Mona Rizeq

The Clinical Impact of Immediate On-Site Cytopathology Evaluation During Endoscopic Ultrasound-Guided Fine Needle Aspiration of Pancreatic Masses: A Prospective Multicenter Randomized Controlled Trial

Objectives:Observational data on the impact of on-site cytopathology evaluation (OCE) during endoscopic ultrasonography-guided fine needle aspiration (EUS–FNA) of pancreatic masses have reported conflicting results. We aimed to compare the diagnostic yield of malignancy and proportion of inadequate specimens between patients undergoing EUS–FNA of pancreatic masses with and without OCE.Methods:In this multicenter randomized controlled trial, consecutive patients with solid pancreatic mass underwent randomization for EUS–FNA with or without OCE. The number of FNA passes in the OCE+ arm was dictated by the on-site cytopathologist, whereas seven passes were performed in OCE− arm. EUS–FNA protocol was standardized, and slides were reviewed by cytopathologists using standardized criteria for cytologic characteristics and diagnosis.Results:A total of 241 patients (121 OCE+, 120 OCE−) were included. There was no difference between the two groups in diagnostic yield of malignancy (OCE+ 75.2% vs. OCE− 71.6%, P=0.45) and proportion of inadequate specimens (9.8 vs. 13.3%, P=0.31). Procedures in OCE+ group required fewer EUS–FNA passes (median, OCE+ 4 vs. OCE− 7, P<0.0001). There was no significant difference between the two groups with regard to overall procedure time, adverse events, number of repeat procedures, costs (based on baseline cost-minimization analysis), and accuracy (using predefined criteria for final diagnosis of malignancy). There was no difference between the two groups with respect to cytologic characteristics of cellularity, bloodiness, number of cells/slide, and contamination.Conclusions:Results of this study demonstrated no significant difference in the diagnostic yield of malignancy, proportion of inadequate specimens, and accuracy in patients with pancreatic mass undergoing EUS–FNA with or without OCE.

Increasing Number of Passes Beyond 4 Does Not Increase Sensitivity of Detection of Pancreatic Malignancy by Endoscopic Ultrasound–Guided Fine-Needle Aspiration

BACKGROUND & AIMS It is not clear exactly how many passes are required to determine whether pancreatic masses are malignant using endoscopic ultrasound–guided fine‐needle aspiration (EUS‐FNA). We aimed to define the per‐pass diagnostic yield of EUS‐FNA for establishing the malignancy of a pancreatic mass, and identify factors associated with detection of malignancies. METHODS In a prospective study, 239 patients with solid pancreatic masses were randomly assigned to groups that underwent EUS‐FNA, with the number of passes determined by an on‐site cytopathology evaluation or set at 7 passes, at 3 tertiary referral centers. A final diagnosis of pancreatic malignancy was made based on findings from cytology, surgery, or a follow‐up evaluation at least 1 year after EUS‐FNA. The cumulative sensitivity of detection of malignancy by EUS‐FNA was calculated after each pass; in the primary analysis, lesions categorized as malignant or suspicious were considered as positive findings. RESULTS Pancreatic malignancies were found in 202 patients (84.5% of the study population). EUS‐FNA detected malignancies with 96% sensitivity (95% confidence interval [CI], 92%–98%); 4 passes of EUS‐FNA detected malignancies with 92% sensitivity (95% CI, 87%–95%). Tumor size greater than 2 cm was the only variable associated with positive results from cytology analysis (odds ratio, 7.8; 95% CI, 1.9–31.6). In masses larger than 2 cm, 4 passes of EUS‐FNA detected malignancies with 93% sensitivity (95% CI, 89%–96%) and in masses ≤2 cm, 6 passes was associated with 82% sensitivity (95% CI, 61%–93%). Sensitivity of detection did not increase with increasing number of passes. CONCLUSIONS In a prospective study, we found 4 passes of EUS‐FNA to be sufficient to detect malignant pancreatic masses; increasing the number of passes did not increase the sensitivity of detection. Tumor size greater than 2 cm was associated with malignancy, and a greater number of passes may be required to evaluate masses 2 cm or less. ClinicalTrials.gov number, NCT01386931.

Diagnosis of clinically unsuspected gallbladder rupture by peritoneal fluid cytology : A case report

BACKGROUND Rupture of the biliary system resulting in bile ascites may occur spontaneously or as a complication of inflammatory disease, biliary tract manipulation or trauma. Leakage of bile into the peritoneal cavity can cause severe chemical peritonitis, requiring rapid surgical intervention. CASE A 64-year-old male status post total laryngectomy for squamous cell carcinoma developed abdominal pain and ascites. Diagnostic paracentesis was performed, and bile pigment was noted on cytologic examination, raising the possibility of biliary rupture. This was confirmed radiographically, and the patient underwent exploratory laparotomy, where a ruptured gallbladder was found and cholecystectomy performed. CONCLUSION Recognition of bile pigment on cytologic examination of ascitic fluid followed by measurement of ascitic fluid bilirubin levels can alert clinicians to the presence of clinically unsuspected bile peritonitis in patients with rupture of the biliary system.

Su1136 Cost Minimization Analysis of Onsite Cytopathologist (CyP) Evaluation During EUS-FNA of Solid Pancreatic Lesions: Results From a Multicenter Prospective Randomized Controlled Trial

had familiar history ofIBD.Among the 93 IBD pts with arthralgias, rheumatologic assessment diagnosed rheumatologic diseases in 33 (88%) UC and in 44 (80%) CD pts. In particular, a diagnosis of SpAewas made in 50 (54%) IBD pts(54% peripheral SpA, 24%, axial SpA, 22% both), 24 (26%)Osteoarthritis, 6 (7%)Fybromialgia,3 (3%), Gout, 3 (3%)Rheumatoid Arthritis, 2 (2%) Psoriatic Arthritis, while diagnosis was inconclusive in 5 (6%) pts. After rheumatological assessment, a higher percentage of IBD pts were treated with diseasemodifying anti-rheumatic drugs (including anti-TNFs)(5.3% vs 15%, p=0.03, RR 1.6)and/ or with anti-COX2 (6.4% vs 27%; p<0.0001; RR 2.3). Anti-TNFs use also significantly increased (19% vs 34%, p=0.009;RR 1.8).Conclusions. Multidisciplinary IBD care including rheumatologists may facilitate the diagnosis and management of arthralgias in IBD. A combined multidisciplinary approach may also lead to an early diagnosis and proper treatment of chronic and debilitating inflammatory arthritis.