A case of intra-abdominal gossypiboma diagnosed preoperatively by endoscopic ultrasound fine-needle-aspiration.

Gossypiboma is an extremely rare adverse event occurring post-surgery, where surgical gauze is left within the body. If aseptically retained, it can lead to the formation of granulation tissue through chronic inflammation and adhesion with surrounding tissues, potentially persisting asymptomatically for many years. While diagnosis of this condition has been reported through various imaging modalities such as abdominal ultrasound and computed tomography, cases not presenting with typical findings are difficult for preoperative diagnosis, and instances where it is discovered postoperatively exist. Particularly when in contact with the gastrointestinal tract within the abdominal cavity, differentiation from submucosal tumors of the digestive tract becomes problematic. This report describes the imaging characteristics of endoscopic ultrasound and the usefulness of endoscopic ultrasound-fine-needle-aspiration for tissue diagnosis in the preoperative diagnosis of intra-abdominal gossypiboma.

A case of needle tract seeding with endoscopic findings of progression over time.

An 83-year-old male underwent three transgastric punctures with endoscopic ultrasound-guided fine-needle aspiration for the examination of a pancreatic body tumor. After a diagnosis of resectable pancreatic cancer and undergoing distal pancreatectomy, the patient was administered postoperative adjuvant chemotherapy with oral S-1 for 6 months, and carcinoembryonic antigen and carbohydrate antigen 19-9 levels were bimonthly evaluated. Carbohydrate antigen 19-9 levels continually increased to 4638.1 U/mL at 45 months post-fine-needle aspiration. Endoscopic ultrasound-guided showed a 25 mm low-echoic, irregularly shaped, and heterogeneous tumor with clear margins protruding from the mucosa outside the gastric wall, and biopsy confirmed adenocarcinoma. Since the immunostaining findings of the specimen matched those of the previously resected specimen, needle tract seeding (NTS) due to puncture of the pancreatic cancer was identified as the cause. After a pylorus-preserving gastrectomy at 46 months post-fine-needle aspiration, postoperative chemotherapy initiation, comprising gemcitabine and nab-paclitaxel, was initiated; however, the patient died despite these interventions as he developed multiple peritoneal dissemination. Although rare, the incidence of NTS will increase in the future owing to the expected extended survival in post-pancreatic cancer resection cases. We suggest regular upper gastrointestinal endoscopy and endoscopic ultrasound-guided evaluations for patients who are at risk for NTS can facilitate early detection. Furthermore, it is extremely relevant to share experiences of encountered NTS cases in practice and extend knowledge of its varying endoscopic appearances.

Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration for diagnostic and staging purposes: a narrative review.

Background and Objective: Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is a feasible and well-tolerated modality that is increasingly used to diagnose intrathoracic lesions. This narrative review summarizes the current application of EUS-B-FNA for diagnosing lung cancer, thoracic sarcoidosis, and metastases from extrathoracic malignancies. Methods: A comprehensive and systematic online literature search via Medline/PubMed for the period January 2005 to December 2022 was conducted for articles published using the keywords "EUS-B-FNA", "endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)", "endoscopic ultrasound fine-needle aspiration (EUS-FNA)", "lung cancer", "staging", and "sarcoidosis". Key Content and Findings: Recent data prove the efficacy and safety of EUS-B-FNA for providing complete lung cancer staging, when combined with EBUS-TBNA, and in the evaluation of para-esophageal lesions. EUS-B-FNA allows access to inferior mediastinal lymph nodes and para-esophageal masses that are not accessible by EBUS-TBNA. Additional advantages of using EUS-B-FNA include significantly lower doses of anesthetics and sedatives, a shorter procedural time, fewer incidents of oxygen desaturation due to a poor respiratory reserve, significantly less cough, and higher operator satisfaction. Moreover, this procedure can be performed sequentially in the same setting with EBUS-TBNA by one operator. Other benefits include a lower cost, a single setting, and scope use. Conclusions: As EUS-B-FNA and EBUS-TBNA have complementary access to the mediastinum, the diagnostic yield of EUS-B-FNA combined with EBUS-TBNA is higher than that of endosonographic techniques alone in the diagnostic workup of intrathoracic lesions.

A case of multiple myeloma with pancreatic involvement diagnosed via endoscopic ultrasound-guided fine needle aspiration.

This report highlights the importance of considering multiple myeloma in the differential diagnosis of a pancreatic tumor with bone lesions. sampling not only from the pancreatic lesion but also from bone lesions may reach an accurate diagnosis.

Current role of endoscopic ultrasound for gastrointestinal and abdominal tuberculosis.

A high incidence of tuberculosis (TB), especially in endemic countries, makes this infectious disease a concern. Abdominal TB contributes to 10% of extrapulmonary TB. Due to nonspecific clinical, radiological, and endoscopic findings, diagnosing abdominal TB continues to be a challenge. Hence, a precise diagnosis is needed. The diagnosis of gastrointestinal disease using endoscopic ultrasound (EUS) is often performed due to its high resolution and ability to provide a real-time visual representation of the gastrointestinal tract and extramural structures. EUS-guided fine-needle aspiration (FNA) and fine-needle biopsy (FNB) have helped diagnose TB as they offer an adequate specimen for cytology or histopathological examination. This method is considered safer, more effective, and more efficient. The capacity of EUS to diagnose abdominal TB based on the affected organs was examined via a literature search. We reviewed the role of EUS in diagnosing esophageal, gastric, pancreatic, peripancreatic, hepatosplenic, peritoneal, and intestinal TB. Generally, EUS aids in diagnosing abdominal TB. In some organs, it is superior to other diagnostic modalities. However, further examinations, such as cytology or histopathology and microbial, are still needed. We also studied the roles of EUS-FNA and EUS-FNB. EUS-FNA has shown a high diagnostic yield in esophageal (94.3-100%), pancreatic and peripancreatic (76.2%), and intestinal TB (84.1%). As minimally invasive methods, EUS-FNA and EUS-FNB can successfully provide sufficient samples. EUS is a functional diagnostic modality for abdominal TB. EUS-FNA and EUS-FNB provide sufficient samples safely and efficiently for further cytology, histopathology, and microbial examinations.

Clinical Utility of the Contrast-Enhanced Endoscopic Ultrasound Guided Fine Needle Aspiration in the Diagnosis of Pancreatic Cyst.

Endoscopic ultrasound fine needle aspiration (EUS-FNA) cytology from an intracystic fluid is useful in the differentiation of pancreatic cysts, with low sensitivity, which increases when the solid component is targeted. The clinical utility of contrast-enhanced guided EUS-FNA (CH-EUS-FNA) in the solid component is not known. We aimed to assess the diagnostic value of CH-EUS-FNA in enhanced mural nodules and discrimination between different cysts using contrast-enhanced endoscopic ultrasound (CH-EUS). The prospective study recruited patients with pancreatic cysts with an unclear diagnosis. The CH-EUS was followed by CH-EUS-FNA. The final diagnosis was based on surgery or the correlation between clinical history, cross-sectional imaging, echoendoscopic morphology, cystic fluid analysis, and follow-up. Fifty-eight patients with pancreatic cysts were evaluated. The mucinous cysts had wall arterial enhancement more often than non- mucinous cysts (p < 0.0001), with 90.2% sensitivity and 70.6% specificity. The CH-EUS-FNA from cystic fluid and mural nodules identified mucinous cysts and malignancy with 82.4% and 84.2% sensitivity and 92% and 100% specificity. Twenty-one cysts had solid components, but only 13 were enhanced mural nodules on EUS assessment with conclusive cytology in all cases and malignancy in 76.9%. Contrast-enhanced endoscopic ultrasound should be completed in all PCN with solid components in order to avoid unnecessary EUS-FNA and to guide FNA for the identification of malignant cysts.

A Gastroenterologist's Approach to the Diagnosis and Management of Gastrointestinal Stromal Tumors.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. These tumors have been shown to harbor oncogenic mutations of the c-kit tyrosine kinase receptor or platelet-derived growth factor receptor alpha (PDGFRA). Immunohistochemical analysis of GISTs allows for the differentiation of these tumors from other mesenchymal tumors of the GI tract such as leiomyomas and leiomyosarcomas. All GISTs have the potential to behave in a malignant fashion. Tumor location, size, and mitotic index are factors used to predict the risk of malignant behavior. Endoscopy and endoscopic ultrasound play a critical role in the diagnosis of GISTs and can yield important information to further risk-stratify tumors and determine management. This article provides a gastroenterologist's perspective on the diagnosis and management of GISTs.

Endoscopic Ultrasound-guided Biopsy of Liver Tumors.

BACKGROUND/AIM: Endoscopic ultrasound (EUS)-guided liver tumor biopsy has some advantages over the percutaneous and surgical route and, in many cases, should be preferred. The aim of this study was to evaluate the role of EUS-fine needle aspiration (FNA) in the diagnosis of liver tumors with an emphasis on its diagnostic accuracy and histological quality of the acquired specimen. PATIENTS AND METHODS: We followed 30 consecutive patients who underwent liver tumor biopsy using EUS guidance. Tissue was acquired using a 22-gauge FNA needle. RESULTS: In 97% of patients, the results of EUS-FNA were adequate for diagnosis. In one case, the pathologist recommended a repeat biopsy. The acquired specimen was a core fragment in 81% of cases while in 19% of cases the specimen was fragmented and subsequently used as a cell block. No complications were reported. CONCLUSION: EUS-FNA is characterized by a high success rate on the acquisition of good-quality tissue specimens, a low rate of complications, and decreased patient discomfort. This procedure should be especially considered in the case of liver lesions that are inaccessible via the percutaneous route or when concurrent biopsies are required for accurate diagnosis.

Direct Comparison of Elastography Endoscopic Ultrasound Fine-Needle Aspiration and B-Mode Endoscopic Ultrasound Fine-Needle Aspiration in Diagnosing Solid Pancreatic Lesions.

Elastography endoscopic ultrasound (E-EUS) has been proved to be a valuable supplement to endoscopic ultrasound fine-needle aspiration (EUS-FNA) in differentiating solid pancreatic lesions, but the improvement of EUS-FNA guided during E-EUS has not been proven. Our study aimed to evaluate whether E-EUS fine-needle aspiration (E-EUS-FNA) was superior to B-mode EUS-FNA for the diagnosis of solid pancreatic masses and whether the diagnostic rate was affected by specific factors. Our prospective study was conducted between 2019-2020 by recruiting patients with solid pancreatic masses. E-EUS examination was followed by one pass of E-EUS-FNA towards the blue part of the lesion and a second pass of EUS-FNA. The final diagnosis was based on surgery, E-EUS-FNA or EUS-FNA results, or a 12-month follow-up. Sixty patients with solid pancreatic lesions were evaluated. The sensitivity, specificity, and accuracy for diagnosing malignancy using E-EUS-FNA and EUS-FNA were 89.5%, 100%, 90%, 93%, 100%, and 93.3%, respectively, but the differences were not significant. Neither mass location nor the lesion size influenced the results. The lengths of the core obtained during E-EUS-FNA and EUS-FNA were similar. E-EUS-FNA in solid pancreatic lesions was not superior to B-mode EUS-FNA.

Gastric Linitis Plastica and role of endoscopic ultrasound: An under-recognised diagnostic modality.

Gastric linitis plastica is an aggressive malignancy with poor prognosis. Timely diagnosis is important for effective management. However, the conventional endoscopic biopsies are often inconclusive leading to delay in diagnosis and subsequent management. We present a case of a 55-year old female with high suspicion of gastric linitis plastica on gastroscopy with repeated negative endoscopic biopsies. She underwent an endoscopic ultrasound fine needle aspiration (EUS-FNA) at our center with establishment of diagnosis of gastric malignancy. There are no established guidelines about the role of EUS-FNA as a sequential diagnostic modality for this tumour. However, EUS-FNA is a highly sensitive modality to establish diagnosis in challenging cases where routine endoscopy remains inconclusive.

A case of esophageal granular cell tumor diagnosed by mucosal incision-assisted biopsy.

For an esophageal submucosal mass suspicious of granular cell tumor (GCT) based on gross appearance and endoscopic ultrasound findings, a sufficient number of biopsy specimens is required for a definite diagnosis using immunohistochemical examination. When the specimen obtained by forceps biopsy is insufficient, endoscopic ultrasound-fine needle aspiration (EUS-FNA) is believed to be an useful alternative. However, it may be difficult to obtain an adequate amount of tumor material using EUS-FNA. Mucosal incision-assisted biopsy (MIAB) is a simple method that can collect larger amounts of specimens. This procedure is helpful for physicians who encounter the problem of obtaining an adequate amount of biopsy material from esophageal tumors suspicious for GCT. We present a case of esophageal GCT that was successfully diagnosed through MIAB.

State-of-the-Art Update of Pancreatic Cysts.

Andrew Canakis.

Needle-based confocal endomicroscopy in the discrimination of mucinous from non-mucinous pancreatic cystic lesions.

BACKGROUND: Pancreatic cystic lesions (PCLs) are considered a precursor of pancreatic cancer. Needle-based confocal endomicroscopy (nCLE) is an imaging technique that enables visualization of the mucosal layer to a micron resolution. Its application has demonstrated promising results in the distinction of PCLs. This study evaluated the utility of nCLE in patients with indeterminate PCLs undergoing endoscopic ultrasound fine-needle aspiration (EUS-FNA) to distinguish mucinous from non-mucinous lesions. AIM: To evaluate the accuracy of nCLE in indeterminate PCLs undergoing EUS-FNA to distinguish mucinous from non-mucinous lesions. METHODS: Patients who required EUS-FNA between 2015 and 2017 were enrolled prospectively. During EUS-FNA, confocal imaging, analyses of the tumor markers carcinoembryonic antigen and amylase, and cytologic examination were conducted. All patients were followed for at least 12 mo and underwent laboratory testing and computed tomography scanning or magnetic resonance imaging. nCLE videos were independently reviewed by 6 observers to reach a final diagnosis (mucinous vs non-mucinous) based on criteria derived from previous studies; if there was disagreement > 20%, a final diagnosis was discussed after consensus re-evaluation. The sensitivity, specificity, and accuracy of nCLE were calculated. Adverse events were recorded. RESULTS: Fifty-nine patients were included in this study. Final diagnoses were derived from surgery in 10 patients, cytology in 13, and imaging and multidisciplinary team review in 36. Three patients were excluded from final diagnosis due to problems with nCLE acquisition. Fifty-six patients were included in the final analysis. The sensitivity, specificity, and accuracy of nCLE were 80% [95% confidence interval (CI): 65-90], 100% (95%CI: 72-100), and 84% (95%CI: 72-93), respectively. Post-procedure acute pancreatitis occurred in 5%. CONCLUSION: EUS-nCLE performs better than standard EUS-FNA for the diagnosis of indeterminate PCL.

Endoscopic ultrasound assessment and tissue acquisition of mediastinal and abdominal lymph nodes.

The differential diagnosis between benign and malignant lymph nodes (LNs) has a fundamental role in the characterization and staging of malignant conditions, as well as in subsequent patients' management. All imaging modalities (i.e. computed tomography and magnetic resonance imaging) rely mainly on size; endoscopic ultrasound (EUS) criteria based on B-mode evaluation and Doppler features fail to adequately characterize with high specificity LNs nature. The introduction of EUS-elastography and contrast-enhanced harmonic EUS are useful techniques to increase the diagnostic yield in identifying metastatic LNs, to identify which suspicious LN should require pathological characterization and, finally, to target tissue acquisition. EUS-guided tissue acquisition (EUS-TA) is increasingly being used for diagnosing lymphadenopathy whenever the characterization modifies patients' subsequent management and when no superficial LN is accessible. Since target therapy are currently available (i.e. lung cancer, breast cancer), EUS-TA of malignant LNs could be required to identify tumor biology. In this field, both fine needle aspiration and biopsy needles are able to guarantee accurate results with almost perfect specificity and sub-optimal sensitivity. We finally propose a diagnostic algorithm based on most recent, high-level evidence for the diagnostic approach to suspected LNs assessment.

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy for pancreatic masses, subepithelial lesions, and lymph nodes.

Endoscopic ultrasound tissue acquisition, in the form of both fine needle aspiration (EUS-FNA) and fine needle biopsy (EUS-FNB), is utilized for pancreatic mass lesions, subepithelial lesions, and lymph node biopsy. Both procedures are safe and yield high diagnostic value. Despite its high diagnostic yield, EUS-FNA has potential limitations associated with cytological aspirations, including inability to determine histologic architecture, and a small quantitative sample for further immunohistochemical staining. EUS-FNB, with its larger core biopsy needle, was designed to overcome these potential limitations. However, it remains unclear which technique should be used and for which lesions. Comparative trials are plagued by heterogeneity at every stage of comparison; including variable needles used, and different definitions of endpoints, which therefore limit generalizability. Thus, we present a review of prospective trials, systematic reviews, and meta-analyses on studies examining EUS-FNA vs EUS-FNB. Prospective comparative trials of EUS-FNA vs EUS-FNB primarily focus on pancreatic mass lesions, and yield conflicting results in terms of demonstrating the superiority of one method. However, consistent among trials is the potential for diagnosis with fewer passes, and a larger quantity of sample achieved for next generation sequencing. With regard to subepithelial lesions and lymph node biopsy, fewer prospective trials exist, and larger prospective studies are necessary. Based on the available literature, we would recommend EUS-FNB for peri-hepatic lymph nodes.

Endoscopic ultrasonography for the evaluation of pancreatic cystic neoplasms.

Endoscopic ultrasonography (EUS) is a modality with high spatial resolution that enables comprehensive observation of the entire pancreas and plays an important role in the diagnosis of pancreatic lesions. Recent advances in diagnostic imaging methods such as ultrasound, computed tomography, and magnetic resonance imaging have increased the incidental detection of pancreatic cystic lesions (PCLs). EUS has been recognized as an essential diagnostic method for the detection and evaluation of PCLs. EUS has two important roles: as a detailed (high-resolution) imaging diagnostic method and as an approach for collecting cyst fluid content by EUS-guided fine needle aspiration for pathological diagnosis or biomarker evaluation. Furthermore, in recent years, the usefulness of contrast-enhanced EUS for the differential diagnosis of PCLs or evaluation of grade of malignancy, and a novel imaging technique called needle-based confocal laser endomicroscopy to observe intraductal structures through a needle, has been reported. An understanding of the morphological characteristics of PCLs depicted by ultrasound imaging and of the benefits and limitations of EUS diagnosis in daily practice is needed.

Gastric gastrointestinal stromal tumor with predominant cystic formation diagnosed by endoscopic ultrasound-fine needle aspiration.

A 69-year-old woman who had no symptoms was found to have an intraperitoneal tumor on abdominal ultrasonography in a medical checkup. Thereafter, she was referred to our hospital for a further detailed examination. Contrast-enhanced computed tomography revealed a thin-walled cystic tumor with a diameter of 8 cm and with a hypervascular solid masses in the cystic wall, along with intraperitoneal multiple nodules. The cystic tumor was contiguous with the stomach wall. For solid mass of cystic lesions, endoscopic ultrasound-fine needle aspiration was performed transgastrically with a 25-gauge Franseen needle. Pathologically, the cells in the tumor were spindle shaped with atypical nucleus and were positive for c-kit, CD34, and smooth muscle actin. The tumor was diagnosed as gastrointestinal stromal tumor (GIST). With the diagnosis of gastric GIST with peritoneal dissemination, imatinib chemotherapy was initiated.

Comparison between two types of needles for Endoscopic Ultrasound (EUS)-guided fine aspiration biopsy of pancreatic and upper gastrointestinal masses.

BACKGROUND: EUS-guided fine-needle aspiration (FNA) has long been the main method for sampling pancreatic lesions. Recently, the method of fine-needle biopsy (FNB) was introduced in practice, allowing for the acquisition of tissue cores while aspirating the lesion. We hereby report our experience with a new FNB needle compared with the standard FNA needle. METHODS: Retrospective data from our department were collected on patients who underwent FNB using the Acquire EUS-FNB needle (Boston Scientific, Massachusetts) and FNA using the EchoTip Ultra EUS-FNA Needle (Cook Medical, Indiana) between January 2017 and February 2018. The cases were reviewed independently by two cytopathologists and evaluated for the presence of cell block or core tissue material, adequacy for potential ancillary testing, and number of passes. RESULTS: The number of passes ranged from 1 to 16, with a mean of 5.52 ± 3.74 in the FNA group, and from 1 to 6, with a mean of 2.74 ± 1.11 passes in the FNB group (P < .0001). Tissue cores were present in 87.23% of the FNB needle samples. A cell block was adequate in 36.36% of cases using the FNA needle. The diagnostic yield as well as the adequacy for ancillary testing were significantly different between the two groups (P = .0001). The tumor size, location and patients' demographics were not statistically significant between the two groups. CONCLUSION: Compared with the conventional needle, the new FNB needle was associated with a lower number of passes and a better yield for histological material.

Endoscopic ultrasonography for pancreatic solid lesions.

The incidence and mortality rates of pancreatic cancer, which has a poor prognosis, are rising rapidly. Endoscopic ultrasonography (EUS) provides superior spatial resolution compared with other imaging modalities such as transabdominal ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), and it is considered among the most reliable and efficient diagnostic modalities for pancreatic diseases. In this review, we show that EUS is useful for detection of pancreatic solid lesions and staging of pancreatic cancer. EUS also plays an important role in screening patients with high-risk factors for pancreatic cancer. Although EUS is useful for detection of small pancreatic lesions, pancreatic lesions are difficult to characterize using this modality, because most pancreatic solid lesions appear hypoechoic on EUS. From this point of view, contrast-enhanced harmonic EUS (CH-EUS) plays an important role in the differential diagnosis of pancreatic lesions. EUS and CH-EUS are also useful for staging pancreatic cancer. Moreover, EUS-guided fine-needle aspiration (EUS-FNA) is superior to other modalities in terms of cytopathological diagnosis. Although EUS-FNA has a high diagnostic ability for pancreatic cancer, the combination of EUS-FNA and CH-EUS improves the diagnostic ability by decreasing the number of false-negative cases. Thus, conventional EUS, EUS-FNA, and CH-EUS are essential in clinical practice for the diagnosis of pancreatic solid lesions.

Rapidly progressed large cell neuroendocrine carcinoma of the stomach with an increased serum alpha fetoprotein level: a case report.

An 82-year-old man who had multiple hepatic tumors, a gastric tumor, and ascites was referred to our hospital. On the time of our hospital visit, he had a high serum alpha fetoprotein (AFP) level of 1206 ng/mL. Upper gastrointestinal endoscopy revealed a Borrmann Type II gastric tumor approximately 40 mm in diameter in the lesser curvature of cardia, and forceps biopsy was performed. Endoscopic ultrasound fine-needle aspiration was also performed for hepatic tumor. The biopsy specimens from the gastric and hepatic tumor were diagnosed as large cell neuroendocrine carcinoma (LCNEC), containing AFP-positive cells only sporadically by immunohistochemistry. He was diagnosed with gastric LCNEC with liver metastasis. Retrospective analysis of endoscopic data obtained at 5 months ago revealed a 0-IIc lesion, approximately 10 mm in size, in the lesser curvature of cardia, the same area of the present gastric tumor. This indicated rapid growth rate of the present tumor. The patient developed jaundice 5 days after he visited our hospital. And he died 18 days after hospital admission.