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113 Predictors of Interobserver Variability (Iov) Among Cytopathologists (Cyps) Evaluating Pancreatic Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) Cytology Specimens: A Multicenter Validation Study
Abstracts
age 64.9 yrs] of which 51% presented with weight loss and 29% jaundice. On EUS, the median lesion size was 27 mm, the majority of lesions were located in the head/ neck (59%) and chronic pancreatitis changes in 9% of cases. Final cytologic diagnosis was malignancy in 60% of cases, atypical 15% and benign 24%. IOV for overall final cytologic diagnosis was moderate [k Z0.57 (95% CI: 0.43-0.71)] with no improvement when combining suspicious + malignant cytologic diagnoses [kZ0.51 (95%CI: 0.34-0.67)]. Jaundice (pZ0.025), weight loss (pZ0.002), age (pZ0.015), and final clinical diagnosis (pZ0.001) were associated with agreement among CyPs on bivariate analysis (Table). The only predictor for uniform agreement among CyPs on multivariable analysis was jaundice [OR 5.3 (CI 1.1-26.89)]. Similar results were noted combining suspicious and malignant diagnoses. Conclusion: Results of this multicenter validation study revealed considerable IOV among CyPs for overall cytologic diagnosis of pancreatic EUS-FNA specimens and the limited benefit of clinical and EUS parameters on agreement among CyPs. These findings underscore the importance of consensus diagnosis in clinical practice (potential quality indicator for EUS/cytopathology) and the need to identify techniques for improving IOV among CyPs. Supported by the DOM Early Scholars Program
Table: Demographic, endoscopic and clinical paramters associated with IOV for EUS-FNA samples with unanimous and no unanimous agreement between CyPs
Demographics Age (median, range), yrs Gender (n, %) EUS Parameters Lesion Size (median, range) Location (n, %)
Table 1- Patient and cyst characteristics
113 Predictors of Interobserver Variability (Iov) Among Cytopathologists (Cyps) Evaluating Pancreatic Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) Cytology Specimens: A Multicenter Validation Study Rawad Mounzer*7, Carrie B. Marshall1, Matt Hall1, Violette C. Simon1, Barbara A. Centeno5, Katie Dennis3, Jasreman Dhillon5, Fang Fan3, Laila Khazai5, Jason B. Klapman5, Sri Komanduri2, Xiaoqi Lin2, David Lu4, Sanjana Mehrotra1, V. Raman Muthusamy4, Ritu Nayar2, Ajit Paintal2, Jianyu Rao4, Sharon Sams1, Janak N. Shah6, Timothy M. Tynan1, Rabindra R. Watson4, Amit Rastogi3, Sachin B. Wani1 1 University of Colorado, Aurora, CO; 2Feinberg School of Medicine: Northwestern University, Chicago, IL; 3University of Kansas Schoolf of Medicine and Kansas City VA Medical Center, Kansas City, KS; 4 University of California Los Angeles, Los Angeles, CA; 5H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; 6Ochsner Medical Center, New Orleans, LA; 7Digestive Institute, Banner University Medical Center, Phoenix, AZ Background: Although EUS-FNA has become the standard modality for diagnosing pancreatic lesions, data on IOV among CyPs assessing EUS-FNA specimens remains scarce. Similarly, limited data exists regarding predictors of agreement among CyPs for the final cytologic diagnosis. Aim: The aim of this multicenter study was to assess IOV and define predictors of agreement among CyPs evaluating pancreatic EUS-FNA cytology specimens at tertiary care centers utilizing a standardized scoring system. Methods: EUS-FNA specimens of pancreatic solid lesions from patients at a tertiary care center were included. Patient demographics, clinical history, EUS findings, final cytologic and clinical diagnoses were collected. EUS-FNA slides were de-identified and evaluated by 11 experienced CyPs at 5 tertiary care centers using a scoring system that was standardized to assess specimen quantity and quality. Final cytologic diagnosis was categorized as: insufficient, benign, atypical, suspicious or malignant and final clinical diagnosis as benign or malignant. IOV was calculated using multi-rater weighted kappa (k) statistics with 95% CI. Bivariate analyses were performed to compare cases with and without uniform agreement among CyPs followed by logistic regression with backward elimination to model the likelihood of uniform agreement. Assuming an overall k of 0.8, prevalence of malignancy of 0.6, and lower limit of 95% CI 0.6 among 11 CyPs and 90% power, a sample size of at least 46 cases was required. Results: 46 patients were included [50% males; mean
AB52 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Echogenicity (n, %) Chronic pancreatitis (n, %) Needle Passes (median, range) Clinical Parameters Weight Loss Jaundice History of acute pancreatitis History of chronic pancreatitis Final Diagnosis** Benign Malignant
Male
Head/ Uncinate Neck Body Tail Hypoechoic
No Unanimous Agreement (n[29, 63%)
Unanimous Agreement (n[17, 37%)
62 (55-66) 14 (48)
73 (63-79) 9 (53)
0.015 0.760
24 (12-34) 13 (45)
27 (21-30) 9 (53)
0.508 0.756
4 (14) 7 (24) 5 (17) 23 (79) 4 (14) 3 (2-4)
1 (6) 3 (18) 4 (24) 17 (100) 0 (0) 2 (2-3)
0.400 0.120 0.191
8 5 4 4
(32) (18) (14) (14)
13 (81) 8 (50) 3 (18) 0 (0)
0.002 0.025 0.725 0.120
13 (45) 16 (55)
0 (0) 17 (100)
0.001
p-value
**Final diagnosis was based on final cytologic diagnosis, surgical pathology or clinical follow up of at least 1 year.
114 Role of EUS in Detecting Pancreatic Cancer Missed on Cross-Sectional Imaging in Patients Presenting With Pancreatitis: A Retrospective Analysis Nicholas Bartell*, Mary S. Vetter, Truptesh Kothari, Vivek Kaul, Krystle Bittner, Shivangi Kothari Department of Medicine, Division of Gastroenterology/Hepatology, Center for Advanced Therapeutic Endoscopy, University of Rochester, Rochester, NY Background: Pancreatic cancer has a very high mortality rate and is currently the fourth leading cause of cancer related deaths in the United States. Earlier stage diagnosis may help improve survival. However, pancreatic lesions may be difficult to detect in the setting of acute and/or chronic pancreatitis. Endoscopic Ultrasound (EUS) is an important tool in the diagnostic evaluation of pancreatitis both in the acute and chronic setting. In addition, EUS is an invaluable tool in the detection of occult pancreatic malignancy that can be missed on cross sectional imaging (CT/ MRI) as a potential etiology of idiopathic acute or chronic pancreatitis. However, studies evaluating the role of EUS in this setting are limited. . Objective: To evaluate the role of EUS as a diagnostic tool in the detection of occult pancreatic malignancy in patients presenting with acute or chronic pancreatitis with cross-sectional imaging negative for any mass lesion. Design: This IRB approved study was conducted at our academic tertiary care center. Patients that presented with pancreatitis, without imaging (CT and/or MRI) evidence of a discrete pancreatic mass, and who subsequently underwent an EUS with finding of pancreatic cancer were included in the study. Results: Between 2005 and 2016, there were 9958 patients with idiopathic acute or chronic pancreatitis identified at our center per billing data. Of this group, 951 patients underwent EUS at our institution for further evaluation. Twenty-five patients were diagnosed to have pancreatic cancer (22 adenocarcinomas and 3 neuroendocrine tumors) on EUS and all these patients had negative cross sectional imaging that did not reveal a pancreatic mass. Thus, 2.6% of patients undergoing EUS for evaluation of pancreatitis had underlying pancreatic cancer with negative CT
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age 64.9 yrs] of which 51% presented with weight loss and 29% jaundice. On EUS, the median lesion size was 27 mm, the majority of lesions were located in the head/ neck (59%) and chronic pancreatitis changes in 9% of cases. Final cytologic diagnosis was malignancy in 60% of cases, atypical 15% and benign 24%. IOV for overall final cytologic diagnosis was moderate [k Z0.57 (95% CI: 0.43-0.71)] with no improvement when combining suspicious + malignant cytologic diagnoses [kZ0.51 (95%CI: 0.34-0.67)]. Jaundice (pZ0.025), weight loss (pZ0.002), age (pZ0.015), and final clinical diagnosis (pZ0.001) were associated with agreement among CyPs on bivariate analysis (Table). The only predictor for uniform agreement among CyPs on multivariable analysis was jaundice [OR 5.3 (CI 1.1-26.89)]. Similar results were noted combining suspicious and malignant diagnoses. Conclusion: Results of this multicenter validation study revealed considerable IOV among CyPs for overall cytologic diagnosis of pancreatic EUS-FNA specimens and the limited benefit of clinical and EUS parameters on agreement among CyPs. These findings underscore the importance of consensus diagnosis in clinical practice (potential quality indicator for EUS/cytopathology) and the need to identify techniques for improving IOV among CyPs. Supported by the DOM Early Scholars Program
Table: Demographic, endoscopic and clinical paramters associated with IOV for EUS-FNA samples with unanimous and no unanimous agreement between CyPs
Demographics Age (median, range), yrs Gender (n, %) EUS Parameters Lesion Size (median, range) Location (n, %)
Table 1- Patient and cyst characteristics
113 Predictors of Interobserver Variability (Iov) Among Cytopathologists (Cyps) Evaluating Pancreatic Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) Cytology Specimens: A Multicenter Validation Study Rawad Mounzer*7, Carrie B. Marshall1, Matt Hall1, Violette C. Simon1, Barbara A. Centeno5, Katie Dennis3, Jasreman Dhillon5, Fang Fan3, Laila Khazai5, Jason B. Klapman5, Sri Komanduri2, Xiaoqi Lin2, David Lu4, Sanjana Mehrotra1, V. Raman Muthusamy4, Ritu Nayar2, Ajit Paintal2, Jianyu Rao4, Sharon Sams1, Janak N. Shah6, Timothy M. Tynan1, Rabindra R. Watson4, Amit Rastogi3, Sachin B. Wani1 1 University of Colorado, Aurora, CO; 2Feinberg School of Medicine: Northwestern University, Chicago, IL; 3University of Kansas Schoolf of Medicine and Kansas City VA Medical Center, Kansas City, KS; 4 University of California Los Angeles, Los Angeles, CA; 5H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; 6Ochsner Medical Center, New Orleans, LA; 7Digestive Institute, Banner University Medical Center, Phoenix, AZ Background: Although EUS-FNA has become the standard modality for diagnosing pancreatic lesions, data on IOV among CyPs assessing EUS-FNA specimens remains scarce. Similarly, limited data exists regarding predictors of agreement among CyPs for the final cytologic diagnosis. Aim: The aim of this multicenter study was to assess IOV and define predictors of agreement among CyPs evaluating pancreatic EUS-FNA cytology specimens at tertiary care centers utilizing a standardized scoring system. Methods: EUS-FNA specimens of pancreatic solid lesions from patients at a tertiary care center were included. Patient demographics, clinical history, EUS findings, final cytologic and clinical diagnoses were collected. EUS-FNA slides were de-identified and evaluated by 11 experienced CyPs at 5 tertiary care centers using a scoring system that was standardized to assess specimen quantity and quality. Final cytologic diagnosis was categorized as: insufficient, benign, atypical, suspicious or malignant and final clinical diagnosis as benign or malignant. IOV was calculated using multi-rater weighted kappa (k) statistics with 95% CI. Bivariate analyses were performed to compare cases with and without uniform agreement among CyPs followed by logistic regression with backward elimination to model the likelihood of uniform agreement. Assuming an overall k of 0.8, prevalence of malignancy of 0.6, and lower limit of 95% CI 0.6 among 11 CyPs and 90% power, a sample size of at least 46 cases was required. Results: 46 patients were included [50% males; mean
AB52 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Echogenicity (n, %) Chronic pancreatitis (n, %) Needle Passes (median, range) Clinical Parameters Weight Loss Jaundice History of acute pancreatitis History of chronic pancreatitis Final Diagnosis** Benign Malignant
Male
Head/ Uncinate Neck Body Tail Hypoechoic
No Unanimous Agreement (n[29, 63%)
Unanimous Agreement (n[17, 37%)
62 (55-66) 14 (48)
73 (63-79) 9 (53)
0.015 0.760
24 (12-34) 13 (45)
27 (21-30) 9 (53)
0.508 0.756
4 (14) 7 (24) 5 (17) 23 (79) 4 (14) 3 (2-4)
1 (6) 3 (18) 4 (24) 17 (100) 0 (0) 2 (2-3)
0.400 0.120 0.191
8 5 4 4
(32) (18) (14) (14)
13 (81) 8 (50) 3 (18) 0 (0)
0.002 0.025 0.725 0.120
13 (45) 16 (55)
0 (0) 17 (100)
0.001
p-value
**Final diagnosis was based on final cytologic diagnosis, surgical pathology or clinical follow up of at least 1 year.
114 Role of EUS in Detecting Pancreatic Cancer Missed on Cross-Sectional Imaging in Patients Presenting With Pancreatitis: A Retrospective Analysis Nicholas Bartell*, Mary S. Vetter, Truptesh Kothari, Vivek Kaul, Krystle Bittner, Shivangi Kothari Department of Medicine, Division of Gastroenterology/Hepatology, Center for Advanced Therapeutic Endoscopy, University of Rochester, Rochester, NY Background: Pancreatic cancer has a very high mortality rate and is currently the fourth leading cause of cancer related deaths in the United States. Earlier stage diagnosis may help improve survival. However, pancreatic lesions may be difficult to detect in the setting of acute and/or chronic pancreatitis. Endoscopic Ultrasound (EUS) is an important tool in the diagnostic evaluation of pancreatitis both in the acute and chronic setting. In addition, EUS is an invaluable tool in the detection of occult pancreatic malignancy that can be missed on cross sectional imaging (CT/ MRI) as a potential etiology of idiopathic acute or chronic pancreatitis. However, studies evaluating the role of EUS in this setting are limited. . Objective: To evaluate the role of EUS as a diagnostic tool in the detection of occult pancreatic malignancy in patients presenting with acute or chronic pancreatitis with cross-sectional imaging negative for any mass lesion. Design: This IRB approved study was conducted at our academic tertiary care center. Patients that presented with pancreatitis, without imaging (CT and/or MRI) evidence of a discrete pancreatic mass, and who subsequently underwent an EUS with finding of pancreatic cancer were included in the study. Results: Between 2005 and 2016, there were 9958 patients with idiopathic acute or chronic pancreatitis identified at our center per billing data. Of this group, 951 patients underwent EUS at our institution for further evaluation. Twenty-five patients were diagnosed to have pancreatic cancer (22 adenocarcinomas and 3 neuroendocrine tumors) on EUS and all these patients had negative cross sectional imaging that did not reveal a pancreatic mass. Thus, 2.6% of patients undergoing EUS for evaluation of pancreatitis had underlying pancreatic cancer with negative CT
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