EUS-FNA Diagnostic Yield and Safety in Suspected Tubercular Intraabdominal Lymphadenopathy

Abstracts

4 (and one main duct type and 3 mixed type), retention cyst in one and serous cystadenoma in one. Among the surgical cases, DNA analysis correctly predicted: 1) a mucinous cyst in 2 of 4 IPMN cases and; 2) a non-mucinous cyst in the serous cystadenoma and retention cyst. Among the remaining 31 non-surgical patients with both CEA and DNA analysis available, a discrepancy was noted in 12 patients (see table). Endosonographers indicated that their decision to manage patients conservatively vs. refer to surgery was influenced by the previously established risk criteria rather than DNA analysis results. Conclusion: Discordance between DNA results and other previously established risk criteria for CPLs exists and requires further studies to evaluate. CEA and DNA analysis results suggestive of mucinous cyst in 31 non-surgical patients. DNA analysis positive DNA analysis negative

CEA D

CEA -

6 5

7 13

W1298 Endoscopic Ultrasound Guided Fine Needle Aspiration (EUS-FNA) of Pancreatic Masses: Patient Preferences At a Tertiary Referral Center Uzma D. Siddiqui, Manmeet S. Padda, Federico Rossi, Lawrence S. Rosenthal, Visvanathan Murali-Dharan, Harry R. Aslanian Background: EUS-FNA accurately diagnoses pancreatic malignancies and may provide life-altering information. Patients often have never met their endosonographer prior to their procedure. It is unclear what impact, if any, a prior relationship with a referring physician plays in the delivery of a cancer diagnosis. Our aims were to study patients referred for EUS-FNA of pancreatic masses and to determine their pre-procedure suspicion of having cancer, whether they would like to receive cytology results from their referring physician (whom they have a relationship with) or the endosonographer (whom they often meet for the first time at the procedure), and would they be willing to tolerate a delay to hear results from their referring doctor. Methods: Patients with suspected pancreatic neoplasms who were referred for EUS-FNA to a tertiary referral center were prospectively enrolled between February 2007 to June 2008. Each patient completed a survey prior to their EUS-FNA assessing whether they had met the endosonographer prior to their EUS, their suspicion of having cancer, and their preferred method of receiving cytology results with respect to who was giving the results and how fast the results would be available. Results: 131 patients were enrolled and underwent EUS-FNA of a pancreatic mass which provided a cytologic diagnosis of malignancy in 120 patients (92%). 90 patients (69%) had abdominal imaging that showed a pancreatic mass prior to undergoing EUS-FNA. 120 patients (92%) had not met the endosonographer prior to their EUS-FNA. 37 patients (28%) thought they had pancreatic cancer prior to their EUS-FNA, while 70 (54%) were unsure. 89 patients (68%) stated they wanted to hear results from the endosonographer vs their referring physician. 100 patients (76%) stated they would like to hear the results as soon as possible from the endosonographer vs waiting to hear from their referring physician. The endosonographer communicated cytology results to patients via telephone in nearly all cases. Conclusions: The majority of patients (92%) referred for EUS-FNA of suspected pancreatic malignancies had not met the endosonographer prior to their procedure. Although a mass was identified on preEUS imaging in the majority of patients, only 28% of patients thought they had cancer prior to EUS-FNA. Despite not having a relationship prior to EUS-FNA, most patients wanted to hear cytology results from the endosonographer as soon as possible. Our data emphasizes the endosonographer’s central role in the delivery of pancreatic cancer diagnoses and in patient education regarding their condition.

W1299 EUS-FNA Diagnostic Yield and Safety in Suspected Tubercular Intraabdominal Lymphadenopathy Rajesh Puri, Randhir Sud, Mandhir Kumar, Peter Vilmann, Mohamad A. Eloubeidi, Sandeep Bhagat Background: Tuberculosis is endemic in Asian countries and there is resurgence of extra pulmonary tuberculosis (EPTB) in developed countries due to AIDS. EPTB poses a diagnostic challenge due to its non-specific clinical presentation and low yield of available routine investigations. Aim: To assess the diagnostic yield and safety of EUS FNA in patients with suspected tubercular intra abdominal lymphadenopathy (IALN). Material and Methods: Patients with IALN with failed or considered inaccessible by USG or CT guided FNA were prospectively evaluated from Sept 2006 to Feb 2008. EUS FNA was performed under conscious sedation using 22-gauge needle. The aspirates were evaluated for acid fast bacilli (AFB) and cytopathological examination by cytopathologists. Patients were observed for 4 hours post procedure and for four days for any complication and re-evaluated with

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repeat EUS at 3 and 6 months for resolution or change in nodal size. Results: Of the 75 patients enrolled there were 44 males and 31 females. The mean age was 26 yrs (13-54 yrs). The procedure was successful in 70 patients. In 5 nodes were retropancreatic and inaccessible. In 70 patients EUS revealed only IALN in 58 (82.85%) and both IALN and mediastinal lymphadenopathy in 12 (17%). IALN was peripancreatic in 42 (60%), periportal in 32 (45.7%) and celiac in 11 (15.7%) respectively. Average nodal size was 2.2 cm (range16 mm-30mm). Nodes were hypoechoic in 55 (78.5%) and heterogenous with an anechoic center in 15 (21.42%) patients . A definitive diagnosis of tuberculosis was made in 50 (71.42%) patients on the basis of positive Ziehl- Nielsen staining for AFB. In this group necrosis was seen in 13, caseating granulomas in 35 and noncaseating granulomas in 2. Caseating granulomas with negative AFB staining were present in 10 patients and were taken as presumptive tuberculosis. Noncaseating granulomas with negative AFB staining were seen in 4 patients. Cytopathological diagnosis of Hodgkin’s disease was made in 4 (5.71%), NHL in 1 and reactive lymphadenitis in 1. Patients with positive AFB staining and caseating granulomas were treated with anti-tubercular drugs for 9 months. A follow up EUS in these patients after 3 months showed a reduction both in number and size (mean 8 mm, range 5 - 17 mm) of lymph nodes and this trend continued over next 6 months . None of the patients had any significant postprocedure complications. Conclusion EUS-FNAC is a safe procedure and has a high diagnostic yield by providing enough material for cytological diagnosis in patients with suspected abdominal tuberculosis especially in those with nodes inaccessible to conventional image guided biopsy.

W1300 The Yield of Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) Is Not Affected By Leaving Out the Stylet Noah M. Devicente, Robert Hawes, Brenda Hoffman, Stacie A. Vela, Joseph Romagnuolo Background: It is generally felt that reinserting the stylet before each FNA pass decreases extraneous tissue (ie. gut wall, adventitia) from plugging the needle, thereby, decreasing the likelihood of a nondiagnostic aspirate. This technique adds procedure time, especially when multiple passes are needed. Anecdotally, some have found that FNA without stylet reinsertion (SR) may yield adequate specimens. We aimed to review our FNA yields with and without SR. Methods: For several months, our team has performed cases with and without SR, at the endoscopist’s discretion. The number and order of passes with and without SR were prospectively noted in our procedure reports. In this retrospective study, we reviewed the procedure and cytology reports of consecutive patients undergoing FNA in a large tertiary EUS practice. We compared the yield and the number of passes required to obtain adequate material among cases with and without SR. Results: The results of 47 consecutive patients (24 male; mean age 64 yrs) referred for EUS-FNA were reviewed. A total of 54 sites were FNA’d. The pancreas was the most common target (55%). Of the pancreatic FNAs, the head was targeted in 57%, followed by the neck, tail and body (10-17%). Non-pancreatic FNA included lymph nodes (14%), liver/biliary (13%), and gastric or other abdominal masses (17%). The most common needle size used was 25G. SR was used for ! 25% of the total passes in 15 cases (group A); SR was used for 25-75% of passes in 16 (group B); in 23, SR was used for O 75% of passes (group C). All but 3 in group C, used 100% SR. The spectrum of pathology was not significantly different among the 3 groups: malignant/neoplastic (or suspicious) FNA result was obtained in 73.3% in group A, 81.3% in group B, and 82.6% in group C. The proportion of pancreatic cases was not significantly different among the groups: 53%, 63%, 49%, nor was the proportion of FNAs that used the transgastric route: 33%, 50%, 30%, respectively. A nondiagnostic FNA was obtained in 0 (0%) cases for group A, 2 (12.5%) for group B and 2 (8.7%) for group C (exact pZ0.47). The median number of FNA passes to achieve adequate on-site cytology was 4 for groups A and B (O25% without SR) vs. 4 for group C (SR with almost every pass) (Mann-Whitney pZ0.4). Qualitatively, our cytologists felt that neither cellularity nor GI contamination was affected by whether or not SR was used. Conclusion: In this non-randomized study, it appeared that the rate of diagnostic specimens was actually (insignificantly) lower when the stylet was reinserted, and the number of passes to achieve adequacy was the same. It appears that EUS-FNA can likely be performed without SR.

W1301 Molecular Analyisis of EGFR and KRAS in Samples Obtained By Endoscopic Ultrasonography-Guided Fine Needle Aspiration (EUS-FNA) in Patients with Non-Small Cell Lung Cancer (NSCLC) Oriol Sendino, Virginia Alonso-Espinaco, Maria Pellise, Manel Sole, ˜oz, Gloria Fernandez-Esparrach, Lluis Colomo, Josep Llach, Jenifer Mun Antoni Castells, Sergi Castellvi-Bel, Angels Gines Background: the presence of somatic mutations in the exons 18-21 of the epidermal growth factor receptor (EGFR) gene is a predictive factor of a good response to the treatment with tyrosine kinase inhibitors (TIKs) in patients with NSCLC. On the other hand, the presence of mutations in the KRAS gene is associated to a poor response to these drugs. Therefore, the possibility of performing molecular analysis of EGFR and KRAS from the samples obtained either

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