Endoscopic Ultrasound-guided Fine-needle Aspiration Biopsy Research Articles

Pancreatic Cystic Neoplasms: Management and Unanswered Questions

Approximately 10% of persons 70 years old or older are now diagnosed with pancreatic cysts, but it is not clear which ones require additional analysis, interventions, or follow-up. Primary care doctors rely on gastroenterologists for direction because no one wants to miss a diagnosis of pancreatic cancer, but meanwhile there is pressure to limit use of diagnostic tests and limit costs. We review the different cystic neoplasms of the pancreas and diagnostic strategies based on clinical features and imaging data. We discuss surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines. Intraductal papillary mucinous neoplasm (particularly the branch duct variant) is the lesion most frequently identified incidentally. We report what is known about its pathology, its risk of developing into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk. We also review surgical treatment and strategies for surveillance of pancreatic cysts.

Endoscopic Ultrasound–Guided Biopsy of Pancreatic Metastases

This study aimed to describe a single-center experience with endoscopic ultrasound (EUS) features as well as the diagnostic role and clinical impact of EUS-guided fine-needle aspiration (EUS-FNA) and Trucut biopsy (EUS-TCB) in patients with pancreatic metastases. Demographic, clinical, EUS, pathological, clinical outcome, and follow-up data of patients who underwent EUS at our institution between October 1998 and March 2010 for a known or suspected pancreatic metastasis were abstracted. Forty-nine patients (23 males; median age, 63 years; range 30-83 years) with 72 pancreatic masses were identified. Primary tumor sites included kidney (21), lung (8), skin (6), colon (4), breast (3), small bowel (2), stomach (2), liver (1), ovary (1), and bladder (1). Of the 72 pancreatic lesions, EUS-FNA of 49 was performed (median, 4.1 passes; range, 2-9 passes) without complications. An EUS-TCB after EUS-FNA was performed in 2 patients and confirmed renal cell carcinoma in one and was nondiagnostic in one. The EUS-FNA provided the first diagnosis of "recurrent malignancy" in all the 44 patients at a median time of 65 months (range, 1-348 months) after diagnosis of the primary tumor. Endoscopic ultrasound-FNA and EUS-TCB may assist with the cytological diagnosis of pancreatic metastases and may have a major clinical impact.

Metastases of Renal Cell Carcinoma to the Thyroid Gland with Synchronous Benign and Malignant Follicular Cell-Derived Neoplasms

Clear cell renal cell carcinoma (CCRCC) is the most common origin for metastasis in the thyroid. A 51-year-old woman was referred to our hospital for a subcarinal lesion. Ten years before, the patient had undergone a nephrectomy for CCRCC. Whole-body fluorodeoxyglucose positron emission tomography revealed elevated values in the thyroid gland, while the mediastinum was normal. An endoscopic ultrasonography-guided fine-needle aspiration biopsy of the mediastinal mass was consistent with CCRCC, and this was confirmed after resection. The thyroidectomy specimen also revealed lymphocytic thyroiditis, nodular hyperplasia, one follicular adenoma, two papillary microcarcinomas, and six foci of metastatic CCRCC involving both thyroid lobes. Curiously two of the six metastatic foci were located inside two adenomatoid nodules (tumor-in-tumor). The metastatic cells were positive for cytokeratins, CD10, epidermal growth factor receptor, and vascular endothelial growth factor receptor 2. No BRAF gene mutations were found in any of the primary and metastatic lesions. The patient was treated with sunitinib and finally died due to CCRCC distant metastases 6 years after the thyroidectomy. In CCRCC patients, a particularly prolonged survival rate may be achieved with the appropriate therapy, in contrast to the ominous prognosis typically found in patients with thyroid metastases from other origins.

EUS-FNAで確定診断し得た膵内副脾の1例

EUS-FNAで確定診断し得た膵内副脾の1例

Two cases of distal duodenal gastrointestinal stromal tumor diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy

Two cases of distal duodenal gastrointestinal stromal tumor diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy

Ultrasound-guidedvsendoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer diagnosis

To clarify the effectiveness and safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for the diagnosis of pancreatic cancer (PC). Patients who were diagnosed with unresectable, locally advanced or metastatic PC between February 2006 and September 2011 were selected for this retrospective study. FNA biopsy for pancreatic tumors had been performed percutaneously under extracorporeal ultrasound guidance until October 2009; then, beginning in November 2009, EUS-FNA has been performed. We reviewed the complete medical records of all patients who met the selection criteria for the following data: sex, age, location and size of the targeted tumor, histological and/or cytological findings, details of puncture procedures, time from day of puncture until day of definitive diagnosis, and details of severe adverse events. Of the 121 patients who met the selection criteria, 46 had a percutaneous biopsy (Group A) and 75 had an EUS-FNA biopsy (Group B). Adequate cytological specimens were obtained in 42 Group A patients (91.3%) and all 75 Group B patients (P = 0.0192), and histological specimens were obtained in 41 Group A patients (89.1%) and 65 Group B patients (86.7%). Diagnosis of malignancy by cytology was positive in 33 Group A patients (78.6%) and 72 Group B patients (94.6%) (P = 0.0079). Malignancy by both cytology and pathology was found in 43 Group A (93.5%) and 73 Group B (97.3%) patients. The mean period from the puncture until the cytological diagnosis in Group B was 1.7 d, which was significantly shorter than that in Group A (4.1 d) (P < 0.0001). Severe adverse events were experienced in two Group A patients (4.3%) and in one Group B patient (1.3%). EUS-FNA, as well as percutaneous needle aspiration, is an effective modality to obtain cytopathological confirmation in patients with advanced PC.

Gastric Schwannoma Diagnosed by Endoscopic Ultrasonography-Guided Trucut Biopsy

Schwannomas of the gastrointestinal (GI) tract are rare subepithelial tumors comprising approximately 3.3% to 12.8% of all mesenchymal tumors of the GI tract. On endoscopic ultrasound (EUS) they are seen as hypoechoic tumors arising most commonly from the 4th proper muscle layer. Although EUS helps to distinguish tumor characteristics, tissue sampling is required for differentiation with other more common tumors such as GI stromal tumors. Both EUS-guided fine needle aspiration and EUS-guided trucut biopsy (EUS-TCB) can be used for tissue sampling. However, only EUS-TCB allows core biopsy and a high yield of immunohistochemical staining. We report a case of a gastric schwannoma diagnosed by EUS-TCB.

A case of small-cell lung cancer with recurrence of solitary pancreatic metastasis detected by FDG-PET/CT

A 63-year-old man visited an outpatient clinic complaining of 3-month continuous cough and left chest pain. He was diagnosed as having small-cell lung cancer with limited disease in the left lung by the bronchoscopy, enhanced CT, FDG-PET/CT and enhanced brain MRI. He received a regime of chemotherapy consisting of six cycles of carboplatin and etoposide with concurrent radiation therapy of 60 Gy. He was evaluated as showing complete response, and prophylactic cranial irradiation was performed. Nine months later, while routine enhanced CT could not detect obvious relapse in the pancreas, abnormal uptake at the pancreas head was detected in fluorine-18 fluorodeoxyglucose positron emission tomography (F-18-FDG-PET)/computed tomography (CT). Transgastric endoscopic ultrasound-guided fine-needle aspiration biopsy of the pancreas head was carried out, which showed small-cell carcinoma. Immunohistochemical staining was positive for thyroid transcription factor-1, synaptophysin, chromogranin A and notably of AE1/AE3. Thus, the patient was diagnosed as having a recurrence of small-cell lung cancer with pancreatic metastasis. He received another four cycles of carboplatin and etoposide for sensitive relapse. The tumor was diminished and showed partial response. We have to be aware of the possibility of solitary metastasis to the pancreas from lung cancer. FDG-PET/CT may be useful for early detection of pancreatic metastasis, leading to the early diagnosis and precise therapy.

Margin-negative limited resection of metastatic pancreatic tumors from rectal cancer preoperatively diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsies: report of two cases

Pancreatic tumor metastasis from colorectal cancer is very rare. This study evaluated the significance of an endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) and surgical treatment. Case 1 was a 67-year-old male with a history of rectal cancer (6 years ago) and lung metastases (5 years ago) who had two masses in the pancreatic head and body. Case 2 was a 58-year-old male with the history of rectal cancer and simultaneous lung metastasis (7 years ago) who had a mass in the pancreatic body. Imaging studies showed stenosis of the pancreatic duct with distal dilatation in both cases, mimicking primary pancreatic cancer. An EUS-FNAB with immunohistochemical staining made a definitive diagnosis of pancreatic metastasis from rectal cancer. Both patients received margin-negative limited resection, middle-segment-preserving pancreatectomy and distal pancreatectomy, respectively, and were alive 16 and 6 months after pancreatectomy, respectively. An EUS-FNAB is helpful to make a definitive diagnosis of pancreatic metastasis and in determining the subsequent therapeutic approach.

Mucosal cutting biopsy technique for histological diagnosis of suspected gastrointestinal stromal tumors of the stomach

The Japanese Gastrointestinal Stromal Tumor (GIST) therapeutic guidelines recommend endoscopic ultrasound-guided fine-needle aspiration biopsy for histological diagnosis. However, before 2010, this technique was only carried out at a minority of medical institutions in Japan. In the present study, we investigated the usefulness of mucosal cutting biopsy. In 18 asymptomatic gastric submucosal tumors, mucosal cutting biopsies were carried out. We examined tumor size, tumor site (lower third: L; middle third: M; upper third: U), histopathological diagnostic yield and complications. In cases that proceeded to surgical resection with a diagnosis of GIST, we compared the pre- and postoperative histopathological diagnosis, and the histological degrees of malignancy. The tumors had a mean size of 20.3 mm and were located at the L site in five cases, M in four, and U in nine. Histological diagnosis of submucosal tumor was obtained in all the cases. (GIST, n = 13; heterotopic pancreas, n = 2; and leiomyoma, n = 3). No complications (e.g. bleeding, perforation or peritonitis) were seen after this procedure. In all 11 patients with GIST who underwent surgical resection, the histopathological findings from the mucosal cutting biopsy specimens were similar to those from the surgically resected specimens, with agreement between the immunostaining findings and the histological degree of malignancy (90.9%) in 10 patients. The mucosal cutting biopsy technique is a useful diagnostic modality for the diagnosis of gastric GIST and for selection of the appropriate treatment.

EUS-FNA Diagnosis Using Pro-Core Needle for Fine Needle Biopsy (FNB) and EUS-Tattooing of a Small Pancreatic Tumor for Laparoscopic Localization

Context Endoscopic ultrasonography (EUS) can show pancreatic tumors of few millimeters; nowadays, in the years of laparoscopic approach, the most difficult and time-consuming issue can be how to identify a tumor throughout the pancreatic parenchyma in order to select the site where to transect the pancreas. Preoperative EUS-tattooing could be of help in locating small pancreatic tumors during pancreatic resections. Case report Because of the onset of recurrent mild abdominal pain and diarrhea lasting for 4 months, a 70-year-old woman performed a trans-abdominal US that showed a hypoecogenic area of about 7 mm in the body of the pancreas. She had no other significant medical history or laboratory index. A CT-scan did not reveal any lesion throughout the pancreas. EUS examination (using a linear echoendoscope Fujinon) confirmed a hypoecogenic, solid, irregular mass of the body of the pancreas of about 7x4 mm. An EUS-guided fine-needle aspiration biopsy of the lesion was performed with a 22-gauge ProCore needle (Cook) and then, EUS-guided tattoo was performed using a 22 gauge EchoTip needle: the needle was inserted 3-5 mm proximal to the lesion and 2 mL of sterile purified carbon particles were injected under direct visualization. The patient received pre-procedural i.v. ciprofloxacin and no complications were observed. Cytological examination reported cells suspicious for adenocarcinoma. Nineteen days later, the patient underwent a laparoscopic left pancreatectomy. Ink was clearly visible on the anterior surface of the pancreas. Operative time was 110 minutes. Postoperative outcome was uneventful. Pathologic evaluation revealed a ductal adenocarcinoma of 5 mm in diameter with 17 negative nodes. Distance between pancreatic resection margin and cancer was 15 mm. Conclusions Preoperative EUS-tattooing could facilitate laparoscopic localization of small lesions. Further studies to assess safety, indications and limits are needed.

Pancreatic neuroendocrine neoplasm: correlation between computed tomography enhancement patterns and prognostic factors of surgical and endoscopic ultrasound-guided fine-needle aspiration biopsy specimens

To retrospectively determine whether enhancement patterns in the pancreatic and equilibrium phases of computed tomography (CT) for pancreatic neuroendocrine neoplasms are related to prognostic factors of surgical and endoscopic ultrasound-guided fine-needle aspiration biopsy specimens. Twenty-five pancreatic neuroendocrine neoplasms in 22 patients underwent preoperative dynamic CT. Tumors were classified into two groups by enhancement patterns on preoperative CT. A washout pattern was defined as peak enhancement in the pancreatic phase with washout of at least 60 Hounsfield units in the equilibrium phase. Group 1 comprised tumors showing a washout pattern in more than half of tumor and Group 2 comprised tumors showing a washout pattern in less than half of the tumor. The Ki-67 index and the presence of vascular invasion were evaluated in surgical specimens. The Ki-67 index from biopsy specimens was compared with that from surgical specimens. There were 12 surgical specimens in Group 1 and 13 in Group 2. Group 2 showed significant correlations with larger Ki-67 indices (p < 0.05) and positive vascular invasion (p < 0.05). The Ki-67 index discrepancy between biopsy and surgical specimens of Group 2 was significantly greater than that of Group 1 (p < 0.05). Pancreatic neuroendocrine neoplasms in which less than half of the tumor showed a washout pattern were correlated with poor prognostic factors. Analysis of enhancement patterns may provide predictive information about whether endoscopic ultrasound-guided fine-needle aspiration biopsy is reliable for the assessment of Ki-67 index.

Effectiveness of combined endoscopic ultrasound-guided fine-needle aspiration biopsy and stenting in patients with suspected pancreatic cancer

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) can be coupled with endoscopic retrograde cholangiopancreatography in the same setting when biliary and/or duodenal stenting are required. Our aim was to examine the effectiveness of EUS-FNA combined with stenting during the same session in patients with pancreatic cancer. Consecutive patients referred for EUS-FNA of a pancreatic mass with symptoms of biliary (±upper digestive) obstruction were included. Consecutive patients undergoing biliary and/or duodenal stenting without EUS-FNA during the same period were used as controls. Procedure-related complications were the primary outcome measure. Duration of the procedure, ability to achieve biliary/duodenal stenting, the yield of EUS-FNA, and clinical outcomes were evaluated. A total of 122 patients underwent combined EUS-FNA and stenting and 68 underwent stenting alone (control group). In the combined group, histological proof of cancer was obtained in 88.52% at first EUS-FNA and 95.08% after a second EUS-FNA. Biliary stent placement was successful in 97.5 and 98% in the combined and the control groups, respectively. There was no statistical difference between the groups for length of stay after endoscopy and for procedure-related mortality and morbidity within 30 days. The median time from endoscopy to chemotherapy in the combined group was 12 days. Combined EUS-FNA and biliary and/or duodenal stenting is feasible in almost all patients with suspected pancreatic cancer, with no additional hazard and a high histological yield.

Diagnosis of Gastric Glomus Tumor by Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy

Diagnosis of Gastric Glomus Tumor by Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy

Prospective evaluation of the optimal number of 25‐gauge needle passes for endoscopic ultrasound‐guided fine‐needle aspiration biopsy of solid pancreatic lesions in the absence of an onsite cytopathologist

A prior study with 22-gauge needles recommended more than seven needle passes for endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) of solid pancreatic lesions (SPL) without onsite cytopathology for optimal acquisition of cytopathological diagnosis. The feasibility of this recommendation should be re-evaluated considering the later development and popularity of 25-gauge EUS-FNA needles. We aimed to determine the optimal number of needle passes for cytopathological specimen acquisition with 25-gauge needles for EUS-FNA of SPL. A preliminary prospective study of 22 patients with an onsite cytopathology technician showed a sensitivity of 93.3% and a specificity of 100% with four needle passes that was not statistically different from five needle passes. Based on our preliminary study, we fixed the number of needle passes to four (Group A). As a control group, we carried out sampling in consecutive patients using 25-gauge needles with an onsite cytopathologist (Group B). Sampling rate, diagnostic value and complications were evaluated. We enrolled 20 patients in each group. Sampling rate was higher in Group B (20/20, 100%) than in Group A (19/20, 95%), but there was no statistical difference between them (P-value = 0.31). In Group A, sensitivity, specificity and accuracy were 100% among 19. In Group B, sensitivity was 94.1%, specificity 100%, accuracy 95%. There were also no statistical differences between the groups. No complications were seen. Our study suggests that four needle passes using a 25-gauge needle may be sufficient for EUS-FNA of SPL where onsite cytology is not available.

Best Practices in Endoscopic Ultrasound–Guided Fine-Needle Aspiration

Over the past 2 decades, endoscopic ultrasound-guided fine-needle aspiration has evolved to become an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. The technique is useful for biopsy of mucosal and submucosal lesions in which prior endoscopic biopsies have been nondiagnostic; to sample peri-intestinal structures such as lymph nodes; and to sample masses in the pancreas, liver, adrenal glands, gallbladder, and bile duct. Also, with the advent of neoadjuvant therapies for diseases such as pancreatic cancer, most patients require a tissue diagnosis before initiating treatment. This review provides a perspective on technical issues that are key for best practices in endoscopic ultrasound-guided fine-needle aspiration.

Su1361 Pancreatic Juice Cytology Strengthen the Diagnostic Ability of Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy for Pancreatic Carcinoma

Endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNA) can now provide a cytopathological diagnosis of pancreatic malignancy with higher success rates. However EUS-FNA can not detect minimal invasive carcinoma and intraductal papillary mucinous carcinoma (IPMC). Recent study has shown the usefulness of pancreatic juice cytology for pancreatic cancer. In present study therefore we retrospectively evaluated if pancreatic juice cytology strength the diagnostic power of EUS-FNA in pancreatic masses.

A case report of benign esophageal schwannoma with FDG uptake on PET-CT and literature review of 42 cases in Japan

We report a rare case of benign esophageal schwannoma showing [18F]-fluorodeoxyglucose (FDG) uptake on positron emission tomography computed tomography (PET-CT). A 43-year-old woman diagnosed with left breast cancer was referred to our hospital for further treatment. Preoperative PET-CT showed a significant accumulation [maximum standardized uptake value (SUVmax) 2.5] in the upper thoracic esophagus. Endoscopy revealed a submucosal tumor about 40 mm in size in the upper thoracic esophagus. Endoscopic ultrasonography-guided fine-needle aspiration biopsy did not reveal the histological diagnosis. The patient underwent thoracoscopic enucleation of the tumor. The resected tumor measured 40 × 20 mm. Microscopically, the tumor consisted of spindle cells. Immunohistochemistry was positive for S-100 and vimentin and was negative for KIT (CD117) and CD34. The final diagnosis was benign esophageal schwannoma.

Fine-Needle Aspiration Biopsy and Endoscopic Ultrasound for Pretreatment Pathological Diagnosis of Gastric Gastrointestinal Stromal Tumors

Background. Although it is possible to visualize gastrointestinal stromal tumors (GIST) of the stomach by endoscopy, their pretreatment histological diagnosis is often difficult. The aim of this study was to investigate predictors of accurate preoperative pathological diagnosis of gastric GIST. Material and Methods. We retrospectively studied patients with gastric GIST who had undergone pretreatment endoscopic biopsy and surgery, and examined their clinicopathological data. Results. Twenty-three patients were eligible. Thirty-four endoscopic biopsies (mean 2.6, range 1–8) were obtained. Preoperative pathological diagnoses of GIST were made in 18 patients. Precise diagnoses were made in 18 (52.9%) of the 34 biopsies. Endoscopic ultrasound (EUS) resulted in precise diagnoses in 11 (91.7%) of the 12 biopsy specimens. Fine-needle aspiration (FNA) biopsy resulted in precise diagnoses in 11 (84.6%) of the 13 biopsy specimens. The accuracy of pathological diagnosis by EUS-guided FNA biopsy was 100%. The procedure of EUS-guided FNA biopsy had no complications or recurrent disease. In a multivariate analysis, only EUS achieved a significantly superior rate of diagnosis (odds ratio, 11.884; 95% confidence interval, 1.204–289.230; P = 0.034). Conclusion. EUS-guided FNA biopsy is the most accurate for pretreatment pathological diagnosis of gastric GIST and for prevention of both of early complications and disease recurrence.

A Case of Metastatic Lymph Node of Invasive Cervical Cancer Diagnosed by Endoscopic Ultrasonography-Guided Fine Needle Aspiration Biopsy

Cervical cancer is the most common malignant gynecological cancer. The incidence and mortality of cervical cancer has been declining in developed countries, but it is still one of the most common cancers in women worldwide. Prognoses of cervical cancer are based on the stage, size, histologic grade of a primary tumor and metastasis of lymph node. CT, MRI, and 18 F-fluoro-2deoxyglucose (FDG) PET are widely utilized and effective for detecting early recurrence in cervical cancer. The lymph node metastasis of cervical cancer begins locally and spreads distantly. Metastasis of cervical cancer has been rarely assessed by means of EUS or EUS-guided fine needle aspiration biopsy (FNAB) as a form of subepithelial lesion of stomach. A 62-year-old female was referred to the department of gastroenterology for evaluation of a mass like gastric subepithelial tumor with high uptake of 18 F-FDG in PET-CT. Four years ago, the patient underwent a total abdominal hysterectomy with bilateral salphingo-oophorectomy for invasive cervical cancer. The specimen obtained by EUS-FNAB appeared to be pus. Finally, the lesion was diagnosed as metastatic squamous cell carcinoma originated from the previous invasive cervical cancer. The patient completely recovered after systemic chemotherapy for the metastatic lesion. (Korean J Helicobacter Up Gastrointest Res 2012;12:207-211)