Advertisement

Association between macroscopically visible tissue samples and diagnostic accuracy of EUS-guided through-the-needle microforceps biopsy sampling of pancreatic cystic lesions

      Background and Aims

      EUS-guided through-the-needle biopsy (TTNB) sampling has been reported to improve diagnostic yield compared with cytology for the evaluation of pancreatic cystic lesions (PCLs). The number of macroscopically visible tissue samples needed to reach an adequate diagnosis is still unknown.

      Methods

      This is a retrospective, single-center study on consecutive patients with PCLs with risk features (cyst >3 cm, thickened wall, cyst growth during follow-up, and mural nodules) who underwent TTNB sampling. The capability of differentiating mucinous versus nonmucinous cysts, ability to obtain a cyst-lining epithelium, definition of the grade of dysplasia, and specific diagnosis of cyst histotype were evaluated for 1, 2, or 3 TTNB macroscopically visible specimens.

      Results

      Sixty-one patients were evaluated. A 100% histologic adequacy was reached by 2 samples (P = .05 versus 1). Compared with cytology, 1 TTNB specimen improved the possibility of defining cyst histotype (P < .0001), whereas 2 specimens increased all 4 diagnostic categories (P < .003). Two specimens also increased diagnostic yield compared with 1 sample (P < .085). The collection of a third sample did not improve the value of any diagnostic categories. A specific diagnosis was reached in 74% of patients with 2 histologic samples. The diagnostic reliability of TTNB sampling compared with surgical histology was 90%, with a 22.9% rate of adverse events.

      Conclusions

      Two TTNB macroscopically visible specimens reached 100% histologic adequacy and a specific diagnosis in 74% of patients. The collection of a third specimen did not add any additional information and should be avoided to possibly decrease the risk of adverse events.

      Graphical abstract

      Abbreviations:

      AE (adverse event), CEA (carcinoembryonic antigen), MCN (mucinous cystic neoplasm), PCL (pancreatic cystic lesion), TTNB (through-the-needle biopsy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mizuno S.
        • Isayama H.
        • Nakai Y.
        • et al.
        Prevalence of pancreatic cystic lesions is associated with diabetes mellitus and obesity: an analysis of 5296 individuals who underwent a preventive medical examination.
        Pancreas. 2017; 46: 801-805
        • Tanaka M.
        • Fernandez-del Castillo C.
        • Adsay V.
        • et al.
        International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.
        Pancreatology. 2012; 12: 183-197
        • Tanaka M.
        • Fernandez-del Castillo C.
        • Kamisawa T.
        • et al.
        Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.
        Pancreatology. 2017; 17: 738-753
        • The European Study Group on Cystic Tumours of the Pancreas
        European evidence-based guidelines on pancreatic cystic neoplasms.
        Gut. 2018; 67: 789-804
        • Brugge W.R.
        • Lewandrowski K.
        • Lee-Lewandrowski E.
        • et al.
        Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.
        Gastroenterology. 2004; 126: 1330-1336
        • de Jong K.
        • Poley J.W.
        • van Hooft J.E.
        • et al.
        Endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions provides inadequate material for cytology and laboratory analysis: initial results from a prospective study.
        Endoscopy. 2011; 43: 585-590
        • Salvia R.
        • Malleo G.
        • Marchegiani G.
        • et al.
        Pancreatic resections for cystic neoplasms: from the surgeon's presumption to the pathologist's reality.
        Surgery. 2012; 152: S135-S142
        • de Pretis N.
        • Mukewar S.
        • Aryal-Khanal A.
        • et al.
        Pancreatic cysts: diagnostic accuracy and risk of inappropriate resections.
        Pancreatology. 2017; 17: 267-272
        • Mittal C.
        • Obuch J.C.
        • Hammad H.
        • et al.
        Technical feasibility, diagnostic yield, and safety of microforceps biopsies during EUS evaluation of pancreatic cystic lesions (with video).
        Gastrointest Endosc. 2018; 87: 1263-1269
        • Basar O.
        • Yuksel O.
        • Yang D.J.
        • et al.
        Feasibility and safety of microforceps biopsy in the diagnosis of pancreatic cysts.
        Gastrointest Endosc. 2018; 88: 79-86
        • Barresi L.
        • Crinò S.F.
        • Fabbri C.
        • et al.
        Endoscopic ultrasound-through-the-needle biopsy in pancreatic cystic lesions: a multicenter study.
        Dig Endosc. 2018; 30: 760-770
        • Zhang M.L.
        • Arpin R.N.
        • Brugge W.R.
        • et al.
        Moray micro forceps biopsy improves the diagnosis of specific pancreatic cysts.
        Cancer Cytopathol. 2018; 126: 414-420
        • Kovacevic B.
        • Klausen P.
        • Hasselby J.P.
        • et al.
        A novel endoscopic ultrasound-guided through-the-needle microbiopsy procedure improves diagnosis of pancreatic cystic lesions.
        Endoscopy. 2018 Nov; 50: 1105-1111
        • Kovacevic B.
        • Karstensen J.G.
        • Havre R.F.
        • et al.
        Initial experience with EUS-guided microbiopsy forceps in diagnosing pancreatic cystic lesions: a multicenter feasibility study (with video).
        Endosc Ultrasound. 2018; 7: 383-388
        • Yang D.
        • Samarasena J.B.
        • Jamil L.H.
        • et al.
        Endoscopic ultrasound-guided through-the-needle microforceps biopsy in the evaluation of pancreatic cystic lesions: a multicenter study.
        Endosc Int Open. 2018; 6: E1423-E1430
        • Yang D.
        • Trindade A.J.
        • Yachimski P.
        • et al.
        Histologic analysis of endoscopic ultrasound-guided through the needle microforceps biopsies accurately identifies mucinous pancreas cysts.
        Clin Gastroenterol Hepatol. 2019; 17: 1587-1596
        • Tarantino I.
        • Fabbri C.
        • Di Mitri R.
        • et al.
        Complications of endoscopic ultrasound fine needle aspiration on pancreatic cystic lesions: final results from a large prospective multicenter study.
        Dig Liver Dis. 2014; 46: 41-44
        • Lee L.S.
        • Saltzman J.R.
        • Bounds B.C.
        • et al.
        EUS-guided fine needle aspiration of pancreatic cysts: a retrospective analysis of complications and their predictors.
        Clin Gastroenterol Hepatol. 2005; 3: 231-236
        • Siddiqui A.A.
        • Shahid H.
        • Shah A.
        • et al.
        High risk of acute pancreatitis after endoscopic ultrasound-guided fine needle aspiration of side branch intraductal papillary mucinous neoplasms.
        Endosc Ultrasound. 2015; 4: 109-114
        • Kang M.J.
        • Jang J.Y.
        • Kim S.J.
        • et al.
        Cyst growth rate predicts malignancy in patients with branch duct intraductal papillary mucinous neoplasms.
        Clin Gastroenterol Hepatol. 2011; 9: 87-93
        • Barresi L.
        • Tarantino I.
        • Traina M.
        • et al.
        Endoscopic ultrasound-guided fine needle aspiration and biopsy using a 22-gauge needle with side fenestration in pancreatic cystic lesions.
        Dig. Liver Dis. 2014; 46: 45-50
        • Fabre M.
        Diagnosis of cystic pancreatic lesions by endoscopic ultrasonography-guided fine-needle aspiration. Which sampling and why? Utility of cystic wall microbiopsy and fluid analysis by monolayer processing.
        Acta Endosc. 2002; 32: 1-13
        • Crinò S.F.
        • Bernardoni L.
        • Gabbrielli A.
        • et al.
        Beyond pancreatic cyst epithelium: evidence of ovarian-like stroma in eus-guided through-the-needle micro-forceps biopsy specimens.
        Am J Gastroenterol. 2018; 113: 1059-1060
        • Kosmahl M.
        • Egawa N.
        • Schröder S.
        • et al.
        Mucinous nonneoplastic cyst of the pancreas: a novel nonneoplastic cystic change?.
        Mod Pathol. 2002; 15: 154-158
        • Adsay N.V.
        • Hasteh F.
        • Cheng J.D.
        • et al.
        Lymphoepithelial cysts of the pancreas: a report of 12 cases and a review of the literature.
        Mod Pathol. 2002; 15: 492-501
        • Kim Y.S.
        • Cho J.H.
        Rare nonneoplastic cysts of pancreas.
        Clin Endosc. 2015; 48: 31-38
        • Othman M.
        • Basturk O.
        • Groisman G.
        • et al.
        Squamoid cyst of pancreatic ducts: a distinct type of cystic lesion in the pancreas.
        Am J Surg Pathol. 2007; 31: 291-297
        • Cotton P.B.
        • Eisen G.M.
        • Aabakken L.
        • et al.
        A lexicon for endoscopic adverse events: report of an ASGE workshop.
        Gastrointest Endosc. 2010; 71: 446-454
        • Krasinskas A.M.
        • Oakley G.J.
        • Bagci P.
        • et al.
        “Simple mucinous cyst” of the pancreas: a clinicopathologic analysis of 39 examples of a diagnostically challenging entity distinct from intraductal papillary mucinous neoplasms and mucinous cystic neoplasms.
        Am J Surg Pathol. 2017; 41: 121-127
        • Chandrasekhara V.
        • Khashab M.A.
        • Muthusamy V.R.
        • et al.
        Adverse events associated with ERCP.
        Gastrointest Endosc. 2017; 85: 32-47
        • Collins B.T.
        Serous cystadenoma of the pancreas with endoscopic ultrasound fine needle aspiration biopsy and surgical correlation.
        Acta Cytol. 2013; 57: 241-251
        • Gómez V.
        • Majumder S.
        • Smyrk T.C.
        • et al.
        Pancreatic cyst epithelial denudation: a natural phenomenon in the absence of treatment.
        Gastrointest Endosc. 2016; 84: 788-793
        • Barresi L.
        • Tacelli M.
        • Chiarello G.
        • et al.
        Mucinous cystic neoplasia with denuded epithelium: EUS through-the-needle biopsy diagnosis.
        Gastrointest Endosc. 2018; 88: 771-774
        • Springer S.
        • Wang Y.
        • Dal Molin M.
        • et al.
        A combination of molecular markers and clinical features improve the classification of pancreatic cysts.
        Gastroenterology. 2015; 149: 1501-1510

      Linked Article

      • Through-the-needle biopsy sampling may allow preoperative intraductal papillary mucinous neoplasia subtyping
        Gastrointestinal EndoscopyVol. 92Issue 1
        • Preview
          We read with great interest the study by Crinò et al1 regarding biopsy sampling of pancreatic cystic lesions (PCL). The investigators, besides establishing the number of samples needed to reach an adequate diagnosis using EUS-guided through-the-needle microforceps biopsy, make the first description that tries to standardize the diagnostic criteria for cystic lesions by use of through-the-needle biopsy (TTNB) specimens. To evaluate the diagnostic capabilities of TTNB sampling, the authors propose the assessment of 4 histologic criteria: (1) provide cyst-lining epithelium, (2) differentiate mucinous from nonmucinous cysts, (3) define the grade of dysplasia, and (4) provide a specific diagnosis of cyst histotype.
        • Full-Text
        • PDF
      • Pancreatic cyst through-the-needle biopsy: two’s the charm
        Gastrointestinal EndoscopyVol. 90Issue 6
        • Preview
          Pancreatic cystic lesions (PCLs) are commonly encountered, with a prevalence of over 40% in patients undergoing cross-sectional imaging; the incidence increases with age.1 The vast majority are discovered incidentally, are branch duct intraductal papillary mucinous neoplasms (IPMNs), and will never progress to cancer. Despite this, and because the guidelines are controversial and based on little evidence, the management of PCLs continues to create anxiety and frustration for both the patient and the gastroenterologist.
        • Full-Text
        • PDF