Diagnosis Of Solid Pancreatic Masses Research Articles

Factors influencing the accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the cytological diagnosis of solid pancreatic masses

Factors influencing the accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the cytological diagnosis of solid pancreatic masses

A prospective comparison of EUS-guided FNB with FNA for diagnosis of pancreatic solid masses

A prospective comparison of EUS-guided FNB with FNA for diagnosis of pancreatic solid masses

Mo1416 Comparison of Fenestrated Versus Standard Needles for Endoscopic Ultrasound-Guided Biopsy of Solid Pancreatic Lesions

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using standard needles(StN) has a significant value in the diagnosis of solid pancreatic masses, Cook medical® ProCore™ fenestrated needles are promoted for fine needle biopsy (FNB) as an alternative requiring fewer number of passes to obtain a diagnosis.

Significance of the diagnostic categories “atypical” and “suspicious for malignancy” in the cytologic diagnosis of solid pancreatic masses

Endoscopic ultrasound guided (EUS) fine-needle aspiration (FNA) investigation of solid pancreatic lesions has been shown to have good sensitivity and specificity. Many lesions can be definitely classified as benign or malignant but some can only be cytologically classified as "atypical" or "suspicious for malignancy". Risk for malignancy in these indeterminate categories has not been well categorized. The cytology records of four University Medical centers were searched for all EUS guided FNAs of solid pancreatic lesions. All cases with a diagnosis of "atypical", or "suspicious for malignancy" were selected for analysis when histologic biopsy or over 18 months clinical follow-up was available. Two hundred and ninety-two cases with a diagnosis of "atypical" or "suspicious for malignancy" and adequate follow-up were obtained from the combined data of the four institutions. The percentage malignant for the categories "atypical" and "suspicious for malignancy" were 79.2 and 96.3%, respectively. If the category "atypical" was classified as benign and "suspicious for malignancy" was classified as malignant, the resulting positive predictive value was 96.3 (95% CI: 92.6-98.5) and the negative predictive value 20.8 (95% CI: 13.4-30.0). The categories of "atypical" and "suspicious for malignancy" stratify risk for malignancy in a fashion, which may aid in patient counseling and selection of follow-up protocols. Classification of "suspicious for malignancy" as malignant optimizes diagnostic sensitivity and specificity.

Tips for endoscopic ultrasound-guided fine needle aspiration of various pancreatic lesions

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a well-established procedure for diagnosis of pancreatic solid masses. This technique is highly accurate and safe and can be performed uneventfully in most cases. However, factors such as unstable scope position, inappropriate location of the lesion, lesion mobility, and lesion characteristics may complicate the procedure. To overcome such difficulties, it is necessary to select the most suitable needle and consider several technical points according to each situation. We introduce our standard technique for EUS-FNA and provide several tips for ensuring a successful procedure.

Continuing Medical Education Exam: October 2013

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Bryant RV, Kuo P, Williamson K, et al. Performance of the Glasgow-Blatchford score in predicting clinical outcomes and intervention in hospitalized patients with upper GI bleeding. Gastrointest Endosc 2013;78:576-83. McGorisk T, Krishnan K, Keefer L, et al. Radiofrequency ablation for refractory gastric antral vascular ectasia (with video). Gastrointest Endosc 2013;78:584-8. Fuccio L, Hassan C, Laterza L, et al. The role of K-ras gene mutation analysis in EUS-guided FNA cytology specimens for the differential diagnosis of pancreatic solid masses: a meta-analysis of prospective studies. Gastrointest Endosc 2013;78:596-608. Hayashi N, Tanaka S, Hewett DG, et al. Endoscopic prediction of deep submucosal invasive carcinoma: validation of the Narrow-Band Imaging International Colorectal Endoscopic (NICE) classification. Gastrointest Endosc 2013;78:625-32. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

Differential diagnosis of solid pancreatic masses by Quantitative Endoscopic Ultrasound Elastography (Q-EUS-E): A validation study

Differential diagnosis of solid pancreatic masses by Quantitative Endoscopic Ultrasound Elastography (Q-EUS-E): A validation study

PWE-058 Tissue Acquisition from Solid Pancreatic Lesions – Endoscopy or Surgery

IntroductionThe accurate diagnosis of solid pancreatic masses is important in directing appropriate management of patients. The methods commonly used are percutaneous, laparoscopic and EUS guided biopsy of these lesions. Laparoscopic...

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

Differential diagnosis of pancreatic solid masses with EUS-guided FNA (EUS-FNA) is still challenging in about 15% of cases. Mutation of the K-ras gene is present in over 75% of pancreatic adenocarcinomas (PADC). To assess the accuracy of K-ras gene mutation analysis for diagnosing PADC. We systematically searched the electronic databases for relevant studies published. Data from selected studies underwent meta-analysis by use of a bivariate model providing a pooled value for sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve. Meta-analysis of 8 prospective studies. Total of 931 patients undergoing EUS-FNA for diagnosis of pancreatic solid masses. K-ras mutation analysis. Diagnostic accuracy of K-ras mutation analysis and of combined diagnostic strategy by using EUS-FNA and K-ras mutation analysis in the diagnosis of PADC. The pooled sensitivity of EUS-FNA for the differential diagnosis of PADC was 80.6%, and the specificity was 97%. Estimated sensitivity and specificity were 76.8% and 93.3% for K-ras gene analysis, respectively, and 88.7% and 92% for combined EUS-FNA plus K-ras mutation analysis. Overall, K-ras mutation testing applied to cases that were inconclusive by EUS-FNA reduced the false-negative rate by 55.6%, with a false-positive rate of 10.7%. Not repeating EUS-FNA in cases in which mutation testing of the K-ras gene is inconclusive would reduce the repeat-biopsy rate from 12.5% to 6.8%. Small number of studies and between-study heterogeneity. K-ras mutation analysis can be useful in the diagnostic work-up of pancreatic masses, in particular when tissue obtained by EUS-FNA is insufficient, and the diagnosis inconclusive.

Quantitative Endoscopic Ultrasound Elastography (Q-EUS-E) is an accurate method for the differential diagnosis of solid pancreatic masses: A validation study

Quantitative Endoscopic Ultrasound Elastography (Q-EUS-E) is an accurate method for the differential diagnosis of solid pancreatic masses: A validation study

Mo1488 Comparison of EUS-Fine Needle Biopsy With EUS-Fine Needle Aspiration As a Historical Control for Diagnosis of Pancreatic Solid Masses

EUS-FNA is the current standard of method for sampling pancreatic solid masses, but cytologic analysis has several limitations for diagnostic accuracy. To overcome the cytology, biopsy needles have been developed to obtain histologic samples during EUS. The aim of this study was to compare EUS-FNB needle with EUS-FNA needle as a historical control for diagnosis of pancreatic solid masses.

Sa1193 Quantitative Endoscopic Ultrasound Elastography (Q-EUS-E) in the Differential Diagnosis of Solid Pancreatic Masses: A Validation Study

Endoscopic ultrasound (EUS) guided biopsy allows cytologic and/or histologic diagnosis of sub-mucosal lesions of the gastrointestinal tract (GIT). The diagnostic yield with fine needle aspiration (FNA), however, is often unsatisfactory (~30-40%). A newly developed Pro-Core needle (PCN) is able to obtain core tissue and may improve diagnostic yield. AIM: To compare the performance of two EUS guided biopsy needle systems, FNA versus PCN, in the evaluation of sub-mucosal lesions in the upper GIT. METHODS: Data related to patients referred for EUS and possible guided biopsy of sub-mucosal lesions in the upper GIT over 24 months were retrospectively reviewed. All specimens were prepared as cell-block for histo-cytological analysis. Measured outcomes were presence of diagnostic material, ability to perform immunohistochemistry (IHC), provision of a diagnosis, and complication. RESULTS: Of 84 patients who had EUS evaluation of an upper GIT sub-mucosal lesion, 30 patients did not have biopsy (lipoma=14, duplication cysts=6, vascular compression=1 and no abnormality=9). EUS-guided biopsy were performed in 54 patients, using 19-22G FNA (n=34) and 22G PCN (n=20) system, to clarify the tissue diagnosis of a hypo-echoic submucosal mass. There were no differences in age (61.1±2.6 vs. 59.2±5.3 yrs), gender (13M:17F vs. 3M:8F), site (22gastric : 8duodenal : 4esophageal vs. 17gastric : 1duodenal : 2esophageal) or size (2.1±0.1 vs. 2.1±0.3 cm) of biopsied lesion between the FNA and PCN groups, respectively. Biopsy with PCN obtained significantly more diagnostic material than FNA, leading to a substantially higher diagnostic yield (18/20 vs. 14/34; P ,0.001). Of the 17 suspected spindle cell tumours from the PCN group, IHC study (c-kit stain) were successful in all cases and provided tissue confirmation of 10 leiomyomas and 7 gastrointestinal stromal tumours (GIST). In contrast, only 7/14 patients with FNA needle had sufficient material for additional IHC study (P=0.008, vs. PCN), confirming GIST in only 3/12 of suspected spindle cell tumours. Neither group had abdominal pain or clinical significant bleeding after the biopsy. CONCLUSIONS: EUS guided biopsy with 22G PCN has substantially higher histocytological yield than that with FNA needles (90% vs. 41%) and without any complication. PCN, therefore, should be the needle of choice for tissue acquisition of sub-mucosal lesions in the GIT.

Rapid on‐site evaluation by endosonographer during endoscopic ultrasound‐guided fine needle aspiration for pancreatic solid masses

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established diagnostic method for patients with suspected pancreatic ductal carcinoma. Rapid on-site evaluation (ROSE) has been reported to improve the accuracy. However, an on-site cytopathologist is not routinely available in many institutions. One of the solutions may be ROSE by endosonographer. The aim was to examine whether diagnostic accuracy increases through ROSE by endosonographer using our cytological criteria. Patients who underwent EUS-FNA of solid pancreatic masses from January 2006 to August 2009 (n = 53, period 1) and September 2009 to April 2011 (n = 85, period 2) were retrospectively identified. Before initiating ROSE at the start of period 2, two endosonographers underwent training for cytological interpretation, which was focused on four cytological features of pancreatic ductal carcinoma: anisonucleosis, nuclear membrane irregularity, overlapping, and enlargement. During EUS-FNA in period 2, endosonographers classified the Diff-Quik smears under three atypical grades and evaluated the adequacy. All diagnoses were made by one pathologist without knowledge of clinical information. The rate of "inconclusive" diagnoses, interpreted as "suspicious," "atypical," and "inadequate for diagnosis" was reduced from 26.4% in period 1 to 8.2% in period 2 (P = 0.004). Moreover, diagnostic accuracy was increased from 69.2% in period 1 to 91.8% in period 2 (P < 0.001). This cytological grading system used in ROSE by endosonographers is invaluable for the diagnosis of pancreatic solid masses.

Endoscopic Ultrasound Elastography for Differential Diagnosis of Pancreatic Masses: A Meta-Analysis

Distinguishing malignant from benign pancreatic tumors is challenging with current imaging techniques. Endoscopic ultrasound (EUS) elastography has further improved the efficacy of EUS for characterizing pancreatic lesions. To assess, by combining data from existing trials, the accuracy of EUS elastography in diagnosing malignant tumors for patients with pancreatic masses. All relevant studies published were identified by systematic searching of databases. A meta-analysis was performed using a random-effects model to combine study results. Seven studies involving 752 patients were included. The sensitivity of EUS elastography for differential diagnosis of solid pancreatic masses was 97 % (95 % CI, 0.95-0.98), and the specificity was 76 % (95 % CI, 0.69-0.82). The area under the curve under summary receiver operating characteristic (SROC) was 0.9529. The combined positive likelihood ratio was 3.71 (95 % CI, 2.72-5.07), and the negative likelihood ratio was 0.05 (95 % CI, 0.02-0.13). Our meta-analysis shows that EUS elastography is a useful tool for differential diagnosis of solid pancreatic neoplasms with very high sensitivity and relatively low specificity. The results indicate that EUS elastography not only provides information complementary to that from EUS but also potentially increases the yield of fine needle aspiration and reduces the number of unnecessary biopsies.

Endoscopic ultrasound-guided fine needle aspiration: from the past to the future.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a technique which allows the study of cells obtained through aspiration in different locations near the gastrointestinal tract. EUS-FNA is used to acquire tissue from mucosal/submucosal tumors, as well as peri-intestinal structures including lymph nodes, pancreas, adrenal gland, gallbladder, bile duct, liver, kidney, lung, etc. The pancreas and lymph nodes are still the most common organs targeted in EUS-FNA. The overall accuracy of EUS is superior to computed tomography scan and magnetic resonance imaging for detecting pancreatic lesions. In most cases it is possible to avoid unnecessary surgical interventions in advanced pancreatic cancer, and EUS is considered the preferred method for loco-regional staging of pancreatic cancer. FNA improved the sensitivity and specificity compared to EUS imaging alone in detection of malignant lymph nodes. The negative predictive value of EUS-FNA is relatively low. The presence of a cytopathologist during EUS-FNA improves the diagnostic yield, decreasing unsatisfactory samples or need for additional passes, and consequently the procedural time. The size of the needle is another factor that could modify the diagnostic accuracy of EUS-FNA. Even though the EUS-FNA technique started in early nineteen's, there are many remarkable progresses culminating nowadays with the discovery and performance of needle-based confocal laser endomicroscopy. Last, but not least, identification and quantification of potential molecular markers for pancreatic cancer on cellular samples obtained by EUS-FNA could be a promising approach for the diagnosis of solid pancreatic masses.

Endoscopic Ultrasound Elastography for Pancreatic Cancer Diagnosis: A Step Forward?

See Endoscopic Ultrasound Elastography for the Pancreas in Korea: A Preliminary Single Center Study by Tae Hee Lee, Young Deok Cho, Sang-Woo Cha, et al., on page 172-177 Endoscopic ultrasound (EUS) is not only useful for providing excellent images for detection and staging of pancreatic cancer; it also provides guidance for fine needle aspiration (FNA) and biopsies detected during a standard procedure. Overall accuracy of EUS-FNA can be considered excellent, with sensitivities between 80% and 85%, and specificities close to 100%. However, differentiation between pancreatic cancer and focal pancreatitis remains a challenge based only on B-mode imaging, particularly in cases of advanced chronic pancreatitis. EUS-FNA and/or biopsy are technically demanding and multiple punctures of the lesions can be necessary to obtain sufficient tissue for cytohistologic assessment. EUS-FNA can also be associated with false negative results, mainly in patients with solid pancreatic masses with the underlying diagnosis of chronic pancreatitis. Furthermore, EUS and EUS-FNA are associated with a small, but not insignificant, morbidity. Therefore, new methods allowing better characterization of lesions evaluated by EUS are essential to avoid unnecessary FNA and/or biopsies, to allow more accurate characterization of lesions before the puncture, and possibly to reduce complication rates. One of these new available methods is elastography.1,2 In the present study, Lee et al.3 first reported the performance of EUS elastography on the pancreas in Korean subjects with normal pancreas and pancreatic cancer. Although the sample size was relatively small, the present study provides evidence supporting EUS elastography as a useful tool for the evaluation of pancreatic cancer. The possible clinical usefulness of this new technique lies in the field of discrimination between benign inflammatory lesions and malignant tumors. Several studies have attempted to establish EUS-imaging criteria, but despite the high resolution of EUS, overall accuracy in this setting is not higher than 75%. On the other hand, overall accuracy of EUS elastography in the differential diagnosis of solid pancreatic lesions was reported with sensitivities between 91% and 100%, and specificities between 65% and 94%.4-8 However, interpretation is not straightforward because the lesions are not colored homogeneously and steadily throughout the procedure. These limitations affect interobserver agreement and can lead to different clinical findings, particularly when differentiating between chronic pancreatitis and pancreatic cancer. As such, qualitative EUS elastography is now considered to be obsolete. Quantitative EUS elastography has emerged as a more objective technique than qualitative EUS elastography because it enables numerical measurements of tissue stiffness. Still, many technical issues can explain the disappointing results in terms of specificity, such as size inequality between the lesion and the reference area, deep position of the target relative to the transducer, degree of transducer compression and angulation. A recent prospective study reported that the diagnostic utility of quantitative EUS elastography for discriminating pancreatic masses was modest,9 suggesting that the technique should only be used to supplement EUS-FNA rather than to replace it. EUS elastography can be helpful in decision making in the appropriate clinical context for every individual patient. Pancreatic cancers can be very heterogeneous tumors, with adjacent neoplastic areas, necrotic regions and inflammatory tissue. This heterogeneity accounts for inaccurate results of EUS-FNA particularly in routine clinical settings in which on-site cytology is unavailable. In this respect, EUS elastography should guide EUS-FNA, and can indicate to the physician where the neoplastic cells are most likely to be found. EUS elastography, both qualitative and quantitative, is an emerging technique, with the capability to differentiate fibrotic or inflammatory tissue from malignant lesions. This new methodology has proven to be useful in the differential diagnosis of solid pancreatic masses and lymph nodes, but also in the evaluation of patients with suspected chronic pancreatitis. However, further research is needed to completely define the place of this technique in routine clinical work and also to determine future indications.

EUS elastography for diagnosis of solid pancreatic masses : a meta-analysis.

EUS elastography for diagnosis of solid pancreatic masses : a meta-analysis.

EUS elastography for diagnosis of solid pancreatic masses: a meta-analysis

The differential diagnosis of solid pancreatic masses has been a significant challenge up until now. EUS elastography is now used as a new technique to distinguish benign from malignant pancreatic masses. However, the sensitivity, specificity, and accuracy are still questionable. To evaluate the accuracy of EUS elastography for diagnosis of solid pancreatic masses. Thirteen articles for EUS elastography diagnosing solid pancreatic masses were selected. The Mantel-Haenszel and DerSimonian Laird methods were used to analyze pooled results. This study involved 1044 patients. EUS elastography. The pooled sensitivity, specificity, likelihood ratios, diagnostic odds ratio, and summary receiver operating characteristic (sROC) curve. The pooled sensitivity, specificity, and diagnostic odds ratio of EUS elastography distinguishing benign from malignant solid pancreatic masses were 0.95 (95% confidence interval [CI], 0.94-0.97), 0.67 (95% CI, 0.61-0.73), and 42.28 (95% CI, 26.90-66.46), respectively. The sROC area under the curve was 0.9046. The subgroup analysis based on excluding the outliers showed that the heterogeneity was eliminated, and the pooled sensitivity and specificity were 0.95 (95% CI, 0.93-0.97) and 0.7 (95% CI, 0.63-0.76), respectively. The sROC area under the curve was 0.8872. Varied diagnostic standards for EUS elastography were used in the enrolled studies. EUS elastography is a reliable technique for the characterization of solid pancreatic masses and may be a useful complementary tool for EUS-guided FNA. However, a more accurate computer-aided diagnosis method for EUS elastography is in demand to reduce various biases and improve the accuracy of EUS elastography for diagnosis of solid pancreatic masses.

How to improve the differential diagnosis of solid pancreatic masses? A prospective comparative study of contrast-enhanced harmonic endoscopic ultrasound vs quantitative-elastography

How to improve the differential diagnosis of solid pancreatic masses? A prospective comparative study of contrast-enhanced harmonic endoscopic ultrasound vs quantitative-elastography

Diagnostic value of EUS elastography in differentiation of benign and malignant solid pancreatic masses: A meta-analysis

Background/AimsEUS elastography is a novel technique that can be used for distinguishing benign from malignant lymph nodes and focal pancreatic masses. However, the studies pertaining to EUS elastography for differential diagnosis of solid pancreatic masses have reported widely varied sensitivities and specificities. A meta-analysis of all relevant articles was performed to estimate the overall diagnostic accuracy of EUS elastography for differentiating benign and malignant solid pancreatic masses. MethodsThe literatures were identified by searching in PubMed and Embase databases. Two reviewers independently extracted the information from the literatures for constructing 2 × 2 table. A random-effect model or a fixed-effect model was used to estimate the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. A summary receiver operating characteristic curve (SROC) also was constructed. Meta-regression and subgroup analysis were used to explore the sources of heterogeneity. Results13 studies including a total of 1042 patients with solid pancreatic masses were selected for meta-analysis. The pooled sensitivity and specificity of EUS elastography for differentiating benign and malignant solid pancreatic masses were 95% (95% confidence interval [CI], 93%–96%), 69% (95% CI, 63%–75%), respectively. The area under SROC (AUC) was 0.8695. Two significant variables were associated with heterogeneity: color pattern and blinding. ConclusionAs a less invasive modality, EUS elastography is a promising method for differentiating benign and malignant solid pancreatic masses with a high sensitivity, and it can prove to be a valuable supplement to EUS-FNA.