Endoscopic Ultrasound Fine Needle Aspiration Research Articles

Pancreatic tuberculosis: A systematic review of symptoms, diagnosis and treatment.

Although pancreatic tuberculosis (TB) is traditionally considered to be a rare clinical entity, in recent times, an increase in the number of reports of pancreatic TB has been noted. We conducted a systematic review in order to summarise currently available data on pancreatic TB. A comprehensive literature search of Medline, Scopus and ISI Web of Science databases was conducted in order to identify papers reporting cases of pancreatic TB. The eligibility criteria for inclusion in the review required that the studies reported patient(s) affected by pancreatic TB and that individual data on age, sex, clinical presentation and outcome were available. In total, 116 studies reporting data on 166 patients were included in the analysis. The majority of patients were males (62.1%) diagnosed at a mean age of 41.61 ± 13.95 years. Most cases were diagnosed in Asia (50.0%), followed by North America (22.9%), Europe (20.5%), Africa (4.2%) and South America (2.4%). Human immunodeficiency virus (HIV) infection was diagnosed in 25.3% of those affected. Pancreatic TB most frequently presented itself in the form of a pancreatic mass (79.5%) localised mainly in the head (59.0%) and less frequently in the body (18.2%) and tail (13.4%). Extrapancreatic TB involvement most frequently affected the peripancreatic lymph nodes (47.3%). More than half of patients (55.2%) were subjected to laparotomy, while 21.08% underwent endoscopic ultrasound fine-needle aspiration biopsy. The presence of TB was identified most frequently through histological analysis (59.6%), followed by culture (28.9%), staining (27.7%) and, in a smaller number, by polymerase chain reaction (9.6%) and cytology (6.6%). Almost all patients received anti-tubercular pharmacological therapy (98.2%), while 24.1% underwent surgery. Despite treatment, 8.7% of patients died. Increased awareness of pancreatic TB is needed, not only in endemic areas but especially in relation to HIV infection and other clinical conditions associated with immunoincompetence.

Lymph node assessment in early stage non-small cell lung cancer lymph node dissection or sampling?

Lymph node assessment is an essential component of the treatment of lung cancer. Identification of the correct "N" stage is important for staging which in turn determines treatment. Assessment of lymph nodes may be accomplished using imaging with CT scan and PET-CT, invasive techniques such as mediastinoscopy, endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) or endoscopic ultrasound fine needle aspiration (EUS-FNA). Ultimately, regardless of any pre-resection assessment, lymph nodes must be assessed at the time of resection. The question to be addressed in this report is the role of mediastinal lymph node dissection versus lymph node sampling. However, the issues surrounding lymph node assessment in NSCLC are complex, depending on clinical stage, imaging and histology.

Is Endoscopic Ultrasound-Fine Needle Aspiration for Ki67 Aspirational Enough?

Is Endoscopic Ultrasound-Fine Needle Aspiration for Ki67 Aspirational Enough?

A84 LINITIS PLASTICA FROM A NON-GASTROINTESTINAL PRIMARY TUMOR: A CASE REPORT

Abstract Background Infiltrative malignancies to the stomach are unusual and are difficult to detect. Linitis Plastic is a syndrome caused by submucosal invasion of the gastric wall. It represents Bormann type III or IV of gastric adenocarcinoma. Uncommonly, the latter can be a manifestation of lobular breast cancer. Aims To present a case report of lobular breast cancer that manifested primarily as Linitis Plastica (LP). We review the literature of LP as a clinical syndrome and the diagnostic challenges associated with this condition. We aim to increase the awareness of LP as a non-gastric tumor and its endoscopic features. Methods - Results A seventy-two-year-old female patient, previously healthy, presented with general deconditioning and distended abdomen. Basic laboratory testing such as complete blood count, electrolytes and kidney function were normal. Computed tomography of the abdomen and pelvis revealed moderately sized peritoneal carcinomatosis deposits on the abdominal wall. Her family history was non-contributary for any gastrointestinal or gynecological malignancies. On review of system, the patient noted a history of successful eradication of Helicobacter pylori infection remotely. Additionally, no preceding age-appropriate malignancy screening tests were reported. A gastroscopy was done looking for a primary gastrointestinal tumor exhibited abnormally stiff gastric wall, erythematous thickened mucosal folds, and non-distensible stomach. No clear lesions, submucosal masses or ulcers were visualized. The duodenal mucosa was noted to be normal. Twelve deep random biopsies were retrieved from the mucosal body and fundus. Following immunohistochemistry, the histological diagnosis revealed lobular adenocarcinoma of the breast. Conclusions Linitis Plastica (leather bottle stomach) or Brinton disease is a rare entity of diffuse gastric mucosa infiltrating tumor. LP depicts 3–10% of primary gastric carcinoma, whilst less than 10% are secondary breast cancer. Endoscopically, breast cancer-related LP can be divided into two morphologies: nodular pattern with ulceration, which is the typical presentation of ductal breast carcinoma and diffuse mural pattern in lobular breast carcinoma. LP is a unique condition with challenging diagnostic features. Many biopsies can result in negative histopathological diagnoses. This can be explained partially by 1. The scirrhous and fibrous stroma that forms LP tumors. 2. The deep location in the submucosa and muscular layer of the gastric wall. 3. Inability to identify this entity endoscopically. In one case report, Endoscopic Ultrasound-Fine Needle Aspirate (EUS-FNA) was incorporated after negative obtained biopsies. There are no standardized diagnostic approaches for LP. Further studies inquiring rates of missed malignant diagnoses and optimum diagnostic assessments in the setting of LP are needed. Funding Agencies None

Surgical treatment of gastric venous congestion in association with extended resection of pancreas: a case report

BackgroundTotal pancreatectomy is performed for chronic pancreatitis, tumors involving the entire pancreas or remnant pancreas after pancreatectomy. Gastric venous congestion and bleeding may be associated with total pancreatectomy. We report the case of a patient who underwent left gastric vein to splenic vein bypass to relieve gastric venous congestion during total pancreatectomy for remnant pancreatic cancer.Case presentationA 60-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy for cancer of the pancreatic head. A follow-up computed tomography revealed a low-density tumor of the remnant pancreas. The pathological diagnosis was adenocarcinoma on endoscopic ultrasound-fine needle aspiration. Total resection of the remnant pancreas was performed for the tumor 3 years after the initial surgery. We ligated the splenic vein at the point of distal side of the left gastric vein confluent. Immediately, the vein congestion around the stomach was confirmed. We found the stenosis of the confluent between the left gastric vein and splenic vein. We subsequently anastomosed the left gastric vein and splenic vein, following which the gastric venous congestion was relieved.ConclusionIn cases wherein all the drainage veins from the stomach are removed, an anastomosis between the left gastric vein and splenic vein can be effectively used to prevent gastric venous congestion and bleeding after total pancreatectomy.

A case of primary pancreatic schwannoma diagnosed by endoscopic ultrasound-fine needle aspiration

Pancreatic schwannoma is difficult to diagnose preoperatively. A 79-year-old man was found to have a 9-mm pancreatic mass on abdominal ultrasonography. On EUS, there was a 9-mm, clearly demarcated, round, solid, hypo-echoic mass in the pancreatic body. The differential diagnosis included a pancreatic neuroendocrine tumor, a solid-pseudopapillary neoplasm, and an atypical pancreatic cancer. EUS-FNA was performed with a 22G needle. On pathology examination, spindle-shaped tumor cells were seen proliferating in bundles. On immunostaining, the lesion was negative for c-kit, CD34, and α-SMA but positive for S-100 protein. The MIB-1 index was < 2%. Based on the above findings, the lesion was diagnosed as a benign pancreatic schwannoma. We, therefore, decided to follow the patient with careful observation rather than resecting the lesion surgically. The tumor has not changed significantly after 3years of follow-up. EUS-FNA is useful for the diagnosis of pancreatic schwannoma. If the tumor can be determined to be benign preoperatively, unnecessary surgery can be avoided. EUS-FNA should be actively implemented for pancreatic tumors that are difficult to diagnose definitively on imaging.

Role of Endoscopic Ultrasound-Fine Needle Aspiration in Management of Submucosal Lesions (SMLs) of GIT and Significant Predictors of Malignancy of GIST Lesions

Background: Submucosal lesion is a mass or bulge covered by normal-appearing mucosa identified during standard endoscopy. Endoscopic Ultrasound (EUS) allows precise differentiation of the individual layers of the gastrointestinal (GI) tract. Endoscopic Ultrasound-Fine Needle Aspiration (EUS-FNA) permits safe and accurate sampling of submucosal lesions (SMLs) for further histopathology. Gastrointestinal stromal tumors are the commonest mesenchymal neoplasms of the GI tract. They should be stratified by malignant potential according to tumor size, location, and mitotic count. Objectives: The aim of work was to evaluate the role of endoscopic ultrasound with EUS-FNA in management of submucosal gastrointestinal lesions, with special concern about gastrointestinal stromal tumors (GISTs) lesions and the criteria highly associated with malignant nature. Patients and methods: This multi-center prospective study included a total of 150 patients with gastrointestinal submucosal lesions, conducted to evaluate EUS and EUS-FNA as diagnostic tools of submucosal lesions, including 68 GIST lesions. All patients underwent conventional endoscopy, EUS-FNA and histopathological examination of the samples obtained in Theodor Bilharz Research Institute, Cairo University Hospital and Kobry El Qubba Military Hospital from 2015 to 2017. Results: There were 150 patients with submucosal GI lesions, including 93(62%) males and 57(38%) females, with the mean age of 52±11.9 years. Presentations included dyspepsia 73(48.7%), asymptomatic SMLs 31(20.7%). The lesions were mainly gastric 102(68%). Final diagnoses were GIST 68 (45.3%), lipoma 11(7.3%), leiomyoma 9(6%) and extramural lesions 7(4.7%). There were 68 patients with GIST lesions, including 43(63.2%) males and 25(36.8%) females, with the mean age of 54±10.3 years. Presentations included dyspepsia 41(63.2%), asymptomatic SMLs 16(23.5%). The lesions were mainly gastric 57(83.8%). Sensitivity and specificity were 88.6% and 100% of EUS-FNA as diagnostic tools for GIST lesions respectively. (PPV) and (NPV) were 100% and 82.8% respectively. Conclusion: It could be concluded that EUS and EUS-FNA were highly significant methods in diagnosis of GIST lesions in relation to final histopathology.

Pancreaticoduodenectomy for benign disease

Background: Pancreaticoduodenectomy (PD) has now become the standard treatment for malignant and benign peri-ampullary pathologies. PD for benign pathologies rates varies between 5-13% in the literature. The aim of this study was to evaluate the incidence of patients with benign disease with PD applied histopathologically and to review our clinical experience in view of the literature. Method: All patients who underwent PD between 2010 and 2017 were included in the study. The incidence, demographic characteristics, morbidity and mortality of the patients with histopathologically diagnosed as benign disease were evaluated. Results: A total of 283 pancreaticoduodenectomies had been performed during the study period. In 20 (7%) of these patients, benign disease was detected in postoperative histopathological evaluation. The mean age of the patients was 55.8 years. In 20 patients with benign disease, 8 patients underwent endoscopic ultrasound fine needle aspiration (EUS-FNA) and 10 endoscopic brush biopsy. EUS-FNA and endoscopic brush biopsy were not performed in 2 patients. The distribution of histopathological diagnosis of patients after PD was chronic pancreatitis in 7 patients, pancreatic intraepithelial neoplasia in 4 patients, tubular villous adenoma in 3 patients, mucinous cystic neoplasia in 3 patients, biliary intraepithelial neoplasia in 1 patient, dysplasia in 1 patient and benign cyst in 1 patient. Conclusion: Because of delays related to diagnosis and treatment for periampullary tumors lead to short survival generally stressed out the surgeons and gastroenterologists, and tent to behave more meticulous during the diagnosis and treatment. There is a tendency to be performed PD in the association of unclear mass and jaundice. PD will continue to be performed due to many benign pathologies in the future. However, more effective use of diagnostic Methods and multimodal approach will be able to reduce this rate.

Systematic review of endoscopy ultrasound-guided thermal ablation treatment for pancreatic cancer.

The development of curvilinear-array EUS and EUS-guided fine-needle aspiration (EUS-FNA) has led these approaches to become interventional procedures rather than purely diagnostic, as a minimally invasive antitumor therapeutic alternative to radiological and surgical treatments. The possibility to accurately position needle devices and to reach a deep target like the pancreas gland under real-time imaging guidance has expanded the use of EUS to ablate tumors. Currently, a variety of probes specifically designed for EUS ablation are available, including radiofrequency, hybrid cryothermal ablation (combining radiofrequency with cryotechnology), photodynamic therapy, and laser ablation. To date, several studies have demonstrated the safety and feasibility of these ablation techniques in the pancreatic setting, but only a few small series on pancreatic thermal ablation under EUS guidance are available. EUS-guided thermal ablation is primarily used for pancreatic cancer. It is well suited to this disease because of its superior anatomical access compared with other imaging modalities and the dismal prognosis despite improvements in chemoradiotherapy and surgery in the management of pancreatic cancer. Other targets are pancreatic neuroendocrine tumors and pancreatic cystic neoplasms, which are curable by surgical resection, but some patients are poor surgical candidates or prefer conservative management. This is a literature review of previously published clinical studies on EUS-guided thermal ablative therapies. Data on the long-term efficacy of EUS-guided antitumor thermal ablation therapy and large prospective randomized studies are still needed to confirm the real clinical benefits of these techniques for the management of pancreatic neoplasms.

Assessment of ARX expression, a novel biomarker for metastatic risk in pancreatic neuroendocrine tumors, in endoscopic ultrasound fine-needle aspiration.

BackgroundThe transcription factors ARX and PDX1, and alternative lengthening of telomeres (ALT) were recently described as prognostic markers for resected non‐functional pancreatic neuroendocrine tumors (PanNETs). ALT positive tumors with ARX expression relapse most often. Currently, tumor size is the only preoperative marker used to decide whether or not to operate, thus additional preoperative prognostic markers are needed. Therefore, it is critical to assess the performance of these biomarkers on preoperative cytologic specimens.MethodsEndoscopic fine‐needle aspiration cellblock material and corresponding surgical specimens of 13 patients with PanNETs were assessed for histology, immunohistochemical staining of ARX, PDX1, Synaptophysin, Ki67, and telomere‐specific fluorescence in situ hybridization to detect ALT, and then associated with clinicopathological features. Scoring for ARX and PDX1 was performed blinded by two independent observers.ResultsOf the 13 surgical specimens, 8 were ARX+/PDX1−, 2 ARX−/PDX1+, and 3 ARX+/PDX1+. Concordance between cytologic and surgical specimens for ARX protein expression was 100%, whereas concordance for PDX1, ALT, and WHO tumor grade was 85%, 91%, and 73%, respectively. There was a perfect inter‐observer agreement in ARX and PDX1 scoring.ConclusionARX can reliably be determined in cytologic specimens and has low inter‐observer variability. For cytology, false‐positive PDX1 expression was observed, possibly due to contamination or sampling, while ALT had a false‐negative case due to incomplete sampling. As previously observed, tumor grade is underestimated in cytologic specimens. Thus, ARX and ALT are the most promising markers to predict metastatic behavior in PanNETs, thereby warranting further validation in larger studies.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of paraesophageal lung tumors - diagnostic yield and added value.

There are few data on the use of endoscopic ultrasound (EUS) for the biopsy of suspected malignant lesions of thelung. The main objective of this study was to evaluate the performance of transesophageal EUS fine needle aspiration (EUSFNA)for the diagnosis of paraesophageal lung tumors and also for the confirmation of metastatic sites of lung cancer duringthe same procedure. We performed a retrospective study in a tertiary care unit including 19 patientswith paraesophageal lung tumors referred to our department for a lung biopsy. Transesophageal EUS-FNA was performedusing a linear echoendoscope and 22G needles. In all 19 patients with suspected lung tumors the confirmation of themalignant disease was achieved. Pathological examination revealed 16 cases of non-small cell lung cancers, 2 small cell lungcancers and one case of lung metastases. Diagnostic yield of lung EUS-FNA was 1, with no post-procedural complications. In7 cases, we performed also biopsies of suspected metastasis and all biopsies revealed the same histopathological type as theprimary tumor. Our study supports the use of this minimally invasive technique for paraesophageally locatedlung tumors and demonstrates that EUS-FNA is safe and has an excellent diagnostic yield.

Clinical impact of celiac ganglia metastasis upon pancreatic ductal adenocarcinoma

BackgroundPre-operative staging of pancreatic adenocarcinoma guides clinical decision making. Limited data indicate that metastasis to celiac ganglia (CG) correlates with poor prognosis. We investigated feasibility and safety of endoscopic ultrasound fine needle aspiration (EUS-FNA) detection of CG metastasis and its impact upon tumor stage, resectability, and survival in pancreatic ductal adenocarcinoma (PDAC). PatientsWe reviewed our prospectively maintained EUS and cytopathology databases to identify patients with FNA proven CG metastasis in patients with PDAC from 2004 to 2017. Clinical demographics, EUS, CT, MRI, cytopathology, cancer stage, and resectability data were analyzed. Survival of PDAC patients with CG metastasis was compared to the expected survival of PDAC patients of similar stage as reported by the United States National Cancer Database. ResultsTwenty-one patients with PDAC [median age 73 (IQR63-78); 14 (67%) female)], had CG metastasis confirmed by cytopathologic assessment. CG metastasis resulted in tumor upstaging relative to other EUS findings and cross sectional imaging findings in 12 (57%) and 15 (71%) patients, and converted cancers from resectable to unresectable relative to EUS and cross sectional imaging in 7 (37%) and 7 (37%) patients, respectively. In patients with PDAC, the survival of patients with CG metastasis was not significantly different from the overall survival (hazard ratio 0.71; 95% confidence interval 0.44, 1.13; p = 0.15). ConclusionsEUS-FNA may safely identify CG metastases. While CG metastasis upstaged and altered the resectability status among this cohort of patients with PDAC, the survival data with regard to PDAC suggest that this may be misguided.

Statins decrease the risk of acute pancreatitis after endoscopic ultrasound fine-needle aspiration of pancreatic cysts

BackgroundBasic and clinical studies suggest that statins may prevent and even ameliorate acute pancreatitis. The present study was to evaluate whether statin decreases the risk of acute pancreatitis in patients undergoing endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts. MethodsOut of 456 patients with pancreatic cysts referred to our center between 2006 and 2018, 365 were finally included in analyses: 86 were treated with statins and 279 were not at the time of endoscopic ultrasound fine-needle aspiration. We compared the acute pancreatitis incidence between the two groups, and we also compared other complications such as bleeding and infections. ResultsMedian age was 64 years [interquartile range (IQR) 62–69] and median cyst size was 24 mm (IQR, 21–29). The most frequent histology was intraductal papillary mucinous neoplasm (45.3% and 42.3% in the two groups, respectively; P = 0.98). All 13 patients experiencing post-endoscopic ultrasound acute pancreatitis were from the control group (4.7%), of which 3 were classified as severe pancreatitis. None of statin users developed post-procedural acute pancreatitis (odds ratio: 0.15; 95% confidence interval: 0.03–0.98; P = 0.03). No difference was registered with regard to severe pancreatitis and other complications. ConclusionsStatins exert a beneficial role in preventing acute pancreatitis in patients with pancreatic cysts undergoing endoscopic ultrasound-guided fine-needle aspiration. If confirmed in prospective trials, our findings may pave the way to an extensive use of statins as prophylactic agents in pancreatic interventional endoscopy.

Pediatric Sarcoidosis: A Review with Emphasis on Early Onset and High-Risk Sarcoidosis and Diagnostic Challenges.

Sarcoidosis is a non-necrotizing granulomatous inflammatory syndrome with multisystemic manifestations. We performed a systematic review of sarcoidosis in the pediatric population with particular emphases on early onset sarcoidosis, high-risk sarcoidosis, and newly reported or unusual sarcoid-related diseases. Blau Syndrome and early onset sarcoidosis/ BS-EOS are seen in children younger than five years old presenting with extra-thoracic manifestations but usually without lymphadenopathy and/or pulmonary involvement. The prevalence of high-risk sarcoidosis is very low in children and is further limited by the difficulty of diagnosis in symptomatic children and underdiagnosis in subclinical or asymptomatic patients. Reports of sarcoidal syndromes in users of E-cigarette/marijuana/other flavorings and their induction in cancer immunotherapies are of interests and may be challenging to differentiate from metastatic malignancy. The diagnostic considerations in pediatric sarcoidosis are to support a compatible clinicoradiographic presentation and the pathologic findings of non-necrotizing granulomas by ruling out granulomas of infective etiology. There is no absolutely reliable diagnostic test for sarcoidosis at present. The use of endoscopic bronchial ultrasound (EBUS) and transbronchial fine needle aspiration (TBNA) sampling of intrathoracic lymph nodes and lung, and for superficially accessible lesions, with cytopathological assessment and pathological confirmations provide fair diagnostic yield and excellent patient safety profile in children.

694P - Diagnostic value of digital multiplexed detection of single nucleotide variants in pancreatic cancer specimens collected by endoscopic ultrasound fine-needle aspiration

BackgroundCurrent diagnostic approaches for pancreatic cancer (PC) mostly rely on cytologic examination of endoscopic ultrasound fine-needle aspiration (EUS-FNA) samples. However, in a subset of cases, PC diagnosis remains inconclusive due to low tumour cellularity. Molecular analysis of EUS-FNAs might be used as an auxiliary tool to strengthen diagnosis in samples with suboptimal cytology. This study aimed to evaluate the diagnostic utility of a single nucleotide variants (SNV) assay using molecular barcode technology performed on EUS-FNAs. Methods28 EUS-FNA samples of pancreatic masses (19PC, 9 non-malignant lesions) were analyzed. FNAs were collected in RNAlater and stored at -80 C. Mutational status was evaluated using the Nanostring Vantage 3D™ DNA SNV Solid Tumor Panel, utilizing digital enumeration of unique barcoded probes to detect 104 SNV from 24 genes of clinical significance. 5ng of tumor-derived DNA was subjected to multiplexed preamplification and hybridization of variant-specific probes to unique fluorescent barcodes. A multiplex KRAS assay (G12/13) droplet digital PCR (ddPCR) was used to confirm SNVs. ResultsThe SNV assay detected at least one variant in 18/19 (95%) PC samples. One PC case harbored 3 SNVs. Among the PC samples, KRAS variants (G12D, G12V, G12R, Q61H, Q61L) were detected in 17 (90%) cases, EGFR in 1 (5%), and PIK3CA in 1 (5%). All KRAS mutations were also detected by ddPCR. Diagnostic accuracy of cytology alone for PC was 68% (19/28). 32% of the FNAs were inconclusive; at least one SNV was detected in 5/6 inconclusive FNAs with a final diagnosis of PC. No SNV was identified in the remaining 3 inconclusive cases diagnosed as chronic pancreatitis. Combining cytology and SNV analysis for inconclusive cases increased the diagnostic accuracy to 96% (27/28). ConclusionsNanostring SNV assay combined with cytology can enhance the diagnostic power of EUS-FNA, especially in inconclusive cases, preventing repeat biopsies, unnecessary resections for benign disease or delay in PC patients care. Given the low DNA input, digital data output and rapid turn-around time, this novel technology may be instrumental for the preoperative molecular diagnosis of PC. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

3007 Santorinirrhage Due to Hemosuccus Pancreaticus as a Rare Manifestation of Upper Gastrointestinal Bleeding

INTRODUCTION: Hemosuccus pancreaticus (HP), bleeding from the pancreatic duct into the gastrointestinal (GI) tract via ampulla of vater, is extremely rare. Some causes include pancreatitis, pseudoaneurysm of the peri-pancreatic vessels, or malignancy. The rarity with which this condition is encountered makes HP difficult to diagnose. We present a case of HP with bleeding from the minor duodenal papilla from a pancreatic pseudocyst. CASE DESCRIPTION/METHODS: A 39-year-old male with alcohol use disorder and chronic pancreatitis presented to the hospital with complaints of abdominal pain and melena. Labs showed significant anemia: hemoglobin, 6.90 g/dL. He was admitted for blood transfusions and further investigation. Endoscopic evaluation showed portal hypertension gastropathy, without evidence of gross bleeding. CT abdominal scan showed cystic lesions at the pancreatic tail and within the pancreatic body (Figure 1). Endoscopic ultrasound fine needle aspiration biopsy of the cystic lesion was done. Fluid analysis was consistent with pancreatic pseudocyst with elevated amylase. He was discharged home in stable condition with gastroenterology follow-up. He returned to the hospital with recurrent episodes of melena and transfusion-dependent anemia. He had IR guided transjugular intrahepatic portosystemic shunt from right hepatic vein to right portal vein. He continued to have episodes of melena with new coffee-ground hematemesis. Repeat endoscopy was performed with frank bleeding noted from the minor duodenal papilla (Figure 2). MRI was unable to confirm pancreas divisum due to pancreatic atrophy and poor visualization of the pancreatic duct. CT abdominal scan now showed hemorrhage within the two pancreatic cysts. Mesenteric angiogram was performed which showed pseudoaneurysm off proximal splenic artery and gastroepiploic artery both of which were embolized (Figure 3). His abdominal distension and pain improved significantly after the procedure with no more episodes of melena or hematemesis. He was discharged home without recurrence of symptoms. DISCUSSION: Our case illustrates the diagnostic dilemma of obscure upper GI bleeding. HP with bleeding from the duct of Santorini has been reported twice. All hemodynamically stable patients with HP should undergo endoscopic, radiographic, and angiographic evaluation. Therapeutic options consist of selective embolization or surgery. A multidisciplinary team approach with a precise protocol is paramount to drastically reduce the mortality and morbidity of patients.

1387 Late Recurrence of Metastatic Pancreatic Angiomyolipoma in Tuberous Sclerosis Following Bilateral Nephrectomy and Transplant

INTRODUCTION: Angiomyolipomas are typically benign tumors often associated with tuberous sclerosis, most commonly occurring in the kidneys. Some variants have malignant potential. Surgical resection remains the most effective form of treatment; however, recurrence after nephrectomy is rare, especially in the pancreas. CASE DESCRIPTION/METHODS: We report a unique case of a 59-year-old female with tuberous sclerosis who underwent bilateral nephrectomy for malignant, hemorrhagic angiomyolipomas with subsequent renal transplant. Almost 10 years after initial discovery of renal angiomyolipoma, patient presented to gastroenterology clinic with elevated liver function tests and was subsequently referred for endoscopic ultrasound (EUS) to evaluate for biliary obstruction as the etiology. If no obstruction was found, an EUS guided liver biopsy was requested. The EUS showed a normal non-dilated common bile duct (CBD) with no evidence of obstruction. EUS guided liver biopsy was then performed using a 19G core biopsy needle. Incidentally, she was found to have pancreatic tail mass lesion which measured 13 mm in diameter. This was not visualized on her previous surveillance CT scans. EUS fine needle aspiration was performed on the pancreatic tail mass with a 25G needle. The liver biopsy showed mild iron overload and minimal macrovesicular steatosis. The cytology from the pancreatic lesion was reported as an angiomyolipoma. The patient was subsequently referred to surgical oncology for evaluation of distal pancreatectomy. DISCUSSION: This is the second reported case of a pancreatic angiomyolipoma in a tuberous sclerosis patient, however guidelines on surveillance are lacking. Radiological imaging has not been an effective form of detecting pancreatic angiomyolipomas. This case highlights the importance of continued surveillance, and the possible role of EUS in that surveillance, for recurrent angiomyolipoma following nephrectomy in patients with tuberous sclerosis.

33 Needle-Base Confocal Laser Endomicroscopy in the Diagnosis of Pancreas Cyst: A Systematic Review and Meta-Analysis

INTRODUCTION: EUS-guided needle-based confocal laser endomicroscopy (nCLE) provides real-time histology assessments and has been reported as an adjunctive tool that can be performed in the same session as EUS-fine needle aspiration. We aimed to perform a systematic review and meta-analysis regarding the diagnostic performance, success rate, and complications of nCLE in pancreas cysts. METHODS: This is a systematic review and meta-analysis following the PRISMA-P principles. Literature was systematically searched in February 2019 by two independent investigators in 3 major databases including PubMed, Embase, and Web of Science by using the terms “confocal endomicroscopy” AND “needle” AND “pancreas cyst.” The search was limited to English-written and in vivo human studies. Additionally, investigators manually reviewed the references of the primary identified studies for other eligible articles. The meta-analysis of success rate, complication rate, pooled diagnostic parameters with the respective 95% confidence interval (CI) of nCLE for diagnosis of pancreas cysts were performed. RESULTS: Of the 159 initially screened studies, 11 studies had 288 patients with pancreatic cystic lesions enrolled. The estimated overall success rate and adverse event rate with random effects model were 96% (95% CI: 92–95%) and 11% (95% CI: 7.5–16%), respectively. There were 7 studies which included 176 patients that reported the diagnostic parameters of nCLE for diagnosis of mucinous pancreas cyst. The estimated diagnostic odd ratio (DOR) was 50 (95% CI: 18.92–132.16). The estimated area under curve (AUC) was 0.939 (95% CI: 0.89–0.992) and AUC for SROC was 0.84 (95% CI: 0.72–0.98). The estimate sensitivity and specificity were 0.77 (95% CI: 0.62–0.87) and 0.91 (95% CI: 0.81–0.96), respectively. The meta-analysis estimated the prevalence rate of mucinous cysts to be 57% (95% CI: 43%–71%). The positive predictive value (PPV) and negative predictive value (NPV) were 0.91 (range: 0.86–0.95) and 0.72 (range: 0.62, 0.84), respectively. I2 index showed no heterogeneity between studies in success rate, adverse event rate, DOR, and specificity. However, heterogeneity was detected in sensitivity, PPV, and NPV between studies. CONCLUSION: nCLE has high sensitivity, specificity, PPV, and NPV for differentiating mucinous pancreas cyst from the other cystic lesion. However there is an increased adverse rate compared to standard EUS-FNA. Measures and methods to decrease the adverse event rate should be further investigated.

46 Comparison of Endoscopic Ultrasound Fine-Needle Aspiration and Fine-Needle Biopsy for Solid Pancreatic Masses

INTRODUCTION: The superiority of endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) over fine needle aspiration (FNA) in sampling pancreatic solid masses is still controversial. FNA samples are relatively small and sometimes required increased number of needle passes to obtain a sample with preserved architecture. METHODS: Medical records of 182 patients who underwent ultrasound guided EUS with FNA and/or FNB of pancreatic lesions from University Louisville Hospital were reviewed in this retrospective study. Only those patients who had pancreatic solid mass lesions as pre-procedure diagnosis were included. Size of the lesions were classified in three groups: 0–1 cm, &gt; 1 cm–2 cm, &gt;2 cm. Adequacy of samples were determined by a pathologist. Post-procedure readmissions and/or ER visits, up to one month after EUS, were obtained from University of Louisville medical records. Welch Two sample t-test analysis was performed to assess the relationship between the number of passes and the technique used for biopsy. A P-value &lt; 0.05 deemed statistically significant. RESULTS: 78 patients were included in analysis. The average age was 63 and males represented 59% of the total population. 64% of the lesions were localized on the head, 16% in the tail, 11% in the body, and 9% in the neck of the pancreas. Size of most of the lesions were &gt;2 cm (74%) and &gt;1 cm–2 cm (19%). The mean number passes was 4, SD = 2. Compared with FNA, FNB did not require significantly lower number of passes (3.58 vs 4.36, 95% CI: −0.49, 2.06; P = 0.216). FNA was performed in 41% of the cases. From all the specimens submitted to pathology, there were 0 unsatisfactory specimens in the FNB group, and 2 (7%) unsatisfactory specimens in the FNA group (P = 0.161). From suspected malignant lesions, FNA could detect 31% of malignant neoplasms, and FNB 41%. Six patients required ER visit/Hospital admission after the procedure, but only 3 patients were admvitted for problems related to the procedure (pancreatitis, intractable nausea and abdominal pain). CONCLUSION: There is no difference between the number of passes between EUS-FNA and EUS-FNB for pancreatic solid masses.

MicroRNA-296-5p Promotes Cell Invasion and Drug Resistance by Targeting Bcl2-Related Ovarian Killer, Leading to a Poor Prognosis in Pancreatic Cancer

Background/Aims: Pancreatic ductal adenocarcinoma (PDAC) is characterized by aggressive invasion, early metastasis, and resistance to chemotherapy, leading to a poor prognosis. To clarify the molecular mechanism of these malignant characteristics, we performed a genome-wide microRNA (miRNA) array analysis utilizing micro-cancer tissues from patients with unresectable PDAC (stage IV), obtained by endoscopic ultrasound-fine needle aspiration (EUS-FNA). Methods: The expression profiles of 2,042 miRNAs were determined using micro-cancer tissues from 13 patients with unresectable PDAC obtained by EUS-FNA. The relationship between individual miRNA levels and overall survival (OS) was analyzed. Possible target genes for miRNAs were bioinformatically analyzed using the online database miRDB. Pancreatic cancer cell lines PANC-1, MIA PaCa-2, and PK-8 were transfected with miRNA mimic or small interfering RNA, and cell invasion, epithelial-mesenchymal transition (EMT), and apoptosis markers were examined. miRNA and mRNA expressions were examined by quantitative polymerase chain reaction. Results: Of 2,042 miRNAs, the 10 that exhibited the lowest correlation coefficient (p ≤ 0.005) between miRNA expression level and OS among the patients were identified. The miRDB and expression analysis in cancer cell lines for the 10 miRNAs identified miR-296-5p and miR-1207-5p as biomarkers predictive of shorter survival (p < 0.0005). Bioinformative target gene analysis and transfection experiments with miRNA mimics showed that Bcl2-related ovarian killer (BOK), a pro-apoptotic gene, is a target for miR296-5p in pancreatic cancer cells; transfection of miR-296-5p mimic into PANC-1, MIA PaCa-2, and PK-8 cells resulted in significant suppression of BOK mRNA and protein expression. These transfectants showed significantly higher invasion capability compared with control cells, and knock down of BOK in pancreatic cancer cells similarly enhanced invasion capability. Transfectants of miR-296-5p mimic also exhibited aberrant expression of EMT markers, including vimentin and N-cadherin. Moreover, these transfectants showed a significantly lower apoptosis rate in response to 5-fluorouracil and gemcitabine with a decrease of BOK expression, suggesting a role of miR-296-5p in drug resistance. Conclusion: These results suggest that miR-296-5p is a useful biomarker for a poor prognosis in patients with PDAC, and that the miR-296-5p/BOK signaling axis plays an important role in cell invasion, drug resistance, and EMT in PDACs.