Accuracy For Malignancy Research Articles

Added value of the EUSOBI diffusion levels in breast MRI

ObjectivesTo investigate whether using the diffusion levels (DLs) proposed by the European Society of Breast Imaging (EUSOBI) improves the diagnostic accuracy of breast MRI.Materials and methodsThis retrospective study included 145 women who, between September 2019 and June 2020, underwent breast 1.5-T MRI with DWI. Reader 1 and reader 2 (R1-R2) independently assessed breast lesions using the BI-RADS on dynamic contrast-enhanced imaging and T2-weighted imaging. DWI was subsequently disclosed, allowing readers able to measure lesions ADC and subjectively express the overall risk of malignancy on a 1–5 Likert scale. ADCs were interpreted as a range of values corresponding to the EUSOBI DLs. The analysis evaluated the inter-reader agreement in measuring ADC and DLs, the per-DL malignancy rate, and accuracy for malignancy using ROC analysis against histological examination or a 3-year follow-up.ResultsLesions were malignant and showed non-mass enhancement in 67.7% and 76.1% of cases, respectively. ADC was measurable in 63.2%/66.7% of lesions (R1/R2), with a minimal discrepancy on Bland–Altman analysis and 0.948 (95%CI 0.925–0.965)/0.989 (95%CI 0.988–0.991) intraclass correlation coefficient in measuring ADC/DLs. The malignancy rate (R1/R2) increased from 0.5/0.5% (“very high” DL) to 96.0/96.8% (“very low” DL), as expected. Likert categorization showed larger areas under the curve than the BI-RADS for both R1 (0.91 versus 0.87; p = 0.0208) and R2 (0.91 versus 0.89; p = 0.1171), with improved specificity (81.5% versus 78.5% for R1 and 84.4% versus 81.2% for R2).ConclusionThough ADC was not measurable in about one-third of lesions, DLs were categorized with excellent inter-reader agreement, improving the specificity for malignancy.Clinical relevance statementDLs proposed by the EUSOBI are a reproducible tool to interpret the ADC of breast lesions and, in turn, to improve the specificity of breast MRI and reduce unnecessary breast biopsies.Key Points• The European Society of Breast Imaging proposed diffusion levels for the interpretation of the apparent diffusion coefficient in diffusion-weighted imaging of the breast.• Adding diffusion levels to the interpretation of magnetic resonance imaging improved the diagnostic accuracy for breast cancer, especially in terms of specificity.• Diffusion levels can favor a more widespread and standardized use of diffusion-weighted imaging of the breast.

Predictors of malignancy in main duct intraductal papillary mucinous neoplasm of the pancreas

The International Consensus Guidelines updated in 2017 recommended surgery to all main duct intraductal papillary mucinous neoplasms (MD-IPMNs) with the main pancreatic duct (MPD) of 10mm or more and those with mural nodules regardless of size. The aim of the present study was to identify predictors of malignancy in MD-IPMN among preoperative factors including MPD and mural nodule size. Twenty-six benign MD-IPMNs (7 resected and 19 nonresected) and 32 malignant MD-IPMNs (31 resected and 1 nonresected) were included in the study. MRCP, CT, EUS, and cytology were performed using pancreatic juice collected by endoscopic retrograde pancrestography (ERP). Resected IPMNs were classified as benign or malignant by histologic examination and nonresected MD-IPMNs by imaging, cytology, and observation. Cutoff values of candidate parameters were determined by receiver operating characteristic curves. Univariate and multivariate analyses by regression model were performed. MPD and mural nodule size and cytology results differed significantly between benign and malignant groups.Cutoff values of MPD and mural nodule sizes were 15mm and 10mm with areas under the curve of .66and .86, respectively. Mural nodules of 10mm or more (odds ratio, 8.32; 95% confidence interval, 1.13-61.2; P= .038) and positive cytology (odds ratio, 42.5; 95% confidence interval, 4.10-439; P= .002) were shown to be independent predictors of malignancy by multivariate analysis. When MD-IPMNs with either predictor were diagnosed to be malignant, sensitivities, specificities, and overall accuracy for malignancy were 94%, 85%, and 90%, respectively. Mural nodules of 10mm or more and positive cytology were independent predictors of malignancy in MD-IPMN.

Endoscopic ultrasound-guided fine-needle aspiration of pelvic lesions via the upper and lower gastrointestinal tract approaches

BackgroundCombining upper and lower gastrointestinal tract (GI) approaches allows expansion of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) indications for pelvic lesions. The upper GI approach has been used for pelvic lesions around the level of the aortoiliac bifurcation in our institution. The aim of this study is to evaluate the feasibility and safety of EUS-FNA for pelvic lesions via the upper and lower GI approaches.MethodsAll consecutive patients who underwent EUS-FNA for the pelvic lesion between January 2008 and December 2018 were retrospectively analyzed. Pelvic lesions were defined as lesions located around and below the aortoiliac bifurcation level. The primary outcome was technical success rate, and the secondary outcomes were the diagnostic capability of EUS-FNA for malignancy and the safety.ResultsEUS-FNA for pelvic lesions was performed in 49 patients: upper and lower GI approaches were used in 28 and 21 patients, respectively. The technical success rates were 91.8% (45/49) in all patients: 89.3% (25/28) and 95.2% (20/21) with the upper and lower GI approaches, respectively. Among patients who achieved technical success, the diagnostic accuracy for malignancy was 97.8% (44/45) in all patients: 100% (25/25) and 95.0% (19/20) with the upper and lower GI approaches, respectively. One (2.0%) patient developed an adverse event of sigmoid colon perforation.ConclusionsEUS-FNA for pelvic lesions via the upper and lower GI approaches was a safe, feasible, and effective method, although careful endoscopic manipulation is required to avoid perforation, especially with the lower GI approach. Further large-scale, well-designed studies are needed to validate our findings.

Prospective evaluation of 25-gauge Franseen needles for endoscopic ultrasound-guided fine-needle biopsy of solid pancreatic masses.

Background and study aims The ideal puncture needle for endoscopic ultrasound (EUS)-guided sampling is maneuverable and easy to puncture with, and can obtain sufficient material in almost one pass. The novel 25-gauge Franseen needle may provide a good balance between maneuverability and sample yield. Patients and methods Between July 2017 and December 2018, 116 patients with solid pancreatic masses were prospectively enrolled and investigated. We evaluated the diagnostic yield associated with using the 25-gauge Franseen needle for EUS-guided sampling of pancreatic masses. Results The technical success rate was 100 % (116/116). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for malignancy were 98 % (105/107), 100 % (9/9), 100 % (105/105), 82 % (9/11), and 98 % (114/116), respectively. Cumulative sensitivities for malignancy were 87 % (93/107) on pass 1, 97 % (104/107) on pass 2, and 98 % (105/107) on pass 3, respectively, with no increase in sensitivity after 4 or more. An adequate specimen for histological assessment was obtained in 79 % (92/116) of cases. Multivariate logistic analyses showed that lesion size smaller than 13 mm was a risk factor for failure of obtaining an adequate specimen for histological assessment ( P = 0.010) Conclusions The novel 25-gauge Franseen needle showed excellent diagnostic yield for solid pancreatic masses. However, its ability to obtain an adequate specimen for histological assessment may still be insufficient, especially when dealing with small lesions.

Diagnostic Efficacy of Liquid-Based Cytology in Endoscopic Ultrasound-Guided Fine Needle Aspiration for Pancreatic Mass Lesions During the Learning Curve: A Retrospective Study.

The diagnostic yield of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology widely varies depending on the treatment method used. Liquid-based cytology (LBC) has gained popularity in the gynecological field because of its efficacy in collection of target cells and simplicity in the manipulation of specimens. Since the introduction of EUS-FNA at our institution, we have used LBC for the diagnosis of pancreatic mass lesions. This study aims to investigate the diagnostic efficacy of EUS-FNA with LBC in patients with pancreatic mass lesions during the learning curve for EUS-FNA. In this study, we retrospectively enrolled 222 patients with pancreatic mass lesions who were diagnosed using EUS-FNA with LBC between 2011 and 2016. The diagnostic yields for EUS-FNA with LBC for pancreatic mass lesions were evaluated. The diagnostic sensitivity, specificity, and accuracy for malignancy were found to be 93.9%, 95.1%, and 94.1%, respectively. This study suggests that EUS-FNA with LBC for specimens provides good diagnostic efficacy in patients with pancreatic mass lesions even during the learning curve for EUS-FNA.

Fine-needle aspiration in all thyroid incidentalomas at 18 F-FDG PET/CT: Can EU-TIRADS revise the dogma?

Focal thyroid incidentalomas (TIs) are observed in 2% of 18 F-FDG PET/CT representing malignancy in one-third of cases. Currently, due to the lack of evidence on their optimal management, guidelines suggest fine-needle aspiration cytology (FNAC). The study aim was to evaluate the role of ultrasound evaluation according to EU-TIRADS to assess the risk of TIs and inform FNAC prescriptions. We retrospectively reviewed 18 F-FDG PET/CT TIs recorded during the period 2014-2017. Enrolled were TIs with histological outcome and autonomous nodules. Cases with uncertain matching between 18 F-FDG PET/CT, ultrasound and histology were excluded. According to the selection criteria, 75 TIs, being 13 (17.3%) malignant and 62 (82.7%) benign, were included. Cancers had significantly higher SUVmax and SUVmax ratio (Mann-Whitney P<0.01) than benign, and the most accurate cut-offs were >7.1 and >3.65, respectively. At ultrasound, the cancer rate was 0% in EU-TIRADS 2, 2.9% in EU-TIRADS 3, 4.2% in EU-TIRADS 4% and 78.6% in EU-TIRADS 5 (chi-squared P<0.001). Sensitivity, specificity, PPV, NPV and accuracy for malignancy were 92%, 64%, 35%, 98% and 69% for SUVmax; 85%, 68%, 36%, 96% and 71% for SUVmax ratio; and 85%, 95%, 79%, 97% and 93% for EU-TIRADS, respectively. The absence of all these three features reached a specificity of 97.1%. EU-TIRADS, within a clinical careful approach, can discriminate with significant accuracy lesions at high risk of malignancy from those at low risk among TIs at 18 F-FDG PET/CT. Additionally, a centre-based threshold for SUV parameters should be useful for the initial assessment of these lesions during PET/CT reading and reporting.

The diagnostic performance of 18F-FAMT PET and 18F-FDG PET for malignancy detection: a meta-analysis

This meta-analysis aims to compare the diagnostic performance of l-3-18F-α-methyl tyrosine (18F-FAMT) positron emission tomography (PET) and 2-deoxy-2-[18F]fluoro-d-glucose (18F-FDG) PET for malignancy detection. The workflow of this study follows Cochrane Collaboration Guidelines of a systematic review of diagnostic test accuracy studies. An electronic search was performed for clinical diagnostic studies directly comparing 18F-FAMT and 18F-FDG PET for malignant tumors. Study quality, the risks of bias and sources of variation among studies were assessed using the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) assessment tool. A separate meta-analysis was performed for diagnostic performance based on visual assessment and diagnostic cut-off values. Whenever possible, a bivariate random-effect model was used for analysis and pooling of diagnostic measures across studies. Electronic search revealed 56 peer-reviewed basic science investigations and clinical studies. Six eligible studies (272 patients) of various type of cancer were meta-analyzed. The 18F-FAMT diagnostic accuracy for malignancy was higher than 18F-FDG based on both visual assessment (diagnostic odd ratio (DOR): 8.90, 95% confidence interval (CI) [2.4, 32.5]) vs 4.63, 95% CI [1.8, 12.2], area under curve (AUC): 77.4% vs 72.8%) and diagnostic cut-off (DOR: 13.83, 95% CI [6.3, 30.6] vs 7.85, 95% CI [3.7, 16.8], AUC: 85.6% vs 80.2%), respectively. While the average sensitivity and specificity of 18F-FAMT and 18F-FDG based on visual assessment were similar, 18F-FAMT was significantly more specific than 18F-FDG (p < 0.05) based on diagnostic cut-off values. 18F-FAMT is more specific for malignancy than 18F-FDG, while their sensitivity is comparable. 18F-FAMT PET is equal to 18F-FDG PET in diagnostic performance for malignancy detection in several cancer types.

The Sonogaphy is a Valuable Tool for Diagnosis of Microcalcification in Screening Mammography

The purpose of our study was to investigate whether sonography an adjunctive imaging for determining benign or malignancy lesions in breast microcalcification after screening mammography. According to BI-RADS assessment categories systems, category 4 or 5 needed further tissue proof. This retrospective study enrolled patients in St. Paul hospital who underwent tissue proof between May 1, 2011 to March 31, 2017. All patients with microcalcification in screening mammography were divided into two subgroups: the group of BI-RADS 0 initially then turn into BI-RADS 4 or 5 after magnified mammography (group A) and the other group of BI-RADS 4 or 5 (group B). We excluded patients with incomplete data including no tissue proof or no sonography report in our hospital. We evaluate the correlation between the pathologic results and the sonographic findings. A total of 133 patients were reviewed, 105 (78.9%) patients were group A. Among 105 specimens in the group A, 23 (21.9%) were proved malignancy. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of sonography were 52%, 84.1%, 48%, 86.3%, and 77.1%, respectively. Sixteen (57.1%) out of 28 patients in the group B were malignant. The findings of sonogrpahy showed high sensitivity, specificity, PPV, NPV, and accuracy for malignancy (87.5%, 75%, 82.4%, 81.8%, and 82.1%, respectively). Sonography could provide good specificity in undetermined microcalfication. A biopsy may be avoided if microcalcifications in mammography appear absolutely benign on sonography and those patients can be followed-up with interval serial exam.

PTU-039 Endoscopic Management of Complex Non Pedunculated Rectal Polyps

Introduction Complex NPRP (non pedunculated rectal polyp) is defined as the polyp which has an increased risk of malignancy, increased risk of incomplete resection/recurrence, increased risk of adverse event or SMSA level 4 polyp. 1 Complex rectal polyps are managed by endoscopic (EMR, ESD, hybrid ESD) techniques or by various surgical techniques (TEMS, TAMIS, TART, TASER), depending on the endoscopic lesion assessment and the local expertise. Methods The aim of this study was to describe the outcomes of the endoscopic management of complex rectal polyps in a large tertiary hospital (single operator). Results Over a period of 33 months (May 2013 to Jan 2016), 77 complex rectal polyps including 10 rectosigmoid polyps were encountered. The size of the polyp varied from 1 cm to 14 cms (median - 3.5 cm). The age of the patient varied from 50 to 92 (median age - 60). 29 polyps (37.6%) was confirmed to have cancer. The pre resection endoscopic accuracy of malignancy was 94%. Frank malignancy was suspected and confirmed in 7 cases and deemed not suitable for endoscopic resection. A small subpedunculated pT1 polyp cancer was resected enbloc, but was not suspected to be a cancer prior to resection.21 polyps were noted to have features suggestive of high risk of malignancy. All had attempted endoscopic resection, including EMR and/or hybrid ESD. Of these, 7 polyps was confirmed to have cancer. The surgery rate for complex rectal polyps (including lesions with endoscopic resections for cancer) is 4.2%. None of the benign polyps (including polyps with EMR/Hybrid ESD for recurrence at previous TEMS/EMR site, post surgery anastomosis site) had surgery. Of the data available for 54 polyps with post endoscopic resection, 46 polyps (85%) did not have any residual lesion at 3 months. Of the available data for 26 polyps at 12 months, no recurrence/residual lesion was noted. None of the resection had perforation. 2 polyp cancers had significant bleeding during attempted hybrid ESD and had surgical resection of the polyp cancer. Another benign polyp with hybrid ESD had significant bleeding controlled with haemospray. The average time of combined EMR/hybrid ESD procedures is 11.4 mins for every cm of polyp resected. Considering the age, co-morbidity, size, location and final histology, ESD or alternative micro surgical techniques would have made a difference to the final outcome in only one patient. Conclusion The pre resection endoscopic accuracy rate for malignancy is significantly high in a high volume centre. EMR and Hybrid ESD in experienced hands is an effective technique in managing complex rectal polyps. Reference 1 British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Disclosure of Interest None Declared

A Multicenter Prospective Validation Study for the Korean Thyroid Imaging Reporting and Data System in Patients with Thyroid Nodules.

ObjectiveTo validate a new risk stratification system for thyroid nodules, the Korean Thyroid Imaging Reporting and Data System (K-TIRADS), using a prospective design.Materials and MethodsFrom June 2013 to May 2015, 902 thyroid nodules were enrolled from four institutions. The type and predictive value of ultrasonography (US) predictors were analyzed according to the combination of the solidity and echogenicity of nodules; in addition, we determined malignancy risk and diagnostic performance for each category of K-TIRADS, and compared the efficacy of fine-needle aspiration (FNA) with a three-tier risk categorization system published in 2011.ResultsThe malignancy risk was significantly higher in solid hypoechoic nodules, as compared to partially cystic or isohyperechoic nodules (each p < 0.001). The presence of any suspicious US features had a significantly higher malignancy risk (73.4%) in solid hypoechoic nodules than in partially cystic or isohyperechoic nodules (4.3–38.5%; p < 0.001). The calculated malignancy risk in K-TIRADS categories 5, 4, 3, and 2 nodules were 73.4, 19.0, 3.5, and 0.0%, respectively; and the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for malignancy were 95.5, 58.6, 44.5, 96.9, and 69.5%, respectively, in K-TIRADS categories 4 and 5. The efficacy of FNA for detecting malignancy based on K-TIRADS was increased from 18.6% (101/544) to 22.5% (101/449), as compared with the three-tier risk categorization system (p < 0.001).ConclusionThe proposed new risk stratification system based on solidity and echogenicity was useful for risk stratification of thyroid nodules and the decision for FNA. The malignancy risk of K-TIRADS was in agreement with the findings of a previous retrospective study.

The clinical efficacy and safety of EUS-FNA for diagnosis of mediastinal and abdominal solid tumors – A single center experience

Summary Background Many tumors are small and located around the gastrointestinal (GI) tract, and they are difficult to obtain tissue from for pathological diagnosis by the guidance of conventional methods (sonography or computed tomography. The aim of this study was to analyze the efficacy and benefit of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the clinical diagnosis of solid tumors in the mediastinum and abdomen. Patients and methods Data from 233 patients with solid tumors on or around the GI tract were reviewed. They had received successful EUS-FNA without on-site cytopathology study. Results The lesions were classified according to the anatomic location as pancreatic tumors (Group A, n = 91), mediastinal tumors (including lymph nodes) (Group B, n = 38), abdominal tumors (including lymph nodes) (Group C, n = 49), focal transmural thickening of the GI tract (Group D, n = 6), and submucosal tumors of the GI tract (Group E, n = 49). The accuracies of pathological diagnosis of malignancy were 79.2%, 76.9%, 93.2%, and 80% for Groups A–D, respectively. The overall accuracy for malignancy was 82.9%. For the submucosal tumors of the GI tract in Group E, FNA cytopathology provided evidence of specific diagnosis all were GI stromal tumor in 47% of the cases, 14% were diagnosed as suspicious (most were of a spindle cell tumor nature), and 39% were considered negative of tumor or non-diagnostic. There were three episodes (1.3%) of complication (GI bleeding, n = 1; septic fever, n = 1; gallbladder puncture, n = 1) which occurred among all patients in this study, and all of them were treated appropriately, with no occurrence of life-threatening events. Conclusion EUS-FNA appears to be a very useful tool for obtaining tissue diagnosis for lesions that are inaccessible by the conventional methods and was shown to be a safe and effective technique in the hands of experienced operators. Pathological diagnosis can be obtained for the guidance of clinical management to avoid the more invasive ways, such as surgery or mediastinal scope.

Study of ultrasound BI-RADS for small solid breast masses

Objective To evaluate the clinical value of ultrasound breast imaging reporting and data system （BI-RADS） in small solid breast masses with diameter 41 cm.Methods The ultrasound features of 230 solid breast masses with diameter ≤ 1 cm were described by ultrasound BI-RADS, the relationship between ultrasound features,BI-RADS final assesment and pathology were analyzed.Results Of these 230 masses,72（31.3%） were pathologically confirmed to be malignant and 158 （68.7%） to be benign. The ultrasound BI-RADS features of mass shape, margin, orientation, posterior acoustic features, and microcalcificaition were significantly different between malignant and benign masses （ P 〈 0.05）. Irregular shape, noncircumscribed, nonparallel orientation, postrior shadowing, microcalcifications were regarded as malignant ultrasound features, their positive predictive values （PPV）, sensitivity, specificity and accuracy for malignancy were 53.3% - 100% ,2.8% - 75.0% ,82.3% - 100% ,69.6% - 80.9% ,respectively. One hundred and fifty-two（66.1%）,62（27.0%）, 16（7.0%） masses were classified into grade 3,4,and 5 ,respectively.The PPV for grade 3,4 and 5 were 10.5 %, 64.5 %, 100 % respectively. Among BI-RADS grade 3 cases, 87.5 % malignant masses were intraductal carcinoma in situ and special type of invasive cancer,among pathological benign BI-RADS grade 4 masses,90.9% were hyperplasia and intraductal papilloma.Conclusions In small breast masses with diameter ≤ 1 cm, due to the sensitivity of malignant signs are not high, the overlap between signs of benign and malignant lesions, pathological type and other factors, the positive predictive value of BI-RADS grade 3 is higher than criteria of American College of Radiology, so BI-RADS classification requires further detailed study. Key words: Ultrasonography ; Breast diseases ; BI-RADS

Diffusion-weighted magnetic resonance imaging for evaluating the histological degree of malignancy in patients with intraductal papillary mucinous neoplasm.

The aim of this study was to evaluate the usefulness of high b-value diffusion-weighted magnetic resonance imaging (DWI) for evaluating the histological degree of malignancy in patients with intraductal papillary mucinous neoplasm (IPMN). A total of 35 patients (mean age 68 ± 10 years, 23 males) who had undergone DWI before surgery were included in this study. Of these 35 patients, 13 had IPMN with low- or intermediate-grade dysplasia, eight had IPMN with high-grade dysplasia, and 14 had IPMN with an associated invasive carcinoma. We evaluated the positive signal rate on DWI and the apparent diffusion coefficient (ADC) value of each pathology. The positive signal rate on DWI of IPMN with low- or intermediate-grade dysplasia, of IPMN with high-grade dysplasia, and of IPMN with an associated invasive carcinoma were 0% (0/13), 38% (3/8), and 93% (13/14), respectively. The sensitivity, specificity, and accuracy for malignancy (IPMN with high-grade dysplasia or IPMN with an associated invasive carcinoma) using DWI were 73%, 100%, and 83%, respectively. The mean ADC value of malignancy was significantly lower than that of benignity (P = 0.002). Diffusion-weighted magnetic resonance imaging, easily applicable in addition to conventional MRI, is considered an efficient modality for evaluating the histological degree of malignancy in patients with IPMN.

Risk prediction model of malignant partially cystic thyroid nodules

Objective A multivariate logistic regression model was built to estimate the risk of malignant partially cystic thyroid nodules.Methods Data of ultrasonographic morphology,microcalcifications,margin,colloid crystals and echogenicity of 766 thyroid nodules (of 506 patients) were analyzed retrospectively.All patients underwent surgery and the diagnosis were confirmed by pathology.The model was built to calculate the individual risk and evaluate the predictive index.Results The regression model was Z =-2.30 + 1.42X2 + 2.39X3 + 1.17X4-1.35 X7 + 0.62X9 ; P =eZ/1 + ez (P represents probability of malignancy,e represents natural constant 2.72).The largest area under the receiver-operating characteristics curve (AUC) was 0.86.When apply the model to the verification group(266 nodules),the accuracy,sensitivity,specificity,misdiagnosis rate,missed diagnosis rate,negative likelihood ratio and positive likelihood ratio were 93.61％,83.33％,94.63％,5.37％,16.67％、0.18 and 15.52 respectively.Conclusions This model based on the ultrasonographic variables increases the diagnostic accuracy of malignancy in patients with partially cystic thyroid nodules. Key words: Ultrasonography; Thyroid nodule; Logistic models

Evaluation of the adequacy and diagnostic accuracy of the histology samples obtained with a newly designed 19-gauge EUS histology needle

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is an accurate technique for sampling intraintestinal and extraintestinal lesions. However, cytology possesses certain limitations, which may be overcome if histological specimens are provided to the pathologist. The aim of the study was to evaluate the accuracy of a newly developed 19G histology needle. Retrospective analysis of a prospectively collected data base including patients who underwent EUS-guided biopsy with the 19G ProCoreTM histology needle for the evaluation of intraintestinal or extraintestinal lesions. Samples were obtained after one needle pass, recovered into ThinPrep® and processed for histological analysis. Results were compared to the gold standard of surgical histopathology, or global pathological, clinical and radiological assessment, and follow-up in non-operated cases. Results are shown as mean + or - SD. Percentage of optimal samples for histological evaluation and the overall diagnostic accuracy were evaluated. 87 patients (mean age 62.9 years, range 25-88 years, 36 woman) were included. Lesions mean size was 41.6 + or - 21.3 mm. 66 lesions (75.9%) were considered as malignant and 21 (24.1%) as benign. EUS-guided biopsy was feasible in all cases (100%). Sample quality was adequate for histological assessment in 82 lesions (94.2%). In the remaining cases the sample was adequate for cell-block evaluation. Sensitivity, specificity, PPV, NPV, and overall accuracy for malignancy were 93.4%, 100%, 100%, 84%, and 95.4%, respectively. There were no complications related to the procedure. The EUS-guided biopsy with the 19G histology needle provides with an optimal core sample for histological evaluation allowing a high histopathologic diagnostic accuracy.

CONTRAST ENHANCED SONOGRAPHIC ASSESSMENT OF FEEDING VESSELS AS A DISCRIMINATOR BETWEEN MALIGNANT VS. BENIGN FOCAL SPLENIC LESIONS

Contrast-enhanced sonography was conducted in 17 confirmed focal splenic lesions (five malignant, 12 benign). Relative echogenicity changes were used for subjective interpretation of lesion perfusion. A rapid influx of contrast agent, resulting in an increased relative echogenicity of the lesion, followed by a rapid clearance of contrast agent was referred to as early washin/early washout. There were 6/12 benign, and 3/5 malignant lesions characterized by early washin/early washout. Therefore, sensitivity, specificity, and accuracy for this parameter in differentiating malignant from benign lesions was 60%, 50%, and 53%, respectively. There were 2/12 benign, and 2/5 malignant lesions with persistent hypoperfusion throughout all phases. Therefore, sensitivity, specificity, and accuracy for malignancy using this criterion were 40%, 83%, and 71%, respectively. However, none of the benign and all malignant lesions were characterized by tortuous and persistently visible feeding vessels. This suggests that interpretation of splenic lesions cannot be performed accurately on the basis of echogenicity or persistent hypoperfusion, but that assessment of vascular tortuosity may be helpful in discriminating between a malignant vs. benign focal splenic lesion.

Usefulness of Acoustic Radiation Force Impulse Imaging in the Differential Diagnosis of Benign and Malignant Liver Lesions

Acoustic radiation force impulse imaging (ARFI) is a newly developed technique for the evaluation of tissue stiffness. It has been applied to evaluate liver fibrosis, but only limited data for liver lesions are available. The aim of this study was to evaluate the tissue stiffness of liver lesions by using ARFI to differentiate benign from malignant liver lesions. ARFI was performed in 116 consecutive patients who had 128 liver lesions (60 benign, 68 malignant). The elastographic images of virtual touch tissue imaging (VTI) and the values of virtual touch tissue quantification (VTQ) were obtained and analyzed. The area under the curve and cutoff value for VTQ value, both of which were obtained by using a receiver operating characteristic curve analysis, were used to assess diagnostic performance. On the elastographic images of VTI, 57 (83.8%) malignant liver lesions and 33 (55.0%) benign liver lesions appeared stiffer compared with the surrounding liver parenchyma. There were statistical differences between malignant and benign liver lesions (P<.05). The VTQ median value of malignant and benign liver lesions were 3.14 m/sec (average value 3.16 ± 0.80 m/sec, range 1.17‒4.45 m/sec) and 1.35 m/sec (average value 1.47 ± 0.53 m/sec, range 0.74‒3.26 m/sec), respectively (P < .001). With a cutoff value of 2.22 m/sec for VTQ value, the sensitivity, specificity, and accuracy for malignancy were 89.7%, 95.0%, and 92.2%, respectively. ARFI can provide the elastographic images and elastographic values of liver lesions by VTI and VTQ, which is helpful in the differentiation between benign and malignant liver lesions and might become the imaging modality of the future.

Real-Time Qualitative Ultrasound Elastography of Cervical Lymph Nodes in Routine Clinical Practice: Interobserver Agreement and Correlation with Malignancy

To evaluate real-time qualitative ultrasound (US) elastography for cervical lymphadenopathy in routine clinical practice, 74 nodes (37 malignant, 37 benign) in 74 patients undergoing sonography underwent US elastography prior to fine needle aspiration for cytology. Dynamic cine loops of elasticity imaging displayed using a chromatic-scale were qualitatively scored by three independent observers for the proportion of stiff areas from ES1-4 (soft to stiff). There was fair to good interobserver agreement as indicated by weighted kappa (κ) statistic from 0.374 to 0.738. Median ES for benign and malignant nodes were 2 and 3 respectively. ES was higher in malignant nodes ( p = 0.0003–0.0049, Mann Whitney U tests) although areas under receiver operating characteristic curves (0.68–0.74) indicated suboptimal discrimination. The optimal discriminatory cut-off, ES > 2, achieved only 62.2% sensitivity, 83.8% specificity and 73% accuracy for malignancy. Improvements in reliability and accuracy of real-time qualitative ultrasound elastography are required for it to be adopted into routine clinical practice. (E-mail: aniltahuja@cuhk.edu.hk)

A performance and theoretical cost analysis of endobronchial ultrasound-guided transbronchial needle aspiration in a UK tertiary respiratory centre

New innovative techniques can improve patient care but may not be appropriately funded. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS) offers a minimally invasive mediastinal staging and diagnostic method for suspected lung cancer. We report the performance and cost analysis of a newly established EBUS service in a prospective real world cohort of patients to assess the impact of Payment by Results (PbR). Prospective cohort study. Fifty-four patients between June 2008 and April 2009 underwent EBUS for evaluation of unexplained mediastinal lymphadenopathy on CT. Cost analysis was performed from local Trust financial data and 2008-09 tariffs. EBUS had an 89% sensitivity, 75% negative predictive value and 92% accuracy for malignancy. EBUS coding was inaccurate in 15.6% of cases. The actual cost of an EBUS is 1252-1433 pounds but is coded as a standard bronchoscopy (561 pounds). EBUS reduces health community costs by 107824 pounds/year, as a result of a Primary Care Trust cost saving of 113968 pounds/year and a Trust cost deficit of 6144 pounds/year. Coding inaccuracies further alter the Primary Care Trust costs. Medical innovation is fundamental to improved patient care. EBUS can potentially reduce morbidity for lung cancer patients and save health community costs. However, with PbR the service provider delivers this at a loss as the tariffs do not reflect innovation and because of coding inaccuracies. We suggest tariffs for innovative procedures need to reflect the true cost.

Endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic masses with rapid on-site cytological evaluation by endosonographers without attendance of cytopathologists

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with rapid on-site evaluation (ROSE) has been reported to provide a more accurate diagnosis than EUS-FNA without such evaluation. However, even endosonographers can evaluate ROSE regarding sample adequacy. The aim of this study was to evaluate the diagnostic accuracy of EUS-FNA with ROSE by endosonographers compared to ROSE by cytopathologists in patients with solid pancreatic masses. Between September 2001 and October 2005, of the 73 EUS-FNA procedures with the final diagnoses, 38 procedures after the introduction of ROSE by endosonographers (September 2001-September 2003, period 1), and 35 procedures after the introduction of ROSE by cytopathologists (October 2003-October 2005, period 2) were included. The specimens were stained with Diff-Quik stain and assessed. When the on-site assessors (endosonographers or cytopathologists) indicated that the amounts of cell samples were adequate, the procedure was stopped. Results are presented with 95% confidence limits. The average numbers of needle passes were 4.0 +/- 1.6 and 3.4 +/- 1.5 in periods 1 and 2, respectively (P = 0.06). The specimen collection rates were 97.4 and 97.1% in periods 1 and 2, respectively (P = 0.51). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for malignancy and benign were 92.9, 100, 100, 83.3, and 94.7%, respectively, in period 1, and 93.1, 100, 100, 75.0, and 94.3%, respectively, in period 2 (P = 0.97, P = 1.0, P = 1.0, P = 0.65, P = 0.93, respectively). No complications were seen. For accurate diagnosis, ROSE should be performed during EUS-FNA by the endosonographer, if no cytopathologist is available.