Final Diagnosis Of Malignancy Research Articles

Single-session endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography for evaluation of pancreaticobiliary disorders

Endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) often are required in the evaluation and treatment of patients with pancreaticobiliary disorders. Few reports of single-session EUS-ERCP have raised questions regarding its safety and accuracy or about which procedure should be performed first. Data from 2005 to 2009 were reviewed from a prospectively maintained EUS-ERCP database at a single tertiary care cancer center. Sensitivity and specificity of EUS and fine-needle aspiration (FNA), bile duct cannulation rate, duration of procedure, and complications were evaluated. Of the 35 patients (15 men and 20 women) studied, 28 had a final diagnosis of malignancy, and 7 had benign disorders. All the patients underwent ERCP and EUS, with FNA performed for 28 patients (80%). For 22 of the 35 patients (62.8%), EUS was the first procedure performed. The sensitivity of EUS-FNA for malignancy was 96.4%. The bile duct cannulation rate during ERCP was 97.1%. Five patients required a precut sphincterotomy for bile duct access, and one patient with chronic pancreatitis had a failed cannulation despite a EUS-guided rendezvous. A stent was successfully placed in 29 patients (96%). No major complications occurred, and no contrast leak was seen when FNA was performed before the cholangiogram. One patient had periduodenal bleeding after FNA, which was managed conservatively. The mean duration of the procedure was 83.7 min. Single-session EUS-ERCP can be performed safely and with efficacy similar to that of the procedures performed separately.

Diagnostic efficacy and discriminatory capacity of positron emission tomography combined with axial tomography of adrenal lesions

IntroductionThe usefulness of 18fluorodeoxyglucose positron emission tomography combined with axial tomography (PET-CT) in diagnosing whether adrenal tumours are benign or malignant is assessed. Material and methodsA retrospective study conducted between June 2005 and May 2009 on a consecutive series of patients on whom a PET-CT scan was performed to study suspected malignant adrenal disease. Focal uptakes were assessed, along with the maximum standard uptake value (SUV), and the ratio of the maximum adrenal/hepatic value. The sensitivity, specificity, positive and negative predictive value of the test, the maximum adrenal uptake values and the ratio for those where the diagnostic yield was maximum. ResultsFifteen patients were included. The final diagnosis showed malignancy in eight and seven were benign. Ten patients had adrenal uptake: three in benign lesions and seven in neoplasias, with a mean uptake value of 6.3 (3.2 in benign lesions and 9.0 in malignant lesions). The mean adrenal/hepatic ratio was 1.8 (0.9 in benign and 2.6 in malignant lesions). When the presence of adrenal uptake is associated with a final diagnosis of malignancy, we obtained a sensitivity of 87.5%, a specificity of 57.1%, and a positive and negative predictive value of 70% and 80%, respectively. An SUV cut-off value of 6, or an adrenal/hepatic uptake ratio of 2, gave a sensitivity of 75%, a specificity of 100%, and a positive and negative predictive value of 100% and 77.7%, respectively. ConclusionsPET-CT has a high ability to discriminate between benign and malignant lesions in the adrenal disease studied.

Analysis of false-negative results after US-guided 14-gauge core needle breast biopsy

To determine the false-negative rate and to evaluate the clinical, radiologic or histologic features of false-negative results at ultrasound (US)-guided 14-gauge core needle biopsy (CNB). A total of 3,724 masses from 3,308 women who had undergone US-guided 14-gauge CNB and who had a rebiopsy or at least 2 years' follow-up were included. The histology of CNB was correlated with the rebiopsy or long-term imaging follow-up. In cases of missed cancer, the time interval between CNB and rebiopsy, the reasons for rebiopsy, and the procedural or lesion characteristics were analysed. Of 1,706 benign CNBs, 50 additional malignancies were found at excision (false-negative rate, 2.5% of 1,982 with a final diagnosis of malignancy). Of 50 false negatives, 41 were found immediately of which 28 had rebiopsy because of imaging-histological discordance. Regarding the frequency of malignancy according to the reasons for rebiopsy, suspicious imaging finding (24%) showed significantly higher frequency than suspicious clinical findings or request (1%). Regarding the characteristics except invasiveness, no significant differences in false-negative rates were found. Most false negatives were found immediately and imaging-histological discordance was the most important clue. Careful correlation of clinical, radiological and histological results as well as appropriate follow-up is essential.

Significance of chronic marked hyperglycemia on FDG-PET: is it really problematic for clinical oncologic imaging?

The purpose of this study was to evaluate the adverse effects of chronic marked hyperglycemia on clinical diagnostic performance of positron emission tomography (PET) using (18)F-fuorodeoxyglucose (FDG). Fifty-seven scans of 54 patients, who received FDG-PET for the diagnosis of various cancer(s), and who showed high plasma glucose level of more than 200 mg/dl at the time of administration of FDG in spite of at least 4-h fasting, were retrospectively analyzed. In the clinical follow-up, this high plasma glucose was confirmed as chronic hyperglycemia derived from uncontrolled diabetes (n = 32) and untreated diabetes (n = 25). Based on the final diagnosis of malignancy obtained by histopathology or clinical follow-up for at least 6 months, the diagnostic performance of visual PET analysis was evaluated. Excluding nine scans of nine patients without sufficient follow-up, final diagnosis was obtained in 48 scans of 45 patients. In 36 scans of 36 patients, at least one malignant lesion was finally confirmed, and true-positive and false-negative results were obtained in 30 and six cases, respectively. Six cases showed false-negative results due to low FDG-avid pathological characteristics (hepatocellular carcinoma, etc.), chemotherapeutic effect or small tumor size. Overall, the patient-based sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 83, 83, 94, 63 and 83%, respectively. In lesion-based diagnosis, 56 of 75 lesions (74%) were depicted by PET, while 19 lesions were negative on PET, also due to low FDG-avid characteristics or small size (less than 15 mm). At the time of chronic hyperglycemia (not acute hyperglycemia), the adverse effect caused by high plasma glucose level was minimum. The FDG uptake of the tumor maintained a sufficiently high level for visual clinical diagnosis in most cases, except in the cases of low FDG-avid tumors or small lesions (15 mm in size).

Endoscopic Ultrasound Guided Fine Needle Aspiration Biopsy in Diagnosis of Pancreatic and Peripancreatic Lesions: A Single Center Experience in Korea

Background/AimsAlthough endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has been introduced and its use has been increasing in Korea, there have not been many reports about its performance. The aim of this study was to assess the utility of EUS-FNA without on-site cytopathologist in establishing the diagnosis of solid pancreatic and peripancreatic masses from a single institution in Korea.MethodsMedical records of 139 patients who underwent EUS-FNA for pancreatic and peripancreatic solid mass in the year 2007, were retrospectively reviewed. By comparing cytopathologic diagnosis of FNA with final diagnosis, sensitivity, specificity, and accuracy were determined, and factors influencing the accuracy as well as complications were analyzed.ResultsOne hundred twenty out of 139 cases had final diagnosis of malignancy. Sensitivity, specificity, and accuracy of EUS-FNA were 82%, 89%, and 83%, respectively, and positive and negative predictive values were 100% and 46%, respectively. As for factors influencing the accuracy of FNA, lesion size was marginally significant (p-value 0.08) by multivariate analysis.ConclusionsEUS-FNA performed without on-site cytopathologist was found to be accurate and safe, and thus EUS-FNA should be a part of the standard management algorithm for pancreatic and peripancreatic mass.

Laparoscopic ultrasound-guided biopsy in upper gastrointestinal tract cancer patients

Noninvasive pretherapeutic staging may be supplemented with laparoscopy and laparoscopic ultrasonography (LUS) in order to detect minute liver metastases, carcinosis or other signs of nonresectable or disseminated disease in patients with upper gastrointestinal tract cancer (UGIC). The aim of this study was to evaluate the use, potential clinical gain, and safety profile of LUS-guided biopsy in patients with UGIC. A prospective consecutive study on LUS-guided biopsy in patients referred with UGIC between May 2007 and May 2008 was carried out. Previous noninvasive imaging methods had found no signs of disseminated disease. Laparoscopic or LUS-guided biopsies were only performed if a malignant result would change patient management. Two hundred and nine patients entered the study and, based on predefined biopsy indications, laparoscopy and LUS-guided biopsies changed patient management in a total of 27.3% (54/198) of the patients with a final malignant diagnosis. There were no complications. Liver and pancreas were the main target areas for LUS-guided biopsies, and more than half of the biopsies (55%) were taken from the primary tumor where other modalities had failed to obtain proof of malignancy. Twenty-six percent of biopsies were taken from a suspected metastatic lesion not seen before, whereas 19% were taken from previously suspected metastases where other imaging modalities had failed to obtain proof of malignancy. LUS-guided biopsy is a safe procedure which in combination with laparoscopic biopsies had an impact on patient management in one-quarter of UGIC patients.

Predictors of a Positive Yield On Brush Cytology Obtained By Endoscopic Retrograde Cholangiopancreatography (ERCP) for Diagnosis of Indeterminate Biliary Strictures

Background and Aims: Biliary brush cytology is an established diagnostic technique in the investigation of patients with indeterminate biliary strictures. Although the specificity of brush cytology is 100%, the sensitivity is low, ranging from 20-50% in most reports. The aim of this study was to determine the factors that are predictive of a positive yield on biliary brush cytology obtained during the initial ERCP for investigation of indeterminate biliary strictures. Methods: Patients who underwent ERCP with biliary brush cytology for investigation of indeterminate biliary strictures at the Cleveland Clinic during the period from 2005 to 2007 were identified. Only those in whom a definite final benign or malignant diagnosis had been determined were included. In patients with multiple brush samples, only the samples obtained at the initial ERCP were evaluated. The factors studied included: age, sex, location of the stricture, evidence of a mass on cross-sectional imaging, type of cancer (pancreatic vs biliary origin), and total serum bilirubin levels. Results: 280 patients met the inclusion criteria. 119 (42.5%) patients had a final diagnosis of malignancy. Of these, 55 had a positive brush cytology. The sensitivity and specificity of biliary brush cytology for diagnosis of malignancy were 46% and 100% respectively. Multivariable logistic regression analysis showed that the age of the subjects, total serum bilirubin levels, and evidence of a mass on cross-sectional imaging were independent predictors of a positive yield on brush cytology. The likelihood of a positive cytology result increased by 20% (OR 1.2 [95% CI: 1.06, 1.4]; p =0.007) for every 5 year increase in age, and 30% (OR 1.3 [CI 1.0, 1.6]; p = 0.04) for every 5 units increase in total serum bilirubin levels. Patients with a mass on cross-sectional imaging were almost 12 times (OR 11.7 [CI 5.1, 27.2]; p < 0.0001) more likely to have a positive brush cytology result compared to those without a mass. Conclusions: Increasing age, higher bilirubin levels, and evidence of a mass on cross-sectional imaging are independent predictors of a positive brush cytology result in patients with indeterminate biliary strictures. Presence of a mass on cross-sectional imaging has the strongest association with a positive yield on brush cytology in this group of patients. Clinical Implication: Young patients with suspicion of malignant biliary strictures but no mass on cross-sectional imaging studies require more extensive tissue sampling techniques such as cholangioscopy-guided targeted biopsies for diagnosis of indeterminate biliary strictures.

False-Negative Diagnoses at Stereotactic Vacuum-Assisted Needle Breast Biopsy: Long-Term Follow-Up of 1,280 Lesions and Review of the Literature

The purpose of this study was to determine retrospectively the frequency and causes of false-negative diagnoses of lesions evaluated with percutaneous stereotactic biopsy performed with vacuum-assisted probes with the patient prone on a biopsy table. The records of 1,152 women (median age, 55 years; range, 31-94 years) with 1,280 lesions consecutively biopsied with 14-gauge (n = 159) or 11-gauge (n = 1,121) vacuum probes were reviewed retrospectively. The histologic diagnoses were malignant (n = 489), high-risk (n = 117), and benign (n = 674) lesions. Benign lesions were evaluated with repeated biopsy (n = 46) or mammographic follow-up for 24 months or longer (n = 506) or less than 24 months (n = 57). In 65 cases (10% of all benign lesions), follow-up was not performed. Fisher's exact tests were used to correlate patient, mammographic, and biopsy variables with false-negative diagnoses. Of 508 lesions with a final diagnosis of malignancy, the initial needle biopsy diagnosis was malignant (n = 489), high-risk (n = 14), or benign (n = 5) lesion. The five false-negative diagnoses were related to gauge of the biopsy probe and specimen radiographic findings regarding calcifications but were not related to lesion type. False-negative diagnoses were made in 4.4% (three of 68) of cases in which 14-gauge vacuum biopsy was performed and in 0.45% (two of 440) of cases in which 11-gauge vacuum biopsy was performed (p = 0.019). False-negative diagnoses were made in 25% (one of four) of cases in which specimen radiographs showed no calcifications and 0.67% (two of 300) of cases in which they did show calcifications (p = 0.0390). False-negative diagnoses were made in 1.2% (three of 248) of cases of calcification lesions and 0.8% (two of 260) of cases of mass lesions (p = 0.679). False-negative findings at stereotactic biopsy were least common with 11-gauge probes and were similar in frequency for calcifications and masses.

Conservative Management of Postoperative Fever in Gynecologic Patients Undergoing Major Abdominal or Vaginal Operations

To develop a standardized protocol for management of postoperative fever in gynecology patients to decrease unnecessary diagnostic workups and empiric use of antibiotics. A prospective analysis of postoperative gynecology patients identified those who experienced fever (maximum temperature [T(max)] > 100.4 degrees F). Patients were triaged into low- and high-risk groups. High-risk patients were managed independent of the protocol. High-risk criteria included bowel operation, preoperative infection, immunodeficiency, indwelling vascular access, mechanical heart valves, and intensive care unit admissions. Low-risk patients were treated with observation and antipyretics. Patients with persistent or high fever, defined as T(max) > 101 degrees F for > 48 hours, were evaluated and treated based on physical examination findings. We evaluated 292 postoperative patients. Forty-seven percent of patients had a final diagnosis of malignancy. Sixty-four patients were high-risk and 33% of these patients experienced fever. Using the standardized protocol, 228 low-risk patients were managed. Thirty-seven of the 228 patients (16%) had fever postoperatively. Nineteen patients had low-grade fever (100.4 to 101 degrees F); none of these patients required antibiotics. Seventeen patients had fever (101.1 to 102 degrees F) and one patient had fever > 102 degrees F. Using the protocol, 6 of 37 patients (16%) were treated with antibiotics for an infectious diagnosis. Although postoperative fever is common in gynecologic patients, the incidence of infection is low (3%). A standardized postoperative fever protocol in low-risk gynecology patients decreases use of empiric antibiotics without compromising morbidity.

Clinical Significance of Dilated Common Bile Duct and Pancreatic Duct in Patients with Or Without Obstructive Jaundice

Background: Identification of a dilated common bile duct (CBD) and pancreatic duct (PD) (double duct sign) in patients with obstructive jaundice (ObJ) is very helpful clinically and is highly suggestive of a pancreatobiliary malignancy (PBM), though it can rarely be due to chronic pancreatitis or ampullary stenosis. Increasingly, presence of dilated CBD and PD is being reported on CT/MRI scans in patients without ObJ. We have observed that double duct sign without ObJ is not as suggestive of PBM as in patients with ObJ, but there is lack of published data to support this observation. We evaluated the prevalence of PBM in patients with dilated CBD and PD with or without associated ObJ. Patients and Methods: This is a retrospective analysis of our prospective database and included patients who had undergone EUS/EUS-FNA for suspected PBM at a university hospital from 2002-06. The CBD and PD were considered dilated if it was so reported on CT/MRI scans and/or were found to be dilated on EUS exam. EUS/EUS-FNA was performed by an experienced endosonographer and a cytopathology attending physician was present for on-site evaluation. Final determination of malignancy was based on surgical pathology or a clinical follow-up of ≥12 months. Results: The mean age of the 234 study patients (132 females) was 69.4 ± 13 years. Recent onset ObJ was noted in 166 of 234 patients. A focal ‘mass’ lesion was identified by EUS in 154 of 166 patients (132 lesions malignant by cytology) with jaundice and 14 of 78 patients (3 lesions malignant by cytology) without ObJ. The median follow-up of patients was 15 months. A final diagnosis of malignancy was made in 142 of 166 patients (85.5%) with jaundice and 4 of 64 (6.3%) without ObJ (p < 0.005). The four patients without ObJ who were finally diagnosed to have cancer included: one patient with duodenal cancer, two patients with mass in pancreatic head and neck and one patient with mass in the pancreatic body in whom the CBD dilation was likely incidental. The accuracy of EUS/EUS-FNA for diagnosing malignancy in patients with or without ObJ was 92.8% vs 98.6%, with sensitivity of 92.9% vs 75%, specificity 91.7% vs 100%, PPV 98.5% vs 100% and NPV of 68.7% vs 98.5%. Summary and Discussion: The prevalence of PBM in patients with dilated CBD and PD is significantly lower in patients without ObJ compared to those with associated ObJ. Identification of dilated CBD and PD on CT/MRI in patients without ObJ probably merits further diagnostic work-up since 6.3% of them had cancer in our cohort. EUS/EUS-FNA seems to have high accuracy and NPV for diagnosing malignancy in this patient group.

Immunohistochemical Staining Improves the Diagnostic Yield of Bile Duct Biopsies

Differentiation of malignant versus benign biliary strictures can be challenging. Histological evaluation of endoscopic biopsies is highly specific, but can lack sensitivity. The aim of our study was to evaluate the utility of immunohistochemical staining of biliary biopsies in the diagnosis of malignant strictures. Methods: 22 cases of biliary strictures were retrospectively reviewed. Biliary biopsy specimens were obtained during routine endoscopic retrograde cholangiopacreatograms. Final diagnoses were established from clinical follow-up or by direct evaluation of surgical specimens. 13 benign and 9 malignant strictures were identified. Benign etiologies included gallstones and chronic pancreatitis; malignancies were 7 cholangiocarcinomas and 2 invasive pancreatic adenocarcinomas. Immunohistochemical staining for p53, M1B, CAM5.2, CEA, CA19-9, and Alcian blue/PAS, alone or in combination were analyzed. For the purpose of this study, atypical samples were considered to be benign. Findings: Histology alone had sensitivity of 55% and specificity of 100% in detection of malignancy. Alcian-blue/PAS stain had the best sensitivity of 64% with specificity of 93%. In one case with final malignant diagnosis Alcian-blue/PAS stain was positive whereas histology was deemed benign. P53 stain had sensitivity and specificity of 55% and 87%, respectively. Addition of p53 stain to histology increased the sensitivity to 64% with specificity of 87% with one case of malignancy staining positive for p53 with negative histology. CAM5.2 stain had sensitivity of 42% with specificity of 100%. Though the specificity of CA19-9 was relatively high at 80%, sensitivity was low at 18%. Both the M1B and CEA increased sensitivity to 74%, but had relatively low specificity of 53% each. Addition of all 6 immunohistochemical markers increased the sensitivity to 82% but decreased specificity to 20%. Conclusion: Addition of immunohistochemical staining to histology can improve diagnostic yield of bile duct biopsies. Alcian-blue/PAS and p53 each offered the best combination of sensitivity and specificity.

Radial scars/complex sclerosing lesions and malignancy in a screening programme: incidence and histological features revisited

Radial scars (RS) are benign entities, frequently identified on screening mammography, which may be associated with malignancy. Much debate has been generated with regard to the optimum management of RS. We present our experience of RS in the first 5 years of a screening programme. The aim was to evaluate (i) the incidence of atypia and malignancy and (ii) the value of the preoperative core biopsy. We also further characterize the histological features. One hundred and twenty-five histologically confirmed cases of RS were reviewed (111 had preoperative biopsies). Thirty-one (24.8%) patients had a final malignant diagnosis (11 with invasive malignancy) and 28 (22.4%) showed atypia (including lobular carcinoma in situ). In those with core biopsies and a final malignant diagnosis, 12 cases were categorized as B5 (41.3%), three as B4 (10.3%), 12 as B3 (41.3%) and two as B2 (7%). Common histological features included obliterated ducts and chronic inflammation with, less frequently, neural hyperplasia (16.8%) and perineural invasion (3.2%). The high incidence of atypia and malignancy identified in our study justifies our policy of removing all mammographically detected RS. We emphasize the utility of preoperative core biopsy evaluation in permitting one-stage surgical therapy in those with B5 diagnoses.

Combined clinical, thyroid ultrasound and cytological features help to predict thyroid malignancy in follicular and Hϋrthle cell thyroid lesions: results from a series of 505 consecutive patients

The cytological patterns of follicular and Hupsilonrthle cell nodules are included among the indeterminate results of fine-needle aspiration cytology, because distinction between benign and malignant lesion can only be made on histological criteria. The diagnostic value of atypia at cytology, clinical parameters and echographic patterns were examined to establish the risk of malignancy in 505 patients with follicular and Hupsilonrthle cell thyroid nodules at cytology. The study included 505 consecutive patients who had undergone thyroidectomy from the period 2002-2005. Histological diagnosis of malignancy was carried out in 125 of 505 (25%) patients, the follicular variant of papillary carcinoma being the most frequent histotype. Only atypia at cytology (P < 0.0001) and spot microcalcifications at ultrasound (P = 0.009) were predictive of malignancy. Male gender, normal thyroid volume, single nodularity, nodule hypoechogenicity, size and blurred margins were associated with malignancy, although not significantly. An arbitrary clinical score allowed the identification of patients with high (41%, 110 patients) and low (16%, 242 patients) risk of malignancy. Combining the clinical score with the presence of atypia at cytology we could identify 30 patients (6%) in whom the risk of malignancy was as high as 63%. Twenty-five per cent of patients with a cytological result of follicular and Hupsilonrthle cell thyroid lesion had a final diagnosis of malignancy. Only atypia at cytology and spot microcalcifications at thyroid ultrasound were significantly associated with malignancy. Other clinical parameters and thyroid ultrasound patterns can be used to set up a clinical score useful for predicting the individual risk of malignancy before surgery.

Identification of breast cancer in patients with pathologic nipple discharge: does ductoscopy predict malignancy?

Objective The purpose of the current study was to review characteristics of patients with nipple discharge who underwent ductoscopy-assisted excisional biopsy who had a final diagnosis of carcinoma. Methods A retrospective review was performed of patients presenting with pathologic nipple discharge (PND) who underwent ductoscopy-assisted excisional biopsy and had a final diagnosis of carcinoma. Results A total of 14 (7%) of 188 patients who underwent ductoscopy-assisted excision had a final pathology of ductal carcinoma-in-situ (DCIS) (12/14, 86%) or invasive breast cancer with DCIS (2/14, 14%). Duct wall irregularities or intraluminal growths were visualized during ductoscopy in 8 of the 14 (57%) breast cancer patients. There were no visual abnormalities noted during ductoscopy that accurately predicted a final diagnosis of malignancy. Conclusions Although occult malignancies can be identified in patients undergoing ductoscopy-assisted biopsy for PND, no clear morphologic changes visualized during ductoscopy definitively indicated the presence of malignancy.

EUS-SOS

Purpose: Bronchoscopy with transbronchial FNA, mediastinoscopy, CT guided bx and laparoscopy are accepted techniques for tissue sampling of intrathoracic and intra-abdominal masses. We report our experience with EUS FNA/Trucut bx (EUS FNA/TCB) as a rescue procedure in patients (pts.) who previously failed or were refused by other bx techniques. Aim: To evaluate the accuracy of EUS FNA in pts with malignant disease and a previously failed bx procedure. Methods: Retrospective analysis of EUS FNA/TCB results in all pts. referred for pancreatic or mediastinal bx from 10/03 to 4/05. Pts. who failed or were refused by other bx modalities and had a final diagnosis of malignancy were included. A positive diagnosis of malignancy by EUS FNA/TCB was considered true positive. All procedures were performed only with linear array EUS by a single endosonographer. No on-site cytopathology was done. FNA was performed in all pts. and TCB was added at the discretion of the endosonographer. Results: A total of 160 pts. were referred for pancreatic or mediastinal bx for solid masses. Thirty-nine pts. (24%) met the inclusion criteria. The mean age was 67 years (18 F and 21 M). There were 26 pancreatic masses and 13 mediastinal masses. In the mediastinal group, 11 failed bronchoscopy with transbronchial FNA, one failed mediastinoscopy, and one was turned down for CT guided bx. In the pancreatic group, sixteen failed CT guided bx, six failed laparoscopy, three were turned down for CT guided bx and one failed prior EUS FNA/TCB. The sensitivity of EUS FNA/TCB for detecting malignancy in 39 pts. was 85%. In the mediastinal and pancreatic subgroups sensitivities were: 100% and 77% respectively. The mean number of FNA passes was 6 (range 3–10), Trucut was used in 19 pts., mean number of passes of 2.4 (range 2–5). All six pts. with pancreatic cancer missed by EUS FNA did not undergo additional EUS TCB due to technical reasons (uncinate process lesions). Four of the six pts. with pancreatic cancer missed by EUS FNA, had at least two prior failed biopsies by CT FNA. Conclusions: In pts. who have failed other bx procedures, EUS FNA/TCB should still be considered an accurate and safe modality to detect malignancy. Addition of TCB to FNA appears safe and should be considered in the absence of on-site cytopathology review.

Improved Diagnostic Efficacy by Rapid Cytology Test in Fluoroscopy-Guided Bronchoscopy

Fluoroscopy-guided bronchoscopy is a safe and routine method used to obtain a histologic or cytologic specimen of peripheral lung nodules, but it has low sensitivity in diagnosing malignant tumors. Although feedback from rapid cytology tests are expected to improve diagnostic rates, the value of the routine use of rapid cytology tests has not been established. We prospectively studied 657 patients with suspected peripheral malignant lung lesions on chest computed tomography who underwent fluoroscopy-guided bronchoscopy between January 2002 and December 2004. Rapid on-site cytopathologic examinations (ROSE) were performed during bronchoscopic examinations. The additional approach to the lesions was performed immediately after conventional bronchoscopic examinations when ROSE was not considered diagnostic. There were 528 patients diagnosed as having malignant lesions. In 477 of these patients (90.3%), final malignant diagnosis was established by the initial bronchoscopy. Among these, 84 patients (15.9%) were diagnosed only with the additional feedback from ROSE. Of 240 peripheral lesions < or =2 cm, 174 were found to be malignant. Without ROSE, 110 (63.2%) of peripheral malignant lesions were diagnosed by bronchoscopy. The integration of ROSE enabled us to diagnose an additional 40 patients (23.0%) by bronchoscopy. ROSE improved diagnostic yield independent of the site and histology of the lesions and experience of the operators. ROSE increased the diagnostic yield of bronchoscopy from 74.4% to 90.3% and therefore is an effective reinforcement in bronchoscopic diagnosis of peripheral pulmonary malignancies. The use of ROSE in routine bronchoscopy should be encouraged.

Irregular Echogenic Foci Representing Coagulation Necrosis: A Useful But Perhaps Under-Recognized EUS Feature of Malignant Lymph Node Invasion

Background: Coagulation necrosis has been described in malignant lymph nodes. Scattered irregular echogenic foci within a lymph node have been considered as more representative of coagulation necrosis as opposed to a normal central echogenic hilum in benign lymph nodes. Hence, our aim was to determine if coagulation necrosis in mediastinal lymph nodes imaged by EUS could be used as a useful echogenic feature for predicting malignant invasion. Methods: The data was collected retrospectively by reviewing cases of patients from May 2002 thru June 2005 with known or suspected lung cancer who underwent mediastinal lymph node staging by EUS at UTMB Galveston. An expert endosonographe (MSB) blinded to the final diagnosis, reviewed the archived digital EUS images of lymph nodes prior to being sampled by FNA. Lymph nodes positive for malignant by FNA were included. The benign group included lymph node images with either negative EUS FNA (or small benign appearing lymph nodes not subjected to EUS FNA) with subsequent surgical correlation of their benign nature. Results: A total of 24 patients were included. A total of 8 patients were found to have coagulation necrosis. Seven of the eight patients had a positive result for malignancy by EUS guided FNA. One patient determined to have coagulation necrosis had a non-malignant diagnosis indicating a false positive result. A total of 16 patients had no coagulation necrosis. Of the six cases, the final diagnosis was malignant and the remaining 10 cases, the final diagnosis was non-malignant. Sensitivity was 54%. Specificity was 91%. Positive predictive value was 88%. Negative predictive value was 63%. Accuracy was 72%. Conclusion: Coagulation necrosis described as scattered irregular echogenic foci within a lymph node is a useful test characteristic for staging mediastinal lymphadenopathy by EUS. Coagulation Necrosis has low sensitivity but high specificity. Coagulation necrosis when seen is a very useful echofeature that is highly specific when trying to differentiate benign from malignant lymph nodes on EUS. This feature may be particularly useful when EUS guided FNA cannot be done [e.g. peritumorous lymph node] or in selecting a lymph node for EUS guided FNA when multiple nodes are visualized. This strategy may help increase the yield of EUS guided FNA and decrease the procedure time. Tabled 1Summary of Results Coagulation Necrosis Final Malignant Diagnosis Final Non-malignant Diagnosis Present 7 1 Absent 6 10 Sensitivity 0.54, Specificity 0.91, Positive predictive value 0.88, Negative predictive value 0.63, Accuracy 0.71 Open table in a new tab Sensitivity 0.54, Specificity 0.91, Positive predictive value 0.88, Negative predictive value 0.63, Accuracy 0.71

Cholangioscopy and Cholangioscopic Forceps Biopsy in Patients With Indeterminate Pancreaticobiliary Pathology

We report the usefulness of cholangioscopy in patients with indeterminate pancreaticobiliary pathology. A prospective collection of 62 consecutive patients during a period of 2.5 years who were referred to our tertiary referral center for cholangioscopy for indeterminate strictures suspicious for malignancy were included. Tissue sampling followed cholangioscopic visualization. Biopsies were obtained under direct visualization (cholangioscopy-directed) or through the duodenoscope (cholangioscopy-assisted). Sixty-two patients had 72 examinations. Forty patients had nondiagnostic sampling before cholangioscopy. Indications were stricture (n = 67: 16 primary sclerosing cholangitis, 51 non-primary sclerosing cholangitis), ductal dilation, or intraductal mass (n = 5). Biopsies were not performed in 19 because cholangioscopy did not identify suspicious lesions. Of the remaining 53 procedures, 29 underwent either cholangioscopy-directed or cholangioscopy-assisted biopsy, and 24 had both. Cholangioscopy findings consisted of primary sclerosing cholangitis only (n = 18), benign stricture or inflammatory changes (n = 18), bile duct cancer (n = 14), normal (n = 10), pancreatic cancer (n = 5), and other (n = 7). Fifty-eight patients (94%) had follow-up for a mean of 12.4 months (95% confidence interval, 10.1-14.7). Sixteen of 18 (89%) patients with a final diagnosis of malignancy were detected with cholangioscopy. The 2 missed cancers were intrahepatic cholangiocarcinomas. Overall, sensitivity to detect malignancy by cholangioscopy with and without biopsy was 89%, specificity 96%, positive predictive value 89%, and negative predictive value 96%. Cholangioscopy with and without biopsy is highly accurate in diagnosing and excluding pancreaticobiliary malignancy in patients with indeterminate strictures.

Pancreatic tumors: Prospective evaluation using MR imaging with MR cholangiography and MR angiography

Objectives: To assess the efficacy of MR imaging, with MR Cholangiography and MR Angiography in pre operative evaluation of pancreatic tumors. Materials and Methods: 30 patients suspected of having pancreatic tumors underwent MR imaging with a 1.5T unit. Images were prospectively analyzed results correlated with surgery and biopsy. Results: Of the total 30 patients, 24 were histologically proven to be malignant of which 21 underwent surgery. MR characterization - benign from malignant lesions resulted in 27 correct diagnosis (accuracy 90%). 2 patients with histologically confirmed chronic pancreatitis were wrongly considered malignant. Among patients with histologically proven malignancy (n=24), MR imaging yielded correct diagnosis in 23 of 24 patients a sensitivity of 96 %. Overall accuracy for determining vascular involvement in patients who underwent surgery (n=21) was 86% (18 out of 21) a sensitivity of 75% (6 of 8). Sensitivity for detection of lymphadenopathy and liver metastasis was only 50% and 60% respectively. Among patients with final diagnosis of malignancy (n=24) who underwent surgery (n=21), overall accuracy for determining tumor nonresectabilty was 81 % (17 out of 21). Conclusion: A comprehensive combination of MR imaging sequences with MRCP and MR Angiography offers excellent potential to depict, characterize and preoperatively determine the resectability of pancreatic masses.

Accuracy of Frozen Section in Distinguishing Primary Ovarian Neoplasia from Tumors Metastatic to the Ovary

Frozen section is widely used in the intra-operative assessment of patients with ovarian tumors. The diagnosis of malignancy is usually straightforward but in some cases it may be difficult to distinguish whether tumors are of ovarian origin or represent matastases from other sites. Recently, Seidman and colleagues presented a simple algorithm based on tumor size and unilateral versus bilateral involvement to aid in intra-operative assessment of ovarian mucinous neoplasms. In this study we have reviewed the accuracy of frozen section in distinguishing primary ovarian malignancies from tumors metastatic to the ovaries encountered in two hospitals over a 5-year period. The algorithm was also applied to our cases retrospectively irrespective of histological type. Nine hundred fourteen ovarian frozen sections were performed in the study period including 266 cases with a final diagnosis of malignancy. Thirty-seven malignancies (13.9%) were of metastatic origin (exclusing one lymphoma), 21 of which (58.8%) were correctly identified on frozen section. In 5 additional cases metastatic origin was included in the differential diagnosis while a primary ovarian tumor was favored un 11 cases (29.7%). Application of the algorithm to the metastatic tumors led to correct classification in 26/33 (78.8%) assessable cases. Conversely, 195/228 primary ovarian malignancies were correctly identified intra-operatively but the possibility of extra-ovarian malignancy was considered or not excluded in 33 cases (14.5%). Application of the algorithm to the latter problematic primary ovarian tumors overall was not helpful in distinguishing primary or metastatic origin. However if only low-grade primary adenocarcinomas were considered then 10/12 assessable cases were correctly assigned. In conclusion frozen section is only moderately successful in distinguishing primary ovarian malignancies fron tumors metastatic to the ovaries. The simple algorithm proposed by Seidman and colleagues for assessment of ovarian mucinous tumors is helpful and can be applied to low-grade adenocarcinomas of other histological types.