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A New Method to Assess the Adequacy of Trucut Core Biopsy Specimens
*T1638 Assessment of Knowledge of the Application and Utility of Endoscopic Ultrasound Among Physicians and Surgeons Tony E. Yusuf, Gavin C. Harewood, Jonathan E. Clain, Michael J. Levy, Kenneth K. Wang, Mark D. Topazian, Elizabeth Rajan Introduction: Endoscopic ultrasound (EUS) is an accurate imaging modality which has demonstrated a diverse range of diagnostic and interventional applications. It is uncertain what is the level of awareness among nongastroenterologists of the applications of EUS. The aim of this study was to assess knowledge of applications and utility of EUS among physicians and surgeons in a large multi-specialty academic practice. Methods: A questionnaire, comprising 25 questions, was designed that addressed applications of EUS in 4 categories: esophagus (5 questions), gastroduodenal (6), hepaticopancreaticobiliary (9), and colorectal (5). The questionnaire was distributed by e-mail to physicians in gastroenterology (GI), internal medicine (IM), non-GI specialties (non-GI) and surgery in a large multi-specialty practice. Results: The survey was distributed to 659 physicians of whom 203 (31%) replied; responses were received from GI (61), IM (74), non-GI specialists (41) and surgeons (27). Overall, 142 respondents (70%) had previously referred a patient for EUS, most commonly among GI (98%) compared to IM (49%), non-GI (68%), surgeons (67%). As expected, mean score (maximum, 25) was highest among GI (21.1) compared to IM (17.3), non-GI (16.3) and surgeons (16.4), p<0.0001 (see table). Among nongastroenterologists, knowledge of EUS for hepaticopancreaticobiliary (mean, 60.3% correct responses) and colorectal applications (mean, 58.7% correct responses) was inferior to knowledge of esophageal (69.3%) and gastroduodenal (80.7%) applications, p<0.01 (see table). Conclusions: Internists, non-GI specialists and surgeons all rank similarly, demonstrating moderate knowledge of the applications and utility of EUS. Knowledge of hepaticopancreaticobiliary and colorectal applications of EUS are poorest among all 3 groups. Considering 60% of these physicians have previously referred patients for EUS, enhancing EUS knowledge levels in this group may improve the appropriateness of referrals.
*T1640 A New Method to Assess the Adequacy of Trucut Core Biopsy Specimens Brian C. Jacobson, Irina Dubinchik, Niall Swan Aim: We sought to develop a simple touch prep method for evaluating trucut core biopsy (TCB) specimens that can be used during EUS to determine specimen adequacy and preliminary diagnoses. Methods: We performed 40 ex-vivo TCBs of fresh surgical specimens under direct visual guidance with the 19 guage QuickCore needle (Wilson-Cook). A touch-prep was then made using one of four methods: 1) touching the biopsy lightly twice to a glass slide while keeping the specimen on the needle (‘‘touch’’), 2) pushing the biopsy 3cm along a slide while keeping the tissue on the needle (‘‘push’’), 3) dragging the specimen 3cm along the slide while keeping the tissue on the needle (‘‘drag’’), and 4) rolling the specimen 2cm along the slide after removing it from the needle with a toothpick (‘‘roll’’). Slides were stained with a Diff-Quik stain and biopsies were processed for histology. For each organ biopsied, the sequence of touch prep method was ‘‘touch’’, ‘‘roll’’, ‘‘push’’, and ‘‘drag’’. Ease of touch prep was rated on a Likert-type scale (1=easy, 5=cumbersome). Biopsy length and fragmentation were documented. Slides were blindly classified as malignant, suspicious, atypical, benign, or inadequate. Results: TCBs were taken of two normal stomachs, two ampullary adenocarcinomas, a normal pancreas, a thyroid adenoma, a uterine leiomyoma, a colon adenocarcinoma, a lung adenocarcinoma, and a lung metastasis of transitional cell carcinoma. Touch prep ease, adequacy, and accuracy are shown in the table. Cytologic interpretation could be made in 34/40 (85%) cases and was correct in 25/34 (74%) cases. Histologic interpretation could be made in 39/40 (98%) cases and was correct in 32/39 (82%) cases. Fragmentation (45% of biopsies) was not associated with a correct cytologic (p=0.7) or histologic (p=0.1) diagnosis. Biopsy length (median 10mm) was not associated with a correct cytologic (p=0.19) or histologic (p=0.96) diagnosis. Conclusions: Touch preps can be made with TCB samples and can predict specimen adequacy and diagnosis. The ‘‘touch’’ method was significantly easier than three other tested methods.
*T1639 A First Report of Tumor Seeding by EUS-FNA Sarto C. Paquin, Tju Siang Chua, Genevieve Tessier, Gilles Gariepy, Ginette Raymond, Raymond Bourdages, Anand Sahai Background: Tumor seeding along the needle biopsy tract is a proven complication of percutaneous biopsy of pancreatic masses by CT or transcutaneous ultrasound. This is a potential advantage often cited for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) since, to date there are no reported cases of tumor seeding secondary to EUS-FNA. We describe a case of apparent gastric wall tumor seeding secondary to EUS-FNA of a pancreatic tail mass. The Case: In 3/2001, a 65 year old man with recent onset of idiopathic recurrent acute pancreatitis was referred for EUS because CT showed a possible pancreatic tail mass. EUS showed a hypodense 22mm poorly-demarcated lesion of the pancreatic tail with malignant-appearing upstream dilation of the main pancreatic duct. EUS-FNA was performed through the gastric wall using a 22g needle. A total of 5 passes were required for a positive result of adenocarcinoma. The patient subsequently underwent distal pancreatectomy and splenectomy with curative intent. The resected specimen showed an 8mm focus of adenocarcinoma within chronic fibrosing pancreatitis, with no vascular or lymphatic involvement and clear margins. No adjuvant treatment was given. 16 months later (8/2002), the patient presented with vague abdominal pain and CT evidence of a 5 3 3 cm heterogeneous mass in the LUQ. EGD showed normal gastric mucosa with no ulcer or suspicious mass lesion. EUS revealed a 3 cm mass located primarily within the gastric wall with some retroperitoneal invasion in the same region were the previous FNA had been performed. EUS-FNA of the mass was positive for adenocarcinoma. There was no other evidence of residual or recurrent disease. The patient underwent chemotherapy and is currently doing well (15 months postrecurrence). Discussion: This case argues strongly in favor of tumor seeding of the stomach wall by EUS-FNA, due probably in part to the large number of passes performed. Conclusions: 1) EUS-FNA can cause tumor seeding along the intestinal biopsy tract. 2) If EUS-FNA results are unlikely to prevent surgery (e.g. very high pretest likelihood of operable cancer) and the surgical procedure will not include resection of the intestinal biopsy tract (e.g. distal pancreatectomy), EUSFNA should be avoided or the number of passes kept to a minimum. 3) If EUSFNA is performed, malignant cells are obtained, and the intestinal biopsy tract is not resected, adjuvant therapy may be indicated in an effort to sterilize the biopsy tract.
VOLUME 59, NO. 5, 2004
*T1641 Prospective Evaluation of On-Site FNA Cytology Analysis vs Final Cytology Analysis in EUS Cases Glen Arluk, Olga Ioffe, Anna Berry, Pat Bourquin, Bruce Greenwald, Peter Darwin OBJECTIVES: On-site cytopathologic interpretation of endoscopic ultrasoundguided fine needle aspiration (EUS-FNA) has been shown to improve the adequacy of tissue obtained. The preliminary diagnosis made within the endoscopy suite can guide therapeutic interventions such as celiac plexus block or biliary wall stent placement in the setting of pancreatic adenocarcinoma. No study to date has evaluated the reliability of a preliminary cytologic diagnosis. Our goal was to compare the on-site and final diagnoses of individual EUS-FNA samples. METHODS: Consecutive patients who underwent EUS- FNA were prospectively evaluated. All samples were prepared by a cytotechnologist using the Diff-Quick staining technique and a preliminary diagnosis, made by a cytopathologist, was recorded. Cytologic diagnoses were classified as unsatisfactory, negative, atypical, suspicious, or positive for malignancy. A final diagnosis was made after complete evaluation of all tissue obtained. Minor discrepancies were defined as a one step change in diagnosis (i.e. atypical to suspicious) while major discrepancies were defined as a two step change in diagnosis (i.e. atypical to positive). RESULTS: EUS-FNA of 29 lesions in 20 patients was performed without complications. This included 16 lymph nodes, 10 pancreatic lesions, 2 adrenal lesions, and 1 submucosal rectal lesion. Overall agreement of on-site diagnoses vs. final diagnoses was 55% (16/29). Agreement of lymph node diagnoses was 62.5% (10/16). 4 lymph nodes originally classified as unsatisfactory were changed to either negative or positive for malignancy after review of the cell block from the needle rinse. Agreement of pancreatic lesion diagnoses was 40% (4/ 10). Three patients overall had major discrepancies between the on-site and final diagnoses. CONCLUSION: In this pilot study, the on-site diagnosis often differed from the final diagnosis. While most were minor discrepancies, there were a few significant differences. This would suggest that the decision to perform irreversible endoscopic therapy should be based on the final diagnosis.
GASTROINTESTINAL ENDOSCOPY
P235
*T1640 A New Method to Assess the Adequacy of Trucut Core Biopsy Specimens Brian C. Jacobson, Irina Dubinchik, Niall Swan Aim: We sought to develop a simple touch prep method for evaluating trucut core biopsy (TCB) specimens that can be used during EUS to determine specimen adequacy and preliminary diagnoses. Methods: We performed 40 ex-vivo TCBs of fresh surgical specimens under direct visual guidance with the 19 guage QuickCore needle (Wilson-Cook). A touch-prep was then made using one of four methods: 1) touching the biopsy lightly twice to a glass slide while keeping the specimen on the needle (‘‘touch’’), 2) pushing the biopsy 3cm along a slide while keeping the tissue on the needle (‘‘push’’), 3) dragging the specimen 3cm along the slide while keeping the tissue on the needle (‘‘drag’’), and 4) rolling the specimen 2cm along the slide after removing it from the needle with a toothpick (‘‘roll’’). Slides were stained with a Diff-Quik stain and biopsies were processed for histology. For each organ biopsied, the sequence of touch prep method was ‘‘touch’’, ‘‘roll’’, ‘‘push’’, and ‘‘drag’’. Ease of touch prep was rated on a Likert-type scale (1=easy, 5=cumbersome). Biopsy length and fragmentation were documented. Slides were blindly classified as malignant, suspicious, atypical, benign, or inadequate. Results: TCBs were taken of two normal stomachs, two ampullary adenocarcinomas, a normal pancreas, a thyroid adenoma, a uterine leiomyoma, a colon adenocarcinoma, a lung adenocarcinoma, and a lung metastasis of transitional cell carcinoma. Touch prep ease, adequacy, and accuracy are shown in the table. Cytologic interpretation could be made in 34/40 (85%) cases and was correct in 25/34 (74%) cases. Histologic interpretation could be made in 39/40 (98%) cases and was correct in 32/39 (82%) cases. Fragmentation (45% of biopsies) was not associated with a correct cytologic (p=0.7) or histologic (p=0.1) diagnosis. Biopsy length (median 10mm) was not associated with a correct cytologic (p=0.19) or histologic (p=0.96) diagnosis. Conclusions: Touch preps can be made with TCB samples and can predict specimen adequacy and diagnosis. The ‘‘touch’’ method was significantly easier than three other tested methods.
*T1639 A First Report of Tumor Seeding by EUS-FNA Sarto C. Paquin, Tju Siang Chua, Genevieve Tessier, Gilles Gariepy, Ginette Raymond, Raymond Bourdages, Anand Sahai Background: Tumor seeding along the needle biopsy tract is a proven complication of percutaneous biopsy of pancreatic masses by CT or transcutaneous ultrasound. This is a potential advantage often cited for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) since, to date there are no reported cases of tumor seeding secondary to EUS-FNA. We describe a case of apparent gastric wall tumor seeding secondary to EUS-FNA of a pancreatic tail mass. The Case: In 3/2001, a 65 year old man with recent onset of idiopathic recurrent acute pancreatitis was referred for EUS because CT showed a possible pancreatic tail mass. EUS showed a hypodense 22mm poorly-demarcated lesion of the pancreatic tail with malignant-appearing upstream dilation of the main pancreatic duct. EUS-FNA was performed through the gastric wall using a 22g needle. A total of 5 passes were required for a positive result of adenocarcinoma. The patient subsequently underwent distal pancreatectomy and splenectomy with curative intent. The resected specimen showed an 8mm focus of adenocarcinoma within chronic fibrosing pancreatitis, with no vascular or lymphatic involvement and clear margins. No adjuvant treatment was given. 16 months later (8/2002), the patient presented with vague abdominal pain and CT evidence of a 5 3 3 cm heterogeneous mass in the LUQ. EGD showed normal gastric mucosa with no ulcer or suspicious mass lesion. EUS revealed a 3 cm mass located primarily within the gastric wall with some retroperitoneal invasion in the same region were the previous FNA had been performed. EUS-FNA of the mass was positive for adenocarcinoma. There was no other evidence of residual or recurrent disease. The patient underwent chemotherapy and is currently doing well (15 months postrecurrence). Discussion: This case argues strongly in favor of tumor seeding of the stomach wall by EUS-FNA, due probably in part to the large number of passes performed. Conclusions: 1) EUS-FNA can cause tumor seeding along the intestinal biopsy tract. 2) If EUS-FNA results are unlikely to prevent surgery (e.g. very high pretest likelihood of operable cancer) and the surgical procedure will not include resection of the intestinal biopsy tract (e.g. distal pancreatectomy), EUSFNA should be avoided or the number of passes kept to a minimum. 3) If EUSFNA is performed, malignant cells are obtained, and the intestinal biopsy tract is not resected, adjuvant therapy may be indicated in an effort to sterilize the biopsy tract.
VOLUME 59, NO. 5, 2004
*T1641 Prospective Evaluation of On-Site FNA Cytology Analysis vs Final Cytology Analysis in EUS Cases Glen Arluk, Olga Ioffe, Anna Berry, Pat Bourquin, Bruce Greenwald, Peter Darwin OBJECTIVES: On-site cytopathologic interpretation of endoscopic ultrasoundguided fine needle aspiration (EUS-FNA) has been shown to improve the adequacy of tissue obtained. The preliminary diagnosis made within the endoscopy suite can guide therapeutic interventions such as celiac plexus block or biliary wall stent placement in the setting of pancreatic adenocarcinoma. No study to date has evaluated the reliability of a preliminary cytologic diagnosis. Our goal was to compare the on-site and final diagnoses of individual EUS-FNA samples. METHODS: Consecutive patients who underwent EUS- FNA were prospectively evaluated. All samples were prepared by a cytotechnologist using the Diff-Quick staining technique and a preliminary diagnosis, made by a cytopathologist, was recorded. Cytologic diagnoses were classified as unsatisfactory, negative, atypical, suspicious, or positive for malignancy. A final diagnosis was made after complete evaluation of all tissue obtained. Minor discrepancies were defined as a one step change in diagnosis (i.e. atypical to suspicious) while major discrepancies were defined as a two step change in diagnosis (i.e. atypical to positive). RESULTS: EUS-FNA of 29 lesions in 20 patients was performed without complications. This included 16 lymph nodes, 10 pancreatic lesions, 2 adrenal lesions, and 1 submucosal rectal lesion. Overall agreement of on-site diagnoses vs. final diagnoses was 55% (16/29). Agreement of lymph node diagnoses was 62.5% (10/16). 4 lymph nodes originally classified as unsatisfactory were changed to either negative or positive for malignancy after review of the cell block from the needle rinse. Agreement of pancreatic lesion diagnoses was 40% (4/ 10). Three patients overall had major discrepancies between the on-site and final diagnoses. CONCLUSION: In this pilot study, the on-site diagnosis often differed from the final diagnosis. While most were minor discrepancies, there were a few significant differences. This would suggest that the decision to perform irreversible endoscopic therapy should be based on the final diagnosis.
GASTROINTESTINAL ENDOSCOPY
P235