlations with diagnosis.

RESULTS

In comparison to surgical diagnoses, cytologic diagnoses were true-positive in 103 cases (61.7%), true-negative in 28 cases (16.8%), false-positive in 9 cases (5.4%), and false-negative in 27 cases (16.1%). The diagnostic accuracy was 78.4%, sensitivity was 79.2%, and specificity was 75.7%. The positive predictive value was 92.0%, and negative predictive value was 50.9%.

CONCLUSIONS

EUS-FNAC has high accuracy, sensitivity, specificity and positive predictive value. Overcoming the limitations of EUS-FNAC will make it a useful and reliable diagnostic tool for accurate evaluation of pancreatic lesions.

Predictive value of intra-abdominal lymph nodes in pancreatic endoscopic ultrasonography-guided fine-needle aspiration biopsy

INTRODUCTION

Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) biopsy is a commonly used method for the evaluation of pancreatic lesions. EUS-guided FNA of the intra-abdominal lymph nodes (LNs) can provide critical diagnostic information that is important for clinical management and tumor staging. This study examines the predictive value of intra-abdominal LN EUS-guided FNA biopsy associated with pancreatic lesions.

MATERIALS AND METHODS

Over a 10-year period, the pathology database was searched for patients with concurrent pancreas and intra-abdominal LN EUS-guided FNA biopsy. The corresponding reports were reviewed, and clinical information and diagnostic results were recorded.

RESULTS

There were 252 cases where both a pancreas lesion and intra-abdominal LN were biopsied. Of this group, 182 LNs were classified as negative (72%), 47 as positive (19%), and 23 as atypical (9%). Within the negative LN cohort, the pancreas FNAs fell into the following diagnostic categories: benign (47%), malignant (30%), and atypical/suspicious (23%). Within the positive LN cohort, the pancreas lesion correlated with the following diagnostic categories: malignant (89%), atypical (4%), and suspicious (6%). A positive LN EUS-guided FNA biopsy had a 98% positive predictive value for malignancy. Within the atypical LN cohort, the pancreas correlated with the following diagnostic categories: malignant (57%), atypical/suspicious (26%), and benign (17%).

CONCLUSIONS

An atypical LN diagnostic category is strongly associated with a malignant pancreas lesion. A positive LN EUS-guided FNA biopsy has a 98% positive predictive value for pancreatic malignancy. A positive diagnostic category for an intra-abdominal LN can provide strong predictive evidence of a corresponding malignancy of the pancreas.

Beyond cytology: why and when does the oncologist require core tissue?

There are 2 main reasons why oncologists may require additional tissue and a histologic section in addition to cytopathology from FNA specimens: improved diagnostic accuracy and molecular characterization of tumors. Rather than mutually exclusive diagnostic procedures, EUS-FNA and EUS-CNB must be viewed as supplementary techniques and both approaches should be incorporated as essential tools in the current endoscopic armamentarium.

Basic technique in endoscopic ultrasound-guided fine needle aspiration for solid lesions: What needle is the best?

Basic technique for endoscopic ultrasound (EUS) of solid lesions has developed during 30 years of EUS, as endoscopes and accessory equipment, particularly needles, have been developed. Systematic high-quality examinations require understanding and planning. Needles used for EUS-guided fine needle aspiration (FNA) have gone through many improvements; some 18 characteristics of any needle are presented and these come under consideration whenever choosing the best needle for each procedure. The bright future of EUS and FNA for solid lesions currently still leaves much room for continued developments.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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