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.

endoscopic ultrasonography-guided biliary drainage:Who,when,which,and how?

Both endoscopic ultrasonography(EUS)-guided choledochoduodenostomy( EUS- CDS) and EUS-guided hepaticogastrostomy(EUS-HGS) are relatively well established as alternatives to percutaneous transhepatic biliary drainage(PTBD). Both EUSCDS and EUS-HGS have high technical and clinical success rates(more than 90%) in high-volume centers. Complications for both procedures remain high at 10%-30%. Procedures performed by endoscopists who have done fewer than 20 cases sometimes result in severe or fatal complications. When learning EUSguided biliary drainage(EUS-BD), we recommend a mentor's supervision during at least the first 20 cases. For inoperable malignant lower biliary obstruction, a skillful endoscopist should perform EUS-BD before EUS-guided rendezvous technique(EUS-RV) and PTBD. We should be select EUS-BD for patients having altered anatomy from malignant tumors before balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography, EUS-RV, and PTBD. If both EUS-CDS and EUS-HGS are available, we should select EUS-CDS, according to published data. EUSBD will potentially become a first-line biliary drainage procedure in the near future.