Randomized Trial Comparing the Flexible 19G and 25G Needles for Endoscopic Ultrasound-Guided Fine Needle Aspiration of Solid Pancreatic Mass Lesions.

OBJECTIVES: Although a large gauge needle can procure more tissue at endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), its advantage over smaller needles is unclear. This study compared flexible 19G and 25G needles for EUS-FNA of solid pancreatic masses. METHODS: This was a randomized trial of patients undergoing EUS-FNA of pancreatic masses using flexible 19G or 25G needle. Main outcome measure was to compare median number of passes for on-site diagnosis. Secondary measures were to compare specimen bloodiness, complications, technical failures, and histological core tissue procurement. RESULTS: One hundred patients were randomized to EUS-FNA using flexible 19G or 25G needle. Median of 1 pass was required to achieve on-site diagnosis of 96% and 92% (P = 0.68) in 19G and 25G cohorts. There was no significant difference in technical failure (0% vs 2%, P = 0.99) or adverse events (2% vs 0%, P = 0.99) between 19G and 25G cohorts. Although histological core tissue procurement was significantly better with flexible 19G needle (88% vs 44%, P < 0.001), specimens were bloodier (severe bloodiness, 36% vs 4%; P < 0.001). CONCLUSIONS: As there is no significant difference in the performance of flexible 19G and 25G needles, needle choice for sampling pancreatic masses should be based on endoscopist preference and need for histology.

Training endosonographers in cytopathology: improving the results of EUS-guided FNA.

BACKGROUND: Although on-site cytopathology services have a significant impact on efficiency and accuracy of EUS-guided FNA (EUS-FNA), the availability of this service is variable. OBJECTIVE: To evaluate the impact of an intensive 2-day training program to educate endosonographers in EUS-related cytopathology. DESIGN: Pilot study. SETTING: Tertiary care medical center. SUBJECTS: Six endosonographers (5 male, median age, 35 years) with minimal previous cytopathology exposure comprised the study cohort. METHODS: Pre- and posttraining testing was administered. Training commenced with a cytopathology tutorial focusing on 4 performance measures: specimen adequacy, sample interpretation, specimen processing, and preliminary diagnosis. Eight live EUS-FNA cases were then performed, and study participants independently completed 4 questions based on performance measures for each case. The ability to independently smear and stain slides and operate a microscope was additionally assessed after a hands-on tutorial. MAIN OUTCOME MEASUREMENTS: Comparison of pretraining and posttraining scores, improvement in performance measures for live cases, and ability to independently handle specimens and operate a microscope. RESULTS: Compared with pretraining, mean posttraining test scores improved by 63% from 48 to 78 out of 100. Mean live case performance score was 95%. Performances improved from 89% on day 1 to 100% on day 2. After training, all endosonographers could independently smear/stain slides and operate a microscope. LIMITATIONS: Long-term impact is unclear. CONCLUSIONS: An intensive 2-day program was effective in training endosonographers in the basics of EUS-related cytopathology. Incorporating basic cytopathology in EUS fellowship curriculum will likely improve diagnostic performance of tissue acquisition procedures.

Comprehensive long-term care of patients with lung cancer: development of a novel thoracic survivorship program.

BACKGROUND: Recent advances have improved the likelihood of long-term survival for patients with lung cancer. However, little attention has been given to the growing need for dedicated survivorship care for these patients. To address this unmet need, we developed a unique follow-up care model. METHODS: In 2006, we convened a multidisciplinary working group to design a thoracic survivorship program (TSP) that provides follow-up by a nurse practitioner (NP) trained in survivorship care. Patients with early-stage lung cancer who were disease free for at least 1 year after resection were eligible for the program, which incorporates a standardized approach to cancer surveillance. Data on symptoms and outcomes were prospectively collected. Real-time electronic medical documentation was developed to optimize communication with primary physicians. RESULTS: Data were analyzed for the initial phase of the program, which comprised 655 patients. Ninety-two percent of eligible survivors who remained disease free chose to continue their care in the TSP, rather than receive follow-up with their thoracic surgeon. Clinically significant posttreatment symptoms were common, including fatigue (46%), anxiety (32%), chronic pain (25%), dyspnea (14%), and depression (12%). The majority of recurrences (72%) and second primary cancers (91%) in this cohort were identified by scheduled chest computed tomography at TSP visits. CONCLUSIONS: Survivorship care for patients with lung cancer, delivered in our NP-led TSP, is feasible, effective, and well accepted by patients. Through the implementation of a uniform self-sustaining patient-centered system, the TSP model improves on the variation of physician-led follow-up care.

The 25-gauge EUS-FNA needle: Good for on-site but poor for off-site evaluation? Results of a randomized trial.

BACKGROUND: When on-site cytopathology support is not available, EUS-guided fine needle aspiration (EUS-FNA) is performed for cell-block preparation to allow off-site interpretation. OBJECTIVE: To identify the number of passes required to obtain a diagnostic cell block by using a 25-gauge needle for sampling pancreatic masses. DESIGN: Randomized trial. SETTING: Tertiary care hospital. PATIENTS: Sixty-two patients with solid pancreatic mass lesions. INTERVENTIONS: EUS-FNA was performed by using a 25-gauge needle. After establishing a preliminary on-site diagnosis, patients were randomized to 2 or 4 FNA passes for a cell block. A cell block was evaluated by a pathologist blinded to on-site interpretation for the presence of a tissue pellet, histological core tissue size, and diagnostic accuracy. MAIN OUTCOME MEASUREMENTS: To determine the number of passes required to obtain a diagnostic cell block with a 25-gauge FNA needle. RESULTS: Sixty-two patients were randomized to undergo either 2 (n = 31) or 4 (n = 31) FNA passes for a cell block. Before randomization, an on-site diagnosis was established in all 62 patients (100%). The final diagnosis was adenocarcinoma in 45 (72.6%), neuroendocrine/other tumor in 7 (11.3%), and chronic pancreatitis in 10 (16.1%). There was no difference in the presence of a tissue pellet (93.5 vs 96.8%; P = .99), the median size of the histological core (0.006 vs 0.05 mm(2); P = .12), or the presence of a diagnostic cell block (80.6 vs 80.6%; P = .99) between patients randomized to 2 or 4 FNA passes, respectively. LIMITATIONS: Only pancreatic masses were evaluated. CONCLUSIONS: The 25-gauge FNA needle yielded a diagnostic cell block in only 81% of patients, irrespective of whether 2 or 4 FNA passes were performed. These findings have important implications for centers without on-site cytopathology services. (Clinical trial registration number NCT01809028.).

Health behaviors of early-stage non-small cell lung cancer survivors.

INTRODUCTION: Lung cancer survivors are at risk for cancer recurrence and other chronic illnesses related predominantly to prior tobacco use and older age. Optimal quality of post-treatment care requires greater knowledge of survivors' adherence to behavioral health recommendations. This study reports the rates of smoking, physical activity, alcohol use, cancer screenings, and routine primary care visits in non-small cell lung cancer (NSCLC) survivors. METHODS: Stage IA and IB NSCLC survivors (N = 183, mean age = 69.0 years) with no evidence of disease 1-6 years post-treatment completed standard survey items regarding health and cancer screening behaviors. RESULTS: Most survivors (83.5%) had a history of smoking, but 64.8% quit prior to diagnosis and only 5.5% continued to smoke. Alcohol intake recommendations were exceeded by 5.4% and 17.3% of men and women, respectively. In a typical week, 23.1% met physical activity guidelines. Regarding cancer screenings, 89.3% were adherent to colorectal cancer screening guidelines. Among women, 72.0% had a mammogram within the previous year and 81.5% had a pap test in the previous 3 years; among men, 86.7% had a prostate-specific antigen test in the previous year. Almost all (97.3%) had seen a primary care provider in the past year. DISCUSSIONS/CONCLUSIONS: The majority of lung cancer survivors were adherent to health promotion recommendations, but few engaged in the recommended level of physical activity. IMPLICATIONS FOR CANCER SURVIVORS: Physical and pulmonary rehabilitation interventions may help lung cancer survivors maintain sufficient levels of physical activity, which can have numerous benefits for older adults.

Health-related quality of life among early-stage, non-small cell, lung cancer survivors.

BACKGROUND: Limited data are available about the physical and mental functioning of individuals diagnosed and treated for early-stage lung cancer. To develop post-treatment guidelines and targeted resources for the growing number of lung cancer survivors, clinically relevant information about longer term health-related quality of life (HQOL) is needed. The current study examines lung cancer survivors' HQOL and identifies associations between HQOL and demographic, disease and medical risk factors. METHODS: A total of 359 individuals diagnosed and surgically treated for stage IA or IB non-small cell lung cancer completed a post-treatment survey via mail or telephone that included the SF-36v2 as well as questions regarding demographic and medical factors. To better understand the impact of lung cancer treatment, we examined age- and gender-adjusted differences in HQOL as compared to a demographically matched sample of older adults, most with a significant smoking history, who participated in a lung cancer screening trial. Risk factors for impairments in HQOL were also identified. RESULTS: Compared to the screening sample, lung cancer survivors reported lower physical health scores, but did not differ in terms of mental health status. Dyspnea and distressed mood were most associated with HQOL impairments. CONCLUSIONS: Early-stage lung cancer survivors are likely to experience mild impairment in physical functioning. They may benefit from management of distressed mood and referral to physical activity and pulmonary rehabilitation programs to promote HQOL outcomes.

Current dyspnea among long-term survivors of early-stage non-small cell lung cancer.

INTRODUCTION: Dyspnea is common among lung cancer patients. As most studies of dyspnea have reviewed patients with active cancer or immediately after treatment, its prevalence during the longer-term period once treatment has been completed is not well characterized. This study quantifies the prevalence of dyspnea among lung cancer survivors and identifies potential correlates that may be amenable to intervention. METHODS: Cross-sectional survey of 342 patients with disease-free, stage I, non-small cell lung cancer, assessed 1 to 6 years after surgical resection. Dyspnea was quantified using the Baseline Dyspnea Index. Any moderate/strenuous physical activity was measured using the Godin Leisure-Time Exercise Questionnaire. Mood disorder symptoms were assessed using the Hospital Anxiety and Depression Scale. Multiple regression analyses were used to examine demographic, medical, and health-related correlates of dyspnea. RESULTS: Mean age was 68.9 years. Average predicted preoperative forced expiratory volume in 1 second was 89.0%. Current dyspnea, defined by a Baseline Dyspnea Index score of 9 or less, existed among 205 (60%) individuals. For 133 (65%) of these patients, dyspnea was absent preoperatively. Multivariate correlates of current dyspnea included preoperative dyspnea (odds ratio [OR] = 5.31), preoperative diffusing capacity (OR = 0.98), lack of moderate/strenuous physical activity (OR = 0.41), and the presence of clinically significant depression symptoms (OR = 4.10). CONCLUSIONS: Dyspnea is common 1 to 6 years after lung cancer resection, and is associated with the presence of preoperative dyspnea, reduced diffusing capacity, clinically significant depression symptoms, and lack of physical activity. Further research is needed to test whether strategies that identify and treat patients with these conditions attenuate dyspnea among lung cancer survivors.