Introduction

The concept of Macroscopic on-site evaluation (MOSE) was introduced in 2015 when the endoscopist observed better diagnostic yield when the macroscopically visible core on MOSE was superior to 4 mm. Few studies have assessed the adequacy of histologic cores in MOSE during endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS- FNA/FNB). Recently, some classifications were published.

Aims & Methods

Our study aimed to evaluate the MOSE of EUS-FNA/FNB using 2 classifications to determine the adequacy of the histologic core specimens.
This multicentric prospective study conducted in 5 centers in 2 countries (Egypt and Morocco) included 312 patients with pancreatic, biliary, or gastrointestinal pathology who were referred for EUS examination. Data from patients with MOSE evaluation of the specimen were collected.

Results

The mean age of the 312 patients was 60 ± 12 years and 172 patients (55%) were males. The mean lesion size was 38.2 ± 18.7 mm. 323 lesions were biopsied, of which 213 were pancreatic lesions (62%). Needle types used were Franseen (Acquire) (n=258, 82.7%) and Procore (n=6, 2%) needles for EUS-FNB and Expect (n=28, 9%) and Echotip (n=20, 6.4%) needles for EUS-FNA. The needle sizes used during the procedures were 22G (95.8%), 20G (2%), and 19G (2.2%). The median number of needle passes was 1.76 [1, 4]. 305 of 312 samples (97.8%) were considered adequate for histological evaluation by the endoscopist. 3 patients presented small blood collection (1%). The overall diagnostic yield of cytopathology was 95%. The cytological examination confirmed the diagnosis of adenocarcinoma in 147 patients (64.2%).

Conclusion

MOSE in EUS-FNA/FNB sampling showed high diagnostic yield and accuracy using different needle sizes. In our study, MOSE helped the endoscopist to improve the quality of the core and, if necessary, to multiply the needle passes. This resulted in a high diagnostic yield for cytopathology.

References

1- Iwashita T, Yasuda I, Mukai T, Doi S, Nakashima M, Uemura S, Mabuchi M, Shimizu M, Hatano Y, Hara A, Moriwaki H. Macroscopic on-site quality evaluation of biopsy specimens to improve the diagnostic accuracy during EUS-guided FNA using a 19-gauge needle for solid lesions: a single-center prospective pilot study (MOSE study). Gastrointest Endosc 2015; 81: 177-185 [PMID: 25440688 DOI: 10.1016/j.gie.2014.08.040]
2- Gaia S, Rizza S, Bruno M, Ribaldone DG, Maletta F, Sacco M, Pacchioni D, Rizzi F, Saracco GM, Fagoonee S, De Angelis CG. Impact of Macroscopic On-Site Evaluation (MOSE) on Accuracy of Endoscopic Ultrasound-Guided Fine-Needle Biopsy (EUS-FNB) of Pancreatic and Extrapancreatic Solid Lesions: A Prospective Study. Diagnostics (Basel) 2022; 12 [PMID: 35204519 DOI: 10.3390/diagnostics12020428]
3- Mangiavillano B, Frazzoni L, Togliani T, Fabbri C, Tarantino I, De Luca L, Staiano T, Binda C, Signoretti M, Eusebi LH, Auriemma F. Macroscopic on-site evaluation (MOSE) of specimens from solid lesions acquired during EUS-FNB: Multicenter study and comparison between needle gauges. Endoscopy International Open. 2021 Jun;9(06):E9

Clinical Case Summary

Although liver involvement is common in leukemia, acute hepatitis as its initial presentation is rare. This case highlights the diagnostic challenge of distinguishing reactive hematological changes from underlying malignancies in patients with unexplained hepatitis.
A 35-year-old woman presented in February 2024 with myalgias, fever with chills (38°C), jaundice, and right upper quadrant discomfort. Relevant history included recent intake of herbal supplements (vitamin C, zinc, echinacea, elderberry).
Initial laboratory findings showed leukocytosis, lymphocytosis (25%), monocytosis (12%), blasts (3%), thrombocytopenia (136×10⁹/L), and abnormal liver tests (AST 448 U/L, ALT 686 U/L, ALP 242 U/L, GGT 147 U/L, total bilirubin 4.14 mg/dL, direct bilirubin 2.9 mg/dL), with normal INR. Peripheral blood smear revealed mononuclear pleomorphism and lymphocytes with prominent nucleoli. Abdominal computed tomography showed moderate hepatomegaly without biliary or vascular abnormalities. Comprehensive testing for infeccious, autoimmune and metabolic causes was negative.
Liver tests improved and leukocytosis turned into leukopenia. Repeat blood smear was deemed reactive by Hematology. She was discharged and in early March re-evaluation, liver parameters normalized and leukopenia improved.
Later that month, she returned with fever, night sweats, and abdominal pain. Laboratory findings showed recurrent cytopenias and cytocholestasis. Blood smear revealed increasing blast count, and immunophenotyping suggested monoclonality. Bone marrow and liver biopsy confirmed B-cell acute lymphoblastic leukemia (ALL) with hepatic infiltration.
This case illustrates an unusual presentation of ALL as relapsing acute hepatitis. It reinforces the need to consider hematological malignancy in cryptogenic hepatitis, particularly when associated with evolving hematological changes. Serial blood smears, immunophenotyping, and timely bone marrow evaluation are essential to avoid diagnostic delay.

References

1. Hepatic biopsy: clusters of intermediate to large cells expressing TdT, CD20, PAX5, CD10, BCL6, CD43.
2. Bone marrow aspirate: 64% blasts, CD10+, CD20+ (strong homogeneous expression).
3. Bone marrow biopsy: increased cellularity due to diffuse interstitial infiltration by intermediate cells with blast-like morphology and lymphoid immunophenotype (TdT+, CD34+, MPO-, CD20+).

Introduction

Endoscopy is the first-line approach for managing Zenker's Diverticulum (ZD). Various endoscopic techniques, each with its own advantages and limitations, have been described. We have proposed a new technique, which we have named Submucosal Injection-Guided septomyotomy (SING technique).

Aims & Methods

The performance of SING technique was evaluated in a prospective observational cohort of patients with ZD who underwent the procedure at two Italian hospitals: San Raffaele Hospital (Milan, Italy) and San Giovanni Bosco Hospital (Turin, Italy).
SING technique involves a classic septotomy, which consists of a mucosal incision with a Hook-Knife in the middle of the septum and a cricopharyngeal myotomy for all the length of the Zenker's Diverticulum and beyond 10 mm into the esophageal proper muscular layer. The novelty of the technique lies in the submucosal injection during the septomyotomy on both the esophageal and diverticular sides, which helps to better delineate the muscular layer and guide the complete myotomy, without the need for bilateral submucosal tunnelling.
Clinical success (CS) was defined as a Dakkak and Bennet Dysphagia Score (DBDS) of ≤1 and a Kothari-Haber Score (KHS) of <2 at 3 months. Recurrence was defined as an increase in DBDS of >1 after achieving CS or a KHS of ≥2 after CS. Follow-up included clinical evaluations at 3 and 6 months, and then annually. Adverse Events (AEs) are classified according to the AGREE Classification.

Results

42 patients with ZD underwent SING technique between March 2021 and January 2024 (median age 74 [IQR 67-80], 66.7% males, BMI 24.6 [IQR 21-27]). The median diverticula depth was 30mm (IQR 25-45) with a median septum length of 20mm (IQR 14-30). Median KHS at diagnosis was 4 (IQR 4-6), dysphagia for solids (42.9%) was the most common symptom, with a median symptom duration of 12 months (IQR 6-24). While a technical success rate was observed in all cases (42/42, 100%), a clinical success rate was observed in 40/42 patients (95.2%). In the 2/42 (4.8%) cases of clinical failure, endoscopic evaluation revealed the presence of a minimal residual muscular septum successfully treated with septomyotomy. Median procedural time was 34 minutes (IQR 29-60), with a hospital stay of 2 days (IQR 2-2). No AEs were recorded. After a median follow-up of 370 days (IQR 297-747), no cases of symptom recurrence were recorded.

Conclusion

SING technique is a safe and effective technique for the endoscopic treatment of ZD. It improves and enhances the efficacy of traditional endoscopic septotomy and can also be utilized as rescue therapy.

Introduction

Pancreatic fibrosis is a major histological feature of chronic pancreatitis (CP) as well as affects a course of vast spectrum of pancreatic disorders. Therefore, pancreatic fibrosis early diagnosis gives an invaluable opportunity to be a part of the strategy for preventing disease progression. So, it makes non-invasive pancreatic fibrosis evaluation techniques research perspective.

Aims & Methods

We aimed to clarify relationships between pancreatic fibrosis grade and results of multidetector computed tomography (MDCT). Results of contrast-enhanced 128-row MDCT from 43 patients who underwent surgery from April to December 2022 due to benign and malignant pancreatic tumors as well as advanced CP, mean age 56.8±14 (25-84) were analyzed. We calculated normalized contrast enhancement ratio during the pancreatic (PP)and venous phases (VP), as well as contrast enhancement ratio between VP and non-contrast MDCT Morphological signs of CP as well as pancreatic fibrosis grade were assessed by experienced pathologists according to Klöppel & Maillet’s scoring system [1] for the evaluation of the extent of fibrosis in CP.

Results

We received significant intergroup differences between mean values of normalized contrast enhancement ratios during PV and pancreatic duct epithelium metaplasia (p=0.02) and within morphological signs of pancreatic inflammation (p=0.017). There were differences in mean values of normalized contrast enhancement ratios during PV in groups divided by perilobular fibrosis grade (p=0.04). Unenhanced pancreas density value significantly differed in patients with pancreatic inflammation signs (33.1±11HU) and pancreatic duct epithelium metaplasia (33.1±8.1 HU) than in patients without both phenomena (40.8±5.9HU and 41.2±9.5HU, respectively), with p=0.01 and p=0.001, respectively. We revealed significant intergroup differences in unenhanced pancreas density value depending on intralobular fibrosis grade. Enhancement ratio values were also significantly different in groups divided by perilobular fibrosis grade (p=0.024).

Conclusion

Morphological signs of CP and pancreatic fibrosis like pancreatic tissue inflammation and pancreatic duct epithelium metaplasia as well as pancreatic peri- and intralobular fibrosis grade affect MDCT pancreas enhancement characteristics. It could be useful for noninvasive pancreatic fibrosis diagnosis and prognosis.

References

1. Esposito I, Hruban RH, Verbeke C, et al. Guidelines on the histopathology of chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and the European Pancreatic Club. Pancreatology. 2020;20(4):586-593. doi:10.1016/j.pan.2020.04.009

Disclosure

This study was conducted within the healthcare research project “Assessment of pancreatic fibrosis as a prognostic factor for its diseases course” funded by Autonomous non-profit organization "Moscow Center for Innovative Technologies in Healthcare" administered by the Moscow Healthcare Department.