EUS-FNA For Diagnosis Research Articles

EUS FNA of Distant Extra-Vascular Migratory Metastasis (EVMM) and Tumor Thrombosis

Background: Vascular invasion impacts cancer staging, prognosis, and therapy. Malignant infiltration usually results from direct and gross extension from a primary tumor and is readily identified by CT. Cancers may also migrate to remote sites along vascular channels, a process termed angiotropism or EVMM. Sometimes this pattern of spread can be seen with CT. Surgical and autopsy studies also demonstrate microscopic or diminutive (1-3 mm thick) spread not seen with CT. Additionally, a tumor thrombus may only be recognized at surgery or autopsy. We report the EUS FNA diagnosis of malignant perivascular cuffing and tumor thrombosis occurring distant from a primary tumor, including microinvasion with negative helical CT. Aims: To examine the capability and safety of EUS FNA for diagnosing distant perivascular tumor infiltration and tumor thrombus in CT positive and negative (i.e. microinvasion) patients. Methods: Using a prospectively maintained EUS database, we identified all examinations from 09/04 to 11/08 in which FNA was performed of a vascular wall or intravascular thrombus. We abstracted and analyzed date regarding demographic, radiology and EUS features, cytology results, and follow up data. Results: EUS FNA was performed from 31 vascular sites [vascular wall (n=27), intravascular thrombus (n=4)] during 29 exams in 27 patients [15 male, age 55±11 years]. Cancer was diagnosed in 24/27 (89%) patients of whom 20 had pancreatic cancer. For diagnosis of vascular involvement remote from cancer (EVMM), a median of 3 FNAs (range 2-9) was obtained from wall of the celiac artery (n=12), SMA (n=6), hepatic artery (n=5), splenic artery (n=2), SMV (n=1), aorta (n=1); and intravascular FNA of portal vein (n=4). FNA cytology was positive (n=17) or suspicious (n=2) among cancer patients. EUS FNA detected and confirmed microinvasion in 3 patients with negative helical CT. CT and EUS identified indeterminate peri- and intravascular findings in 3 patients ultimately diagnosed with benign disorders after a median follow-up of 3 (0.4-7) months. EUS FNA was negative in each of these patients. Conclusion: CT and EUS can identify peri- and intravascular tumor extension remote from the primary tumor and not resulting from gross infiltration. EUS can detect microinvasion (1-3mm) not seen on helical CT. Further study is needed to determine the prevalence, to establish the safety and accuracy of EUS FNA, and impact on prognosis, clinical care, and outcomes.

EUS/EUS-FNA for suspected pancreatic cancer: influence of chronic pancreatitis and clinical presentation with or without obstructive jaundice on performance characteristics

The clinical utility of EUS-FNA is debated in patients with obstructive jaundice (ObJ) because of a very high pretest probability of pancreatobiliary malignancy (PBM) and biliary stent-induced inflammation that can potentially confound EUS-FNA diagnosis. EUS-FNA also has lower accuracy in patients with underlying chronic pancreatitis (CP). Our purpose was to determine the clinical value of EUS-FNA for PBM diagnosis based on clinical presentation and presence of CP. Retrospective analysis of prospective database. University hospital. Patients who underwent EUS-FNA from 2002 to 2006 for suspected PBM based on (1) ObJ with biliary stricture or a mass lesion or (2) abnormal pancreatic imaging by CT/MRI: a focal pancreatic "mass" lesion; dilated pancreatic duct +/- common bile duct; or an enlarged head of pancreas. EUS was performed with a radial echoendoscope followed by a linear echoendoscope if a focal pancreatic lesion was identified. Fine-needle aspirates were assessed immediately by an attending cytopathologist. (1) Prevalence of cancer and (2) performance characteristics of EUS-FNA. PBM was diagnosed in 73.9% of patients with ObJ and biliary stricture or pancreatic mass, in 49.6% of patients with pancreatic mass, and in 7.0% of patients with an enlarged head of pancreas or dilated pancreatic duct +/- common bile duct. The prevalence of PBM was lower in all 3 presentations with associated CP. Both CP and presentation with ObJ lowered performance characteristics of EUS-FNA, but CP did so only in the subset of patients with ObJ. All except 1 false-negative diagnoses were due to cytologic misinterpretation. Retrospective design. Among patients with suspected PBM, the accuracy of EUS-FNA is significantly lower only in a subset of patients with ObJ with underlying CP, largely as a result of difficulty in cytologic interpretation.

Predictors of Malignancy and Recommended Follow-Up for Patients with Negative Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Suspected Pancreatic Lesions

Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can characterize and diagnose pancreatic lesions as malignant, but cannot definitively rule out the presence of malignancy. Outcome data regarding the length of follow-up in patients with negative or nondiagnostic EUS-FNA of pancreatic lesions are not well-established. To determine the long-term outcome and provide follow-up guidance for patients with negative EUS-FNA diagnosis of suspected pancreatic lesions based on imaging predictors. A retrospective review of patients undergoing EUS-FNA for suspected pancreatic lesions, but with negative or nondiagnostic FNA results was conducted at a tertiary care referral medical centre. Patient demographics, EUS imaging characteristics and follow-up data were examined. Seventeen of 55 patients (30.9%) with negative/nondiagnostic FNA were subsequently diagnosed with pancreatic malignancy. The risk of cancer was significantly higher for patients who had associated lymph nodes on EUS (P<0.001) and vascular involvement on EUS (P=0.001). The mean time to diagnosis in the group with falsenegative EUS-FNA diagnosis was 66 days. The true-negative EUSFNA patients were followed for a mean of 403 days after negative EUS-FNA results without the development of malignancy. For patients undergoing EUS-FNA for a suspected pancreatic lesion, a negative or nondiagnostic FNA does not provide conclusive evidence for the absence of cancer. Patients for whom vascular invasion and lymphadenopathy are detected on EUS are more likely to have a true malignant lesion and should be followed closely. When a patient has been monitored for six months or more with no cancer being diagnosed, there appears to be much less chance that a pancreatic malignancy is present.

Role of endoscopic ultrasound in diagnosis and therapy of pancreatic adenocarcinoma

Since its advent more than 20 years ago, endoscopic ultrasound (EUS) has undergone evolution from an experimental to a diagnostic instrument and is now established as a therapeutic tool for endoscopists. Endoscopic ultrasound cannot accurately distinguish benign from malignant changes in the primary lesion or lymph node on imaging alone. With the introduction of the curved linear array echoendoscope in the 1990s, the indications for EUS have expanded. The curved linear array echoendoscope enables the visualization of a needle as it exits from the biopsy channel in the same plane of ultrasound imaging in real time. This allows the endoscopist to perform a whole range of interventional applications ranging from fine needle aspiration (FNA) of lesions surrounding the gastrointestinal tract to celiac plexus block and drainage of pancreatic pseudocyst. This article reviews the current role of EUS and EUS-FNA in diagnosis, staging and interventional application of solid pancreatic cancer.

Role of EUS-guided FNA in the Diagnosis of Solid Pancreatic Lesions. A Single Center Experience

Introduction: Mass lesions of the pancreas can be malignant or benign, which is often difficult to differentiate. Differentiating these tumors is essential for optimal management and outcome. The purpose of this study was to retrospectively evaluate the accuracy of EUS-FNA in cytologic diagnosis of pancreatic solid lesions. Methods: A retrospective review was done to identify patients who underwent EUS from year 2002 to year 2005 for an abnormal pancreatic imaging (mass lesion, fullness or prominent head of pancreas). EUS-FNA was performed using 22-gauge needle. Onsite cytopatholgist was available to determine the adequacy of the sample. Results: 320 patients underwent EUS for an abnormal pancreatic image. Out of these, 123 patients had a solid pancreatic lesion and had EUS-FNA performed. The cytopathology results of EUS-FNA are as shown in table 1. Surgical confirmation of pancreatic adenocarcinoma was available in 41 out of 72 patients. Follow up of patients with atypical cytology on subsequent surgery revealed pancreatic malignancy in 4 patients. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-FNA in the diagnosis of solid pancreatic tumors at our center is 89.13%, 100%, 100% and 27.5% respectively.

Improving the Accuracy of Ultrasound-Endoscopy Fine- Needle Aspiration (EUS-FNA): Factors Predicting a Correct Diagnosis and Usefulness of an Attendant Pathologist

Background: EUS-FNA is a well established technique for staging gastrointestinal and lung cancer and for diagnosing pancreatic masses. Aim: To evaluate the predictive factors of a correct diagnosis by EUS-FNA and to establish the usefulness of an attendant pathologist. Patients and methods: Between January 2001 and February 2003, we evaluated all consecutive patients referred for EUS-FNA. The procedure was carried out with a linear echoendoscop and a 22G needle. An attendant pathologist examinated the samples. Epidemiological data, EUS characteristics,and citological results were registered. EUS-FNA diagnosis was compared with the gold standart (pathology of resected specimen or clinical follow-up). In order to establish the importance of an attendant cytopathologist, the actual results were compared with those that would have been obtained if a particular number of passes had been performed without on-site evaluation. Once a price per pass was established, a cost-minimization study of the availability of an attendant pathologist was performed. Results: 262 lesions were sampled: pancreatic masses (n= 115), lymph nodes (n= 96), cysts (n= 40) and intramural lesions (n= 11). A total of 551 samples was obtained, thus representing 2.1 +/− 1.1 passes per patient on average (range, 1-6). EUS-FNA ascertained the correct diagnosis in 235 (overall accuracy, 89%). Location within the gastrointestinal wall was the only independent factor predicting failure in the diagnosis (multivariate regression analyses). Effectiveness of EUS-FNA in the whole series increased with every pass from 36% to 89% plateauing in the 4th pass. This curve was similar for pancreatic masses, lymph nodes and cyst but the plateau appeared in the 3rd pass in these last two types of lesions. The effectiveness of EUS-FNA for the intramural lesions was always lower, increasing from 0.9% to 45% and reaching a plateau in the 4th pass. The assistance of an attendant cytopathologist was costless with respect to the corresponding strategy without on-site examination for the whole series and for lymph nodes, masses and cysts. Conclusion:1) Location within the gastrointestinal wall was the only independent factor predicting failure in the diagnosis. 2) The availability of an attendant pathologist seems to increase the diagnostic yield of EUS-FNA, minimizing the number of passes and resulting in a costless strategy.

Rendevous laproscopic endoscopy for resection of gastroduodenal submucosal tumors after Eus-Fna diagnosis: A minimally invasive therapy for difficult tumors

Rendevous laproscopic endoscopy for resection of gastroduodenal submucosal tumors after Eus-Fna diagnosis: A minimally invasive therapy for difficult tumors

Rendezvous laproscopic endoscopy for resection of gastroduodenal submucosal tumors after eus-fna diagnosis: a minimally invasive therapy for difficult tumors

Rendezvous laproscopic endoscopy for resection of gastroduodenal submucosal tumors after eus-fna diagnosis: a minimally invasive therapy for difficult tumors