Ultrasound-guided vs endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer diagnosis

AIM: To clarify the effectiveness and safety of endo- scopic ultrasound-guided fine-needle aspiration (EUS-FNA) for the diagnosis of pancreatic cancer (PC). METHODS: Patients who were diagnosed with unresectable, locally advanced or metastatic PC between February 2006 and September 2011 were selected for this retrospective study. FNA biopsy for pancreatic tumors had been performed percutaneously under extracorporeal ultrasound guidance until October 2009; then, beginning in November 2009, EUS-FNA has been performed. We reviewed the complete medical records of all patients who met the selection criteria for the following data: sex, age, location and size of the targeted tumor, histological and/or cytological findings, details of puncture procedures, time from day of puncture until day of definitive diagnosis, and details of severe adverse events. RESULTS: Of the 121 patients who met the selection criteria, 46 had a percutaneous biopsy (Group A) and 75 had an EUS-FNA biopsy (Group B). Adequate cytological specimens were obtained in 42 Group A patients (91.3%) and all 75 Group B patients (P=0.0192), and histological specimens were obtained in 41 Group A patients (89.1%) and 65 Group B patients (86.7%). Diagnosis of malignancy by cytology was positive in 33 Group A patients (78.6%) and 72 Group B patients (94.6%) (P=0.0079). Malignancy by both cytology and pathology was found in 43 Group A (93.5%) and 73 Group B (97.3%) patients. The mean period from the puncture until the cytological diagnosis in Group B was 1.7 d, which was significantly shorter than that in Group A (4.1 d) (P < 0.0001). Severe adverse events were experienced in two Group A patients (4.3%) and in one Group B patient (1.3%). CONCLUSION: EUS-FNA, as well as percutaneous needle aspiration, is an effective modality to obtain cytopathological confirmation in patients with advanced PC.

Diagnostic value of liquid-based cytology and smear cytology in pancreatic endoscopic ultrasound-guided fine needle aspiration: A meta-analysis

BACKGROUND Smear cytology(SC)using endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)is the established and traditional choice for diagnosing pancreatic lesions.Liquid-based cytology(LBC)is a novel alternative cytological method,however,the comparative diagnostic efficacy of LBC remains inconclusive.AIM To examine the diagnostic efficacy of LBC and SC for pancreatic specimens obtained through EUS-FNA via a systematic review and meta-analysis.METHODS A systematic literature search was performed using PubMed,EMBASE,the Cochrane Library,and Web of Science.The numbers of true positives,false positives,true negatives,and false negatives for each cytological test(LBC and CS)were extracted from the included studies.The pooled sensitivity and specificity and the area under the summary receiver operating characteristic curve(AUC)were calculated,and the AUC was compared by Tukey's multiple comparisons test.The quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies II tool.RESULTS A total of 1656 patients in eight studies were included.The pooled sensitivity and specificity and the AUC for LBC were 0.76(95%CI:0.72-0.79),1.00(95%CI:0.98-1.00),and 0.9174,respectively,for diagnosing pancreatic lesions.The pooled estimates for SC were as follows:Sensitivity,0.68(95%CI:0.64-0.71);specificity,0.99(95%CI:0.96-100.00);and AUC,0.9714.Similarly,the corresponding values for LBC combined with SC were 0.87(95%CI:0.84-0.90),0.99(95%CI:0.96-1.00),and 0.9894.Tukey’s multiple comparisons test was used to compare the sensitivities and AUCs of the three diagnostic methods;statistically significant differences were found between the three methods,and LBC combined with SC was superior to both LBC(P<0.05)and SC(P<0.05).The pooled sensitivity and AUC did not change significantly in the sensitivity analysis.CONCLUSION LBC may be sensitive than SC in the cytological diagnosis of pancreatic lesions,however,the superior diagnostic performance of their combination emphasizes their integrated usage in the clinical evaluation of pancreatic lesions.

Peritoneal dissemination of pancreatic cancer caused by endoscopic ultrasound-guided fine needle aspiration:A case report and literature review

BACKGROUND Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)is a biopsy technique widely used to diagnose pancreatic tumors because of its high sensitivity and specificity.Although needle-tract seeding caused by EUS-FNA has been recently reported,dissemination of pancreatic cancer cells is generally considered to be a rare complication that does not affect patient prognosis.However,the frequency of dissemination and needle-tract seeding appears to have been underestimated.We present a case of peritoneal dissemination of pancreatic cancer due to preoperative EUS-FNA.CASE SUMMARY An 81-year-old man was referred to the Department of Surgery of our hospital in Japan owing to the detection of a pancreatic mass on computed tomography during medical screening.Trans-gastric EUS-FNA revealed that the mass was an adenocarcinoma;hence laparoscopic distal pancreatectomy with lymphadenectomy was performed.No intraoperative peritoneal dissemination and liver metastasis were visually detected,and pelvic lavage cytology was negative for carcinoma cells.The postoperative surgical specimen was negative for carcinoma cells at the dissected margin and the cut end margin;however,pathological findings revealed adenocarcinoma cells on the peritoneal surface proximal to the needle puncture site,and the cells were suspected to be disseminated via EUSFNA.Hence,the patient received adjuvant therapy with S-1(tegafur,gimeracil,and oteracil potassium);however,computed tomography performed 5 mo after surgery revealed liver metastasis and cancerous peritonitis.The patient received palliative therapy and died 8 mo after the operation.CONCLUSION The indications of EUS-FNA should be carefully considered to avoid iatrogenic dissemination,especially for cancers in the pancreatic body or tail.

Can the wet suction technique change the efficacy of endoscopic ultrasound-guided fine-needle aspiration for diagnosing autoimmune pancreatitis type 1? A prospective single-arm study

BACKGROUND Other than surgery,endoscopic ultrasound-guided fine-needle aspiration(EUSFNA)is the only procedure for histologically diagnosing autoimmune pancreatitis(AIP).However,adequate specimens are difficult to obtain.Recently,more adequate specimens were reported to be obtained with EUS-FNA with a wet suction technique(WEST)than with conventional EUS-FNA.AIM To histologically diagnose AIP by EUS-FNA with a WEST.METHODS Eleven patients with possible type 1 AIP between February 2016 and August 2018 underwent EUS-FNA with a WEST(WEST group),with four punctures by 19 or 22 G needles.As a historical control,23 type 1 AIP patients who underwent no fewer than four punctures with 19 or 22 G needles were enrolled(DRY group).Patient characteristics and histological findings were compared between the two groups.RESULTS Three histopathological factors according to the International Consensus Diagnostic Criteria were significantly greater in the WEST group than the DRY group[lymphoplasmacytic infiltrate without granulocytic infiltration:9(81.8%)vs 6(26.1%),P=0.003,storiform fibrosis:5(45.5%)vs 1(4.3%),P=0.008,abundant(>10 cells/HPF)IgG4-positive cells:7(63.6%)vs 5(21.7%),P=0.026].Level 1 or level 2 histopathological findings were observed more often in the WEST group than in the DRY group[8(72.7%)vs 3(13.0%),P=0.001].CONCLUSION EUS-FNA with a WEST was more successful than standard EUS-FNA in histologically diagnosing AIP.

Push vs pull method for endoscopic ultrasound-guided fine needle aspiration of pancreatic head lesions: Propensity score matching analysis

AIM To evaluate the efficacy of endoscopic ultrasoundguided fine needle aspiration(EUS-FNA) of pancreatic head cancer when pushing(push method) or pulling the echoendoscope(pull method).METHODS Overall, 566 pancreatic cancer patients had their first EUS-FNA between February 2001 and December 2017. Among them, 201 who underwent EUS-FNA for pancreatic head lesions were included in this study. EUS-FNA was performed by the push method in 85 patients, the pull method in 101 patients and both the push and pull methods in 15 patients. After propensity score matching(age, sex, tumor diameter, and FNA needle), 85 patients each were stratified into the push and pull groups. Patient characteristics and EUSFNA-related factors were compared between the two groups.RESULTS Patient characteristics were not significantly different between the two groups. The distance to lesion was significantly longer in the push group than in the pull group(13.9 ± 4.9 mm vs 7.0 ± 4.9 mm, P < 0.01). The push method was a significant factor influencing the distance to lesion(≥ median 10 mm)(P < 0.01). Additionally, tumor diameter ≥ 25 mm(OR = 1.91, 95%CI: 1.02-3.58, P = 0.043) and the push method(OR = 1.91, 95%CI: 1.03-3.55, P = 0.04) were significant factors contributing to the histological diagnosis of malignancy.CONCLUSION The pull method shortened the distance between the endoscope and the lesion and facilitated EUS-FNA of pancreatic head cancer. The push method contributed to the histological diagnosis of pancreatic head cancer using EUS-FNA specimens.

Endoscopic Ultrasound-Guided Fine Needle Aspiration Cytology of Gastrointestinal Tract Tumors and Related Organs: Predictive Factors for Accurate Cytopathological Diagnosis

Background: Endoscopic ultrasonography (EUS) is well-established, highly accurate clinical diagnostic test for detection and staging of gastrointestinal tract lesions and related organs. The addition of endoscopic guided fine needle aspiration cytology (EUS-FNAC) has improved the performance characteristics of EUS. Aim: Evaluate the validity of EUS-FNAC in diagnosis of gastrointestinal tract lesions and related organs and assess predictive factors for an accurate EUS-FNAC diagnosis. Methods: Our study included cytological sampling from one hundred sixty-six lesions obtained from gastrointestinal tract and related organs. Factors affecting EUS-FNA accuracy were analyzed. The histopathological results or clinical follow-up were used as the gold standard method. Results: Samples were obtained from: pancreatic masses (n = 80), gastric masses (n = 34), lymph nodes (n = 22), hepatobiliary masses (n = 18) and rectal masses (n = 2). Statistical analysis of sensitivity, specificity, Positive Predictive Value, Negative Predictive Value, and diagnostic accuracy of EUS alone was 80.4%, 51.6%, 75.8%, 76.2% and 75.9% respectively. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-FNAC are 78.8%, 96.8%, 97.6% and 73.2% respectively. Addition of FNAC to EUS improved diagnostic accuracy to 85.5%. Positive statistical association was present between cytological adequacy and adequate cell block preparations, larger lesion size, presence of rapid on site evaluation (ROSE) and obtaining at least two passes from target lesion. Conclusions: EUS is valuable diagnostic and cost effective tool for gastrointestinal tract lesions and related organs when combined with FNAC.

Pancreatic paraganglioma diagnosed by endoscopic ultrasoundguided fine needle aspiration: A case report and review of literature

BACKGROUND Pancreatic paragangliomas(PPGL)are rare benign neuroendocrine neoplasms but malignancy can occur.PPGL are often misdiagnosed as pancreatic neuroendocrine tumor or pancreatic adenocarcinoma.CASE SUMMARY We reviewed 47 case reports of PPGL published in PubMed to date.Fifteen patients(15/47)with PPGL underwent endoscopic ultrasound-guided fine needle aspiration(EUS-FNA).Only six(6/15)were correctly diagnosed as PPGL.All patients with PPGL underwent surgical resection except three(one patient surgery was aborted because of hypertensive crisis,two patients had metastasis or involvement of major vessels).Our patient remained on close surveillance as she was asymptomatic.CONCLUSION Accurate preoperative diagnosis of PPGL can be safely achieved by EUS-FNA with immunohistochemistry.Multidisciplinary team approach should be considered to bring the optimal results in the management of PPGL.

Comparison of cytological and histological preparations in the diagnosis of pancreatic malignancies using endoscopic ultrasoundguided fine needle aspiration

BACKGROUND:Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) has become a crucial diagnostic technique for pancreatic malignancies.The specimen obtained by EUS-FNA can be prepared for either cytological or histological examinations.This study was to compare diagnostic performance of cytological and histological preparations using EUSFNA in the same lesions when pancreatic malignancies were suspected.METHODS:One hundred and eighteen patients who underwent EUS-FNA for suspected pancreatic malignancies were consecutively enrolled.All procedures were conducted by a single echoendoscopist under the same conditions.Four adequate preparations were obtained by 22-gauge needles with 20 to-and-fro movements for each pass.The 4 preparations included 2 cytological and 2 histological specimens.The pathologic reviews of all specimens were conducted independently by a single experienced cytopathologist.Sensitivity,specificity,and accuracy of the 2 preparations were compared.RESULTS:The enrolled patients consisted of 62 males(52.5%),with the mean age of 64.6±10.5 years.Surgery was performed in 23(19.5%) patients.One hundred and sixteen(98.3%) lesions were classified as malignant,while 2(1.7%) were benign.Sensitivity of cytology and histology were 87.9% and 81.9%,respectively,with no significant difference(P=0.190).Accuracy was also not significantly different.Cytological preparation was more sensitive when the size of lesion was <3 cm(86.7% vs 68.9%,P=0.033).CONCLUSIONS:Our results suggested that the diagnostic performances of cytological and histological preparations are not significantly different for the diagnosis of pancreatic malignancies.However,cytological preparation might be more sensitive for pancreatic lesions <3 cm.

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy in solid lesions:A multi-center analysis

BACKGROUND While endoscopic ultrasound(EUS)-guided fine needle aspiration(FNA)is considered a preferred technique for tissue sampling for solid lesions,fine needle biopsy(FNB)has recently been developed.AIM To compare the accuracy of FNB vs FNA in determining the diagnosis of solid lesions.METHODS A retrospective,multi-center study of EUS-guided tissue sampling using FNA vs FNB needles.Measured outcomes included diagnostic test characteristics(i.e.,sensitivity,specificity,accuracy),use of rapid on-site evaluation(ROSE),and adverse events.Subgroup analyses were performed by type of lesion and diagnostic yield with or without ROSE.A multivariable logistic regression was also performed.RESULTS A total of 1168 patients with solid lesions(n=468 FNA;n=700 FNB)underwent EUS-guided sampling.Mean age was 65.02±12.13 years.Overall,sensitivity,specificity and accuracy were superior for FNB vs FNA(84.70%vs 74.53%;99.29%vs 96.62%;and 87.62%vs 81.55%,respectively;P<0.001).On subgroup analyses,sensitivity,specificity,and accuracy of FNB alone were similar to FNA+ROSE[(81.66%vs 86.45%;P=0.142),(100%vs 100%;P=1.00)and(88.40%vs 85.43%;P=0.320].There were no difference in diagnostic yield of FNB alone vs FNB+ROSE(P>0.05).Multivariate analysis showed no significant predictor for better accuracy.On subgroup analyses,FNB was superior to FNA for non-pancreatic lesions;however,there was no difference between the techniques among pancreatic lesions.One adverse event was reported in each group.CONCLUSION FNB is superior to FNA with equivalent diagnostic test characteristics compared to FNA+ROSE in the diagnosis of non-pancreatic solid lesions.Our results suggest that EUS-FNB may eliminate the need of ROSE and should be employed as a first-line method in the diagnosis of solid lesions.

Modified endoscopic submucosal tunnel dissection for large esophageal submucosal gland duct adenoma: A case report

BACKGROUND With the recent improvement of endoscopic techniques,endoscopic ultrasoundguided fine needle aspiration and endoscopic submucosal tunnel dissection(ESTD)have been widely used for accurate diagnosis and dissection acceleration of esophageal tumors.CASE SUMMARY We used a modified submucosal tunnel technique during endoscopic en bloc resection in a 58-year-old man with large esophageal submucosal gland duct adenoma(ESGDA).During modified ESTD,the oral end of the involved mucosa was cut transversely,followed by a submucosal tunnel created from the proximal to the distal end,and the anal end of the involved mucosa blocked by the tumor was incised.As a result of retaining submucosal injection solutions using the submucosal tunnel technique,it was possible to reduce the amount of injection required and increase the efficiency and safety of dissection.CONCLUSION Modified ESTD is an effective treatment strategy for large ESGDAs.Single-tunnel ESTD appears to be a time-saving procedure compared with conventional endoscopic submucosal dissection.

Gastric linitis plastica with autoimmune pancreatitis diagnosed by an endoscopic ultrasonography-guided fine-needle biopsy: A case report

BACKGROUND Gastric linitis plastica(GLP)is a subset of gastric cancer with a poor prognosis.It is difficult to obtain a definitive diagnosis by endoscopic mucosal biopsies,and the usefulness of an endoscopic ultrasonography-guided fine-needle biopsy(EUSFNB)for GLP has been recently reported.Meanwhile,autoimmune diseases are occasionally known to coexist with malignant tumors as paraneoplastic syndrome.We herein report the usefulness of an EUS-FNB for detecting GLP and the possibility of paraneoplastic syndrome coexisting with GLP.CASE SUMMARY An 81-year-old man was admitted to our hospital for a 1-mo history of epigastric pain that increased after eating.His laboratory data revealed high levels of serum carbohydrate antigen 19-9 and immunoglobulin-G4.Endoscopic examinations showed giant gastric folds and reddish mucosa;however,no epithelial changes were observed.The gastric lumen was not distensible by air inflation,suggesting GLP.Computed tomography showed the thickened gastric wall,the diffuse enlargement of the pancreas,and the peripancreatic rim,which suggested autoimmune pancreatitis(AIP)coexisting with GLP.Because the pathological findings of the endoscopic biopsy showed no malignancy,he underwent an EUSFNB and was diagnosed with GLP.He received chemotherapy for unresectable gastric cancer due to peritoneal metastasis,after which both the gastric wall thickening and diffuse enlargement of the pancreas were improved.CONCLUSION An EUS-FNB for GLP with a negative endoscopic biopsy is useful,and AIP may develop as a paraneoplastic syndrome.

Interventional endoscopic ultrasound:Therapeutic capability and potential

The linear echoendoscope,introduced in the 1990s,opened the era of interventional endoscopic ultrasound(IEUS).The linear echoendoscope enabled EUS guided Fine Needle Aspiration(EUS-FNA) allowing the path of the needle to be traced during the puncture process.After EUS-FNA,other interventional procedures were introduced in clinical practice.Tissue acquisition was the first EUS-guided interventional procedure and its higher diagnostic quality has undoubtedly been established.After EUS-FNA,Celiac plexus neurolysis(CPN) and block(CPB),pancreatic pseudocyst drainage,abdominal and mediastinal collections/abscesses drainage,and in selected cases,pancreatic and biliary ductal system drainage,were introduced in clinical practice.EUS-guided fine needle injection with local delivery of antitumor agents is considered a promising modality.We have reviewed published data on EUS guided interventional procedures with the object of summarizing the diagnostic capability of endoscopic ultrasound and elaborates in detail its therapeutic capability and potential.

Endoscopic ultrasound-through-the-needle biopsy in pancreatic cystic lesions: A large single center experience

BACKGROUND Establishing a diagnosis of pancreatic cystic lesions(PCLs)preoperatively still remains challenging.Recently,endoscopic ultrasound(EUS)-through-the-needle biopsy(EUS-TTNB)using microforceps in PCLs has been made available.AIM To assess the efficacy and safety of EUS-TTNB in the diagnosis of PCLs.METHODS We retrospectively collected data of patients with PCLs who underwent both EUS-fine-needle aspiration(FNA)for cytology and EUS-TTNB at our institution since 2016.EUS-FNA for cytology was followed by EUS-TTNB in the same session.Evaluation of the cyst location,primary diagnosis,adverse events,and comparison between the cytologic fluid analyses and histopathology was performed.Technical success of EUS-TTNB was defined as visible tissue present after biopsy.Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis.RESULTS A total of 56 patients(mean age 66.9±11.7,53.6%females)with PCLs were enrolled over the study period.The mean cyst size was 28.8 mm(12-85 mm).The EUS-TTNB procedure was technically successful in all patients(100%).The clinical success rate using EUS-TTNB was much higher than standard EUS-FNA,respectively 80.4%(45/56)vs 25%(14/56).Adverse events occurred in 2 patients(3.6%)who developed mild pancreatitis that resolved with medical therapy.Using TTNB specimens,23 of 32 cases(71.9%)with intraductal papillary mucinous neoplasm were further differentiated into gastric type(19 patients)and pancreaticobiliary type(4 patients)based on immunochemical staining.CONCLUSION EUS-TTNB for PCLs was technically feasible and had a favorable safety profile.Furthermore,the diagnostic yield for PCLs was much higher with EUS-TTNB than standard EUS-FNA cytology and fluid carcinoembryonic antigen.EUSTTNB should be considered as an adjunct to EUS-FNA and cytologic analysis in the diagnosis and management of PCLs.

Severe mediastinitis and pericarditis after endobronchial ultrasoundguided transbronchial needle aspiration:A case report

BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration(EBUS-TBNA)is a safe and minimally invasive diagnostic tool for mediastinal and hilum evaluation.However,infectious complications may occur after EBUS-TBNA.Among these,mediastinitis and pericarditis are rare.CASE SUMMARY A 67-year-old woman was referred to our hospital due to paratracheal lymph node enlargement on chest computed tomography(CT).EBUS-TBNA was performed on the lymph node lesions,and prophylactic oral antibiotics were administered.Seven days after EBUS-TBNA,the patient visited the emergency room with a high fever and chest pain.Laboratory test results revealed leukocytosis with a left shift and elevated C-reactive protein level(25.7 mg/dL).Chest CT revealed the formation of a mediastinal abscess in the right paratracheal lymph node and pericardial and bilateral pleural effusions.The patient received intravenous antibiotic treatment,cardiac drainage through pericardiocentesis,and surgical management.The patient recovered favorably and was discharged 31 d after the operation.CONCLUSION Mediastinitis and pericarditis after EBUS-TBNA are rare but should be considered even after the use of prophylactic antibiotics.

Role of endoscopic ultrasound in pediatric patients: A single tertiary center experience and review of the literature

BACKGROUND Although endoscopic ultrasound(EUS)is now widely available and has an established role in adults,the utility of EUS and EUS-guided fine needle aspiration(EUS-FNA)in pediatrics is insufficiently described compared to adults and is supported by only a few studies.AIM To report the experience of a single tertiary center in the use of EUS and EUS-FNA in a pediatric population and to further assess its safety,feasibility,and clinical impact on management.METHODS A retrospective study of 13 children(aged 18 years or younger)identified from our medical database was conducted.A retrospective review of demographic data,procedure indications,EUS findings,and the clinical impact of EUS on the subsequent management of these patients was performed.RESULTS During the 4-year study period,a total of 13(1.7%)pediatric EUS examinations out of 749 EUS procedures were performed in our unit.The mean age of these 8 females and 5 males was 15.6 years(range:6-18).Six of the 13 EUS examinations were pancreatobiliary(46.1%),followed by mediastinal 2/13(15.4%),peri-gastric 2/13(15.4%),abdominal lymphadenopathy 1/13(7.7%),tracheal 1/13(7.7%)and rectal 1/13(7.7%).Overall,EUS-FNA was performed in 7 patients(53.8%)with a diagnostic yield of 100%.The EUS results had a significant impact on clinical care in 10/13(77%)cases.No complications occurred in these patients during or after any of the procedures.CONCLUSION EUS and EUS-FNA in the pediatric population are safe,feasible,and have a significant clinical impact on the subsequent management;thus avoiding invasive and unnecessary procedures.

Young patient with a giant gastric bronchogenic cyst:A case report and review of literature

BACKGROUND Gastric bronchogenic cysts(BCs)are extremely rare cystic masses caused by abnormal development of the respiratory system during the embryonic period.Gastric bronchial cysts are rare lesions that were first reported in 1956;as of 2023,only 33 cases are available in the PubMed online database.BCs usually have no clinical symptoms in the early stage,and imaging findings also lack specificity.Therefore,they are difficult to diagnose before histopathological examination.CASE SUMMARY A 34-year-old woman with respiratory distress presented at our hospital.Endoscopic ultrasound revealed an anechoic mass between the spleen,left kidney and gastric fundus,with hyperechogenic and soft elastography textures and with a size of approximately 6.5 cm×4.0 cm.Furthermore,a computed tomography scan demonstrated high density between the posterior stomach and the spleen and the left kidney,with uniform internal density and a small amount of calcification.The maximum cross section was approximately 10.1 cm×6.1 cm,and the possibility of a cyst was high.Because the imaging findings did not suggest a malignancy and because the patient required complete resection,she underwent laparotomy surgery.Intraoperatively,this cystic lesion was found to be located in the posterior wall of the large curvature of the fundus and was approximately 8 cm×6 cm in size.Finally,the pathologists verified that the cyst in the fundus was a gastric BC.The patient recovered well,her symptoms of chest tightness disappeared,and the abdominal drain was removed on postoperative day 6,after which she was discharged on day 7 for 6 months of follow-up.She had no tumor recurrence or postoperative complications during the follow-up.CONCLUSION This is a valuable report as it describes an extremely rare case of gastric BC.Moreover,this was a very young patient with a large BC in the stomach.

Updates in diagnosis and management of pancreatic cysts

Incidental pancreatic cysts are commonly encountered with some cysts having malignant potential.The most common pancreatic cystic neoplasms include serous cystadenoma,mucinous cystic neoplasm and intraductal papillary mucinous neoplasm.Risk stratifying pancreatic cysts is important in deciding whether patients may benefit from endoscopic ultrasound(EUS)or surgical resection.Surgery should be reserved for patients with malignant cysts or cysts at high risk for developing malignancy as suggested by various risk features including solid mass,nodule and dilated main pancreatic duct.EUS may supplement magnetic resonance imaging findings for cysts that remain indeterminate or have concerning features on imaging.Various cyst fluid markers including carcinoembryonic antigen,glucose,amylase,cytology,and DNA markers help distinguish mucinous from nonmucinous cysts.This review will guide the practicing gastroenterologist in how to evaluate incidental pancreatic cysts and when to consider referral for EUS or surgery.For presumed low risk cysts,surveillance strategies will be discussed.Managing pancreatic cysts requires an individualized approach that is directed by the various guidelines.

Diagnostic yield of EUS-FNA of small(≤15 mm) solid pancreatic lesions using a 25-gauge needle

Background: Early detection of small solid pancreatic lesions is increasingly common. To date, few and contradictory data have been published about the relationship between lesion size and endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) diagnostic yield. The aim of this study was to assess the relation between the size of solid pancreatic lesions and the diagnostic yield of EUS-FNA using a 25-gauge needle in a center without available rapid on-site evaluation.Methods: In the retrospective cohort study, we selected patients who underwent EUS-FNA for solid pancreatic lesions with a 25-gauge needle from October 2014 to October 2015. Patients were divided into three groups(≤15 mm, 16–25 mm and >25 mm), and the outcomes were compared.Results: We analyzed 163 patients. Overall adequacy, sensitivity, specificity and accuracy were 85.2%,81.8%, 93.7%, and 80.4%, respectively. When stratified by size, the sensitivity and accuracy correlated with size(P = 0.016 and P = 0.042, respectively). Multivariate analysis showed that lesion size was the only independent factor(P = 0.019, OR = 4.76) affecting accuracy. The role of size as an independent factor affecting accuracy was confirmed in a separate multivariate analysis, where size was included in the model as a covariate(P = 0.018, OR = 1.08).Conclusion: Our study demonstrates that, in the absence of rapid on-site evaluation, mass size affects the accuracy of EUS-FNA of solid pancreatic lesions.

Opinion: How to manage subepithelial lesions of the upper gastrointestinal tract?

Subepithelial lesions(SELs) in the upper gastrointestinal(GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound(EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor(GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration(EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions(size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.

Similarities and differences in guidelines for the management of pancreatic cysts

Accurate diagnosis of Pancreatic cysts(PC) is key in the management. The knowledge of indications for surgery, the role of endoscopic ultrasound-guided fine needle aspiration, cyst fluid analysis, imaging, and surveillance of PC are all important in the diagnosis and management of PC. Currently, there are many guidelines for the management of PC. The optimal use of these guidelines with a patient-centered approach helps diagnose early cancer and prevent the spread of cancer.