Viney Wadehra

EUS-FNA versus Biliary Brushings and Assessment of Simultaneous Performance in Jaundiced Patients with Suspected Malignant Obstruction

CONTEXT Individuals with suspected malignant biliary obstruction commonly undergo ERCP for drainage and tissue sampling via biliary brushings. EUS with EUS-FNA facilitates staging and potentially more accurate tissue sampling. OBJECTIVE The aim is to compare the diagnostic performance of EUS-FNA and ERCP with biliary brushings (ERCP-BB) in the diagnosis of pancreatobiliary carcinoma and the utility of combining the two procedures under conscious sedation. DESIGN Retrospective analysis of a prospectively maintained database. PATIENTS Thirty-seven patients with suspected malignant obstructive jaundice underwent 39 paired procedures, either combined (n=22) or within a few days (n=17). RESULTS Using strict cytological criteria the sensitivity of EUS-FNA in the diagnosis of malignancy was 52.9% (95% CI: 35.1-70.2%) versus 29.4% (95% CI: 15.1-47.5%) for ERCP-BB. Combining the two tests improved sensitivity to 64.7% (95% CI: 46.5-80.3%) which was significantly better than ERCP-BB alone (P=0.001) but not EUS-FNA alone (P=0.125). When both procedures were performed under the same conscious sedation, there was a significant difference (P=0.031) between the sensitivity of EUS-FNA (52.6%; 95% CI: 28.9-75.6%) and that of ERCP-BB (21.1%; 95% CI: 6.1-45.6%). When both procedures were performed together the mean±SD in-room time was 79±14 min (range: 45-105 min). Two of the patients (9.1%) had a complication. CONCLUSIONS In patients undergoing EUS-FNA and ERCP-BB under the same sedation, EUS-FNA was significantly more sensitive in diagnosing malignancy. Combining the results of both tests improved diagnostic accuracy. Combining therapeutic ERCP and EUS-FNA under the same conscious sedation is feasible, with a complication rate similar to that of ERCP alone.

Prospective evaluation of fine needle aspiration in the diagnosis of lung cancer.

The role of fine needle aspiration biopsy has been assessed prospectively in the diagnosis of discrete lung shadows. A questionnaire was completed before each of 100 biopsies (in 97 patients) to determine the clinicians pretest diagnosis and the likelihood of malignancy. The latter estimates were combined with the previously established sensitivity (71%) and specificity (100%) of the procedure for diagnosing malignancy in the unit to allow calculation in each case of the change in certainty of malignancy as a result of the investigation. Among the 100 biopsies there were 73 true positive and 13 true negative results. There were no false positive results but there were 14 false negatives (cases where malignancy was later proved but where the biopsy did not show unequivocal evidence of malignancy). Among the 27 negative biopsy results the clinician had estimated the likelihood of malignancy as 80% or more in 13 cases. In 11 of these 13 patients the eventual diagnosis proved to be a malignant tumour; on the other hand, six of the 10 patients given a less than 50% chance of malignancy had a benign outcome. A positive biopsy result was therefore quantitively of greatest value when the prior estimate of malignancy was low. In the case of the false negative results the prior probability of malignancy was usually sufficiently high to merit further investigation. It is estimated that the procedure led to the avoidance of thoracotomy in up to 14 of 97 patients.

Fine needle aspiration biopsy in diagnosis of metastases to thyroid gland.

Three cases of metastasis to the thyroid gland are reported, in each of which fine needle aspiration biopsy confirmed the diagnosis and obviated the need for surgery. Fine needle aspiration biopsy is able to confirm suspected intrathyroid metastasis and can be performed as an outpatient or bedside procedure.

Effect of dedicated and supervised training on achieving competence in EUS-FNA of solid pancreatic lesions

Abstract Background and Aim. The diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been suggested as a benchmark of quality performance in EUS. However, there is paucity of data on the training requirement for competency in EUS-FNA of the pancreas. KO commenced the service without prior formal training in EUS-FNA. A formally trained colleague (MN) who underwent a fellowship in the same unit was appointed to a substantive post in 2007. The aims of the study were to assess if a dedicated training program in pancreaticobiliary (PB) EUS-FNA of solid lesions: (1) produced better results at the outset of independent practice than produced at the initiation of service without formal training and (2) produced results comparable with those of an experienced endosonographer. Material and methods. This is a retrospective review comparing the first 80 consecutive cases at the onset of practice of operator KO1 (2003/2004) and MN (2007/2008) as well as consecutive cases of operator KO2 (2007/2008) in the same time frame as the initial cases of operator MN. Results. There was a significant difference in EUS-FNA sensitivity for pancreatic malignancy between operator KO1 (56%) and operator MN (77%) p < 0.05. There was no significant difference in test performance between operator KO2 (82%) and MN (77%) (p > 0.05). Conclusion. Our data show that formal training in PB EUS produces test performance at the outset of independent practice that is comparable with an experienced endosonographer, in line with the published standards for EUS-FNA of the pancreas and significantly better than that achieved without training.

Does On-Site Adequacy Assessment by Cytotechnologists Improve Results of EUS guided FNA of Solid Pancreaticobiliary Lesions?

CONTEXT Rapid onsite adequacy assessment is stated to improve the diagnostic performance of EUS-FNA. OBJECTIVES The aim of this study was to establish if the introduction of adequacy assessment performed by a biomedical scientist (cytotechnologist) to an established EUS service improved the diagnostic accuracy of EUS guided FNA of solid pancreaticobiliary lesions. DESIGN AND PATIENTS This retrospective study includes all patients with solid pancreaticobiliary lesions who underwent EUS-FNA from April 2009 to September 2010. An in room cytotechnologist was present for 2 out of the 4 weekly EUS lists and therefore there were two groups identified: Group 1, cytotechnologist absent; and Group 2, cytotechnologist present. RESULTS There were 82 patients in Group 1 and 97 patients in Group 2. There was no statistically significant difference in the number of passes (4.1 vs. 4.3), the inadequate aspirate rate (7.3% vs. 5.1%) or the mean size of the lesions (34.7 vs. 32.6 mm) between the groups. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value in Group 1 were 89%, 88%, 100%, 100% and 50% respectively. The results in Group 2 were 91%, 90%, 100%, 100% and 69% respectively. There was no statistically significant difference between the two groups. CONCLUSIONS In this study the adequacy assessment performed by a cytotechnologist did not improve the diagnostic accuracy of EUS-FNA. In an established EUS-FNA service with low inadequate aspirate rates, onsite adequacy assessment may not improve results of the test.

A case of metastatic non-neural granular cell tumor in a 13-year-old girl.

Conventional granular cell tumor represents a mesenchymal neoplasm observed in a variety of locations and is now believed to be of Schwann cell origin. Granular cell change has also been observed in a variety of different tumors, but recently described in the skin has been a distinct entity termed non‐neural granular cell tumor, which lacks expression of S100 protein and is of uncertain histogenesis. This tumor typically displays a greater degree of nuclear atypia and mitotic activity than conventional granular cell tumor but appears to behave in a relatively benign fashion, as only two previous instances of lymph node metastasis have been documented. Herein, we report a case of non‐neural granular cell tumor arising on the back of a 13‐year‐old girl, and later axillary lymph node metastasis with extracapsular extension was observed.

A prospective randomized comparison of fine needle aspiration biopsy and fibreoptic bronchoscopy in the investigation of peripheral pulmonary opacities

Twenty-nine patients, aged 66(+/- 7) years with a peripheral pulmonary opacity (mean diameter 3.6 +/- 1.8 cm) believed to be a tumor, were randomly allocated to initial investigation by either fibreoptic bronchoscopy or percutaneous fine needle aspiration biopsy, the latter performed under fluoroscopic control. The patients proceeded to the alternative investigation in the event of the first failing to achieve a diagnosis. Malignancy was confirmed by the initial procedure in 14/15 patients randomized to fine needle aspiration biopsy but only in 1/14 patients randomized to fibreoptic bronchoscopy (P less than 0.01). Overall, these figures were 25/28 fine needle aspiration biopsy and 2/15 fibreoptic bronchoscopy (P less than 0.01). These results confirm the clinical suspicion that fine needle aspiration biopsy is far more likely than fibreoptic bronchoscopy to establish the presence of malignancy in peripheral pulmonary opacities.

Utility of cyst fluid CEA cut-off of 192ng/ml in the diagnosis of mucinous cysts of the pancreas

Introduction The differentiation of mucinous from non-mucinous pancreatic cysts is important because of the malignant potential of the latter. EUS-FNA allows for high resolution imaging of pancreatic cysts as well as sampling for markers (CEA), cytology and a visual assessment of cyst content. The Cooperative cyst study found an elevated fluid CEA (>192 ng/ml) to be the single most accurate test in correctly predicting mucinous cysts with a sensitivity of 73%. The CEA value of 192ng/ml has subsequently been widely adopted as a definitive cut-off value. Methods The aims of the present study were to assess the utility of a cut-off value of 192 ng/ml in differentiating mucinous from non-mucinous pancreatic cysts and to compare this to general EUS assessment. IPMN and mucinous cyst adenoma/adenocarcinoma (MCA and MCAC) were considered separately. The study population comprised all the patients undergoing EUS-FNA at a tertiary centre for assessment of suspected pancreatic neoplastic cysts between June 2003 and April 2010. Results During this period 267 procedures were performed on 235 individuals, of whom 71 had a definitive diagnosis (60 resection histology, 5 histology, 6 malignant cytology), cystic degeneration of pancreatic adenocarcinoma (3) being excluded. 68 patients (51 females), (78 procedures) formed the study group. There were 25 mucinous cyst adenomas (11 MCA, 14 MCAC). There were 22 IPMN (2 malignant) and 21 non-mucinous cysts. For MCA/MCAC using a cut-off of 192 ng/ml the sensitivity, specificity, accuracy and NPV of detecting a mucinous lesion were 62.5%, 94.4%, 79.4%, 73.9%. Combining EUS morphology, cytology and visual assessment of aspirate (mucoid/non-mucoid) gave figures of 100%, 70.8%, 86%, 100%. The combination was significantly more sensitive p=0.007, but no significant difference in specificity. ROC area under the curve was numerically greater 0.861 versus 0.785 (not significant). For the IPMN patients the cut-off 192 ng/ml showed a sensitivity of 20% in the diagnosis of IPMN. EUS diagnosis had a sensitivity of 85%. Sensitivity of aspirate appearance: 87%, cytology: 50%; combining fluid appearance, EUS and cytology: 93%. Comparing the performance of CEA 192 versus combination in differentiating IPMN from non-mucinous cyst, ROC curve area was 0.864 versus 0.623 p =0.02. Conclusion A CEA cut-off of 192 ng/ml demonstrated good specificity and moderate sensitivity in the diagnosis of MCA, however it performed poorly in the diagnosis of IPMN. Combining EUS, aspirate appearance and cytology was significantly more sensitive in diagnosing mucinous cysts with a very high NPV.

PTU-179 Diagnostic Yield of Eus-Fna in Pancreatic Neuro-Endocrine Tumours (PNET) – Solid Versus Cystic Pnets – 9 Year Experience from a Tertiary Centre

Introduction The detection and diagnosis of pNETs remains challenging. EUS and EUS-FNA has a significant role in the detection, precise localisation and cytological confirmation of pNETs. Methods A retrospective review of all pNET patients undergoing EUS-FNA between April 2003 and September 2011 was carried out to determine the efficacy of EUS-FNA in confirming pNETs and compare performance over two consecutive 4 year period. Results 10 patients (3% of EUS procedures for cystic lesions) with cystic pNETs and 44 (4% of EUS procedures for solid lesions) with solid pNETs were identified. Table 1 compares the size, demographics and diagnostic performance of radiology, EUS & cytology in solid and cystic pNETs. 17 and 5 solid and cystic pNETs respectively were diagnosed between 2003 and 2007 while 27 and 5 solid and cystic pNETs were diagnosed between 2008 and 2011. EUS-FNA diagnosis of cystic and solid pNETs has improved from 20% and 59% respectively between 2003 and 2007 to 100% and 81% respectively between 2008 and 2011. Overall, sensitivity of EUS cytology has improved from 50% to 84.4% (p = 0.015) during this period. Malignant potential of solid pNETs was higher (54.5% vs 20%) compared to cystic pNETs. Curative resection was higher in patients with cystic pNETs (80% vs 68%) compared to solid pNETs. Conclusion EUS & EUS-FNA is a useful test in diagnosing pNETs. Overall, the sensitivity of combined EUS imaging and cytology was significantly better compared to CT/MRI (p < 0.05) in detecting pNETs across all groups. Sensitivity of combined EUS imaging and cytology was significantly better compared to EUS imaging alone (p < 0.05) in the solid and combined pNET cohort of patients. Sensitivity of EUS cytology was significantly better compared to EUS imaging (p < 0.05) in the solid and combined pNET cohort of patients. Comparing the first 4 years to the second, there has been an increase in the number of cases of pNETs and statistically significant improvement in the diagnostic performance of cytology. Abstract PTU-179 Table 1 Combined solid & cystic pNETs (n= 54) Solid pNETs (n= 44) Cystic pNETs (n= 10) Mean Age (yrs) 61.3 61.5 60.2 Sex (Male %) AB59 AB64 40 Mean size of lesion in cm (range) 2.73 (0.7 – 9.5) 2.95 (0.7 – 9.5) 1.96 (0.8 – 5) Sensitivity of CT/MRI in detecting pNET (%) 33.3 ¹® 38.5 ¹® 10 1 Sensitivity of EUS imaging in detecting pNET (%) 51.8 * 57 * AB30 Sensitivity of EUS cytology in detecting pNET (%) 70.4 ® 73 ® AB60 Sensitivity of combined EUS imaging and cytology in detecting pNET(%) 81.5 *1 84.1*1 70 1 Note: * p < 0.05, ¹ p < 0.05, ® p < 0.05 comparison within columns Disclosure of Interest None Declared.

Impact of on-site adequacy assessment for EUS FNA of solid pancreatic lesions

Introduction There are a number of factors which can influence the accuracy of EUS FNA but the presence of an in-room cytotechnician (IRC) has been shown to be one of the important factors. The aim of this study was to establish if the introduction of an IRC improved the diagnostic accuracy of EUS guided FNA of solid pancreatico biliary lesions Methods This is a prospective study and includes all patients with solid pancreatico biliary lesions who underwent EUS FNA from April 2009 to September 2010. We have been performing EUS FNA since 2003 but did not have an IRC till this period. The IRC attended 2 of the 4 EUS lists and therefore there were two groups identified: Group 1 – Cytotechnician absent; Group 2 – Cytotechnician present. Final diagnosis was based on a positive diagnosis on cytology, other forms of tissue acquisition and/or a years follow up for the benign/indeterminate cases. Only patients with a final diagnosis were included in the study. Results The final results are shown in table 1. Table 1 OC-101 Comparative results for both groups of patients. Group 1 82 patients Group 2 97 patients p Value Mean age (range) 64.4(22–89) 63.1(33–83) NS Mean passes(range) 4.01(1–8) 4.3(1–8) NS Inadequate aspirate rate 7.3% 5.1% NS Accuracy (%) 89 91 NS Sensitivity (%) 88 90 NS Specificity (%) 100 100 NS Positive predictive value (%) 100 100 NS Negative predictive value (%) 50 69 NS We compared our data to the 6 months prior to this study (October 2008–March 2009) when there was no IRC available. The accuracy, sensitivity, specificity, PPV and NPV during this period were 86%, 82%, 100%, 100% and 57.6% respectively. The inadequate aspirate rate during this period was 14.2%. There was no statistical difference when this data was compared to either Groups 1 or 2. Conclusion This study shows that the presence of an IRC does not necessarily improve the diagnostic accuracy of EUS FNA of pancreatobiliary lesions. There are a number of factors which influence the results but experience of the cytopathologist/cytotechnician has shown to be one of the important factors. By keeping the number of inadequate aspirates low and reducing the number of highly suspicious samples the accuracy of the test can be improved. Large studies may be required to show a significant difference. Cost effectiveness and experience of the cytopathologist/cytotechnician should be taken into consideration when setting up this service.