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Background:
Early detection of small solid pancreatic lesions is increasingly common. To date, few and contradictory data have been published about the relationship between lesion size and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) diagnostic yield. The aim of this study was to assess the relation between the size of solid pancr...
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Citations
... However, a prospective study by Hisada et al. [3] reported a relatively high adverse event rate of 9% when EUS-TA was used for comprehensive genomic profiling with a 19-gauge fine needle biopsy (FNB) needle. Additionally, diagnosing small lesions such as Stage 0/I PDAC using EUS-TA can be challenging [4][5][6][7], leading to reliance on cytology in some cases. Furthermore, the usefulness of cytology via conventional endoscopic retrograde cholangiopancreatography (ERCP) for early-stage PDAC diagnosis has recently been reported [6,[8][9][10]. ...
Recently, endoscopic ultrasound-guided tissue acquisition (EUS-TA) has been widely used to diagnose pancreatic ductal adenocarcinoma (PDAC). The histological examination of core tissues acquired using novel biopsy needles is the primary diagnostic approach for patients with PDAC. However, in patients with early-stage PDAC, such as Stages 0 and I, EUS-TA can be challenging, and its diagnostic accuracy may be limited. This presents a clinical dilemma: The earlier that clinicians attempt to accurately diagnose PDAC, the more difficult it becomes to do so using EUS-TA. Liquid-based cytology (LBC) is a technique for preparing pathological specimens from liquefied cytology specimens by placing the collected material in a special fixative preservative fluid. LBC offers advantages, such as specimen optimization with reduced blood interference, a high cell-collection rate, and the simplicity of the procedure in the endoscopy room. The use of LBC may improve diagnostic accuracy, particularly for early-stage PDAC. Therefore, we emphasize that cytology remains a valuable tool for the endoscopic diagnosis of PDAC. In this review, we discuss the role of LBC in the endoscopic diagnosis of PDAC.
... In terms of sampling, the proportion of inconclusive cytological findings including the "non-diagnostic" (PSC I and WHO I) and "atypical" (PSC III and WHO III) categories is influenced by the characteristics of the lesion (uncinate process location, less than 2 cm in size, the presence of necrotic areas, increased vascularization, benign etiology) and the technical aspects of EUS-FNA (smaller needle diameter, suction technique, the use of contrastenhanced EUS or EUS elastography, the technique of smear preparation, obtaining FFPE, ROSE, macroscopic on-site evaluation). [24][25][26][27][28] Previous studies have shown a significant variation among cytopathologists in the use of indeterminate diagnostic categories. 22,29,30 The enhancement of cytological diagnostic criteria, standardization of specimen quality evaluation, and training for cytopathologists have the potential to enhance agreement among cytopathologists, which would lead to increased repeatability of cytological diagnosis and reduction of inconclusive and false negative cases. ...
Background
The standardized diagnostic categories defined by the World Health Organization (WHO) reporting system support the interdisciplinary interpretation of cytological findings in the management of pancreatic cancer.
Objective
To compare this classification to the Papanicolaou Society of Cytopathology (PSC) system in terms of predictive value and risk of malignancy (ROM) in solid pancreatic lesions.
Design
Retrospective cohort study.
Methods
All consecutive patients with solid pancreatic lesions who underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) sampling at the University of Szeged from 2014 to 2021 were retrospectively enrolled. The predictive value and ROM of cytological findings were determined with comparison to histologic outcome and/or clinical follow-up.
Results
A total of 521 EUS-FNAs were performed with a malignancy rate of 81.76%. In both classification systems, the absolute ROM of “non-diagnostic,” “negative for malignancy,” “atypical,” “suspicious for malignancy,” and “malignant” categories were 48.2%, 2.3%, 78.1%, 100.0%, and 99.4%, respectively. Despite the heterogeneous nature of the “neoplastic: other” category of the PSC system, the absolute ROM for solid lesions was 100%. Pancreatic neoplasm: high-risk/grade category including only two endosonographically solid cases of high-grade intraductal papillary mucinous neoplasms showed 100% ROM. There were no differences between PSC and WHO systems in sensitivity, specificity, and negative and positive predictive values: excluding the “atypical” category, these were 99.7%, 95.6%, 97.7%, and 99.5%, respectively. The “atypical” category considered benign resulted in a higher decrease in validity and negative predictive value, compared to “atypical” considered true malignant (93.6% vs 97.7% and 65.8% vs 97.7%).
Conclusion
For solid pancreatic lesions, the WHO system was identical to the PSC system in terms of ROM and predictive values.
... The primary issue with low tumor cell sampling is sample contamination by blood, inflammatory cells, and even gut wall epithelial cells. [20] Several tumor factors have been identified to be associated with EUS-TA outcomes, including tumor size, [21] tumor location in the head/uncinate, [13] presence of fibrosis, [13] and CP. [22,23] These results were consistent with our study. ...
Background and Objectives
EUS-guided tissue acquisition (EUS-TA) is the preferred method to acquire pancreatic cancer (PC) tissues. The factors associated with false-negative outcomes and inadequate samples should be explored to gain an understanding of EUS-TA.
Methods
The patients who underwent EUS-TA for suspected solid PC but whose results were false-negative were analyzed. The PC patients who underwent EUS-TA with true-positive results on the first day of every month during the study period were selected as the control group. The factors influencing diagnostic accuracy and sample adequacy were explored.
Results
From November 2017 to January 2022, 184 patients were included in the false-negative group, and 175 patients were included in the control group. Multivariate logistic regression demonstrated that the recent acute pancreatitis [odds ratio (OR): 0.478, 95% confidence interval (CI): 0.250–0.914, P = 0.026] and high echo component within the tumor (OR: 0.103, 95% CI: 0.027–0.400, P = 0.001) were independently associated with false-negative EUS-TA results. Meanwhile, using fine-needle biopsy (FNB) needles (OR: 2.270, 95% CI: 1.277–4.035, P = 0.005), more needle passes (OR: 1.651,95% CI: 1.239–2.199, P = 0.005), large tumor size (OR: 1.053, 95% CI: 1.029–1.077, P < 0.001), and high CA-19-9 level (OR: 1.001, 95% CI: 1.000–1.001, P = 0.019) were independently associated with true-positive EUS-TA outcomes. Three needle passes are needed to achieve optimal EUS-TA outcomes. Tumor location in the body/tail (OR: 1.38, 95% CI: 1.01–1.72; P = 0.04), needle passes ≥3 (OR: 1.90; 95% CI: 1.22–2.56; P < 0.001), and using the FNB needle (OR: 2.10; 95%: 1.48–2.85; P < 0.001) were independently related to sample adequacy.
Conclusion
Numerous factors were identified to be associated with the diagnostic accuracy and sample adequacy of EUS-TA.
... Few studies have addressed the accuracy of EUS-TA for the histopathologic diagnosis of small SPLs [11][12][13], reporting contrasting results. Moreover, the effect of lesion size on diagnostic accuracy has been obtained from a large series after stratifying patients by lesion diameter [13]. ...
... Unfortunately, the number of cases in each group was not reported. In a previously published series from our center where EUS-FNA of SPLs was performed with a 25-gauge standard needle, the lesion size was the only independent factor related to diagnostic accuracy, ranging from 80.6% to 92.5% when the diameter was less than 15 mm and more than 25 mm, respectively [11]. However, whether newgeneration FNB needles may improve diagnostic accuracy for small SPLs is unknown. ...
A small tumor size may impact the diagnostic performance of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for diagnosing solid pancreatic lesions (SPLs). We aimed to compare the diagnostic yield of EUS-guided fine-needle aspiration (FNA) and biopsy (FNB) in SPLs with a diameter ≤ 15 mm. Consecutive patients who underwent EUS-TA for SPLs ≤ 15 mm between January 2015 and December 2022 in a tertiary referral center were retrospectively evaluated. The primary endpoint was diagnostic accuracy. The final diagnosis was based on surgical pathology or disease evolution after a minimum follow-up of 6 months. Inadequate samples were all considered false negatives for the study. Secondary outcomes included sample adequacy, factors impacting accuracy, and safety. We included 368 patients (52.4% male; mean age: 60.2 years) who underwent FNA in 72 cases and FNB in 296. The mean size of SPLs was 11.9 ± 2.6 mm. More than three passes were performed in 5.7% and 61.5% of patients in the FNB and FNA groups, respectively (p < 0.0001). FNB outperformed FNA in terms of diagnostic accuracy (89.8% vs. 79.1%, p = 0.013) and sample adequacy (95.9% vs. 86.1%, p < 0.001). On multivariate analysis, using FNA (OR: 2.10, 95% CI: 1.07–4.48) and a final diagnosis (OR: 3.56, 95% CI: 1.82–6.94) of benign conditions negatively impacted accuracy. Overall, the adverse event rate was 0.8%, including one pancreatitis in the FNA group and one pancreatitis and one bleeding in the FNB group, all mild and conservatively managed. EUS-TA for SPLs ≤ 15 mm has a high diagnostic yield and safety. This study suggests the superiority of FNB over FNA, with better performance even with fewer passes performed.
... Finally, new markers (e.g. ATRX/DAXX) assessed on EUSguided fine needle biopsy specimens could be of help for proper patient selection and choice between surgical resection or EUS-RFA [97][98][99]. ...
Introduction
Insulinomas are the most common functional pancreatic neuroendocrine tumors (PNETs) that lead to incapacitating hypoglycemia. Guidelines recommend surgical resection as the mainstay of management. However, surgery is fraught with complications, causing significant peri/post-operative morbidity. Since insulinomas are usually benign, solitary, small (<2 cm), and do not need lymphadenectomy, hence, in this regard, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is now being increasingly performed, to circumvent these adverse events and impairment of pancreatic function.
Areas covered
A comprehensive literature search was undertaken across various databases (PubMed/Medline, Embase, Scopus), with no language restriction, for relevant articles (case series, reviews, case reports) pertaining to EUS-RFA for insulinoma and PNETs, till October 2023. In this review, we have explicated the role of EUS-RFA for insulinoma management, detailing thoroughly its mechanism of action, EUS-RFA devices with data on its safety and efficacy, and an algorithmic approach for its management.
Expert opinion
EUS-RFA is being advocated as a ‘mini-invasive’ option with the potential to replace surgery as a first-line approach for benign, sporadic, solitary, and small (<2 cm) insulinomas. Under real-time guidance, EUS-RFA has immense precision, is safe, predictable, with acceptable safety profile. Presently, it is being frequently performed for high-risk or inoperable candidates. Current need-of-the-hour is a randomized controlled trial to substantiate its role in the therapeutic algorithm for insulinoma management.
... However, in another study, this accuracy was only achievable when ROSE was available [39]. Similar to several other studies, we have also verified that the size of the lesion influences the outcomes of EUS-FNA [37,40,41]. In our study, the rate of inconclusive cytological results was significantly increased for lesions smaller than 2 cm. ...
Background:
The inconclusive cytological findings of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) remain a major clinical challenge and often lead to treatment delays.
Methods:
Patients who had undergone EUS-FNA sampling for solid pancreas lesions between 2014 and 2021 were retrospectively enrolled. The "atypical" and "non-diagnostic" categories of the Papanicolaou Society of Cytopathology System were considered inconclusive and the "negative for malignancy" category of malignancy was suspected clinically. We determined the frequency and predictors of inconclusive cytological finding.
Results:
A total of 473 first EUS-FNA samples were included, of which 108 cases (22.83%) were inconclusive. Significant increases in the odds of inconclusive cytological findings were observed for lesions with a benign final diagnosis (OR 11.20; 95% CI 6.56-19.54, p < 0.001) as well as with the use of 25 G FNA needles (OR 2.12; 95% CI 1.09-4.01, p = 0.023) compared to 22 G needles. Furthermore, the use of a single EUS-FNA technique compared to the combined use of slow-pull and standard suction techniques (OR 1.70; 95% CI 1.06-2.70, p = 0.027) and less than three punctures per procedure led to an elevation in the risk of inconclusive cytology (OR 2.49; 95% CI 1.49-4.14, p < 0.001). Risk reduction in inconclusive cytology findings was observed in lesions between 2-4 cm (OR 0.40; 95% CI 0.23-0.68, p = 0.001) and >4 cm (OR 0.16; 95% CI 0.08-0.31, p < 0.001) compared to lesions ≤2 cm.
Conclusions:
The more than two punctures per EUS-FNA sampling with larger-diameter needle (19 G or 22 G) using the slow-pull and standard suction techniques in combination may decrease the probability of inconclusive cytological findings.
... This procedure has a sensitivity ranging from 54% to 96%, high specificity, and accuracy between 83% and 95%. However, the conventional 22G and 25G needles used during EUS-FNA have limitations, such as the poor ability to provide histological samples suitable for immunohistochemistry (IHC) or other ancillary methods [3,4]. ...
Objectives:
Compare the 22G needle versus EchoTip ProCore® 20 (Cook Medical, Bloomington, IN, USA) on their handling, specimen suitability, amount of tissue obtained, diagnostic performance, the possibility of immunohistochemistry, and rate of adverse events.
Materials and methods:
This is a retrospective, comparative study of consecutively examined patients with pancreatic masses who underwent endosonography-guided fine needle aspiration (FNA) via the 22G needle, and endosonography-guided tissue acquisition (TA) via ProCore 20 (PC20). The operator evaluated needle insertion and subjectively classified the specimen. The pathologist measured the samples, classified the amount of tissue, and determined the influence of bleeding on the interpretation.
Results:
A total of 129 patients participated in the study, out of whom 52 underwent endosonography-guided FNA with 22G and 77 underwent endosonography-guided TA with a PC20 needle. Malignant lesions were found in 106, and 23 had benign lesions. The duodenal route was used in 62% of patients. The 22G needle was easier to introduce (p=0.0495). However, PC20 obtained a larger amount (p<0.01) with fewer punctures (p<0.001). The PC20 also yielded a larger average microcore diameter (p=0.0032). Microhistology was adequate for 22G and PC20 in 22 (42.2%) and 50 (78.1%) specimens, respectively (p<0.001). Bleeding was not significantly different (p>0.999). Immunohistochemistry was possible in 36 (69.2%) and 40 (51.9%) specimens obtained by 22G and PC20, respectively (p=0.075). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 22G were 93.5%, 100%, 100%, 66.7%, and 94.2%, respectively; and for PC20, it was 95%, 100%, 100%, 85%, and 96.1%, respectively. Mild bleeding was the most common early adverse event, occurring in 2/52 (3.8%) 22G and 4/77 (5.2%) PC20 cases (p>0.05).
Conclusions:
The PC20 required fewer punctures and reduced the need for immunohistochemistry as it yielded better and larger microcores. Its ease of insertion into the target lesion makes it a good option to obtain satisfactory microcore specimens in difficult positions, such as the transduodenal route.
... P = 0.02). This is presumably due to mild wall thickness potentially misdiagnosed as flogistic tissue; moreover, small lesions are difficult to sample as previously reported [15][16][17]. ...
Background and aim:
The diagnostic role of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) and fine needle biopsy (FNB) of pelvic masses has not been well established. We aimed to evaluate the diagnostic accuracy of EUS plus FNA/FNB in suspected local recurrence of pelvic masses.
Materials and methods:
All consecutive patients with a history of lower gastrointestinal and pelvic mass undergone EUS-FNA/FNB were included in the study.
Results:
In total 34 patients who underwent EUS-guided FNA or FNB of a perirectal mass were enrolled. The sampled lesion was a mass in 22 patients (64.7%) and a lymph node in 10 patients (29.4%). The univariate logistic regression analysis for diagnostic accuracy showed lesion size as a significant predictor of diagnostic accuracy [odds ratio (OR), 1.61; 1.08-2.27; P = 0.02]. Diagnostic sensitivity was 100% (71.5-100%) with EUS-FNB and 75% (34.9-96.8%) with EUS-FNA (P = 0.12); specificity was 100% in both groups (P = 1.0). Sample adequacy was 94.1% in the whole cohort, with 20/20 adequacy rate (100%) in the EUS-FNB group and 12/14 (85.7%) in the EUS-FNA group (P = 0.28).
Conclusion:
This is the first study demonstrating the diagnostic yield of EUS plus FNA/FNB in patients with pelvic masses comparing the two needles. Our results highlight the relevance of this technique, especially in undefined masses during oncological follow-up.
... 3,4 In addition, its diagnostic accuracy for small lesions is low in the early stages. 5,6 Although carcinoma in situ (CIS) of the pancreas without mass formation occurs, its diagnosis by EUS-FNA is not possible; instead, conventional diagnostic endoscopic retrograde cholangiopancreatography (ERCP) is required. 7,8 The efficacy of serial pancreatic juice aspiration cytological examination (SPACE) via an endoscopic naso-pancreatic drainage (ENPD) tube has also been reported, 8 but it is sometimes difficult to collect an adequate volume for analysis. ...
... The overall sensitivity of EUS-FNA for the diagnosis of pancreatic cancer is approximately 90%; however, its diagnostic ability for small lesions remains limited. 5,6 EUS-FNA is not indicated for cases in which a mass cannot be delineated by EUS. Specifically, this applies to cases of noninvasive cancer (CIS) that do not form a mass and to cases in which a pancreatic mass F I G U R E 2 Findings of stage 0 pancreatic ductal adenocarcinoma (Case 5 in Table 4, carcinoma in situ). ...
Objectives:
Serial pancreatic juice aspiration cytological examination (SPACE) via endoscopic retrograde cholangiopancreatography is a useful diagnostic method for early-stage pancreatic cancer, such as carcinoma in situ that are difficult to diagnose by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). However, the diagnostic accuracy of SPACE is low, which is attributed to problems regarding specimen treatment. Hence, we evaluated the diagnostic efficacy of liquid-based cytology (LBC) in pancreatic juice cytology for pancreatic cancer.
Methods:
We retrospectively analyzed 24 patients with suspected pancreatic cancer that was difficult to diagnose by endoscopic ultrasound-guided fine needle aspiration who underwent SPACE using LBC between April 2017 and April 2021.
Results:
The most common reason for performing SPACE was localized stenosis of the main pancreatic duct without a mass. Eleven patients were diagnosed with malignancy after surgical resection, nine of whom had pancreatic ductal adenocarcinoma. Ten patients were diagnosed as benign after a follow-up of more than 1 year. The nine cases of malignancy were diagnosed before surgical resection by SPACE using LBC, with a sensitivity of 81.8% and specificity of 100%. The overall diagnostic accuracy was 91.7%. A total of 152 LBC examinations were performed via SPACE, with an adequate sample collection rate of 88.9%. No adverse events, including acute pancreatitis, occurred after endoscopic retrograde cholangiopancreatography.
Conclusion:
SPACE with LBC offers good diagnostic efficacy in patients with pancreatic cancer that is difficult to diagnose by endoscopic ultrasound-guided fine needle aspiration.
... Original Article INTRODUCTION EUS-guided tissue acquisition (EUS-TA) represents the procedure of choice for the characterization of solid pancreatic lesions (SPLs). [1] Several factors can impact the diagnostic accuracy of EUS-TA, such as needle type [2,3] and caliber, [4,5] lesion size, [6,7] use of EUS enhancement techniques, [8] sampling technique, [5,9] specimen processing, [10][11][12][13] number of passes, [14,15] and availability of rapid on-site evaluation (ROSE). [16,17] Tumors located in the pancreatic head/uncinate process are often responsible for jaundice, which is usually the first clinical symptom. ...
... [25] The relation between lesion size and diagnostic yield has been previously reported for the diagnosis of pancreatic lesions. [6,7] In patients with biliary stent, the acoustic shadow/reverberation artifact could completely mask small lesions, making its sampling difficult. Conceivably, it is likely that a portion of larger masses remains visible beside the placement of a stent. ...
Background and Aims
Whether an indwelling biliary stent negatively impacts the diagnostic yield of
endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) for diagnosing pancreatic
lesions is unknown. We aimed to evaluate the association between the presence of
biliary stents and the diagnostic accuracy of EUS-FNB.
Methods
A multicenter retrospective study including all jaundiced patients secondary to
pancreatic head masses was performed. Patients were divided into two groups
according to the presence of a biliary stent placed before EUS-FNB. Pathological
results were classified according to the Papanicolaou classification and compared
against the final diagnosis. Diagnostic measures in the two groups were compared.
Multivariate logistic regression analyses including potential factors affecting EUS-FNB
accuracy were performed.
Results
Overall, 842 patients were included, 495 (58.8%) without and 347 (41.2%) with biliary
stent. A plastic or a metal stent was placed in 217 (62.5%) and 130 (37.5%) cases,
respectively. Diagnostic sensitivity and accuracy were significantly higher in patients
without biliary stent than in those with stent (91.9% and 92.1% vs. 85.9% and 86.4%,
p=0.010 and p=0.014, respectively). At multivariate analyses, lesion size (OR 1.05,
95%CI 1.02-1.09, p=0.01) and presence of biliary stent (OR 0.51, 95%CI 0.32-0.89,
p=0.01) were independently associated with diagnostic accuracy. In the subgroup of
patients with biliary stent, the type of stent (plastic vs. metal) did not impact EUS-FNB
yield, whereas the use of larger bore needles enhanced diagnostic accuracy (OR 2.29,
95%CI 1.28-4.12, p=0.005).
Conclusions
In this large retrospective study, an indwelling biliary stent negatively impacted the
diagnostic accuracy of EUS-FNB. Preferably, EUS-FNB should precede ERCP,
especially in the case of small tumors.
