How good is fine needle aspiration? What results should you expect?

The role of fine-needle aspiration biopsy in the diagnosis of malignant tumors

Cytopathology and histopathology play a key role in the process of diagnosing oncological diseases and premalignant conditions. Fine-needle aspiration (FNA) is one of the techniques used for obtaining biopsy of a wide variety of body tissues, causing patients minimal discomfort. Therefore, it is often considered to be the best strategy for investigating and diagnosing some precancerous or potential malignant lesions. Being successful as a means of confirming the clinical suspicion of metastatic recurrence in the cases of an already known cancer, the interest has further focused on the preliminary diagnosis of various types of benign or malignant tumors. In cases of inoperable tumors, this technique is useful for formulating the final diagnosis. FNA biopsy proved its effectiveness as a highly accurate, cost-effective, and safe technique, with potential high diagnostic yield. Immunohistochemistry, used as an additional tool to classical histopathological examination, remains a very practical and reliable technique that promises good results especially in determining the site of origin within metastatic disease.

Diagnostic role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in abdominal lymphadenopathy of unknown etiology

Background

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established method for the evaluation of abdominal organ lesions. However, there are few studies on EUS-FNA for abdominal lymph node (LN) lesions. The purpose of this study was to evaluate the diagnostic role of EUS-FNA in isolated abdominal lymphadenopathy (LAP).

Methods

A retrospective analysis was performed on patients with isolated abdominal LAP who underwent a EUS-FNA examination. The diagnosis was made based on cytology, histology, and immunohistochemical (IHC) studies. The area under curve (AUC) value, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated.

Results

A total of 99 patients were included in this study. The final diagnoses were metastatic tumor (n = 32), lymphoma (n = 32), tuberculosis (n = 17), sarcoidosis (n = 5), castleman's disease (n = 1), and reactive LAP (n = 12). The AUC value, sensitivity, specificity, PPV, NPV, and accuracy of EUS-FNA in the diagnosis of malignant LAP were 0.9531, 90.6, 100, 100, 85.4, and 93.9%, respectively. For the diagnosis of lymphoma, the accuracy of EUS-FNA combined with IHC staining was 94.9%. Retroperitoneal LN enlargement is more commonly associated with lymphoma, while hepatic hilar LN enlargement predominantly suggests benign conditions or metastatic tumors. Malignant lymph nodes are more likely to be regular border, circular/quasi-circular, and fusion. Lymphomas are more likely to present with fusion and heterogeneous echogenicity than metastatic tumors.

Conclusion

EUS-FNA is a safe and effective method to diagnose isolated abdominal LAP.

Rapid On-Site Evaluation (ROSE): A Microfluidic Approach

Rapid on-site evaluation (ROSE) increases the diagnostic accuracy of fine-needle aspiration (FNA) samples from cysts, a sack-like fluid-containing tissue that sometimes can be precancerous, but is highly dependent on the skills and availability of cytopathologists. We present a semiautomated sample preparation device for ROSE. The device consists of a smearing tool and a capillary-driven chamber that allow smearing and staining of an FNA sample in a single platform. Here, we show the capability of the device to prepare samples for ROSE, using a human pancreatic cancer cell line (PANC-1) and liver, lymph node, and thyroid FNA model samples. Using microfluidics, the device reduces the equipment needed in an operating room for FNA sample preparation, which may lead to a wider implementation of ROSE in healthcare centers.

The utility of chest ultrasound-guided fine-needle biopsy in the diagnosis of plasmacytoma

Background

Plasmacytoma is a plasma cell dyscrasia originating from a single clone of plasma cells of B-lymphocyte lineage and produces a monoclonal immunoglobulin. Transthoracic fine-needle aspiration (TTNA) under ultrasound (US) guidance is a well-validated technique for the diagnosis of many neoplasms and has been shown to be safe and cost effective, with diagnostic yields comparable to more invasive techniques. However, the role of TTNA in the diagnosis of thoracic plasmacytoma is not well established.

Objectives

The aim of this study was to assess the utility of TTNA and cytology in confirming a diagnosis of plasmacytoma.

Methods

All cases of plasmacytoma diagnosed from January 2006 to December 2017 by the Division of Pulmonology, Tygerberg Hospital, were retrospectively identified. All patients who underwent an US-guided TTNA and of whose clinical records could be retrieved were included in this cohort. The International Myeloma Working Group's definition of a plasmacytoma was used as the gold standard.

Results

A total of 12 cases of plasmacytoma were identified and 11 patients included (one patient was excluded owing to missing medical records). Six of the 11 patients (mean age 59.5 ± 8.5 years) were male. Radiologically, most had multiple lesions (n=7), most commonly bony (n=6) with vertebral body involvement (n=5) and pleural-based lesions (n=2). Rapid onsite evaluation (ROSE) was performed and documented in 6 of the 11 cases, and a provisional diagnosis of plasmacytoma was suggested in 5 of the 6 patients (83.3%). The final laboratory cytological diagnoses of all 11 cases were compatible with plasmacytoma which was further confirmed via a bone marrow biopsy (n=4) and by serum electrophoresis (n=7).

Conclusion

US-guided fine-needle aspiration is feasible and is useful to confirm a diagnosis of plasmacytoma. Its minimally invasive nature may be the ideal investigation of choice in suspected cases.

Semi-automated preparation of fine-needle aspiration samples for rapid on-site evaluation

Rapid on-site evaluation (ROSE) significantly improves the diagnostic yield of fine needle aspiration (FNA) samples but critically depends on the skills and availability of cytopathologists. Here, we introduce a portable device for semi-automated sample preparation for ROSE. In a single platform, the device combines a smearing tool and a capillary-driven chamber for staining FNA samples. Using a human pancreatic cancer cell line (PANC-1) and liver, lymph node, and thyroid FNA model samples, we demonstrate the capability of the device to prepare samples for ROSE. By minimizing the equipment needed in the operating room, the device may simplify the performance of FNA sample preparation and lead to a wider implementation of ROSE.

Rapid On-Site Evaluation by Endosonographer of Endoscopic Ultrasound Fine-Needle Aspiration of Solid Pancreatic Lesions: A Randomized Controlled Trial

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.

The diagnostic performance of novel torque technique for endoscopic ultrasound-guided tissue acquisition in solid pancreatic lesions: A prospective randomized controlled trial

BACKGROUND AND AIM

Although several techniques for improved outcomes in endoscopic ultrasound (EUS)-guided tissue acquisition have been reported, the reported diagnostic yield for pancreatic masses is not satisfactory. The effects of novel technique (torque method) on twisting the scope in the clockwise or counterclockwise direction during EUS-fine needle biopsy (EUS-FNB) are unknown. We compared the diagnostic yield of EUS-FNB for pancreatic masses using the torque and standard techniques.

METHODS

From April 20, 2017, to March 16, 2018, 124 consecutive patients with solid pancreatic mass who underwent EUS-FNB using either the torque or standard technique were randomly assigned. Three passes were made with each technique, comprising 10 uniform to-and-fro movements on each pass with a 10-mL syringe suction. The primary outcome was procurement rates of histologic cores, and the secondary outcomes were the diagnostic performance and technical failure.

RESULTS

There were significant differences between the groups regarding the procurement rate of the histologic core and optimal quality core (standard vs torque: 87.1% [54/62] vs 98.4% [61/62], P = 0.038 and 79.0% [49/62] vs 93.5% [58/62], P = 0.037). The sensitivity, specificity, positive predictive value, and negative predictive values of EUS-FNB were 85.45%, 100%, 100%, and 46.67%, respectively, for the standard technique and 96.49%, 100%, 100%, and 71.43%, respectively, for the torque technique. The diagnostic accuracies of the standard and torque techniques were 87.10% and 96.77%, respectively.

CONCLUSIONS

The torque technique for EUS-FNB offered acceptable technical feasibility and superior diagnostic performance, including optimal histologic core procurement, compared with the standard technique.

Diagnostic yield of endoscopic ultrasound with fine-needle aspiration in pancreatic cystic lesions

INTRODUCTION

Despite advances in imaging techniques, in many cases they are insufficient to establish the diagnosis of pancreatic cystic lesions (PCL). There are few publications in our setting that evaluate the combination of several methods obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The aim of the study was to evaluate the overall utility of EUS-FNA in the diagnosis of PCL.

MATERIAL AND METHODS

Retrospective study based on a database updated prospectively of a cohort of patients referred for EUS-FNA due to PCL detected in an imaging test. The sensitivity, specificity and diagnostic yield of carcinoembryonic antigen (CEA), cytology and viscosity were studied to detect mucinous lesions.

RESULTS

From November 2013 to April 2018, 122 EUS were performed for PCL. EUS-FNA was performed in 94/122 (77%) and 21/122 (17.2%) patients were operated on. We included 33/122 patients who had diagnostic confirmation by histology, imaging (serous cyst with typical pattern) or clinical evolution. The study of the ROC curve determined the cutoff point ≥419 ng/ml to differentiate mucinous/non-mucinous cystic lesions. The diagnostic yield of CEA was 87.5% (21/24), cytology 81.8% (27/33) and viscosity 84.4% (27/32). The three parameters in combination obtained the best result (30/33, 90.9%).

CONCLUSION

The combination of CEA analysis, cytology and viscosity of pancreatic fluid obtained by EUS-FNA increases the performance in the diagnosis of mucinous pancreatic cystic lesions, with it being greater than 90%.

High diagnostic adequacy and accuracy of the new 20G procore needle for EUS-guided tissue acquisition: Results of a large multicentre retrospective study

BACKGROUND AND OBJECTIVE

EUS-guided fine-needle biopsy has become the standard for tissue sampling. A new 20G ProCore™ (PC) needle has been developed to overcome the limitations of tissue acquisition of the smaller needles (22G, 25G) and the rigidity of the larger one (19G). The aim of this study is to assess the performance of the 20G PC needle.

MATERIALS AND METHODS

Patients who underwent EUS-guided tissue acquisition with the 20G PC needle of pancreatic and extra-pancreatic mass lesions were retrospectively identified at three Italian centers (Bologna, Fermo, and Palermo). Diagnostic adequacy, accuracy, and tissue core acquisition were the outcome measures. All the cases were performed without rapid on-site evaluation.

RESULTS

A total of 384 patients with pancreatic (62.2%) and extra-pancreatic lesions were included in the study. For pancreatic lesions, adequacy, accuracy, sensitivity, and specificity were 92.4%, 91.5%, 90.8%, and 100%, respectively, with a number needed to misdiagnose (NNM) of 11.8. The tissue core was obtained in 72% of cases. Transduodenal approach was performed in 150 pancreatic lesions; adequacy, accuracy, and tissue core acquisition were 88.7%, 90%, and 66%, respectively (NNM 10). For extrapancreatic lesions, adequacy, accuracy, sensitivity, specificity, and tissue core sampling were 95.3%, 95.3%, 92.6%, 100%, and 84.5% (NNM 21.3).

CONCLUSIONS

The 20G PC needle showed high diagnostic adequacy and accuracy, regardless the access route.

Accuracy of EUS and CEH EUS for the diagnosis of pancreatic tumours

OBJECTIVES

The main objective is to compare the accuracy of EUS and CEH EUS for the diagnosis of pancreatic cancer (PC). The secondary objective is to evaluate the accuracy of EUS FNA and to determine to what extent EUS and CEH EUS findings are affected by endosonographer subjectivity.

METHODS

A prospective single-centre study was conducted in patients with pancreatic lesions detected on CT. The patients were examined by EUS, CEH EUS and EUS FNA. The obtained results were compared with the final diagnosis that was based on cytology and further clinical findings and on histopathological findings from subjects who underwent surgery. A second reading of the EUS and CEH EUS images was performed by the endosonographer, who was blinded to clinical data of patients.

RESULTS

We examined 116 patients, 73 had a final diagnosis of PC, 14 had NETs and 20 had other tumours. The sensitivity, specificity, NPV, PPV, and accuracy of EUS for diagnosis of PC were 83.1, 62.5, 83.1, 70.7 and 78.6%, for CEH EUS 94.5, 61.7, 84.1, 84 and 84.1% and for EUS FNA 87.6, 91.2, 95.5, 77.5 and 88.8, respectively. The inter-observer agreement for EUS marker of PC was good (κ = 0.75), and that for CEH EUS was average (κ = 0.59 for arterial phase and κ = 0.68 for washout in venous phase).

CONCLUSION

CEH EUS is a non-invasive method that allows more accurate identification of PC than EUS. The subjectivity of CEH EUS evaluation is worse than that of EUS but acceptable.

Biliary plastic stent does not influence the accuracy of endoscopic ultrasound-guided sampling of pancreatic head masses performed with core biopsy needles

OBJECTIVE

While the presence of biliary stent significantly decreases the accuracy of endoscopic ultrasound (EUS) for pancreatic head cancer staging, its impact on the EUS-guided sampling accuracy is still debated. Furthermore, data on EUS-fine needle biopsy (EUS-FNB) using core biopsy needles in patients with pancreatic mass and biliary stent are lacking. The aim of this study was to evaluate the influence of biliary stent on the adequacy and accuracy of EUS-FNB in patients with pancreatic head mass.

METHODS

All patients who underwent EUS-guided sampling with core needles of solid pancreatic head masses causing obstructive jaundice were retrospectively identified in a single tertiary referral center. Adequacy, defined as the rate of cases in which a tissue specimen for proper examination was achieved, with and without biliary stent, was the primary outcome measure. The diagnostic accuracy and complication rate were the secondary outcome measures.

RESULTS

A total of 130 patients with pancreatic head mass causing biliary obstruction were included in the study: 74 cases of them were sampled without stent and 56 cases with plastic stent in situ. The adequacy was 96.4% in the stent group and 90.5% in the group without stent (p=0.190). No significant differences were observed for sensitivity (88.9% vs. 85.9%), specificity (100% for both groups), and accuracy (89.3% vs. 86.5%) between those with and without stent, respectively. The accuracy was not influenced by the timing of stenting (<48h or ≥48h before EUS). No EUS-FNB related complications were recorded.

CONCLUSION

The presence of biliary stent does not influence the tissue sampling adequacy, the diagnostic accuracy and the complication rate of EUS-FNB of pancreatic head masses performed with core biopsy needles.

Endoscopic ultrasound-assisted transmural cholecystoduodenostomy or cholecystogastrostomy as a bridge for per-oral cholecystoscopy therapy using double-flanged fully covered metal stent

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the 'gold standard' for the treatment of symptomatic gallstones. Innovative methods are being introduced, and these procedures include transgastric or transcolonic endoscopic cholecystectomy. However, before clinical implementation, instruments still need modification, and a more convenient treatment is still needed. Moreover, some gallbladders still have good functionality and cholecystectomy may be associated with various complications. The aim of this study was to evaluate the trans-gastrointestinal tract cholecystoscopy technique in the treatment of gallbladder disease without cholecystectomy.

METHOD

Endoscopic ultrasound (EUS)-guided cholecystoduodenostomy or cholecystogastrostomy with the placement of a double-flanged fully covered metal stent was performed and endoscopic sphincterotomy (EST) was also performed during this procedure for those patients with accompanying common bile duct stones. One or two weeks later the stent was removed and an endoscope was advanced into the gallbladder via the fistula, and cholecystolithotomy or polyp resection was performed. Four weeks later gallbladder was assessed by abdominal ultrasound.

RESULTS

EUS guided cholecystoduodenostomy (n = 3) or cholecystogastrostomy (n = 4) with double flanged mental stent deployment was successfully performed in all of 7 patients. After the procedure, fistulas had formed in each of the patients and the stents were removed. Endoscopic cholecystolithotomy(7) and polyps resection(2) were successfully performed through the fistulas. Common bile duct stones were also successfully removed in 5 patients. The ultrasound examination of the gallbladder 4 weeks later showed no stones remaining and also showed satisfactory functioning of the gallbladder.

CONCLUSION

The EUS-guided placement of a novel metal stent is a safe and simple approach for performing an endoscopic cholecystoduodenostomy or cholecystogastrostomy, which can subsequently allow procedures to be performed for treating biliary disease, including cholecystolithotomy.

Diagnostic value of endoscopic ultrasonography guided biopsy in large gastric folds

AIM: To compare the accuracy of endoscopic ultrasonography (EUS) vs EUS-guided biopsy in the diagnosis of large gastric folds.

METHODS: Thirty-four patients with suspected large gastric folds who underwent EUS and EUS-guided biopsy from July 2011 to December 2013 were included. The diagnostic accuracy and safety of EUS-guided biopsy were evacuated according to the final results.

RESULTS: Twenty-nine patients were finally diagnosed. The overall accuracy rate of EUS-guided biopsy was 75.9%. Severe complications such as perforation and severe bleeding were not seen during and after the process of EUS-guided biopsy. Deep biopsy guided by EUS was easier to cause bleeding than large mucosal biopsy (P < 0.05). According to the characteristics of ultrasound imaging of each lesion, the diagnostic accuracy rate of EUS for gastric cancer was 69%, sensitivity 63.2%, and specificity 80.0%; accuracy 62.1%, sensitivity 25.0%, and specificity 76.2% for lymphoma.

CONCLUSION: EUS-guided biopsy is an effective diagnostic method for large gastric folds.