Endoscopic Ultrasound-guided Core Biopsy Research Articles

S2564 A Rare Case of Heavily Calcified Gastrointestinal Stromal Tumor Diagnosed by Endoscopic Ultrasound-Guided Core Biopsy

S2564 A Rare Case of Heavily Calcified Gastrointestinal Stromal Tumor Diagnosed by Endoscopic Ultrasound-Guided Core Biopsy

Endoscopic Ultrasound–Guided Core Biopsy for Diagnosis of Autoimmune Pancreatitis

Once thought to be rare, autoimmune pancreatitis (AIP) is now recognized as one of the more common etiologies of acute pancreatitis. However, the

A Rare Pancreatic Mass Diagnosed by Endoscopic Ultrasound-Guided Biopsy

Carcinosarcoma's are uncommon neoplasms primarily located in the uterus. Pancreatic carcinosarcoma is a more rare entity, generally identified in the middle aged or elderly. Histologically, pancreatic carcinosarcoma is characterized by carcinomatous and sarcomatous components. A small number of pancreatic carcinosarcoma has been reported in literature; for which the diagnosis was made via surgery. Prognosis of pancreatic carcinosarcoma is poor with average survival of 6 months. A 69-year-old female presented with cough and chest pain. She underwent CT chest, revealing pericardial effusion, pleural effusion, and pulmonary nodules. With concern for malignancy, patient underwent CT abdomen/pelvis, revealing heterogeneously enhancing mass in the genu of the pancreas. Laboratory studies were significant for CA 19-9 of 13.5 U/L, CEA of 0.7 ng/mL, aspartate aminotransferase of 16 U/L, alanine aminotransferase of 19 U/L, alkaline phosphatase of 119 U/L, and total bilirubin of 0.6 mg/dL. She underwent upper endoscopy and endoscopic ultrasound (EUS). Gastroscopy revealed ulcerated gastric polyps that were biopsied with cold forceps. EUS demonstrated a hypoechoic mass in the pancreatic genu measuring 3.1 x 2 cm with abutment of the portal vein. Fine needle biopsy was performed with a 22-gauge biopsy needle (Sharkcore, Medtronic, Minneapolis, MN) via a trangastric approach. An enlarged lymph node was also biopsied in the peripancreatic region. Pancreatic mass biopsy revealed carcinosarcoma, with gastric polyp and peripancreatic lymph node biopsies revealing identical morphology. Patient was offered chemotherapy for treatment, but given poor prognosis, opted for hospice. This case is unique in that only approximately 20 cases of pancreatic carcinosarcoma have been reported in literature and all were diagnosed following surgical resection. To our knowledge, this is the first case of pancreatic carcinosarcoma being diagnosed by EUS guided core biopsy. Previous studies have demonstrated over 90% sensitivity for diagnostic yield with either a 22 or 25-gauge EUS guided core biopsy. This case demonstrates the rapidly emerging role and diagnostic ability for initial EUS guided biopsy for solid neoplasms in lieu of fine needle aspiration. It also reaffirms the importance of obtaining a histologic diagnosis prior to surgical resection or chemotherapy.

First Reported Case of Endoscopic Ultrasound-Guided Core Biopsy Yielding Diagnosis of Primary Adrenal Leiomyosarcoma

Introduction Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or core biopsy (EUS-CB) is a safe, effective modality for sampling adrenal lesions [1]. We present the first case of primary adrenal leiomyosarcoma diagnosed by EUS-CB. Case Description 50 year old male presented with abdominal pain and weight loss for a year. Physical exam and labs were normal. Computed Tomography (CT) abdomen showed an 8.1 cm heterogeneous left adrenal mass and several hypodense liver lesions concerning for metastatic disease. Positron Emission Tomography (PET) scan showed FDG avid left adrenal mass and mildly avid lung and liver lesions suggestive of metastatic disease. Pheochromocytoma was ruled out with negative urine metanephrines and catecholamines. There was no clinical evidence of Cushing's Syndrome. Adrenal cortical carcinoma was considered but as there was no evidence of precursor steroids being produced, EUS-CB of the left adrenal mass was performed. This revealed a spindle cell neoplasm with extensive necrosis. Tumor cells stained positive for desmin, cytokeratin Mak6, and S-100, and negative for CD34 and chromogranin. Based on these findings, a diagnosis of primary leiomyosarcoma of the left adrenal gland was made. Adriamycin and olaratumab with palliative radiation for pain was then initiated as metastatic disease precluded surgery. Discussion Primary adrenal leiomyosarcomas are extremely rare, with less than 35 cases reported [2]. They grow rapidly, do not produce any adrenal hormonal derangements, and lack characteristic tumor markers or imaging findings, making preoperative diagnosis difficult. Diagnosis is usually made on surgical resection or autopsy [2]. To our knowledge, this is the first case of primary adrenal leiomyosarcoma diagnosed by EUS. In our case, in which metastatic disease was noted, this diagnosis affected clinical management and prevented further invasive procedures.Figure: CT abdomen showing 8.1 cm heterogeneous left adrenal mass.Figure: EUS showing irregular, hypoechoic left adrenal mass measuring 63 x 44 mm.Figure: Spindle cell neoplasm with extensive tumor necrosis (A). High power view showing fascicular growth pattern and cytological pleomorphism (B).

Mo1484 The Utility of Endoscopic Ultrasound (EUS)-Fine Needle Aspiration (FNA) for the Diagnosis of Pancreatic Cystic Neuroendocrine Tumors (PCNETs): a Decade of Single Center Experience

performance of EUS guided core biopsy. The yield of the core biopsy as compared to FNA with onsite cytopathologists is not known. Methods: All patients referred for EUS guided biopsy were considered for EUS guided core biopsy followed by EUS guided FNA between February 2011 and November 2012 at the Houston Veterans’ Affairs Medical Center. Patients were excluded if they had cystic lesions, small lesions ( 1cm) or if interposing vascular structures prevented the intervention. Study patients were evaluated with two core biopsies using 22 gauge needles followed by FNA guided by a bedside cytopathologist. Results of the core biopsy were reported by a second pathologist at a later date. The yield (percent accurate diagnosis) was compared between the two groups. The agreement between the 2 approached was examined using the Kappa (K) statistic. The final diagnosis was defined using a conglomerate of surgical pathology, follow-up studies, and clinical course. Results: Twenty six patients were included in the final analysis, of which 96% were male and 61% were Caucasian. 69.2% had pancreatic lesions and 30.8% had other upper GI lesions including lymph nodes and subepithelial lesions. The mean number of passes was 3.2 for FNA, and the mean procedure time was 39.4 minutes. The final diagnosis was malignant in 92.3% and benign in 7.7%. Sensitivity and specificity were 83% and 100% respectively for FNA, and 71% and 100% respectively for core biopsy. Diagnostic accuracy was 84.6% for FNA and 73.1% for core biopsy. The two approaches yield was in agreement in 88.4% with a kappa statistic of 0.66 (95% CI: 0.33 0.99) indicating substantial agreement. Conclusions: The diagnostic yield of two passes with a 22 gauge core biopsy needle is comparable to the current gold standard of FNA with a bedside cytopathologist. Performance of two core biopsies could represent a time efficient and widely available alternative to FNA with a bedside cytopathologist.