Age and cystic size are associated with clinical impact of endoscopic ultrasonography-guided fine-needle aspiration on the management of pancreatic cystic neoplasms.

Objectives: The clinical impact of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) in managing pancreatic cystic neoplasms (PCNs) remains controversial. The aim of this study was to identify which patients with PCNs would benefit from EUS-FNA. Methods: A retrospective study was performed on patients with PCNs who underwent EUS-FNA between January 2009 and June 2018. A discordant or a consistent diagnosis after EUS-FNA was analyzed and was correlated with the clinical demographic data and cystic features. Predictors of the change in the diagnosis after EUS-FNA were analyzed. Results: One hundred eighty-eight cases of PCNs were analyzed. EUS-FNA changed the diagnosis in 45.7% of all patients with PCNs and 54.5% patients with presumed branch ductal type intraductal papillary mucinous neoplasm (BD-IPMN) and impacted the recommendation in 35.6% of patients with PCNs and 50.5% patients with BD-IPMN. Patients with a discordant diagnosis after EUS-FNA were younger in age (54.8 ± 12.6 vs. 61.2 ± 14.2; p=.037) and had a cyst size larger than 3 cm than patients with a consistent diagnosis after EUS-FNA. The only worrisome feature (WF) that differed between patients with a discordant and a consistent diagnosis after EUS-FNA was the main pancreatic duct (MPD) between 5 and 9 mm (p=.013). In multivariate analysis, a cyst size >3 cm and age were independent predictors of diagnostic changes after EUS-FNA (OR: 5.33, 95% CI: 1.79-15.88, p = .003; OR: 0.96, 95% CI: 0.93-0.99, p = .031). Conclusions: EUS-FNA made a significant change in the management of nearly half of the patients with PCNs, especially in younger patients and in patients with a cyst size larger than 3 cm.

Endoscopic Ultrasonography-Guided Fine Needle Aspiration Can Be Used to Rule Out Malignancy in Autoimmune Pancreatitis Patients.

OBJECTIVES: The aim of this study was to review the suitability of endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) for ruling out malignancy in autoimmune pancreatitis patients. METHODS: We retrospectively reviewed 40 autoimmune pancreatitis patients (type 1:37 patients; type 2: two patients; possible autoimmune pancreatitis: one patient) who received EUS-FNA. Among the 40 autoimmune pancreatitis patients, 34 were not histopathologically diagnosed with autoimmune pancreatitis by EUS-FNA, and they were followed up for more than 6 months in our hospital. Moreover, 14 pancreatic cancer patients who were not diagnosed by EUS-FNA were selected as a control group. These 14 patients constituted 3.9% of the 360 pancreatic cancer patients who received EUS-FNA. We evaluated the prognoses of the 34 autoimmune pancreatitis patients and the clinical differences between these 34 autoimmune pancreatitis patients and the 14 pancreatic cancer patients. RESULTS: All 34 autoimmune pancreatitis patients showed reduced pancreatic swelling. The main pancreatic duct dilation ( > 3 mm), the diameter of the main pancreatic duct, the capsule-like rim sign, and serum CA19-9 levels were significantly different between the autoimmune pancreatitis and pancreatic cancer patients (2.9% versus 69.2%, P < .01; 1.7 ± 1.6 mm versus 6.8 ± 5.0 mm, P < .01; 79.4% versus 0%, P < .01; 41.4 ± 79.0 U/mL versus 2079.1 ± 275.3 U/mL, P = .02). CONCLUSIONS: Almost all pancreatic cancers can be diagnosed by EUS-FNA. Furthermore, other clinical characteristics of pancreatic cancer undiagnosed by EUS-FNA were different from autoimmune pancreatitis undiagnosed by EUS-FNA. Endoscopic ultrasonography-guided FNA can be used to rule out malignancy in autoimmune pancreatitis patients.

Diagnostic efficacy of liquid-based cytology for solid pancreatic lesion samples obtained with endoscopic ultrasound-guided fine-needle aspiration: Propensity score-matched analysis.

BACKGROUND AND AIM: There is a paucity of data on the diagnostic efficacy of liquid-based cytology (LBC) for pancreatic samples obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Using propensity score matching, we retrospectively analyzed the additional diagnostic value of LBC compared to a conventional Papanicolaou smear (CPS) for samples of solid pancreatic lesions obtained by EUS-FNA. METHODS: This cohort study included 126 matched patients who underwent initial EUS-FNA for solid pancreatic lesions between January 2009 and August 2014. CPS was used for cytology of EUS-FNA samples obtained until May 2012 (63 patients). Subsequently, LBC was used for cytological analysis (63 patients). Diagnostic yields of CPS and LBC for malignancy were compared. Risk factors for cytological misdiagnosis with LBC were investigated. RESULTS: Overall rate of malignancy was 86% after matching. LBC had higher diagnostic sensitivity and accuracy than CPS (96.6% vs 84.0%, P = 0.03; and 96.8% vs 87.3%, P = 0.05). LBC was significantly more sensitive for diagnosing pancreatic head lesions (96.4% vs 78.1%, P = 0.04). The sensitivity for pancreatic ductal adenocarcinoma (PDAC) with LBC was higher (98.1% vs 83.0%, P = 0.009). Multivariate analysis revealed that malignant tumors other than PDAC (P = 0.004) and lesion size ≤20 mm (P = 0.046) were risk factors for LBC misdiagnosis in all participants. CONCLUSIONS: For solid pancreatic lesions, LBC of EUS-FNA samples contributes to the diagnosis of malignancy. Malignant tumors other than PDAC and small tumors are difficult to diagnose using EUS-FNA and LBC.

Endoscopic ultrasound-guided fine-needle aspiration of solid lesions on clopidogrel may not be a high-risk procedure for bleeding: A case series.

The major gastrointestinal endoscopy society guidelines list endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as a high-risk procedure for bleeding. However, there are no studies evaluating the risk of bleeding for EUS-FNA of solid organs while patients continue to take clopidogrel. The aim of the present case series was to evaluate the rate of bleeding in a cohort of patients who underwent EUS-FNA for solid lesions while on clopidogrel. Bleeding was measured at the time of the procedure by bleeding seen on EUS, endoscopic visualization of blood, or drop in hemoglobin after the procedure. From 2013 to 2015, 10 patients were identified for this case series. Lesions that underwent EUS-FNA included gastric and rectal subepithelial lesions, pancreas masses, and liver masses. No immediate or delayed bleeding was observed in any of the patients. EUS-FNA of solid lesions on clopidogrel may not be a high-risk procedure for bleeding. Larger studies are needed to confirm this finding.

Diagnostic potential of endoscopic ultrasonography-elastography for gastric submucosal tumors: A pilot study.

BACKGROUND AND AIM: Qualitative diagnosis for gastric submucosal tumors (SMT) is not easy. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in combination with EUS-elastography (EUS-EG) is reported useful for qualitatively diagnosing pancreatic tissues. We prospectively studied whether EUS-EG could be useful in qualitative diagnosis of gastric SMT. METHODS: We prospectively registered 25 consecutive patients with gastric SMT diagnosed by esophagogastroduodenoscopy and carried out qualitative evaluations using EUS-EG (May 2013 to March 2015) followed by histopathological diagnosis using EUS-FNA or endoscopic mucosal cutting biopsy. Elastic scores of gastric SMT were compared to the cytological diagnosis. RESULTS: Of 25 patients, 22 had a confirmed cytological diagnosis. Regarding the Giovannini elastic score, of three patients with aberrant pancreas, one was score 1 and two were score 2; of eight patients with leiomyoma, seven were score 2 and one was score 3. Both of two patients with schwannoma were score 4. Of nine patients with gastrointestinal stromal tumor, six were score 4 and three were score 5. Gastrointestinal stromal tumor (GIST) is harder than other types of gastric SMT, and our study's findings suggested the usefulness of EUS-EG, which can also assess tumor hardness of gastric SMT. CONCLUSION: EUS-EG might be helpful for the differential diagnosis of gastric SMT, especially to differentiate GIST from other SMT.

Conventional versus contrast-enhanced harmonic endoscopic ultrasonography-guided fine-needle aspiration for diagnosis of solid pancreatic lesions: A prospective randomized trial.

OBJECTIVES: Contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) has been used to diagnose solid pancreatic lesions (SPLs). The aim of this study was to investigate the efficacy of CEH-EUS-guided fine-needle aspiration (CEH-EUS-FNA) compared with that of conventional EUS-FNA for the diagnosis of SPLs. METHODS: Forty patients with solid pancreatic lesions who visited Fukushima Medical University between September 2013 and June 2014 were recruited for this prospective study. Twenty patients underwent CEH-EUS-FNA, and 20 patients underwent conventional EUS-FNA. The sampling rate, sensitivity, accuracy, and number of needle passes required to obtain sufficient samples were compared between the two groups. RESULTS: Patient characteristics, sampling rate, accuracy, and sensitivity were not significantly different between the two groups. The final diagnosis of patients who underwent CEH-EUS-FNA was pancreatic cancer in 19 and intraductal papillary mucinous carcinoma in one. Nineteen patients who underwent conventional EUS-FNA were finally diagnosed with pancreatic cancer and one was diagnosed as cancer of the common bile duct. There was a significant difference in the number of needle passes required. A sufficient sample was obtained on one needle pass in 60% (12/20) of CEH-EUS-FNA group compared with 25% (5/20) of the conventional EUS-FNA group. CONCLUSIONS: Fewer needle passes were required to obtain samples from solid pancreatic lesions using CEH-EUS-FNA than those required using conventional EUS-FNA. Therefore, CEH-EUS-FNA may be more efficient and safer than conventional EUS-FNA for the diagnosis of solid pancreatic lesions.

Successful radiotherapy for recurrent obstructive pancreatitis secondary to pancreatic metastasis from cervical squamous-cell carcinoma.

Metastatic pancreatic cancer is a rare condition and cases of pancreatic metastasis from cervical cancer are infrequently reported. Furthermore, the incidence rates of pancreatic tumors as the cause of pancreatitis and of pancreatitis in patients with pancreatic tumors are similarly low. Pancreatitis may occur when a tumor obstructs the pancreatic duct. This condition may be difficult to manage and significantly reduces the quality of life because of severe abdominal pain. Here, we present a rare case of obstructive pancreatitis caused by pancreatic metastasis from cervical squamous-cell carcinoma, pathologically confirmed using endoscopic ultrasonography-guided fine-needle biopsy and treated with palliative irradiation to achieve rapid therapeutic relief. It is important to obtain appropriate tissue samples, confirm the pathological diagnosis, and compare the pathological findings with those of the primary tumor to select the appropriate treatment for obstructive pancreatitis caused by a metastatic pancreatic tumor.

Nonfunctional pancreatic neuroendocrine tumours misdiagnosed as autoimmune pancreatitis: A case report and review of literature.

BACKGROUND: Nonfunctional pancreatic neuroendocrine tumours are difficult to diagnose in the early stage of disease due to a lack of clinical symptoms, but they can rarely manifest as autoimmune pancreatitis. Autoimmune pancreatitis is an uncommon disease that may cause recurrent acute pancreatitis and is therefore often regarded as a special type of chronic pancreatitis. CASE SUMMARY: We report a case of a 42-year-old female who had nonspecific upper abdominal pain for 4 years and radiological abnormalities of the pancreas that mimicked autoimmune pancreatitis. The symptoms and pancreatic imaging did not improve following 1 year of steroid therapy. Finally, pancreatic biopsy was performed through endoscopic ultrasonography-guided fine-needle aspiration biopsy, and nonfunctional pancreatic neuroendocrine tumours were ultimately diagnosed. Pancreatectomy has resolved her symptoms. CONCLUSION: Therefore, the differentiation of nonfunctional pancreatic neuroendocrine tumours from autoimmune pancreatitis is very important, although it is rare. We propose that endoscopic ultrasonography-guided fine-needle aspiration biopsy should be performed if imaging characteristics are equivocal or the diagnosis is in question.

Subclinical Needle Tract Seeding by Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Pancreatic Cancer.

A 77-year-old woman with epigastralgia was referred to our hospital. Abdominal computed tomography showed a hypointense mass in the pancreatic tail. Abdominal and endoscopic ultrasonography (EUS) showed a hypo-echoic mass, 25 × 25 mm in size, with pancreatic duct dilatation. EUS-guided fine-needle aspiration (EUS-FNA) was performed to the mass through gastric posterior wall. Pathological examination showed atypical cells growing papillary or tubular fashion, leading to the diagnosis of adenocarcinoma. Under the preoperative diagnosis of T2N0M0 pancreatic cancer, the patient underwent distal pancreatectomy and splenectomy. Macroscopic view of the resected specimen showed a presumed puncture-induced pancreatic pseudocyst adjacent to the pancreas. Pathological examination showed well-differentiated adenocarcinoma and a pseudocyst with presumed migrated atypical cells in the pseudocyst wall. The patient recovered uneventfully and has been on outpatient follow-up with adjuvant TS-1 therapy. Optimal treatment of pancreatic cancer naturally needs preoperative definitive diagnosis more strictly than other solid malignancies due to its much higher operative harm to the patients. EUS-FNA is a safe and effective diagnostic method but needs careful attention to the needle tract seeding.

Endoscopic ultrasonography-fine needle aspiration of solid pancreatic masses: Do we need the fourth pass? A prospective study.

BACKGROUND: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is important for the differential diagnosis of solid pancreatic lesions. Sample adequacy is related to the number of needle passes, and European guidelines recommend three to four needle passes with a standard EUS-FNA needle. We aimed to evaluate the optimal number of passes with standard EUS-FNA needles in solid pancreatic lesions. METHODS: Patients with solid pancreatic masses without cystic component >20% on computed tomography scan, and without biliary metallic stents, or coagulation problems were included prospectively. Standard 22G needles were used (maximum four passes); each sample was paraffin-embedded and analyzed separately. Final diagnosis was established by EUS-FNA, repeat EUS-FNA, surgery, or follow-up. RESULTS: Sixty-one of 65 patients were included. The final diagnoses were adenocarcinoma (n = 44, 72%), neuroendocrine tumor (NET) (n = 10, 16%), metastasis (n = 1, 4%) and nonmalignant lesion (n = 6, 10%). Immunohistochemical staining was possible in 17 cases. The diagnosis was established by the first pass in 62% of cases (n = 38), by the second in 15% (n = 9), by the third in 15% (n = 9), and by the fourth in 3% (n = 2). The diagnostic accuracy for all four passes compared to the first three passes was 95% vs 92% (P = .5). The contribution of the fourth pass was not different between adenocarcinoma and NET (2% vs 10%, respectively; P = .667). CONCLUSION: Three passes with standard EUS-FNA was optimal for a specific diagnosis of solid pancreatic masses, regardless of the histological type of the lesion.

Endoscopic ultrasound-guided fine-needle biopsy histology with a 22-gauge Franseen needle and fine-needle aspiration liquid-based cytology with a conventional 25-gauge needle provide comparable diagnostic accuracy in solid pancreatic lesions.

BACKGROUND AND AIM: Fine-needle biopsy (FNB) needles obtain more core samples and support the shift from cytologic to histologic evaluation; however, recent studies have proposed a superior diagnostic potential for liquid-based cytology (LBC). This study compared the diagnostic ability of endoscopic ultrasound (EUS)-guided FNB histology with a 22-gauge Franseen needle (22G-FNB-H) and fine-needle aspiration (FNA) LBC with a conventional 25-gauge needle (25G-FNA-LBC). METHODS: We analyzed 46 patients who underwent both 22G-FNB-H and 25G-FNA-LBC in the same lesion during the same endoscopic procedure. This study evaluated the diagnostic ability of each needle, diagnostic concordance between needles, and incremental diagnostic effect of both needles compared to using each needle alone. RESULTS: The agreement rate for malignancy between both techniques was 93.5% (kappa value = 0.82). There was no significant difference in the diagnostic ability of both methods. 22G-FNB-H and 25G-FNA-LBC provided an incremental diagnostic accuracy in two (4.3%) cases and one (2.2%) case, respectively. CONCLUSION: Our study demonstrated that the diagnostic accuracy of 25G-FNA-LBC and 22G-FNA-H for solid pancreatic lesions were comparable. A conventional 25-gauge needle that punctures lesions with ease can be used in difficult cases and according to the skill of the endoscopist.

Gastric glomus tumor with a preoperative diagnosis by endoscopic ultrasonography-guided fine needle aspiration: a case report.

A gastric glomus tumor (GGT) is a rare gastric submucosal tumor that can become malignant. A preoperative diagnosis would allow for a more informed decision regarding the treatment strategy. We present the case of an asymptomatic man with a GGT that was diagnosed during a preoperative examination. Upper gastrointestinal endoscopy was performed in a 64-year-old man and revealed a submucosal tumor at the lesser curvature of the antrum of the stomach. Endoscopic ultrasonography showed a 12-mm-sized hypoechoic tumor in the second and third layers of the stomach wall. A histologic diagnosis of GGT was made using endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Abdominal contrast-enhanced computed tomography was performed, but the identification of the tumor was difficult owing to poor enhancement. The gradual growth of the tumor made it necessary to perform an operation. Laparoscopy and endoscopy cooperative surgery was performed without any complications. The tumor cells were immunohistochemically positive for alpha-smooth muscle actin, h-caldesmon, and collagen type IV but were negative for desmin, discovered on GIST-1, S-100 protein, cluster of differentiation 34, epithelial membrane antigen, and cytokeratin AE1/AE3. The final diagnosis was identical to the preoperative diagnosis made using EUS-FNA. EUS-FNA is a useful method for the preoperative diagnosis of small submucosal tumors, including GGTs.

Comparison of smear cytology with liquid-based cytology in pancreatic lesions: A systematic review and meta-analysis.

BACKGROUND: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is a safe and accurate technique to confirm the diagnosis of pancreatic cancers. Recently, numerous studies comparing the diagnostic efficacy of smear cytology (SC) and liquid-based cytology (LBC) for pancreatic lesions yielded mixed results. AIM: To compare and identify the better cytology method for EUS-FNA in pancreatic lesions. METHODS: A comprehensive search of PubMed, Embase, and Cochrane was undertaken through July 18, 2020. The primary endpoint was diagnostic accuracy (sensitivity and specificity). Secondary outcomes included sample adequacy and post procedure complications. In addition, factors affecting diagnostic efficacy were discussed. RESULTS: Data on a total of 1121 comparisons from 10 studies met the inclusion criteria. Pooled rates of sensitivity for SC and LBC were 78% (67%-87%) vs 75% (67%-81%), respectively. In any case, both SC and LBC exhibited a high specificity close to 100%. Inadequate samples more often appeared in LBC compared with SC. However, the LBC samples exhibited a better visual field than SC. Very few post procedure complications were observed. CONCLUSION: Our data suggested that for EUS-FNA in pancreatic lesions (particularly solid lesions), SC with Rapid On-Site Evaluation represents a superior diagnostic technique. If Rapid On-Site Evaluation is unavailable, LBC may replace smears. The diagnostic accuracy of LBC depends on different LBC techniques.

Nationwide epidemiological survey of autoimmune pancreatitis in Japan in 2016.

BACKGROUND: To further clarify the clinico-epidemiological features of autoimmune pancreatitis (AIP) in Japan, we conducted the fourth nationwide epidemiological survey. METHODS: This study consisted of two stage surveys; the number of AIP patients was estimated by the first survey and their clinical features were assessed by the second survey. We surveyed the AIP patients who had visited hospitals in 2016. RESULTS: The estimated number of AIP patients in 2016 was 13,436, with an overall prevalence rate of 10.1 per 100,000 persons. The estimated number of newly diagnosed patients was 3984, with an annual incidence rate of 3.1 per 100,000 persons. Compared to the 2011 survey, both numbers more than doubled. We obtained detailed clinical information of 1474 AIP patients. The male-to-female sex ratio was 2.94, the mean age was 68.1, and mean age at diagnosis was 64.8. At diagnosis, 63% patients were symptomatic and nearly half of them presented jaundice. Pancreatic cysts were found in 9% of the patients and calcifications in 6%. Histopathological examination was performed in 64%, mainly by endoscopic ultrasonography-guided fine needle aspiration. Extra-pancreatic lesions were detected in 60% of the patients. Eighty-four % patients received the initial steroid therapy, and 85% received maintenance steroid therapy. Kaplan-Meier analysis revealed that the relapsed survival was 14% at 3 years, 25% at 5 years, 40% at 10 years, and 50% at 15 years. Mortality was favorable, but pancreatic cancer accounted for death in one quarter of fatal cases. CONCLUSION: We clarified the current status of AIP in Japan.

Accuracy of endoscopic ultrasound-guided needle aspiration specimens for molecular diagnosis of non-small-cell lung carcinoma.

BACKGROUND: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are highly sensitive for diagnosing and staging lung cancer. In recent years, targeted therapy has shown great significance in the treatment of non-small cell lung carcinoma (NSCLC). Using these minimally invasive techniques to obtain specimens for molecular testing will provide patients with a more convenient diagnostic approach. AIM: To evaluate the feasibility and accuracy of tissue samples obtained using EUS-FNA and EBUS-TBNA for molecular diagnosis of NSCLC. METHODS: A total of 83 patients with NSCLC underwent molecular testing using tissues obtained from EUS-FNA or EBUS-TBNA at the Tianjin Medical University Cancer Hospital from January 2017 to June 2019. All enrolled patients underwent chest computed tomography or positron emission tomography/computed tomography prior to puncture. We detected abnormal expression of EGFR, KRAS, MET, HER2, ROS1 and anaplastic lymphoma kinase protein. Two patients failed to complete molecular testing due to insufficient tumor tissue. The clinical features, puncture records, molecular testing results and targeted treatment in the remaining 81 patients were summarized. RESULTS: In a total of 99 tissue samples obtained from 83 patients, molecular testing was successfully completed in 93 samples with a sample adequacy ratio of 93.9% (93/99). Biopsy samples from two patients failed to provide test results due to insufficient tumor tissue. In the remaining 81 patients, 62 cases (76.5%) were found to have adenocarcinoma, 11 cases (13.6%) had squamous cell carcinoma, 3 cases (3.7%) had adenosquamous carcinoma and 5 cases (6.2%) had NSCLC-not otherwise specified. The results of molecular testing showed EGFR mutations in 21 cases (25.9%), KRAS mutations in 9 cases (11.1%), ROS-1 rearrangement in 1 case (1.2%) and anaplastic lymphoma kinase-positive in 5 cases (6.2%). Twenty-four patients with positive results received targeted therapy. The total effectiveness rate of targeted therapy was 66.7% (16/24), and the disease control rate was 83.3% (20/24). CONCLUSION: Tissue samples obtained by EUS-FNA or EBUS-TBNA are feasible for the molecular diagnosis of NSCLC and can provide reliable evidence for clinical diagnosis and treatment.

Endoscopic Ultrasonography-guided Fine-needle Aspiration Revealed Metastasis-induced Acute Pancreatitis in a Patient with Adrenocortical Carcinoma.

A 26-year-old woman complained of upper abdominal pain. Computed tomography (CT) showed acute pancreatitis, a left adrenal tumor and solitary right pulmonary metastasis. She underwent left adrenalectomy; the adrenal tumor was diagnosed as adrenocortical carcinoma (ACC). When preparing to resect the pulmonary metastasis, she suffered a second acute pancreatic attack. Magnetic resonance cholangiopancreatography (MRCP) showed that the proximal main pancreatic duct (MPD) was dilated, and the distal MPD was diminished; however, no pancreatic tumor was observed on CT or MRCP. Endoscopic ultrasonography revealed a solitary pancreatic mass, which was diagnosed as pancreatic metastasis from ACC by endoscopic ultrasonography-guided fine-needle aspiration.

Endoscopic ultrasonography guided transgastric trans-portal system fine needle aspiration for diagnosing pancreatic head and uncinate process malignancy.

BACKGROUND: Endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) is a well-established technique for diagnosing pancreatic malignancy. In general, tissue of pancreatic head and uncinate process lesions is obtained via a transduodenal approach. However, this tissue-acquisition modality is not applicable in cases of pyloric obstruction and duodenal bulb ulceration. The aim of this study is to determine the feasibility and safety of a novel EUS-guided transgastric trans-portal system FNA in the diagnosis of pancreatic head and uncinate process cancer. METHODS: This study retrospectively analyzed 26 consecutive inpatient patients who had undergone EUS-FNA for highly suspected malignancy of pancreatic head or uncinate process between December 2013 and December 2018. EUS-guided transgastric trans-portal vein (trans-PV, n=2) or trans-superior mesenteric vein (trans-SMV, n=24) FNA was performed in the patients under conscious sedation. Feasibility, diagnostic yield and complication rates of the technique were evaluated. RESULTS: Specimens obtained by EUS-guided transgastric trans-portal system FNA were adequate for cytological evaluation in all 26 patients. Cytological diagnosis of adenocarcinoma was established in 22 patients, while the remaining 4 patients were negative. The diagnostic accuracy, sensitivity and specificity were 92.3%, 91.7% and 100% respectively. No immediate or delayed procedure-related complications were observed. CONCLUSIONS: EUS-guided transgastric trans-portal system FNA is a feasible and probably safe method for diagnosing pancreatic head and uncinate process malignancy. Careful selection of the potential candidates and close periprocedural observation are mandatory.

Appropriate number of biliary biopsies and endoscopic retrograde cholangiopancreatography sessions for diagnosing biliary tract cancer.

BACKGROUND: Biliary ductal cancer (BDC) is a lethal disease; however, diagnosing BDC is challenging. Biliary biopsies are performed to pathologically diagnose BDC, but the appropriate parameters for biliary biopsy [number of biliary biopsies, number of endoscopic retrograde cholangiopancreatography (ERCP) sessions, etc.] are unknown. AIM: To clarify what constitutes an adequate method for biliary biopsy. METHODS: In total, 95 patients who underwent endoscopic biliary biopsy without choledochoscopy and who were pathologically diagnosed with BDC were enrolled in this study. The patients were divided into two groups. Seventy-six patients who were diagnosed by biliary biopsy were defined as the positive group (P group), and nineteen patients who were not diagnosed by biliary biopsy were defined as the negative group (N group). The patient characteristics and ERCP-related procedures were compared between the P and N groups. RESULTS: The numbers of ERCP sessions and biliary biopsies were significantly different between the two groups [ERCP sessions (one/two), P group 72/4 vs N group 15/4, P value = 0.048; number of biliary biopsies, P group 2 (1-6) vs N group 2 (1-7), P value = 0.039]. In a multivariate analysis, fewer than 2 ERCP sessions was an independent factor influencing the positivity of the biliary biopsies. CONCLUSION: This study clarified that ERCP and biliary ductal biopsy should only be performed once. If biliary cancer is not pathologically diagnosed after the first ERCP session, other methods (Endoscopic ultrasonography-guided fine needle aspiration or choledochoscopy-guided biliary ductal biopsy) should be employed.

Diagnosis of gastric duplication cyst by positron emission tomography/computed tomography: A case report.

BACKGROUND: Gastric duplication cysts (GDCs) are extremely uncommon lesions and the definitive diagnosis of GDCs is challenging for gastrointestinal specialists. It is important that a differential diagnosis is performed to rule out the possibility of other diseases, mainly malignancies with a cystic component. Despite the use of multiple diagnostic modalities including endoscopy, the preoperative diagnosis of GDCs is challenging. CASE SUMMARY: A 53-year-old female patient with a GDC was confirmed by positron emission tomography/computed tomography (PET/CT) instead of more conventional procedures such as endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). We propose that 18F-FDG-PET/CT has higher accuracy than EUS-FNA and may be an effective technique for the characterization of duplication cysts. CONCLUSION: Preoperative diagnosis of GDCs in adults is difficult largely due to their rarity and the absence of characteristic findings. In addition, few endoscopists include GDCs in the differential diagnosis when they encounter a lesion with cystic characteristics. 18F-FDG-PET/CT with additional imaging data, may complement EUS-FNA in the diagnosis of GDCs.

Surgically resected pancreatic metastasis from nasal malignant melanoma: case report and literature review.

A 13-mm mass was observed in the pancreatic head of a 70-year-old woman who had undergone melanoma resection in the nasal cavity 10 years earlier. Endoscopic ultrasonography (EUS) showed that the mass consisted of multiple hypoechoic nodules. EUS-guided fine needle aspiration and pancreatic juice cytologies revealed neoplastic cells positive for HMB45 and melan-A staining with a few melanin granules, indicating the presence of a metastatic malignant melanoma. These additional stainings were evaluated after surgery. In the surgically resected specimen, the mass had multiple nodule-like structures, some of which were brown colored. Immunocytochemistry and electronic microscopy findings confirmed the diagnosis of malignant melanoma. Microscopic findings were similar to the nasal specimen; therefore, the pancreatic lesion was considered to be a metastasis from the nasal cavity.