Pancreatic Fine-needle Aspiration Research Articles

Reporting Pancreatic FNAC using the Papanicolaou System: Still a Diagnostic Challenge.

The Papanicolaou Society of Cytopathology System for reporting Pancreaticobiliary Cytology (PSCPC) is a reliable method to classify pancreatic fine needle aspiration cytology (FNAC) smears. However, it is not without practical problems which can diminish the diagnostic accuracy of the cytological diagnosis. To determine the diagnostic pitfalls while reporting cytomorphology of pancreatic lesions according to PSCPC on correlating FNAC findings with histopathology. Retrospective analysis of pancreatic FNAC smears received in the Department of Pathology of our tertiary care institute over a period of 2 years was done. The cytological diagnoses were classified according to the Papanicolaou Society of Cytopathology system of reporting pancreaticobiliary cytology and correlated with histopathology. The reasons of cyto-histological discordance were analyzed. Out of 50 cases in which both FNAC and biopsy of pancreatic lesions were done, 34 cases were positive/malignant (Category VI), eight cases were suspicious for malignancy (Category V), three cases were neoplastic (Category IV), two cases were atypical (Category III), two cases were negative for malignancy (Category II), and one case was non-diagnostic (Category I). Out of 50 cases, histopathology was non-diagnostic due to inadequate material in six cases. The cytological diagnoses were compared with histopathology in the remaining 44 cases. Categories III, IV V, and VI were considered as positive for neoplastic pathology. The sensitivity of FNAC to predict neoplastic pathology was 97.5%, while the specificity was 25%. The positive predictive value was 92.9%. Two cases reported as atypical (Category III) turned out to be adenocarcinoma on histopathology. One case reported as neuroendocrine tumor and two cases reported as adenocarcinoma on cytology displayed features of chronic pancreatitis on histology. One case reported as neoplastic mucinous cyst (Category IV) turned out to be adenocarcinoma on histology (limited concordance). The cytopathologist needs to be wary of the potential pitfalls to improve the diagnostic accuracy of FNACs.

Analytical Validation of Loss of Heterozygosity and Mutation Detection in Pancreatic Fine-Needle Aspirates by Capillary Electrophoresis and Sanger Sequencing.

Pancreatic cystic disease, including duct dilation, represents precursor states towards the development of pancreatic cancer, a form of malignancy with relatively low incidence but high mortality. While most of these cysts (>85%) are benign, the remainder can progress over time, leading to malignant transformation, invasion, and metastasis. Cytologic diagnosis is challenging, limited by the paucity or complete absence of cells representative of cystic lesions and fibrosis. Molecular analysis of fluids collected from endoscopic-guided fine-needle aspiration of pancreatic cysts and dilated duct lesions can be used to evaluate the risk of progression to malignancy. The basis for the enhanced diagnostic utility of molecular approaches is the ability to interrogate cell-free nucleic acid of the cyst/duct and/or extracellular fluid. The allelic imbalances at tumor suppressor loci and the selective oncogenic drivers are used clinically to help differentiate benign stable pancreatic cysts from those progressing toward high-grade dysplasia. Methods are discussed and used to determine the efficacy for diagnostic implementation. Here, we report the analytical validation of methods to detect causally associated molecular changes integral to the pathogenesis of pancreatic cancer from pancreatic cyst fluids.

The WHO system versus the Papanicolaou society of cytopathology system for reporting pancreaticobiliary cytology for risk stratification-which is better?

Recently, the World Health Organization (WHO) has proposed a reporting system for pancreaticobiliary cytopathology. We applied this classification for pancreatic lesion samples by fine needle aspiration (FNA) and compared the results to the previous classification of the Papanicolaou Society of Cytopathology (PSC) system for risk stratification. The computerized database was searched for all pancreatic endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and transabdominal ultrasound-guided FNA (TUS-FNA) samples from 2016 to 2020 and cases were reassigned as per the PSC and the WHO diagnostic categories. Cases with follow-up, clinicoradiological, and/or histopathology were included in the study. The risk of malignancy (ROM) was calculated across all diagnostic categories based on clinical data, imaging data, and histopathology wherever available. There were a total of 625 pancreatic FNA. In 230 cases, follow-up information was available which included 116 EUS and 114 TUS-FNA samples. The ROM for PSC categories I-VI was 40%, 19.7%, 28.6%, 57.1%, 94.7%, and 97.9% and for the WHO categories (I-VII), it was 60%, 21.3%, and 35.7%, not representative, not applicable, 94.7% and 94.9%. The overall sensitivity and specificity of PSC was 68.2% and 96.2% when categories V and VI were taken as positive and 78.9% and 93.3% for WHO when categories VI and VII were taken as positive. Pancreatic FNA samples reported as per the WHO system showed better sensitivity as compared to the PSC system resulting in better risk stratification and consequently better patient management. The overall high specificity and moderate sensitivity reaffirm the utility of FNA in pancreatic lesions.

A deep learning model to triage and predict adenocarcinoma on pancreas cytology whole slide imaging

Pancreatic fine-needle aspirations are the gold-standard diagnostic procedure for the evaluation of pancreatic ductal adenocarcinoma. A suspicion for malignancy can escalate towards chemotherapy followed by a major surgery and therefore is a high-stakes task for the pathologist. In this paper, we propose a deep learning framework, MIPCL, that can serve as a helpful screening tool, predicting the presence or absence of cancer. We also reproduce two deep learning models that have found success in surgical pathology for our cytopathology study. Our MIPCL significantly improves over both models across all evaluated metrics (F1-Score: 87.97% vs 88.70% vs 91.07%; AUROC: 0.9159 vs. 0.9051 vs 0.9435). Additionally, our model is able to recover the most contributing regions on the slide for the final prediction. We also present a dataset curation strategy that increases the number of training examples from an existing dataset, thereby reducing the resource burden tied to collecting and scanning additional cases.

Pancreaticobiliary Cytology Practice in 2021: Results of a College of American Pathologists Survey.

The College of American Pathologists (CAP) surveys provide national benchmarks of pathology practice. To investigate pancreaticobiliary cytology practice in domestic and international laboratories in 2021. We analyzed data from the CAP Pancreaticobiliary Cytology Practice Supplemental Questionnaire that was distributed to laboratories participating in the 2021 CAP Nongynecologic Cytopathology Education Program. Ninety-three percent (567 of 612) of respondent laboratories routinely evaluated pancreaticobiliary cytology specimens. Biliary brushing (85%) was the most common pancreaticobiliary cytology specimen evaluated, followed by pancreatic fine-needle aspiration (79%). The most used sampling methods reported by 235 laboratories were 22-gauge needle for fine-needle aspiration (62%) and SharkCore needle for fine-needle biopsy (27%). Cell block was the most used slide preparation method (76%), followed by liquid-based cytology (59%) for pancreatic cystic lesions. Up to 95% (303 of 320) of laboratories performed rapid on-site evaluation (ROSE) on pancreatic solid lesions, while 56% (180 of 320) performed ROSE for cystic lesions. Thirty-six percent (193 of 530) of laboratories used the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology in 2021. Among all institution types, significant differences in specimen volume, specimen type, ROSE practice, and case sign-out were identified. Additionally, significant differences in specimen type, slide preparation, and ROSE practice were found. This is the first survey from the CAP to investigate pancreaticobiliary cytology practice. The findings reveal significant differences among institution types and between domestic and international laboratories. These data provide a baseline for future studies in a variety of practice settings.

Risk of Malignancy in Pancreatic Fine Needle Aspiration Biopsies: A Single Institution Experience with PSC and WHO Reporting Systems

Risk of Malignancy in Pancreatic Fine Needle Aspiration Biopsies: A Single Institution Experience with PSC and WHO Reporting Systems

Study of Non-diagnostic Category for Pancreatic Fine Needle Aspirations

Study of Non-diagnostic Category for Pancreatic Fine Needle Aspirations

Fine-Needle Aspiration Biopsy of Pancreatic Masses: Failure Factors

Objectives: The main objective of this work is to determine the factors affecting the failure rate of pancreatic aspiration cytology, in particular the size, location, and nature of the mass as well as the size of the needle, the aspiration site, the number of passages, and realization of Fanning. Materials and methods: This is a retrospective study conducted in the EFD-HGE department at Ibn Sina Hospital in Rabat from March 2017 to May 2023. 138 patients with a solid or cystic pancreatic mass on imaging were included. A video-linear Pentax-type echoendoscope was used with needles of different gauges: 19G, 20G, 22G, and 25G. Statistical analysis was performed using R software and the level of significance was set at p < 0.05. Results: The sex ratio F/M was 1.35. The average age was 59 years old. The average tumor size was 40.5 mm. Fine needle aspiration (FNA) under ultrasound-endoscopy (EUS) was positive in 70% of cases: adenocarcinoma in 60% of cases, chronic pancreatitis in 9.33% of cases, neuroendocrine tumor in 8% of cases, solid and pseudo-papillary tumor of the pancreas in 4% of cases, mucinous cystadenoma with low-grade (LGD) in 1.33% of the cases, an intraductal papillary mucinous neoplasm (IPMN) in 2.66% of the cases, pancreatic tuberculosis in 1.33% of the cases. Normal pancreatic parenchyma without signs of malignancy in 13.33% of the cases. The failure rate of pancreatic fine-needle aspiration was estimated at 30% of cases (inconclusive result). By univariate analysis, we demonstrated that the risk of having an inconclusive fine needle aspiration increases on the one hand by the location of the mass at the head of the pancreas (p = 0.02), the presence of a cystic component (p = 0.01), the infiltrating character of the mass (p = 0.01), and on the other hand by the absence of Fanning (p = 0.03). However, this study did not show a significant correlation with the other factors, in particular the size of the mass, the size of the needle, the site of fine-needle aspiration, and the number of passages. No complications were noted. Conclusion: The failure rate of fine-needle aspiration biopsy was 30%. We demonstrated that it increases by the location of the mass at the head of the pancreas (p = 0.02), the presence of a cystic component (p = 0.01), the infiltrating character of the mass (p = 0.01), and the absence of fanning. An additional study with a larger sample or a multicenter study seems necessary to confirm our results.

Challenging Pancreatic Fine Needle Aspirations - Second Opinion Consultation Experience from an Academic Institution

Challenging Pancreatic Fine Needle Aspirations - Second Opinion Consultation Experience from an Academic Institution

Primary Pancreatic Lymphoma Evaluated by Fine-Needle Aspiration.

Primary pancreatic lymphoma (PPL) is rare, mimicking pancreatic ductal adenocarcinoma (PDAC) clinically and radiologically. The aim of this study is to evaluate the clinical, radiologic, and pathological characteristics of PPL diagnosed by fine-needle aspiration (FNA) in our institution. Patient clinical, radiologic, and pathological information was collected from the electronic health record system. In total, 11 of 4,353 pancreatic FNAs met the criteria. The most common clinical symptom was jaundice, followed by abdominal pain, weight loss, and diarrhea. Abnormal laboratory findings included elevated alkaline phosphatase, total bilirubin, lactate dehydrogenase, and cancer antigen 19-9. Abnormal radiologic findings included pancreatic mass, biliary dilatation, vessel encasement, and common bile duct encasement and thickening. Five patients underwent more than 1 tissue sampling procedure before the final diagnosis of lymphoma. Final pathologic diagnosis included 7 large B-cell lymphomas and 4 follicular lymphomas. Flow cytometric analysis was performed on 9 specimens, and all demonstrated an aberrant monoclonal B-cell population. PPL mimics PDAC clinically and radiologically and could be a challenge for pathologic diagnosis if lymphoma is not included in the differential diagnosis during immediate evaluation. If lymphoma is suspected during immediate evaluation, PPL could be reliably diagnosed by FNA with the aid of ancillary studies.

Evaluation of cytomorphological findings and diagnostic efficacy in liquid-based cytology and smear cytology of pancreatic endoscopic ultrasound-guided fine-needle aspiration

Evaluation of cytomorphological findings and diagnostic efficacy in liquid-based cytology and smear cytology of pancreatic endoscopic ultrasound-guided fine-needle aspiration

Pancreatic neuroendocrine tumor trapped in a cyst

Pancreatic neuroendocrine tumor (Pan NET) accounts for only 1–2% of pancreatic neoplasms and <1% of tumors present as cystic lesions. A diagnosis of cystic tumor in the pancreas can be very challenging and confusing. Endoscopic ultrasound (USG) and fine needle aspiration (FNA) of these cystic lesions can help the clinician to narrow down the differential diagnosis. A multidisciplinary approach is warranted for a definitive diagnosis and optimal treatment. Here, we present to you a very rare case of Pan NET presenting as a cystic mass. A 65-year-old man was admitted with a history of abdominal pain. Laboratory tests showed increased levels of serum amylase, and other biochemical tests were normal. The patient underwent transabdominal USG and computed tomography (CT). CT showed well-defined cystic lesion in the proximal body of the pancreas. Endoscopic guided FNA (EUS-FNA) using 22 gauges was done. Cytological examination demonstrated clusters and sheets of plasmacytoid cells. EUS core needle biopsy was done which showed loose clusters of cells with fine uniformly distributed chromatin that stained positively for insulinoma associated protein-1 which was suggestive of a Pan NET. The differential diagnosis of cystic lesions in the pancreas is very difficult with conventional radiology such as CT and magnetic resonance imaging. Cytology is helpful for a pre-operative diagnosis of cystic Pan NET. A diagnosis of Pan NET in a pancreatic biopsy or FNA with limited and suboptimal material is often challenging. This unusual case highlights the importance of pre-operative workup of EUS followed by FNAC in cystic pancreatic lesions.

Metastatic tumors to the pancreas, a 12-year single institution review.

Tumors of the pancreas are often primary in nature, but are occasionally proven to be secondary. We report a 12-year review of all pancreatic tumors shown to be metastatic at the University of Colorado. The electronic pathology database was searched between 2008 and 2020, for all pancreatic fine-needle aspiration cases at the University of Colorado to identify and review metastatic tumors to the pancreas. Additional data points to include age, sex, radiographic features, and clinical management were analyzed. Our data retrieval identified 39 metastatic tumors to the pancreas comprised of 12 (31%) renal cell carcinomas, 6 (15%) lung carcinomas, and 5 (13%) melanomas with the remainder of tumors originating from a variety of other sites. The most common location of these metastases within the pancreas was the pancreatic head (49%) followed by the body (20%). Eighty-five percentage of cases presented with a single radiographically identified mass. While the majority of pancreatic tumors represent primary processes, metastatic tumors to the pancreas represent a possible pitfall. The most common tumors to metastasize to the pancreas in this series were renal cell carcinoma, lung carcinoma, and melanoma. General awareness of the most frequent tumors to metastasize to the pancreas is practical when faced with a pancreatic lesion that could represent a metastasis, or in the absence of clinical history.

Cytopathological characteristics of solitary fibrous tumour involving the pancreas by fine needle aspiration: Making an accurate preoperative diagnosis in an uncommon location.

Solitary fibrous tumour (SFT) is a unique mesenchymal neoplasm with classic features on histology and is characterised by the NAB2-STAT6gene fusion. There are rare reports of SFTs with pancreatic involvement and only two cases in the literature reporting its features by preoperative fine needle aspiration (FNA). Herein, we characterise the cytomorphological features of four SFTs involving the pancreas by FNA to establish a preoperative diagnostic approach. The anatomic pathology archives of two academic medical centres were searched to identify patients with a pancreatic FNA cytology specimen and a confirmed diagnosis of SFT by surgical resection. The clinical history, pathological diagnosis, cytomorphological findings, and results of immunohistochemistry (IHC) were reviewed. Four SFTs were identified from four patients with a median age of 59years. The morphological features were variable but most frequently showed a bland spindled-to-epithelioid proliferation in fragments and single cells with small, oval, elongated, and hypochromatic nuclei in a haphazard arrangement with or without dense collagen. One tumour presented with a concurrent metastasis and showed a pure epithelioid component with necrosis and enlarged, hyperchromatic nuclei with conspicuous nucleoli and scattered mitoses. IHC was necessary for all diagnoses which were confirmed by surgical resection. SFTs with pancreatic involvement are rare, and non-specific features and tumour heterogeneity can pose a diagnostic challenge on FNA; however, IHC can be used to make a definitive diagnosis. As a result, FNA is a simple, safe, cost-effective, and accurate approach that can be used to diagnose SFT in the pancreas.

S3378 Yield of Pancreatic Head Fine Needle Aspiration Is Not Affected by Prior Biliary Stent Placement

S3378 Yield of Pancreatic Head Fine Needle Aspiration Is Not Affected by Prior Biliary Stent Placement

S1665 Pancreatitis Associated With EUS-Guided Pancreatic Cyst Ablation or Fine Needle Aspiration: An Adverse Event With a Therapeutic Benefit

S1665 Pancreatitis Associated With EUS-Guided Pancreatic Cyst Ablation or Fine Needle Aspiration: An Adverse Event With a Therapeutic Benefit

Alcian Blue/Periodic Acid-Schiff (AB/PAS) Special Stain is a Useful Ancillary Test to Determine Neoplastic Mucin in Pancreatic Cyst Fine Needle Aspirate Biopsy Samples: A Single Institution Retrospective Study

Alcian Blue/Periodic Acid-Schiff (AB/PAS) Special Stain is a Useful Ancillary Test to Determine Neoplastic Mucin in Pancreatic Cyst Fine Needle Aspirate Biopsy Samples: A Single Institution Retrospective Study

Endoscopic endosonography with fine-needle aspiration biopsy in the diagnosis of pancreatic tumors

Objectives of the study: efficiency assessment of cytological methods in the diagnosis of pancreatic tumors.
 Material and methods. Our study includes results of 163 pancreatic fine needle aspirations of solid and cystic tumors, from 160 patients of the N.N. Petrov Cancer Research Center for the 4-year period (2016–2020).
 Results. Representative cell material for morphological studies was obtained in 98.6% of cases. The results of cytological examination of 35 patients with pancreatic tumors were compared with histological data. Malignant process was correctly established in 30 out of 32 patients, benign process- in all three cases. The sensitivity of cytological examination was 93.1%, specificity — 100%.
 Conclusion. Pancreatic fine-needle aspiration cytology is safe, rapid, accurate and cost‐beneficial modality of investigation of pancreatic mass lesion.

Acinar cell induced autolysis is a frequent occurrence in CytoLyt-fixed pancreatic fine needle aspiration specimens: An analysis of 157 cytology samples.

Although 10% formalin is a standard preservative in pancreatic FNAs, the effect of CytoLyt on pancreatic tissue preservation has not been systematically explored. Smears and cell blocks from CytoLyt-fixed (CF-CBs) and formalin-fixed (FF-CBs) pancreatic FNAs were blindly reviewed without knowledge of the fixative used, and the presence of tissue/tumor autolysis was noted. Controls included FF-CBs from pancreatic FNAs, CF-CBs from nonpancreatic FNAs, and 4 pancreatic FNAs with matched CF-CBs and FF-CBs. We found that 62 of 85 (73%) pancreatic FNAs with CF-CBs showed significant autolysis, which was most pronounced in acinar cells and/or tumor cells with benign acinar cells in the background, compared with 2 of 46 (4%) FF-CBs (P < .0001) and 3 of 26 (12%) CF-CBs from nonpancreatic FNAs (73% vs 12%; P < .0001). Of the 4 pancreatic FNAs with matched CF-CBs and FF-CBs, all 4 CF-CBs showed marked autolysis versus none of the matched FF-CBs. Of the 23 (27%) pancreatic FNAs with CF-CBs that did not show autolysis, 10 had no acinar cells, and 7 had only minute tissue fragments on CB. While CytoLytis a useful fixative for nonpancreatic FNAs it is a suboptimal fixative for pancreatic FNAs and is associated with tissue/tumor autolysis in the majority of cases, influencing morphologic evaluation, and potentially immunocytochemical staining. Autolysis appears to be due to acinar enzymes whose effect is likely interrupted/inhibited by formalin fixation. Cytopathologists and cytotechnologists should be mindful of this pitfall and should avoid using CytoLytas a fixative for pancreatic FNAs.

The utility of immunohistochemical testing for mismatch repair proteins in fine needle aspiration specimens of pancreatic adenocarcinoma

IntroductionMicrosatellite instability (MSI) testing is recommended for all colonic and endometrial carcinomas to screen for Lynch syndrome. The role of MSI testing in pancreatic adenocarcinoma has not been well-established. Screening can be done via immunohistochemical (IHC) staining for mismatch repair (MMR) proteins (MLH1, MSH2, MSH6, PMS2). We report our experience and the clinical utility of MMR IHC on pancreatic adenocarcinomas in fine-needle aspiration (FNA) specimens. Materials and methodsWe performed a retrospective review to identify all patients diagnosed with pancreatic adenocarcinoma by FNA at our institution between December 2017 and September 2019. For cases with sufficient tumor cells for testing, the MMR results and morphology were summarized, as well as corresponding clinical information, including age, clinical stage, treatment, and concurrent other cancers. ResultsFrom December 2017 to September 2019, there were a total of 184 pancreatic FNAs with a diagnosis of adenocarcinoma. Of these 184 FNAs, 65 (35%) contained sufficient material in the cell block to perform IHC for MMR. The cell block material was collected in either RPMI or CytoLyt. Poor technical quality precluded interpretation of PMS2 in 4 cases and MSH6 in 2 cases. All other cases showed intact expression of all four proteins. ConclusionsIHC for MMR proteins can be done on specimens collected in RPMI or CytoLyt, but RPMI appears to be more reliable. None of the pancreatic adenocarcinomas in this study showed loss of MMR protein expression. Routine testing of MMR loss may not be indicated in pancreatic adenocarcinomas in the general patient population.