Endoscopic Ultrasound Fine Needle Aspiration Research Articles

A retrospective analysis of 142 pancreatic masses in a tertiary referral center in west india

Objectives:To study and characterize pancreatic masses using endoscopic ultrasound (EUS) with fine needle aspiration (FNA) and prove that not all pancreatic masses are malignant and require surgery.Methods:A total of 142 cases with pancreatic masses were studied with EUS FNA. FNA was done with a 22-gauge needle for lesions in the body and tail and 25-gauge needle from the duodenum.Results:Age 42+/-15.3 Sex Male: Female: 95:47 Location: head-68, body and neck-38, uncinate-26, tail-10. Echo characteristics: hypoechoic-82, hyperechoic-15, mixed solid and cystic-45 (areas of necrosis). Size 4.6+/-3.9 cm. Cytology: ductal adenocarcinoma-77 (54.2%), nonmalignant (inflammatory)-14 (9.9%), neuroendocrine tumors (NETs)-13 (9.1%), tuberculosis-10 (7.1%), solid pseudopapillary tumors (SPTs)-10 (7.1%), walled-off necrosis-11 (7.7%), mucinous adenocarcinoma-03 (2.1%), diagnosis not reached on FNA-04 (2.8%). Complications: Mild pancreatitis in two cases. No infection or major bleed was noted in our series.Discussion:Not all pancreatic tumors are malignant. Inflammatory lesions in chronic pancreatitis are common. Tuberculosis in India should be thought of. NET and SPT are most common in females and majority in body and tail.Conclusion:All pancreatic tumors are not ductal adenocarcinomas. A large differential diagnosis is seen in studies. Therefore, it would be worth to sample these lesions before subjecting them to major pancreatoduodenal resections as the management plan or the surgical approach would be altered depending on the cytological diagnosis achieved. EUS FNA is a very good option with minimal risk to give a tissue diagnosis before planning surgery.

Accuracy of endoscopic ultrasound-fine needle aspiration of solid lesions over time: Experience from a new endoscopic ultrasound program at a Canadian community hospital.

Background and Objectives:A Canadian Community Hospital launched a new Endoscopic Ultrasound (EUS) Program in 2011. The aim of this study was to report the accuracy of EUS-fine needle aspiration (EUS-FNA) of solid lesions over time as it pertains to cytotechnologists’ involvement and learning curves.Methods:The electronic medical records of patients that had a EUS from July 2011 to January 2014 were retrospectively reviewed. Only solid lesions with FNA sampling were included in the study. The primary outcome assessed was the accuracy of specimen acquisition for pathological review. The secondary outcome was diagnostic accuracy. Cases were separated by chronological order into thirds for the assessment of learning curves. Cytotechnologists’ involvement was correlated to determine its impact on accuracy.Results:Two hundred and seventy-one EUS-FNA procedures were completed for solid lesions. Cytotechnologists’ involvement resulted in a specimen acquisition accuracy of 82.6%, compared with 68.8% without a cytotechnologist (P = 0.009; 95% confidence interval [CI] 3.2%–25.0%). Diagnostic accuracy was 74.2% with a cytotechnologist while 62.4% without a cytotechnologist (P = 0.038; 95% CI 0.3%–23.7%). The specimen acquisition accuracy increased from 73.2% from the first third of cases to 92.3% for the last third with a cytotechnologist (P = 0.004; 95% CI 6%–33.0%). Without a cytotechnologist, the specimen accuracy was 67.6% for the first third while 57.7% for the last third of cases (P = 0.434; 95% CI − 33.9–14.4%). In the multivariable regression analysis, after adjusting for other predictors, a present cytotechnologist (P = 0.022) and lesion size 21 mm–30 mm (P = 0.039) and >30 mm (P = 0.001) were significantly associated with increased specimen acquisition accuracy. Only a present cytotechnologist (P = 0.046) was significantly associated with increased diagnostic accuracy.Interpretation:Cytotechnologists’ involvement significantly improved the accuracy of specimen acquisition. Although accuracy was impacted by a cytotechnologist learning curve, our results highlight the importance of a cytotechnologist being present for EUS-FNA sampling of solid lesions.

Pancreatic paracoccidioidomycosis: An uncommon diagnostic made by endoscopic ultrasound fine needle aspiration

Paracoccidioidomycosis, or South American blastomycosis, or Lutz disease, is a granulomatous infection caused by fungus. Pancreatic infection with mass formation is very uncommon. We report a case of a 72-year-old man with abdominal pain and weight loss for the past 4 months. Abdominal computed tomography (CT) showed masses in the pancreatic head and body. He was referred to our Clinic for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), with suspicious of pancreatic adenocarcinoma. EUS-FNA was performed with a 22G Pro-Core® needle (Cook Medical In., Limerick, Ireland) and cytology material was obtained after three needle passes. The slides were stained and analyzed by a cytopathologist, showing numerous Paracoccidioides forms. It seems to be the first report of this diagnostic issue made by EUS-FNA.

Pancreatic metastasis from skin melanoma diagnosed by endoscopic ultrasound fine needle aspiration

Malignant melanoma is reported to metastasize to all organs of the human body. Although pancreatic metastases are rare, they range from 2% to 5% of pancreatic malignancies. Differentiating a primary pancreatic malignancy from a metastasis can be difficult due to similarities on imaging findings, but it is crucial to ensure proper treatment. Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is often needed to provide a cytologic diagnosis. We present a case of a 48-year-old man who had 4 years later surgical treatment for a skin melanoma located in the right axillary region. Abdominal computed tomography showed two round masses in the body of the pancreas. He was referred to our Clinic for EUS-FNA. EUS-FNA was performed with a 22G Pro-Core® Needle (Cook Medical Inc., Limerick, Ireland) and cytology material was obtained after three needle passes. The slides and cell-block were stained and analyzed by cytopathologists, showing pancreatic metastases of malignant melanoma.

Onsite evaluation of endoscopic ultrasound fine needle aspiration: the endosonographer, the cytotechnologist and the cytopathologist.

Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has become an essential tool in the management of multiple diseases. Its accuracy is related to different aspects of the technique, one of the most important being the experience and interaction of the endosonographer and pathologist. Certain studies over the past years have highlighted the importance of having rapid on-site evaluation (ROSE) of samples obtained at the time of EUS-FNA. We have reviewed the role of ROSE, performed by the same endosonographer, a cytotechnologist and an expert cytopathologist. The available data suggest that ROSE (either by the endosonographer, the cytotechnologist, or the cytopathologist) improves sample adequacy and diagnostic yield, with the best option to have ROSE performed by an expert cytopathologist. However, if non-ROSE accuracy is already very high, any improvement is harder to achieve.

Diagnostic adequacy and safety of endoscopic ultrasound-guided fine needle aspiration in patients with lymphadenopathy in a large cohort

Background and Objectives:Role of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) in patients with lymphadenopathy in terms of diagnostic adequacy and safety in large population is not well defined. The aim of the current study was to evaluate diagnostic adequacy and safety of EUS FNA in patients with lymphadenopathy.Methods:This was a retrospective study from October 2010 to September 2015 at tertiary care center in Delhi-National Capital Region. We analyzed data of 1005 EUS-guided FNA of the lymph node.Results:The study cohort comprised 1005 lymph nodes in 865 patients; 68% were males, mean age was 50 ± 14 years. Indication of FNA was to look for etiology of pyrexia of unknown origin, staging of malignancy, or unexplained weight loss. FNA was taken from mediastinal nodes (n = 528, 52.5%) and abdominal nodes (n = 477, 47.5%). Median size of nodes at long axis and short axis was 17 (12–25.7) and 10 (8–15) mm, respectively. Adequate material by FNA was obtained in 92.8% cases. The cytopathologic diagnoses were malignancy in 153 (15.2%), granulomatous change in 452 (42%), and reactive lymphadenopathy in 328 (35.6%). Lymph node with a size >1 cm at short axis (n = 444) was more pathological (70.6%) than size <1 cm (n = 133, pathological in 43.1%), P = 0.00. There was no statistically difference between the groups regarding type of needle, number of passes, and cellularity. Procedure-related adverse effects were encountered in six patients (0.8%). Four patients had mild mucosal bleeding in chronic liver disease patients and two had mild hepatic encephalopathy related to sedation.Conclusion:EUS FNA of the lymph nodes has good diagnostic adequacy and safety.

Endosonography in the differentiation of neoplastic and nonneoplastic pancreatic cysts

Background and Objectives:Pancreatic cystic lesions (PCLs) are increasingly found in the clinical practice because of the widespread use of imaging modalities. Although differential diagnosis of nonneoplastic and neoplastic pancreas cysts is not certain markers, endosonography which has been taken place in cyst management shows morphologic specialty of cyst and cyst fluids by fine needle aspiration (FNA). Endoscopic ultrasound (EUS) and EUS-FNA performed patients were evaluated to pancreas cyst features for the differentiation of neoplastic or nonneoplastic.Method:Between January and July 2016, sixty patients with PCLs were retrospectively evaluated. Patients were recorded with undergoing pancreatitis, diabetes mellitus, and hematologic and biochemical parameters. EUS evaluation of PCLs was noted according to size, focal irregularity, wall thickness, and echo-dens mucus or debris. EUS FNA fluid was evaluated with biochemical (amylase, carcinoembryonic antigen, carbohydrate antigen 19-9) and cytology.Results:Finally, 73.3% were nonneoplastic cases, whereas 26.7% were found to have malignant or premalignant. On comparing nonneoplastic and neoplastic groups, age (P = 0.002), alkaline phosphatase (P = 0.001), and g-glutamyl transferase (P = 0.004) were high and hematocrit (P = 0.001) and albumin (P = 0.001) were low in malignant groups. Of the non-neoplastic PCLs, 61.3% were atypical pseudocysts, 20.4% were serous cystadenomas, and 18.1% were simple cysts, whereas of the malignant PCLs, 26.7% was intraductal papillary mucinous neoplasms, 18% were mucinous cystic neoplasms, and 25% were adenocacinomas. The septation in the nonneoplastic group was 25% and in the neoplastic group was 56.2% (P = 0.023). Cyst lobulation was 25% in the nonneoplastic groups and 56.2% in the neoplastic group (P = 0.014). Mural nodularity was 2.5% in the nonneoplastic group and 26.7% in neoplastic group (P = 0.005).Conclusion:Majority of patients who needed EUS-FNA that EUS and clinical investigation were insufficient for final diagnosis were nonneoplastic. This situation is thought that the management of PCLs for clinician poses still problems. Although cholestasis findings in the malign PCLs are more common than the non-neoplastic group, EUS-FNA performed in this cholestasis group is thought helping to differentiation of between neoplastic and nonneoplastic situation. In our study, the presence of mural nodularity and cyst septation in PCLs were found effective in differentiation of pre-malign and benign as in other studies. In addition to, we think that cyst lobularity may help differentiation of neoplastic and nonneoplastic.

Isolated pancreatic tuberculosis mimicking inoperable pancreatic cancer

Background:Pancreatic tuberculosis is an uncommon disease, presenting as hypoechoic mass on imaging mimicking malignancy. Consequently, it represents a diagnostic challenge necessitating a tissue diagnosis.Case Report:A 75-year-old female presented with progressive jaundice and weight loss; imaging with computed tomography (CT) showed a large (5.8 cm × 4.6 cm) pancreatic head mass with encasement of portal and superior mesenteric veins, peripancreatic nodes, atrophic pancreatic parenchyma, and dilated main pancreatic duct. Cancer antigen 19-9 was moderately elevated. With a diagnosis of inoperable pancreatic malignancy, she was planned for tissue diagnosis and palliative chemotherapy. Endoscopic ultrasonography (EUS) showed a heterogeneous mass with vascular invasion as in the CT. Fine needle aspiration (FNA) and biliary decompression with a plastic stent performed in the same sitting. Cytology demonstrated granuloma with caseous necrosis and presence of acid-fast bacilli. Antituberculosis treatment was started, and repeat CT after 6 months showed resolution of the mass.Discussion and Conclusion:A diagnosis of isolated pancreatic tuberculosis is rare and is difficult by clinical presentation alone; in India, it should be considered as a differential diagnosis of a pancreatic tumor. Benign lesions can also present with vascular invasions mimicking inoperable malignancy. EUS FNA is a very useful tool in accurate diagnosis of pancreatic head mass avoiding unnecessary surgeries.

Complications encountered during interventional endoscopic ultrasound - a tertiary care center experience

Background and Objectives:Interventional endoscopic ultrasound (EUS) includes fine needle aspiration (FNA), pancreatic cystogastrostomy, aspiration of cystic cavity or collection, hepaticogastrostomy, and coiling. It is considered safe. This study was undertaken to note frequency of various complications that arose with interventional EUS at our center.Methods:This was a retrospective cohort study done at a tertiary level referral center. Records of all patients who underwent EUS intervention over a period of 6 years (October 2010 to September 2016) were reviewed. Procedure-related minor adverse events such as throat pain and abdominal pain were noted. Complications were defined as acute pancreatitis, perforation, mucosal tear, hepatic encephalopathy, pneumomediastinum, pneumoperitoneum, peritoneal leak, bleeding, hematoma, and fever requiring hospital admission.Results:A total of 4654 EUS were done, of which 2030 intervention performed. Of these, 1780 were EUS FNA, 146 aspiration, 64 cystogastrostomy, and 40 others. Procedure-related minor adverse events were noted in 42% cases (throat pain - 31% and abdominal pain - 11%). Complications were observed in 35 patients (1.72%); minor mucosal bleeding (12), mild acute pancreatitis (5), asymptomatic duodenal hematoma (4), fever requiring hospitalization (3), duodenal perforations (2), cervical esophageal tear (2), mild hepatic encephalopathy (2), pneumomediastinum (1), pneumoperitoneum (1), bleeding from gastroduodenal artery (1), cystogastostomy site bleeding (1), and peritoneal leak (1). All the complications were managed conservatively except duodenal perforations which required surgery and peritoneal leak requiring drain placement percutaneously. On subgroup analysis, there were significant fewer complications with operator experience of >1000 EUS (P = 0.002).Conclusion:EUS intervention is a safe procedure, especially in experienced hands.

A prospective comparative study of efficacy of endoscopic ultrasound-guided fine needle aspiration versus endoscopic retrograde cholangiopancreatography-guided brush cytology in attainment of histopathology of distal common bile duct masses

Objectives:To study the efficacy of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for attaining tissue from distal CBD masses and comparing it to endoscopic retrograde cholangiopancreatography (ERCP)-guided brush cytology from mass.Methods:Fifty-six cases with distal bile duct mass with obstructive jaundice in the last 3 years were taken for the study. First EUS was done with a linear echoendoscope, mass was identified, FNA was performed with a 25-gauge needle making at 2–5 passes, and then material was sent for cytology. The same patients then subjected to ERCP and brush cytology was taken making 2–3 passes.Results:Cases 56, age range 57.2+/-13.6, 40 males, mean serum bilirubin 9 mg/dl, mean size of mass 12 mm (7-30mm). Mean number of passes with fine needle aspiration (FNA) needle was 2.5 (2–5 passes). Mean number of passes with cytology brush was 2 (2–5). Positive diagnosis obtained with FNA was 47 (83.9%). Positive diagnosis obtained by brush was 34 (60.7%). Positive diagnosis was reached in more patients with FNA compared to cytology ( malignancy 80.8% vs 67.6%, suspicious for malignancy 10.6% vs 20.5%, and benign 8.5% vs 8.5%).Conclusions:EUS FNA is a very effective method for diagnosis of distal bile duct masses. Its efficacy is better than ERCP-guided brush cytology. Even small masses are amenable to FNA using EUS guidance. Male over 57 years with jaundice and distal bile duct obstruction has a very likelihood of have a distal CBD cholangiocarcinoma.

Endoscopic ultrasound-guided fine needle aspiration of adrenal lesions: A single-center experience of eighty cases

Background and Objectives:It is difficult to get tissue diagnosis from the adrenal glands by radiological imaging, particularly from left adrenal due to their anatomic location. Endoscopic ultrasound-guided offers less invasive mode of fine needle aspiration (FNA) due to proximity to adrenals. The aim of this study was to evaluate the diagnostic yield of EUS-FNA of adrenal lesions.Methods:It was a retrospective study conducted from October 2010 to September 2016 at a single tertiary care center in Delhi-National Capital Region. We analyzed data of eighty patients with adrenal lesions, in whom EUS FNA was performed.Results:Of the eighty patients, mean age was 56 ± 12.2 years; there were 63 males. Indications of FNA were pyrexia of unknown origin (n = 52), evaluation for metastasis (n = 18), and incidentally detected adrenal enlargement (n = 10). FNA were taken from left adrenal in seventy patients by transgastric route, while in ten patients, FNA was taken from right adrenal using transduodenal route. Technical successes and diagnostic adequacy of specimen were achieved in 100% cases. A 19-gauge needle was used in majority (80%). Median number of passes was 3. The cytopathological diagnoses were tuberculosis (n = 36), histoplasmosis (n = 13), metastatic lung carcinoma (n = 10), adrenal adenoma (n = 9), hepatocellular carcinoma (n = 4), carcinoma gall bladder (n = 2), lymphoma (n = 2), endometrioid carcinoma (n = 1), neuroendocrine tumor (n = 1), adrenal lipoma (n = 1), and adrenal myelolipoma (n = 1). No procedure-related adverse events were reported.Conclusions:EUS-FNA is a safe and effective method for evaluating adrenal lesions.

Endoscopic ultrasound-guided ethanol ablation for functioning insulinoma

Background:Most diagnosed pancreatic neuroendocrine tumors (pNETs) are nonfunctioning tumors (90.8%); the remaining 9% are malignant functioning tumors. While surgical resection is the standard of care, alternative management options may be mandated in symptomatic patients who refuse or are ineligible for surgery. We present a case of endoscopic ultrasound (EUS)-guided ethanol ablation of symptomatic insulinoma in a patient who refused surgery.Case Presentation:A 35-year-old man was referred to our facility with suspected insulinoma for EUS evaluation. During a 48-h supervised fast, a plasma glucose of 30 mg/dl was obtained with a corresponding serum insulin level of 235 μIU/mL (normal: 20–80) and C-peptide level of 19.9 ng/mL (normal: 2.8–9.9). Computed tomography abdomen revealed a normal pancreas with no detected masses. On admission, he was on intravenous glucose 25% at an infusion rate of 250 mL/h and octreotide (150 mcg subcutaneously three times daily). EUS examination revealed a small hypoechoic pancreatic tail mass 2 cm ×1.5 cm with no vascular involvement or detected lymph nodes. EUS-fine needle aspiration was done using a 25G needle. Pathological examination was consistent with NET. The patient's family initially refused surgery; EUS-guided ethanol ablation was therefore considered. The lesion was injected with 3 mL of ethanol using 25G needle resulting in a hyperechoic blush within the center of the tumor. Following the procedure, there was partial clinical success with the patient's glucose infusion rate decreased to 100 mL/h. After 3 days, a second session was considered. The lesion was re-injected with 3 mL of ethanol using 22G needle resulting in a hyperechoic blush of the lesion. Again, there was partial clinical success with the patient's glucose infusion rate decreased to 50 mL/h. There were no postprocedural complications. The patient's family decided to do surgery and distal pancreatectomy was done.Discussion:EUS-guided ethanol ablation of functioning pNETs is a less common therapeutic tool. A recent literature review showed 19 patients who underwent EUS-guided ethanol ablation of functioning pNETs from 2006 to 2015 with technical and clinical success in 100% of cases. This case reports another EUS-guided ethanol ablation of functioning insulinoma added to the documented cases, with partial clinical success. Despite partial clinical success, EUS-guided ethanol ablation is feasible and safe when applied to symptom relief in functioning tumors in patients who refuse or are ineligible for surgery.

Maximizing the endosonography: The role of contrast harmonics, elastography and confocal endomicroscopy.

New technologies in endoscopic ultrasound (EUS) evaluation have been developed because of the need to improve the EUS and EUS-fine needle aspiration (EUS-FNA) diagnostic rate. This paper reviews the principle, indications, main literature results, limitations and future expectations for each of the methods presented. Contrast-enhanced harmonic EUS uses a low mechanical index and highlights slow-flow vascularization. This technique is useful for differentiating solid and cystic pancreatic lesions and assessing biliary neoplasms, submucosal neoplasms and lymph nodes. It is also useful for the discrimination of pancreatic masses based on their qualitative patterns; however, the quantitative assessment needs to be improved. The detection of small solid lesions is better, and the EUS-FNA guidance needs further research. The differentiation of cystic lesions of the pancreas and the identification of the associated malignancy features represent the main indications. Elastography is used to assess tissue hardness based on the measurement of elasticity. Despite its low negative predictive value, elastography might rule out the diagnosis of malignancy for pancreatic masses. Needle confocal laser endomicroscopy offers useful information about cystic lesions of the pancreas and is still under evaluation for use with solid pancreatic lesions of lymph nodes.

Role of endoscopic ultrasound and endoscopic-ultrasound-guided fine-needle aspiration in endoscopic biopsy negative gastrointestinal lesions.

Background and Objectives:Many cases of gastrointestinal (GI) tumors as lymphoma, adenocarcinoma, and most of submucosal tumors (SMT) such as gastrointestinal stromal tumor (GIST) and leiomyoma are difficult to diagnose as they frequently yield negative endoscopic biopsies. We evaluated the accuracy of endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of endoscopic biopsy negative GI tumors.Patients and Methods:One hundred and nine patients with biopsy negative GI tumors were included in this prospective study. EUS and EUS-FNA were performed to all patients with cytopathologic examination.Results:There were 109 patients with endoscopic biopsy negative GI lesions, including 61 males (56%) and 48 females (44%), with the mean age of 54 years. Sixty-three cases (57.8%) were proved to have malignant lesions, among them there were 15 cases with high-risk GIST as proved by FNA and excision biopsy. Forty-six cases (42.2%) were proved to be benign; among them there were 21 cases presented with non-high-risk GIST. Endoscopic ultrasound had a sensitivity of 96.8%, specificity of 89.1%, positive predictive value (PPV) of 92.4%, negative predictive value (NPV) of 95.3%, and accuracy of 93.6%. EUS-FNA had a sensitivity of 87.3%, specificity of 100%, PPV of 100%, NPV of 85.2%, and accuracy of 92.7%.Conclusion:EUS with EUS-FNA is an accurate procedure in the diagnosis of GI tumors with negative endoscopic biopsies.

The value of endoscopic ultrasound-fine needle aspiration in the suspicion of pancreatic hydatid cyst in endemic areas with negative serology (with video).

The value of endoscopic ultrasound-fine needle aspiration in the suspicion of pancreatic hydatid cyst in endemic areas with negative serology (with video).

Harmonic contrast-enhanced endoscopic ultrasound fine-needle aspiration: Fact or fiction?

The negative predictive value of endoscopic ultrasonography fine-needle aspiration is relatively low. To achieve the improvement of the diagnostic yield, the following were proposed: a higher number of passes, the presence of the rapid on-site cytopathologist evaluation, the fanning technique, or the repetition of the fine needle biopsy. Harmonic contrast-enhanced endosonography may better identify the targeted area in the lesions by avoiding the inside necrosis and the vessels of fibrosis, so it can guide the fine-needle aspiration. Both techniques are complementary, not competitive, and they can be done in the same session. The combined technique is simple, safe, and requires only a few minutes with minimal extra costs compared to standard fine-needle aspiration. It minimally increases the diagnostic rate, and it permits the decrease of the number of passes. However, we will know its real clinical impact only in the future and whether it will be incorporated into the lesion assessment process.

Long-term outcomes after endoscopic ultrasonography-guided ablation of pancreatic cysts

Objectives:The aim of this study was to investigate the long-term outcomes after endoscopic ultrasonography (EUS)-guided pancreatic cyst ablation.Methods:In a single-center, prospective study, 164 patients with pancreatic cysts underwent EUS-guided cyst ablation using ethanol with paclitaxel. The inclusion criteria were as follows: unilocular or oligolocular cysts, clinically indeterminate cysts that required EUS fine-needle aspiration, and/or cysts that grew during the observation period. Treatment response was classified as complete resolution (CR), partial resolution (PR), or persistent cyst, with <5%, 5%–25%, and 25% of the original cyst volume, respectively.Results:The median largest diameter of the cyst was 32 mm and the median volume was 17.1 mL. Based on cyst fluid analysis, there were 71 mucinous cystic neoplasms, 16 serous cystic neoplasms, 11 intraductal papillary mucinous neoplasms, 3 pseudocysts, and 63 indeterminate cysts. Sixteen treated patients (9.8%) had adverse events (severe 1, moderate 4, and mild 11). Treatment response was as follows: CR, 114 (72.2%); PR, 31 (19.6%); and persistent cysts, 13 (8.2%). Twelve of 13 patients with persistent cysts underwent surgery. During clinical and imaging follow-up (median 72 months, interquartile range 50–85 months) of the 114 patients with CR, only two patients (1.7%) showed cyst recurrence. Based on multivariate analysis, the absence of septa (odds ratio [OR], 7.12; 95% confidence interval [CI], 2.72–18.67) and cyst size <35 mm (OR, 2.39; 95% CI, 1.11–5.16) predicted CR.Conclusion:Among patients with pancreatic cysts who achieved CR after EUS-guided cyst ablation, 98.3% remain in remission at 6-year follow-up. Unilocular and small cyst was predictive of CR.

Therapeutic Endoscopy Can Be Performed Safely in an Ambulatory Surgical Center: A Multicenter, Prospective Study.

Background. Even amongst experienced endoscopists, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound with fine needle aspiration (EUS-FNA) carry a potential risk for complications. These procedures are typically performed in a hospital-based endoscopy unit with general anesthesia. Aims. The goal of our study was to evaluate the feasibility of ERCP and EUS-FNA in an ambulatory surgical center (ASC). Methods. From June to November of 2014, we prospectively enrolled consecutive subjects undergoing ERCP and/or EUS-FNA in an ASC. An anesthesiologist, who was not involved in our study group, screened all subjects prior to their scheduled procedure. In order to monitor for adverse events (AE), all subjects received a telephone call at day 1 and 30 days after procedure. Results. 375 subjects (98 inpatients and 277 from an ASC) were enrolled. In the total population, a high proportion of subjects underwent procedures for neoplasms (21 (23.3%) inpatients versus 44 (17.1%) from an ASC) and for sphincter of Oddi dysfunction (SOD) (27 (27.5%) versus 48 (17.3%)) and had the American Society for Anesthesiologists (ASA) class ≥III (75 (76.5%) versus 140 (50.5%)) and high-risk features (17 (17.3%) versus 75 (27.1%)). Overall ERCP-related AE (10 (13.2%) versus 12 (7.5%), p = 0.2), pancreatitis (7 (9.2%) versus 11 (6.9%), p = 0.6), and hemorrhage (3.9% versus 0.6%, p = 0.25) were not different between inpatients and ASC subjects. There was also no difference between inpatients and ASC subjects' EUS-related AE (1 (4.5%) versus 4 (3.4%), p = 0.6), pancreatitis (1 (4.5%) versus 3 (2.6%), p = 0.2), and hemorrhage (0% versus 1 (0.9%), p = 0.9). Conclusions. ERCP and EUS can be performed in a higher risk population under the supervision of anesthesia in ASCs. Overall, the AE are equivalent between inpatients and ASC subjects.

Cyst Fluid Telomerase Activity Predicts the Histologic Grade of Cystic Neoplasms of the Pancreas.

Pancreatic cysts frequently pose clinical dilemmas. On one hand, cysts with high-grade dysplasia offer opportunities for cure, on the other hand, those with low-grade dysplasia are easily over treated. Cyst fluid markers have the potential to improve the evaluation of these cysts. Because telomerase activity is commonly activated in malignant cells, we evaluated the diagnostic performance of cyst fluid telomerase activity measurements for predicting histologic grade. Telomerase activity was measured using telomerase repeat amplification with digital-droplet PCR in surgically aspirated cyst fluid samples from 219 patients who underwent pancreatic resection for a cystic lesion (184 discovery, 35 validation) and 36 patients who underwent endoscopic ultrasound fine-needle aspiration. Methodologic and clinical factors associated with telomerase activity were examined. Telomerase activity was reduced in samples that had undergone prior thawing. Among 119 samples not previously thawed, surgical cyst fluids from cystic neoplasms with high-grade dysplasia ± associated invasive cancer had higher telomerase activity [median (interquartile range), 1,158 (295.9-13,033)] copies/μL of cyst fluid than those without [19.74 (2.58-233.6) copies/μL; P < 0.001)]. Elevated cyst fluid telomerase activity had a diagnostic accuracy for invasive cancer/high-grade dysplasia of 88.1% (discovery), 88.6% (validation), and 88.2% (merged). Among cysts classified preoperatively as having "worrisome features," cyst fluid telomerase activity had high diagnostic performance (sensitivity 73.7%, specificity 90.6%, accuracy, 86.1%). In multivariate analysis, telomerase activity independently predicted the presence of invasive cancer/high-grade dysplasia. Cyst fluid telomerase activity can be a useful predictor of the neoplastic grade of pancreatic cysts. Clin Cancer Res; 22(20); 5141-51. ©2016 AACRSee related commentary by Allen et al., p. 4966.

Value of adding GNAS testing to pancreatic cyst fluid KRAS and carcinoembryonic antigen analysis for the diagnosis of intraductal papillary mucinous neoplasms.

Molecular analysis of pancreatic cyst fluid (PCF) has been proposed as a novel method for differentiating pancreatic cystic lesions (PCL). The present study aimed to investigate the value of GNAS testing when added to KRAS and carcinoembryonic antigen (CEA) testing of PCF for the diagnosis of intraductal papillary mucinous neoplasms (IPMN). Prospectively collected endoscopic ultrasonography fine-needle aspiration (EUS-FNA) data were analyzed retrospectively for GNAS and KRAS mutations and CEA results. IPMN were histologically confirmed or supported by imaging and EUS-FNA findings (KRAS, CEA, cytology). Performance characteristics of GNAS added to KRAS and CEA for the diagnosis of IPMN were calculated. The study population consisted of 197 patients with cyst fluid test results. Cysts were histologically classified in 33 patients and by clinical criteria in 164 patients. The IPMN group included 108 patients and the non-IPMN group included 89 patients. GNAS was positive in 51 patients (47.2%) with IPMN. Forty-two of these patients (82.3%) also had a KRAS mutation. Adding GNAS to KRAS increased the diagnostic accuracy from 76.6% to 79.1% (P>0.05). Adding GNAS to CEA increased the diagnostic accuracy from 66.4% to 80.7% (P<0.05), but did not achieve a diagnostic superiority to KRAS testing alone (80.7% vs 76.6%, P>0.05). The diagnostic accuracy of the triple combination was significantly better than all single tests (P<0.05). GNAS mutation is a highly specific test for IPMN. When GNAS testing is added to CEA and KRAS, a significantly greater overall accuracy (86.2%) is achieved.