Diagnostic Accuracy Of EUS-FNA Research Articles

Endoscopic ultrasound-guided fine-needle aspiration in the diagnostic value of focal liver lesions: A systematic analysis of 88 cases (with video)

Background and aimsEndoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions in the gastrointestinal tract and adjacent organs. Our study aimed to evaluate the safety and effectiveness of EUS-FNA in focal liver lesions (FLLs). MethodData from 88 patients diagnosed with FLLs by imaging who underwent EUS-FNA from 1 January 2017 to 31 August 2022 were reviewed in our retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of the School of Medicine of Shanghai Jiao Tong University. The EUS-FNA biopsy results were compared with the final diagnosis to evaluate diagnostic value. The relevant factors were analysed to determine their influence on EUS-FNA biopsy results. ResultsThe 88 patients analysed in this study resulted in a final diagnosis of 86 malignant and two benign cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18 % (82/88; 95 % Confidence Interval [CI], 87.9–98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02 % (80/86; 95 %CI, 87.6–98.4), 100 % (2/2; 95 %CI, 100–100), 100 % (80/80; 95 %CI, 100–100), and 25 % (2/8; 95 %CI, -5–55.0), respectively. The parameters related to lesion and procedure were not significantly different between these two groups (p > 0.05). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001). ConclusionOur data revealed that EUS-FNA is a safe and reliable diagnostic method for FLLs that shows high accuracy.

Predicting Factors for Pancreatic Malignancy with Computed Tomography and Endoscopic Ultrasonography in Chronic Pancreatitis.

Diagnosing pancreatic malignancy is challenging, especially in patients with chronic pancreatitis (CP). Endoscopic ultrasonography (EUS) is a promising diagnostic procedure for discriminating between malignancy and CP. We aimed to investigate the predictive factors and reliability of computed tomography (CT) and EUS for differentiating pancreatic mass lesions and the diagnostic accuracy of EUS-FNA or FNB in patients with CP. Forty patients with CP, receiving CT and EUS-FNA or FNB for pancreatic mass lesion evaluation, were enrolled in the study. Patients’ data, CT and EUS characteristics, image-based diagnosis, cytopathology, and final diagnosis were recorded. EUS was superior to CT in terms of diagnostic accuracy (92.5% vs. 82.5%, p = 0.02). Both CT and EUS showed significant predictive factors (all p < 0.05) with the tumor image hypoattenuation pattern or vessel invasion on CT and pancreatic duct dilatation, or distal pancreatic atrophy on EUS. EUS imaging is a reliable modality for evaluating pancreatic lesions, even with a CP background. The EUS image has a higher diagnostic accuracy than CT. Predicting factors, including hypoechoic pattern, pancreatic duct dilatation, and distal pancreas atrophy, may help to differentiate benign or malignant in patients with CP.

Diagnostic accuracy of EUS-FNA in the evaluation of pancreatic neuroendocrine neoplasms grading: Possible clinical impact of misclassification.

Background and Objectives:Prognosis of pancreatic neuroendocrine neoplasms (PanNENs) mostly depend on tumor stage and grade, determined by Ki-67 labeling index. EUS-FNA is considered the gold-standard technique to obtain it. The aims of our study were to establish diagnostic accuracy of preoperative EUS-FNA Ki-67 evaluation considering final pathological assessment on surgical specimen as gold standard and to investigate the possible impact on prognosis of misclassification.Methods:This is a retrospective study from a prospectively collected database. EUS-FNA grading (eG) and surgical one (sG) measured according to Ki-67 proliferative index values, according to 2017 WHO classification, were compared. eG-sG correlation was evaluated by Spearman index. Logistic regression investigated factors associated with misclassification. Prognostic difference in terms of progression-free survival was evaluated by Kaplan Meier method.Results:One hundred and twelve PanNENs patients enrolled. In 13.4% of patients (15/112) EUS-FNA “undergraded” patients (eG1 vs. sG2), while in 12.5% (n = 14) it “overgraded” PanNENs (eG2 to sG1). No misclassifications in G3 patients. In patients with tumors <20 mm (n = 44), 2 (4.5%) eG1 and 10 (22.7%) eG2 were finally classified respectively as G2 and G1 at surgical histology. No factors, as i.e. the lesions’ size or their morphological aspect, were associated with misclassification. In overgraded PanNENs, no progression occurred, while in patients correctly classified/undergraded the progression rate was 14.3%.Conclusions:This is the largest cohort of surgical PanNENs with preoperative EUS-FNA grading evaluation. Despite an acceptable eG-sG correlation, about 25% of patients are misclassified. Clinical impact of misclassification should be carefully considered especially in small tumors undergoing observation.

Endoscopic ultrasound guided fine needle aspiration for the diagnosis of intra-abdominal lymphadenopathy: a systematic review and meta-analysis

Background: It is difficult to diagnose the cause of abdominal lymphadenopathy without determining the primary lesions. With the advent of curved ultrasound endoscopy, EUS-FNA can sample lymph nodes safely, accurately and conveniently. Due to the lack of formal quantitative and comprehensive literature review to determine the diagnostic value of EUS-FNA in the diagnosis of enlarged intra-abdominal lymph nodes of unknown origin, we conducted this study to systematically evaluate the diagnostic accuracy of EUS-FNA in the enlarged intra-abdominal lymph nodes.Methods: We performed a systematic review and meta-analysis to evaluate the accuracy of EUS-FNA for the diagnosis of intra-abdominal lymphadenopathy. We searched PubMed, Embase, and Cochrane Library to collect related studies and diagnostic performance data. We used a random-effects model to estimate the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio (DOR). Heterogeneity was assessed by subgroup and meta-regression analysis.Results: Twelve eligible studies involved 774 patients were identified. The pooled sensitivity and specificity of all studies is 94% (95% CI: 91% to 96%) and 98% (95% CI: 96% to 99%), respectively. The pooled positive and negative likelihood ratios are 17.44 (95% CI, 6.50 to 46.79) and 0.09 (95% CI: 0.06 to 0.14). The pooled DOR is 277.82 (95% CI, 97.65 to 790.46).Conclusions: EUS-FNA is a safe and feasible technique with high sensitivity and specificity for the diagnosis of abdominal lymph node enlargement. Considering the limitations and heterogeneity, high-quality studies are needed to further explore the diagnostic value of EUS-FNA.

Comparison of 22G standard and Franseen needles in endoscopic ultrasound-guided fine-needle aspiration for diagnosing pancreatic mass lesions: Study protocol for a controlled trial

BackgroundEndoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was developed with the aim of further improving the diagnostic performance of endoscopic ultrasound. Although novel puncture needles have been specifically designed for collecting sufficient tissue specimens, clinical studies have indicated no clear difference in diagnostic performance between these novel needles and conventional puncture needles. Recently, a needle with Franseen geometry was developed specifically for EUS-FNA biopsy. Due to the characteristic shape of its tip, the Franseen needle is expected to be effective for scraping tissues, thus potentially increasing the diagnostic accuracy of EUS-FNA biopsy. We plan to carry out a prospective, multicenter, open-labeled, controlled trial to compare conventional and Franseen needles in terms of the diagnostic accuracy of EUS-FNA for evaluating the malignancy of pancreatic mass lesions.Methods/designThe study will enroll 520 patients with pancreatic mass managed at any of 21 participating endoscopic centers. Lesion samples obtained using 22G conventional and Franseen needles will be assessed to compare the efficacy and safety of these two types of needles in EUS-FNA for evaluating the malignancy of mass lesions in the pancreas. Tissue samples will be fixed in formalin and processed for histologic evaluation. For the purpose of this study, only samples obtained with the first needle pass will be used for comparing the: (i) accuracy of the malignancy diagnosis, (ii) sensitivity and specificity for the malignancy diagnosis, (iii) procedure completion rate, (iv) sample cellularity, and (v) incidence of complications. Patient enrollment begins on July 17, 2018.DiscussionThe outcomes of this study may provide insight into the optimal needle choice for evaluating the malignancy of pancreatic solid lesions, thus aiding in the development of practice guidelines for pancreatic diseases.Trial registrationUniversity Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR), UMIN000030634. Registered on 29 December 2017.http://www.umin.ac.jp/Version number: 01.2017.12.28.

2801 Does Rapid On-Site Evaluation by a Cytopathologist During Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS FNA) of Pancreatic Masses Improve Diagnostic Yield and Accuracy? A Systematic Review and Meta-Analysis

INTRODUCTION: EUS FNA plays an important role in the diagnostic evaluation of pancreatic masses. Studies comparing the diagnostic yield of EUS FNA of pancreatic masses when performed with rapid onsite evaluation (ROSE) by a cytopathologist vs. without ROSE have reported conflicting results. By systematic review and meta-analysis, we aim to compare the diagnostic yield and diagnostic accuracy of EUS FNA when performed with and without ROSE in the evaluation of pancreatic masses. METHODS: We reviewed Pubmed, Scopus and Web of Science from inception to November 15, 2018 to identify studies comparing EUS FNA with and without ROSE for evaluation of pancreatic masses. The primary outcome of interest was diagnostic yield for malignancy. Secondary outcomes were diagnostic accuracy and sample inadequacy. A random effects model was used to analyze the data. Pooled odds ratios (ORs) with 95% confidence interval (CI) were used to summarize the data. Heterogeneity was assessed by I2statistic. RESULTS: We included 7 studies (6 publications and 1 abstract) comprising 1327 patients. EUS FNA was performed with and without ROSE in 641 and 686 patients, respectively. 5 studies were retrospective and 2 were randomized controlled trials. Diagnostic yield and accuracy were similar between the two groups. Seven studies reported data on diagnostic yield for malignancy; pooled OR was 0.96 (0.71, 1.31) with low heterogeneity (I2 = 26%; Figure 1). 4 studies reported data on diagnostic accuracy; pooled OR was 0.73 (0.39, 1.36) with low heterogeneity (I2 = 42%; Figure 2). 4 studies reported data on inadequate samples; no difference was observed between groups (OR 1.99; 95% CI 0.82, 4.85; I2 = 36%). CONCLUSION: This meta-analysis found that ROSE by a cytopathologist during EUS FNA of pancreatic masses does not improve diagnostic yield or diagnostic accuracy.

The diagnostic value of endoscopic ultrasonography guided fine needle aspiration for occupying pancreatic lesions

Objective To evaluate safety and efficacy of EUS-FNA for occupying pancreatic lesions. Methods Data of 62 patients with occupying pancreatic lesions, who underwent EUS-FNA between June 2011 and June 2014, were analyzed for completion and complications, with surgery and clinical follow-up as the golden standard. Accuracy, sensitivity and specificity of EUS-FNA were calculated. Results A total of 62 patients with pancreatic lesions successfully underwent EUS-FNA and median puncture number was 4.2(3 to 8). Success rate of puncture was 100% and sampling satisfaction rate was 90.3%(56/62). No complications such as fever, infection, bleeding, perforation, severe pancreatitis or death were found. With the final diagnosis as the golden standard(39 malignant lesions and 23 benign lesions), overall diagnostic accuracy of EUS-FNA was 88.7%(55/62). The cytology diagnostic accuracy was 69.4%(43/62), significantly higher than that of the tissue pathology of 30.6%(19/62, P<0.01). Sensitivity and specificity of the procedure were 87.2%(34/39) and 91.3%(21/23) respectively. Conclusion EUS-FNA is an effective and safe procedure in diagnosis of occupying pancreatic lesions. Key words: Ultrasonography; Pancreatic diseases; Cytopathology; Histopathology; Fine needle aspiration

Diagnostic accuracy of EUS-FNA for pancreatic mass in the background of chronic pancreatitis

Diagnostic accuracy of EUS-FNA for pancreatic mass in the background of chronic pancreatitis

Mo1419 Diagnostic Accuracy of EUS-FNA for Pancreatic Solid Lesion With Conventional Needle Using Slow Pull Technique : a Prospective Study

Mo1419 Diagnostic Accuracy of EUS-FNA for Pancreatic Solid Lesion With Conventional Needle Using Slow Pull Technique : a Prospective Study

Effect of pancreatic juice cytology and/or endoscopic ultrasound‐guided fine‐needle aspiration biopsy for pancreatic tumor

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) can now provide a cytopathological diagnosis of pancreatic malignancy with higher success rates. However, EUS-FNA cannot be carried out for lesions of minimally invasive carcinoma because they cannot be detected by endoscopic ultrasonography, and in cases of intraductal papillary mucinous carcinoma (IPMC) because of the potential for needle tract seeding. A recent study has shown that pancreatic juice cytology (PJC) is useful for diagnosing pancreatic cancer. This study's aim was to evaluate whether PJC strengthens the diagnostic power of EUS-FNA for pancreatic masses. A total of 161 patients, who were suspected to have a pancreatic mass on conventional ultrasound and/or computed tomography, was enrolled. EUS-FNA was carried out in 121 cases, and PJC was performed in 83 cases. An adequate specimen was obtained for EUS-FNA in 96.0% and for PJC in 98.9%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86.0%, 100%, 100%, 70.5%, and 89.5% for EUS-FNA, and 71.4%, 100%, 100%, 84.4%, and 88.8% for PJC, respectively. EUS-FNA and/or PJC for the diagnosis of pancreatic tumor had a sensitivity of 92.5%, specificity of 100%, positive predictive value of 100%, negative predictive value of 91.7%, and accuracy of 95.9%. The diagnostic accuracy of EUS-FNA and/or PJC was significantly higher than that of EUS-FNA alone or PJC alone. PJC improved the diagnostic utility of EUS-FNA for pancreatic tumor.

Addition of EUS-FNA and On-site Cytology to EUS-FNB Increases Procedure Time but Not Diagnostic Accuracy

Purpose: The diagnostic accuracy of EUS-FNA in non-pancreatic lesions is poor relative to pancreas adenocarcinoma; accuracy is improved with EUS-FNB. As histology is often needed in these lesions, it may be possible to forgo initial EUS-FNA and rapid on-site cytology evaluation (ROSE). The goal of this study was to compare the diagnostic accuracy of EUS-FNB alone with a conventional sampling algorithm of EUS-FNA with ROSE followed by EUS-FNB in non-pancreas adenocarcinoma lesions. Methods: Retrospective cohort study of subjects who underwent EUS sampling of non-pancreatic adenocarcinoma lesions over a 28-month time period (2/2011-5/2013) since introduction of new core biopsy needle (Echotip Procore, Cook Endoscopy, USA). Lesions included lymphadenopathy or retroperitoneal/mediastinal mass (LRMM), subepithelial mass (SEM), non-adenocarcinoma pancreas, or gastrointestinal wall thickening. Two cohorts were compared: EUS-FNB without EUS-FNA or ROSE (EUS-FNB group) and EUS-FNA with ROSE and if needed, EUS-FNB (EUS-FNA/B group). The primary outcome of this study was to compare diagnostic accuracy, defined as the percentage of total cases where an accurate cytologic or histologic diagnosis was achieved. The secondary outcome was total procedure time. Results: Over the study period, there were 96 lesions (43 in EUS-FNB, 53 in EUS-FNA/B groups). In the EUS-FNB cohort, SEM was the most common indication (48.8%) followed by LRMM (20.0%). In the cohort of EUS-FNA/B patients, LRMM (50.9%) was the most common indication followed by SEM (26.4%). Mean lesion size was similar between EUS-FNB and EUS-FNA/B groups (23.8 mm vs. 27.6mm; p=0.35). In the EUS-FNA/B group, a median of a 4±1.4 EUS-FNA passes were performed prior to either procedure termination or EUS-FNB. A diagnosis was obtained by EUS-FNA alone in nine patients (17.0%). Overall diagnostic accuracy was similar between the EUS-FNB and EUS-FNA/B groups (83.7% vs. 84.9%; p=NS; Table 1). In the subgroup of SEM lesions, diagnostic accuracy remained similar in the EUS-FNB and EUS-FNA/B groups (81.0% and 70.6%; p=0.7). In cases where only a single needle size was used, diagnostic accuracy was numerically greater when a 19-gauge needle was used compared to 22-gauge or 25-gauge needles (Table 2). EUS-FNB procedures were significantly shorter than those in the EUS-FNA/B group (58.4 min vs. 73.5 min; p<0.0001).Table 1: Diagnostic accuracyTable 2: Diagnostic accuracy of needle sizes (EUS-FNB only)Conclusion: EUS-FNB without ROSE has a high diagnostic accuracy in lesions where histology is likely needed. Addition of EUS-FNA and ROSE is associated with increased time and resource utilization but does not improve diagnostic accuracy. This data suggests EUS-FNB without ROSE may be the optimal technique for lesions other than pancreas adenocarcinoma. Disclosure - Dr. Keswani - Consultant, Cook Medical Dr. Komanduri - Consultant, Cook Medical.

Advanced Endoscopic Imaging

Advanced Endoscopic Imaging

Accuracy and Quality Assessment of EUS-FNA: A Single-Center Large Cohort of Biopsies

Introduction. Thorough quality control (QC) study with systemic monitoring and evaluation is crucial to optimizing the effectiveness of EUS-FNA. Methods. Retrospective analysis was composed of investigating consecutive patient files that underwent EUS-FNA. QC specifically focused on diagnostic accuracy, impacts on preexisting diagnoses, and case management. Results. 268 patient files were evaluated. EUS-FNA cytology helped establish accurate diagnoses in 92.54% (248/268) of patients. Sensitivity, specificity, PPV, NPV, and accuracy were 83%, 100%, 100%, 91.6%, and 94%, respectively. The most common biopsy site was the pancreas (68%). The most accurate location for EUS-FNA was the esophagus, 13/13 (100%), followed by the pancreas (89.6%). EUS-FNA was least informative for abdominal lymph nodes (70.5%). After FNA and followup, eight false negatives for tumors were found (3%), while 7.5% of samples still lacked a definitive diagnosis. Discussion. QC suggests that the diagnostic accuracy of EUS-FNA might be improved further by (1) taking more FNA passes from suspected lesions, (2) optimizing needle selection (3) having an experienced echo-endoscopist available during the learning curve, and (4) having a cytologist present during the procedure. QC also identified remediable reporting errors. In conclusion, QC study is valuable in identifying weaknesses and thereby augmenting the effectiveness of EUS-FNA.

Advances in Diagnosis and Treatment of Biliopancreatic Diseases

Management of biliopancreatic diseases has seen great progress in recent years. Innovations in endoscopy have allowed gastroenterologists to assist in the care of many conditions of the biliary tree and pancreas, which were previously only managed surgically. Outcomes for many of these endoscopic interventions are comparable to their surgical counterpart. However, endoscopists taking care of these patients should be well aware of the limitations of their procedures and the advantages of surgery for certain patients. This special issue will address some of the main challenges faced today by physicians taking care of patients with pancreatic and biliary diseases. Endosonography, or endoscopic ultrasound (EUS), which previously was only considered a diagnostic tool, has now emerged as a useful therapeutic technique. In contrast, endoscopic retrograde cholangiopancreatography, or ERCP, has now become mainly a therapeutic tool. Some ERCP techniques have been adopted by endosonographers and allowed interventions for draining bile ducts and peripancreatic fluid collections, previously considered outside the realm of endoscopy. Despite the advances in outcomes and minimal invasiveness of EUS and ERCP-guided interventions, several risks and complications still remain. Pancreatitis is a well-recognized complication of ERCP with a significant incidence that has not been reduced greatly throughout recent years. Numerous studies have looked at ways of decreasing the risk of this dreadful complication. This special issue will discuss and review the problem of post-ERCP pancreatitis, a topic that raises a high level of concern for many who do this procedure, and ways to reduce its risk, especially in patients considered at high risk for developing this complication. Incidental pancreatic cysts continue to pose a diagnostic dilemma for gastroenterologists and surgeons alike. Despite the ability of safely obtaining a tissue sample during EUS examination, the utility of cytopathology in determining the exact nature of these lesions remains limited. More recently, DNA analysis of fluid obtained during aspiration has shown promise in improving the diagnostic accuracy of EUS-FNA. However, the effect of these newer tests in terms of deciding when to observe versus surgically resect in many of these incidental cysts remains to be proven. Pancreatologists agree that a reliable method for determining the nature and prognosis of pancreatic cystic neoplasms is required for improving the management strategy in asymptomatic patients. Abdominal pain is a cardinal symptom of chronic pancreatitis. The effectiveness of medical therapy, in the form of pancreatic enzyme supplementation or octreotide injections, is dismal. Pain relief can certainly be obtained with the use of narcotic medications, but at the cost of significant side effects, such as constipation, sedation, and drug dependence. Endoscopic alternatives for improving pain in chronic pancreatitis include those guided by ERCP, such as intraductal stone removal, stricture dilation, or drainage procedures, and EUS-guided celiac plexus block. This special issue will review the ERCP-guided interventions and discuss the efficacy of EUS-guided celiac plexus neurolysis for the treatment of pain in patients with pancreatic cancer. As advances in endoscopy and surgical innovations are introduced into the field of biliary and pancreatic diseases, many diseases previously requiring complicated surgeries with prolonged recovery are now being managed by minimally invasive techniques. Many of these procedures have a reduced risk when compared to their surgical alternative. However, long-term efficacy and patient risk factors need close consideration when deciding between different management alternatives. Many, if not all, biliary and pancreatic disorders require a close interaction between gastroenterologist and surgeon. The phrase “No man is an island” by John Donne (1572–1631) emphasizes the importance of consensus between specialists and should always be in the minds of those managing patients with biliopancreatic diseases. Fauze Maluf-Filho Jose G. de la Mora Levy Carlos G. Micames

Diagnostic Accuracy of EUS-FNA for Pancreatic tumors Smaller than 20mm

Diagnostic Accuracy of EUS-FNA for Pancreatic tumors Smaller than 20mm

Impact of on-site adequacy assessment for EUS FNA of solid pancreatic lesions

IntroductionThere are a number of factors which can influence the accuracy of EUS FNA but the presence of an in-room cytotechnician (IRC) has been shown to be one of the...

Endoscopic ultrasound-guided fine-needle aspiration cytology in the evaluation of suspected tuberculosis in patients with isolated mediastinal lymphadenopathy

Patients with suspected tuberculosis without pulmonary lesions and with mediastinal lymphadenopathy often pose a diagnostic challenge. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) cytology is an established modality to evaluate mediastinal and abdominal lesions. The aim of the present study was to evaluate the role of EUS-FNA in isolated mediastinal lymphadenopathy in patients suspected of having tuberculosis. Consecutive patients suspected of having tuberculosis with isolated mediastinal lymphadenopathy were included in a prospective study. Mediastinal lymphadenopathy was diagnosed on a contrast-enhanced computed tomography scan of the chest. Patients with concomitant lung parenchymal lesions were excluded. Previous attempts to diagnose the etiology of lymphadenopathy had failed in 69 % of patients. EUS-FNA was performed on an outpatient basis under conscious sedation. The sensitivity, specificity, and diagnostic accuracy of EUS-FNA were calculated. A total of 60 consecutive patients (mean age 39.8 years, 58 % males) with mediastinal lymphadenopathy were included. EUS confirmed the presence of mediastinal lymph nodes ranging in size from 8 mm to 40 mm (mean 26 mm) in all patients. EUS-FNA provided an adequate tissue sample in 54 patients during the first examination and repeat EUS-FNA was necessary in six patients. A final diagnosis was obtained by EUS-FNA in 42 patients (tuberculosis in 32, sarcoidosis in six, and Hodgkin's disease in four patients). An additional 14 patients were treated for tuberculosis based on EUS-FNA and clinical features. Mediastinoscopy was required for diagnosis in the remaining four patients. EUS-FNA had an overall diagnostic yield of 93 %, sensitivity of 71 %, specificity of 100 %, and positive predictive value of 100 %. EUS-FNA is an accurate, safe, and minimally invasive modality for evaluating isolated mediastinal lymphadenopathy in patients suspected of having tuberculosis in an endemic area with a high prevalence of tuberculosis.

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.

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.