On-site Cytopathologist Research Articles

2812 Impact of Rapid On-Site Evaluation (ROSE) on Endoscopic Ultrasound-Guided FNA of Pancreatic Cysts: A Five-Year Comparative Study Between Two Academic Institutions

INTRODUCTION: Endoscopic Ultrasound Guided-Fine Needle Aspiration (EUS-FNA) is considered the modality of choice for diagnosing intermediate pancreatic lesions. Rapid-on site evaluation (ROSE), when performed by a cytopathologist, has been suggested to improve the diagnostic yield of EUS-FNA. Prior studies were inconsistent regarding the benefit of ROSE. In our study, we evaluated the diagnostic yield of EUS-FNA in the presence of an on-site cytopathologist providing real-time feedback to the endoscopist compared to EUS-FNA alone in two academic hospitals. METHODS: We conducted a 2010-2015 retrospective chart review of all EUS-FNA performed at two academic medical centers (UT and UR). The policy at UT is to perform all EUS-FNA with ROSE, whereas it is not routinely done at UR. Cases where included when surgical pathology was available. Patients’ demographics, pancreatic cyst characteristics and EUS techniques were analyzed. EUS-FNA were considered valuable when it provided a classifying cytopathologic diagnosis. Student T-test and Analysis of Variance (ANOVA) were performed when appropriate for descriptive purposes. RESULTS: Forty-five cases (13 at UT, 32 at UR) were identified. EUS FNAs coupled with ROSE (UT) rendered 100% (13/13) valuable diagnoses, while those done with no cytopathologist on site (UR) had valuable diagnosis in 37.5% of the cases (12/32, P < 0.0001). The sensitivity of EUS-FNA at UT was 85% compared to 33% at UR. There was no statistically significant difference in gender, age, site or size of the tumor. The mean number of needle passes at UT was 1.9 (range 1-6) vs. 1.1 (range 1-3) at UR. The majority of needles used were 19G (55%) at UT vs 22G (83%) at UR (P < 0.001). Only one patient at UR had a minor cyst bleeding to the main pancreatic duct that required no therapeutic action. CONCLUSION: The results highlight the advantage of bed-side cytopathologist interaction with the endoscopist during EUS-FNA of pancreatic cysts. Absence of malignant cells despite suspicious ultrasound findings may have prompted more needle passes. The use of 19G needle may have improved outcomes with no significant increase of complications. In addition to the small sample size and the retrospective nature, the study is limited by the variability in personnel experience (endoscopists and cytopathologists) and the techniques used, indicating that further studies are necessary to confirm these findings.

Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy in Gastrointestinal Subepithelial Tumors.

The incidence of asymptomatic and incidentally found upper gastrointestinal subepithelial tumors (SETs) is increasing with the implementation of national cancer screening and the development of high-resolution endoscopy in Korea. However, endoscopy alone cannot be used to determine whether SETs are benign or malignant. Endoscopic ultrasound (EUS) is used to further characterize these lesions through the examination of their layered structure, internal echogenicity, size, and relationship to the extramural structure. These provide additional information on whether the lesion is benign or malignant. Nevertheless, the sensitivity and specificity of EUS alone in predicting malignancy is unsatisfactory. Recent guidelines have recommended deciding the timing of EUS-fine needle aspiration and biopsy (EUS-FNA/B) for SETs based on tumor size, malignant features on endoscopy, and high-risk features on EUS. The diagnostic accuracy of EUS-FNA/B is reportedly influenced by factors including needle size, number of needle passes, use of suction, use of a stylet in the needle assembly, fanning technique, availability of an on-site cytopathologist, and experience of the endosonographer. Therefore, according to the characteristics of the SETs, various subsequent methods and techniques should be appropriately employed to improve the diagnostic yield of EUS-FNA/B.

Optimizing Outcomes of Single-Operator Cholangioscopy–Guided Biopsies Based on a Randomized Trial

Although single-operator cholangioscopy is considered to be the most sensitive method for tissue acquisition in patients with indeterminate bile duct strictures (IBDS), methods are needed to optimize the specimen collection and processing techniques. We aimed to determine the optimal method for specimen processing and identify the number of biopsies required to establish a definitive diagnosis. Patients with IBDS were randomly assigned to groups that underwent specimen processing using the onsite (n= 32) or offsite (n= 30) method. The primary outcome was to compare operating characteristics of onsite vs offsite specimen processing techniques. The secondary outcome was number of biopsies needed to establish definitive diagnosis. A final diagnosis was established at surgery or after a minimum clinical follow-up period of 18 months RESULTS: The final diagnosis was benign disease in 33 patients and malignancy in 29 patients. There were no significant differences between the offsite and onsite groups in diagnostic accuracy (90% vs 87.5%; P=.99), sensitivity (76.9% vs 75%; P=.99), specificity (100% vs 100%; P=.99), positive predictive value (100% vs 100%; P=.99), or negative predictive value (85% vs 80%; P=.99). Although diagnoses were established by analysis of a median of 1 biopsy in the onsite cohort (interquartile range, 1-1.5), the diagnostic accuracy was identical (90%) in each group, regardless of whether 3 or 4 biopsies were collected from each patient in the offsite cohort. In a prospective comparative study, we found that centers without onsite cytopathology support that analyze 3 single-operator cholangioscopy-guided biopsies of a biliary stricture and process the specimens offsite make the correct diagnosis for 90% of cases. ClinicalTrials.gov, Number: NCT01815619.

Endoscopic Ultrasound-Guided Tissue Acquisition: Techniques and Challenges.

Endoscopic ultrasound-guided fine needle aspiration (EUS FNA) has made pathological diagnosis of pancreatic neoplasms, diseases involving lymph nodes at various mediastinal and abdominal sites, gastrointestinal submucosal lesions, perirectal lesions, adrenal lesions, and mediastinal masses easy. EUS-guided FNA is a multistep procedure that involves assessment of proper clinical indication, correct selection of FNA needles, and adoption of evidence-based techniques for tissue sampling. EUS FNA is done by needles that are available in different sizes, mainly 25, 22, and 19-gauge needle. The need of onsite cytopathologist, dependence on histology/core biopsy occasionally to get a diagnosis, and inability to reliably assess for molecular markers are important limitations of EUS FNA. EUS-guided fine needle biopsy (FNB) that samples the core of tissue is an exciting new development in the field of diagnostic EUS. FNB needles are expensive than FNA needles, and although the initial results are encouraging, more studies with robust evidence proving their superiority beyond any doubt are needed before they can be widely used.

Comparison of Franseen and fork-tip needles for EUS-guided fine-needle biopsy of solid mass lesions: A systematic review and meta-analysis.

Franseen-tip and Fork-tip needles have been widely used in EUS guided fine-needle biopsy (FNB) of solid organs. There is conflicting data on the performance of these needles and unanswered questions on the ideal number of needle-passes and the requirement of an onsite cytopathologist (ROSE). We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through July 2018) to identify studies that reported on the use of Forktip and Franseen-tip needles in EUS-FNB of solid organs. The primary outcome was to estimate and compare the pooled rates of diagnostic-yield. A subgroup analysis compared the outcomes based on the number of needle-passes and the availability of ROSE. A total of 23 study-arms were available for analysis. The pooled rate of diagnostic yield with Fork-tip needle was 92.8% (95% CI 85.3 - 96.6, I2 = 73.1) and the pooled rate of diagnostic yield with Franseen-tip needle was 92.7% (95% CI 86.4 - 96.2, I2 = 88.4).

State of endoscopic ultrasonography in Spain in 2017

Abstract Aim To understand the current state of endoscopic ultrasonography (EUS) in Spain. Methods Descriptive analysis from a national survey with 11 questions: 10 related to technique and 1 to the training and experience of the endoscopists. Results Sixty endoscopists from 48 of the 97 (49.5%) hospitals that perform EUS in Spain responded to the survey. A total of 28,678 procedures (20,311 diagnostic, 7446 with puncture and 921 therapeutic) were recorded over the course of one year. Approximately 64% of the hospitals perform between 300 and 999 tests per year. All have radial and sectorial echoendoscopes, with a median of 2 (2–8) scopes. For cytological diagnosis, the 22-gauge needle is the most commonly used (98%) and, for histological diagnosis, the Procore (72%). The study of the pancreas and bile duct is the most common indication for diagnostic EUS (60%), followed by the staging of digestive tract neoplasms (20%). Approximately 72% of the hospitals perform on-site cytopathology evaluations and sedation is administered in equal parts by both endoscopists and anaesthetists. In terms of experience, 45% of echoendoscopists perform fewer than 300 annual exams and the median training duration is 6 months (0.5–36). Conclusions EUS is adequately implemented in Spain and good equipment is available. However, it is necessary to establish a standardised EUS training programme since the one undertaken by many echoendoscopists could prove insufficient according to the standards established by Scientific Societies.

Efficacy of 3 fine-needle biopsy techniques for suspected pancreatic malignancies in the absence of an on-site cytopathologist

EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) has a high diagnostic accuracy for pancreatic tumors. Most reports have focused on the diagnostic yield of cytology or histology; the ability of various FNA/B techniques to obtain an adequate mass of cells or tissue has rarely been investigated. Patients with suspected pancreatic malignancy underwent EUS-FNB using a 22-gauge ProCore needle by either the stylet slow-pull-back technique (group A), conventional negative suction after stylet removal (group B), or non-suction after stylet removal (group C) in the absence of an on-site cytopathologist. The adequacy of the 3 techniques based on the diagnostic yield, cellularity, blood contamination, and core-tissue acquisition was evaluated. A total of 50 patients (27 males) were analyzed. The mean tumor size was 21 to 40mm in 54%. The rate of a good or excellent proportion of cellularity was highest in group A compared with groups B and C (72% vs 60% vs 50%, P= .049). A >25% rate of blood contamination was more prevalent in group B (30% vs 42% vs 10%, P= .009). The rate of adequate core-tissue acquisition was not different (52% vs 34% vs 50%, P= .140). Based on the multivariate generalized estimation equation, the stylet slow-pull-back technique and a tumor size >40mm were favorable factors for diagnostic adequacy. The stylet slow-pull-back technique might enable acquisition of tissue and assessment of cellularity for the diagnosis of pancreatic tumors suspected to be malignant. (Clinical trial registration number: KCT0002190.).

Differential diagnosis of mesenchymal neoplasms of the digestive tract by cell block and immunohistochemistry.

To evaluate the diagnostic yield of the cell block (CB) technique with immunohistochemistry in patients with mesenchymal neoplasms of the gastrointestinal tract collected by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Tissue samples from consecutive patients with subepithelial lesions collected by EUS-FNA, without analysis by on-site cytopathology, were evaluated by the same pathologist only using CBs in AAF fixative. Sections were stained with haematoxylin-eosin and underwent complementary immunohistochemical staining for SMA, CD117, DOG-1 and S100 in the presence of mesenchymal neoplasms. Specimens were defined as diagnostic when sufficient tissue was present for histopathological evaluation and immunohistochemistry analysis. If they were insufficient for complete evaluation, the specimens were considered nondiagnostic. Between September 2012 and December 2016, a total of 158 patients (median age: 57years, 64.5% women) underwent EUS-FNA with an average of three needle passes for every lesion. The median lesion size was 17mm. There were 113 mesenchymal neoplasms confirmed by immunohistochemistry (66 leiomyomas, 44 GISTs, two schwannomas, one leiomyosarcoma). The overall diagnostic yield of CBs was 84.17%. However, diagnosis was obtained in 98.5% (133/135) of the cases after exclusion of 23 cases in which EUS-FNA sampling was insufficient or without tumoural tissue. Only two mesenchymal neoplasms were not confirmed by CBs even after immunohistochemistry. CBs collected by EUS-FNA and analysed by immunohistochemistry showed a high diagnostic yield in patients with mesenchymal neoplasms, even without on-site cytopathology.

A Unique Case of Metastatic Merkel Cell Carcinoma Without a Dermatologic Primary

INTRODUCTION: Merkel cell carcinoma (MCC) is a rare neuroendocrine carcinoma. It is predominately seen on sun-exposed areas in elderly patients or in immunocompromised populations. About 80% of cases are associated with Merkel cell polyomavirus, suggesting a viral-induced oncogenesis. The most common presentation is a rapidly growing pink-red, dome-shaped nodule on the skin. We present a rare case of metastatic MCC diagnosed by endoscopic ultrasound of an incidentally discovered portacaval lymph node. CASE DESCRIPTION: An 81-year-old male with no dermatologic history presented to the emergency department with fever and chills. His fever was documented at 39.3 deg C, was tachycardic at a HR of 117, and a leukocyte count of 11.6. He also endorsed unintentional weight loss of nearly 20 lbs. The ED obtained abdomen/pelvis which noted radiographic evidence of diverticulitis as well as a large portacaval lymph node measuring 8.6 x 4.5 cm. He was discharged oral antibiotics for treatment of diverticulitis with plan for outpatient endoscopic evaluation of the enlarged lymph node. An upper endoscopy was performed and no intraluminal masses or lesions were noted. Next, linear endoscopic ultrasound was performed which identified the portacaval lymph node which measured 42.3 mm x 37.4 mm. We used a 25-gauge fine needle biopsy with on-site cytopathology confirming cellular adequacy. Cytology demonstrated positive CK20, CD56, and synaptophysin with high rate of KI-67 and negative TTF-1 consistent with neuroendocrine differentiation and a diagnosis of Merkel cell carcinoma. The patient was referred to oncology for further management. Staging workup with a PET/CT noted metastatic disease also involving the right shoulder and he was subsequently initiated on systemic immunotherapy with the checkpoint inhibitor pembrolizumab.1275_A.tif Figure 1: Coronal view of CT abdomen/pelvis which identified a bilobed porta-caval lymph node measuring 55.2 mm x 64.5 mm.1275_B.tif Figure 2: Endoscopic Ultrasound view of porta-caval lymph node measured at 48.5 mm sampled via FNA which diagnosed the finding of Merkel Cell Carcinoma.DISCUSSION: MCC is a rare, aggressive neuroendocrine carcinoma that usually presents with a skin lesion. Only 0.4% of cases have been reported in locations other than the skin. While there are multiple reports of recurrence of MCC in the gastrointestinal tract, very few cases present initially without an apparent skin lesion. Gastroenterologists should be aware of this uncommon neoplasm, given that MCC is an aggressive malignancy that requires prompt diagnosis and oncologic treatment in order to optimize patient outcomes.

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.

It is necessary to exam bottom and top slide smears of EUS-FNA for pancreatic cancer

BackgroundDespite many reports on the diagnostic yield of cytology from endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), inter-slide differences are unknown. This prospective study aimed to compare diagnostic yield and cellular characteristics of bottom slides (BS) and top slides (TS) from EUS-FNA cytology performed without an on-site cytopathologist. MethodsIn patients with suspected pancreatic cancer on previous imaging explorations, a single endoscopist performed EUS-FNA and obtained 2 sets of cytology slide (8 BS and 8 TS), 1 cellblock slide, and 1 biopsy slide. Both slide sets were randomly assigned. A cytopathologist with more than 10 years of expertise in pancreatic cytopathology blindly inspected and compared two slide sets. ResultsIn total, 73 specimens [42 head (57.5%), 16 body (21.9%), and 15 tail (20.5%)] were acquired for final analysis. Seventy-one cases were finally diagnosed with pancreatic cancer. The sensitivity and specificity of BS were 80.3% and 100.0%; and of TS 78.9% and 100.0%, respectively. In analyzing inter-slide difference, 66 cases (90.4%) showed consistent results between BS and TS. However, seven (9.6%) were positive only in one slide sets (4 BS and 3 TS). The proportions of specimens more than moderate and high cellularity were 75.3% and 60.3% in both slide sets (P> 0.99), and the proportion of artifact-free sets were 50.7%, and 52.1% for the BS and TS, respectively (P= 0.869). ConclusionsAlthough BS and TS exhibited highly consistent diagnostic yields in cytologic smears from EUS-FNA, the proportion of inter-slide discordance is clinically considerable. Both slide sets need to be examined if there is no on-site cytopathologist.

Estado de la ecoendoscopia en España en 2017

AimTo understand the current state of endoscopic ultrasonography (EUS) in Spain. MethodsDescriptive analysis from a national survey with 11 questions: 10 related to technique and 1 to the training and experience of the endoscopists. ResultsSixty endoscopists from 48 of the 97 (49.5%) hospitals that perform EUS in Spain responded to the survey. A total of 28,678 procedures (20,311 diagnostic, 7,446 with puncture and 921 therapeutic) were recorded over the course of one year. Approximately 64% of the hospitals perform between 300 and 999 tests per year. All have radial and sectorial echoendoscopes, with a median of 2 (2-8) scopes. For cytological diagnosis, the 22-gauge needle is the most commonly used (98%) and, for histological diagnosis, the Procore (72%). The study of the pancreas and bile duct is the most common indication for diagnostic EUS (60%), followed by the staging of digestive tract neoplasms (20%). Approximately 72% of the hospitals perform on-site cytopathology evaluations and sedation is administered in equal parts by both endoscopists and anaesthetists. In terms of experience, 45% of echoendoscopists perform fewer than 300 annual exams and the median training duration is 6months (0.5-36). ConclusionsEUS is adequately implemented in Spain and good equipment is available. However, it is necessary to establish a standardised EUS training program since the one undertaken by many echoendoscopists could prove insufficient according to the standards established by Scientific Societies.

Efficacy and safety of endobronchial ultrasound-guided transbronchial needle aspiration through the pulmonary arteries for the diagnosis of left hilar lesions.

Endobronchial ultrasonography (EBUS) is an endoscopic method that aids needle aspiration to see the bronchial wall and adjacent tissues with an ultrasound probe. Pulmonary arteries are rarely present between the bronchus wall and the tissue. In this case, it was necessary to make a selection between invasive processes and transbronchial needle aspiration (TBNA) through the pulmonary artery. There are few case reports about the safety of TBNA through the pulmonary artery. We aimed to present the results of EBUS guided TBNA through the pulmonary arteries. The data on four cases (three men) in whom EBUS guided TBNA was performed through the pulmonary artery between August 2010 and December 2015 were reviewed retrospectively. Procedures were conducted under local anesthesia and conscious sedation. For TBNA, 22-gauge needles were used. Cases were monitored for 24 hour after the procedures. Antibiotic prophylaxis and onsite cytopathology were not used. All lesions existed were on the left hilar localization. Two of the diagnosed cases were carcinoma and one was the granulomatous lymphadenitis. We were not able to diagnose the last case. No complication was observed in any cases during the procedure. EBUS guided TBNA through the pulmonary arteries at left hilar lesions is safe. The rate of diagnoses from the tissues obtained is high. No special preparation is needed for the cases have no the pulmonary hypertension.

EUS-FNA WITH 19 OR 22 GAUGES NEEDLES FOR GASTRIC SUBEPITHELIAL LESIONS OF THE MUSCLE LAYER.

ABSTRACTBackground: Tissue diagnosis is required for gastric subepithelial lesions for differential diagnosis of GISTs. However, there has not been consensus about the best needle for EUS-guided sampling of these lesions. Aim: To evaluate the diagnostic yield of EUS-FNA for gastric subepithelial lesions of the proper muscle layer with large-bore 19 gauge needles. Methods: A prospectively maintained database was retrospectively reviewed to identify consecutive patients who underwent EUS-FNA with 19 and 22 gauge needles for gastric subepithelial lesions of the fourth endosonographic layer in a tertiary care referral center. EUS-FNA was performed by the same endosonographer, using the fanning technique, without on-site cytopathologist. Specimens were analysed through cell blocks by the same pathologist. Procedure results were categorized into diagnostic, defined as enough material for histopathology and immunohistochemistry, or nondiagnostic. Results: Eighty-nine patients (mean age: 59 years, 77% women) underwent 92 EUS-FNA with 19 (75) or 22 (17) gauge needles. Mean lesion size was 22.6 mm. Overall diagnostic yield was 88%. The diagnostic yield of 19 gauge was higher than that of 22 gauge needle (92%x70.6%; p=0.0410), and similar for lesions >2 cm and <2 cm (93.7%x90.7%; p=0.9563). The best performance for 19 gauge needles was obtained performing <3 needle passes. Complication rate was 2.8%. Conclusions: Diagnostic yield of EUS-FNA with 19 gauge needles is 92% for gastric subepithelial lesions of the proper muscle layer. It is safe and highly valuable for differentiation between GIST and leiomyoma, no matter the size of the lesion.

Study Design and Rationale: A Multicenter, Prospective Trial of Electromagnetic Bronchoscopic and Electromagnetic Transthoracic Navigational Approaches for the Biopsy of Peripheral Pulmonary Nodules (ALL IN ONE Trial)

BackgroundPulmonary nodules are a common but difficult issue for physicians as most identified on imaging are benign but those identified early that are cancerous are potentially curable. Multiple diagnostic options are available, ranging from radiographic surveillance, minimally invasive biopsy (bronchoscopy or transthoracic biopsy) to more invasive surgical biopsy/resection. Each technique has differences in diagnostic yield and complication rates with no established gold standard. Currently, the safest approach is bronchoscopic but it is limited by variable diagnostic yields. Percutaneous approaches are limited by nodule location and complications. With the recent advent of electromagnetic navigation (EMN), a combined bronchoscopic and transthoracic approach is now feasible in a single, staged procedure. Here, we present the study design and rationale for a single-arm trial evaluating a staged approach for the diagnosis of pulmonary nodules. MethodsParticipants with 1–3 cm, intermediate to high-risk pulmonary nodules will undergo a staged approach with endobronchial ultrasound (EBUS) followed by EMN-bronchoscopy (ENB), then EMN-transthoracic biopsy (EMN-TTNA) with the procedure terminated at any stage after a diagnosis is made via rapid onsite cytopathology. We aim to recruit 150 EMN participants from eight academic and community settings to show significant improvements over other historic bronchoscopic guided techniques. The primary outcome is overall diagnostic yield of the staged approach. ConclusionThis is the first study designed to evaluate the diagnostic yield of a staged procedure using EBUS, ENB and EMN-TTNA for the diagnosis of pulmonary nodules. If effective, the staged procedure will increase minimally invasive procedural diagnostic yield for pulmonary nodules.

CT-guided Lung Fine Needle Aspiration Biopsy: Analysis of Efficacy, Yield and Intricacies

AbstractAim: This study aims to evaluate various factors that affect the cytological yield while performing computed tomography (CT) guided lung fine needle aspiration biopsy and to determine the complication rate of this procedure. Materials and Methods: In this cross sectional study, we analyzed 70 patients undergoing CT-guided transthoracic lung fine-needle aspiration biopsy (FNAB). 22-gauge spinal needle was used in sixty patients and 20-gauge in ten patients. The presence and absence of an onsite cytopathologist affecting the adequacy of yield for a conclusive cytodiagnosis was compared in groups of 35 patients each. The incidence of complications such as pneumothorax, pulmonary hemorrhage was recorded. Results: Cytological yield was adequate for a conclusive cytodiagnosis in 59 cases (84.2%). Thirty-seven cases (52.8%) were malignant with adenocarcinoma (70.2%) being the most common, 22 cases (31.4%) had benign etiology. Cytological yield was adequate for a conclusive diagnosis in the group (n = 35) with an onsite cytopathologist (100%) compared with those cases without an onsite cytopathologist (68.6%) (P = 0.005). Pneumothorax was observed in 16 cases (22.8%), the incidence of pneumothorax was higher when there was an intervening parenchyma (P = 0.005). Conclusion: CT-guided transthoracic FNAB is an accurate method to rule out malignancy with a reasonable rate of complications. The presence of an onsite-cytopathologist significantly improves the adequacy of yield for a conclusive cytodiagnosis, and should be routinely employed. Pneumothorax and pulmonary hemorrhage are the most common complications as a result of FNAB. The incidence of pneumothorax is higher when there is intervening lung parenchyma.

A prospective randomized trial of EUS-guided tissue acquisition using a 25-gauge core biopsy needle with and without a stylet.

Endoscopic ultrasound (EUS)-guided tissue acquisition has become the most effective method of obtaining specimens from a solid lesion adjacent to the gastrointestinal tract. No data exist regarding the use of a stylet in the core biopsy needle during EUS-guided tissue acquisition. The aims of this study were to evaluate the feasibility, safety, and diagnostic yield of a 25-gauge core biopsy needle without (S-) a stylet and to compare its performance with that of a 25-gauge core biopsy needle with (S+) a stylet in patients with solid lesions adjacent to the gastrointestinal tract. From November 2013 to January 2016, we performed 114 EUS-guided tissue acquisitions for the diagnosis of solid lesions adjacent to the gastrointestinal tract in a randomized controlled trial. Patients were randomly assigned to the S+ group (n = 57) or the S- group (n = 57). EUS-guided tissue acquisition was performed using a 25-gauge core biopsy needle without an on-site cytopathologist. There were no significant differences in technical success (100 vs. 100%, p = 1.000), the mean number of needle passes (7.0 ± 1.6 vs. 6.8 ± 1.5, p = 0.556), needle malfunction (0 vs. 1.8%, p = 1.000), or complications (1.8 vs. 0%, p = 1.000) between the S+ and S- groups. Both groups exhibited comparable outcomes with respect to cytological diagnostic accuracy (93.0 vs. 91.2%, p = 1.000) and histological diagnostic accuracy (86.0 vs. 87.7%, p = 1.000) for malignancy. The procedure time was significantly shorter in the S- group than in the S+ group (32.4 ± 11.7 vs. 39.7 ± 8.6min, p < 0.001). EUS-guided tissue acquisition using a 25-gauge core biopsy needle without a stylet did not decrease the diagnostic yield for malignancy and was associated with a shorter procedure time than that associated with a stylet.

Per-Pass Performance Characteristics of Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Malignant Solid Pancreatic Masses in a Large Multicenter Cohort.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is widely performed for the evaluation of pancreatic masses. We evaluated the performance characteristics of EUS-FNA in obtaining a diagnosis of pancreatic malignancy. We performed a multicenter study of patients who underwent EUS-FNA for a solid pancreatic mass. Endoscopic ultrasound-guided FNA was standardized using a 25-gauge needle, slow-pull stylet technique for specimen acquisition, and on-site cytopathology. For the primary analysis, only malignant cytology was regarded as positive. A secondary analysis was performed in which malignant and/or suspicious cytology was regarded as positive. A total of 138 patients underwent EUS-FNA. In the primary analysis, the sensitivity of EUS-FNA for malignancy was 56.7% on first pass, 73.3% on second pass, 83.3% on third pass, 89.2% on fourth pass, and 90.8% on fifth pass, with no increase beyond the fifth pass. In the secondary analysis, the sensitivity was 75.0% on first pass, 89.2% on second pass, 93.3% on third pass, and 95.8% on fourth pass, with no increase beyond the fourth pass. No significant relationship was seen between lesion size and diagnostic yield. Using a 25-gauge needle, the maximal diagnostic yield of EUS-FNA for a solid pancreatic mass is reached after 4 needle passes.

3:09 PM Abstract No. 92 Impact of rapid onsite pathology evaluation (ROSE) on biopsy adequacy: a retrospective review of 610 image-guided biopsies

Rapid onsite evaluation (ROSE) for percutaneous biopsy is a system in which a cytopathologist is available at the time of procedure to evaluate sample adequacy. The aim of our study is to evaluate sample adequacy rates at two academic hospitals staffed by the same group of interventional radiologists, one which uses ROSE and one which does not. We hypothesize ROSE improves the rate of diagnostic specimens obtained and decreases both the number of needle passes and the need for repeat biopsy. IRB approval was obtained at center 1 (with ROSE) and waived at center 2 (without ROSE) for this retrospective review of 610 liver, lung and thyroid biopsies. Center 1 included 96 thyroid, 110 liver, and 114 lung biopsies; center 2 included 117 thyroid, 60 liver, and 112 lung biopsies. The two groups were compared using the t-test and ANOVA for age and sex, respectively. Comparisons of the number of needle passes were done using least squares regression, adjusting for age, sex, and target site. Comparison of whether a specimen was diagnostic was done using a multivariate logistic regression model. After performing multivariate analysis adjusting for age, sex, and tissue type, the odds of having a diagnostic specimen were almost 4 times greater at center 1 than at center 2 (OR 3.97, p<0.01). The rebiopsy rate was significantly lower at center 1 when compared to center 2 (p<0.01). There was no significant difference in the number of needle passes taken per biopsy site when compared between the two centers. ROSE improves the diagnostic yield of image-guided liver, lung, and thyroid biopsies. Our large study presents evidence that on-site cytopathology is a valuable resource; it improves the time to diagnosis by increasing the diagnostic yield at the time of procedure, and it decreases the need for rebiopsy. Thus, centers that utilize image-guided percutaneous biopsy should allocate resources to cover on-site cytopathologic evaluation.

Predictors of Malignancies in Patients with Inconclusive or Negative Results of Endoscopic Ultrasound-guided Fine-needle Aspiration for Solid Pancreatic Masses.

This study analyzed the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic solid masses in patients with or without chronic pancreatitis as well as the clinical parameters relevant to a malignancy when EUS-FNA was negative or inconclusive. A total of 97 patients, who underwent EUS-FNA for solid pancreatic masses over 2 years at a single institution, were evaluated. All patients underwent EUS-FNA for 3-5 passes with 22 or 25 G needles without an on-site cytopathologist. The final diagnosis was obtained by surgery or compatible clinical outcomes for a more than 12 month follow-up. The diagnostic yields in the patients with or without chronic pancreatitis were compared and the histories and laboratory data relevant to pancreatic ductal adenocarcinoma (PDAC) or pseudo-tumor were analyzed. The final diagnoses were adenocarcinoma in 88 patients (90.7%) and inflammatory pseudo-tumor in 9 (9.3%). The results of EUS-FNA were adenocarcinoma (74), suspicious (7), atypical (5), negative (10), and inadequate specimen (1). The diagnostic accuracies were 76.9% and 91.6% in patients with or without chronic pancreatitis, respectively. Among the 23 cases with non-diagnostic results of EUS-FNA, PDAC was finally diagnosed in 5 out of 7 suspicious, 3 out of 5 atypical, and 5 out of 10 negative cytology cases. The clinical parameters related to a pseudo-tumor were a history of alcohol consumption and pancreatitis, and normal alkaline phosphatase levels. The diagnostic accuracy of pancreatic masses in the background of chronic pancreatitis was low. When EUS-FNA produced inconclusive results, the histories of alcohol consumption, pancreatitis, and serum levels of alkaline phosphatase are useful for making a final diagnosis.