Introduction

EUS-FNA and EUS-FNB have become the standard of care for the diagnosis of pancreatic and peripancreatic tumors, and several factors are associated with its diagnostic accuracy. The aim of this study is to evaluate factors that are associated with the diagnostic accuracy of EUS-FNA/B in two referal centers

Aims & Methods

Data from patients with pancreatic and peripancreatic lesions who underwent EUS-FNA/B from 2017 to 2023 were collected retrospectively. The associations between mass location, mass size, needle type, number of needle passes, the presence of a biliary stent and the cytology result were analyzed.

Results

A total of 438 patients underwent 440 EUS-FNA/B procedures. The overall accuracy of EUS-FNA/B was 90,6% (398/440). Mass location on the head of the pancreas was associated with a higher diagnostic accuracy (p<0.05). Two or more needle passes were statistically significantly correlated with higher diagnostic accuracy (p<0.05) compared to single-pass EUS-FNA/B. Mass size, needle type and presence of a biliary stent did not reach statistical significance for the diagnostic yield of the cytology. A subgroup of 109 patients (24,7%) had lesions in the corpus or the tail of the pancreas. In this subgroup, tumor size greater than 3 cm was statistically significant correlated with a diagnostic cytology result (p<0.05).

Conclusion

The results of this study suggest that 2 or more needle passes and lesions in the head of the pancreas are associated with higher diagnostic accuracy of EUS-FNA/B in two referal centers.

References

Johnson G et al. Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2021; 53: 1071—1087

Introduction

Pancreatic cystic lesions (PCLs) are common and could vary from a simple benign cyst to a highly malignant cyst.¹ Mixed lesions with a solid part and a cystic part are very uncommon. They could be a sign of malignant transformation of a cyst.² Recently the awareness of these lesions has increased, especially with the increased incidence of asymptomatic pancreatic cysts worldwide primarily due to improved detection by different advanced imaging modalities.³Therefore, the proper diagnosis, differentiation and staging of these lesions are crucial for proper management and avoiding unnecessary treatment of benign ones and missing early treatment of the pre-malignant lesions.⁴ EUS-guided fine needle biopsy (EUS-FNB) may overcome these limitations of EUS-FNA through acquisition of core tissue samples that provide the ability to assess cyst wall architecture via histology. At this point, ESGE does not recommand use of EUS-FNB for diagnosis of cystic lesions.⁵

Aims & Methods

Aim: Based to the literature, there are few reports regarding the role of EUS-FNB replacing EUS-FNA in the diagnosis of PCL. This work aims to study the feasibility and safety of EUS-FNB 22G in diagnosis of PCLs.
Methods: Of 640 consecutive EUS-FNB 22G for different lesions between January,2019 and December,2023 at our center. 60 EUS-FNB 22G were done for the patients who underwent EUS-guided sampling of pancreatic cystic or mixed lesions diagnosed by abdominal MRI and/or CT scan. The patients were retrospectively and prospectively followed. All the solid lesions, pancreatic pseudocysts (round, non-septated lesions, presence of internal debris, recent acute pancreatitis or radiologic imaging of chronic pancreatitis) and lesions interposed vessels or main pancreatic duct are excluded from this study.Patients with history of severe hemorrhagic risk (platelet count <50,000 /Lor prothrombin activity <50%) are excluded. We statistically analyse the clinical and technical success rates, in addition to evaluate the diagnostic accuracy of EUS-FNB in differentiating benign and malignant pancreatic cystic lesions. Evaluation of the cyst location, primary diagnosis, adverse events, and comparison between the cytologic fluid analyses and histopathology was performed. Technical success was defined as visible tissue present after biopsy. Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis.

Results

A total of 60 patients (mean age 65.0 ± 12.1, 36.6% females) with 60 PCLs consecutively were referred for EUS-FNB 22G and enrolled in a prospective study. 41/60 (68.3%) lesions were mixed (cystic and tissue) and 19/60 (31.7%) lesions are cystic lesions. The mean lesion size was 32.4 ± 16.6mm. The EUS-FNB 22G procedure was technically and clinically successful in all patients (100%). The mean number of needle passes, as defined as unique transluminal needle insertions into the cystic compartment, was 1.9 ± 0.6. No immediate adverse events were developed after the procedure. In 57/60 (95.0%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. Among the 10 patients who had surgical teatment, the concordance of FNB compared to surgical pathology was noticed.

Conclusion

The diagnosis of pancreatic cystic and mixed lesions with a solid and liquid component can be achieved with fine needle biopsy using a 22-gauge needle in a safe and practicable manner. This method has a great diagnostic yield and does not increase the rate of complications.

References

1. Basturk O, Coban I, Adsay NV. Pancreatic cysts: pathologic classification, differential diagnosis, and clinical implications. Arch Pathol Lab Med. 2009;133:423–438.
2.Da Silva RJ, Oliveira INF, Ribeiro TC da R, Chebli LA, Pace FH de L, Chebli JMF. A Rare Presentation of a Solid Pseudopapillary Neoplasm of the Pancreas. GE Port J Gastroenterol. mars 2022;29(2):135‑8.
3. De Jong K, Bruno MJ, Fockens P. Epidemiology, diagnosis, and management of cystic lesions of the pancreas. Gastroenterol Res Pract. 2012;2012:147465.
4. Okasha H, E Behiry M, Ramadan N, Ezzat R, Yamany A, El-Kholi S, Ahmed G. Endoscopic ultrasound-guided fine needle aspiration in diagnosis of cystic pancreatic lesions. Arab J Gastroenterol. 2019;20:86–90.
5.Polkowski M, Jenssen C, Kaye P, Carrara S, Deprez P, Gines A, et al. Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline - March 2017. Endoscopy. oct 2017;49(10):989‑1006.

Introduction

Endoscopic ultrasound-guided (EUS) tissue acquisition is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fine needle aspiration (FNA) and fine needle biopsy (FNB) remains unclear. The aim of the study was to evaluate and compare the diagnostic yields between FNA and FNB using puncture by conventional needle aspiration (PAA) and Franseen-tip needles of the same size, 22G, in patients retrospectively. All procedures were performed without a cytologist on site. The diagnostic yield and average number of needle passes between FNB and FNA were then compared.

Aims & Methods

All cases of EUS-PAA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a tertiary care hospital were retrospectively reviewed. All procedures were performed without a cytologist on site. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared.

Results

91 patients (FNA n = 45; BNF, n = 46) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-PAA. The average age was 62.3 ± 12.8 years, 55 (60.4%) were female. Age, sex, mass location, tumor size, and disease stage on imaging studies were not significantly different between the two groups. Diagnostic yield was higher in EUS-FNB (96%) than in EUS-FNA (91%). The average number of needle passes was clearly lower in FNB than in FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was shorter in BNF (24 min) than in FNAC (31 min). The rate of adverse events between FNB and FNA was not significantly different.

Conclusion

The diagnostic yield of solid pancreatic mass was higher in FNB with a Franseen-tip needle than in FNA with a conventional needle in a center where ROSE is not available, without serious adverse events. Additionally, FNB had fewer needle passes and a shorter total procedure time.

Introduction

The incidence of pancreas cysts is increasing, and the use of EUS-guided through-the-needle-biopsy (EUS-TTNB) is gradually increasing for accurate diagnosis. However, studies including a large number of patients on clinical outcomes and safety of EUS-TTNB for pancreatic cysts are still lacking. In this study, we evaluated the diagnostic yield, adverse events(AE), and risk factors of AE related to EUS-TTNB in a large number of cohorts.

Aims & Methods

We reviewed the prospectively collected EUS-TTNB for pancreatic cysts database at Asan Medical Center, between January 2019 and December 2022. We analyzed technical success rate, diagnostic yield, AE, and risk factors for AE.

Results

A total of 248 patients were analyzed. Technical success could be achieved in 247 patients, except one patient (100%). Among them, 191 patients had a specific histologic diagnosis (diagnostic yield, 77.3%). There was no significant difference in diagnostic yield according to the number of biopsy specimen, the presence of septation in the cysts, the size of cysts, and location of cysts. AE occurred in 41 patients (16%), and there was no serious AE. Acute pancreatitis was the most common AE (12/248, 12%) following cyst hemorrhage (7/247, 3%). In univariate analysis on the risk factors of acute pancreatitis related to EUS-TTNB, male (HR 2.22, 95% CI: 1.02-4.83, P=0.045) and IPMN (HR 3.08, 95% CI: 1.35-7.03, P=0.01) were statistically significant. In multivariate analysis, IPMN (HR 2.75, 95% CI: 1.24-6.11, P=0.01) was the significant risk factor of acute pancreatitis after EUS-TTNB.

Risk factors of acute pancreatitis after TTNB

Characteristics	Univariate analysis			Multivariable analysis
	OR	95% CI	P value	Adjusted OR	95% CI	P value
Age > 70 years	2.52	0.85 – 7.49	0.09
Male sex	2.22	1.02 – 4.83	0.045
Needling > 2	1.25	0.56 – 2.77	0.58
Biopsy > 4	1.93	0.86 – 4.31	0.11	1.89	0.84 – 4.27	0.13
IPMN	3.08	1.35 – 7.03	0.01	2.75	1.24 – 6.11	0.01

Note. OR, odds ratio; CI, Confidence interval;

Conclusion

EUS-TTNB showed a relatively high technical success rate and diagnostic yield. IPMN was the most significant risk factor of AE related to EUS-TTNB.

References

The clinical relevance of the increasing incidence of intraductal papillary mucinous neoplasm, Clin Gastroenterol Hepatol. 2012 May;10(5):555-8
European evidence-based guidelines on pancreatic cystic neoplasms, Gut. 2018 May;67(5):789-804
International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas, Pancreatology 2012;12:183–197.
Diagnosis of pancreatic lesions collected by endoscopic ultrasound-guided fine-needle aspiration using next-generation sequencing, HPB (Oxford). 2015 May; 17(5): 377–386.
Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study, Gastrointest Endosc. 2015 Dec;82(6):1060-9
Efficacy and safety of EUS-guided through-the-needle microforceps biopsy sampling in categorizing the type of pancreatic cystic lesions, Gastrointest Endosc. 2022 Feb;95(2):299-309

Introduction

Pancreatic cysts are a common finding in imaging studies, and, considering the different malignant potentials of mucinous and non-mucinous cysts, it is necessary to develop accurate methods and algorithms to differentiate between them. We conducted this study to compare the diagnostic performance of glucose levels and CEA levels in the diagnosis of mucinous pancreatic cysts.

Aims & Methods

We conducted a retrospective study of patients who underwent EUS-FNA of pancreatic cystic lesions between September 2020 and March 2023 at a tertiary referral center. We included patients whose glucose and CEA levels had been measured. Indicators of mucinous cysts include glucose levels less than 2.7 mmol/l and CEA levels greater than 192 ng/ml. It was compared to the final pathology (obtained after surgery or by EUS-FNB) result to determine their accuracy.

Results

	Non-mucinous	Mucinous
Gender (%male)	47.3%	33.3%
Age ( Median)	50.2	58.3
Cyst location
head	9	3
body	2	5
tail	8	4

A total of 31 patients were included in the study, 13 males and 18 females. The mean age was 55.7 years. Of the 31 patients, 12 (38.7%) were diagnosed with mucinous cysts (6 mucinous cystic neoplasms, 6 intraductal papillary mucinous neoplasms), and 19 (61.2%) were diagnosed with non-mucinous cysts (9 serous cystic neoplasm, 8 pseudocysts, 1 solid pseudopapillary neoplasm, and 1 lymphoepithelial cyst). There was a female prevalence in patients with mucinous cysts (8 females and 4 males) with a mean age of 59,6 years. From the cyst fluid analysis, the sensitivity, specificity, and accuracy of glucose in diagnosing mucinous cysts were 91.7%, 89.5%, and 90.3%, respectively. CEA’s sensitivity, specificity, and accuracy were 81.8%, 85.0%, and 83.9%, respectively.

Conclusion

In the diagnosis of pancreatic cystic lesions, glucose levels have high diagnostic performance with high sensitivity and accuracy. In contrast, CEA levels have a lower diagnostic performance. The findings of our study support the use of EUS-FNA and glucose levels in the diagnosis of pancreatic cystic lesions, as well as EUS-FNB to obtain histological specimens for a more accurate diagnosis of pancreatic cysts. Further studies are needed to validate these findings and explore the potential of other biomarkers in diagnosing and managing pancreatic cystic lesions.

Introduction

The prediction of positive results of endoscopic ultrasonography guided tissue acquisition(EUS TA), including EUS fine needle aspiration(EUS FNA) and EUS fine needle biopsy(EUS FNB), has changed from rapid on-site evaluation(ROSE) to macroscopic on-site evaluation (MOSE). The average predictive positive rate is about eighties percent under MOSE. The intraoperative frozen section evaluation has been widely used by the surgeons. We conducted the study to evaluate if there is any benefit of intraoperative frozen section evaluation for increasing the predictive diagnostic yield of EUS FNB.

Aims & Methods

Aims: We compared the yield rate of EUS FNB for pancreatic solid lesions between MOSE and intraoperative frozen section evaluation and MOSE only.
Methods: The study was conducted at a single tertiary referral center from Aug. 2021 to Mar. 2023.
The patients who were indicated for EUS FNB were enrolled into the study.
During EUS FNB we sent the specimens from the first two passes for the frozen section after we considered adequate macroscopic visible tissue core. Later we would obtain other specimens from later passes for the permanent section (MOSE + Frozen group (MF group)). As for the control group we sent the specimens for the permanent section only (MOSE only group (M group)).
We compared the histological results of frozen and permanent sections and divided them into three subgroups as the frozen section being equal, inferior and superior to the permanent one.
The p-value <0.05 was defined as statistically significant.

Results

Total one hundred ninety four patients were enrolled into the study and ninety seven patients were divided into each group equally. Demographic characters were as the followings with MOSE with frozen group versus MOSE only one:
age 62+-14 vs 63+-12 years old
gender male to female 1.6: 1 vs 1.6 : 1
diagnosis of pancreatic solid lesion adenocarcinoma : neuroendocrine tumor : chronic pancreatitis 71:5:2 vs 41:5:12
average size of lesion 37.2+-16 vs 34.3+-13 mm
location of lesion uncinate process: head: neck: body: tail 4:32:5:20:11 vs 5:22:0:16:13
the most common location of lesion was head of pancreas on both groups
As for the results of EUS FNB, the pass for permanent section was 5.5 versus 5.8 (MF group vs M group, p=0.018 ) and the transgastric puncture route was 51 versus 53 patients and transduodenal route was 46 vs 44 patients (MF group vs M group). About the yield rate the MF group was 92.8% and the M group was 79.4% (p=0.006).
When comparing the histological results of frozen and permanent sections the frozen section was equal, inferior and superior to the permanent one as 63 (65%), 33 (34%) and 1 (1%) patient(s)(Table).
Table

	MOSE + Frozen (n= 97)	MOSE only (n=97)	p value
EUS FNB pass for permanent section puncture route (%) transgastric transduodenal	5.5 51 (53) 46 (47)	5.8 53 (55) 44 (45)	0.018
Yield rate (%)	92.8	79.4	0.006
frozen vs permanent section (%) equal inferior superior	63 (65) 33 (34) 1 (1)

Conclusion

When performing EUS FNB for pancreatic solid lesions, it seems to increase the predictive yield rate if we combine MOSE and intraoperative frozen section evaluation. There are some pitfalls about combined MOSE and intraoperative frozen section evaluation, such as prolonged procedure time and increased medical expenses due to frozen section evaluation.

References

1. Iwashita T, Yasuda I, Mukai T, et al. 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;81:177-85.

Introduction

The sensitivity of endoscopic ultrasound (EUS) in detecting pancreatic tumors exceeds 90% and can detect tumors with a diameter of less than 2 cm. EUS plays an important role in the management of patients with pancreatic cancer, providing precise diagnosis, determining local-regional extension and resectability assessment, conducting biopsies, and managing complications.
The objective of our study was to specify the impact of EUS on the diagnosis, staging, histological proof, and treatment of complications of solid pancreatic tumors.

Aims & Methods

A retrospective study was conducted over 5 years (2019-2024), including all patients admitted with clinical suspicion of solid pancreatic tumors and who experienced EUS.

Results

Out of the 115 patients admitted with clinical suspicion of pancreatic tumor, 86 (74.8%) had undergone EUS. The mean age was 68.2 years, ranging from 30 to 90 years, with a clear male predominance (sex ratio 1.1).
Biological assessment showed cholangitis grade I and grade II in 35.6% (n=31) of cases, and grade III in 4 patients (4.6%).
EUS revealed a pancreatic mass in 98.9% (n=85) of cases, with 75.5% (n=64) in the head, 14% (n=12) in the uncinate process, 7% (n=6) in the body, and 3.5% (n=3) in the neck. The size was over 3 cm in 59 cases (69.4%), between 2-3 cm in 23 cases (27.1%), and less than 2 cm in 3 cases (3.5%). double duct dilation was shown in 57 cases (66.3%), isolated bile duct dilation in 31 cases (36%), and isolated Wirsung duct dilation in 4 cases (4.6%). Pancreatic atrophy was observed in 31.4% (n=27) of cases.
EUS allowed the determination of vascular invasion in 78 cases (90.7%), invasion of the portal trunk (TP) and superior mesenteric vein (SMV) was present in 43 cases (55.1%), with invasion over >180 in 28 cases (35.9%) and <180 in 15 cases (19.2%), thrombosis in 3 cases (3.5%), and absence of invasion in 15 cases (19.2%). Invasion of the celiac trunk (CT) and superior mesenteric artery (SMA) was present in 31 cases (39.9%), with invasion over >180 in 22 cases (28.2%) and <180 in 9 cases (11.6%), thrombosis in 2 cases (2.3%), and absence of invasion in 24 cases (30.7%). Invasion of the common hepatic artery (CHA) was present in 6 cases (7.7%), with invasion over >180 in 5 cases (83.3%) and <180 in one case (16.7%), and absence of invasion in 6 cases (7.7%).
Locoregional lymph node extension was observed in 12 cases (15.4%), invasion of the common bile duct (CBD) in one case (1.3%), duodenal invasion in 3 cases (3.9%), secondary hepatic localization in 7 cases (9%), and peritoneal in 2 cases (2.6%).
Cytopuncture under EUS was performed in 70 cases (89.7%), the results of which were conclusive in 65.4% (n=51) of cases and inconclusive in 24.6% (n=19). The histological type was adenocarcinoma in 48 cases (94.1%), clear cell carcinoma, squamous cell carcinoma, and neuroendocrine tumor in one case (1.9%).
Therapeutically, EUS allowed the treatment of pancreatic abdominal pain resistant to medical treatment by celiac plexus block in 2 cases, neurolysis in one case, and also performing anterograde hepatic gastric biliary drainage after the failure of retrograde drainage due to duodenal strictures in 5 cases.

Conclusion

EUS reveals pancreatic tumors in 98.9% of cases, with its main importance lying in locoregional staging, where vascular invasion was correctly determined in 90.7% of cases, and lymph node extension in 15.4%. The value of EUS lies in determining histological type (65.4%), as well as therapeutic aspects such as pain management and biliary drainage.