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 EUSFNB.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 ultrasound-guided sampling of solid pancreatic masses:the fine needle aspiration or fine needle biopsy dilemma. Is the best needle yet to come?

Fine needle aspiration (FNA) is currently the standard of care for sampling pancreatic solid masses by using endoscopic ultrasound (EUS).The accuracy of the technique is reported to be high,especially if coupled with the rapid on site evaluation (ROSE),and it has a high safety profile.However,FNA presents some limitations,such as the small amount of tissue that can be collected and the inability of obtaining a core tissue with intact histological architecture,which is relevant to perform immunohistochemical analysis,molecular profiling and,therefore,targeted therapies.Moreover,the presence of the ROSE by an expert cytopathologist is very important to maximize the diagnostic yield of FNA technique;however,it is not widely available,especially in small centers.Hence,the introduction of EUS fine needle biopsy (FNB) with a new generation of needles,which show a high safety profile too and a satisfying diagnostic accuracy even in the absence of ROSE,could be the key to overcome the limitations of FNA.However,FNB has not yet shown diagnostic superiority over FNA.Considering all the technical aspects of FNA and FNB,the different types of needle currently available,comparisons in term of diagnostic yield,and the different techniques of sampling,a tailored approach should be used in order to determine the needle that is most appropriate for the different specific scenarios.

Diagnostic utility of endoscopic ultrasound-guided fineneedle aspiration biopsy for glomus tumor of the stomach

A 52-year-old man was referred for further investigation of a gastric submucosal tumor on the greater curvature of the antrum. Endoscopic ultrasonography demonstrated a hypoechoic solid mass, which was primarily connected to the muscular layer of the stomach. We performed endoscopic ultrasoundguided fine-needle aspiration biopsy. The pathological examination showed proliferation of oval-shaped cells with nest formation, which stained strongly positive for muscle actin, and negative for c-kit, CD34, CD56,desmin, S-100, chromogranin, and neuron-specific enolase. Therefore, we performed laparoscopy and endoscopy cooperative surgery based on the preoperative diagnosis of glomus tumor of the stomach. The final histological diagnosis confirmed the preoperative diagnosis. Although preoperative diagnosis of glomus tumor of the stomach is difficult with conventional images and endoscopic biopsy, endoscopic ultrasoundguided fine-needle aspiration biopsy is an essential tool to gain histological evidence of glomus tumor of the stomach for early diagnosis.

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.

Endoscopic ultrasound-guided fine-needle aspiration biopsy-Recent topics and technical tips

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is a useful procedure that enables reliable pathological diagnoses of pancreatobiliary diseases, subepithelial lesions, and swollen lymph nodes. In recent years, a pathological diagnosis based on EUS-FNA has made it possible to provide accurate treatment methods not only in these fields, but also in respiratory organs and otorhinolaryngology. This review discusses the latest topics pertaining to EUS-FNA as well as procedural tips.

Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration

AIM： to evaluate the role of endoscopic ultrasonographyguided fine needle aspiration （EUS-FNA） in the preoperative diagnosis of gastrointestinal stromal tumor （GIST）.METHODS： From September 2002 to June 2006, Fiftythree consecutive EUS-FNAs of GI tract subepithelial hypoechoic tumors with continuity to proper muscle layer suspected as GIST by standard EUS were evaluated prospectively. The reference standards for the final diagnosis were surgery （n = 31）, or clinical follow-up （n = 22）. Additionally, immunophenotyping of specimens obtained by EUS-FNA and surgical resection specimens were compared.RESULTS： In 2 cases puncture was not performed because of anatomical problems. The collection rate of adequate specimens from the GI tract subepithelial hypoechoic tumor with continuity to proper muscle layer was 82% （42/51）. The diagnostic rate for the tumor less than 2 cm, 2 to 4 cm, and 4 cm or more were 71% （15/21）, 86% （18/21）, and 100% （9/9）,respectively. In 29 surgically resected cases, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EUS-FNA using immunohistochemical analysis of GIST were 100%（24/24）, 80% （4/5）, 96% （24/25）, 100% （4/4）, and 97% （28/29）, respectively. No major complications were encountered.CONCLUSION： EUS-FNA with immunohistochemical analysis is a safe and accurate method in the pretherapeutic diagnosis of GIST. It should be taken into consideration in decision making, especially in early diagnosis following minimal invasive surgery for GIST.

Endoscopic ultrasound guided fine needle aspiration and useful ancillary methods

The role of endoscopic ultrasound(EUS) in evaluating pancreatic pathology has been well documented from the beginning of its clinical use. High spatial resolution and the close proximity to the evaluated organs within the mediastinum and abdominal cavity allow detection of small focal lesions and precise tissue acquisition from suspected lesions within the reach of this method. Fine needle aspiration(FNA) is considered of additional value to EUS and is performed to obtain tissue diagnosis. Tissue acquisition from suspected lesions for cytological or histological analysis allows, not only the differentiation between malignant and non-malignant lesions, but, in most cases, also the accurate distinction between the various types of malignant lesions. It is well documented that the best results are achieved only if an adequate sample is obtained for further analysis, if the material is processed in an appropriate way, and if adequate ancillary methods are performed. This is a multi-step process and could be quite a challenge in some cases. In this article, we discuss the technical aspects of tissue acquisition by EUS-guided-FNA(EUS-FNA), as well as the role of an on-site cytopathologist, various means of specimen processing, and the selection of the appropriate ancillary method for providing an accurate tissue diagnosis and maximizing the yield of this method. The main goal of this review is to alert endosonographers, not only to the different possibilities of tissue acquisition, namely EUS-FNA, but also to bring to their attention the importance of proper sample processing in the evaluation of various lesions in the gastrointestinal tract and other accessible organs. All aspects of tissue acquisition(needles, suction, use of stylet, complications, etc.) have been well discussed lately. Adequate tissue samples enable comprehensive diagnoses, which answer the main clinical questions, thus enabling targeted therapy.

Simultaneous endoscopic ultrasound fine needle aspiration and endoscopic retrograde cholangio-pancreatography:Evaluation of safety

AIM: To investigate the rate of complications of endoscopic retrograde cholangio-pancreatography (ERCP) performed immediately after endoscopic ultrasound fine needle aspiration (EUS-FNA) in a large series of patients. METHODS: Patients with the following conditions were considered candidates for EUS-FNA and ERCP: diagnosis of locally advanced or metastatic pancreatic lesion not eligible for surgery, and patients with pancreatic lesion of unknown nature causing jaundice. Data were prospectively collected on the following parameters: indication for FNA, EUS findings, pathological diagnosis, procedure duration of EUS-FNA and combined EUS-FNA and ERCP, and immediate and late complications. RESULTS: From January 2004 to October 2006, 72 patients were deemed eligible for combined EUS and ERCP. In 25/72 EUS-FNA was performed to obtain a pathology diagnosis of lesions causing biliary obstruction, and ERCP sequentially performed to drain the biliary system. No immediate complications occurred except for two mild bleeding episodes post sphincterotomy. No late complications were recorded except for one patient who experienced fever, promptly recovered with antibiotic therapy. CONCLUSION: Simultaneous approach appears to be feasible and safe. When possible, this can be considered the reference standard to avoid double sedation and reduce duration of the procedure and hospital stay.

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.

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.

Endoscopic ultrasound-guided fine needle aspiration in the differentiation of type 1 and type 2 autoimmune pancreatitis

AIM:To investigate the usefulness of endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) in the differentiation of autoimmune pancreatitis(AIP).METHODS:We retrospectively reviewed 47 of 56 AIP patients who underwent EUS-FNA and met the Asian diagnostic criteria.On 47 EUS-FNA specimens,we evaluated the presence of adequate material and characteristic features of lymphoplasmacytic sclerosing pancreatitis(LPSP) and idiopathic duct-centric pancreatitis(IDCP) mentioned in the International Consensus Diagnostic Criteria and examined if these findings make a contribution to the differential diagnosis of type 1 and type 2 AIP.A disposable 22-gauge needle was used for EUS-FNA.RESULTS:Adequate specimens including pancreatic tissue for differentiating AIP from cancer were obtained from 43 of 47 patients who underwent EUSFNA.EUS-FNA was performed from the pancreatic head in 21 cases,which is known to be technically difficult when performed by core biopsy;there was no significant difference in the results compared with pancreatic body-tail.Nine of 47 patients met level 1 findings of LPSP and 5 patients met level 2 findings of LPSP.No one met level 1 findings of IDCP,but 3 patients met level 2 findings of IDCP.Of 10 seronegative cases,2 cases were diagnosed with "definitive type 1 AIP",and 3 cases were diagnosed with "probable type 2 AIP" when considering both the level 2 histological findings and response to steroids.CONCLUSION:EUS-FNA is useful in the differentiation of type 1 and type 2 AIP,particularly in seronegative cases.

Diagnostic approach using endosonography guided fine needle aspiration for lymphadenopathy in primary sclerosing cholangitis

We report a case of primary sclerosing cholangitis (PSC) with benign lyphadenopathy which was diagnosed with endosonography guided fine needle aspiration (EUS-FNA). A 65-year-old woman was admitted to Jikei University Hospital with severe jaundice. Although endoscopic retrograde cholangiography and liver biopsy revealed the findings consistent with PSC, abdominal computed tomography revealed numerous large perihepatic lymph nodes with a maximum diameter of more than 3 cm. Therefore, EUS-FNA was done in order to exclude malignant lymphadenopathy, and adequate specimens obtained by EUS-FNA showed reactive hyperplasia of lymphnode. The patients were scheduled to undergo liver transplantation.

Impact of endoscopic ultrasound-guided fine needle biopsy for diagnosis of pancreatic masses

AIM： To evaluate the diagnostic accuracy of histological evaluation of pancreatic tissue samples obtained by a modified method for recovering and processing the endoscopic ultrasound （EUS）-guided fine needle aspiration （FNA） material in the differential diagnosis of pancreatic solid masses. METHODS： Sixty-two consecutive patients with pancreatic masses were prospectively studied. EUS was performed by the linear scanning Pentax FG-38UX echoendoscope. Three FNAs （22G needle） were carried out during each procedure. The materials obtained with first and second punctures were processed for cytological study. Haterials of the third puncture were recovered into 10% formol solution by careful injection of saline solution through the needle, and processed for histological study. RESULTS： Length of the core specimen obtained for histological analysis was 6.5±5.3 mm （range 1-22 mm）. Cytological and histological samples were considered as adequate in 51 （82.3%） and 52 cases （83.9%）, respectively. Overall sensitivity of both pancreatic cytology and histology for diagnosis of malignancy was 68.4%. Conbary to cytology, histology was able to diagnose tumours other than adenocarcinomas, and all cases of inflammatory masses. Combination of cytology and histology allowed obtaining an adequate sample in 56 cases （90.3%）, with a global sensitivity of 84.21%, specificity of 100% and an overall accuracy of 90.32%. The complication rate was 1.6%.CONCLUSION： Adequate pancreatic core specimens for histological examination can be obtained by EUS-guided FNA. This technique is mainly useful for the diagnosis of different types of pancreatic tumours and evaluation of benign diseases.

Cytopathologic diagnosis of fine needle aspiration biopsies of thyroid nodules

Fine-needle aspiration(FNA) cytology is an important diagnostic tool in patients with thyroid lesions.Several systems have been proposed for the cyropathologic diagnosis of the thyroid nodules.However cases with indeterminate cytological findings still remain a matter of debate.In this review we analyze all literature regarding Thyroid Cytopathology Reporting systems trying to identify the most suitable methodology to use in clinical practice for the preoperative diagnosis of thyroid nodules.A review of the English literature was conducted,and data were analyzed and summarized and integrated from the authors' perspective.The main purpose of thyroid FNA is to identify patients with higher risk for malignancy,and to prevent unnecessary surgeries for benign conditions.The Bethesda System for Reporting Thyroid Cytopathology is the most widely used system for the diagnosis of thyroid FNA specimens.This system also contains guidelines for the diagnosis and treatment of indeterminate or suspicious for malignancy cases.In conclusion,patients who require repeated FNAs for indeterminate diagnoses will be resolved by repeat FNA in a percentage of 72%-80%.

Ultrasound-guided fine needle biopsy of intra- hepatic nodules and low elevation of AFP in early diagnosis of hepatocellular carcinoma

BACKGROUND: With the progress in early clinical treat- ment of hepatocellular carcinoma (HCC), early detection and diagnosis of HCC have been increasingly pressing. Combined alpha-fetoprotein ( AFP) determination and ul- trasonography has become the main method for the detec- tion of small HCC; but the relationship between low eleva- tion of AFP and pathologic findings of small HCC has not been well defined. The aim of this study was to assess the value of ultrasound-guided fine needle biopsy of intrahe- patic nodules and low elevation of serum AFP in the early diagnosis of HCC. METHODS; Fifty-nine patients with serum AFP exceeding 20 ng/ml and intrahepatic nodules varying from 0.8 cm to 5.0 cm in diameter who had been detected by ultrasonogra- phy underwent ultrasound-guided percutaneous fine needle biopsy, and cytological staining and histological sectioning were performed at the same time. RESULTS: Among the 59 patients, 11 patients (18.6%) showed AFP level above 400 ng/ml, 5 (8. 5%) from 200 ng/ml to 400 ng/ml, 18 (30. 5%) from 50 ng/ml to 200 ng/ml and 25 (42. 4% ) from 20 ng/ml to 50 ng/ml. Fol- low-up demonstrated that 53 patients (89.8%) had a pro- gressive increase of AFP level. In 58 patients (98.3%) cancer cells were found by cytological staining and/or his- tological sectioning. CONCLUSIONS: In those patients with slightly increased or continuously positive AFP, hepatic carcinoma should be highly suspected when AFP increases gradually and intrahe- patic nodules are detected by ultrasonography in follow-up. Once intrahepatic carcinoma nodules are suspected, ultra- sound-guided fine needle biopsy should be performed as early as possible for early diagnosis and treatment.

Efficacy of endoscopic ultrasonography-guided fine needle aspiration for pancreatic neuroendocrine tumor grading

AIM: To evaluate the efficacy of endoscopic ultrasonography-guided fine needle aspiration(EUS-FNA) for grading pancreatic neuroendocrine tumors(PNETs).METHODS: A total of 22 patients were diagnosed with PNET by EUS-FNA between October 2001 and December 2013 at Fukushima Medical University Hospital.Among these cases,we targeted 10 PNET patients who were evaluated according to the World Health Organization(WHO) 2010 classification.Surgery was performed in eight patients,and chemotherapy was performed in two patients due to multiple liver metastases.Specimens obtained by EUS-FNA were first stained with hematoxylin and eosin and then stained with chromogranin,synaptophysin,CD56,and Ki-67.The specimens were graded by the Ki-67 index according to the WHO 2010 classification.Specimens obtained by surgery were graded by the Ki-67 indexand mitotic count(WHO 2010 classification).For the eight specimens obtained by EUS-FNA,the Ki-67 index results were compared with those obtained by surgery.In the two cases treated with chemotherapy,the effects and prognoses were evaluated.RESULTS: The sampling rate for histological diagnosis by EUS-FNA was 100%.No adverse effects were observed.The concordance rate between specimens obtained by EUS-FNA and surgery was 87.5%(7/8).Fo r t h e t w o c a s e s t re a t e d w i t h c h e m o t h e ra p y,case 1 received somatostatin analog therapy and transcatheter arterial infusion(TAI) targeting multiple liver metastases.Subsequent treatment consisted of everolimus.During chemotherapy,the primary tumor remained unconfirmed,although the multiple liver metastases diminished dramatically.Case 2 was classified as neuroendocrine carcinoma(NEC) according to the Ki-67 index of a specimen obtained by EUS-FNA; therefore,cisplatin and irinotecan therapy was started.However,severe adverse effects,including renal failure and diarrhea,were observed,and the therapy regimen was changed to cisplatin and etoposide.TAI targeting multiple liver metastases was performed.Although the liver metastases diminished,the primary tumor remained unconfirmed.These chemotherapy regimens had immediate effects for both unresectable neuroendocrine tumor(NET) and NEC cases.These two subjects are still alive.CONCLUSION: EUS-FNA was effective for PNET diagnosis and Ki-67 index grading for WHO 2010 classification,enabling informed decisions on unresectable PNET treatment by identifying NET or NEC.

Testicular fine needle aspiration as a diagnostic tool in nonobstructive azoospermia

Aim： To report the fine needle aspiration cytology （FNAC） of the testes used as a diagnostic tool in non-obstructive azoospermic patients. Methods： One hundred and twenty-five non-obstructive azoospermic male candidates to intracytoplasmic sperm injetion （ICSI） were analysed for follicle stimulating hormone （FSH）, luteinizing hormone （LH）, testosterone and inhibin B plasma levels. They were classified into three groups on the basis of FNAC： 1） Sertoli cell-only syndrome （SCOS） （70）; 2） severe hypospermatogenesis （42）; and 3） maturation arrest （13）, Then, all men underwent testicular sperm extraction （TESE） for sperm recovery for ICSI. Results： Mature spermatozoa were detected by FNAC in 24 of 42 men with severe hypospermatogenesis and nine of 13 men with maturation arrest; while they were retrieved by TESE in 29 of 70 men with SCOS, 35 of 42 men with severe hypospermatogenesis （including the 24 by FNAC） and 10 of 13 men with maturation arrest （including the nine by FNAC）. The sensitivity and specificity of FNAC were 44.6 % and 100 %, respectively. There was no difference on testicular volume and hormonal parameters in men with and without sperm retrieved. Conclusion： These findings suggest that FNAC may be a simple and valid diagnostic parameter in non-obstructive azoospermic men and it may represent a valid positive prognostic parameter for sperm recovery at TESE, （Asian J Androl 2005 Sep; 7： 289-294）

Pancreatic cystic lesions:How endoscopic ultrasound morphology and endoscopic ultrasound fine needle aspiration help unlock the diagnostic puzzle

Cystic lesions of the pancreas are being diagnosed with increasing frequency,covering a vast spectrum from benign to malignant and invasive lesions.Numerous investigations can be done to discriminate between benign and non-evolutive lesions from those that require surgery.At the moment,there is no single test that will allow a correct diagnosis in all cases.Endoscopic ultrasound(EUS) morphology,cyst fluid analysis and cytohistology with EUS-guided fine needle aspiration can aid in this difficult diagnosis.