Accuracy Of EUS-FNA Research Articles

Performance of EUS-FNA for mediastinal lymphadenopathy: impact on patient management and costs in low-volume EUS centers

BackgroundEndoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mediastinal lymphadenopathy has been shown to be a valuable diagnostic tool in high-volume EUS centers (≥50 mediastinal EUS-FNA/endoscopist/year). Our goal was to assess the diagnostic accuracy of EUS-FNA and its impact on clinical management and costs in low-volume EUS centers (<50 mediastinal EUS-FNA/endoscopist/year).MethodsConsecutive patients referred to two Dutch endoscopy centers in the period 2002–2008 for EUS-FNA of mediastinal lymphadenopathy were reviewed. The gold standard for a cytological diagnosis was histological confirmation or clinical follow-up of more than 6 months with repeat imaging. The impact of EUS-FNA on clinical management was subdivided into a positive impact by providing (1) adequate cytology that influenced the decision to perform surgery or (2) a diagnosis of a benign inflammatory disorder, and a negative impact which was subdivided into (1) false-negative or inconclusive cytology or (2) an adequate cytological diagnosis that did not influence patient management. Costs of an alternative diagnostic work-up without EUS-FNA, as established by an expert panel, were compared to costs of the actual work-up.ResultsIn total, 213 patients (71% male, median age = 61 years, range = 23–88 years) underwent EUS-FNA. Sensitivity, specificity, and negative and positive predictive values were 89%, 100%, 80%, and 100%, respectively. EUS-FNA had a positive impact on clinical management in 84% of cases by either influencing the decision to perform surgery (49%) or excluding malignant lymphadenopathy (35%), and a negative impact in 7% of cases because of inadequate (3%) or false-negative (4%) cytology. In 9% of cases, EUS-FNA was performed without an established indication. Two nonfatal perforations occurred (0.9%). Total cost reduction was €100,593, with a mean cost reduction of €472 (SD = €607) per patient.ConclusionsMediastinal EUS-FNA can be performed in low-volume EUS centers without compromising diagnostic accuracy. Moreover, EUS-FNA plays an important role in the management of patients with mediastinal lymphadenopathy and reduces total diagnostic costs.

EUS-FNA in the preoperative staging of non-small cell lung cancer

Background According to current guidelines, transesophageal ultrasound-guided fine needle aspiration (EUS-FNA) can be performed as an alternative for surgical staging to confirm mediastinal metastases in patients with non-small cell lung cancer (NSCLC). To date however, data regarding the routine use of EUS-FNA in the preoperative staging of unselected patients with NSCLC are limited. Aims and objectives (1) To evaluate the diagnostic value of EUS-FNA in consecutive, patients with NSCLC regardless of nodal size at CT. (2) To determine the impact of EUS-FNA on the prevention of surgical staging procedures. (3) To assess the accuracy of mediastinal staging by combining EUS-FNA and mediastinoscopy. (4) To investigate whether a subgroup of patients exists that can be accurately staged by EUS-FNA alone. Methods 152 consecutive operable patients with proven or suspected NSCLC who underwent EUS-FNA were retrospectively analyzed. In the absence of mediastinal metastases, mediastinoscopy and/or thoracotomy with lymph node dissection was performed. Results The prevalence of mediastinal metastases was 49%. Sensitivity, negative predictive value (NPV) and accuracy of EUS-FNA for N2/N3 disease were 74%, 73% and 85% respectively, whereas these values for the combined staging of EUS-FNA and mediastinoscopy were 92%, 85% and 95%. Additional surgical staging in patients staged N0 at EUS-FNA reduces the false negative EUS-findings by 55%. The NPV of EUS-FNA for left-sided tumors was 68%. EUS-FNA prevented surgical staging procedures in 60 of 152 patients (39%). No major complications occurred during EUS-FNA. Conclusion Routine use of EUS-FNA in unselected patients with NSCLC reduces the need for surgical staging procedures in nearly half of patients. Additional surgical staging in patients without nodal metastases at EUS-FNA reduces the false negative EUS-FNA findings considerably regardless of the location of the primary lung tumor.

EUS-FNA predicts 5-year survival in pancreatic endocrine tumors

Pancreatic endocrine tumors (PETs) differ in clinical behavior and prognosis. Determination of malignant potential through specimens obtained by EUS-FNA can help in the management of these patients. To determine the value of EUS-FNA for diagnosing PETs and for classifying their underlying malignant potential based on the World Health Organization (WHO) classification. Single-center, retrospective, cohort study. Tertiary referral hospital. This study involved 86 consecutive patients (44 men, mean age 58 +/- 14 years) who had been diagnosed with PETs and submitted to EUS-FNA from January 1999 to August 2008. EUS-FNA of a pancreatic mass and/or a metastasis site. Immunohistochemistry on microbiopsies or on monolayer cytology was routinely used. The lesions were classified as recommended by the WHO. EUS-FNA sensitivity and 5-year survival rate. Overall, in 90% (77 of 86) of patients in this study, PET was diagnosed with EUS-FNA. The sensitivity did not vary with tumor size, type, location, or the presence of hormonal secretion. Of 86 patients, 30 (35%) were submitted to surgical resection. The kappa correlation index between the WHO classification obtained by EUS-FNA and by surgery was 0.38 (P = .003). Major discrepancies were found in the group of patients diagnosed with endocrine tumor of uncertain behavior by EUS-FNA, because 72% turned out to have well-differentiated endocrine carcinoma. Sixteen patients (27%) died during a mean follow-up period of 34 +/- 27 months. The 5-year survival rates were 100% for endocrine tumors, 68% for well-differentiated endocrine carcinomas, and 30% for poorly differentiated endocrine carcinomas (P = .008, log-rank test). Retrospective design, selection bias, and small sample size. This largest single-center experience to date demonstrated the accuracy of EUS-FNA in diagnosing and determining the malignant behavior of PETs. EUS-FNA findings predict 5-year survival in patients with PETs.

EUS FNA of Distant Extra-Vascular Migratory Metastasis (EVMM) and Tumor Thrombosis

Background: Vascular invasion impacts cancer staging, prognosis, and therapy. Malignant infiltration usually results from direct and gross extension from a primary tumor and is readily identified by CT. Cancers may also migrate to remote sites along vascular channels, a process termed angiotropism or EVMM. Sometimes this pattern of spread can be seen with CT. Surgical and autopsy studies also demonstrate microscopic or diminutive (1-3 mm thick) spread not seen with CT. Additionally, a tumor thrombus may only be recognized at surgery or autopsy. We report the EUS FNA diagnosis of malignant perivascular cuffing and tumor thrombosis occurring distant from a primary tumor, including microinvasion with negative helical CT. Aims: To examine the capability and safety of EUS FNA for diagnosing distant perivascular tumor infiltration and tumor thrombus in CT positive and negative (i.e. microinvasion) patients. Methods: Using a prospectively maintained EUS database, we identified all examinations from 09/04 to 11/08 in which FNA was performed of a vascular wall or intravascular thrombus. We abstracted and analyzed date regarding demographic, radiology and EUS features, cytology results, and follow up data. Results: EUS FNA was performed from 31 vascular sites [vascular wall (n=27), intravascular thrombus (n=4)] during 29 exams in 27 patients [15 male, age 55±11 years]. Cancer was diagnosed in 24/27 (89%) patients of whom 20 had pancreatic cancer. For diagnosis of vascular involvement remote from cancer (EVMM), a median of 3 FNAs (range 2-9) was obtained from wall of the celiac artery (n=12), SMA (n=6), hepatic artery (n=5), splenic artery (n=2), SMV (n=1), aorta (n=1); and intravascular FNA of portal vein (n=4). FNA cytology was positive (n=17) or suspicious (n=2) among cancer patients. EUS FNA detected and confirmed microinvasion in 3 patients with negative helical CT. CT and EUS identified indeterminate peri- and intravascular findings in 3 patients ultimately diagnosed with benign disorders after a median follow-up of 3 (0.4-7) months. EUS FNA was negative in each of these patients. Conclusion: CT and EUS can identify peri- and intravascular tumor extension remote from the primary tumor and not resulting from gross infiltration. EUS can detect microinvasion (1-3mm) not seen on helical CT. Further study is needed to determine the prevalence, to establish the safety and accuracy of EUS FNA, and impact on prognosis, clinical care, and outcomes.

How Good Is EUS-FNA in Diagnosing the Correct Etiology for a Solid Pancreatic Mass? A Meta-Analysis and Systematic Review

Background: The published data on accuracy of EUS-FNA in diagnosing the correct etiology for a solid pancreatic mass has been varied. Detecting the correct etiology for a pancreatic mass help in triaging patients for appropriate therapies and might obviate the need for invasive surgery. Aim: To evaluate the accuracy of EUS-FNA in diagnosing the correct etiology for a solid pancreatic mass. Method: Study Selection Criteria: EUS-FNA studies with a gold standard (either confirmed by surgery or appropriate follow-up) were selected. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, Cumulative index for nursing & allied health literature, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. Statistical Method: Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and by the DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights. Results: Initial search identified 3610 reference articles, of these 360 relevant articles were selected and reviewed. Data was extracted from 69 studies (N= 6493) which met the inclusion criteria. Pooled sensitivity of EUS-FNA in diagnosing the correct etiology for solid pancreatic mass was 86.9% (95% CI: 85.9 - 87.9). EUS-FNA had a pooled specificity of 95.9% (95% CI: 94.9 - 96.7). The positive likelihood ratio of EUS was 14.7 (95% CI: 9.4 - 22.9) and negative likelihood ratio was 0.18 (95% CI: 0.15 - 0.23). The diagnostic odds ratio, the odds of having correct histologic etiology of pancreatic mass in positive as compared to negative EUS-FNA studies was 93.5 (95% CI: 58.6 - 149.1). All the pooled estimates calculated by fixed and random effect models were similar. SROC curves showed an area under the curve of 0.95. Egger bias, an indicator for publication bias, was 0.59 (95% CI = -0.23 to 1.43, p = 0.1525), and confirmed no publication bias. The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. Conclusions: EUS-FNA is an excellent diagnostic tool to detect the correct etiology for solid pancreatic mass. When available, EUS-FNA should be strongly considered as the first diagnostic tool for sampling solid pancreatic lesions to guide patient management.

EUS-FNA Predicts 5-Year Survival in Pancreatic Endocrine Tumors (PETs)

Background: PETs differ in clinical behavior and prognosis. Determination of malignant potential by EUS-FNA can help management. Aim: To determine the performance of EUS-FNA for diagnosing and classifying the malignant potential of PETs based on WHO classification. Methods: Single-center retrospective study. A review of medical records from 01/1999 to 08/2008 was performed to identify patients who had been diagnosed with PETs and submitted to EUS-FNA. The diagnosis of PET was established by EUS-FNA and/or histopathologic evaluation obtained by surgical resection. Antibodies against synaptophysin, chromogranin A, p53, Ki-67 were used. The lesions were classified as recommended by the WHO. Results: In overall, 90% (77/86) of patients had the diagnosis obtained by EUS-FNA. The sensitivity did not vary with size, type, location, and presence of hormonal secretion. Of 86 patients, 30 (35%) were submitted to surgery. The kappa index between the classification obtained by EUS-FNA and by surgery was 0.38 (p=0.003). Major discrepancies were found in the group of endocrine tumor of uncertain behavior(UBWDET) obtained by EUS-FNA, since 72% turned out to be well-differentiated endocrine carcinoma(WDEC). Sixteen patients(27%) died during a mean follow-up of 34 ± 27 months. The 5-year survival rates were 100% for endocrine tumors, 68% for WDEC, and 30% for poorly-differentiated endocrine carcinomas(PDEC)(p=0,008). Conclusions: This largest single-center experience demonstrated the accuracy of EUS-FNA in diagnosing and determining the malignant behavior of PETs. EUS-FNA predicts 5-year survival. Notes: BBWET=well differentiated endocrine tumor of benign behaviour

EUS-FNA for Mediastinal Restaging of Non Small Cell Lung Carcinoma (NSCLC)

79 patients underwent EUS-FNA for mediastinal restaging. At CT, 76% had a partial or complete response and 24% had stable disease. EUS-FNA found persistent nodal metastases (N2) in 27 patients (34%). Of the remaining 52 patients who were staged N0 at EUS, 40 patients subsequently underwent additional staging procedures (thoracotomy, n=34; reMS, n=4; EBUS-TBNA, n=2). In 16 patients (40%), a complete mediastinal response (N0) was confirmed by thoracotomy, whereas persistent N2-disease was found in 24 (60%) patients. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of EUS-FNA for mediastinal restaging were 52%, 100%, 100%, 40% and 64% respectively. No complications occurred. Conclusions

Predictors of Diagnostic Accuracy of EUS-FNA for Pancreatic Malignancy

Background: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is an established useful modality for the diagnosis of malignant lesions of the pancreas. However, EUS-FNA may be inconclusive for malignancy in a subset of cases. Objective: To evaluate the sensitivity, specificity, predictive value, and determinants of accuracy of EUS-FNA of the pancreas for malignancy in a series of patients evaluated at a large tertiary referral hospital for pancreatic disease. Methods: Retrospective case series of all EUS-FNAs of mass lesions of the pancreas performed specifically to evaluate for malignancy at a tertiary referral center for pancreatic disorders from January 2005 through June 2008. Multivariate analysis of a variety of factors was performed by logistic regression. These included: indication for EUS, presence of a biliary or pancreatic stent, location of the mass, number of FNA passes, and utilization of “in-room” quick read preliminary cytology by a cytopathologist or trained technologist. For inclusion, a final diagnosis must have been confirmed by histological analysis of a surgical specimen and/or clinical follow up. Results: Of 344 cases reviewed, 284 met the inclusion criteria. The most common indications for the procedure were a mass lesion seen on prior imaging (82.4%), biliary obstruction without evidence of a mass (14.1%), and chronic pancreatitis (2.8%). Among patients with a mass on EUS, the location was in the head in 53.5%, body in 25.4%, neck in 9.2%, tail in 6.3%, and uncinate process in 5.6%. A biliary or pancreatic stent was present in 28.5% of cases. On average, 4.4±2.5 FNA passes were made into the pancreas for each case. Quick read preliminary cytology was utilized in 145 cases (51.1%). Malignancy was ultimately diagnosed in 239 (84.2%). These malignancies included adenocarcinoma (90%), neuroendocrine tumor (7.9%), lymphoma (1.3%), and metastatic renal cell carcinoma (0.8%). Pancreatitis was the final diagnosis is 27 (9.5%). EUS-FNA of the pancreas had a sensitivity of 83.7%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 53.6% for malignancy. Overall accuracy for malignancy was 86.2%. On multivariate analysis, only utilization of quick read preliminary cytology had a statistically significant affect on diagnostic accuracy for malignancy (p=0.002). Conclusions: EUS-FNA has good sensitivity and excellent specificity for the diagnosis of pancreatic malignancy. Quick read preliminary cytology should be obtained in order to maximize the accuracy of EUS-FNA for malignant lesions of the pancreas.

Accuracy of EUS-FNA to Diagnose Solid Pancreatic Lesions in Chronic Pancreatic vs. Normal Pancreatic Parenchyma: A Meta-Analysis and Systematic Review

Accuracy of EUS-FNA to Diagnose Solid Pancreatic Lesions in Chronic Pancreatic vs. Normal Pancreatic Parenchyma: A Meta-Analysis and Systematic Review

EUS/EUS-FNA for suspected pancreatic cancer: influence of chronic pancreatitis and clinical presentation with or without obstructive jaundice on performance characteristics

The clinical utility of EUS-FNA is debated in patients with obstructive jaundice (ObJ) because of a very high pretest probability of pancreatobiliary malignancy (PBM) and biliary stent-induced inflammation that can potentially confound EUS-FNA diagnosis. EUS-FNA also has lower accuracy in patients with underlying chronic pancreatitis (CP). Our purpose was to determine the clinical value of EUS-FNA for PBM diagnosis based on clinical presentation and presence of CP. Retrospective analysis of prospective database. University hospital. Patients who underwent EUS-FNA from 2002 to 2006 for suspected PBM based on (1) ObJ with biliary stricture or a mass lesion or (2) abnormal pancreatic imaging by CT/MRI: a focal pancreatic "mass" lesion; dilated pancreatic duct +/- common bile duct; or an enlarged head of pancreas. EUS was performed with a radial echoendoscope followed by a linear echoendoscope if a focal pancreatic lesion was identified. Fine-needle aspirates were assessed immediately by an attending cytopathologist. (1) Prevalence of cancer and (2) performance characteristics of EUS-FNA. PBM was diagnosed in 73.9% of patients with ObJ and biliary stricture or pancreatic mass, in 49.6% of patients with pancreatic mass, and in 7.0% of patients with an enlarged head of pancreas or dilated pancreatic duct +/- common bile duct. The prevalence of PBM was lower in all 3 presentations with associated CP. Both CP and presentation with ObJ lowered performance characteristics of EUS-FNA, but CP did so only in the subset of patients with ObJ. All except 1 false-negative diagnoses were due to cytologic misinterpretation. Retrospective design. Among patients with suspected PBM, the accuracy of EUS-FNA is significantly lower only in a subset of patients with ObJ with underlying CP, largely as a result of difficulty in cytologic interpretation.

The additional value of EUS-guided Tru-cut biopsy to EUS-guided FNA in patients with mediastinal lesions

EUS-guided FNA is a sensitive method to obtain cytologic specimens from solid lesions in close proximity to the GI tract. Although FNA provides cells for analysis, large-caliber Tru-cut biopsy (EUS-TCB) needles obtain samples that can be used for additional histopathologic analysis. We assessed the additional diagnostic yield of EUS-TCB in patients with solid mediastinal lesions in whom EUS-FNA was performed. In the period from July 2003 to July 2007, all patients with mediastinal lesions accessible to EUS-FNA and EUS-TCB were evaluated. In all patients, a mean of 3 passes of EUS-FNA was followed by EUS-TCB. Cytologic and histologic specimens were evaluated by 2 pathologists blinded for patient condition. A final diagnosis was obtained by combining all information present (EUS-FNA and EUS-TCB results, mediastinoscopy, bronchoscopy [if performed], and other investigations). The diagnostic accuracy of EUS-FNA, EUS-TCB, and the combination of both techniques was 93%, 90%, and 98%, respectively (not significant). In EUS-FNA-negative patients, EUS-TCB provided a final diagnosis in an additional 3 patients (5%). Malignant disease found by EUS-FNA could be specified by EUS-TCB in 15 patients (25% of patients). The granulomatous disease established by cytologic samples of clinically suspected tuberculosis could be specified by EUS-TCB in 2 patients (3%). In 1 patient (2%), both FNA and TCB were inconclusive. Retrospective study. The diagnostic yield of EUS-FNA and EUS-TCB is comparable. We recommend limiting the use of EUS-TCB to specific cases in which EUS-FNA is not conclusive.

Is it possible that tumor cells could be disseminated in the abdominal cavity during EUS-FNA examinations for pancreatic tumor?

Background: Usefulness of Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in diagnosis for gastrointestinal disease has been reported in many literatures. It is reported that the outcome of EUS-FNA to pancreatic tumors results in high accuracy, actually the accuracy of EUSFNA for pancreatic tumor in our institution from Jan. in 2001 to Sep. in 2006 was 97.4%. However, dissemination of tumor cells or needle tract seeding, secondary to EUS-FNA, is reported to occur in some cases. In this study, our purpose is to evaluate the dissemination of tumor cells secondary to EUS-FNA by investigation of cases with pancreatic tumor that underwent both EUS-FNA and cytology of lavage fluid collection in abdominal cavity during surgery.

Comparison of CEA and DNA Analysis in 100 Consecutive Patients with Pancreatic Cysts

Background: Pancreatic cyst fluid CEA levels and DNA analysis have been proposed as useful diagnostic tests in differentiating mucinous from serous cysts. However, studies comparing these two approaches are lacking. Aim: To compare CEA level with DNA analysis of pancreatic cyst fluid obtained by EUS-FNA. Methods: EUS database at our institution was searched, and consecutive patients who underwent EUS-FNA for evaluation of pancreatic cysts were identified. Those with acute pancreatitis within 4 months were excluded. Following was used to designate a cyst mucinous: CEA criteria - level ≥ 192 ng/ml and DNA analysis criteria - DNA quantity ≥40ng/ul or k-ras-2-point mutation or ≥2 allelic imbalance mutations. Pathologic analysis of cyst served as the reference standard. Results: From 2006 - 2007, 100 patients met study criteria. The average age of patients was 63 years, 65% were women and 30% were symptomatic. The mean short-axis diameter of pancreas cysts was 19 mm, and mean long-axis diameter was 26 mm. Thirty-four percent of cysts were in pancreatic head, 17% had an intrinsic nodule /mass, and 44% were multi-loculated. Of the 84 patients for whom results of both CEA and DNA analysis were available, the median CEA value was 83 ng/ml [range1-50,000], mean DNA content was 16 ng/ul [range1-212], 11% had k-ras mutations, and 43% had ≥ 2 allelic imbalance mutations. Using pre-specified criteria, there was only fair agreement between CEA and DNA analysis[considering all 3 aspects together] for the classification of mucinous and serous cysts [Kappa = 0.2]. Poor to fair agreement existed between CEA and DNA quantity [Spearman's correlation = 0.2;p = 0.1], k-ras mutation [kappa = 0.3] and ≥ 2 allelic imbalance mutations [kappa = 0.1]. Of the 19 patients for whom a final pathological diagnosis was available, CEA had an accuracy of 84 % compared with 79% % for DNA analysis for correctly identifying mucinous cysts. When CEA level and DNA analysis were combined, all mucinous cysts were correctly identified. Conclusion: Pancreatic cyst fluid CEA and DNA analysis appear to measure different aspects of cyst characteristics, and considering both together may improve diagnostic accuracy of EUS-FNA in differentiation mucinous from serous cysts. Tabled 1Test characteristics of CEA and molecular analysis Sens Spec Accuracy CEA 82% 100% 84% Molecular Analysis 77% 100% 79% K-ras mutation 11% 100% 21% Allelic Imbalance 70% 100% 73% Open table in a new tab

EUS-Guided FNA of Pancreatic Mass Lesions: Significance of Suspicious Or Atypical Histopathology

Establishing the diagnosis of pancreatic cancer has improved significantly with the addition of EUS to the diagnostic armamentarium. The further introduction of FNA has allowed tissue conformation previously limited to percutaneous approach or at the time of surgical exploration. Consistently adequate tissue sampling to establish a diagnosis has been problematic with current technology. The significance of suspicious or atypical histology in the setting of pancreatic mass lesions is unclear. Aim: To determine the frequency and significance of suspicious or atypical histology in patients with pancreatic mass lesions. Methods: Over a 10-year-period, 286 patients were identified with pancreatic carcinoma confirmed by EUS-FNA, percutaneous CT-guided biopsy, surgical exploration or long-term follow-up. Of these, 191 patients underwent attempted EUS-FNA. During this period 26 patients with chronic pancreatitis with tumorous appearing parenchymal abnormalities underwent EUS-FNA. All patients had established benign disease by EUS-FNA and confirmed by surgery or long-term follow-up. EUS-FNA histopathology was reviewed and compared to final diagnosis. Pathology results included adenocarcinoma, benign/inflammatory, suspicious/atypical or insufficient. Patients with cystic neoplasm and neuroendocrine tumors were excluded from this review. Results: Overall accuracy of EUS-FNA for pancreatic carcinoma was 145/191 = 76%. The 46 (negative) cytology results included suspicious/atypical (n = 29, 15%), benign/inflammatory (n = 6, 3%) and insufficient (n = 11, 5.9%). Overall accuracy of EUS-FNA for chronic pancreatitis was 21/25 = 84%. The 4 incorrect cytology results included suspicious/atypical (n = 1, 4%) and insufficient (n = 3, 12%). The ability of suspicious/atypical EUS-FNA cytology in predicting pancreatic adenocarcinoma was highly specific (96%) with high positive predictive value (97%). The sensitivity and negative predictive value was comparatively lower (83% and 78% respectively). Conclusions: 1) EUS-FNA of pancreatic mass lesions is less than optimal. 2) The significance of suspicious and/or atypical histopathology in the setting of pancreatic mass lesions carries a high specificity and positive predictive value for pancreatic carcinoma. These results along with a positive cytology can be used collectively to increase the accuracy of EUS-FNA in pancreatic mass lesions. Tabled 1 EUS-FNA results Final diagnosis Pt. (n) ACA Suspicious/Atypical Benign Insufficient Pancreatic Cancer 191 145 29 6 11 Chronic Pancreatitis 26 0 1 21 3 ACA = Adenocarcinoma Open table in a new tab ACA = Adenocarcinoma

Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Non-small Cell Lung Cancer Staging: A Systematic Review and Metaanalysis

Background:Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a minimally invasive alternative technique for mediastinal staging of non-small cell lung cancer. A metaanalysis was performed to estimate the diagnostic accuracy of EUS-FNA for staging mediastinal lymph nodes (N2/N3 disease) in patients with lung cancer.Methods:Relevant studies were identified using Medline (1966 to November 2005), CINAHL, and citation indexing. Included studies used histology or adequate clinical follow-up (> 6 months) as the “gold standard,” and provided sufficient data for calculating sensitivity and specificity. Summary receiver operating characteristic curves metaanalysis was performed to estimate the pooled sensitivity and specificity.Results:In 18 eligible studies, EUS-FNA identified 83% of patients (95% confidence interval [CI], 78 to 87%) with positive mediastinal lymph nodes (pooled sensitivity) and 97% of patients (95% CI, 96 to 98%) with negative mediastinal lymph nodes (pooled specificity). In eight studies that were limited to patients who had abnormal mediastinal lymph nodes seen on CT scans, the sensitivity was 90% (95% CI, 84 to 94%) and the specificity was 97% (95% CI, 95 to 98%). In patients without abnormal mediastinal lymph nodes seen on CT scans (four studies), the pooled sensitivity was 58% (95% CI, 39 to 75%). Minor complications were reported in 10 cases (0.8%). There were no major complications.Conclusions:EUS-FNA is a safe modality for the invasive staging of lung cancer that is highly sensitive when used to confirm metastasis to mediastinal lymph nodes seen on CT scans. In addition, among lung cancer patients with normal mediastinal adenopathy seen on CT scans, despite lower sensitivity, it has the potential to prevent unnecessary surgery in a large proportion of cases missed by CT scanning.

EUS-SOS

Purpose: Bronchoscopy with transbronchial FNA, mediastinoscopy, CT guided bx and laparoscopy are accepted techniques for tissue sampling of intrathoracic and intra-abdominal masses. We report our experience with EUS FNA/Trucut bx (EUS FNA/TCB) as a rescue procedure in patients (pts.) who previously failed or were refused by other bx techniques. Aim: To evaluate the accuracy of EUS FNA in pts with malignant disease and a previously failed bx procedure. Methods: Retrospective analysis of EUS FNA/TCB results in all pts. referred for pancreatic or mediastinal bx from 10/03 to 4/05. Pts. who failed or were refused by other bx modalities and had a final diagnosis of malignancy were included. A positive diagnosis of malignancy by EUS FNA/TCB was considered true positive. All procedures were performed only with linear array EUS by a single endosonographer. No on-site cytopathology was done. FNA was performed in all pts. and TCB was added at the discretion of the endosonographer. Results: A total of 160 pts. were referred for pancreatic or mediastinal bx for solid masses. Thirty-nine pts. (24%) met the inclusion criteria. The mean age was 67 years (18 F and 21 M). There were 26 pancreatic masses and 13 mediastinal masses. In the mediastinal group, 11 failed bronchoscopy with transbronchial FNA, one failed mediastinoscopy, and one was turned down for CT guided bx. In the pancreatic group, sixteen failed CT guided bx, six failed laparoscopy, three were turned down for CT guided bx and one failed prior EUS FNA/TCB. The sensitivity of EUS FNA/TCB for detecting malignancy in 39 pts. was 85%. In the mediastinal and pancreatic subgroups sensitivities were: 100% and 77% respectively. The mean number of FNA passes was 6 (range 3–10), Trucut was used in 19 pts., mean number of passes of 2.4 (range 2–5). All six pts. with pancreatic cancer missed by EUS FNA did not undergo additional EUS TCB due to technical reasons (uncinate process lesions). Four of the six pts. with pancreatic cancer missed by EUS FNA, had at least two prior failed biopsies by CT FNA. Conclusions: In pts. who have failed other bx procedures, EUS FNA/TCB should still be considered an accurate and safe modality to detect malignancy. Addition of TCB to FNA appears safe and should be considered in the absence of on-site cytopathology review.

Role of EUS-guided FNA in the Diagnosis of Solid Pancreatic Lesions. A Single Center Experience

Introduction: Mass lesions of the pancreas can be malignant or benign, which is often difficult to differentiate. Differentiating these tumors is essential for optimal management and outcome. The purpose of this study was to retrospectively evaluate the accuracy of EUS-FNA in cytologic diagnosis of pancreatic solid lesions. Methods: A retrospective review was done to identify patients who underwent EUS from year 2002 to year 2005 for an abnormal pancreatic imaging (mass lesion, fullness or prominent head of pancreas). EUS-FNA was performed using 22-gauge needle. Onsite cytopatholgist was available to determine the adequacy of the sample. Results: 320 patients underwent EUS for an abnormal pancreatic image. Out of these, 123 patients had a solid pancreatic lesion and had EUS-FNA performed. The cytopathology results of EUS-FNA are as shown in table 1. Surgical confirmation of pancreatic adenocarcinoma was available in 41 out of 72 patients. Follow up of patients with atypical cytology on subsequent surgery revealed pancreatic malignancy in 4 patients. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-FNA in the diagnosis of solid pancreatic tumors at our center is 89.13%, 100%, 100% and 27.5% respectively.

A randomized comparison of EUS-guided FNA versus CT or US-guided FNA for the evaluation of pancreatic mass lesions

Diagnosing pancreatic cancer by EUS-FNA is a potentially appealing alternative to percutaneous biopsy. To compare EUS-FNA with CT or US-guided FNA for diagnosing pancreatic cancer. Single center, prospective, randomized, cross-over. Duke University Medical Center. Eighty-four patients referred with suspicious solid pancreatic mass lesions randomized to CT/US-FNA (n = 43) or EUS-FNA (n = 41). Patients underwent an imaging procedure/FNA. If cytology was nondiagnostic, cross over to the other modality was offered. Final outcome was determined by clinical follow-up every 6 months for 2 years and/or surgical pathology for patients with negative FNA. Sensitivity and accuracy of EUS-FNA versus CT/US-FNA for pancreatic cancer. There were 16 true positive (TP) by CT/US-FNA and 21 TP by EUS-FNA. Sixteen of the 20 CT/US-FNA negative patients crossed over to EUS-FNA; 12 underwent FNA, 4 had no mass at EUS. Seven of the 12 had positive EUS-FNA. Eight EUS-FNA negative crossed over to CT/US; 4 had no mass at CT/US, 3 remained true negative throughout follow-up, 1 had chronic pancreatitis at surgery. The sensitivity of CT/US-FNA and EUS-FNA for detecting malignancy was 62% and 84%, respectively. A comparison of the accuracy for CT/US-FNA and EUS-FNA was not statistically significant (P = .074, chi(2)). Failure to meet target enrollment resulted in an inability to demonstrate a statistically significant difference between the 2 modalities. EUS-FNA is numerically (though not quite statistically) superior to CT/US-FNA for the diagnosis of pancreatic malignancy.

Utility of EUS-FNA and Cyst Fluid Analysis in the Diagnosis of Intraductal Papillary Mucinous Tumors: Correlation with Histopathology in 74 Patients

Utility of EUS-FNA and Cyst Fluid Analysis in the Diagnosis of Intraductal Papillary Mucinous Tumors: Correlation with Histopathology in 74 Patients Shireen A. Pais, Siriboon Attasaranya, Julia Leblanc, Stuart Sherman, Lee Mchenry, Max Schmidt, John Dewitt Background: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are precancerous cystic tumors characterized by dilation of the main pancreatic duct (IPMN-M) alone, side branches alone (IPMN-Br) or both. The aim of this study is to evaluate the accuracy of EUS-FNA and cyst fluid analysis in the diagnosis of IPMNs. Methods: Databases at our hospital from 7/96-11/05 were used to retrospectively identify patients who underwent EUS followed by surgery for IPMNs. EUS was performed by 7 experienced endosonographers with on-site cytopathologists. Surgical pathology was the diagnostic gold standard. The following were classified as benign: IPMN adenoma, low grade, borderline or highgrade dysplasia. Only invasive carcinoma was considered as malignant. Results: 74 patients (38M; mean age: 65 G 10 yrs) were identified with 21 (28%) malignant and 53 (72%) benign IPMNs. Tumor locations: pancreatic head alone, body alone, tail alone or multifocal in 39 (53%), 17 (23%), 5 (6%) and 9 (12%) respectively. The tumors were classified as IPMN-M, IPMN-Br or both in 21 (28%), 18 (25%) and 35 (47%) respectively. Only one patient had high-grade dysplasia (1.3%). EUS-FNA (mean 3.4 passes; range: 1-8) was performed in 65 (88%). Compared to surgical pathology, the sensitivity, specificity, PPV, NPV, and accuracy of EUS-FNA for the diagnosis of malignancy were 75%, 91%, 79%, 89% and 86% respectively. There was no significant difference in the mean number of passes performed between malignant (3.7 G 2.3) and benign (3.4 G 2.0) tumors respectively (p Z 0.42). Cyst fluid CEA and CA 19-9 were available in 8 and 5 patients in the malignant group and 15 and 4 patients in the benign group respectively. There was no statistically significant difference between the mean CEA in the malignant IPMNs (1769.8 ng/ml G 4159.9; range: 2.5 to 12765) compared to the benign tumors (511 ng/ml G 1192.5; range 0.5-4878; p Z 0.28) or the mean CA 19-9 in the malignant IPMNs (2973.2 U/ml G 14651; range: 29.4-40490) compared to the benign tumors (16390 U/ml G 4218; range: 15-10236; p Z 0.08). If a CEA of 1000 ng/ml is used as the arbitrary cutoff between benign and malignant, CEA has sensitivity, specificity, PPV, NPV and accuracy of 38%, 60%, 33%, 64% and 52% respectively. Similarly, a CA 19-9 cutoff of 10,000 U/mL has a sensitivity, specificity, PPV, NPV and accuracy of 80%, 50%, 67%, 67% and 67% respectively for differentiating benign from malignant IPMNs. Conclusions: The sensitivity, specificity and accuracy of EUS-FNA for the diagnosis of malignancy in IPMN were 75%, 91% and 86% respectively. Tumor markers are only moderately accurate in differentiating malignant from benign IPMNs.

Endoscopic Ultrasound (EUS)-Guided FNA in Lung Cancer Staging-a Meta-Analysis of Diagnostic Performance

Background: Accurate staging of lung cancer is critical for deciding the most appropriate therapy. CT and PET are non-invasive tests limited by poor specificity. Invasive staging is commonly performed with mediastinoscopy. EUS-FNA is an alternative with less morbidity. Aim: To estimate the diagnostic accuracy of EUS-FNA for staging mediastinal lymph nodes (N2/N3 disease) in lung cancer via meta-analysis of all studies in the literature. Methods: Relevant studies were identified using Medline (1966-November 2005), CINAHL, and citation indexing.