Endoscopic Ultrasound Fine Needle Aspiration Research Articles

Diagnostic accuracy of ki-67 labelling index in endoscopic ultrasonography-fine needle aspiration cytology and biopsy of pancreatic neuroendocrine neoplasms

Diagnostic accuracy of ki-67 labelling index in endoscopic ultrasonography-fine needle aspiration cytology and biopsy of pancreatic neuroendocrine neoplasms

THU361 Diabetic Ketoacidosis As The Initial Presentation Of Pancreatic Adenocarcinoma, A Case Report

Abstract Disclosure: U. Siddiqui: None. M. Ahmad: None. A. Shaikh: None. D. Rosenberg: None. Introduction: Signs and symptoms of pancreatic adenocarcinoma may be vague early in its course and is often discovered when it has quite advanced. Type 2 diabetes has been known to be linked with pancreatic adenocarcinoma with proposed mechanisms of hyperglycemia in these patients including increased insulin resistance, rapid beta cell turnover and oxidative stress. Rarely, diabetic ketoacidosis has been reported as an initial presentation of pancreatic carcinoma. We describe the case of a 61-year-old male with no previous diabetic history presenting with diabetic ketoacidosis (DKA) and found to have pancreatic adenocarcinoma. Case description: A 61-year-old male with no significant past medical history presented to the emergency department (ED) for a one week history of vision changes, nausea, abdominal pain and non-bloody vomiting. He reported heavy alcohol use on weekends, drinking 12 beers a day. He was found to be in DKA with his lab work demonstrating: venous pH 7.0, glucose 717 mg/dL, bicarbonate 7 mmol/L, anion gap 34 and positive beta hydroxybutyrate >60 mg/dL. After fluid resuscitation and IV insulin infusion he eventually had resolution of his DKA. Anti-GAD 65 screen was negative and c-peptide level was 5.71 ng/ml. His hemoglobin A1C was found to be 12.6. CT abdomen-pelvis with contrast demonstrated a patchy hypodensity of with dilation of pancreatic duct and a 2.0 cm pancreatic mass, resulting in pancreatic duct dilation with an MRI confirming these findings. Endoscopic Ultrasound fine needle aspiration confirmed pancreatic adenocarcinoma. The patient proceeded to have distal pancreatectomy and splenectomy. Surgical samples did not show lymph node involvement. After pancreatectomy the patient did have significantly decreased insulin requirements. Discussion: Pancreatic cancer is often discovered late in its course due to its subtle signs and symptoms. Evidence shows that type 2 diabetes is strongly linked with pancreatic cancer, with newly diagnosed type 2 diabetes or glucose intolerance being found in 80% of patients. Insulin resistance caused by pancreatic cancer has been proposed as an etiology of this new-onset diabetes and hyperglycemia. DKA as an initial manifestation of pancreatic cancer, however, is rare. Through this case we hope to highlight this association and suggest, in the right clinical setting, pancreatic cancer workup be considered in adults presenting with new onset type 2 diabetes and DKA. Presentation: Thursday, June 15, 2023

Comparison of 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma using endoscopic ultrasound fine-needle aspiration.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using a 19-gauge needle is an efficient sampling method for the diagnosis of lymphadenopathy. This study compared 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma (ML). Patient characteristics, number of needle passes, puncture route, sensitivity, specificity, and accuracy of cytology/histology for lymphadenopathy were analyzed in patients diagnosed with lymphadenopathy by EUS-FNA using conventional or Franseen needles. Between 2012 and 2022, 146 patients met the inclusion criteria (conventional [n=70] and Franseen [n=76]). The median number of needle passes was significantly lower in the conventional group than in the Franseen group (3 [1-6] vs. 4 [1-6], p=0.023). There were no significant differences in cytological/histological diagnoses between the two groups. For ML, the immunohistochemical evaluation rate, sensitivity of flow cytometry, and cytogenetic assessment were not significantly different in either group. Bleeding as adverse events (AEs) were observed in three patients in the Franseen group. Both the 19-gauge conventional and Franseen needles showed high accuracy in lymphadenopathy and ML classification. Considering sufficient tissue collection and the avoidance of AEs, the use of 19-gauge conventional needles seems to be a good option for the diagnosis of lymphadenopathy.

Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration for diagnostic and staging purposes: a narrative review.

Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is a feasible and well-tolerated modality that is increasingly used to diagnose intrathoracic lesions. This narrative review summarizes the current application of EUS-B-FNA for diagnosing lung cancer, thoracic sarcoidosis, and metastases from extrathoracic malignancies. A comprehensive and systematic online literature search via Medline/PubMed for the period January 2005 to December 2022 was conducted for articles published using the keywords "EUS-B-FNA", "endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)", "endoscopic ultrasound fine-needle aspiration (EUS-FNA)", "lung cancer", "staging", and "sarcoidosis". Recent data prove the efficacy and safety of EUS-B-FNA for providing complete lung cancer staging, when combined with EBUS-TBNA, and in the evaluation of para-esophageal lesions. EUS-B-FNA allows access to inferior mediastinal lymph nodes and para-esophageal masses that are not accessible by EBUS-TBNA. Additional advantages of using EUS-B-FNA include significantly lower doses of anesthetics and sedatives, a shorter procedural time, fewer incidents of oxygen desaturation due to a poor respiratory reserve, significantly less cough, and higher operator satisfaction. Moreover, this procedure can be performed sequentially in the same setting with EBUS-TBNA by one operator. Other benefits include a lower cost, a single setting, and scope use. As EUS-B-FNA and EBUS-TBNA have complementary access to the mediastinum, the diagnostic yield of EUS-B-FNA combined with EBUS-TBNA is higher than that of endosonographic techniques alone in the diagnostic workup of intrathoracic lesions.

Ethical Considerations of Biopsies in Early-Stage Pancreatic Cancer.

The standard of care in resectable and borderline resectable pancreatic ductal adenocarcinoma (PDAC) has evolved to include neoadjuvant treatment before surgical resection. Current guidelines call for obtaining histologic tissue diagnosis via endoscopic ultrasound fine-needle aspiration before administration of neoadjuvant therapy, which differ from guidelines discouraging delay in surgical resection for a biopsy. Whether to proceed with treatment before a biopsy confirms that malignancy is a nuanced decision and includes considerations of physical and psychological risks entailed in both pursuing and forgoing a biopsy. Accuracy of imaging and biopsy results, the presence of contributing clinical signs/symptoms, and the existing precedents of considering biopsies as waivable such as in scenarios with high clinical suspicion and primary surgical resection. When considering the aspects of ethical medical practice including beneficence (doing good), nonmaleficence (avoiding harm), autonomy (allowing patients to make decisions about their care), and utilitarianism (doing the most good for the most people), analysis of whether guidelines guiding biopsies should continue to differ between resection and neoadjuvant treatments in PDAC is prudent.

Exploring a novel composite method using non-contrast EUS enhanced microvascular imaging and cyst fluid analysis to differentiate pancreatic cystic lesions

Background and AimsDifferentiating pancreatic cystic lesions (PCLs) remains a diagnostic challenge. The use of high-definition imaging modalities which detect tumor microvasculature have been described in solid lesions. We aim to evaluate the usefulness of cystic microvasculature when used in combination with cyst fluid biochemistry to differentiate PCLs. MethodsWe retrospectively analyzed 110 consecutive patients with PCLs from 2 Italian Hospitals who underwent EUS with H-Flow and EUS fine needle aspiration to obtain cystic fluid. The accuracy of fluid biomarkers was evaluated against morphological features on radiology and EUS. Gold standard for diagnosis was surgical resection. A clinical and radiological follow up was applied in those patients who were not resected because not surgical indication and no signs of malignancy were shown. ResultsOf 110 patients, 65 were diagnosed with a mucinous cyst, 41 with a non-mucinous cyst, and 4 with an undetermined cyst. Fluid analysis alone yielded 76.7% sensitivity, 56.7% specificity, 77.8 positive predictive value (PPV), 55.3 negative predictive value (NPV) and 56% accuracy in diagnosing pancreatic cysts alone. Our composite method yielded 97.3% sensitivity, 77.1% specificity, 90.1% PPV, 93.1% NPV, 73.2% accuracy. ConclusionsThis new composite could be applied to the holistic approach of combining cyst morphology, vascularity, and fluid analysis alongside endoscopist expertise.

Contrast-enhanced endoscopic ultrasound for swollen lymph nodes.

Endoscopic ultrasound (EUS) is an important tool for the evaluation of lymphadenopathy, especially in intra-thoracic or intra-abdominal regions. EUS also provides tissue diagnosis via EUS fine-needle aspiration or biopsy. To select the target for biopsy or aspiration, conventional B-mode images are used for the evaluation, but this approach still lacks diagnostic accuracy. Contrast-enhanced EUS has been used to evaluate the vascularity of lesions. Most malignant lymphadenopathy shows heterogenous enhancement or defect of enhancement, while quantitative studies using time-intensity curves in contrast-enhanced harmonic EUS show a rapid decline in enhancement pattern. These findings are useful as an auxiliary method for tissue diagnosis or in cases in which tissue diagnosis is contraindicated.

Liver Mass Caused by Mycobacterium fortuitum: A Rare Case Diagnosed by EUS-FNA

ABSTRACT Mycobacterium fortuitum is associated with skin and soft-tissue infections, yet isolated liver involvement is rare. A 67-year-old asymptomatic man was referred for endoscopic ultrasound (EUS) to evaluate a gastric lesion and an incidental liver mass. EUS revealed a heterogeneous liver mass that was sampled. Pathology revealed necrotic granulomatous inflammation and positive acid-fast bacilli stain with M. fortuitum deoxyribonucleic acid. Levofloxacin plus trimethoprim and sulfamethoxazole for 3 months were used for complete resolution of liver lesion. Isolated nontuberculous liver involvement is uncommon. We report the first case of a liver mass caused by M. fortuitum diagnosed by EUS-fine needle aspiration.

Diagnosis of tuberculous pericarditis with transgastric EUS fine-needle aspiration (with video)

Diagnosis of tuberculous pericarditis with transgastric EUS fine-needle aspiration (with video)

An unrecognized undifferentiated tumor of the pancreas: a case report

SMARCA4-deficient tumors are gaining attention, and this type of tumor is highly malignant with a poor prognosis. The frequency of SMARCA4 deletion varies in different tumors. However, it has never been identified in the pancreas. A 67-year-old woman presented with upper abdominal pain lasting for half a month. Computed tomography indicated a space-occupying lesion in the head of the pancreas, considered a malignant tumor. Further Endoscopic ultrasound fine-needle aspiration was performed and reported as SMARCA4-deficient undifferentiated pancreatic tumor. The patient received no treatment and survived only two and a half months from diagnosis to death. We are the first to report SMARCA4-deficient pancreatic undifferentiated tumor in which this new tumor entity presents with poorer overall survival. We also summarized the advances of SMARCA4 in oncology and treatment.

Sensitivity of endoscopic ultrasound-guided fine-needle aspiration cytology and biopsy for a diagnosis of pancreatic ductal adenocarcinoma: A comparative analysis.

The utility of endoscopic ultrasound fine-needle aspiration cytology (EUS-FNAC) or endoscopic ultrasound fine-needle aspiration biopsy (EUS-FNAB) for diagnosis of small and large pancreatic ductal adenocarcinomas (PDACs) remains in question. We addressed this by analyzing 97 definitively diagnosed cases of PDAC, for which both EUS-FNAC and EUS-FNAB had been performed. We subclassified the 97 solid masses into small (n = 35) or large (n = 62) according to the maximum tumor diameter (<24 mm or ≥24 mm) and compared the diagnostic sensitivity (truly positive rate) of EUS-FNAC and of EUS-FNAB for small and large masses. Diagnostic sensitivity of EUS-FNAC did not differ between large and small masses (79.0% vs. 60.0%; p = 0.0763). However, the diagnostic sensitivity of EUS-FNAB was significantly higher for large masses (85.5% vs. 62.9%; p = 0.0213). Accurate EUS-FNAC-based diagnosis appeared to depend on the degree of cytological atypia of cancer cells, which was not associated with quantity of cancer cells. The accuracy of EUS-FNAB-based diagnosis appeared to depend on cancer cell viability in large masses and cancer volume in small masses. Based on the advantages or disadvantages in each modality, both modalities play an important role in the qualitative diagnosis of PDAC as a complementary procedure.

Pancreatic Juice Cytology Evaluations Using Synthetic Secretin and Serial Pancreatic Juice Aspiration Cytological Examination for the Diagnosis of Pancreatic Ductal Adenocarcinoma.

Pathological examination by endoscopic ultrasound-fine needle aspiration is not possible in approximately 10% of pancreatic tumor cases. Pancreatic juice cytology (PJC) is considered an alternative diagnostic method. However, its diagnostic capability is insufficient, and PJC has been repeatedly redevised. Serial pancreatic juice aspiration cytological examination (SPACE) and secretin-loaded PJC (S-PJC) have been recently introduced as alternative diagnostic methods. This study aimed to determine the diagnostic capacity and safety of SPACE and S-PJC using a propensity score-matched analysis. The sensitivity, specificity, and accuracy were 75.0%, 100%, and 92.3% for S-PJC, respectively, and 71.4%, 100%, and 92.3% for SPACE, respectively, meaning that there was no significant difference between the groups. Four patients (15.4%) each in the S-PJC and SPACE groups experienced complications, including postendoscopic retrograde cholangiopancreatography, pancreatitis, and cholangitis. Overall, there was no difference in efficacy and safety between the SPACE and S-PJC groups.

Aortic Wall Abrasion Caused by Needle Injury after Endoscopic Ultrasound-Guided Fine Needle Aspiration of a Mediastinal Hemangioma

Benign mediastinal cysts are challenging to diagnose. Although Endoscopic Ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) can accurately diagnose mediastinal foregut cysts, little is known about their complications. This paper reports a rare case in which EUS-FNA performed on mediastinal hemangioma resulted in an aortic hematoma. A 29-year-old female patient was commissioned for EUS of an asymptomatic accidental mediastinal lesion. Chest CT revealed a 4.9×2.9×10.1 cm thin-walled cystic mass in the posterior mediastinum. EUS revealed a large, anechoic cystic lesion with a regular thin wall with negative Doppler. EUS-guided FNA was performed using a single-use 19-gauge aspiration needle (EZ Shot 3; Olympus, Tokyo, Japan), and approximately 70 cc of serous pinkish fluid was aspirated. The patient was in a stable condition with no signs of acute complication. One day after EUS-FNA, thoracoscopic resection for mediastinal mass was conducted. The purple and multi-loculated large cyst was removed. Upon removal, however, an aortic hematoma caused by a focal descending aortic wall injury was observed. After a few days of close observation, the patient was discharged upon stable 3D aorta angio CT findings. This paper reports a rare and severe complication of EUS-FNA, in which an aspiration needle caused a direct injury to the aorta. The injection must be performed carefully to avoid damaging the adjacent organs or digestive tract walls.

Solid Pseudopapillary Epithelial Neoplasm of the Pancreas: A Rare Entity with Diagnostic Dilemma

The solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas is a relatively uncommon entity. The aim of the present study was to summarize our experiences with regard to diagnostic dilemma, surgery, postoperative follow-up, and management. This retrospective data were collected during the period from January 1, 2018 to December 31, 2020. A total of four patients (three females and one male) were identified within an age range of 13 to 25 years. All the patients were presented with nonspecific symptoms such as abdomen lumps, swelling in the abdomen, and abdominal pain. To reach a definite diagnosis, imaging studies were conducted along with endoscopic ultrasound fine-needle aspiration (EUS-FNA) and biopsy. After confirmation of SPEN on biopsy, all the patients underwent surgery without any complications. Patients are on follow-up, and to date, no metastasis has been detected. SPEN is a rare pancreatic tumor with unusual pathological features leading to a diagnostic dilemma. The pathologist should be familiar with SPEN and its salient histological characteristics that differentiate it from other look-alike pancreatic tumors and can help in timely surgery and management.

Are biopsies during endoscopic ultrasonography necessary for a suspected esophageal leiomyoma? Is laparoscopy always feasible?

The present letter to the editor is related to the work entitled "Large leiomyoma of lower esophagus diagnosed by endoscopic ultrasonography-fine needle aspiration: A case report." Although endoscopic ultrasonography seems necessary in a suspected leiomyoma of the esophagus, the performance of biopsies via fine needle aspiration is controversial as it increases the risk of complications such as bleeding, infection, and intraoperative perforations. Laparoscopy is the best treatment strategy for small tumors. Laparotomy with tumor enucleation or esophageal resection can be considered in large leiomyomas.

Circulating Tumor DNA Is an Accurate Diagnostic Tool and Strong Prognostic Marker in Pancreatic Cancer.

The objectives of the study are to investigate the sensitivity and specificity of circulating tumor DNA (ctDNA) for the diagnosis of pancreatic cancer and to assess the utility of ctDNA as a prognostic marker in this disease. Cell-free DNA was extracted from plasma of patients who underwent endoscopic ultrasound fine-needle aspiration or surgical resections for pancreatic cancer. The cell-free DNA was then analyzed using droplet digital polymerase chain reaction for KRAS G12/13 mutations. Eighty-one patients with pancreatic cancer and 30 patients with benign pancreatic disease were analyzed. ctDNA KRAS G12/13 mutations were detected in 63% of all patients with pancreatic cancer and in 76% of those patients who also had KRAS G12/13 mutations detected in the pancreatic primary. Specificity and tissue concordance were both 100%. Circulating tumor DNA corresponded with tumor size and stage, and high ctDNA was associated with significantly worse prognosis on both univariate and multivariate testing. Our study shows that ctDNA is an accurate diagnostic tool and strong prognostic marker in patients with pancreatic cancer. The continued investigation of ctDNA will enable its implementation in clinical practice to optimize the care and survival outcomes of patients with pancreatic cancer.

Solitary Uncommon Metastasis in Non-Small Cell Lung Cancer

The major sites of metastasis in non-small cell lung cancer (NSCLC) are bones, the brain, adrenal glands, the liver, the contralateral lung, and distant lymph nodes. Solitary metastasis in an uncommon site is very rare; therefore, it has not often been reported. Identifying whether a solitary lesion is a metastatic lesion is important because it decisively influences the stage and treatment decisions. We report a series of cases of NSCLC diagnosis with uncommon solitary metastasis. (1) A 71-year-old man was diagnosed with poorly differentiated NSCLC after a bronchoscopic biopsy of a tumor in the bronchus of the right middle lobe. A hypermetabolic lesion was observed in the tail of the pancreas using positron emission tomography/computed tomography (PET/CT), and metastasis of NSCLC was confirmed using endoscopic ultrasound fine-needle aspiration (EUS-FNA). (2) A 77-year-old man was diagnosed with squamous cell carcinoma after a bronchoscopic biopsy of a tumor in the bronchus of the left upper lobe. A hypermetabolic lesion was observed in the bilateral lobes of the thyroid gland using PET/CT, and metastasis of the squamous cell carcinoma was confirmed by FNA and cytology. (3) A 79-year-old woman was diagnosed with adenocarcinoma by brushing cytology performed on the apicoposterior segmental bronchus of the left upper lobe. Hypermetabolic lesions were observed using PET/CT in the subcutaneous layer of the right back and the left breast, and metastases of adenocarcinoma were confirmed by biopsies in each lesion. These three patients were treated with platinum-based chemotherapy for stage IV lung cancer. With this case series, we recommend that, when a solitary lesion is observed in NSCLC patients, a tissue biopsy should be performed, even if the lesion is located in an organ where lung cancer metastasis is uncommon.

Diagnostic adequacy of FNA and FNB pancreatic lesions performed at St George Hospital

Endoscopic ultrasound-fine needle aspiration (EUS-FNA) is the current primary technique for evaluating pancreatic lesions, with increasing use of fine needle biopsy (FNB) to obtain larger tissue sample. In this study, we aimed to determine the diagnostic yield of FNA and FNB of pancreatic lesions performed at St George Hospital in a two year period from 2020 to 2021 inclusive. There were 92 FNA and 69 FNB performed. The diagnostic yield of FNA was 86% and FNB was 87%. This result is in concordance to diagnostic yield ranges in published literature.

The Diagnosis of Gastric Bronchogenic Cyst with Endoscopic ultrasound fine-needle aspiration

The Diagnosis of Gastric Bronchogenic Cyst with Endoscopic ultrasound fine-needle aspiration

Recent advances in the management of autoimmune pancreatitis in the era of artificial intelligence

Autoimmune pancreatitis (AIP) is a type of immune-mediated pancreatitis subdivided into two subtypes, type 1 and type 2 AIP. Furthermore, type 1 AIP is considered to be the pancreatic manifestation of the immunoglobulin G4 (IgG4)-related disease. Nowadays, AIP is increasingly researched and recognized, although its diagnosis represents a challenge for several reasons: False positive ultrasound-guided cytological samples for a neoplastic process, difficult to interpret levels of IgG4, the absence of biological markers to diagnose type 2 AIP, and the challenging clinical identification of atypical forms. Furthermore, 60% and 78% of type 1 and type 2 AIP, respectively, are retrospectively diagnosed on surgical specimens of resected pancreas for suspected cancer. As distinguishing AIP from pancreatic ductal adenocarcinoma can be challenging, obtaining a definitive diagnosis can therefore prove difficult, since endoscopic ultrasound fine-needle aspiration or biopsy of the pancreas are suboptimal. This paper focuses on recent innovations in the management of AIP with regard to the use of artificial intelligence, new serum markers, and new therapeutic approaches, while it also outlines the current management recommendations. A better knowledge of AIP can reduce the recourse to surgery and avoid its overuse, although such an approach requires close collaboration between gastroenterologists, surgeons and radiologists. Better knowledge on AIP and IgG4-related disease remains necessary to diagnose and manage patients.