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Does EUS-Guided FNA Impact the Management of Cystic Pancreatic Neoplasms?
Abstracts
W1281 Can Endosonographers Evaluate On-Site Cytologic Adequacy? A Comparison with Cytotechnologists Alan Savoy, Massimo Raimondo, Timothy Woodward, Kyung Noh, Surakit Pungpapong, Julia Crook, Arthur D. Jones, Michael Wallace Background: On-site determination of cytological adequacy increases the accuracy of EUS-FNA. On-site cytotechnologists are not available to all endosonographers. We hypothesize that experienced endosonographers can accurately assess if an onsite FNA specimen is adequate. Methods: A prospective, blinded study comparing 3 experienced endosonographers to a certified cytotechnologist was performed. Each blinded evaluator reviewed 117 consecutive EUS-FNA Diff-Quick slides. Samples were classified as adequate or inadequate, and suspicious/malignant or benign. Accuracy of each endosonographer was compared to the cytotechnologist using a board certified cytopathologist as the gold standard. An endosonographer was concluded to be non-inferior to the cytotechnician if the 95% confidence interval for differences in accuracies in determining specimen inadequacy had upper limit of less than 10%. Results: There were 59 lymph node, 49 pancreas, and 9 liver specimens (117 total). Sensitivity, specificity and accuracy for inadequate specimens are in Table 1. One endosonographer had lower accuracy than the cytotechnician (p Z 0.004). For suspicious/malignant vs. benign, all three endosonographers were inferior (p%0.001) to the cytotechnologist. In subgroup analysis, all endosonographers were similar to the cytototechnologist for interpretation of lymph nodes, but worse for pancreatic cytology, however the study was not powered to detect differences within subgroups. Conclusions: Trained endosonographers are not necessarily equivalent to cytotechnologists at determining adequacy of FNA samples. All screeners had poor sensitivity for inadequate specimens, though a higher specificity. This may result in an EUS procedure being terminated prematurely. On-site interpretation of lymph node adequacy by endosonographers trained at cytological interpretation, is a reasonable alternative to on-site cytotechnology, but is not reasonable for pancreas FNA.
a third patient had a nodule seen on EGD with a biopsy revealing adenocarcinoma. EUS with EMR of the nodule confirmed T1 recurrence. In the fourth patient, CT scan revealed perigastric lymphadenopathy and EUS-FNA confirmed adenocarcinoma in the lymph node. There were 2 deaths. One patient with progression of disease died of metastatic adenocarcinoma. The second patient died of unrelated causes. Overall rate of recurrent/persistent ACA after PDT in this series was 4/67 Z 6%. EUS surveillance in 67 of these patients did not detect recurrent/persistent carcinoma that was otherwise detected by surveillance endoscopy using Seattle biopsy protocol and contrast enhanced computed tomography. Conclusions: While considered critical for the initial evaluation of patients being considered for endoscopic ablation therapy, EUS appears to have little role in the subsequent surveillance of these patients, unless discreet abnormalities are found on EGD or cross-sectional imaging.
Table 1. Estimated reviewer accuracy regarding inadequacy of specimen compared to the cytotechnician
W1283 Does EUS-Guided FNA Impact the Management of Cystic Pancreatic Neoplasms? Alan D. Savoy, Massimo Raimondo, Timothy Woodward, Kyung Noh, Surakit Punpapong, Michael B. Wallace
W1282 Is EUS Superior to Standard Surveillance After Endoscopic Ablation for Barrett’s Dysplasia? Alan Savoy, Herbert Wolfsen, Massimo Raimondo, Kyung Noh, Surakit Pungpapong, Michael B. Wallace Background: Barrett’s esophagus (BE) patients with high-grade dysplasia (HGD) or early carcinoma treated with surgery or photodynamic therapy (PDT) are at risk for disease recurrence in the esophagus or lymph nodes. Although used to select patients for PDT, the role of EUS for surveillance after PDT is unknown. We hypothesize that EUS is better than EGD and/or CT scan for surveillance of BE neoplasia after PDT. Methods: Consecutive patients with BE with HGD or carcinoma in situ treated with PDT using 2mg/kg porfimer sodium at light doses of 150-225 J/cm fiber length without a fiber centering device were followed with EUS, CT scan and EGD with 4 random jumbo biopsies every 1 cm at 3, 6, 9, 12, and then every 6 month intervals. Patients were excluded if they had less than 6 months of follow up and/or !2 EUS procedures. The outcome was detection of recurrent or residual carcinoma by any method. Results: Thirty of 97 patients did not meet inclusion criteria leaving 67 patients in the analysis (56 men and 11 women) with a median follow up of 16 months. Recurrent or residual adenocarcinoma was detected in 4 patients during follow up (17, 24, 30, and 36 months). Pre-PDT diagnosis in all four was HGD. EGD with random biopsies detected 2 patients,
AB300 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
Background: The decision to surgically resect a pancreatic cystic lesion is based on clinical history, imaging, and FNA. No discriminators reliably predict underlying malignancy. The aim of our study was to evaluate the independent impact of EUS imaging and FNA on the decision to resect a pancreatic cystic lesion. Methods: All patients with EUS-guided FNA of pancreatic cysts from 1/1996 through 11/2004 at Mayo Clinic Jacksonville were retrospectively reviewed. To determine the impact of EUS and FNA, the clinical history and initial cross-sectional imaging were given to 2 experienced endosonographers, blinded to future studies, then sequentially presented EUS then FNA data. A decision to resect was recorded after reviewing each test. Pre-determined surgical criteria included: macrocystic cyst O1 cm (not clearly a microcystic adenoma), mural nodule or solid component, IPMN O1 cm, FNA dysplasia, cyst CEA level O198 ng/ml, and pancreatic type pain. Results: Sixtyfour patients (37 men) with a mean age of 75 years (range 30 – 87) were studied. Seventeen (27%) patients went to surgery revealing 14 (82%) pre-malignant or malignant lesions (10 mucinous tumors and 4 carcinomas). A decision to resect could be made based on clinical history and cross-sectional imaging alone in 8%. EUS imaging supported surgery in an additional 27%. FNA independently supported resection in an additional 17%. EUS and FNA supported surgery in another 11 (17%) patients were surgery was withheld due to age and co-morbidity. There was 100% intra-observer agreement. Patients in whom surgery was recommended but not performed have been followed for a median of 6 months. No CT evidence of disease progression was seen. One patient that underwent surgery died of postoperative complications. Two other deaths in the non-surgical group were unrelated to the cyst. Conclusions: EUS and/or FNA impacted the decision process in 44% of patients. In almost one third of patients however, a decision to operate can be made without FNA, particularly when a resectable complex cyst or associated mass/nodule is seen. If the imaging results (CT, EUS) do not support resection, FNA and the presence of mucin or abnormal cytology is a strong predictor of pre-malignant or malignant cysts.
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W1281 Can Endosonographers Evaluate On-Site Cytologic Adequacy? A Comparison with Cytotechnologists Alan Savoy, Massimo Raimondo, Timothy Woodward, Kyung Noh, Surakit Pungpapong, Julia Crook, Arthur D. Jones, Michael Wallace Background: On-site determination of cytological adequacy increases the accuracy of EUS-FNA. On-site cytotechnologists are not available to all endosonographers. We hypothesize that experienced endosonographers can accurately assess if an onsite FNA specimen is adequate. Methods: A prospective, blinded study comparing 3 experienced endosonographers to a certified cytotechnologist was performed. Each blinded evaluator reviewed 117 consecutive EUS-FNA Diff-Quick slides. Samples were classified as adequate or inadequate, and suspicious/malignant or benign. Accuracy of each endosonographer was compared to the cytotechnologist using a board certified cytopathologist as the gold standard. An endosonographer was concluded to be non-inferior to the cytotechnician if the 95% confidence interval for differences in accuracies in determining specimen inadequacy had upper limit of less than 10%. Results: There were 59 lymph node, 49 pancreas, and 9 liver specimens (117 total). Sensitivity, specificity and accuracy for inadequate specimens are in Table 1. One endosonographer had lower accuracy than the cytotechnician (p Z 0.004). For suspicious/malignant vs. benign, all three endosonographers were inferior (p%0.001) to the cytotechnologist. In subgroup analysis, all endosonographers were similar to the cytototechnologist for interpretation of lymph nodes, but worse for pancreatic cytology, however the study was not powered to detect differences within subgroups. Conclusions: Trained endosonographers are not necessarily equivalent to cytotechnologists at determining adequacy of FNA samples. All screeners had poor sensitivity for inadequate specimens, though a higher specificity. This may result in an EUS procedure being terminated prematurely. On-site interpretation of lymph node adequacy by endosonographers trained at cytological interpretation, is a reasonable alternative to on-site cytotechnology, but is not reasonable for pancreas FNA.
a third patient had a nodule seen on EGD with a biopsy revealing adenocarcinoma. EUS with EMR of the nodule confirmed T1 recurrence. In the fourth patient, CT scan revealed perigastric lymphadenopathy and EUS-FNA confirmed adenocarcinoma in the lymph node. There were 2 deaths. One patient with progression of disease died of metastatic adenocarcinoma. The second patient died of unrelated causes. Overall rate of recurrent/persistent ACA after PDT in this series was 4/67 Z 6%. EUS surveillance in 67 of these patients did not detect recurrent/persistent carcinoma that was otherwise detected by surveillance endoscopy using Seattle biopsy protocol and contrast enhanced computed tomography. Conclusions: While considered critical for the initial evaluation of patients being considered for endoscopic ablation therapy, EUS appears to have little role in the subsequent surveillance of these patients, unless discreet abnormalities are found on EGD or cross-sectional imaging.
Table 1. Estimated reviewer accuracy regarding inadequacy of specimen compared to the cytotechnician
W1283 Does EUS-Guided FNA Impact the Management of Cystic Pancreatic Neoplasms? Alan D. Savoy, Massimo Raimondo, Timothy Woodward, Kyung Noh, Surakit Punpapong, Michael B. Wallace
W1282 Is EUS Superior to Standard Surveillance After Endoscopic Ablation for Barrett’s Dysplasia? Alan Savoy, Herbert Wolfsen, Massimo Raimondo, Kyung Noh, Surakit Pungpapong, Michael B. Wallace Background: Barrett’s esophagus (BE) patients with high-grade dysplasia (HGD) or early carcinoma treated with surgery or photodynamic therapy (PDT) are at risk for disease recurrence in the esophagus or lymph nodes. Although used to select patients for PDT, the role of EUS for surveillance after PDT is unknown. We hypothesize that EUS is better than EGD and/or CT scan for surveillance of BE neoplasia after PDT. Methods: Consecutive patients with BE with HGD or carcinoma in situ treated with PDT using 2mg/kg porfimer sodium at light doses of 150-225 J/cm fiber length without a fiber centering device were followed with EUS, CT scan and EGD with 4 random jumbo biopsies every 1 cm at 3, 6, 9, 12, and then every 6 month intervals. Patients were excluded if they had less than 6 months of follow up and/or !2 EUS procedures. The outcome was detection of recurrent or residual carcinoma by any method. Results: Thirty of 97 patients did not meet inclusion criteria leaving 67 patients in the analysis (56 men and 11 women) with a median follow up of 16 months. Recurrent or residual adenocarcinoma was detected in 4 patients during follow up (17, 24, 30, and 36 months). Pre-PDT diagnosis in all four was HGD. EGD with random biopsies detected 2 patients,
AB300 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
Background: The decision to surgically resect a pancreatic cystic lesion is based on clinical history, imaging, and FNA. No discriminators reliably predict underlying malignancy. The aim of our study was to evaluate the independent impact of EUS imaging and FNA on the decision to resect a pancreatic cystic lesion. Methods: All patients with EUS-guided FNA of pancreatic cysts from 1/1996 through 11/2004 at Mayo Clinic Jacksonville were retrospectively reviewed. To determine the impact of EUS and FNA, the clinical history and initial cross-sectional imaging were given to 2 experienced endosonographers, blinded to future studies, then sequentially presented EUS then FNA data. A decision to resect was recorded after reviewing each test. Pre-determined surgical criteria included: macrocystic cyst O1 cm (not clearly a microcystic adenoma), mural nodule or solid component, IPMN O1 cm, FNA dysplasia, cyst CEA level O198 ng/ml, and pancreatic type pain. Results: Sixtyfour patients (37 men) with a mean age of 75 years (range 30 – 87) were studied. Seventeen (27%) patients went to surgery revealing 14 (82%) pre-malignant or malignant lesions (10 mucinous tumors and 4 carcinomas). A decision to resect could be made based on clinical history and cross-sectional imaging alone in 8%. EUS imaging supported surgery in an additional 27%. FNA independently supported resection in an additional 17%. EUS and FNA supported surgery in another 11 (17%) patients were surgery was withheld due to age and co-morbidity. There was 100% intra-observer agreement. Patients in whom surgery was recommended but not performed have been followed for a median of 6 months. No CT evidence of disease progression was seen. One patient that underwent surgery died of postoperative complications. Two other deaths in the non-surgical group were unrelated to the cyst. Conclusions: EUS and/or FNA impacted the decision process in 44% of patients. In almost one third of patients however, a decision to operate can be made without FNA, particularly when a resectable complex cyst or associated mass/nodule is seen. If the imaging results (CT, EUS) do not support resection, FNA and the presence of mucin or abnormal cytology is a strong predictor of pre-malignant or malignant cysts.
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