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As cytological aspirates from endoscopic-ultrasound-guided fine needle aspiration (EUS-FNA) has limited diagnostic sensitivity and are suboptimal for molecular profiling and morphological characterisation of certain neoplasms, a fine needle biopsy (FNB) with three-pronged (Franseen geometry) cutting edge has been developed to procure histology. In a randomised trial of 46 patients with pancreatic masses, procurement of histological core tissue as evidenced by total tissue and tumour areas was significantly higher for 22G FNB than FNA needle. Also, retention of tissue architecture and presence of desmoplastic fibrosis, which are critical for ancillary testing and molecular profiling, respectively, were significantly higher for FNB. Given the poor outcomes of traditional chemotherapy, there is increased focus on molecular profiling so that pancreatic cancer treatment can be personalised. Pancreatic tissue with architecture containing both tumour cells and desmoplastic stroma is pivotal for molecular analysis. Although EUS-FNA is diagnostically accurate, the cytological aspirate is suboptimal for DNA sequencing.1–3 Therefore, clinical trials evaluating personalised treatment in pancreatic cancer prefer tissue procurement via percutaneous or surgical biopsies over EUS-FNA.4 Recently, a three-plane symmetric needle with Franseen geometry has been developed for performing EUS-guided FNB.5 The large crown-tip with three cutting edges and long insertion length were postulated to facilitate histological tissue procurement (figure 1A). We conducted a randomised trial comparing tissue acquisition between the 22-gauge (G) Franseen biopsy (Acquire, Boston Scientific) and 22G standard bevel FNA (Expect, Boston Scientific) (figure 1B) needles in patients undergoing EUS-guided sampling of pancreatic masses. Figure 1 The 22G Franseen design with a crown-shaped needle tip revealing the three symmetrical planes for histological core tissue acquisition (A). The standard bevel needle used at fine needle aspiration for procurement of cytological aspirates (B). EUS-guided sampling was performed using both needle types, the 22G FNB and 22G FNA needles, with randomisation of the order in which the …

Background and Aim Recently, a 22 gauge (G) needle with a Franseen tip design was developed for EUS-guided fine needle biopsy (EUS-FNB). This study evaluated the performance of the Franseen biopsy needle in EUS-guided tissue acquisition. Methods This is a retrospective study of patients who underwent EUS-FNB using the Franseen needle. Lesions were sampled either using only the Franseen needle or after failed diagnostic fine needle aspiration (FNA). After rapid onsite evaluation (ROSE), two dedicated passes were performed for histological assessment using the cell block technique. Main outcomes were (a) rates of diagnostic adequacy for ROSE and histological diagnosis and (b) quality of histology as determined by total tissue area and tumor percentage in tissue. Results 30 patients underwent EUS-FNB of pancreatic or other masses over a 3-month period. 24 lesions were sampled using only the Franseen needle and 6 after failed diagnostic FNA. The final diagnosis was pancreatic cancer in 12, gastrointestinal stromal cell tumor in 5, other tumors in 4 and benign disease in 9. Diagnostic adequacy for ROSE was 96.6% and a histological diagnosis was established in 96.7% of patients. The median tissue area was 2.9mm2 (IQR=0.68-8.71mm2) and the median tumor percentage in tissue was 73.9% (IQR=44-97.6). The rates of technical success and adverse events were 96.7% and 3.3%, respectively. Conclusions Preliminary data suggest that the Franseen needle yields diagnostic material for ROSE and histology in greater than 95% of patients. This article is protected by copyright. All rights reserved.

Background and Aims Digital cholangioscopes provide higher-resolution imaging of the pancreatobiliary tract compared with fiberoptic instruments. The role of a new, digital, single-operator cholangiopancreatoscopy (SOC) system for diagnosis and treatment of pancreatobiliary disorders in clinical practice is not known. Methods We performed a multicenter, observational study of 105 consecutive patients with suspected pancreatobiliary disorders. The main outcome measures were (1) sensitivity and specificity of SOC visual appearance and biopsies in the diagnosis of indeterminate biliary strictures and (2) achieving complete duct clearance in patients with biliary or pancreatic duct stones. Results A total of 98 cholangioscopy and 7 pancreatoscopy procedures were performed in 105 patients. Superior views of the ductal lumen and mucosa were obtained in all 44 patients with indeterminate biliary strictures. Among the 44 patients who underwent SOC-guided biopsies, the specimen was adequate for histologic evaluation in 43 patients (97.7%). The sensitivity and specificity of SOC visual impression for diagnosis of malignancy was 90% (95% confidence interval [CI], 69.9%-97.2%) and 95.8% (95% CI, 79.8%-99.3%), respectively. The sensitivity and specificity of SOC-guided biopsies for diagnosis of malignancy was 85% (95% CI, 64.0%-94.8%) and 100% (95% CI, 86.2%-100%). In patients with biliary or pancreatic duct stones (N = 36), complete duct clearance with stone removal in 1 session was accomplished in 86.1% of patients (31/36). Three patients (2.9%) experienced SOC-related adverse events that included cholangitis in 2 patients and postprocedure pancreatitis in 1 patient. Conclusions SOC has become an integral part of the ERCP armamentarium and has high accuracy in the evaluation of indeterminate biliary strictures. Complete stone clearance was achieved in all but 1 patient with challenging biliary or pancreatic duct stones. (Clinical trial registration number: NCT01815619.)

Background and Aims Tissue diagnosis, regardless of technique or endoscope used, can be challenging in patients with indeterminate biliary strictures (IDBSs). This exploratory study evaluated the utility and role of rapid onsite evaluation of touch imprint cytology (ROSE-TIC) when single-operator cholangioscopy (SOC)-guided biopsies of IDBSs are performed. Methods Patients with IDBSs were evaluated by intraprocedural ROSE-TIC during SOC-guided biopsy procedures. Final diagnosis was established by long-term patient follow-up in conjunction with off-site findings or surgical histology. The main outcome measure was to evaluate the utility of ROSE-TIC by determination of its operating characteristics and comparison with off-site histologic assessment. Results Of 31 patients with IDBSs, tissue diagnosis was indeterminate at prior ERCP-guided brush and/or biopsy in 14, prior EUS-guided FNA (EUS-FNA) in 6, and a mass could not be identified at EUS in 11. The mean number of biopsies performed was 3.3 (range 1-8), and diagnostic interpretation by ROSE-TIC was diagnostic and/or suspicious for carcinoma in 15, benign in 13, atypical-reactive in 2, and bile duct intraductal papillary mucinous neoplasm in 1. Final diagnosis by surgical histology (n = 4), death by disease (n = 10), and patient follow-up (n = 17) showed that the overall sensitivity of ROSE-TIC for diagnosing malignancy was 100%, specificity 88.9%, positive predictive value 86.7%, negative predictive value 100%, and diagnostic accuracy 93.5%. Conclusions Preliminary data suggest that the diagnostic outcomes of SOC-guided biopsies in IDBSs can be significantly improved by using ROSE-TIC. This technique also may benefit centers that rely mainly on fluoroscopy-guided intraductal biopsies.

Renal cell carcinoma (RCC) has the propensity to hematogenously metastasize to the lung, bone, or liver, however, metastasis to the esophagus is exceedingly rare. We report a case of ulcerative esophagitis secondary to recurrent metastatic renal cell cancer status post remote nephrectomy. An 82-year-old Caucasian male presented with dark tarry stools for two days, progressive dysphagia to solid food for several weeks and unintentional weight loss. His past medical history was significant for hypertension, diverticulosis and right-sided renal cell cancer for which he underwent nephrectomy 13 years ago. Physical examination was unremarkable. Laboratory data showed hemoglobin of 12.5 g/dL, with normal platelet count and an international normalized ratio (INR). His stools were positive for occult blood. Esophagogastroduodenoscopy (EGD) revealed a fragile mid esophageal mass and antral erosive gastritis which were both biopsied. Colonoscopy showed diverticulosis without stigmata of active gastrointestinal (GI) bleed. CT scan (computed tomography) of the chest showed a solid esophageal mass in the lower esophagus as well as a right upper lobe lung mass for which CT-guided needle biopsy was obtained. The histopathology revealed metastatic renal cell cancer of clear cell subtype. The patient was started on palliative radiotherapy. On completion of radiotherapy two months later, his dysphagia had resolved. The patient is currently on chemotherapy with Sunitinib. Metastatic involvement of esophagus is relatively uncommon and is reported in 6% of patients with metastatic lung, breast and prostate cancer. Esophageal metastasis of clear cell RCC is very rare and so far only seven cases have been reported. Diagnosis is confirmed by endoscopy, imaging and histopathology. Treatment options include surgical or endoscopic resection for a solitary metastatic lesion. If the tumor is unresectable, multidisciplinary treatment including radiation and chemotherapy is indicated.

Ever since the first endoscopic ultrasound-guided fine needle aspiration (FNA) was done in 1992, the procedure has evolved to become an indispensable tool for tissue acquisition in patients with gastrointestinal tumors and periluminal lesions. With the growing evidence of neoadjuvant therapy and research into intratumoral therapy, the need to obtain tissue diagnosis for tumors is quite apparent. This review provides an overall perspective to the endosonographer on various issues that are a key for best practices in FNA, in addition to being an update for practicing experienced endosonographers.

Background Although on-site cytopathology services have a significant impact on efficiency and accuracy of EUS-guided FNA (EUS-FNA), the availability of this service is variable. Objective To evaluate the impact of an intensive 2-day training program to educate endosonographers in EUS-related cytopathology. Design Pilot study. Setting Tertiary care medical center. Subjects Six endosonographers (5 male, median age, 35 years) with minimal previous cytopathology exposure comprised the study cohort. Methods Pre- and posttraining testing was administered. Training commenced with a cytopathology tutorial focusing on 4 performance measures: specimen adequacy, sample interpretation, specimen processing, and preliminary diagnosis. Eight live EUS-FNA cases were then performed, and study participants independently completed 4 questions based on performance measures for each case. The ability to independently smear and stain slides and operate a microscope was additionally assessed after a hands-on tutorial. Main Outcome Measurements Comparison of pretraining and posttraining scores, improvement in performance measures for live cases, and ability to independently handle specimens and operate a microscope. Results Compared with pretraining, mean posttraining test scores improved by 63% from 48 to 78 out of 100. Mean live case performance score was 95%. Performances improved from 89% on day 1 to 100% on day 2. After training, all endosonographers could independently smear/stain slides and operate a microscope. Limitations Long-term impact is unclear. Conclusions An intensive 2-day program was effective in training endosonographers in the basics of EUS-related cytopathology. Incorporating basic cytopathology in EUS fellowship curriculum will likely improve diagnostic performance of tissue acquisition procedures.

Supplemental digital content is available in the text., Objectives Although a large gauge needle can procure more tissue at endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), its advantage over smaller needles is unclear. This study compared flexible 19G and 25G needles for EUS-FNA of solid pancreatic masses. Methods This was a randomized trial of patients undergoing EUS-FNA of pancreatic masses using flexible 19G or 25G needle. Main outcome measure was to compare median number of passes for on-site diagnosis. Secondary measures were to compare specimen bloodiness, complications, technical failures, and histological core tissue procurement. Results One hundred patients were randomized to EUS-FNA using flexible 19G or 25G needle. Median of 1 pass was required to achieve on-site diagnosis of 96% and 92% (P = 0.68) in 19G and 25G cohorts. There was no significant difference in technical failure (0% vs 2%, P = 0.99) or adverse events (2% vs 0%, P = 0.99) between 19G and 25G cohorts. Although histological core tissue procurement was significantly better with flexible 19G needle (88% vs 44%, P < 0.001), specimens were bloodier (severe bloodiness, 36% vs 4%; P < 0.001). Conclusions As there is no significant difference in the performance of flexible 19G and 25G needles, needle choice for sampling pancreatic masses should be based on endoscopist preference and need for histology.

Background and Aims Recently, a 3-plane symmetric needle with Franseen geometry and a Fork-tip biopsy needle have been developed for histologic tissue procurement. We compared 22-gauge Franseen and 22-gauge Fork-tip needles in patients undergoing EUS-guided sampling of pancreatic masses. Methods Fifty patients underwent sampling using both 22-gauge Franseen and 22-gauge Fork-tip needles, with randomization of needle order. Two dedicated passes were performed using both needles for cell block. Subsequent passes were performed for rapid onsite evaluation (ROSE) using both needles alternately until diagnosis was established. The main outcome was to evaluate for histologic core tissue by comparing area of total tissue, tumor, desmoplastic fibrosis, and rate of retained tissue architecture between cohorts. Other outcomes were rates of diagnostic cell block and diagnostic adequacy at ROSE. Results Final diagnosis was pancreatic cancer in 44 patients, neuroendocrine tumor in 2, lymphoma in 1, and chronic pancreatitis in 3. There was no significant difference in area of total tissue (median 6.1 [interquartie range {IQR}, 3.5-10.5] vs 8.2 mm 2 [IQR, 4.0-13.0], P = .50), tumor (median .9 [IQR .3-2.8] vs 1.0 mm 2 [IQR .4-2.7], P = .33), desmoplastic fibrosis (median 4.3 [IQR, 2.0-6.7] vs 5.2 mm 2 [IQR, 1.7-6.1], P = .71), retained architecture (100% vs 83%, P = .25), diagnostic cell block (96.0% vs 92.0%, P = .32), and diagnostic adequacy at ROSE (94.0% vs 98.0%, P = .32) between Franseen and Fork-tip needles, respectively. Conclusions There was no significant difference between Franseen and Fork-tip needles in yielding histologic tissue. Given their ability to yield diagnostic cell block in greater than 90% of patients, the new-generation fine-needle biopsy needles may obviate the need for ROSE. (Clinical trial registration number: NCT02910960.)

Introduction Telecytopathology for endoscopic ultrasound–guided fine-needle aspiration (EUS-FNA) has been shown to be an alternative to rapid on-site evaluation (ROSE). Gastroenterologists (endosonographers) performing EUS-FNA can be trained to evaluate a specimen for adequacy. This study examined the ability of an endosonographer with focused cytopathologic training to assess the adequacy of pancreatic FNA specimens and transmit diagnostic images to a remotely located cytopathologist as compared to an experienced cytotechnologist. Materials and methods This was a retrospective study of consecutive pancreatic lesions sampled by EUS-FNA reviewed by an endosonographer and a cytotechnologist. The participants were assessed based on their ability to (1) determine adequacy, (2) locate and transmit representative cell groups, (3) provide a preliminary diagnosis, and (4) provide concordance with actual diagnosis. Results 105 consecutive cases of EUS-FNA of the pancreas were analyzed, including: adenocarcinoma (n = 39), cyst (n = 17), neuroendocrine neoplasia (n = 7), pancreatitis (n = 14), benign pancreas (n = 9), other neoplasms (n = 6), suspicious/atypical (n = 3), and nondiagnostic (n = 10). The cytotechnologist demonstrated superiority in accuracy 92.7% versus 70% (P = 0.003) and subcategorization 95.0% versus 76% (P = 0.007). There was no difference in “broad” categorization (benign/malignant) between the endosonographer and cytotechnologist, 98% and 98.2% (P = 0.946), respectively. Also, there was no difference with regard to adequacy assessment (P = 0.29). A steady learning curve for the endosonographer was demonstrated in their cytologic assessment (P = 0.041). The endosonographer was shown to be able to remotely transmit diagnostic images to a pathologist. Conclusion An endosonographer with limited training can examine for specimen adequacy, transmit images, and demonstrate representative cell groups. Larger studies are required though preliminary results are encouraging.

Background When on-site cytopathology support is not available, EUS-guided fine needle aspiration (EUS-FNA) is performed for cell-block preparation to allow off-site interpretation. Objective To identify the number of passes required to obtain a diagnostic cell block by using a 25-gauge needle for sampling pancreatic masses. Design Randomized trial. Setting Tertiary care hospital. Patients Sixty-two patients with solid pancreatic mass lesions. Interventions EUS-FNA was performed by using a 25-gauge needle. After establishing a preliminary on-site diagnosis, patients were randomized to 2 or 4 FNA passes for a cell block. A cell block was evaluated by a pathologist blinded to on-site interpretation for the presence of a tissue pellet, histological core tissue size, and diagnostic accuracy. Main Outcome Measurements To determine the number of passes required to obtain a diagnostic cell block with a 25-gauge FNA needle. Results Sixty-two patients were randomized to undergo either 2 (n = 31) or 4 (n = 31) FNA passes for a cell block. Before randomization, an on-site diagnosis was established in all 62 patients (100%). The final diagnosis was adenocarcinoma in 45 (72.6%), neuroendocrine/other tumor in 7 (11.3%), and chronic pancreatitis in 10 (16.1%). There was no difference in the presence of a tissue pellet (93.5 vs 96.8%; P = .99), the median size of the histological core (0.006 vs 0.05 mm 2 ; P = .12), or the presence of a diagnostic cell block (80.6 vs 80.6%; P = .99) between patients randomized to 2 or 4 FNA passes, respectively. Limitations Only pancreatic masses were evaluated. Conclusions The 25-gauge FNA needle yielded a diagnostic cell block in only 81% of patients, irrespective of whether 2 or 4 FNA passes were performed. These findings have important implications for centers without on-site cytopathology services. (Clinical trial registration number NCT01809028.)

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become well established as a minimally invasive technique in diagnosing and staging various gastrointestinal, pancreaticobiliary, and retroperitoneal malignancies. The diagnostic accuracy of this procedure is significantly enhanced by the presence of on-site cytopathology. However, in many EUS centers, cytopathology is not readily available for on-site evaluation. This article is intended to assist the independent endosonographer in the assessment of diagnostic sufficiency and in specimen handling.

Endoscopic ultrasound (EUS) is an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. While fine-needle aspiration (FNA) has been routinely carried out for establishing tissue diagnosis, the emerging concept of tailoring chemotherapeutic agents based on molecular markers has increased the demand for core tissue procurement by means of EUS-guided fine-needle biopsy (EUS-FNB). In addition, FNB may offset the limitations of FNA wherein the diagnostic sensitivity is incumbent on the availability of an onsite cytopathologist. Given the increasing number of procedures being done, developing a unit-specific algorithmic approach for needle selection is important to improve the procedural efficiency and utilization of resources. Finally, the best outcomes can be attained only by practicing evidence-based techniques, procuring adequate quantity of sample for ancillary studies and processing the specimens appropriately.

A meta-analysis has not been previously performed to evaluate critically the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solely pancreatic ductal adenocarcinoma and address factors that have an impact on variability of accuracy. The aim of this study was to determine whether the presence of a cytopathologist, variability of the reference standard and other sources of heterogeneity significantly impacts diagnostic accuracy.We conducted a comprehensive search to identify studies, in which the pooled sensitivity, specificity, likelihood ratios for a positive or negative test (LR+, LR-) and summary receiver-operating curves (SROC) could be determined for EUS-FNA of the pancreas for ductal adenocarcinoma using clinical follow-up, and/or surgical biopsy or excision as the reference standard.We included 34 distinct studies (3644 patients) in which EUS-FNA for a solid pancreatic mass was evaluated. The pooled sensitivity and specificity for EUS-FNA for pancreatic ductal adenocarcinoma was 88.6% [95% confidence interval (CI): 87.2-89.9] and 99.3% (95% CI: 98.7-99.7), respectively. The LR+ and LR- were 33.46 (95% CI: 20.76-53.91) and 0.11 (95% CI: 0.08-0.16), respectively. The meta-regression model showed rapid on-site evaluation (ROSE) (P = 0.001) remained a significant determinant of EUS-FNA accuracy after correcting for study population number and reference standard.EUS-FNA is an effective modality for diagnosing pancreatic ductal adencarcinoma in solid pancreatic lesions, with an increased diagnostic accuracy when using on-site cytopathology evaluation.

Background A needle made of nitinol has been developed with enhanced flexibility to overcome the limitations of the currently available 19-G EUS-FNA needles. Objective Evaluate the ability to perform transduodenal FNAs, procure histologic specimens, and undertake therapeutic interventions using the flexible 19-G needle. Design Prospective cohort study. Setting Tertiary-care academic medical center. Patients Consecutive patients with subepithelial masses, pancreatic head or uncinate lesions, or lesions adjacent to the pancreatic head, and patients undergoing therapeutic intervention. Interventions Perform tissue acquisition and interventions with the flexible 19-G FNA needle. Main Outcome Measures Evaluate the ability to perform transduodenal passes with the flexible 19-G FNA needle. Also, assess the utility of the needle to yield both cytologic and histologic samples and to perform therapeutic interventions. Results Of the 50 patients enrolled, tissue acquisition was undertaken in 38 and therapeutic intervention in 12. Of 38 patients from whom tissue was procured, 32 tissue samples were from pancreatic head/uncinate or peripancreatic masses and 6 were from subepithelial masses. Tissue acquisition, which included transduodenal passes, was successful and adequate for cytologic assessment in all 38 patients (100%). Satisfactory histologic specimens were procured from 36 of 38 (94.7%) patients. An onsite diagnosis was established in 35 of 38 (92.1%) patients. In 3 patients with indeterminate/suspicious lesions, a definitive diagnosis was established at histology. A mean of 1.45 ± 0.79 passes per patient was performed. All 12 therapeutic interventions were successful (100%) and included pseudocyst drainage in 5, pelvic abscess drainage in 2, fiducial placement in 2, celiac plexus neurolysis in 2, and cholangiogram in 1. Needle dysfunction or procedural complications were not encountered. Limitations Single-center study with limited power. Conclusions Preliminary data suggest that the flexible 19-G needle can be used for procuring cytologic aspirates and histologic specimens and to undertake therapeutic interventions even by the transduodenal route. Confirmatory studies are required in a larger cohort of patients with varied pathologic conditions to validate these findings.

Despite the extensive use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), there still exists a wide variation in the number of samples required to ensure acquisition of diagnostic material from pancreatic lesions. Although multiple passes can be performed during EUSFNA, prolonging the procedure likely increases risk, decreases procedural efficiency, and increases the probability of samples being tainted with blood. It has been 21 years since EUS-FNA was used to obtain pancreatic tissue for cytologic analysis [1, 2], 16 years since the publication of the first reports evaluating the clinical impact and staging of pancreatic lesions sampled by EUSFNA [3], and 14 years since the publication of the initial reports of the evaluation of the number of passes needed to obtain a diagnostic yield and the significance of on-site cytopathology during the procedure [4–7]. During this time, the focus has been on determining the necessity of on-site cytopathologic evaluation, the optimal number of needle passes, and the most effective needle type used for tissue acquisition. Despite numerous studies addressing these issues, many endoscopists are still perplexed about the nature of the best practices needed to ensure optimal results, in particular with regard to the need for on-site cytopathology for skilled and experienced endosonographers practicing at a high-volume center. To date, multiple meta-analyses have confirmed the diagnostic accuracy, cost-effectiveness, accuracy, and safety of EUS-FNA for solid pancreatic lesions [8–12]. Moreover, structured literature reviews have concluded that rapid on-site evaluation (ROSE) improves diagnostic accuracy [8, 9]. Notwithstanding these considerable successes, ongoing refinements to EUS-FNA continue to be explored. Regardless of the likelihood that increasing numbers of passes raises the risk of needle failure, tissue injury, postprocedural complications, and medical expenses, the endosonographer is caught between the need to provide adequate tissue needed to optimize diagnostic yield weighed against the cost and risk of making additional passes. Failed EUS-FNA often engenders additional risk and expense due to the need to repeat EUS or to obtain tissue with radiologic or surgical guidance. Moreover, as treatment options for pancreatic cancer advance, rendering an onsite diagnosis alone may not be adequate, since additional tissue may be required to perform ancillary studies and molecular mapping. Nevertheless, ROSE may not be financially viable due to excess time commitment, limited resources, relatively low reimbursements, and acceptable adequacy rates achieved by more experienced endosonographers. In order to have a sustainable EUS practice with optimal clinical outcomes, it may be beneficial to provide some degree of ROSE training for endosonographers incorporating the ‘‘fanning’’ FNA technique combined with an algorithmic approach to needle selection [13–15]. In this issue of Digestive Diseases and Sciences, Schmidt et al. [16] examined current practices of lesion sampling, weighing diagnostic accuracy against the probability of adverse events in the presence and absence of ROSE. The authors provide empirical data regarding the diagnostic yield and performance characteristics of EUS-FNA of solid pancreatic lesions using mathematical modeling to determine the likelihood of adverse events with a fixed number of passes (no-ROSE) versus a variable number of passes (ROSE) while controlling for other variables. Schmidt and colleagues used a discrete-event simulation model to conclude that ROSE reduces the number of passes, thereby reducing the S. Hebert-Magee R. H. Hawes S. Varadarajulu (&) Center for Interventional Endoscopy, Florida Hospital, 601 East Rollins Street, Orlando, FL 32803, USA e-mail: svaradarajulu@yahoo.com

Metastases to the pancreas are much less common than primary pancreatic lesions, and there are few reports in the literature of metastatic urothelial carcinoma (UC) found in the pancreas. We report two cases of metastatic UC mimicking a primary pancreatic lesion. Two female patients, aged 48 and 83 years, presented with isolated pancreatic lesions causing obstructive jaundice suspicious for pancreatic adenocarcinoma and underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with rapid on-site evaluation (ROSE). On cytopathology, the lesions were found to be UC, confirmed with immunohistochemical (IHC) staining. UC rarely metastasizes to the pancreas, and diagnosis through EUS-FNA can be challenging. However, the utilization of ROSE, dedicated cell block passes, and IHC have proved to be effective in obtaining this unusual pancreatic diagnosis by EUS-FNA.

Background To overcome limitations of cytology, biopsy needles have been developed to procure histologic samples during EUS. Objective To compare 22-gauge (G) FNA and 22G biopsy needles (FNB) for EUS-guided sampling of solid pancreatic masses. Design Randomized trial. Setting Tertiary-care medical center. Patients This study involved 56 patients with solid pancreatic masses. Intervention Sampling of pancreatic masses by using 22G FNA or 22G FNB devices. Main Outcome Measurements Compare the median number of passes required to establish the diagnosis, diagnostic sufficiency, technical performance, complication rates, procurement of the histologic core, and quality of the histologic specimen. Results A total of 28 patients were randomized to the FNA group and 28 to the FNB group. There was no significant difference in median number of passes required to establish the diagnosis (1 [interquartile range 1-2.5] vs 1 [interquartile range 1-1]; P = .21), rates of diagnostic sufficiency (100% vs 89.3%; P = .24), technical failure (0 vs 3.6%; P = 1.0), or complications (3.6% for both) between FNA and FNB needles, respectively. Patients in whom diagnosis was established in passes 1, 2, and 3 were 64.3% versus 67.9%, 10.7% versus 17.9%, and 25% versus 3.6%, respectively, for FNA and FNB cohorts. There was no significant difference in procurement of the histologic core (100% vs 83.3%; P = .26) or the presence of diagnostic histologic specimens (66.7% vs 80%; P = .66) between FNA and FNB cohorts, respectively. Limitations Only pancreatic masses were evaluated. Conclusion Diagnostic sufficiency, technical performance, and safety profiles of FNA and FNB needles are comparable. There was no significant difference in yield or quality of the histologic core between the 2 needle types. (Clinical trial registration number: NCT01394159.)

Purpose: A single nucleotide polymorphism (SNP) in exon-4 of the TP53 gene (Arg72Pro) has been associated with an increased risk of developing various human malignancies. Since a 16-base pair polymorphism (insertion/duplication) intron-3 (PIN3) is in linkage disequilibrium with Arg72Pro of TP53, we assessed whether these two polymorphisms serve as breast cancer risk alleles for African Americans (AAs) and non-Hispanic Caucasians (CAs). Methods: Genomic DNA was extracted from formalin-fixed, paraffin-embedded invasive ductal carcinoma tissues [cases, n = 120 (AAs = 55 and CAs = 65)] and from blood of healthy women [controls, n = 152 (AA = 74 and CAs = 78)]. Exon-4 of TP53 was amplified by PCR using exon-specific primers, followed by Sanger sequencing. Identification of SNP was done by using DNASTAR software. TP53 PIN3 polymorphism was detected by amplifying genomic DNA using specific primers followed by gel electrophoresis. The A1 allele (no duplication) resulted in 162 bp fragment and the A2 allele (with 16 bp duplication) resulted in 178 bp fragment. The phenotypes of Arg72Pro (Arg/Arg, Arg/Pro, and Pro/Pro) were correlated with PIN3 status, clinicopathologic features, race/ethnicity, and patient survival using the χ2 test and Kaplan-Meier analyses. A p value of Results: In cases, the Arg/Arg/, Pro/Arg, and Pro/Pro phenotypes were 15%, 31%, and 55% in AAs and 57%, 29%, and 14% in CAs (p Conclusion: These preliminary findings suggest that Arg72Pro polymorphism and PIN3 in TP53 are related with higher breast cancer susceptibility for both African American and non-Hispanic Caucasian patients. This work was supported by a pilot grant from UAB Breast SPORE grant of the National Institutes of Health/National Cancer Institute (5P50CA089019). Citation Format: Trafina Jadhav, Jesus Salazar-Gonzalez, Shantel Hebert-Magee, Michael Behring, Balananda-Dhurjati Putcha, Jeehyun Helen Bae, Andra Frost, Isam-Eldin Eltoum, Sejong Bae, Upender Manne. Codon 72 and Intron-3 polymorphisms in TP53 are risk factors for breast cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2776. doi:10.1158/1538-7445.AM2015-2776

100 Multi-Center Randomized Trial Comparing the 19G and 25G Needles for EUS-Guided FNA of Large Solid Pancreatic Mass Lesions Muhammad Hasan, Jayapal Ramesh, Ji Young Bang, Bronte a. Holt, Shantel Hebert-Magee, Amy L. Logue, Robert Hawes, Shyam Varadarajulu* Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; Medicine, University of Alabama at Birmingham, Birmingham, AL Background: Retrospective studies suggest that given the increased necrosis in large solid pancreatic mass lesions, more passes are required at EUS-FNA for establishing onsite diagnostic adequacy. The hypothesis of this study is that a larger gauge needle will procure more tissue than a smaller gauge needle and therefore will establish the diagnosis with fewer FNA passes. Aim: To compare 19 and 25G needles for EUS-FNA of large solid pancreatic mass lesions. Methods: In this multi-center trial, patients with solid pancreatic mass lesions 35mm or greater in size were randomized to undergo EUS-FNA using 19 or 25G needle. FNA maneuvers were performed using the fanning technique and without the use of suction. A pathologist blinded to randomization sequence evaluated specimens onsite for diagnostic adequacy. Main outcome measures: Compare the median number of passes needed to establish onsite diagnostic adequacy, specimen quality (bloodiness graded as mild if!33%, moderate if 34-66%, severe if O67%) and complications between 19 and 25G needles. Sample size was estimated based on detecting a difference of one pass required to establish onsite diagnostic adequacy, using standard deviation of 1 for 19G and 1.9 for 25G needle (power 80%, aZ0.05). Results: Of 80 randomized patients (19GZ40; 25GZ40) there was no significant difference in patient or disease characteristics between the cohorts (Table). Except for specimen bloodiness that was significantly greater in the 19G cohort, there was no difference in the median number of passes required to establish onsite diagnostic adequacy, final diagnosis, technical failures (none) or complications (none) between the two cohorts. Conclusion: 19G needle has no advantage over a 25G needle for establishing onsite diagnostic adequacy when performing EUS-FNA of large solid pancreatic mass lesions.

Diagnosis of Bilateral Adrenal Metastases Secondary to Malignant Melanoma by EUS-Guided FNA

Background: MicroRNAs (miRNAs) are a class of conserved, non-coding RNAs that are dysregulated in various cancers, including breast cancers. The potential of miRNAs to serve as biomarkers for breast cancer diagnosis and prognosis is being explored, but their clinical value based on race/ethnicity and molecular subtypes (luminal and triple negative breast cancers, TNBCs) has not been examined. Thus, we evaluated expression levels of a panel of miRNAs in luminal (A and B) breast cancers and TNBCs of African Americans (Blacks) and non-Hispanic Caucasians (Whites). We further evaluated the prognostic value of miRNAs based on molecular type of breast cancer and patient race. Methods: TaqMan® miRNA assays were used to quantify expression of miR-181a, miR181b, miR-21, miR-106a, miR-155, miR-210, miR-335, miR-206, and miR-126 in 105 breast cancers (luminal=51 and TNBCs=54) and their corresponding benign/normal tissues. Cancer tissuefrom 48 Blacks (luminal=23 and TNBCs=25) and 57 Whites (luminal=28 and TNBC=29) were analyzed. Fold change in the expression levels between tumor-normal pairs were determined using the 2-∆∆Ct method. A cutoff value for each miRNA was determined by utilizing the Cutoff Finder software application [PLoS ONE 7(12):e51862, 2012]. The cutoff values were used to categorize the tumors into two groups (High expression or positive and low expression or negative). The expression status of tumors was correlated with patient overall survival by univariate Kaplan-Meier analysis. Results: Since the survival probabilities of Blacks and Whites with TNBCs (log rank, p=0.899) were similar, TNBCs from both racial groups were pooled. Similarly, no survival differences were noted in patients of both racial groups with luminal breast cancers (log rank, p=0.178). Therefore, luminal cancers of Blacks and Whites were also pooled together to perform survival analyses based on miRNA expression levels. MiRNA expression profiling studies indicated that, in both the racial groups, miR-181a, miR-181b, miR-21, miR-106a, miR-155, and miR-210 were up-regulated in luminal cancers and TNBCs. In contrast, miR-335, miR-206, and miR-126 were down-regulated in both molecular types. When the prognostic value of miRNAs was evaluated in each molecular type separately, it was found that over-expression of miR-106a (p=0.037) and miR-210 (p=0.039) were associated with poor prognosis of TNBCs. However, none of the evaluated miRNAs were useful in assessing the prognosis of patients with luminal cancers. Conclusions: These findings suggest that increased expression of miR-106a and miR-210 were poor prognostic indicators of TNBCs collected from both Black and White patients. Additionally, our results suggest that in the evaluation of clinical utility of miRNAs molecular types of breast cancer should be considered. This study was funded in part by the National Cancer Institute of the National Institute of Health UAB/TU/MSM Partnership grant (U54 CA118948). This abstract is also presented as Poster C21. Citation Format: Balananda-Dhurjati Kumar Putcha, Trafina Jadhav, Shantel Hebert-Magee, Jeehyun Helen Bae, Andra R. Frost, Isam-Eldin Eltoum, Sejong Bae, Upender Manne. Prognostic value of miRNAs in breast cancer: Molecular type and patient race. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr PR5. doi:10.1158/1538-7755.DISP13-PR5

Background: Triple-negative (negative for estrogen receptor, progesterone receptor, and HER-2 receptor) breast cancers (TNBCs) are aggressive, difficult to treat, and more likely to recur compared to other subtypes. TNBCs are more commonly found in African American (AA) than Caucasian (CA) patients. Since The Cancer Genome Atlas (TCGA) and other studies have reported a higher incidence of mutations in the TP53 gene in TNBCs, we sequenced p53 in TNBCs collected from AAs and CAs by use of a NextGen sequencing platform (Personal Genome Machine, PGM of Ion Torrent) to assess whether genetic variants in TP53 vary based on patient race. Methods: Genomic DNA was extracted from 18 (10 AAs and 8 CAs) macro-dissected TNBC tumors and their matching normal tissues. Primers were designed using the Ion AmpliseqTM designer (Life Technologies) for a panel of non-silent somatic mutations (PIK3CA, TP53, MAP3K1, MAP2k4, GATA3, MLL3, CDH1, PTEN, PIK3R1, and AKT1) as well as missense point mutations (SF3B1, CDKN1B, RB1, AFF2, NF1, PTPN22, and PTPRD) reported in the TCGA breast cohort study. Using 10 ng of DNA from each sample, 1,541 target sequences were obtained from this panel of genes. Each target sequence was ∼100 bp. These sequences were amplified, and DNA libraries were generated using a protocol recommended by the manufacturer (Ion Torrent, Life Technologies). Samples were barcoded with the Ion Xpress Barcode Adapters, multiplexed for emulsion PCR on Ion OneTouch-2, and sequenced on a PGM sequencer (Life Technologies). Sequencing was performed on 318 chips, and the data were processed using the Ion reporter 4.0 (Life Technologies). Tumor-normal pairs were compared, and the variants were called and further filtered by the Ingenuity variant analysis plug-in. Cancer-driver variants, as identified by Ingenuity, were analyzed according to patient race and molecular subtype. Statistical analyses were performed using the Mann-Whitney or Fisher Exact probability test. Furthermore, we validated our findings with the TCGA data (NIH) using the cBio portal. The TNBC status of TCGA cases was determined based on the clinical data available on the TCGA data portal. Results: In the panel of genes, cumulative mutations and mutation frequencies of individual genes were not significantly different between AAs and CAs. However, the number of cases with TP53 mutations was higher in CAs (7 of 8, 88%) as compared to AAs (3 of 10, 33%) (p=0.027). Of note, 6 of 7 TNBCs of CAs had mutations in the DNA-binding domain (DBD) of TP53. In contrast, all three TNBCs of AAs had mutations both within and outside the DBD of TP53. Analyses of TCGA data on TNBCs suggested that the frequency of TP53 mutations between CAs (28 of 40, 70%) and AAs (3 of 9, 33%) (p=0.058) was similar to the mutation frequency observed in our analyses. Conclusion: In TNBCs, the TP53 mutation frequency, especially in the DBD, is higher in CA patients relative to AA patients. These studies were supported by the Charles Barkley Foundation and by NIH 2U54-CA118948. Citation Format: Balananda-Dhurjati Kumar Putcha*, Shantel Hebert-Magee*, Trafina Jadhav, Andra R. Frost, Isam-Eldin Eltoum, Upender Manne. Racial disparity in the TP53 mutation spectra in triple-negative breast cancers: Validation with TCGA data. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-287. doi:10.1158/1538-7445.AM2014-LB-287

Introduction: Onsite cytopathology services have a significant impact on the efficiency and accuracy of endoscopic ultrasound-guided fine needle * Exempt Fellow **Current Off-Cycle Fellow to date aspiration (EUS-FNA). This pilot study evaluated the impact of an intensive two day training program to educate endosonographers in EUS-related cytopathology. Materials and Methods: Six endosonographers (maleZ 5; median ageZ35yrs) with minimal prior cytopathology exposure, representing all time zones in the United States, with a median annual EUS volume of 250 procedures (academic: private practiceZ3:3) comprised the study cohort. A preand post-training cytopathology test was administered at the beginning and end of the two-day program. Training commenced with a 90 minute cytopathology tutorial focusing on four performance measures: specimen adequacy, sample interpretation, specimen processing and preliminary diagnosis. Eight live EUS-FNA cases were then performed and study participants independently completed four questions based on the performance measures for each case. The ability to independently smear and stain slides and operate a microscope was additionally assessed after a hands-on tutorial. Main outcome measures were improvement in pre and posttraining scores, improvement in performance measures for live cases, and the ability to independently handle specimens and operate a microscope. Results: Compared to pre-training, the mean post-training test scores improved by 63% from 48 to 78 out of 100. The mean live case performance score was 95%. Performances improved from 89% on day 1 to 100% on day 2. After training, all endosonographers could independently smear and stain slides and operate a microscope. Conclusions: An intensive two day program was effective in training endosonographers in some functions related to EUS-cytopathology. Incorporating basic cytopathology in EUS fellowship curriculum will likely improve the diagnostic performance of tissue acquisition and handling and lead to substantial cost and time savings for cytopathologists, because many programs do not have onsite cytopathology this training could have a major impact in advancing/improving EUS-FNA worldwide.