EUS-FNA Procedures Research Articles

Improved diagnostic yield of endoscopic ultrasound-fine needle biopsy with histology specimen processing.

BACKGROUNDEndoscopic ultrasound-guided fine needle biopsy (EUS-FNB) has emerged as a safe, efficacious alternative to fine needle aspiration (FNA) for tissue acquisition. EUS-FNB is reported to have higher diagnostic yield while preserving specimen tissue architecture. However, data on the optimal method of EUS-FNB specimen processing is limited.AIMTo evaluate EUS-FNB with specimen processing as histology vs EUS-FNA cytology with regards to diagnostic yield and specimen adequacy.METHODSAll EUS-FNA and EUS-FNB performed at our institution from July 1, 2016, to January 31, 2018, were retrospectively analyzed. We collected data on demographics, EUS findings, pathology, clinical outcomes, and procedural complications in two periods, July 2016 through March 2017, and April 2017 through January 2018, with predominant use of FNB in the second data collection time period. FNA specimens were processed as cytology with cell block technique and reviewed by a cytopathologist; FNB specimens were fixed in formalin, processed for histopathologic analysis and immunohistochemical staining, and reviewed by an anatomic pathologist. Final diagnosis was based on surgical pathology when available, repeat biopsy or imaging, and length of clinical follow up.RESULTSOne hundred six EUS-FNA and EUS-FNB procedures were performed. FNA alone was performed in 17 patients; in 56 patients, FNB alone was done; and in 33 patients, both FNA and FNB were performed. For all indications, diagnostic yield was 47.1% (8/17) in FNA alone cases, 85.7% (48/56) in FNB alone cases, and 84.8% (28/33) in cases where both FNA and FNB were performed (P = 0.0039). Specimens were adequate for pathologic evaluation in 52.9% (9/17) of FNA alone cases, in 89.3% (50/56) of FNB alone cases, and 84.8% (28/33) in cases where FNA with FNB were performed (P = 0.0049). Tissue could not be aspirated for cytology in 10.0% (5/50) of cases where FNA was done, while in 3.4% (3/89) of FNB cases, tissue could not be obtained for histology. In patients who underwent FNA with FNB, there was a statistically significant difference in both specimen adequacy (P = 0.0455) and diagnostic yield (P = 0.0455) between the FNA and FNB specimens (processed correspondingly as cytology or histology).CONCLUSIONEUS-FNB has a higher diagnostic yield and specimen adequacy than EUS-FNA. In our experience, specimen processing as histology may have contributed to the overall increased diagnostic yield of EUS-FNB.

An exclusive fine-needle biopsy approach to sampling solid lesions under EUS guidance: a prospective cohort study.

BackgroundEndoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is increasingly utilized to enhance the cytological yield of sampling solid lesions, but its superiority over existing fine-needle aspiration (FNA) platforms has not been clearly demonstrated. The aim of our study was to compare the diagnostic accuracy and procedural outcomes of FNB using a new Franseen-tip needle to that of a traditional FNA in sampling solid lesions under EUS guidance.MethodsConsecutive patients with solid lesions referred for EUS-FNB sampling were included. Procedure-related outcomes were collected prospectively including patient demographics, number of passes performed, diagnostic sample adequacy, adverse events, and recovery time. The Acquire needle was used to sample all lesions in the study group. Consecutive EUS-FNA procedures performed to sample solid lesions using the Expect needle were utilized as controls.ResultsThere were 180 patients undergoing EUS-FNB compared to 183 patients undergoing EUS-FNA procedures for solid-lesion sampling. The procedure time was significantly shorter in patients who underwent FNB compared to FNA (mean: 37.4 vs 44.9 minutes, P < 0.001). Significantly fewer passes were performed in the FNB cohort compared to the FNA group (mean: 2.9 vs 3.8, P < 0.001). The cytologic diagnostic yield was significantly higher in the FNB group compared to the FNA group (98.3% vs 90.2%, P = 0.003). No significant difference in the incidence of adverse events was observed between the FNB and FNA groups (1.1% vs 0.5%, P = 0.564).ConclusionsAn FNB-exclusive approach to sampling solid lesions under EUS guidance is safe and feasible, and may result in fewer overall passes, shorter procedure time, and improved diagnostic adequacy. FNB may replace FNA as the primary sampling modality of choice in all solid lesions.

2791 Metastatic Lesions to the Pancreas: A Tertiary EUS Center Experience

INTRODUCTION: Metastatic lesions of the pancreas present with varying clinical features and biological behaviors. They account for approximately 2% of all pancreatic lesions. This study was conducted to investigate metastatic pancreatic lesions distinctive clinical and EUS features compared to primary solid pancreatic neoplasms. METHODS: Patients who underwent EUS-FNA at a tertiary referral center between July 15th, 2011 and November 30th, 2017 for a solid pancreatic neoplasm were identified. Data on clinical features, cross-sectional imaging findings, EUS findings, and cytology results were collected. The clinical and EUS features in patients with metastatic pancreatic lesions were compared with those with intrinsic solid pancreatic tumors (adenocarcinoma and neuroendocrine tumors). RESULTS: 8 patients who underwent 9 EUS-FNA procedures were diagnosed with a metastatic pancreatic lesion while 184 cases of solid primary pancreatic neoplasms (157 adenocarcinomas and 27 neuroendocrine tumors) were found. 5 of 8 metastatic pancreatic lesions were renal cell carcinoma (62.5%). Patients in the metastatic pancreatic lesions group were less likely to present with abdominal pain (33.3% vs. 71.7%, P = 0.014). Patients with metastatic pancreatic lesions also had lower CA 19-9 values (mean value: 82.50 U/mL vs. 4374 U/mL) and more frequently manifested as having multiple pancreatic locations involvement (55.6% vs. 4.9%). CONCLUSION: The most common metastatic pancreatic lesion is renal cell carcinoma. The clinical manifestation of metastatic pancreatic lesion patients is more insidious and is mostly identified by using surveillance imaging to identify the primary malignancy. A high index of clinical suspicion is needed for diagnosing these cases.

113 Are Antibiotics Necessary for EUS-FNA of Pancreatic Cysts: A Retrospective Study

INTRODUCTION: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is commonly used to further characterize cystic lesions of the pancreas. Antibiotic prophylaxis has been recommended by the Americal Society for Gastrointestinal Endoscopy for EUS-FNA of cystic pancreatic lesions. The aim of this study was to compare the rate of post-procedural infection in patients who received periprocedural antibiotics for EUS-FNA of pancreatic cystic lesions versus those who did not. METHODS: A retrospective review of medical records of individuals with pancreatic cysts who underwent EUS-FNAs at a tertiary academic hospital between January 2015 and March 2018 was performed. All procedures were performed by four board-certified gastroenterologists. The data reviewed included patient demographics, cyst description, FNA needle size, cytology and use of antibiotics. Post-procedural infections were identified by the presence of leukocytosis, fever, or positive blood cultures during follow-up clinic or hospital visits for 30 days after FNA. Excluded from the study were solid neoplasms, obvious side branch intraductal papillary mucinous neoplasm without high risk features and subjects with evidence of infection or leukocytosis before the FNA. RESULTS: Two hundred and ten EUS-FNA procedures were included in this analysis. Ninety six were males and 114 were females; median age was 65 years. Cysts were 1–5 cm in diameter and evenly distributed throughout the pancreas. One hundred and fifteen of the 210 (55%) cysts were &gt;2 cm and 95 (44%) were &lt;2 cm. 27 out of 210 (13%) were pancreatitis related cysts. 22-gauge needle was used for 55% of the procedures with the remaining procedures using 19 and 25-gauge needles. Eighty nine of 210 (43%) patients received periprocedural antibiotics. Only one of the total 210 patients (0.4%) developed post-procedural gram-negative bacteremia related to EUS within 1 week of procedure. This patient had received periprocedural antibiotics. None of the patients in the “no antibiotic” group had post-procedural infections (Table 1). CONCLUSION: The evidence supporting universal use of antibiotics for all cystic lesions as recommended is lacking and overall infection risk with FNA is low, at approximately 0.3% based on small studies. Our study of 210 patients including pancreatitis related cysts demonstrate that routine use of antibiotics may not be required for FNA of pancreatic cysts. Further prospective studies may be required to support this.

Additive Benefit of Confocal Laser Endomicroscopy and Micro-Forceps Needle Biopsy in the Evaluation of a Mucinous Cystic Neoplasm

A 76 F presented with 6 months of abdominal pain and CT images of a pancreatic cyst. Multiple inconclusive EUS FNA procedures were performed at an outside hospital. We used a linear array echoendoscope to visualize the pancreatic parenchyma at our facility and then passed a confocal probe (AQ Flex) and micro-forceps (Moray needle) through a 19g needle (Cook Medical) into the cystic lesion. Initial on-site cytopathology evaluation of cyst fluid suggested atypical cells. Cyst fluid analysis subsequently demonstrated elevated CEA 8537 ng/mL and amylase 1788 U/L. The AQ flex probe was advanced along the cyst wall for CLE and the pattern demonstrated a single thick band suggestive of a mucinous cystic neoplasm (MCN). The micro forceps were advanced to that region and biopsy the cyst wall. Touch prep evaluation of the forceps biopsy and cell block analysis were positive for mucinous lesion. The patient received Cipro 400 mg IV during the procedure then discharged on 3-day oral course. She developed intense abdominal pain with syncope before outpatient resection. An outside hospital CT showed the pancreatic cyst with moderate amount of peripancreatic fluid with an intralesional linear density, possibly a stent or remnant of a biopsy apparatus. A distal pancreatectomy, splenectomy, left nephrectomy and left adrenalectomy was performed and revealed MCN with dysplasia measuring 8 cm with no invasive carcinoma. Margins were negative for tumor and no malignancy was identified in the lymph node sampled. Also obtained was the foreign body. At 2 week follow up, patient was doing well with no abdominal pain. We examined a pancreatic cyst case using EUS-FNA, CLE, micro-forceps needle biopsy and surgical pathology. This unique case report demonstrates the additive efficacy of EUS-FNA, CLE and micro-forceps biopsy for diagnosis. The case also describes a complication of retained foreign material within the cyst cavity; 19 g needle from the EUS device. Future prospective studies evaluating the added benefit of pancreatic cyst confocal and micro-biopsy are warranted. Additionally, it is important to note that many products utilized in clinical practice have not been designed for that specific purpose. The passage of the CLE probe and moray needle through the 19g needle at an appropriate echoendoscope position for cyst sampling may have resulted in breakage of the needle. Our institution now performs evaluations on devices after use as part of a post-procedure checklist.1382_A.tif Figure 1: CT of pancreas tail cystic lesion.1382_B.tif Figure 2: The dysplastic images show the mucinous cystic neoplasm with multilayered cells and nuclei that are coming off the basement membrane. There is also some nuclear pleomorphism as well. This is in contrast to the non-dysplastic image attached which shows a single layer of uniform cells. Note in both instances the ovarian type stroma underneath the epithelial layer, characteristic of a mucinous cystic neoplasm1382_C.tif Figure 3: FNA needle in the surgically resected pancreatic cyst specimen.

A223 FACTORS ASSOCIATED WITH EUS DIAGNOSTIC YIELD AND ADVERSE EVENT RISK: A LARGE RETROSPECTIVE SINGLE CENTRE STUDY

Maximizing endoscopic ultrasound (EUS) diagnostic yield (DY) and safety is key to providing high quality care, yet the influence of patient and procedure factors on both these outcomes have only been examined using limited sample sizes. We aim to examine factors associated with EUS diagnostic yield and adverse event (AE) risk using a large cohort of patients who underwent a EUS procedure at our centre. A retrospective chart review of EUS procedures performed between 2009 and 2015 at The Ottawa Hospital was conducted. Data regarding patient demographics and details of the lesion, procedure, medications, and DY were collected. All patient ER visits or hospitalizations within 30 days of the EUS procedure were also collected and reviewed. Relation of the hospital encounter (definitely, possibly, and not) to the EUS procedure was established by consensus using pre-defined criteria. 1647 EUS procedures were examined. The median patient age was 64 (IQR, 53–73) years and 50% were female. Of all EUS cases, 105 (6.4%) presented to the ER or were hospitalized; however, only 58 (3.5%) were related to EUS. DY was 78% for EUS-FNA cases only. Rapid on-site evaluation impacted DY (73% vs. 80%, p = 0.02) but not AE risk (p = 0.53). Multivariate analysis of all cases demonstrated performing a FNA (OR 2.1, 95% CI 1.0–4.4) and having anesthesia-guided sedation (OR 3.9, 95% CI 1.8–8.5) was associated with an increased AE risk. DY was associated being a smoker (OR 0.7, 95% CI 0.5–0.9). Upon separating out EUS-FNA procedures only, we found on multivariate analysis that lesions > 3 cm (OR 2.4, 95% CI 1.1–5.3), using anesthesia-guided sedation (OR 3.9, 95% CI 1.3–12.0), and using a P2Y12 inhibitor (OR 7.9, 95% CI 2.5–25.1) was associated with an increased AE risk. Solid lesions (OR 2.0, 95% CI 1.1–3.6) and lesions > 3 cm (OR 1.9, 95% CI 1.2–3.2) were associated with an increased DY. Lesions > 3 cm should be subject to fewer FNA passes to decrease AE risk. EUS procedures on patients who expect to receive anesthesia-guided sedation should be reconsidered. Finally, patients receiving P2Y12 inhibitors should not be subject to FNA, unless their medication is stopped. Table 1. Factors associated with adverse events within 30 days of EUS procedure diagnostic and yield, multivariate analysis. Table 1. Factors associated with adverse events within 30 days of EUS procedure diagnostic and yield, multivariate analysis. None

The Application of EUS-guided FNA in the Diagnosis of Pancreatic Neoplasms in the Elderly

Summary Background Endoscopic ultrasound guided fine needle aspiration has become a standard procedure in diagnosis of pancreatic neoplasms with a high diagnosis yield. However, the clinical application focusing on the elderly population is scanty. Methods Consecutive procedures for EUS-FNA diagnosis of pancreatic neoplasms at a tertiary referral center from March 2014 to December 2015 were analyzed retrospectively. The procedures were divided into two groups according to their age, the control group consisted of patients ≤60 years old and the elderly groups consisted of patients >60 years old. The primary outcome is the accuracy of the diagnosis in the two groups. The secondary outcome is the safety during the procedure. Results A total of 28 EUS-FNA procedures were performed. The mean age of the control group was 48.7 years (n = 14) versus 70.2 years (n = 14) for the elderly cohort. Diagnostic accuracy of the EUS-FNA procedure in detecting malignant (true positive) and benign (true negative) lesions were higher in the control group (nonelderly: 85.7% vs. elderly: 50%; P = 0.046). There were two mild acute pancreatitis associated to the EUS-FNA procedures in the control group. Conclusion Although EUS-FNA is safe and well tolerated in the elderly patients, our study showed a lower EUS-FNA diagnosis accuracy in this group. Focal fibrotic changes in the pancreas associated with the elderly patients resembled that of chronic pancreatitis microscopically.

Validation of a realistic, simple, and inexpensive EUS-FNA training model using isolated porcine stomach.

Background and study aims: Trainees are required to learn EUS-FNA using a model before working with a patient. The aim of the current study was to validate a new training model developed for EUS-FNA. Patients and methods: Several fresh chicken tenderloins were embedded as target lesions in the submucosal layer of an isolated porcine stomach. The stomach was fixed to a plate with nails, and was placed in a tub filled with water. The primary endpoint was feasibility of the newly developed model for EUS-FNA training, evaluated as follows: 1) visualization of the target lesion with blinding for lesion location; 2) penetrability of the needle; 3) sampling rate of macroscopic specimen; and 4) ROSE capability. Secondary endpoints were its durability and utility for multiple EUS-FNA procedures during EUS-FNA training, and the ease and cost of preparing the model. Results: Six endoscopists (1 expert, 5 trainees) attempted EUS-FNA procedures using this model. The target lesion could be identified clearly, and EUS-FNA could be performed with realistic resistance felt. In addition, rapid on-site evaluation could be easily achieved. Based on 10 needlings by each endoscopist, adequate specimens for histology could be macroscopically taken with an average 85 % success rate. Visibility and maneuverability were maintained throughout all needlings. Preparation time for this model was less than 30 minutes with a total cost of $ 22. Conclusions: An easy-to-use and inexpensive training model with a realistic feel of needling was created. This model can potentially enable beginners to practice safe and effective EUS-FNA procedures.

PTU-144 EUS in The Diagnosis and Staging of Lung Cancer: Single Centre Experience at Glasgow Royal Infirmary

Introduction Lung cancer is the leading cause of cancer related death in the Western World. 1 Accurate staging is required to identify those patients with localised Non Small Cell Lung Cancer (NSCLC) who have resectable disease. Patients with Small Cell Lung Cancer (SCLC) or T4,N2-3 or M1 NSCLC are not suitable for surgery. Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) can help obtain a tissue diagnosis where Endobronchial Ultrasound (EBUS)-FNA or CT guided biopsy is not possible. 2 Methods We performed a retrospective search of prospectively recorded data on all patients who were referred for EUS-FNA between 2012 and 2015 for the following indications: Suspicious lung mass with or without associated lymphadenopathy. This group has been subdivided into those who underwent EUS-FNA to obtain a tissue diagnosis and those who already had a tissue diagnosis and the EUS-FNA was performed for tumour staging. Suspicious mediastinal or epigastric lymph nodes alone. This group has been subdivided into those for whom EUS-FNA was performed to investigate possible recurrence of previously resected lung cancer and those who had unexplained mediastinal or epigastric lymphadenopathy. Procedure: The EUS-FNA procedures were all undertaken by AJS or SP, with a 22 g FNA needle (Cook Ltd), using a standard linear echoendoscope with ultrasound (Pentax Ltd & Hitachi Ltd). We collected data on patient demographics, EUS findings and procedures, cytology and prior pathology and radiology using our electronic clinical reporting system Results 35 patients were referred for EUS-FNA for the diagnosis or staging of lung cancer during the study period. 2 patients were unsuitable candidates. 25 patients had a suspicious lung mass and 8 had suspicious lymph nodes alone. In the group with a suspicious lung mass, EUS-FNA led to a diagnosis of lung cancer in 15 patients with 7 patients having benign pathology. 3 patients already had a diagnosis of lung cancer; EUS-FNA led to upgrading of tumour stage in 1 patient. In the group with suspicious lymph nodes alone, 3 diagnoses of lung cancer were made. Of the remaining 5 patients, 4 had benign pathology and 1 had gastric cancer. No procedural complications were encountered in any patient. EUS-FNA therefore led to a diagnosis of lung cancer in 60% (18/30) of the cases referred without a prior diagnosis. Conclusion EUS-FNA is a useful modality in the diagnosis and staging of lung cancer when EBUS and/or CT guided biopsy fail to obtain a tissue diagnosis. References 1 Ferlay J, Shin HR, Bray F, et al . Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer . 2010 ;127:2893–917. 2 Colella S, Vilmann P, Konge L, et al . Endoscopic ultrasound in the diagnosis and staging of lung cancer. Endoscopic Ultrasound . 2014; 3 (4):205–212. Disclosure of Interest None Declared

Gastrointestinal Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy Specimens: Adequate Diagnostic Yield and Accuracy Can Be Achieved without On-Site Evaluation

Background: Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is the preferred method for biopsying the gastrointestinal tract, and rapid on-site cytological evaluation is considered standard practice. Our institution does not perform on-site evaluation; this study analyzes our overall diagnostic yield, accuracy, and incidence of nondiagnostic cases to determine the validity of this strategy. Design: Data encompassing clinical information, procedural records, and cytological assessment were analyzed for gastrointestinal EUS-FNA procedures (n = 85) performed at Vancouver General Hospital from January 2012 to January 2013. We compared our results with those of studies that had on-site evaluation and studies that did not have on-site evaluation. Results: Eighty-five biopsies were performed in 78 patients, from sites that included the pancreas, the stomach, the duodenum, lymph nodes, and retroperitoneal masses. Malignancies were diagnosed in 45 (53%) biopsies, while 24 (29%) encompassed benign entities. Suspicious and atypical results were recorded in 8 (9%) and 6 (7%) cases, respectively. Only 2 (2%) cases received a cytological diagnosis of ‘nondiagnostic'. Our overall accuracy was 72%, our diagnostic yield was 98%, and our nondiagnostic rate was 2%. Our results did not significantly differ from those of studies that did have on-site evaluation. Conclusion: Our study highlights that adequate diagnostic accuracy can be achieved without on-site evaluation.

Application of Endoscopic Ultrasonography in the Diagnosis and Treatment of Lower Gastrointestinal Disease

Application of Endoscopic Ultrasonography in the Diagnosis and Treatment of Lower Gastrointestinal Disease

Outcomes of single-dose peri-procedural antibiotic prophylaxis for endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions.

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a technique frequently used to diagnose solid and cystic lesions of the pancreas. Antibiotic prophylaxis has been recommended for EUS-FNA of pancreatic cystic lesions but is not universally observed. The most effective antibiotic and the most efficacious route and regimen of administration are also unknown. This cohort study was undertaken to evaluate whether single-dose piperacillin/tazobactam or ciprofloxacin given at the time of the procedure effectively prevents major adverse events and to audit the adherence to this protocol in the setting of EUS-FNA of pancreatic cystic lesions. Consecutive EUS-FNA procedures of pancreatic cystic lesions were performed at Concord Hospital and significant variables regarding the procedure and adverse events were recorded. Patients were also contacted by telephone to follow-up any subacute adverse events they may have experienced. Over a 30 month period (January 2010-July 2012), a total of 85 EUS-FNAs of pancreatic cysts were performed on 80 different patients. The mean age was 63.2 years (range 17-89 years; 58% females). Single-dose piperacillin/tazobactam IVs was administered to 87% of patients, while 12% of patients received ciprofloxacin IVs. No patients developed cyst infection, fever, or sepsis (0%) and one patient (1.2%) was hospitalised for self-limited nausea without adverse sequelae. Single-dose piperacillin/tazobactam at the time of EUS-FNA of pancreatic cysts is an effective prophylaxis of cyst infection or sepsis and can be conveniently given as a single-dose peri-procedurally without further oral antibiotics.

Mo1421 Molecular Analysis of EUS-FNA of the Pancreas: Is There a Better Needle?

Cytologic material collected during the EUS-FNA of the pancreas is being increasingly used for molecular testing. To date, no study has determined the ideal needle for procuring tissue for molecular analysis from EUS-FNA procedures of pancreatic mass lesions. The hypothesis of this study is that a larger gauge needle will procure more tissue than a smaller gauge needle and therefore yield more diagnostic material for molecular testing, independent of the preservative solution.

Performance of the forward-viewing linear echoendoscope for fine-needle aspiration of solid and cystic lesions throughout the gastrointestinal tract: a large single-center experience

A newly developed forward-viewing linear echoendoscope (FV-EUS) has recently become available. To date, however, only scanty data on the performance of the FV-EUS scope for fine-needle aspiration (FNA) of lesions throughout the gastrointestinal (GI) tract are available. This study aimed to evaluate the technical performance of the FV-EUS scope for FNA of solid and cystic lesions located throughout the GI tract in a large cohort of patients referred to a tertiary care center. All patients who underwent endoscopic ultrasound (EUS)-guided FNA using the FV-EUS scope between January 2007 and December 2008 were included in this retrospective study. The performance of the FV-EUS scope for FNA was evaluated. During the study period, 285 patients with solid or cystic lesions throughout the GI tract underwent the procedure with the FV-EUS scope. A total of 300 FNAs were attempted, 6 (2%) of which could not be performed. Of the 294 successful EUS-FNA procedures, 130 (44.2%) were performed using a 22-gauge needle, 89 (30.3%) using a 25-gauge needle, and 75 (25.5%) using a 19-gauge needle. In all 67 cases of pancreatic cyst or dilated pancreatic duct, a specimen for cystic fluid analysis or cytologic examination could be obtained. Among the remaining 217 patients with solid lesion, a definitive diagnosis could be established for 211 patients (97.2%). The FV-EUS scope had a sensitivity of 74.7% (95% confidence interval [CI] 68.1-80.6%), a specificity of 100% (95% CI 89.9-100%), a positive likelihood ratio of infinity, and a negative likelihood ratio of 0.251 (95% CI 0.196-0.323). The FV-EUS scope is highly effective for FNA of solid and cystic lesions throughout the GI tract. Prospective studies comparing the FV-EUS scope and a curved linear scope are needed.

Practice patterns in FNA technique: A survey analysis.

To ascertain fine needle aspiration (FNA) techniques by endosonographers with varying levels of experience and environments. A survey study was performed on United States based endosonographers. The subjects completed an anonymous online electronic survey. The main outcome measurements were differences in needle choice, FNA technique, and clinical decision making among endosonographers and how this relates to years in practice, volume of EUS-FNA procedures, and practice environment. A total of 210 (30.8%) endosonographers completed the survey. Just over half (51.4%) identified themselves as academic/university-based practitioners. The vast majority of respondents (77.1%) identified themselves as high-volume endoscopic ultrasound (EUS) (> 150 EUS/year) and high-volume FNA (> 75 FNA/year) performers (73.3). If final cytology is non-diagnostic, high-volume EUS physicians were more likely than low volume physicians to repeat FNA with a core needle (60.5% vs 31.2%; P = 0.0004), and low volume physicians were more likely to refer patients for either surgical or percutaneous biopsy, (33.4% vs 4.9%, P < 0.0001). Academic physicians were more likely to repeat FNA with a core needle (66.7%) compared to community physicians (40.2%, P < 0.001). There is significant variation in EUS-FNA practices among United States endosonographers. Differences appear to be related to EUS volume and practice environment.

Transesophageal Ultrasonography for Lung Cancer Staging: Learning Curves of Pulmonologists

Accurate mediastinal nodal staging is essential for patients with resectable non-small-cell lung cancer and is achieved by combined endobronchial ultrasound and transesophageal endoscopic ultrasound (EUS). Training requirements for EUS-guided fine-needle aspiration (FNA) for lung cancer staging are unknown. Pulmonologists from Denmark and The Netherlands were enrolled in a dedicated, supervised training program. They performed standardized EUS-FNA procedures for mediastinal nodal analysis and their performances were assessed by EUS experts using a validated EUS assessment tool. Data were collected prospectively and used to plot learning curves and relate these to procedures performed by experienced investigators. Four participants performed 91 EUS-FNA procedures (range, 19-24). The performances of the participants improved significantly and became more consistent, but were still highly variable even in the latter part of the learning curves. Only two of the participants reached the mean score of experienced operators-after 17 and 23 procedures, respectively. Pulmonologists with knowledge of lung cancer staging and experience in bronchoscopy quickly improved their performance of EUS-FNA. However, acquisition of skills varies between individuals, and certification should be based on assessment of performance of multiple cases. Twenty procedures were not enough to secure consistent and competent performance of all trainees.

Forward-view Endoscopic Ultrasound: A Systematic Review of Diagnostic and Therapeutic Applications.

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and therapeutic procedures have been performed by a curved linear array (CLA) echoendoscope since the early 1990's. This particular echoendoscope, allowing real time visualization of aspiration needles and of other devices, has substantially remained unchanged since its introduction to the market. In a context of rapidly expanding indications for EUS-guided procedures, a dedicated forward view (FV) echoendoscope has been developed and tested under different clinical conditions. The FV echoendoscope is equipped with front endoscopic and EUS view, allowing deployment of needles and other devices through the working channel in straight direction. Several new diagnostic and therapeutic applications may thereby potentially be feasible with the FV echoendoscope and the established ones may prove easier to accomplish. The published literature with the FV echoendoscope has been systematically reviewed and the results are presented analytically and discussed in detail. EUS-FNA and therapeutic procedures, including pancreatic pseudocyst drainage, treatment of gastric fundal varices, celiac plexus neurolysis, and duct drainage were reported. The FV echoendoscope showed some unique advantages, opening new possibilities such as EUS-FNA in difficult gastrointestinal tracts and combined endoscopic/EUS treatment with frontal approach. However, no statistically significant evidence of superiority of the FV echoendoscope vs. the CLA echoendoscope was found in pancreatic pseudocyst drainage. No complications specifically attributable to the use of the FV echoendoscope were reported.

Implementation of Telecytology for Immediate Assessment of Endoscopic Ultrasound-Guided Fine-Needle Aspirations Compared to Conventional On-Site Evaluation: Analysis of 240 Consecutive Cases

Objective: To evaluate the implementation of telecytology in an academic cytology service for immediate assessment of endoscopic ultrasound (EUS) and endobronchoscopic ultrasound (EBUS) fine-needle aspiration (FNA). Study Design: Telecytology was evaluated over a 10-month period. Using an Olympus BX41® microscope and an Olympus DP72® camera with Olympus cellSens® software, real-time dynamic images of air-dried Diff-Quik®-stained smears were transmitted by a cytopathology fellow or cytotechnologist using a secure internet connection. The cytopathologists remotely accessed the real-time images on a computer in their office and rendered immediate assessments. Mean procedure times, and preliminary and final diagnoses were compared between telecytology and conventional on-site evaluation. Results: Two hundred and forty consecutive EUS-FNA and EBUS-FNA procedures with immediate assessments were performed during the evaluation period, of which 158 (66%) utilized telecytology and 82 (34%) did not utilize telecytology. The mean procedure time required for cytotechnologists and cytology fellows was 1.1 h for both conventional on-site and telecytology evaluations. The mean procedure time for cytopathologists was 0.74 h for conventional on-site evaluations and 0.2 h for telecytology. Conclusions: Incorporation of telecytology for immediate assessment of EUS-FNA increased cytopathologist efficiency.

Comparison of endoscopic ultrasonography‐guided fine‐needle aspiration cytology results with and without the stylet in 3364 cases

Endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNA) is traditionally carried out with the stylet, as it is believed to prevent blockage or contamination of the needle by tissue coming from the gastrointestinal wall. However, this recommendation has not been demonstrated on an empirical basis. The aim of the present study was to compare the yield of EUS-FNA in a very large series of patients with (S+) and without (S-) the stylet. Until 2004, the stylet was used for EUS-FNA in our center. After that, the stylet was never used. The results of all EUS-FNA in solid lesions carried out by one endosonographer with the same needle type were compared before and after stylet use was stopped. 3364 EUS-FNA procedures (in 3078 patients) in solid lesions were included (1483 S+ and 1881 S-). There was no significant difference between the S+ and S- results for any variable other than the number of passes required. The number of passes was significantly lower in the S- group when sampling lymph nodes, wall lesions and when carrying out biopsies through the gastric or rectal wall. However the statistical differences disappeared after controlling for malignancy, location and lesion size. This very large comparative study showed no benefit in diagnostic yield when using the stylet for EUS-FNA.

OC-112 Utility of cyst fluid amylase in the differentiation of suspected pancreatic neoplastic cysts

IntroductionThe Differentiation of mucinous (MCA, IPMN) from non-mucinous pancreatic cysts is important because of the malignant potential of the former. Cyst fluid amylase is known to be elevated in cysts...