Endoscopic Ultrasound-guided Fine Needle Research Articles

Incidental detection of pancreatic cancer by F-18-fluorodeoxyglucose positron emission tomography/computed tomography in a patient with hereditary breast and ovarian cancer syndrome

Patients with hereditary breast and ovarian cancer syndrome (HBOC) are associated with an increased risk of developing pancreatic cancer (PC) than the general population. There is no consensus about the clinical value of F-18-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) in patients with HBOC. We report a patient with HBOC in whom PC was detected incidentally by PET/CT. A 48-year-old woman complaining of a right breast mass sought evaluation at our hospital. Her older brother died of PC at 49 years of age. Histologic analysis of the breast mass revealed breast cancer (BC). FDG-PET/CT showed unanticipated FDG accumulation in the pancreas. Magnetic resonance cholangiopancreatography (MRCP) revealed a mass in the pancreas approximately 25mm in size. Endoscopic ultrasound guided-fine needle aspiration biopsy (EUS-FNA) demonstrated PC. Genetic testing showed a BRCA2 pathologic variant [NM_000059.4(BRCA2): c.9076C > T (p.Gln3026Ter)]. She was referred to a university hospital and underwent surgery after neoadjuvant chemotherapy for PC. It is difficult to detect operable PC in most patients. The diagnostic utility of PET/CT for PC in high-risk patients, such as those with HBOC, is undetermined. Our case has demonstrated the clinical value of PET/CT in detecting incidental PC in HBOC patients.

Endoscopic Ultrasound Guided-Tissue Acquisition in Pancreatic Melanoma. Report of Two Cases and Literature Review.

We present two cases of primary melanomas that during their surveillance developed metastasis to the pancreas. After an initial approach, tissue samples of the pancreatic lesions were obtained by endoscopic ultrasound guided-fine needle biopsy (EUS-FNB). The histopathological report was compatible, in both cases, with a metastatic melanoma.

Artificial Intelligence in Endoscopic Ultrasonography-Guided Fine-Needle Aspiration/Biopsy (EUS-FNA/B) for Solid Pancreatic Lesions: Opportunities and Challenges.

Solid pancreatic lesions (SPLs) encompass a variety of benign and malignant diseases and accurate diagnosis is crucial for guiding appropriate treatment decisions. Endoscopic ultrasonography-guided fine-needle aspiration/biopsy (EUS-FNA/B) serves as a front-line diagnostic tool for pancreatic mass lesions and is widely used in clinical practice. Artificial intelligence (AI) is a mathematical technique that automates the learning and recognition of data patterns. Its strong self-learning ability and unbiased nature have led to its gradual adoption in the medical field. In this paper, we describe the fundamentals of AI and provide a summary of reports on AI in EUS-FNA/B to help endoscopists understand and realize its potential in improving pathological diagnosis and guiding targeted EUS-FNA/B. However, AI models have limitations and shortages that need to be addressed before clinical use. Furthermore, as most AI studies are retrospective, large-scale prospective clinical trials are necessary to evaluate their clinical usefulness accurately. Although AI in EUS-FNA/B is still in its infancy, the constant input of clinical data and the advancements in computer technology are expected to make computer-aided diagnosis and treatment more feasible.

A pilot study for single cell RNA-sequencing of patient-derived pancreatobiliary cancer organoid.

739 Background: For precision medicine, patient-derived organoid (PDO) is regarded as one of the promising models. However, current PDOs were mainly derived from surgical specimens. We aimed to analyze the single cell RNA-sequencing (scRNA-seq) of PDO from various sampling methods with different pathologic outcomes. Methods: In 2021, three pancreatic cancer and one gallbladder cancer samples were collected from surgical specimen, endoscopic ultrasound guided-fine needle biopsy (EUS-FNB), and endoscopic retrograde cholangiopancreatography (ERCP)-guided biopsy. The samples were mechanically dissociated with dissociation buffer and incubated using shaking incubator. Dissociated cells were seeded into growth factor reduced Matrigel. From these PDOs, we generated scRNA-seq data in each experimental design, and corrected batch effects that could occur when multiple samples are considered simultaneously in downstream analysis. Marker genes representing each cell subcluster were identified, and statistical hypothesis tests were performed to identify genes differentially expressed according to differences in biopsy methods and/or pathological results. Results: We found the optimal 8 types of sub cell-type clusters with a resolution parameter of 0.3 in clustering analysis based on the Uniform Manifold Approximation and Projection (UMAP) algorithm in terms of silhouette score. As a result of examining the expression levels of KRT19, a marker gene for malignant ductal cells, and RGS5, a stellate marker gene, which showed the same pattern as the existing PDAC transcriptome studies, it was confirmed that most of the cells derived from PDOs were malignant ductal cells. Finally, we identified a heterogeneous effect on gene expression patterns in ductal cells depending on not only pathological positivity, but also biopsy methods for organoid. Conclusions: According to our scRNA-seq, most cells were malignant cells and EUS-FNB could be a good sampling method for PDOs. However, further analysis about a heterogeneous effect on gene expression patterns is necessary.[Table: see text]

How to Perform Endoscopic Ultrasound-Guided Fine Needle Aspiration/Biopsy of Pancreatic Lesions?

A endoscopic ultrasound-guided fine needle aspiration/biopsy (EUS-FNA/B) of pancreatic solid and cystic lesions is a modality, which huge numbers of articles has showed its high diagnostic accuracy. The degree of technical difficulty, size and type of needle, endoscopic technique, use of suction to aspirate tissue, use or not use of a stylet in the needle assembly, maneuvers to have high quality tissue, availability of an on-site cytopathologist, and, finally, end sonographer’s experience and skills who does the procedure have impact on the EUS-FNA results. Standard 19-G and 22-G fine-needle aspiration needles with or without high negative pressure have proven to be reliable in obtaining high-quality histologic samples in various indications. Twenty-five-gauge (25-gauge) needles provide better diagnostic yield when sampling pancreatic lesions compared with 22-G needles. The novel 19-G and 22-G ProCore™ needles have demonstrated a high yield in obtaining histologic samples, whereas 25-G. ProCore™ seems unsuitable for histology. A cytopathology service should be involved early in the planning process for establishing an EUS-FNA service. Data on the newly developed 20-G ProCore™, SharkCore® and Acquire® needles are limited, but appear very promising. Use of the stylet does not increase the yield of endoscopic ultrasonography-fine-needle aspiration and is more cumbersome to use. In perspective, endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is expected to refine differential diagnostic capabilities, favor widespread EUS utilization, and pave the road to targeted therapies and monitoring of treatment response. Approximately 3 to 5 passes should be sufficient to obtain a diagnosis. We need further studies for assessment of the use of Suction, Capillary (“Slow-Pull”), Wet and Fanning techniques.

Pancreatic Cystic Lesions: A Focused Review on Cyst Clinicopathological Features and Advanced Diagnostics.

Macroscopic, endomicroscopic, and histologic findings and correlation are an integral part of the diagnostic evaluation of pancreatic cystic lesions (PCLs), as complementing morphologic features seen by different specialties are combined to contribute to a final diagnosis. However, malignancy risk stratification of PCLs with worrisome features can still be challenging even after endoscopic ultrasound guided-fine needle aspiration (EUS-FNA) with cytological evaluation. This review aims to summarize cyst clinicopathological features from the pathologists' perspective, coupled with knowledge from advanced diagnostics-confocal laser endomicroscopy and cyst fluid molecular analysis, to demonstrate the state-of-art risk stratification of PCLs. This review includes illustrative photos of surgical specimens, endomicroscopic and histologic images, and a summary of cyst fluid molecular markers.

P-292 Endoscopic ultrasound guided-fine needle aspiration for the diagnosis of secondary pancreatic lesions. Experience of a reference center

It is estimated that about 2% to 5% of pancreatic malignant tumors are metastatic lesions. Lung, kidney and breast cancer as well as melanoma are the most common primary tumors affecting the pancreas. Histologic or cytologic confirmation is essential for differential diagnosis from the much more common primary adenocarcinoma of the pancreas. The aim of this study is to assess the diagnostic value and safety of endoscopic ultrasound guided-fine needle aspiration (EUS-FNA) of pancreatic tumors in patients with extra-pancreatic malignancy.

Establishment of patient-derived pancreatic cancer organoid using Endoscopic Ultra Sound-guided Fine Needle Aspiration

Establishment of patient-derived pancreatic cancer organoid using Endoscopic Ultra Sound-guided Fine Needle Aspiration

Gastroblastoma: Cytologic Findings with Resection and Molecular Correlation

Abstract Casestudy Gastroblastoma is a rare tumor with biphasic components showing epithelial and mesenchymal differentiation. To date, <15 cases have been reported, with molecular confirmation of the recently identified MALAT1-GLI1 translocations only in a subset. Aspiration cytologic and small biopsy findings have not yet been reported. We present a case of gastroblastoma, arising in a 22-year-old female. Results A CT scan was performed, showing a 7 cm heterogeneous mass in the distal stomach and pancreas, clinically suspected to represent at gastrointestinal stromal tumor (GIST). She underwent two preoperative samples, including endoscopic ultrasound guided-fine needle aspiration and core biopsy, followed by a distal gastrectomy. Diff- Quik stained touch preparations performed on the core needle biopsy during rapid on-site evaluation showed a hypercellular neoplasm composed of large, three-dimensional aggregates of neoplastic cells in a background of numerous isolated single cells and bare nuclei. The neoplastic cells were bland with spindled to epithelioid nuclei, occasional nuclear grooves, and small nucleoli. Immunostains were only helpful in excluding GIST (CD117 and DOG1 negative). Distal gastrectomy showed a nodular/plexiform tumor with variably epithelioid to spindle cell cytology and solid to focally myxoid/microcystic architecture. Pancytokeratins CAM5.2 (patchy) and AE1/AE3 (very focal) were positive, with negative S100, SMA, Desmin, Melan-A, Inhibin, Calretinin, and Synaptophysin. Based on the age, location, histology and immunophenotype, gastroblastoma was suspected, and multiplex NGS-based fusion sequencing identified a MALAT1-GLI1 fusion. Staging studies were negative for metastasis at presentation. Conclusion Based on this experience, we recommend consideration of gastroblastoma for a gastric tumor in a young patient, especially if encountering a cytologic sample showing non-pleomorphic epithelioid and spindle cell cytology. Lack of expression of GIST, smooth muscle, neuroendocrine, and neural sheath-associated markers should particularly raise consideration of this rare neoplasm. While in this case molecular studies clinched the diagnosis upon resection, increasingly used GLI1 immunostain may be of use prospectively for diagnosis of limited samples.

Factors affecting cytological results of endoscopic ultrasound guided-fine needle aspiration during learning

BackgroundEndoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a standard procedure used to obtain tissue samples for diagnosis of solid retroperitoneal tumours. However, this procedure demands high technical expertise and requires a strong learning curve. Our aim was to identify factors associated with false-negative EUS-FNA results during the learning for endoscopists.MethodsOur retrospective analysis was based on the EUS-FNA specimens collected by two novice endoscopists in 200 patients with retroperitoneal lesions who had confirmed image- or tissue-based diagnoses of malignancy or benign lesions.ResultsIn the first 40 performances endoscopists, the false-negative diagnostic rate of EUS-FNA was higher among patients with chronic pancreatitis than in patients without chronic pancreatitis. Patients who underwent FNA through the trans-duodenal puncture route also had lower success cytological diagnosis rate than through the trans-gastric puncture route. The rate of successful cytological diagnoses with EUS-FNA improved after 40 procedures and was not influenced by chronic pancreatitis presentation or difference puncture route.ConclusionRegarding the learning curve, more than 40 procedures were required to achieve a stable success rate of EUS-FNA. Chronic pancreatitis and trans-duodenal puncture route are the predictive factors for a false-negative FNA cytological result during learning.Trial registrationThis was a retrospective study.

2812 Impact of Rapid On-Site Evaluation (ROSE) on Endoscopic Ultrasound-Guided FNA of Pancreatic Cysts: A Five-Year Comparative Study Between Two Academic Institutions

INTRODUCTION: Endoscopic Ultrasound Guided-Fine Needle Aspiration (EUS-FNA) is considered the modality of choice for diagnosing intermediate pancreatic lesions. Rapid-on site evaluation (ROSE), when performed by a cytopathologist, has been suggested to improve the diagnostic yield of EUS-FNA. Prior studies were inconsistent regarding the benefit of ROSE. In our study, we evaluated the diagnostic yield of EUS-FNA in the presence of an on-site cytopathologist providing real-time feedback to the endoscopist compared to EUS-FNA alone in two academic hospitals. METHODS: We conducted a 2010-2015 retrospective chart review of all EUS-FNA performed at two academic medical centers (UT and UR). The policy at UT is to perform all EUS-FNA with ROSE, whereas it is not routinely done at UR. Cases where included when surgical pathology was available. Patients’ demographics, pancreatic cyst characteristics and EUS techniques were analyzed. EUS-FNA were considered valuable when it provided a classifying cytopathologic diagnosis. Student T-test and Analysis of Variance (ANOVA) were performed when appropriate for descriptive purposes. RESULTS: Forty-five cases (13 at UT, 32 at UR) were identified. EUS FNAs coupled with ROSE (UT) rendered 100% (13/13) valuable diagnoses, while those done with no cytopathologist on site (UR) had valuable diagnosis in 37.5% of the cases (12/32, P < 0.0001). The sensitivity of EUS-FNA at UT was 85% compared to 33% at UR. There was no statistically significant difference in gender, age, site or size of the tumor. The mean number of needle passes at UT was 1.9 (range 1-6) vs. 1.1 (range 1-3) at UR. The majority of needles used were 19G (55%) at UT vs 22G (83%) at UR (P < 0.001). Only one patient at UR had a minor cyst bleeding to the main pancreatic duct that required no therapeutic action. CONCLUSION: The results highlight the advantage of bed-side cytopathologist interaction with the endoscopist during EUS-FNA of pancreatic cysts. Absence of malignant cells despite suspicious ultrasound findings may have prompted more needle passes. The use of 19G needle may have improved outcomes with no significant increase of complications. In addition to the small sample size and the retrospective nature, the study is limited by the variability in personnel experience (endoscopists and cytopathologists) and the techniques used, indicating that further studies are necessary to confirm these findings.

Diagnostic Utility of Clinical, Laboratory, Radiology Findings to Predict Malignant Outcome in Endoscopic Ultrasound Guided-Fine Needle Aspirations of Solid Pancreatic Lesions with Atypical Results

Diagnostic Utility of Clinical, Laboratory, Radiology Findings to Predict Malignant Outcome in Endoscopic Ultrasound Guided-Fine Needle Aspirations of Solid Pancreatic Lesions with Atypical Results

Su1202 ENDOSCOPIC ULTRASOUND FINE NEEDLE ASPIRATION VERSUS FINE NEEDLE BIOPSY IN SOLID LESIONS: A MULTICENTER RETROSPECTIVE ANALYSIS

Endoscopic ultrasound guided-fine needle aspiration (EUS-FNA) has been a preferred technique for tissue sampling for several years. To overcome limitation of FNA cytology, fine needle biopsy (FNB) has recently been developed with the promise of histological tissue samples. The main objective of this study is to compare the accuracy of FNB versus FNA in determining the diagnosis of solid lesions.

The accuracy and clinical impact of endoscopic ultrasound-guided dual needle sampling in solid pancreatic lesions

Background and Objectives:Different tissue entities can present as solid pancreatic lesions (SPLs). This study aimed to explore the diagnostic accuracy of endoscopic ultrasound-guided dual needle sampling (endoscopic ultrasound-guided fine needle aspiration/biopsy [EUS-FNA/B]) in SPLs.Methods:In 2012-2016, consecutive patients with SPLs were prospectively included in a single-center setting aiming at dual sampling with EUS-FNA (22/25-gauge) and reverse bevel EUS-FNB (22-gauge) in each lesion. Randomization decided if the first pass should be EUS-FNA or EUS-FNB. The primary outcome was the diagnostic accuracy including mandatory immunostaining of all tumors but pancreatic ductal adenocarcinoma (PDAC). The secondary outcome was the clinical impact of dual needle sampling EUS-FNA/B in comparison with single needle EUS-FNA of SPLs performed in the same center 2006-2011 (the comparison cohort).Results:In 108 study subjects, 68 dual needle sampling procedures were performed. The four most common entities were PDAC (32%), neuroendocrine tumor (34%), pancreatitis (15%), and metastasis (6%). EUS-FNA and EUS-FNB had comparable diagnostic accuracy. EUS-FNA/B, compared with EUS-FNA, had a higher sensitivity for malignancy (91% vs. 75%, P = 0.004), higher sensitivity for non-PDAC malignancy (89% vs. 69%, P=0.02), and higher overall accuracy (91% vs. 78%, P=0.004). The performance of an additional diagnostic procedure was less frequent after EUS-FNA/B compared with EUS-FNA of the comparison cohort (4% vs. 21%, P=0.007).Conclusions:Reverse bevel EUS-FNB is not superior to EUS-FNA in the sampling of solid pancreatic lesions. However, dual needle sampling with both modalities (EUS-FNA/B) seems to improve the diagnostic accuracy and facilitate the clinical management, especially in malignant entities other than ductal adenocarcinomas.

A Case of Inconspicuous Pancreatic Cancer with Invasion of the Celiac Axis and Superior Mesenteric Artery

A 66-year-old man was referred to our hospital due to carbohydrate antigen 19-9 (CA19-9) elevation. Further examination revealed no obvious malignancy, but abdominal enhanced computed tomography (CT) showed soft tissue density around the celiac axis and superior mesenteric artery (SMA). Although pancreatic cancer was considered as a possible diagnosis, there was no clear evidence within the pancreas itself. Furthermore the patient was observed without intervention. Another abdominal enhanced CT performed 10 months later showed a dilated pancreatic duct in the tail of the pancreas, along with a low density area measuring 10 mm in the body of the pancreas. Endoscopic ultrasound guided-fine needle aspiration (EUSFNA) led to a diagnosis of pancreatic cancer. In the present case, the tumor in the pancreas was inconspicuous, but it might be characterized by extensive extrapancreatic invasion.

Autoimmune pancreatitis with colonic stenosis: an unusual complication and atypical pancreatographic finding

BackgroundType 1 autoimmune pancreatitis (AIP) often accompanies various systematic disorders such as sclerosing cholangitis, sialoadenitis, retroperitoneal fibrosis, interstitial pneumonitis and nephritis. Although rarely reported in acute pancreatitis, colonic stenosis is an uncommon complication in cases with AIP.Case presentationA 69-year-old Japanese man complained of abdominal pain and continuous diarrhea, resistant to intake of antimuscarinic and probiotic agents. A colonoscopy demonstrated a stenosis at the splenic flexure. Computed tomography revealed a focal enlargement of the pancreatic tail with a capsule-like rim, contacting with the descending colon. Endoscopic retrograde pancreatography (ERP) was unable to visualize the main pancreatic duct (MPD) at the pancreatic tail, despite a full contrast injection. A high serum IgG4 level (1060 mg/dL) and exclusion of pancreatic cancer by endoscopic ultrasound guided-fine needle aspiration suggested AIP, but did not fulfill the diagnostic criteria, and steroid therapy was initiated. One month after starting steroid intake, pancreatic swelling was minimized and the MPD was visualized by ERP, fulfilling the international consensus diagnostic criteria (ICDC) of AIP. Colonic stenosis was relieved and the patient’s symptoms disappeared.ConclusionThe present case is the first report of AIP developing colonic stenosis by the inflammatory infiltration. In this case, steroid therapy was effective for the diagnosis and treatment of pancreatic mass involving the descending colon.

Rupture of a suspected pancreatic lymphoepithelial cyst causing chemical peritonitis after endoscopic ultrasound guided-fine needle aspiration

Rupture of a suspected pancreatic lymphoepithelial cyst causing chemical peritonitis after endoscopic ultrasound guided-fine needle aspiration

Endosonographic features of histologically proven gastric ectopic pancreas.

Gastric ectopic pancreas is an uncommon developmental anomaly and its histological diagnosis is usually difficult by using a conventional biopsy forceps. In the literature, most cases of gastric ectopic pancreas were usually diagnosed by gross pattern during endoscopic examination or features of endoscopic ultrasound. In contrast, this disease was seldom diagnosed by histology in clinical practice. Although the typical endoscopic ultrasonographic features of ectopic pancreas include heterogeneous echogenicity, indistinct borders, and a location within 2 or more layers, it can also exhibit hypoechoic homogeneous echogenicity and a distinct border within the fourth sonographic layer (muscularis propria) similar to the endoscopic ultrasonographic features of gastrointestinal stromal tumors. In our study, we found that 53% of gastric ectopic pancreas originated within the fourth sonographic layer, demonstrating hypoechoic, homogeneous echogenicity, and distinct borders. Therefore, recognizing endoscopic ultrasonographic features, combining with deep biopsy, endoscopic ultrasound-guided fine needle aspiration/core needle biopsy can prevent conducting unnecessary resection. Surgical resection is the mainstay treatment for symptomatic gastric ectopic pancreas, but endoscopic resection using endoscopic mucosal resection or endoscopic submucosal dissection technique provides an alternative method of removing superficial-type and deep-type gastric ectopic pancreas.

Endoscopic ultrasound-guided fine needle aspiration and biopsy using a 22-gauge needle with side fenestration in pancreatic cystic lesions

Cytologic diagnosis by endoscopic ultrasound-guided fine needle aspiration is associated with low sensitivity and adequacy. A newly designed endoscopic ultrasound-guided fine needle biopsy device, endowed with a side fenestration, is now available. We carried out a study with the aim of evaluating the feasibility, safety, and diagnostic yield of the 22-gauge needle with side fenestration for endoscopic ultrasound fine needle aspiration and biopsy of pancreatic cystic lesions. 58 patients with 60 pancreatic cystic lesions consecutively referred for endoscopic ultrasound guided-fine needle aspiration were enrolled in a prospective, dual centre study, and underwent fine needle aspiration and biopsy with the 22-gauge needle with side fenestration. Fine needle aspiration and biopsy was technically feasible in all cases. In 39/60 (65%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. In lesions with solid components, and in malignant lesions, adequacy was 94.4% (p = 0.0149) and 100% (p = 0.0069), respectively. Samples were adequate for histologic evaluation in 18/39 (46.1%) cases. There were only 2 (3.3%) mild complications. Fine needle aspiration and biopsy with the 22-gauge needle with side fenestration is feasible, and superior to conventional endoscopic ultrasound-guided fine needle aspiration cytology from cystic fluid, particularly in pancreatic cystic lesions with solid component or malignancy, with a higher diagnostic yield and with no increase in complication rate.

A Case of Left Adrenal Gland Metastatic Cancer Diagnosed by Endoscopic Ultrasound-Guided Fine Needle Aspiration

With widespread use of imaging techniques, the discovery of adrenal incidentalomas is increasing recently. Benign tumors are more frequent than malignant tumors in adrenal incidentalomas. Among malignant adrenal incidentalomas, metastatic neoplasms are the most common etiology. Traditional techniques to obtain tissue of adrenal gland include percutaneous approach under computed tomography or abdominal ultrasound guidance as well as open or laparoscopic adrenalectomies. They are invasive and associated with considerable complications such as pneumothorax, pancreatitis, adrenal abscesses, bacteremia, needle-tract metastases, and hemorrhage. Currently, endo scopic ultrasound-guided fine needle aspiration (EUS-FNA) is increasingly used to obtain tissue for diagnosis if the lesion is located in close proximity to the gut lumen. Compared with the traditional percutaneous techniques of tissue acquisition, EUS-FNA has many advantages including less invasiveness and lower complication rate. Here, we report a case of metastatic non-small cell carcinoma of left adrenal gland diagnosed by EUS-FNA with a review of literature. (Korean J Helicobacter Up Gastrointest Res 2012;12:202-206)