Introduction

Rapid on-site evaluation at EUS-TA is often performed by a cytotechnologist. In our hospital, a pathologist makes a rapid diagnosis using HE staining during EUS-TA. It is unclear whether rapid diagnosis by a pathologist using HE staining is useful.

Aims & Methods

Aim: The aim of this study is to clarify the accuracy of rapid diagnosis performed by pathologists and whether non-IDC can be differentiated at the stage of rapid diagnosis. Design: A single center retrospective study. Method: Patients who underwent EUS-FNA for pancreatic disease at our hospital between 2020 and 2022 were included. When EUS-TA was performed, the slow-pull technique and standard suction technique were combined in all cases. Puncture was added when immunostaining was deemed necessary. IDCs include adenocarcinoma, adenosquamous carcinoma, mucinous carcinoma, anaplastic carcinoma, and IPMC, non-IDCs include NEN (neuroendocrine neoplasia), ACC (acinar cell carcinoma), SPN (solid-pseudopapillary neoplasm), GCT (granular cell tumor), and metastasis.

Results

Two hundred and thirty-nine patients were included, including 37 benign, 179 IDC, and 23 non-IDC cases. 25G needles were used for 178 cases (74.5%). There were 188 FNA needles and 51 FNB needles. The average number of punctures was 3.2. The accuracy for distinguishing between benign and malignancy was 96.7% for rapid diagnosis and 97.9% for final diagnosis of EUS-TA. Of the 77 surgical cases, 11 were non-IDC, and all were diagnosed as non-IDC at the rapid diagnosis stage. Discussion: At our hospital, it is extremely rare for the rapid diagnosis and the final diagnosis of EUS-TA to diverge. In the case of IDC, it is possible to hold an in-hospital conference when the results of rapid diagnosis are available and to start treatment early. Furthermore, since many cases of IDC or non-IDC can be diagnosed at the stage of rapid diagnosis,

Conclusion

Rapid diagnosis by pathologists using HE staining enabled a rapid and high accuracy rate, and made it possible to diagnose non-IDC at the stage of rapid diagnosis.

Introduction

Solid-pseudopapillary neoplasm (SPN) is a rare tumor of low malignancy that occurs predominantly in young females. Imaging of SPN is often described as a well-defined and heterogeneous tumor with calcifications or cysts, otherwise small size SPN often shows a homogeneously solid tumor. However, the differential diagnosis between SPN and other cystic tumors is often difficult due to the variety of imaging findings. In this report, we describe the clinical features and preoperative diagnosis of SPN we experienced at our hospital.

Aims & Methods

We studied 18 cases of SPN that were pathologically diagnosed by surgical resection at our hospital between 1997 and 2022.

Results

There were 12 female and 6 male patients, with a median age of 39.5 years (range: 9-67) and a median tumor size of 23 mm (range: 9-66). The tumor location was in the pancreatic head in 4 cases, body in 6 cases, and tail in 8 cases. The median follow-up period was 89.5 months (range: 8-265), and recurrence-free survival was achieved in all cases during the follow-up period. The tumors were incidentally detected in 15 cases during health check-ups (mainly by ultrasonography) or other medical examinations, while the other 3 cases were detected due to subjective symptoms that were thought to be caused by SPN. SPN could be diagnosed by contrast-enhanced CT in 10 of 18 cases (56%) and by EUS in 7 of 12 cases (58%). Contrast-enhanced CT showed enhancing mass in 10 cases, cystic component in 9 cases (50%), and calcification in 8 cases (44%). Among the 8 cases in which SPN could not be diagnosed by contrast-enhanced CT, EUS was performed in 7 cases, and we could diagnose SPN in 2 cases. Both cases had small lesions of less than 13 mm without cystic components, which made the differentiation from other tumors difficult on contrast-enhanced CT, however EUS showed well-circumscribed, well-defined, and homogeneously hypoechogenic tumors. MRI was performed in 12 cases, and could diagnose SPN in 5 cases, but MRI did not improve the diagnostic accuracy compared to contrast-enhanced CT. The diagnostic accuracy of EUS-guided fine needle aspiration (EUS-FNA) was 89% (8/9 cases). There were 5 cases in which SPN could not be diagnosed preoperatively. Among them, 3 cases had small tumor sizes (12-16 mm), and 4 cases lacked calcification, making it difficult to differentiate them from neuroendocrine tumors or solid-cystic neoplasms.

Conclusion

Most cases of SPN are detected incidentally, and regular abdominal ultrasonography during medical check-ups is important for early detection. Diagnosis can be more difficult in cases with small tumor diameter, and no cystic component or calcification. However adding EUS to contrast-enhanced CT imaging may improve accuracy. Furthermore, EUS-FNA contributes to preoperative diagnosis with a high diagnostic accuracy.

Introduction

Chronic pancreatitis (CP) is a persistent inflammation of the pancreatic parenchyma that can lead to irreversible endocrine and exocrine dysfunction as well as pancreatic cancer. As the disease progresses, the pancreatic parenchyma becomes irregularly fibrotic and atrophic, resulting in the formation of the so-called “hard pancreas”. Although endoscopic ultrasound (EUS) has been widely used for diagnosing CP, the assessment of fibrosis using the Rosemont criteria (RC) is generally subjective. Shear wave elastography using EUS (EUS-SWE) has been advocated as an objective approach to evaluating pancreatic fibrosis; however, the diagnostic accuracy and the optimal pancreatic region or the number for the measures are still unknown.it is unknown which pancreatic region is taken measurement. This study compares the measurement site diagnostic accuracy in diagnosing CP and its correlation with RC.

Aims & Methods

Fifty patients with CP or suspected CP who underwent EUS-SWE were analyzed retrospectively. As per the RC, they were classified into two groups: CP and non-CP. The pancreatic stiffness was evaluated by measuring the velocities of the shear wave (Vs) and determining the relevant cutoff value of Vs for diagnosing CP. In addition, the correlation between Vs and RC, and the factors of the RC affecting pancreatic stiffness were evaluated.

Results

We finally analyzed 34 CP group cases and 16 non-CP group cases. Vs values were significantly higher for the CP group in all regions (p<0.001). Vs values by region for diagnostic accuracy of chronic pancreatitis were highest in the body (cut off, 2.33, AUC 0.87, 95%CI 0.76-0.98). The number of EUS criteria and Vs values were significantly correlated in all regions, but the correlation coefficient was highest in the pancreatic body (rs=0.55). Multivariate analysis revealed that lobularity with honeycombing was an independent factor for EUS criteria affecting pancreatic stiffness (p=0.02).

		Univariate analysis			Multivariate analysis
	OR	95%CI	P value	OR	95% CI	P value
Hyperechoic foci with shadowing	2.94	1.09–2.7	0.006	4.5	0.40–50.7	0.22
Hyperechoic foci without shadowing	1.26	0.38–4.2	0.71
Lobularity with honeycomb	11.8	2.3–60.0	0.003	11.1	1.4–88.1	0.02
Lobularity without honeycomb	2.4	0.57–10.4	0.23
Irregular MPD contour	7.4	1.78–30.8	0.005	6.6	0.73–58.9	0.09
Dilated side branches	5.4	1.58–18.7	0.007	0.93	0.14–6.17	0.94
Hyperechoic MPD margin	29.0	3.29–256.0	0.002	4.18	0.37–1.37	0.25
MPD dilation	3.1	0.58–16.5	0.19

Table. Endoscopic ultrasonography findings by Rosemont criteria related to Vs values of the pancreatic body by univariate and multivariate analysis

Conclusion

Quantifying pancreatic hardness by EUS-SWE is useful as an objective indicator in diagnosing CP. In addition, the SWE measurement in the pancreatic body is suitable for pancreatic hardness evaluation and correlates well with the Rosemont criteria.

References

1) Braganza JM, Lee SH, McCloy RF, et al. Chronic pancreatitis. The Lancet. 2011;377(9772):1184-1197.
2) Itoh Y, Itoh A, Kawashima H, et al. Quantitative analysis of diagnosing pancreatic fibrosis using EUS-elastography (comparison with surgical specimens). J Gastroenterol. Jul 2014;49(7):1183-1192.
3) Kuwahara T, Hirooka Y, Kawashima H, et al. Usefulness of shear wave elastography as a quantitative diagnosis of chronic pancreatitis. J Gastroenterol Hepatol. Mar 2018;33(3):756-761.

Introduction

Biopsy samples obtained with fine-needle biopsy (FNB-EUS) using Franseen needles by EUS with endoscopist evaluation (Macroscopic OnSite Evaluation: MOSE) improves the diagnostic accuracy of pancreatic solid lesions. The achievement of macroscopic visible core (MVC) >4mm has a high diagnostic accuracy with MOSE.

Aims & Methods

Aim: To compare diagnostic accuracy of Rapid On-Site Evaluation (ROSE) and MOSE by endoscopist in pancreatic solid lesions.
Methods: Prospective bicentric study, consecutive recruitment of patients with pancreatic solid lesions in 2 general hospitals (MOSE was performed in hospital A and ROSE in hospital B). Franseen needles were used (Adquire, Boston Scientific). We evaluated: 1) diagnostic achievement and accuracy (including sensitivity, specificity, positive predictive value and negative predictive value) in solid pancreatic lesions; 2) MVC >4mm acquisition; and 3) number of needle passes needed with MOSE vs ROSE.

Results

A total of 132 patients were included (33 women, 68 men, median age 68,2±1,025). MOSE was performed in 90 (68.2%) and ROSE in 42 (31.8%); in 110 (83.3%) malign and 22 (16.7%) benign pancreatic solid lesions. Correct diagnosis by EUS-FNB was achieved in 89.4% patients (with MOSE 88.8%; and ROSE 92.9%; p=0.54). Sensitivity was 100%, specificity 89%, PPV 81.3% and NPV 100% (with MOSE: sensitivity 100%, specificity 87.5%, PPV 88.8% and NPV 100%; with ROSE: sensitivity 100%, specificity 92.1%, PPV 92.6% and NPV 100%). MVC >4mm was obtained in 72.7% (71.1% in MOSE, 76.2% in ROSE, p=0.67). There were no statistica ly significant differences in diagnosis achievement between MVC >4mm and <4mm (88.6% in MOSE and 90.6% in ROSE, p=0.74). No differences in number of passes necessary to achieve diagnosis was found between MOSE and ROSE.

Conclusion

Evaluation of biopsy samples of pancreatic solid lesions obtained by FNB-EUS with Franseen needles by endoscopist (MOSE) has a diagnostic accuracy similar to ROSE, making unnecessary the presence of a pathologist in the endoscopy suite.

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 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

Differential diagnosis of solid pancreatic tumours (SPT) is a clinical challenge. Development of advanced imaging techniques associated with EUS, such as elastography and contrast enhancement, has been a step forward in this context. EUS-guided detective flow imaging (DFI) is a very recent technology allowing the evaluation of microvascularization and low-velocity blood flow without the need of contrast agents.

Aims & Methods

Aim of our study was to evaluate the findings obtained by EUS-DFI in SPT and compare them with contrast enhanced harmonic EUS (CEH-EUS).
Methods: A prospective, single-centre, observational study in patients who underwent EUS for the evaluation of SPT was designed. Procedures were performed with a linear echoendoscope (Fujifilm 740UT) attached to the ultrasound system Arietta 850. Lesions were characterized according to the vascularization pattern (hypervascular, isovascular and hypovascular) described with both methods. Final diagnosis was based on histology after EUS-guided biopsy. Data area shown as mean ± SD and percentage.

Results

44 patients were included (mean age 67 years, range 24-88, 23 males). Mean tumour size was 26.1 ± 15.7 mm. Fourteen (31.8%) lesions were located in the head of the pancreas, 19 (43.2%) in the body, 9 (20.5%) in the tail and 2 (4.5%) in the uncinate process. Final diagnosis was adenocarcinoma in 24 patients (54.5%), neuroendocrine tumour in 13 (29.5%), inflammatory mass in 3 (6.8%), autoimmune pancreatitis in 1 (2.3%), pancreatic necrosis in 1 (2.3%), accessory spleen in 1 (2.3%) and lipoma in 1 (2.3%). Agreement regarding the vascular pattern of SPT between CEH-EUS and EUS-DFI was reached in 97.7% of the cases. All adenocarcinomas were hypovascular, inflammatory masses and autoimmune pancreatitis isovascular, pancreatic necrosis avascular, and accessory spleen and lipoma hypervascular at both CEH-EUS and EUS-DFI. All 13 neuroendocrine tumours were hypervascular at CEH-EUS, 12 of them (90%) at EUS-DFI.

Conclusion

EUS-DFI allows evaluating the microvascular pattern of SPT with a similar accuracy than CEH-EUS, but without the need of using contrast agents.

Disclosure

Julio Iglesias-Garcia. Advisor Pentax, FujiFilm, Mediglobe