EUS-FNA Of Solid Pancreatic Lesions Research Articles

S122 Endoscopic Ultrasound Evaluation of Primary Pancreatic Lymphoma Compared to Adenocarcinoma: A Case-Control Study

Introduction: Primary pancreatic lymphoma (PPL) is a rare extranodal lymphoma representing 0.5% of all pancreatic neoplasms. Prognosis and treatment strategies of PPL vastly differ from pancreatic ductal adenocarcinoma (PDAC), therefore making an accurate diagnosis is vital. Our aim is to describe the presentation, endoscopic ultrasound (EUS) features, and the role of fine needle aspiration (FNA) in the diagnosis of PPL compared with PDAC. Methods: Out of 1,946 patients who underwent EUS-FNA of solid pancreatic lesions, 11 were diagnosed with PPL. Patients who had peripancreatic lesions, lymph nodes, or bile duct masses were excluded. Age and gender- matched controls with a diagnosis of PDAC were identified in a 1:3 ratio. Presenting symptoms, demographics, and EUS characteristics were evaluated. Results: There were 11 patients with PPL and 33 age and gender-matched controls with PDAC. The median age was 65 years (60-76) and 63.6% were males. There was no difference between two groups in smoking, alcohol consumption, or history of a second malignancy. PPL patients were more likely to present with abdominal pain (81.8% vs 26.4%, p=0.01). Pancreatic head location was most common in both groups. Both PPL and PDAC tended to be hypoechoic and poorly defined on EUS, while PPL were more commonly described as heterogeneous (36.4% vs 6.1%, p=0.01). PPL were significantly larger on EUS (45.8 mm vs 31 mm, p< 0.01) and less likely associated with pancreatic duct dilation. A higher number of FNA passes was required for the diagnosis of PPL compared to PDAC (5 vs 3, p< 0.01). Conclusion: While PPL remains rare, making an accurate distinction with PDAC is critical as treatment and prognosis radically differ. On presentation, PPL is more likely to cause abdominal pain. Certain EUS features were found to be beneficial in differentiating PPL from PDAC in our study, as PPL tend to be larger, more likely heterogeneous, and are less likely associated with pancreatic duct dilation compared to PDAC. Tissue diagnosis is more challenging in PPL as reflected by a significantly higher number of passes obtained on EUS- FNA. Table 1. - Adenocarcinoma (n=33) Primary Pancreatic Lymphoma (n=11) P value Ethnicity, white n (%) 21 (63.6) 8 (72.7) 0.58 Smoking history ( >15 pack-years), n (%) 9 (27.3) 5 (45.5) 0.26 Alcohol history ( >1 drink/day), n (%) 7 (21.2) 2 (18.2) 0.83 History of cancer diagnosis, n (%) 10 (30.3) 3 (27.3) 0.85 Multiple pancreatic lesions, n (%) 1 (3) 0 0.56 Presenting symptoms Abdominal pain, n (%) 12 (36.4) 9 (81.8) 0.01 Jaundice, n (%) 11 (33.3) 6 (54.5) 0.21 Weight loss, n (%) 8 (24.2) 3 (27.3) 0.84 Incidental, n (%) 5 (15.2) 1 (9.1) 0.61 Located in the head of the pancreas, n (%) 23 (69.7) 9 (81.8) 0.43 Regional lymphadenopathy on imaging, n (%) 20 (60.6) 10 (90.9) 0.06 EUS features Hypoechoic, n (%) 31 (93.9) 9 (81.8) 0.23 Heterogeneous, n (%) 2 (6.1) 4 (36.4) 0.01 Poorly defined, n (%) 23 (69.7) 8 (72.7) 0.85 Common bile duct dilation, n (%) 14 (42.4) 5 (45.5) 0.86 Pancreatic duct dilation, n (%) 23 (69.7) 3 (27.3) 0.01 Number of passes on FNA, mean (IQR) 3 (1-3) 5 (2-7) 0.008 Largest diameter on EUS (mm), median (IQR) 31 (25-38.8) 45.8 (35.5-56) 0.001 Treatment Chemotherapy, n (%) 29 (87.9) 10 (90.9) 0.78 Radiation therapy, n (%) 17 (51.5) 2 (18.2) 0.053 Surgery, n (%) 7 (21.2) 1 (9.1) 0.37

Two Needle Passes Achieve Similar Diagnostic Yield Compared to Three Passes Regarding Diagnosis of Solid Pancreatic Lesions in Endoscopic Ultrasound-Guided Fine Needle Aspiration.

Current guidelines advocate 3–4 passes with a fine-needle aspiration (FNA) to achieve high rates of diagnostic samples for malignancy when performing endoscopic ultrasound (EUS)-guided sampling of solid pancreatic lesions, in the absence of on-site cytologic evaluation. The aim of this study is to compare 2 vs. 3 needle passes in EUS-FNA for solid pancreatic lesions in terms of incremental diagnostic yield and to identify factors associated with the procedure’s outcome. In this retrospective study, 2 passes of EUS-FNA were found to have similar diagnostic yield compared to 3 passes for the diagnosis of solid pancreatic masses, suggesting that there might be no significant incremental tissue yield when 3 passes are performed.

Optimizing cytological specimens of EUS-FNA of solid pancreatic lesions: A pilot study to the effect of a smear preparation training for endoscopy personnel on sample quality and accuracy.

BackgroundIn the absence of rapid on‐side pathological evaluation, endoscopy staff generally “smears” endoscopic ultrasound guided fine needle aspiration (EUS‐FNA) specimens on a glass slide. As this technique is vulnerable to preparation artifacts, we assessed if its quality could be improved through a smear‐preparation‐training for endoscopy staff.MethodsIn this prospective pilot study, 10 endosonographers and 12 endoscopy nurses from seven regional EUS‐centers in the Netherlands were invited to participate in a EUS‐FNA smear‐preparation‐training. Subsequently, post training slides derived from solid pancreatic lesions were compared to pre‐training “control” slides. Primary outcome was to assess if the training positively affects smear quality and, consequently, diagnostic accuracy of EUS‐FNA of solid pancreatic lesions.ResultsParticipants collected and prepared 71 cases, mostly pancreatic head lesions (48%). Sixty‐eight controls were selected from the pretraining period. The presence of artifacts was comparable for smears performed before and after training (76% vs 82%, P = .36). Likewise, smear cellularity (≥50% target cells) before and after training did not differ (44% (30/68) vs 49% (35/71), P = .48). Similar, no difference in diagnostic accuracy for malignancy was detected (P = .10). Conclusion In this pilot EUS‐FNA smear‐preparation‐training for endoscopy personnel, smear quality and diagnostic accuracy were not improved after the training. Based on these results, we plan to further study other training programs and possibilities.

Mo1383 – Diagnostic Yield of Eus-Fna for Solid Pancreatic Lesions in the Presence Or the Absence of Chronic Pancreatitis

Mo1383 – Diagnostic Yield of Eus-Fna for Solid Pancreatic Lesions in the Presence Or the Absence of Chronic Pancreatitis

Mo1291 TELECYTHOPATOLOGY FOR RAPID ON-SITE EVALUATION (ROSE) OF ENDOSCOPIC ULTRASOUND-GUIDED FINE-NEEDLE (EUS-FNA) ASPIRATION SPECIMENS OF SOLID PANCREATIC MASS

Telepathology has been defined as a form of communication between medical professionals that includes the transmission of pathology images and associated clinical information for various clinical applications, including diagnosis. ROSE for EUS-FNA of the pancreas provides immediate information regarding cellular adequacy, avoiding repeated procedures and improving diagnosis. However, cytopathologist is not available for ROSE in all endoscopy units. A multi-platform mobile phone application, such as WhatsApp Messenger, could be useful as a tool for TCP, since it could enable remote real-time information exchange, avoiding unnecessary procedures. To evaluate the feasibility and the impact of TCP using WhatsApp Messenger as an auxiliary tool for ROSE in EUS-FNA of solid pancreatic lesions. We prospectively evaluated 20 patients (65% male, median age 57.5 yrs [range 36 to 86]) with pancreatic solid lesions, according to previous CT scans, referred to EUS-FNA. Patients with entirely cystic lesions were excluded. All endoscopic procedures were performed with the patient under conscious sedation with linear therapeutic echoendoscopes (Fujifilm Corporation, EG-53OUT2, Saitama, Japan) and 22G-needles (Expect, Boston Scientific Corporation). After each pass, aspirated material was spread over a glass slide and stained by the endoscopist. The glass slide was then reviewed on a microscope equipped with a mobile phone (Android Platform) in order to capture images. The most representative fields were photographed and sent by WhatsApp Messenger to the cytopathologist. The images were analyzed regarding cellular adequacy of the material and preliminary diagnosis whenever possible. The number of needle passes was determined according to initial evaluation of the cytopathologist. This initial evaluation was compared to the final pathology report (FPR) regarding cellular adequacy and diagnosis. Gold standard for diagnosis of malignancy was surgical report or 12-month follow-up. The endoscopist had training in basic cytology for slide preparing. In the initial evaluation using TCP ROSE, adequate cellularity of the glass slide was detected in 13/20 (65%), vs. 16/20 in FPR (P = 0.37). An initial diagnosis of malignancy was possible in 11/20 (55%) vs, 16/20 (80%) after FPR (P = 0.07). The final diagnosis was malignant in 16/20 (80%). Sensitivity and specificity for diagnosing malignant lesions after FPR were both 100%. The present study demonstrates the feasibility of a low-cost, Internet-based, telecytopathology system using WhatsApp Messenger to provide a rapid on-site evaluation of EUS-FNA slides in patients with solid pancreatic lesions.

Su1136 Cost Minimization Analysis of Onsite Cytopathologist (CyP) Evaluation During EUS-FNA of Solid Pancreatic Lesions: Results From a Multicenter Prospective Randomized Controlled Trial

had familiar history ofIBD.Among the 93 IBD pts with arthralgias, rheumatologic assessment diagnosed rheumatologic diseases in 33 (88%) UC and in 44 (80%) CD pts. In particular, a diagnosis of SpAewas made in 50 (54%) IBD pts(54% peripheral SpA, 24%, axial SpA, 22% both), 24 (26%)Osteoarthritis, 6 (7%)Fybromialgia,3 (3%), Gout, 3 (3%)Rheumatoid Arthritis, 2 (2%) Psoriatic Arthritis, while diagnosis was inconclusive in 5 (6%) pts. After rheumatological assessment, a higher percentage of IBD pts were treated with diseasemodifying anti-rheumatic drugs (including anti-TNFs)(5.3% vs 15%, p=0.03, RR 1.6)and/ or with anti-COX2 (6.4% vs 27%; p<0.0001; RR 2.3). Anti-TNFs use also significantly increased (19% vs 34%, p=0.009;RR 1.8).Conclusions. Multidisciplinary IBD care including rheumatologists may facilitate the diagnosis and management of arthralgias in IBD. A combined multidisciplinary approach may also lead to an early diagnosis and proper treatment of chronic and debilitating inflammatory arthritis.

THE RELIABILITY OF ENDOSCOPIC ULTRASOUND (EUS)-GUIDED FINE NEEDLE ASPIRATION (FNA) FOR DIAGNOSING SOLID PANCREATIC LESIONS

Purpose: The development of EUS-FNA has revolutionalized our ability to differentiate benign from malignant pancreatic masses. The purpose of this study was to assess the diagnostic accuracy of EUS-FNA in patients with solid pancreatic lesions. Methods: All patients referred for EUS evaluation of solid pancreatic mass between 1998 and 2002 were reviewed. Patient demographics and clinical history were recorded. Cytopathology was compared with operative histopathology in patients who underwent surgery. Patients who did not have surgery were followed clinically. Results: A total of 302 patients (mean age 69, 172 M/130 F) underwent EUS-FNA for solid pancreatic lesions. FNA was consistent with pancreatic malignancy in 53% (160/302) while 39% (117/302) had no evidence of malignancy. In the remaining 8% (25/302), biopsy was inconclusive. Of the pancreatic cancer patients, 90% (144/160) had adenocarcinoma, 4% (6/160) had neuroendocrine tumors, and 6% (10/160) had other malignancies. In the group with a definitive FNA diagnosis, 27% (74/277) underwent surgery and operative histopathology was compared with FNA cytopathology. There were one false positive and four false-negative FNA diagnoses; and the sensitivity, specificity, PPV, and NPV were 92%, 97%, 98% and 89% respectively. The false-positive diagnosis was due to misinterpretation by the initial pathologist. In the 4 false-negative cases, 75% (3/4) had cytologic evidence of chronic pancreatitis. In patients with an inconclusive FNA, 32% (8/25) had surgery and 5 had adenocarcinoma. The remaining 70% (220/302) of patients who did not undergo surgery were followed clinically. The mean survival for patients with a positive, negative, and inconclusive FNA was 18, 48, and 31 months respectively. Conclusions: 1. EUS-FNA accurately provides a cytologic diagnosis in most patients with solid pancreatic lesions. 2. Cytologic evaluation of pancreatic tissue in the setting of chronic inflammatin can be difficult. 3. A false-positive diagnosis was uncommon and in this study was due to interpretation error. 4. A proportion of patients with inconclusive EUS-FNA may have underlying cancer and should be followed carefully.

The Accuracy of Endoscopic Ultrasound (EUS)-Guided Fine Needle Aspiration (FNA) for Diagnosing Solid Pancreatic Lesions Using a New 25-Gauge Needle System

Introduction: EUS-FNA has enhanced our ability to diagnose pancreatic masses. Most of the published data is based on the use of a 22-gauge needle. The aim of this study was to evaluate our center's experience with a new disposable 25-gauge needle system in the diagnosis of solid pancreatic lesions. Methods: Our institution began utilizing this FDA approved 25-gauge EUS-FNA needle system (Echotip, Wilson Cook, Winston Salem, NC) in 2/2001. All patients referred for EUS evaluation of solid pancreatic mass between 2/2001 and 12/2002 were reviewed. Patient demographics, clinical history including follow-up, and pathology findings were recorded. Cytopathology was compared with operative histopathology in patients who had surgery. Patients who did not have surgery were followed clinically. Results: A total of 163 patients (mean age 66, 88 M/75 F) underwent EUS-FNA for solid pancreatic lesions using the 25-gauge needle. FNA was consistent with pancreatic malignancy in 48% (78/163) while 45% (74/163) had no evidence of malignancy. In the remaining 7% (11/163), biopsy was inconclusive. No complications were reported. Of the pancreatic cancer patients, 96% (75/78) had adenocarcinoma and 4% (3/78) had other malignancies. In the group with a definitive FNA diagnosis, 14% (23/163) underwent surgery and operative histopathology was compared with FNA cytopathology. There was one false-negative and no false-positive diagosis; and the sensitivity, specificity, PPV, and NPV were 94%, 100%, 100%, and 86% respectively. In the false-negative case, patient had cytologic evidence of chronic pancreatitis. In patients with an inconclusive FNA, 27% (3/11) had surgery and 2 had adenocarcinoma. The remaining 84% (137/163) of patients who did not undergo surgery were followed clinically. The mean survival for patients with a positive, negative, and inconclusive FNA was 11, 23, and 14 months respectively. Conclusions: 1. EUS-FNA using a 25-gauge needle system can accurately and safely provide a cytologic diagnosis of pancreatic masses. 2. The patient who had a false-negative FNA diagnosis had chronic pancreatitis, confirming previous reports that cytologic evaluation of pancreatic tissue in the setting of chronic inflammation can be difficult. 3. Studies with larger sample size and randomized arms are now needed to further assess the accuracy and complication rate of this smaller needle system.

7009 Endoscopic ultrasound guided fine needle aspiration of solid pancreatic lesions: one year md anderson cancer center experience.

Aim: A prospective evaluation of EUS-FNA of solid pancreatic lesions over a one-year period at a quarternary referral center. Methods: 104 consecutive patients undergoing EUS for suspected pancreatic malignancy at MDACC from 11/1/98 to 10/31/99 were prospectively entered into this study. Procedures were performed using the Pentax FG36-UX echoendoscope, Hitachi EUB-525 processor and Wilson-Cook EUS N-1 22 gauge FNA needle. Passes were made until the endosonographer felt adequate material had been obtained. The aspirate was collected by a cytopathology technician who smeared slides in the room. Examination of the slides was performed by a cytopathologist after the procedure had been completed. Final diagnosis was based on biopsy results, surgical specimen, or clinical follow-up. Data collected included size of mass, number of needle passes, complications of procedure, and final diagnosis. 20 patients with pancreatic cysts on EUS were excluded from further analysis. Results: The average age of patients was 64.6 years. The average size of the mass was 3.2cm (range 1.3 - 7cm). The average number of needle passes was 2.5 (range 1 - 5) per patient. No complications occurred. 79 of 84 patients had malignant pancreatic tumors. EUS-FNA correctly identified 73 while cytology showed atypia in one and suspicious for malignancy in another. In the remaining 4 malignant lesions, FNA was non diagnostic due to poor cellularity. There were no false positives. Of the 5 benign lesions, no mass was seen on EUS. 3 of the 5 benign lesions were shown to have chronic pancreatitis. Of the 4 patients with non - diagnostic FNA specimens later proven to be malignant, one had chronic pancreatitis with no mass seen on EUS while 3 had masses clearly identified by EUS. 2 of these 4 patients were found to have adenocarcinoma while the other 2 had a neuroendocrine tumor. Of the 2 patients with atypia or suspicious lesions, surgical resection specimen showed an islet cell carcinoma in one and adenocarcinoma in the other. Among patients in whom adequate cellularity was obtained (counting atypia and suspicious findings on FNA as signs of malignancy), the sensitivity, specificity, positive predictive value, negative predictive value and accuracy was 100%, 100%, 100%,100%, and 95% respectively. Conclusions: EUS-FNA in the hands of an experienced endosonographer is a remarkably powerful tool with a high sensitivity and specificity at diagnosing pancreatic cancer.