Endoscopic Ultrasound-guided Fine-needle Aspiration Group Research Articles

Diagnostic Evaluation of Solid Pancreatic Lesions: Endoscopic Ultrasound-Guided Fine Needle Aspiration Versus Percutaneous Ultrasound-Guided Core Needle Biopsy.

The main objective of the present study is to compare the safety, technical success and diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) versus ultrasound-guided percutaneous core-needle biopsy (US-CNB) in patients with solid pancreatic lesions. This is a retrospective study that involved all patients with a solid pancreatic lesion who underwent EUS-FNA or US-CNB between November 2019 and February 2021. Of all patients, 69 (84.1%) had inoperable malignancy, whereas 13 (15.9%) had chronic pancreatitis. Resectability status was ascertained by computed tomography. All core needle biopsies were performed by the same interventional radiologist via ultrasound guidance with an 18-gauge semi-automatic tru-cut needle. All EUS-FNA procedures were performed by the same gastroenterologist with a 27-gauge EUS-FNA needle. Technical success is defined as if the region of interest is reached and specimen taken from the pancreatic lesion. Diagnostic yield is defined as the procurement of sufficient tissue for pathological examination. Overall, 52 patients (mean age 58.5 ± 9.8years) who underwent EUS-FNA and 30 patients (60.1 ± 12.1years) who underwent US-CNB were included. Solid lesions were most commonly (61.5% in EUS-FNA and 50.0% in US-CNB groups) located in pancreatic head in both groups. Mean size of the lesions was comparable in both groups as well. The technical success was 100% in both groups. In 12 (14.6%) patients, pathology results revealed inadequate sampling (11 × in the EUS-FNA and 1 × in the US-CNB group). The diagnostic yield was significantly higher in US-CNB group than in EUS-FNA group (96.7% vs. 78.8%, respectively, p = 0.048). Of 11 patients in the EUS-FNA with inadequate sampling, pancreatic lesions were located in the pancreatic head in 7 (63.6%). No major complications were observed in neither of the groups. As a minor complication, one case of slight abdominal pain was detected in the EUS-FNA group. Based on the results of the present study, both US-CNB and EUS-FNA appeared safe; however, diagnostic yield in the US-CNB group was significantly higher.

S46 EUS-Guided Through the Needle Biopsy vs Fine Needle Aspiration for Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis

Introduction: Endoscopic Ultrasound guided fine needle aspiration (EUS-FNA) has been widely used to collect samples from pancreatic cystic lesions (PCLs) for cytology and fluid analysis. However, EUS guided FNA has relatively lower sensitivity in discriminating the types of lesions as well as detection of malignancy. Recent studies have investigated the EUS guided through the needle biopsy (EUS-TTNB) as an alternative method for sample collections in PCLs. We conducted a systemic review and meta-analysis on the studies that compared EUS-FNA and EUS-TTNB for adequate sampling and diagnostic accuracy in patients with PCLs. Methods: We performed a comprehensive search of the databases: PubMed/MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception through May 10th, 2022. We considered randomized controlled trials, cohort studies, and case-control studies. We excluded abstracts, animal studies, case reports, reviews, editorials, and letters to editors. The primary outcome was sample adequacy which is defined as the presence of enough sample for histopathological evaluation. The secondary outcome was sample accuracy which is defined as the ability to have a definite diagnosis. The random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CI). A p value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Higgins I2 index. Results: Nine observational studies involving 520 patients were included in the meta-analysis. The rate of sample adequacy was significantly higher in the EUS-TTNB group compared to the EUS-FNA group (RR 1.64, 95% CI 1.19-2.26, p =0.003, I2 = 95%) (Figure 1A). Only four studies compared the accuracy rate between the EUS-TTNB method and the EUS-FNA group. The diagnostic accuracy was significantly higher in the EUS-TTNB group compared to the EUS-FNA group (RR 2.03, 95% CI 1.13-3.65, p = 0.02, I2 = 87%) (Figure 1B). Conclusion: Our meta-analysis demonstrated that the rates of both sample adequacy and accuracy were higher in the EUS-TTNB group compared to the EUS-FNA group. EUS-TTNB should be considered where applicable clinically for improving the diagnostic yield in patients undergoing evaluation of PCLs. Further randomized controlled trials are needed to confirm our findings.Figure 1.: a) sample adequacy rate b) diagnostic accuracy rate

Endoscopic ultrasound with combined fine needle aspiration plus biopsy improves diagnostic yield in solid pancreatic masses

Goals Our aim was to compare the diagnostic yield of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) versus combined fine needle aspiration and fine needle biopsy (EUS-FNA + FNB) in the evaluation of solid pancreatic masses (SPMs). Background EUS-FNA and EUS-FNB are established methods to diagnose SPMs. No studies have evaluated the efficacy of combination of both (EUS-FNA + FNB). Our senior author (MRS) hypothesized that combining the two techniques by using a single FNB needle improves diagnostic yield and started combination technique in October 2016. Study Patients who underwent EUS for SPMs by MRS during January 2014–September 2019 were included. They were divided into the EUS-FNA group and EUS-FNA + FNB group. EUS-FNA was performed using a 22 or 25 gauge Expect Slimline needle (Boston Scientific, Marlborough, MA) and EUS-FNA + FNB was performed using a single 22 or 25 gauge Shark-core needle (Medtronics, Minneapolis, MN, USA). Our primary outcome was to compare the diagnostic yield in the two groups. Results Among 105 patients included, 58 were in the EUS-FNA group and 47 were in the EUS-FNA + FNB group. EUS-FNA + FNB group had significantly higher diagnostic yield and required fewer needle passes compared to EUS-FNA group, 95.7% vs. 77.6%, p = .01: and 4 vs. 5, p = .002; respectively. Procedural duration was similar in both groups but the combined technique required less number of needles per procedure. There was no difference in adverse events in the two groups. Conclusion Our study showed that combined EUS-FNA + FNB had higher diagnostic yield compared to EUS-FNA in SPMs along with less number of needle passes and needles required. Further prospective studies are needed to validate these findings and cost-effectiveness of this strategy.

Comparative Study of an Ultrasound-guided Percutaneous Biopsy and Endoscopic Ultrasound-guided Fine-needle Aspiration for Liver Tumors.

Objective Both a percutaneous biopsy and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) have been widely performed for liver tumors. However, no studies have compared these two biopsy methods. Method A retrospective study was conducted using medical records for patients who underwent a liver tumor biopsy from 2012 to 2019. The cases were classified into two groups for a comparison: an ultrasound-guided percutaneous biopsy group (percutaneous group) and an EUS-FNA group (EUS group). Results A total of 106 patients (47 in the percutaneous group and 59 in the EUS group) were included. The final diagnosis was malignant in 100 cases and benign in the remaining 6 cases. While the median lesion diameter was 62 mm in the percutaneous group, it was significantly smaller (34 mm) in the EUS group (p <0.01). The EUS group had more left lobe tumors than right lobe tumors. All cases of caudate lobe tumor (four cases) underwent EUS-FNA. The sensitivity, specificity, and accuracy of the procedure were 95%, 100%, and 96% in the percutaneous group and 100%, 100%, and 100% in the EUS group, respectively showing no significant difference. Adverse events were reported in 17% of the percutaneous group, which was significantly lower than in the EUS group (2%; p <0.01). Conclusion A percutaneous biopsy and EUS-FNA have equivalent diagnostic qualities for liver tumors, although EUS-FNA tends to be associated with fewer adverse events. A complete understanding of the characteristics of each procedure is essential when choosing the best biopsy method for each particular case.

Effectiveness of EUS-Guided Fine-Needle Biopsy versus EUS-Guided Fine-Needle Aspiration: A Retrospective Analysis.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic tumors and subepithelial lesions (SEL) of the gastrointestinal tract are effective for histological diagnosis. There are also reports that tissue sampling is possible with a smaller number of punctures by EUS-guided fine-needle biopsy (EUS-FNB). In this study, we retrospectively compared the diagnostic abilities of EUS-FNA and EUS-FNB. We examined 130 patients who underwent EUS-FNA/EUS-FNB for pancreatic tumors and SEL from July 2018 to January 2021. None of the cases underwent rapid on-site evaluation. There were 94 and 36 cases in the EUS-FNA and EUS-FNB groups, respectively. The median tumor size in the EUS-FNB group was 30 mm, which was significantly larger than the EUS-FNA group (p = 0.02). In addition, transgastric puncture was significantly more common in the EUS-FNB group (p = 0.01). The EUS-FNA and EUS-FNB groups had a sensitivity of 82.9% and 91.7% and an accuracy rate of 85.1% and 91.7%, respectively. However, both procedures had a comparable diagnostic ability.

Non-negligible rate of needle tract seeding after endoscopic ultrasound-guided fine-needle aspiration for patients undergoing distal pancreatectomy for pancreatic cancer.

Needle tract seeding after preoperative endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic body and tail cancer has been reported. This study aimed to investigate the long-term outcomes, including the needle tract seeding ratio, of patients undergoing distal pancreatectomy for pancreatic body and tail cancer diagnosed preoperatively by EUS-FNA. This retrospective, observational cohort study assessed patients from three university hospitals and 11 tertiary referral centers. All patients who underwent distal pancreatectomy for invasive cancer of the pancreatic body and tail between January 2006 and December 2015 were identified and reviewed. Needle tract seeding rate, recurrence-free survival (RFS), and overall survival (OS) were evaluated. Of the 301 total patients analyzed, 176 underwent preoperative EUS-FNA (EUS-FNA group) and 125 did not (non-EUS-FNA group). The median follow-up periods of the EUS-FNA group and non-EUS-FNA group were 32.8 and 30.1months. Six patients (3.4%) in the EUS-FNA group were diagnosed as having needle tract seeding. The 5-year cumulative needle tract seeding rate estimated using Fine and Gray's method was 3.8% (95% CI 1.6-7.8%). The median RFS or OS was not significantly different between the EUS-FNA group and the non-EUS-FNA group (23.7 vs 16.9months: P=0.205; 48.0 vs 43.9months: P=0.392). Although preoperative EUS-FNA for pancreatic body and tail cancer has no negative effect on RFS or OS, needle tract seeding after EUS-FNA was observed to have a non-negligible rate. (UMIN000030719).

Mucosal incision-assisted biopsy versus endoscopic ultrasound-guided fine-needle aspiration with a rapid on-site evaluation for gastric subepithelial lesions: A randomized cross-over study.

This study aimed to compare the diagnostic yield of mucosal incision-assisted biopsy (MIAB) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with a rapid on-site evaluation (ROSE) for gastric subepithelial lesions (SEL) suspected of being gastrointestinal stromal tumors (GIST) with an intraluminal growth pattern. This was a prospective randomized, cross-over multicenter study. The primary outcome was the diagnostic yield of EUS-FNA and MIAB. The secondary outcomes were the technical success rate, complication rate, procedure time and biopsy frequency. A total of 47 patients were randomized to the MIAB group (n = 23) and EUS-FNA group (n = 24). There was no significant difference in the diagnostic yield of MIAB and EUS-FNA (91.3% vs 70.8%, P = 0.0746). The complication rates of MIAB and EUS-FNA did not differ to a statistically significant extent. The mean procedure time in the MIAB group was significantly longer than that in the EUS-FNA group (34 vs 26 min, P = 0.0011). The diagnostic yield of MIAB was satisfactorily as high as EUS-FNA with ROSE for gastric SEL with an intraluminal growth pattern.

Mo1295 LONG-TERM OUTCOMES OF PATIENTS UNDERGOING DISTAL PANCREATECTOMY FOR PANCREATIC ADENOCARCINOMA DIAGNOSED PREOPERATIVELY BY ENDOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION

Preoperative endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic adenocarcinoma has been widely performed because of its high diagnostic ability and safety. However, needle tract seeding after EUS-FNA has been reported in the pancreatic body or tail. Thus, there is concern about its negative effects on long-term survival. In this study, we examined the long-term outcomes of patients undergoing distal pancreatectomy for pancreatic adenocarcinoma diagnosed preoperatively by EUS-FNA. The frequency of gastric and peritoneal cancer recurrence was also investigated. We reviewed the electronic medical records of 85 consecutive patients who underwent distal pancreatectomy between January 2004 and February 2016 in our hospital. The median tumor diameter was 25 mm [interquartile range: 16-35 mm]. Preoperative adjuvant chemotherapy was performed in 18 patients (21.2%). The UICC (7th) staging distributions were 0 (n=3), IA (n=10), IIA (n=28), IIB (n=43), III (n=1), IV (n=4). R0 resection was achieved in 81 patients (90.40%). Postoperative adjuvant chemotherapy was performed in 65 patients (76.5%). Of the 85 patients, 50 (58.8%) underwent preoperative EUS-FNA; the remaining 35 (41.2%) did not. Site of tumor recurrence, recurrence-free survival (RFS), and overall survival (OS) were compared between EUS-FNA group and non-EUS-FNA group. The overall sensitivity for cancer diagnosis of EUS-FNA was 90.0% (45/50). There were no postprocedural adverse events. During the follow-up period (median 29 months, range 2-115), 49 (57.6%) patients had recurrence: 27 patients in the EUS-FNA group (peritoneal 1, gastric wall 2, others 24) and 22 patients in the non-EUS-FNA group (peritoneal 4, others 18). There was no significant difference between the two groups. Two cases of gastric wall recurrence due to needle tract seeding were diagnosed from the clinical course, and CT, endoscopic, and histological findings. In the EUS-FNA group and non-EUS-FNA group, the median RFS were 809 days (95%CI 515-1216) and 1040 days (95%CI 557-1625), respectively (p = 0.752). The median OS were 1566 days (95%CI 1135-NA) and 1591 days (95%CI 1002-2218), respectively (p = 0.867). In the multivariate analysis, stage ≥ IIB (HR 2.47, 95%CI 1.33-4.61) was shown to be a significant risk factor associated with RFS; EUS-FNA was not a significant risk factor. Preoperative EUS-FNA in patients undergoing distal pancreatectomy for pancreatic adenocarcinoma was not a significant risk factor associated with RFS. Although the recurrence site was not significantly different between the two groups, needle tract seeding occurred in 2 patients in the EUS-FNA group.

Yield of endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography for solid pancreatic neoplasms

Objective: Both endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) cytology may provide tissue diagnoses in solid pancreatic neoplasms. However, there are scant data comparing these two methods. This study aims at retrospectively comparing EUS-FNA and ERCP tissue sampling and ability of cytopathological diagnosis in solid pancreatic neoplasms and to determine usefulness and adverse events of combining both procedures. Material and methods: Two hundred and thirty four patients suspected to have solid pancreatic mass on abdominal ultrasound and/or computed tomography (CT) were enrolled. EUS-FNA (group A), ERCP cytology (group B) and combined procedures (Group C) performed in 105, 91 and 38 cases, respectively. Results: Sensitivity, specificity and accuracy were 98.9%, 93.3% and 98.1% for group A, and 72.1%, 60% and 71.4% for group B. Those for group C were all 100%. Sensitivity for malignancy in the pancreas head was 100% for group A and 82.4% for group B, and in the pancreas body and tail, 97.6% for group A and 57.1% for group B. EUS-FNA was more sensitive than ERCP cytology in diagnosing malignant pancreatic neoplasms 21–30 mm in size (p = 0.0068), 31–40 mm (p = 0.028) and ≥41 mm (p < 0.0001). Sensitivity for pancreatic malignancy with group C was 100% regardless of mass location or size. Adverse events were 1.9%, 6.6% and 2.6% following EUS-FNA, ERCP and combined procedures, respectively. Conclusions: EUS-FNA is superior to ERCP cytology for diagnosis of solid pancreatic neoplasms. Although combination of both procedures provide efficient tissue diagnosis and with a minimal adverse events rate, a prospective study including larger number of patients is required.

Comparison of 22G reverse-beveled versus standard needle for endoscopic ultrasound-guided sampling of solid pancreatic lesions.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using standard needles has a high diagnostic value in the evaluation of solid pancreatic masses. Fenestrated needles have been developed to improve the quality of EUS-guided tissue sampling by providing core biopsies (FNB). Patients with solid pancreatic masses of >2 cm were prospectively included in our study and randomized to receive EUS sampling, using either a standard 22G FNA or a 22G Procore® FNB needle. The main study endpoint was the number of needle passes required to obtain a diagnosis in more than 90% of cases. We included 100 patients (male = 63, female = 37; mean age = 68.4 years) in our study. We found that 88% of the lesions were malignant, with a mean size of 32 mm. A sample adequate for diagnosis was obtained in more than 90% of cases after the second needle pass in the FNB group, versus the third needle pass in the FNA group. Slide cellularity and presence of tissue microfragments were significantly higher in the FNB group. Sensitivity for the diagnosis of malignancy was 88.4% versus 97.8% for the EUS-FNA and EUS-FNB group, respectively, while specificity for both techniques was 100%. No complications were recorded. Although the accuracy of both needle types for proving malignancy was similar, a lower number of passes was required with the FNB needles to achieve the same contributive sample rate as with the FNA needles. FNB also improved the histopathological quality of specimens, suggesting an overall superiority of FNB sampling.

Transbronchial vs Transesophageal Needle Aspiration Using an Ultrasound Bronchoscope for the Diagnosis of Mediastinal Lesions: A Randomized Study

The purpose of this study was to compare the tolerance, efficacy, and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) with transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with an endobronchial ultrasound scope for the first pathologic diagnosis of lesions accessible by both procedures. Patients who had lesions accessible by both EBUS-TBNA and EUS-FNA were enrolled and were randomized to undergo either procedure. Patients quantified tolerance, and operators charted the quality of examination using a 100-mm visual analog scale (VAS). A specific diagnosis was made in 50 of 55 patients (91%) in the EBUS-TBNA group and in 48 of 55 patients (87%) in the EUS-FNA group (P = .76). Compared with EBUS-TBNA, EUS-FNA was associated with a shorter duration of procedure (median, 15.3 min vs 11.3 min; P < .001), lower doses of IV midazolam (mean, 4.4 mg vs 4 mg; P = .02) and intraairway lidocaine (mean, 303 mg vs 189 mg; P < .001), less frequent oxygen desaturations (23 of 55 vs two of 55, P < .001), and higher operator satisfaction (P < .001). There was no significant difference in patient tolerance according to the patients' VAS. Lymph node infection occurred in one patient in the EBUS-TBNA group and in two patients in the EUS-FNA group. Both EBUS-TBNA and EUS-FNA provide high accuracy with good tolerance, although the occurrence of infectious complications should be monitored carefully. EUS-FNA has the advantage of comparable tolerance with fewer doses of anesthetics and sedatives, a shorter procedure time, and fewer oxygen desaturations during the procedure. UMIN Clinical Trials Registry; No.: UMIN000005757; URL: http://www.umin.ac.jp/ctr/.

Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: The PIPE Study

There have been concerns about peritoneal seeding after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mucinous pancreatic cystic lesions. The aims of this study were to determine the frequency of postoperative peritoneal seeding in patients with intraductal papillary mucinous neoplasm (IPMN) who had undergone pre-operative EUS-FNA and to compare it with that of patients with IPMN who had surgery with no pre-operative tissue sampling. A total of 175 patients who had undergone resection of IPMNs with pre-operative EUS-FNA (EUS-FNA group) were analyzed and compared with 68 patients who had undergone resection with no pre-operative tissue sampling (No Sampling group). Patient characteristics, pathology, and frequency of peritoneal seeding after surgery were analyzed and compared. Peritoneal seeding was diagnosed based on pathology or image findings. The two groups were comparable with respect to sex, age, follow-up duration, involvement of the pancreatic head, involvement of the main duct, grade of dysplasia, and size of histologically proven branch-duct IPMNs. Four patients (2.3 %) with invasive IPMN developed peritoneal seeding in the EUS-FNA group, whereas three (4.4 %, two with invasive IPMN and one with high-grade dysplasia) developed peritoneal seeding in the No Sampling group (P = 0.403). No peritoneal seeding was noted during surgery in these cases. Except for one patient in the EUS-FNA group, no spillage occurred during resection in these patients. In this cohort of patients undergoing resection of IPMN, the difference in the frequency of peritoneal seeding in the EUS-FNA group and the No Sampling group was not significant.

Risk of gastric or peritoneal recurrence, and long-term outcomes, following pancreatic cancer resection with preoperative endosonographically guided fine needle aspiration

There have been concerns regarding tumor cell seeding along the needle track or within the peritoneum caused by preoperative endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The aim of this study was to evaluate whether preoperative EUS-FNA is associated with increased risk of stomach/peritoneal recurrence and whether the procedure affects long term survival. The records of patients diagnosed with malignant solid and cystic pancreatic neoplasms who underwent surgery with curative intent between 1996 and 2012 were reviewed. A total of 256 patients with similar baseline characteristics were included: 48 patients in the non-EUS-FNA group and 208 in the EUS-FNA group. Recurrence data were available for 207 patients. Median length of follow-up was 23 months (range 0 - 111 months). A total of 19 patients had gastric or peritoneal recurrence; 6 (15.4 %) in the non-EUS-FNA group vs. 13 (7.7 %) in the EUS-FNA group (P = 0.21). Three patients had recurrence in the stomach wall: one (2.6 %) patient in the non-EUS-FNA group vs. two patients (1.2 %) in EUS-FNA group (P = 0.46). A total of 16 patients had peritoneal recurrence: 5 patients (12.8 %) in the non-EUS-FNA group and 11 patients (6.5 %) in the EUS-FNA group (P = 0.19). In a multivariate analysis, undergoing EUS-FNA was not associated with increased cancer recurrence or decreased overall survival. Pre-operative EUS-FNA was not associated with an increased rate of gastric or peritoneal cancer recurrence in patients with resected pancreatic cancer. Two patients had gastric wall recurrence following the procedure, but this may be explained by direct tumor extension. This suggests that EUS-FNA is not associated with an increased risk of needle track seeding.

Endoscopic ultrasound-guided fine needle aspiration versus percutaneous ultrasound-guided fine needle aspiration in diagnosis of focal pancreatic masses

Objective:Pancreatic carcinoma is one of the leading cancer morbidity and mortality world-wide. Controversy has arisen about whether the percutaneous approach with computed tomography/ultrasonography-guidance fine needle aspiration (US-FNA) or endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the preferred method to obtain diagnostic tissue. Our purpose of this study is to compare between the diagnostic accuracy of EUS-FNA and percutaneous US-FNA in diagnosis of pancreatic cancer.Patients and Methods:A total of 197 patients with pancreatic masses were included in the study, 125 patients underwent US-FNA (Group 1) and 72 patients underwent EUS-FNA (Group 2).Results:EUS-FNA has nearly the same accuracy (88.9%) as US-FNA (87.2%) in diagnosis of pancreatic cancer. The sensitivity, specificity, positive predictive value and negative predictive value for EUS-FNA was 84%, 100%, 100%, 73.3% respectively. It was 85.5%, 90.4%, 94.7%, 76% respectively for US-FNA. EUS-FNA had a lower complication rate (1.38%) than US-FNA (5.6%).Conclusion:EUS-FNA has nearly the same accuracy as US-FNA of pancreatic masses with a lower complication rate.

Risk of peritoneal carcinomatosis by endoscopic ultrasound-guided fine needle aspiration for pancreatic cancer

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an accurate method for cytological confirmation of pancreatic malignancy, but peritoneal dissemination caused by EUS-FNA could be a matter of concern because it may lead to poorer prognosis. Our aim was to estimate the risk of peritoneal carcinomatosis by EUS-FNA for pancreatic cancer. Two hundred and seventeen patients with cytopathologically proven pancreatic cancer in a tertiary referral center were retrospectively reviewed. They were divided into two groups: 161 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) alone (ERCP group), and 56 patients who had ever undergone EUS-FNA (EUS-FNA group). Peritoneal carcinomatosis was diagnosed by computed tomography and/or cytology during follow-up. Hazard ratios of factors including EUS-FNA for the development of peritoneal carcinomatosis were analyzed by the Cox proportional hazard model. There was no significant difference in baseline characteristics between ERCP and EUS-FNA groups. Peritoneal carcinomatosis developed in 14.9% (24/161) during an average follow-up period of 545days, and 17.9% (10/56) during 599days among ERCP and EUS-FNA group, respectively. The EUS-FNA was not identified as a significant risk factor with hazard ratios (HR) of 1.07 [95% confidence interval (CI) 0.51-2.25, p=0.85] by univariate analysis and 1.35 (95% CI 0.62-2.95, p=0.45) by multivariate analysis. Nodal involvement (HR 2.19, 95% CI 1.03-4.63, p=0.04) and non-resection (HR 2.64, 95% CI 1.11-6.25, p=0.03) were shown to be statistically significant risk factors by multivariate analysis. EUS-FNA for pancreatic cancer did not significantly increase the risk of peritoneal carcinomatosis.

Diagnostic yield of endoscopic retrograde cholangiography and of EUS‐guided fine needle aspiration sampling in gallbladder carcinomas

Obtaining histological evidence of gallbladder carcinoma (GBC) is difficult due to its extraductal nature, and pathological confirmation remains challenging. We compared the diagnostic value and safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with endoscopic retrograde cholangiography (ERC) in patients with suspected GBC. Eighty-three patients with GBC were evaluated. Prior to definitive management, pathological evidence of GBC was obtained through either ERC cytopathologic sampling (n=33), EUS-FNA (n=24) or both (n=26). Among the 83 patients, 59 (71.0%) with biliary obstruction were sampled using ERC with 47.4% (28/59) sensitivity. In 19 of the remaining 31 cases, EUS-FNA sampling had 100% diagnostic sensitivity. Likewise, 50 (60.2%) of the 83 patients with suspected GBC underwent EUS-FNA of regional lymph nodes or the gallbladder (GB) mass itself with 94.8% sensitivity. The overall diagnostic sensitivity rates of ERC and EUS-FNA were 47.4 and 96%, respectively (P<0.001). Post-procedural complications were seen in 6.7% of the ERC group (4/59, all were mild pancreatitis), and in none of the EUS-FNA group (P=0.10). Gallbladder carcinoma sampling using ERC and EUS-FNA should be incorporated into the diagnostic workup of GB lesions as complementary tools, and EUS-FNA should be applied in the setting of failed or not indicated ERC.

EUS-FNA vs. CT-guided Core Biopsy for Presumed Pancreatic cancer: A Comparison of Accuracy, Risk and Cost

Purpose: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an important tool for assessing pancreatic masses. CT-guided core biopsy (CT-CB) is also widely used for this purpose. We examined the accuracy, risk and costs of these two modalities. Methods: We reviewed all patients who underwent either EUS-FNA or CT-CB for pancreatic masses seen on CT scan at one institution (VMMC) between January 2005 and September 2008. Results were categorized as: negative, atypical, positive or suspicious for malignancy. Final diagnosis was confirmed by histologic examination of surgical specimens or clinical follow-up. Diagnostic yields were compared and costs were calculated using 2008 Medicare rates. Results: A total of 344 patients underwent EUS-FNA and 66 patients underwent CT-CB. 20 EUS-FNA patients and 4 CT-CB patients were excluded due to inadequate follow-up or uncertain final diagnosis. In the 260 EUS-FNA patients ultimately diagnosed with malignancy, histology was positive in 219 (84%), suspicious for malignancy in 15 (6%), and negative or atypical in 26 cases (10%). Malignancies included adenocarcinoma (86%), neuroendocrine tumors (8%), lymphoma (3%), and metastases from kidney, lung, and breast (2%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were 84%, 100%, 100%, 51%, and 86%, respectively. All patients with suspicious cytology were ultimately proven to have cancer. Inclusion of these cases increased sensitivity to 90%. Among the 47 CT-CB patients found to have cancer, histology was positive for malignancy in 35 cases (sensitivity 74%) with no false positive results (specificity 100%). PPV, NPV, and diagnostic accuracy were 100%, 56%, and 84%, respectively. However, 22 of these patients who underwent CT-CB had undergone prior negative EUS-FNA. When these cases are excluded, CT-CB sensitivity increases to 93%. There was a trend toward a difference in sensitivity between the EUS and CT groups (p=0.06) when these 22 CT-CB patients are considered and when they are excluded (p=0.07). There was one bleed in the CT-CB group (1.6%) and 3 cases of pancreatitis in the EUS-FNA group (0.8%) (p=0.54). There was no procedure related mortality in either group. Using 2008 Medicare payment data and assuming a negative EUS-FNA or CT-CB case could be resolved with a second procedure using the other modality, the cost of a positive diagnosis using EUS-FNA was $1,078 versus $1,155 for CT-CB. Conclusion: Both EUS-FNA and CT-CB are safe and accurate methods for tissue diagnosis in patients with solid pancreatic lesions. EUS-FNA appears to be at least as accurate as CT-CB and less expensive.