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Antiapoptotic protein, including Mcl-1, expression is frequently observed in pancreatic cancer. Gemcitabine plus nabpaclitaxel (GnP) is the standard chemotherapy for metastatic pancreatic cancer (MPC); however, predictive markers for its efficacy remain unestablished. This study evaluated the association between GnP’s therapeutic effects and Mcl-1 expression in tissue samples obtained using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic tumor or percutaneous ultrasound-guided biopsy for metastatic liver tumor. We retrospectively reviewed 38 patients with histologically diagnosed MPC who received GnP as the first-line chemotherapy at our institute between December 2014 and July 2018. Post-immunohistochemistry analysis for Mcl-1 expression detection, patients were divided to into two groups based on the cell proportion showing Mcl-1 immunoreactivity: positive (> 20%; 23 [60.5%] patients) and negative (≤ 20%; 15 [39.5%] patients) groups. Clinical characteristics did not differ between the two groups. The Mcl-1 positive group showed a significantly higher disease control rate (95.7% vs. 73.3%; P = 0.046), longer progressionfree survival (PFS) (7.2 months vs. 4.9 months; P = 0.018) and longer overall survival (OS) (14.9 months vs. 9.2 months; P = 0.008) than the Mcl-1 negative group. Multivariate analysis showed that Mcl-1 expression was an independent predictive marker for PFS and OS. Mcl-1 expression could be a predictive marker for favorable response to GnP. [ABSTRACT FROM AUTHOR]

Abstract Antiapoptotic protein, including Mcl-1, expression is frequently observed in pancreatic cancer. Gemcitabine plus nabpaclitaxel (GnP) is the standard chemotherapy for metastatic pancreatic cancer (MPC); however, predictive markers for its efficacy remain unestablished. This study evaluated the association between GnP’s therapeutic effects and Mcl-1 expression in tissue samples obtained using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic tumor or percutaneous ultrasound-guided biopsy for metastatic liver tumor. We retrospectively reviewed 38 patients with histologically diagnosed MPC who received GnP as the first-line chemotherapy at our institute between December 2014 and July 2018. Post-immunohistochemistry analysis for Mcl-1 expression detection, patients were divided to into two groups based on the cell proportion showing Mcl-1 immunoreactivity: positive (> 20%; 23 [60.5%] patients) and negative (≤ 20%; 15 [39.5%] patients) groups. Clinical characteristics did not differ between the two groups. The Mcl-1 positive group showed a significantly higher disease control rate (95.7% vs. 73.3%; P = 0.046), longer progressionfree survival (PFS) (7.2 months vs. 4.9 months; P = 0.018) and longer overall survival (OS) (14.9 months vs. 9.2 months; P = 0.008) than the Mcl-1 negative group. Multivariate analysis showed that Mcl-1 expression was an independent predictive marker for PFS and OS. Mcl-1 expression could be a predictive marker for favorable response to GnP.

Renal leiomyosarcoma metastasis to the pancreas is exceptionally rare. Here, we present a case of metastatic recurrence in the pancreas seven years after renal leiomyosarcoma resection. A 73-year-old female with a history of renal leiomyosarcoma surgery seven years prior presented with a well-defined 40 × 30 mm pancreatic tail tumor detected by a computed tomography (CT) scan. The tumor exhibited hypo-enhancement in the arterial phase and a progressive enhancement pattern toward the equilibrium phase, similar to pancreatic cancer. Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) revealed bundles of spindle cells that matched those in the previously resected renal sample. Immunohistochemistry showed positive staining for desmin, confirming the diagnosis of pancreatic metastasis from renal leiomyosarcoma. The patient underwent a distal pancreatectomy to remove the metastatic lesion. The extended interval of seven years before the detection of metastasis underscores the challenges in monitoring and diagnosing metastatic patterns of renal leiomyosarcoma. EUS-FNB can assist in distinguishing metastatic pancreatic leiomyosarcoma from primary pancreatic cancer, thus influencing treatment decisions. [ABSTRACT FROM AUTHOR]

Pancreatic ductal adenocarcinoma (PDAC) with a diameter ≤10 mm and high-grade pancreatic intraepithelial neoplasia (HG-PanIN) require pre-operative diagnosis. Most cases present only indirect imaging findings without visible tumors on endoscopic ultrasound (EUS). Therefore, EUS-guided fine-needle aspiration/biopsy is not applicable. An alternative diagnostic method is pancreatic juice cytology (PJC) via endoscopic naso-pancreatic drainage (ENPD-PJC), which is not the standard practice. This study aimed to investigate ENPD-PJC for diagnosing suspected PDAC/HG-PanIN cases without visible tumors on EUS. Data of patients with suspected PDAC/HG-PanIN without visible tumors who underwent PJC were retrospectively evaluated. One PJC sample was collected during endoscopic retrograde pancreatography (ERP-PJC), and 12 samples were collected during ENPD-PJC, 3-hourly for cytological analysis. ERP-PJC, ERP/ENPD-PJC, and ENPD-PJC positivity indicated cytologically positive samples. Patients with positive/negative PJC with follow-up for <4-years were excluded as undiagnosed cases. A non-malignant diagnosis was based on histopathological absence/stable imaging findings for ≥4-years. The primary endpoint was to demonstrate that ERP/ENPD-PJC has a higher diagnostic ability than ERP-PJC. Twenty-two patients with histopathologically diagnosed PDAC/HG-PanIN and 31 with a non-malignant diagnosis were enrolled. ERP-PJC, ERP/ENPD-PJC, and ENPD-PJC showed sensitivities of 36.4 %, 86.4 %, and 77.3 %, specificities of 93.5 %, 87.1 %, and 93.5 %, and accuracies of 69.8 %, 86.7 %, and 86.7 %, respectively. ERP/ENPD-PJC and ENPD-PJC demonstrated superior sensitivity and accuracy compared to ERP-PJC. A greater occurrence of positive outcomes markedly distinguished true positives from false positives. ERP/ENPD-PJC and ENPD-PJC had higher diagnostic accuracies for PDAC/HG-PanIN without visible tumors on EUS. ENPD-PJC is recommended for the diagnosis of these lesions. [ABSTRACT FROM AUTHOR]

Background/Aims Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using a 19-gauge needle is an efficient sampling method for the diagnosis of lymphadenopathy. This study compared 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma (ML). Methods Patient characteristics, number of needle passes, puncture route, sensitivity, specificity, and accuracy of cytology/histology for lymphadenopathy were analyzed in patients diagnosed with lymphadenopathy by EUS-FNA using conventional or Franseen needles. Results Between 2012 and 2022, 146 patients met the inclusion criteria (conventional [n=70] and Franseen [n=76]). The median number of needle passes was significantly lower in the conventional group than in the Franseen group (3 [1–6] vs. 4 [1–6], p=0.023). There were no significant differences in cytological/histological diagnoses between the two groups. For ML, the immunohistochemical evaluation rate, sensitivity of flow cytometry, and cytogenetic assessment were not significantly different in either group. Bleeding as adverse events (AEs) were observed in three patients in the Franseen group. Conclusions Both the 19-gauge conventional and Franseen needles showed high accuracy in lymphadenopathy and ML classification. Considering sufficient tissue collection and the avoidance of AEs, the use of 19-gauge conventional needles seems to be a good option for the diagnosis of lymphadenopathy.

Background/Aims Endoscopic ultrasound-guided tissue acquisition (EUS-TA) using Franseen needles is reportedly useful for its high diagnostic yield. This study compared the diagnostic yield and puncturing ability of EUS-TA using 22-gauge cobalt-chromium (CO-Cr) needles with those of stainless-steel Franseen needles in patients with solid pancreatic lesions. Methods Outcomes were compared between the 22-gauge Co-Cr Franseen needle (December 2019 to November 2020; group C) and stainless-steel needle (November 2020 to May 2022; group S). Results A total of 155 patients (group C, 75; group S, 80) were eligible. The diagnostic accuracy was 92.0% in group C and 96.3% in group S with no significant intergroup differences (p=0.32). The rate of change in the operator (from training fellows to experts) was 20.0% (15/75) in group C and 7.5% (6/80) in group S. Stainless-steel Franseen needles showed less inter-operator difference than Co-Cr needles (p=0.03). Conclusions Both Co-Cr and stainless-steel Franseen needles showed high diagnostic ability. Stainless-steel Franseen needles are soft and flexible; therefore, the range of puncture angles can be widely adjusted, making them suitable for training fellows to complete the procedure.

Background/Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using a 19-gauge needle is an efficient sampling method for the diagnosis of lymphadenopathy. This study compared 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma (ML). Methods: Patient characteristics, number of needle passes, puncture route, sensitivity, specificity, and accuracy of cytology/histology for lymphadenopathy were analyzed in patients diagnosed with lymphadenopathy by EUS-FNA using conventional or Franseen needles. Results: Between 2012 and 2022, 146 patients met the inclusion criteria (conventional [n=70] and Franseen [n=76]). The median number of needle passes was significantly lower in the conventional group than in the Franseen group (3 [1-6] vs. 4 [1-6], p=0.023). There were no significant differences in cytological/histological diagnoses between the two groups. For ML, the immunohistochemical evaluation rate, sensitivity of flow cytometry, and cytogenetic assessment were not significantly different in either group. Bleeding as adverse events (AEs) were observed in three patients in the Franseen group. Conclusions: Both the 19-gauge conventional and Franseen needles showed high accuracy in lymphadenopathy and ML classification. Considering sufficient tissue collection and the avoidance of AEs, the use of 19-gauge conventional needles seems to be a good option for the diagnosis of lymphadenopathy. [ABSTRACT FROM AUTHOR]

Background The role of rapid on-site evaluation (ROSE) for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic lesions is debatable. In this study, we aimed to compare the diagnostic yield of ROSE vs. non-ROSE in solid pancreatic lesions. Methods This retrospective single-center study included patients undergoing EUS-FNA of solid pancreatic lesions from 2019-2021. Patients with cystic lesions, those undergoing fine-needle core biopsy, those undergoing repeat procedures, and patients with non-diagnostic smears with less than 6-month follow up were excluded. The diagnostic yield, need for repeat procedures and number of passes required with and without ROSE were analyzed in these patients. Results Of the 111 patients included, 56 underwent ROSE. The majority of lesions were malignant in both groups (79.6% ROSE vs. 75% non-ROSE). The diagnostic yield was 96.4% in the ROSE group and 94.5% in the non-ROSE group. Repeat samples were needed in 1 ROSE and 2 non-ROSE patients. The median number of passes made was significantly fewer in the ROSE group (3.5, interquartile range - 3,4) compared with the non-ROSE group (4, interquartile range - 3,5) P=0.01. However, the frequency of procedure-related complications was similar in both groups. Conclusion The utilization of ROSE during EUS-FNA of solid pancreatic lesions does not affect the diagnostic yield or the need for repeat samples, but reduces the number of passes needed for acquiring samples. [ABSTRACT FROM AUTHOR]

Background: Pancreatic adenocarcinoma (PDAC) is associated with a 5‐year survival rate of less than 6%, and current treatments have limited efficacy. The diagnosis of PDAC is mainly based on a cytologic analysis of endoscopic ultrasound–guided fine‐needle aspiration (EUS‐FNA) samples. However, the collected specimens may prove noncontributory in a significant number of cases, delaying patient management and treatment. The combination of EUS‐FNA sample examination and KRAS mutation detection can improve the sensitivity for diagnosis. In this context, the material used for molecular analysis may condition performance. Methods: The authors prospectively compared the performance of cytologic analysis combined with a KRAS droplet digital polymerase chain reaction (ddPCR) assay for PDAC diagnosis using either conventional formalin‐fixed, paraffin‐embedded cytologic samples or needle‐rinsing fluids. Results: Molecular testing of formalin‐fixed, paraffin‐embedded cytologic samples was easier to set up, but the authors observed that the treatment of preanalytic samples, in particular the fixation process, drastically reduced ddPCR sensitivity, increasing the risk of false‐negative results. Conversely, the analysis of dedicated, fresh needle‐rinsing fluid samples appeared to be ideal for ddPCR analysis; it had greater sensitivity and was easily to implement in clinical use. In particular, fluid collection by the endoscopist, transportation to the laboratory, and subsequent freezing did not affect DNA quantity or quality. Moreover, the addition of KRAS mutation detection to cytologic examination improved diagnosis performance, regardless of the source of the sample. Conclusions: Considering all of these aspects, the authors propose the use of an integrated flowchart for the KRAS molecular testing of EUS‐FNA samples in clinical routine. The use of fresh needle‐rinsing fluid offers better sensitivity than formalin‐fixed, paraffin‐embedded cytology samples for the detection of KRAS G12/G13 mutations using droplet digital polymerase chain reaction. The addition of KRAS G12/G13 mutation detection by droplet digital polymerase chain reaction analysis to cytologic examination improves pancreatic ductal adenocarcinoma diagnostic performance compared with cytology alone and can be proposed in cases of negative or noncontributory cytologic results. [ABSTRACT FROM AUTHOR]

Objectives: To compare the diagnostic efficiency of 19G fine‐needle aspiration (FNA) and 22G fine‐needle biopsy (FNB) in endoscopic ultrasound (EUS)‐guided sampling for subepithelial tumors (SETs). Methods: The data of patients with SETs who underwent 19G FNA or 22G FNB were reviewed retrospectively in two tertiary hospitals. Tissue cores were assessed by macroscopic on‐site evaluation (MOSE). Cytological or histological diagnosis were classified as definite, suspect, or no diagnosis. Results: Seventy five patients (mean age: 55 years, 44 males) underwent 19G EUS‐FNA (31) or 22G EUS‐FNB (44). The overall diagnostic yield was 82.7%. The rate of definite cytological diagnoses was 9.7% (3/31) in 19G and 13.6% (6/44) in 22G group (x2 = 1.520, P =.468). In terms of MOSE, 19G needle, requiring only two punctures, achieved a higher good tissue core rate than 22G group (100.0% [31/31] versus 84.1% [37/44], x2 = 5.440, P =.020]). For histological diagnosis, the 19G group achieved higher definite rate than the 22G group, 93.6% (29/31) versus 65.9% (29/44) (x2 = 7.957, P =.019) on the first puncture, 90.3% (28/31) versus 63.6% (28/44) (x2 = 7.139, P =.028) on the second puncture, 96.8% (30/31) versus 70.5% (31/44) (x2 = 7.319, P =.026) on both the first and second punctures, and 96.8% (30/31) versus 72.7% (32/44) (x2 = 7.538, P =.023) on all three punctures. Conclusions: The 19G EUS‐FNA requires only two punctures to achieve better tissue core quality by MOSE and yields a higher rate of histological diagnosis than 22G ProCore needle for SETs. The bigger 19G FNA needle seems to play an important role in the evaluation of SETs. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasonography (EUS) is an important diagnostic technique to accurately diagnose diseases originating from organs near the gastrointestinal tract. EUS-guided fine-needle aspiration (FNA) has improved the histopathological diagnosis. EUS-FNA has been further developed over a long period of 40 years. The history of the development of endosonographic scopes, ultrasonographic observation systems, puncture needles, and puncture methods will provide a springboard for future development. [ABSTRACT FROM AUTHOR]

Now that tissue cores can be obtained using fine-needle biopsy (FNB) needles, the ways tissues are handled for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are changing. Direct smear, touch smear of core tissues, and centrifugation have been used for cytological examinations, and liquid-based cytology (LBC), which allows immunostaining and genetic tests that use residual samples, is emerging as an alternative. We emphasize that liquid cytology (Cytospin™ cytology and LBC) is still important, because it enables the diagnosis of pancreatic ductal adenocarcinoma (PDAC) when cancerous cells are scarce in specimens. Cell blocks are being replaced by core tissues obtained via FNB needles. Recent reports indicate that rapid on-site evaluation (ROSE) is not necessary when FNB needles are used, and macroscopic on-site evaluation is used to evaluate specimen adequacy. Macroscopic findings of specimens are helpful in the diagnostic workup and for clarifying specimen-handling methods. In addition to the red strings and white cores observed in PDAC, mixed red and white strings, gray tissues, and gelatinous tissues are observed. Gray (necrotic) tissues and gelatinous (mucus) tissues are more suitable than histology for cell block or cytological processing. Tumor cells in neuroendocrine tumors (NETs) are numerous in red strings but cannot be observed macroscopically. ROSE might thus be necessary for lesions that may be NETs. Core tissues can be used for genetic tests, such as those used for KRAS mutations and comprehensive genomic profiling. Cytological materials, including slides and LBC specimens, can also be genetic test materials. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the first-choice procedure for obtaining pathological tissue samples from gastrointestinal (GI) subepithelial lesions (SELs). However, its diagnostic accuracy is lower than that for pancreatic masses owing to puncture difficulty and the need for immunostaining for definitive diagnosis. The advent of fine-needle biopsy needles, which have become well known in recent years, improves the diagnostic accuracy of EUS-FNA for GI SELs. The forward-viewing echoendoscope and rapid on-site evaluation (ROSE) have also helped to improve diagnostic accuracy. Furthermore, in facilities where ROSE is not available, endosonographers perform a macroscopic on-site evaluation. With these procedural innovations, EUS-FNA is now performed aggressively even for SELs smaller than 20 mm. The incidence of procedure-related adverse events such as bleeding and infection is low, and thus, EUS-FNA can be safely performed to diagnose SELs. [ABSTRACT FROM AUTHOR]

Abstract Background Duodenal tuberculosis (TB) is extremely rare, and its diagnosis is challenging owing to the lack of specific symptoms and radiological or endoscopic findings. When it leads to gastric outlet obstruction (GOO), diagnosing it accurately and providing appropriate treatment is crucial. However, this is often overlooked. Case presentation A 35-year-old man presented with abdominal pain, fullness, vomiting, and weight loss. Upper gastrointestinal endoscopy and radiography revealed nearly pinpoint stenosis with edematous and reddish mucosa in the D1/D2 portion of the duodenum. Computed tomography (CT) showed the duodenal wall thickening, luminal narrowing, multiple enlarged abdominal lymph nodes, and portal vein stenosis. Conventional mucosal biopsy during endoscopy revealed ulcer scars. We initially suspected stenosis due to peptic ulcers; however, chest CT revealed cavitary lesions in both lung apices, suggesting tuberculosis. Due to the suspicion of duodenal TB and the need to obtain deeper tissue samples, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed. The tissue sample showed caseating granulomas with multinucleated giant cells, and acid-fast bacilli were positive by Ziehl–Neelsen staining. The patient was diagnosed with duodenal TB and subsequent GOO. Because the patient had difficulty eating, surgical intervention was prioritized over antitubercular drugs, and laparoscopic gastrojejunostomy was performed. The patient started an oral diet on the 3rd postoperative day and began antitubercular treatment immediately after discharge on the 11th day. During the 6th month of treatment, endoscopic examination revealed residual duodenal stenosis; however, the bypass route functioned well, and the patient remained asymptomatic. Conclusions An aggressive biopsy should be performed to diagnose duodenal TB. EUS-FNA has proven to be a useful tool in this regard. Both nutritional improvement and antitubercular treatment were achieved early and reliably by performing laparoscopic gastrojejunostomy for duodenal TB with GOO.

Background/Aims In stereomicroscopic sample isolation processing, the cutoff value (≥4 mm) of stereomicroscopically visible white cores indicates high diagnostic sensitivity. We aimed to evaluate endoscopic ultrasound-guided tissue acquisition (EUS-TA) using a simplified stereomicroscopic on-site evaluation of upper gastrointestinal subepithelial lesions (SELs). Methods In this multicenter prospective trial, we performed EUS-TA using a 22-gauge Franseen needle in 34 participants with SELs derived from the upper gastrointestinal muscularis propria, requiring pathological diagnosis. The presence of stereomicroscopically visible white core (SVWC) in each specimen was assessed using stereomicroscopic on-site evaluation. The primary outcome was EUS-TA’s diagnostic sensitivity with stereomicroscopic on-site evaluation based on the SVWC cutoff value (≥4 mm) for malignant upper gastrointestinal SELs. Results The total number of punctures was 68; 61 specimens (89.7%) contained stereomicroscopically visible white cores ≥4 mm in size. The final diagnoses were gastrointestinal stromal tumor, leiomyoma, and schwannoma in 76.5%, 14.7%, and 8.8% of the cases, respectively. The sensitivity of EUS-TA with stereomicroscopic on-site evaluation based on the SVWC cutoff value for malignant SELs was 100%. The per-lesion accuracy of histological diagnosis reached the highest level (100%) at the second puncture. Conclusions Stereomicroscopic on-site evaluation showed high diagnostic sensitivity and could be a new method for diagnosing upper gastrointestinal SELs using EUS-TA.

Background: Duodenal tuberculosis (TB) is extremely rare, and its diagnosis is challenging owing to the lack of specific symptoms and radiological or endoscopic findings. When it leads to gastric outlet obstruction (GOO), diagnosing it accurately and providing appropriate treatment is crucial. However, this is often overlooked. Case presentation: A 35-year-old man presented with abdominal pain, fullness, vomiting, and weight loss. Upper gastrointestinal endoscopy and radiography revealed nearly pinpoint stenosis with edematous and reddish mucosa in the D1/D2 portion of the duodenum. Computed tomography (CT) showed the duodenal wall thickening, luminal narrowing, multiple enlarged abdominal lymph nodes, and portal vein stenosis. Conventional mucosal biopsy during endoscopy revealed ulcer scars. We initially suspected stenosis due to peptic ulcers; however, chest CT revealed cavitary lesions in both lung apices, suggesting tuberculosis. Due to the suspicion of duodenal TB and the need to obtain deeper tissue samples, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed. The tissue sample showed caseating granulomas with multinucleated giant cells, and acid-fast bacilli were positive by Ziehl–Neelsen staining. The patient was diagnosed with duodenal TB and subsequent GOO. Because the patient had difficulty eating, surgical intervention was prioritized over antitubercular drugs, and laparoscopic gastrojejunostomy was performed. The patient started an oral diet on the 3rd postoperative day and began antitubercular treatment immediately after discharge on the 11th day. During the 6th month of treatment, endoscopic examination revealed residual duodenal stenosis; however, the bypass route functioned well, and the patient remained asymptomatic. Conclusions: An aggressive biopsy should be performed to diagnose duodenal TB. EUS-FNA has proven to be a useful tool in this regard. Both nutritional improvement and antitubercular treatment were achieved early and reliably by performing laparoscopic gastrojejunostomy for duodenal TB with GOO. [ABSTRACT FROM AUTHOR]

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Background: Accurate diagnosis of pancreatic lesions by endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) or fine‐needle biopsy can be challenging. Although surrogate immunohistochemical markers for genetic alterations associated with pancreatic ductal adenocarcinoma (PDAC) have been identified, they have modest sensitivity. Biallelic loss of CDKN2A occurs in up to 46% of PDACs, and methylthioadenosine phosphorylase (MTAP) immunohistochemistry (IHC) has been identified as a reliable surrogate marker for this alteration. The current study evaluates the utility of MTAP IHC for the diagnosis of PDAC. Methods: In total, 136 cases of EUS‐FNA cell block or core biopsy targeting solid pancreatic masses were identified. MTAP IHC was performed and evaluated for complete loss of expression in neoplastic cells. These results were correlated with available clinical next‐generation sequencing that was performed on a subset of cases. Results: Complete loss of MTAP expression was identified in 23 of 80 (29%) PDACs. A subset of cases classified as suspicious (4 of 21) and atypical (4 of 22) showed MTAP loss. All morphologically indeterminate cases with MTAP loss were confirmed as PDAC on resection/additional sampling. No benign samples (n = 13) showed loss of MTAP. In samples that had available clinical next‐generation sequencing data (n = 13), copy number loss of CDKN2A was detected in all cases that had loss of MTAP expression (n = 4). Conclusions: Loss of MTAP was identified in approximately 30% of PDAC small biopsy specimens. As loss of MTAP expression is not expected in nonneoplastic cells, and these findings suggest that MTAP IHC can support a diagnosis of PDAC in small biopsy samples. MTAP immunohistochemistry is a useful marker for the diagnosis of pancreatic ductal adenocarcinoma in fine‐needle aspirates and small biopsy specimens of solid pancreatic masses. [ABSTRACT FROM AUTHOR]

EUS-FNA/B for pancreatic ductal adenocarcinoma (PDAC) is generally considered to be safe; however, while the incidence is low, there are occurrences of complications. Among these complications, there are serious ones like needle tract seeding (NTS), and it is not known than which types of tumors have the risks of EUS-FNA/B complications. This study aimed to evaluate the risk of EUS-FNA/B complications in patients with PDAC, focusing on morphological features. Overall, 442 patients who underwent EUS-FNA/B for solid pancreatic masses between January 2018 and May 2022 in four institutions were retrospectively surveyed. Finally, 361 patients histopathologically diagnosed with PDAC were analyzed. Among these patients, 79 tumors with cysts or necrotic components were compared with 282 tumors without cysts or necrotic components. The incidence and risk of EUS-FNA/B complications including NTS were evaluated. There were 9 (2.4 %) of total EUS-FNA/B complications and 3 (0.8 %) of NTS. The incidence of total complication rate and NTS in tumors with cysts or necrotic components were significantly higher than in those without cysts or necrotic components (total complication 6.3 % vs. 1.4 %, p = 0.026, NTS 3.7 % vs. 0 %, p = 0.01). The transgastric route of puncture (OR: 93.3, 95 % CI: 3.81–2284.23) and the existence of cysts or necrotic components (OR: 7.3, 95 % CI: 1.47–36.19) were risk factors for EUS-FNA/B complications identified by the multivariate analysis. We should pay attention to the risks of EUS-FNA/B complications, including NTS, when the tumor has cysts or necrotic components. [ABSTRACT FROM AUTHOR]

Abstract Background and Aim Reports have indicated that a surface area of 4 mm2 or more of collected tissue sections could provide the recommended total DNA for the OncoGuide NCC Oncopanel system, which is a cancer gene panel test developed in Japan. We wished to compare the percentage of tissue sections collected by endoscopic ultrasound‐assisted tissue acquisition (EUS‐TA) with surface areas of ≥4 mm2 between a conventional needle, namely the EZ Shot 3 Plus (Olympus Medical Japan, Tokyo, Japan) (EZ3), and the recent SonoTip TopGain (MediGlobe, Rohrdorf, Germany) (TopGain). Method From April 2010 to December 2021, among 693 EUS‐TA cases, EZ3 was used in 390 cases and TopGain in 45. The EZ3 and TopGain groups were matched in a 1:1 ratio with a tolerance of 0.2, with 35 patients each matched using propensity score analysis. Results The TopGain group had a significantly higher percentage of cases with a tissue area of ≥4 mm2 than the EZ3 group (42.9% vs 68.6%, P = 0.030). Multivariate analysis revealed an association between TopGain and tissue areas of ≥4 mm2 (odds ratio 2.996, 95% confidence interval 1.068–8.403, P = 0.037). Conclusions EUS‐TA using TopGain significantly collected more ≥4 mm2 tissue area compared with EZ3, suggesting its usefulness for cancer gene panel testing.

Abstract Background and Aims Endoscopic ultrasonography‐guided fine‐needle aspiration/biopsy (EUS‐FNA/B) is considered to be a first‐line procedure for the pathological diagnosis of pancreatic cancer owing to its high accuracy and low complication rate. The number of new cases of pancreatic ductal adenocarcinoma (PDAC) is increasing, and its accurate pathological diagnosis poses a challenge for cytopathologists. Our aim was to develop a hyperspectral imaging (HSI)‐based convolution neural network (CNN) algorithm to aid in the diagnosis of pancreatic EUS‐FNA cytology specimens. Methods HSI images were captured of pancreatic EUS‐FNA cytological specimens from benign pancreatic tissues (n = 33) and PDAC (n = 39) prepared using a liquid‐based cytology method. A CNN was established to test the diagnostic performance, and Attribution Guided Factorization Visualization (AGF‐Visualization) was used to visualize the regions of important classification features identified by the model. Results A total of 1913 HSI images were obtained. Our ResNet18‐SimSiam model achieved an accuracy of 0.9204, sensitivity of 0.9310 and specificity of 0.9123 (area under the curve of 0.9625) when trained on HSI images for the differentiation of PDAC cytological specimens from benign pancreatic cells. AGF‐Visualization confirmed that the diagnoses were based on the features of tumor cell nuclei. Conclusions An HSI‐based model was developed to diagnose cytological PDAC specimens obtained using EUS‐guided sampling. Under the supervision of experienced cytopathologists, we performed multi‐staged consecutive in‐depth learning of the model. Its superior diagnostic performance could be of value for cytologists when diagnosing PDAC.

Abstract Scirrhous gastric cancer (SGC) is diagnosed using endoscopy and/or biopsy; however, SGC diagnosis remains challenging owing to its special growth form and morphologic features. Hence, endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA), which is minimally invasive and has a high proportion of diagnostic tissue, may be an alternative investigative modality for patients with suspected SGC. This systematic review and meta‐analysis aimed to identify and evaluate the evidence for the efficacy and safety of EUS‐FNA in patients with suspected SGC. We conducted a systematic review using the PubMed (MEDLINE) and Ichushi‐Web (NPO Japan Medical Abstracts Society) databases and included all entries in which SGC was evaluated using EUS‐FNA in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement from the databases′ inception to October 10, 2022. The primary outcome was the proportion of SGC diagnosed using EUS‐FNA. In addition, we analyzed the proportion of adverse events associated with EUS‐FNA. The electronic search identified 1890 studies; overall, four studies met the selection criteria and reported data on EUS‐FNA performed on 114 patients with suspected SGC. The overall diagnostic yield of EUS‐FNA for SGC was 82.6% (95% confidence interval, 74.6–90.6%) and the statistical heterogeneity was 0% (I2 = 0%), indicating a low heterogeneity. Furthermore, the EUS‐FNA diagnostic proportion for SGC lymph node metastasis was 75–100%, indicating a high diagnostic performance. The adverse event rate of EUS‐FNA was 0%. EUS‐FNA may be an alternative investigation mode for SGC patients with negative esophagogastroduodenoscopy‐biopsy results.

Aim: There are few reports on the safety of endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) in the elderly. In this study, we investigated the safety of EUS‐FNA for pancreatic solid masses in patients aged ≥80 years. Methods: This is a single‐center retrospective study. A total of 600 patients with pancreatic solid masses who underwent EUS‐FNA under midazolam‐based sedation at our institution between September 2016 and December 2022 were enrolled in this study. Eligible patients were divided into two groups: an elderly group aged ≥80 (n = 84), as well as a nonelderly group aged ≤79 (n = 516). These two groups were compared. Results: The elderly group required significantly fewer midazolam doses for sedation (P < 0.001). Adverse events occurred in eight patients (1.3%), including one (1.2%) and seven (1.4%) in the elderly and nonelderly groups, respectively (P = 0.90). There were no cases of early adverse events in the elderly group and six cases (1.2%) in the nonelderly group (P = 0.32). There was one case of late adverse events in both the elderly and nonelderly groups (P = 0.14), and both were needle tract seeding. There was no significant difference between the two groups in the proportion of cases in which percutaneous oxygen saturation decreased to ≤90% during the EUS‐FNA. Conclusions: Our analysis suggests that EUS‐FNA for pancreatic solid masses can be safely performed in patients aged >80 years without increasing the adverse event rate compared to nonelderly patients aged <80 years. Geriatr Gerontol Int 2023; 23: 836–841. [ABSTRACT FROM AUTHOR]

Purpose: The main objective of the present study is to compare the safety, technical success and diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) versus ultrasound-guided percutaneous core-needle biopsy (US-CNB) in patients with solid pancreatic lesions. Methods: This is a retrospective study that involved all patients with a solid pancreatic lesion who underwent EUS-FNA or US-CNB between November 2019 and February 2021. Of all patients, 69 (84.1%) had inoperable malignancy, whereas 13 (15.9%) had chronic pancreatitis. Resectability status was ascertained by computed tomography. All core needle biopsies were performed by the same interventional radiologist via ultrasound guidance with an 18-gauge semi-automatic tru-cut needle. All EUS-FNA procedures were performed by the same gastroenterologist with a 27-gauge EUS-FNA needle. Technical success is defined as if the region of interest is reached and specimen taken from the pancreatic lesion. Diagnostic yield is defined as the procurement of sufficient tissue for pathological examination. Results: Overall, 52 patients (mean age 58.5 ± 9.8 years) who underwent EUS-FNA and 30 patients (60.1 ± 12.1 years) who underwent US-CNB were included. Solid lesions were most commonly (61.5% in EUS-FNA and 50.0% in US-CNB groups) located in pancreatic head in both groups. Mean size of the lesions was comparable in both groups as well. The technical success was 100% in both groups. In 12 (14.6%) patients, pathology results revealed inadequate sampling (11 × in the EUS-FNA and 1 × in the US-CNB group). The diagnostic yield was significantly higher in US-CNB group than in EUS-FNA group (96.7% vs. 78.8%, respectively, p = 0.048). Of 11 patients in the EUS-FNA with inadequate sampling, pancreatic lesions were located in the pancreatic head in 7 (63.6%). No major complications were observed in neither of the groups. As a minor complication, one case of slight abdominal pain was detected in the EUS-FNA group. Conclusion: Based on the results of the present study, both US-CNB and EUS-FNA appeared safe; however, diagnostic yield in the US-CNB group was significantly higher. [ABSTRACT FROM AUTHOR]

Solid pancreatic lesions (SPLs) encompass a variety of benign and malignant diseases and accurate diagnosis is crucial for guiding appropriate treatment decisions. Endoscopic ultrasonography-guided fine-needle aspiration/biopsy (EUS-FNA/B) serves as a front-line diagnostic tool for pancreatic mass lesions and is widely used in clinical practice. Artificial intelligence (AI) is a mathematical technique that automates the learning and recognition of data patterns. Its strong self-learning ability and unbiased nature have led to its gradual adoption in the medical field. In this paper, we describe the fundamentals of AI and provide a summary of reports on AI in EUS-FNA/B to help endoscopists understand and realize its potential in improving pathological diagnosis and guiding targeted EUS-FNA/B. However, AI models have limitations and shortages that need to be addressed before clinical use. Furthermore, as most AI studies are retrospective, large-scale prospective clinical trials are necessary to evaluate their clinical usefulness accurately. Although AI in EUS-FNA/B is still in its infancy, the constant input of clinical data and the advancements in computer technology are expected to make computer-aided diagnosis and treatment more feasible. [ABSTRACT FROM AUTHOR]

Background and Aim: Reports have indicated that a surface area of 4 mm2 or more of collected tissue sections could provide the recommended total DNA for the OncoGuide NCC Oncopanel system, which is a cancer gene panel test developed in Japan. We wished to compare the percentage of tissue sections collected by endoscopic ultrasound‐assisted tissue acquisition (EUS‐TA) with surface areas of ≥4 mm2 between a conventional needle, namely the EZ Shot 3 Plus (Olympus Medical Japan, Tokyo, Japan) (EZ3), and the recent SonoTip TopGain (MediGlobe, Rohrdorf, Germany) (TopGain). Method: From April 2010 to December 2021, among 693 EUS‐TA cases, EZ3 was used in 390 cases and TopGain in 45. The EZ3 and TopGain groups were matched in a 1:1 ratio with a tolerance of 0.2, with 35 patients each matched using propensity score analysis. Results: The TopGain group had a significantly higher percentage of cases with a tissue area of ≥4 mm2 than the EZ3 group (42.9% vs 68.6%, P = 0.030). Multivariate analysis revealed an association between TopGain and tissue areas of ≥4 mm2 (odds ratio 2.996, 95% confidence interval 1.068–8.403, P = 0.037). Conclusions: EUS‐TA using TopGain significantly collected more ≥4 mm2 tissue area compared with EZ3, suggesting its usefulness for cancer gene panel testing. [ABSTRACT FROM AUTHOR]

Abstract Background and Aims Distinguishing pancreatic cancer from nonneoplastic masses is critical and remains a clinical challenge. The study aims to construct a deep learning‐based artificial intelligence system to facilitate pancreatic mass diagnosis, and to guide EUS‐guided fine‐needle aspiration (EUS‐FNA) in real time. Methods This is a prospective study. The CH‐EUS MASTER system is composed of Model 1 (real‐time capture and segmentation) and Model 2 (benign and malignant identification). It was developed using deep convolutional neural networks and Random Forest algorithm. Patients with pancreatic masses undergoing CH‐EUS examinations followed by EUS‐FNA were recruited. All patients underwent CH‐EUS and were diagnosed both by endoscopists and CH‐EUS MASTER. After diagnosis, they were randomly assigned to undergo EUS‐FNA with or without CH‐EUS MASTER guidance. Results Compared with manual labeling by experts, the average overlap rate of Model 1 was 0.708. In the independent CH‐EUS video testing set, Model 2 generated an accuracy of 88.9% in identifying malignant tumors. In clinical trial, the accuracy, sensitivity, and specificity for diagnosing pancreatic masses by CH‐EUS MASTER were significantly better than that of endoscopists. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were respectively 93.8%, 90.9%, 100%, 100%, and 83.3% by CH‐EUS MASTER guided EUS‐FNA, and were not significantly different compared to the control group. CH‐EUS MASTER‐guided EUS‐FNA significantly improved the first‐pass diagnostic yield. Conclusion CH‐EUS MASTER is a promising artificial intelligence system diagnosing malignant and benign pancreatic masses and may guide FNA in real time. Trial registration number: NCT04607720.

Background and Aims: Endoscopic ultrasonography‐guided fine‐needle aspiration/biopsy (EUS‐FNA/B) is considered to be a first‐line procedure for the pathological diagnosis of pancreatic cancer owing to its high accuracy and low complication rate. The number of new cases of pancreatic ductal adenocarcinoma (PDAC) is increasing, and its accurate pathological diagnosis poses a challenge for cytopathologists. Our aim was to develop a hyperspectral imaging (HSI)‐based convolution neural network (CNN) algorithm to aid in the diagnosis of pancreatic EUS‐FNA cytology specimens. Methods: HSI images were captured of pancreatic EUS‐FNA cytological specimens from benign pancreatic tissues (n = 33) and PDAC (n = 39) prepared using a liquid‐based cytology method. A CNN was established to test the diagnostic performance, and Attribution Guided Factorization Visualization (AGF‐Visualization) was used to visualize the regions of important classification features identified by the model. Results: A total of 1913 HSI images were obtained. Our ResNet18‐SimSiam model achieved an accuracy of 0.9204, sensitivity of 0.9310 and specificity of 0.9123 (area under the curve of 0.9625) when trained on HSI images for the differentiation of PDAC cytological specimens from benign pancreatic cells. AGF‐Visualization confirmed that the diagnoses were based on the features of tumor cell nuclei. Conclusions: An HSI‐based model was developed to diagnose cytological PDAC specimens obtained using EUS‐guided sampling. Under the supervision of experienced cytopathologists, we performed multi‐staged consecutive in‐depth learning of the model. Its superior diagnostic performance could be of value for cytologists when diagnosing PDAC. [ABSTRACT FROM AUTHOR]

Scirrhous gastric cancer (SGC) is diagnosed using endoscopy and/or biopsy; however, SGC diagnosis remains challenging owing to its special growth form and morphologic features. Hence, endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA), which is minimally invasive and has a high proportion of diagnostic tissue, may be an alternative investigative modality for patients with suspected SGC. This systematic review and meta‐analysis aimed to identify and evaluate the evidence for the efficacy and safety of EUS‐FNA in patients with suspected SGC. We conducted a systematic review using the PubMed (MEDLINE) and Ichushi‐Web (NPO Japan Medical Abstracts Society) databases and included all entries in which SGC was evaluated using EUS‐FNA in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement from the databases′ inception to October 10, 2022. The primary outcome was the proportion of SGC diagnosed using EUS‐FNA. In addition, we analyzed the proportion of adverse events associated with EUS‐FNA. The electronic search identified 1890 studies; overall, four studies met the selection criteria and reported data on EUS‐FNA performed on 114 patients with suspected SGC. The overall diagnostic yield of EUS‐FNA for SGC was 82.6% (95% confidence interval, 74.6–90.6%) and the statistical heterogeneity was 0% (I2 = 0%), indicating a low heterogeneity. Furthermore, the EUS‐FNA diagnostic proportion for SGC lymph node metastasis was 75–100%, indicating a high diagnostic performance. The adverse event rate of EUS‐FNA was 0%. EUS‐FNA may be an alternative investigation mode for SGC patients with negative esophagogastroduodenoscopy‐biopsy results. [ABSTRACT FROM AUTHOR]

Background/Aims Immune checkpoint blockade has recently been reported to be effective in treating microsatellite instability (MSI)-high tumors. Therefore, sufficient sampling of histological specimens is necessary in cases of unresectable pancreatic cancer (UR-PC). This multicenter study investigated the efficacy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) using a Franseen needle for MSI evaluation in patients with UR-PC. Methods A total of 89 patients with UR-PC who underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or EUS-FNB using 22-G needles at three hospitals in Japan (2018–2021) were enrolled. Fifty-six of these patients (FNB 23 and FNA 33) were followed up or evaluated for MSI. Patient characteristics, UR-PC data, and procedural outcomes were compared between patients who underwent EUS-FNB and those who underwent EUS-FNA. Results No significant difference in terms of sufficient tissue acquisition for histology was observed between patients who underwent EUS-FNB and those who underwent EUS-FNA. MSI evaluation was possible significantly more with tissue samples obtained using EUS-FNB than with tissue samples obtained using EUS-FNA (82.6% [19/23] vs. 45.5% [15/33], respectively; p

Introduction: Imaging diagnosis of pancreatic solid-pseudopapillary neoplasms (SPNs) is difficult. Preoperative diagnosis by endosonography-guided fine-needle aspiration (EUS-FNA) is possible and has been reported in the literature in pancreatic tumors. However, its usefulness is still controversial. The aim of this study was to determine the accuracy of the EUS-FNA in the diagnosis of patients with SPN and describe the findings in computerized tomography (CT), magnetic resonance cholangiopancreatography imaging (MRI/MRCP), and EUS therefore comparing the imaging methods alone to the findings of microhistology (McH) obtained by EUS-FNA. Materials and Methods: We retrospectively reviewed the medical records of patients undergoing EUS-FNA with suspected SPN in imaging studies in 5 Brazilian high-volume hospitals (two university hospitals and three private hospitals). The demographic data; findings in CT, MRI/MRCP, and EUS; and McH results obtained by EUS-FNA were noted prospectively. The final diagnosis was obtained after the anatomopathological examination of the surgical specimen in all patients (gold standard), and we compared the results of CT, MRI/MRCP, EUS, and the McH with the gold standard. Results: Fifty-four patients were included in the study, of which 49 (90.7%) were women with an average age of 33.4 (range 11–78) years. The most common symptom presented was abdominal pain, present in 35.2% patients. SPN was detected incidentally in 32 (59%) patients. The average size of the tumors was 3.8 cm (SD: 2.26). The most common finding at EUS was a solid, solid/cystic, and cystic lesion in 52.9%, 41.1%, and 7.8% patients, respectively. The final diagnosis was 51 patients with SPN and 3 with nonfunctioning pancreatic neuroendocrine tumors (NF-NET). The correct diagnosis was made by CT, MRI/MRCP, EUS isolated, and EUS-FNA in 21.9%, 28.88%, 64.71%, and 88.24%, respectively. EUS-FNA associated with CT and MRI increased diagnostic performance from 22.72% to 94.11% and from 29.16% to 94.11%, respectively. Conclusions: SPN are rare, incidentally identified in most cases, and affect young women. Differential diagnosis between SPN, NF-NET, and other types of tumors with imaging tests can be difficult. EUS-FNA increases preoperative diagnosis in case of diagnostic doubt and should be used whenever necessary to rule out NF-NET or other type of solid/cystic nodular lesion of the pancreas.

Background and Aims: Distinguishing pancreatic cancer from nonneoplastic masses is critical and remains a clinical challenge. The study aims to construct a deep learning‐based artificial intelligence system to facilitate pancreatic mass diagnosis, and to guide EUS‐guided fine‐needle aspiration (EUS‐FNA) in real time. Methods: This is a prospective study. The CH‐EUS MASTER system is composed of Model 1 (real‐time capture and segmentation) and Model 2 (benign and malignant identification). It was developed using deep convolutional neural networks and Random Forest algorithm. Patients with pancreatic masses undergoing CH‐EUS examinations followed by EUS‐FNA were recruited. All patients underwent CH‐EUS and were diagnosed both by endoscopists and CH‐EUS MASTER. After diagnosis, they were randomly assigned to undergo EUS‐FNA with or without CH‐EUS MASTER guidance. Results: Compared with manual labeling by experts, the average overlap rate of Model 1 was 0.708. In the independent CH‐EUS video testing set, Model 2 generated an accuracy of 88.9% in identifying malignant tumors. In clinical trial, the accuracy, sensitivity, and specificity for diagnosing pancreatic masses by CH‐EUS MASTER were significantly better than that of endoscopists. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were respectively 93.8%, 90.9%, 100%, 100%, and 83.3% by CH‐EUS MASTER guided EUS‐FNA, and were not significantly different compared to the control group. CH‐EUS MASTER‐guided EUS‐FNA significantly improved the first‐pass diagnostic yield. Conclusion: CH‐EUS MASTER is a promising artificial intelligence system diagnosing malignant and benign pancreatic masses and may guide FNA in real time. Trial registration number: NCT04607720. [ABSTRACT FROM AUTHOR]

On computed tomography scanning, a 63-year-old man with vomiting and anorexia was discovered to have a mass in the pancreatic body and a retroperitoneal mass extending to the right lobe of the liver. An esophagogastroduodenoscopy revealed an advanced gastric carcinoma in the middle gastric body, and a biopsy specimen revealed a poorly differentiated adenocarcinoma. The pancreatic and retroperitoneal masses were considered metastatic lesions of gastric cancer, and a biopsy was taken from the pancreatic lesion using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The histology of the EUS-FNA pancreatic specimen revealed atypical spindle-shaped cells and increased stromal collagen fibrosis, and liposarcoma was considered. Conversely, a percutaneous ultrasound-guided biopsy was taken for the retroperitoneal lesion, and the histology revealed that it was a dedifferentiated liposarcoma. On the basis of histopathological and imaging findings, the retroperitoneal liposarcoma was identified as the primary lesion, the pancreatic lesion as a metastasis of the primary liposarcoma, and the gastric carcinoma as an independent tumor. As far as we know, there have only been three reports of metastatic pancreatic liposarcoma diagnosed via EUS-FNA. In this case, the patient also had gastric cancer, and EUS-FNA was helpful in differentiating metastatic pancreatic tumors from gastric cancer. [ABSTRACT FROM AUTHOR]

This study evaluated the feasibility and clinical utility of liquid-based cytology (LBC) specimens via endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) for next-generation sequencing (NGS) of pancreatic cancer (PC). We prospectively evaluated the performance of DNA extraction and NGS using EUS-FNB samples obtained from PC. Thirty-three consecutive patients with PC who underwent EUS-FNB at our hospital were enrolled. DNA samples were obtained from 96.8% of the patients. When stratified with a variant allele frequency (VAF) > 10% tumor burden, the NGS success rate was 76.7% (n = 23) in formalin-fixed paraffin-embedded (FFPE), 83.3% (n = 25) in LBC, and 76.7% (n = 23) in frozen samples. The overall NGS success rate was 86.7% (n = 26) using FFPE, LBC, or frozen samples. The detection rates for the main mutated genes were as follows: 86.7% for KRAS, 73.3% for TP53, 66.7% for CDKN2A, 36.7% for SMAD4, and 16.7% for ARID1A. LBC had the highest median value of VAF (23.5%) for KRAS and TP53. PC mutation analysis using NGS was successfully performed using LBC compared with FFPE and frozen samples. This approach provides an alternative and affordable source of molecular testing materials. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is useful for the diagnosis of pancreatic masses. According to three meta-analyses, the sensitivity, specificity, and accuracy of EUS-FNA are 84–92%, 96–98%, and 86–91%, respectively. However, the occurrence of false-negative and false-positive results indicates that the diagnostic performance of EUS-FNA needs to be improved. Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is used for the characterization of pancreatic masses and can be applied to improve the performance of EUS-FNA. When CH-EUS is used to evaluate intratumor blood flow, an avascular area inside the pancreatic mass that is considered to be fibrosis is often detected. This area can be avoided by performing EUS-FNA under CH-EUS guidance. In this review, we summarize the data on contrast-enhanced harmonic endoscopic ultrasound-guided fine-needle aspiration (CH-EUS-FNA), which suggest that its benefit is still a matter of debate. Of eight studies analyzed, only one showed that CH-EUS improved the sensitivity of EUS-FNA. The future challenge is to determine under what circumstances CH-EUS-FNA is useful. [ABSTRACT FROM AUTHOR]

A 66‐year‐old man underwent a single endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) session and distal pancreatectomy for the pancreatic body adenocarcinoma measuring 12 mm in diameter. At 3 years after surgery, we diagnosed needle tract seeding (NTS) and performed total gastrectomy. NTS can occur with small tumors or after a single session of EUS‐FNA. [ABSTRACT FROM AUTHOR]

Background/Aims: Three-dimensional cultures of human pancreatic cancer tissue also known as “organoids” have largely been developed from surgical specimens. Given that most patients present with locally advanced and/or metastatic disease, such organoids are not representative of the majority of patients. Therefore, we used endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to collect pancreatic cancer tissues from patients with advanced pancreatic cancer to create organoids, and evaluated their utility in pancreatic cancer research. Methods: Single-pass EUS-FNA samplings were employed to obtain the tissue for organoid generation. After establishment of the organoid, we compared the core biopsy tissues with organoids using hematoxylin and eosin staining, and performed whole exome sequencing (WES) to detect mutational variants. Furthermore, we compared patient outcome with the organoid drug response to determine the potential utility of the clinical application of such organoid-based assays. Results: Organoids were successfully generated in 14 of 20 tumors (70%) and were able to be passaged greater than 5 times in 12 of 20 tumors (60%). Among them, we selected eight pairs of organoid and core biopsy tissues for detailed analyses. They showed similar patterns in hematoxylin and eosin staining. WES revealed mutations in KRAS, TP53, CDKN2A, SMAD4, BRCA1, and BRCA2 which were 93% homologous, and the mean nonreference discordance rate was 5.47%. We observed moderate drug response correlations between the organoids and clinical outcomes in patients who underwent FOLFIRINOX chemotherapy. Conclusions: The established organoids from EUS-FNA core biopsies can be used for a suitable model system for pancreatic cancer research.

Abstract A 66‐year‐old man underwent a single endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) session and distal pancreatectomy for the pancreatic body adenocarcinoma measuring 12 mm in diameter. At 3 years after surgery, we diagnosed needle tract seeding (NTS) and performed total gastrectomy. NTS can occur with small tumors or after a single session of EUS‐FNA.

Background/Aims: Immune checkpoint blockade has recently been reported to be effective in treating microsatellite instability (MSI)- high tumors. Therefore, sufficient sampling of histological specimens is necessary in cases of unresectable pancreatic cancer (UR-PC). This multicenter study investigated the efficacy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) using a Franseen needle for MSI evaluation in patients with UR-PC. Methods: A total of 89 patients with UR-PC who underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or EUS-FNB using 22-G needles at three hospitals in Japan (2018-2021) were enrolled. Fifty-six of these patients (FNB 23 and FNA 33) were followed up or evaluated for MSI. Patient characteristics, UR-PC data, and procedural outcomes were compared between patients who underwent EUS-FNB and those who underwent EUS-FNA. Results: No significant difference in terms of sufficient tissue acquisition for histology was observed between patients who underwent EUS-FNB and those who underwent EUS-FNA. MSI evaluation was possible significantly more with tissue samples obtained using EUS-FNB than with tissue samples obtained using EUS-FNA (82.6% [19/23] vs. 45.5% [15/33], respectively; p<0.01). In the multivariate analysis, EUS-FNB was the only significant factor influencing the possibility of MSI evaluation. Conclusions: EUS-FNB using a Franseen needle is desirable for ensuring sufficient tissue acquisition for MSI evaluation. [ABSTRACT FROM AUTHOR]

Esophageal tuberculosis (ET) is a rare infectious disease of the gastrointestinal tract. Awareness of ET is deficient due to its low incidence. Unexplained dysphagia and upper gastrointestinal bleeding are the most common symptoms of ET. The prognosis is generally good if patients are diagnosed properly and receive anti-tubercular treatment promptly. However, ET is difficult to differentiate from other diseases. Endoscopic techniques such as esophagogastroduodenoscopy (EGD), endoscopic ultrasonography (EUS), contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS), elastography, and endoscopic ultrasound--guided fine-needle aspiration (EUS-FNA) improve the diagnosis of ET. Thus, the characteristics of ET and other difficult-to-detect diseases according to EGD and EUS were summarized. Intriguingly, there is no literature relevant to the application of CH-EUS and elastography in ET. The authors' research center was first in introducing CH-EUS and elastography into the field of ET. The specific manifestation of ET based on CH-EUS was discovered for the first time. Correlative experience and representative cases were shared. The role of endoscopy in acquiring esophageal specimens and treatment for ET was also established. In this review, we aim to introduce a promising technology for the diagnosis and treatment of ET. [ABSTRACT FROM AUTHOR]

Objectives: Suction pressure is one of the most important factors influencing the amount of tissue obtained during endoscopic ultrasound‐guided fine‐needle aspiration/biopsy (EUS‐FNA/FNB). In this study we aimed to elucidate actual suction pressure generated by various suction methods and the weight of suctioning liquid. Methods: Different types of fine needles and suction techniques were used, including the slow pull technique (SPT), dry suction technique (DST), wet suction technique (WST), neutralizing negative pressure technique (NNPT), and residual negative pressure technique (RNPT). Actual suction pressure was measured and the amount of suctioning liquid was weighed. Results: Actual suction pressure and weight of the suctioning liquid were lower using SPT than using DST, while they were higher when using WST compared with those using DST. In general, the actual suction pressure increased and the weight of suctioning liquid decreased as the diameter of the FNA needles decreased. While weight of the suctioning liquid using FNB needles was significantly larger than that using FNA needles. In general, the actual suction pressure generated using RNPT was larger than that using NNPT. Conclusions: WST is superior to SPT and DST in terms of actual suction pressure and weight of suctioning liquid. Diameter of the FNA needle was an important factor that may affect the actual suction pressure and weight of suctioning liquid. FNB needles are superior to FNA needles when it comes to the weight of suctioning liquid. Actual suction pressure obtained by novel suction methods (NNPT and RNPT) may provide a basis for future research. [ABSTRACT FROM AUTHOR]

Biloma is a severe complication that can result from bile duct disruption or hepatic trauma. It can occur after biliary surgery such as cholecystectomy or an endoscopic retrograde cholangiopancreatography manipulation and endoscopic biliary sphincterotomy. We present the case of a 59-year-old man admitted for jaundice, with pain in his right flank and fever, 10 days after an endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for an ill-defined pancreatic lesion, associated with an infected biloma. Severe complications can occur after an EUS-FNA; therefore, this diagnosis should not be neglected after the intervention in symptomatic patients, to ensure an early and proper treatment.

Solid pancreatic lesions (SPLs) encompass a variety of benign and malignant diseases and accurate diagnosis is crucial for guiding appropriate treatment decisions. Endoscopic ultrasonography-guided fine-needle aspiration/biopsy (EUS-FNA/B) serves as a front-line diagnostic tool for pancreatic mass lesions and is widely used in clinical practice. Artificial intelligence (AI) is a mathematical technique that automates the learning and recognition of data patterns. Its strong self-learning ability and unbiased nature have led to its gradual adoption in the medical field. In this paper, we describe the fundamentals of AI and provide a summary of reports on AI in EUS-FNA/B to help endoscopists understand and realize its potential in improving pathological diagnosis and guiding targeted EUS-FNA/B. However, AI models have limitations and shortages that need to be addressed before clinical use. Furthermore, as most AI studies are retrospective, large-scale prospective clinical trials are necessary to evaluate their clinical usefulness accurately. Although AI in EUS-FNA/B is still in its infancy, the constant input of clinical data and the advancements in computer technology are expected to make computer-aided diagnosis and treatment more feasible.

Background/Aims Several fine-needle biopsy (FNB) needles are available for endoscopic ultrasound (EUS)-guided tissue acquisition. However, there is disagreement on which type of needle has the best diagnostic yield. The aim of this study was to compare the performance and safety of two commonly used EUS-FNB needles. Methods We retrospectively analyzed consecutive patients who underwent EUS-FNB between June 2016 and March 2020 in our hospital. Two types of needles were evaluated: a 20-gauge Menghini needle with a lateral forward bevel and a 22-gauge Franseen needle. Rapid on-site evaluation was performed in all the cases. A multivariate analysis was performed to clarify the negative predictive factors for obtaining a histological diagnosis. Propensity score matching was performed to compare the diagnostic yields of these two needles. Results We analyzed 666 patients and 690 lesions. The overall diagnostic rate of histology alone was 88.8%, and the overall adverse event rate was 1.5%. Transduodenal access and small lesions (≤2 cm) were identified as negative predictive factors for obtaining a histological diagnosis. After propensity score matching, 482 lesions were analyzed. The diagnostic accuracy rates of histology in the M and F needle groups were 89.2% and 88.8%, respectively (p=1.00). Conclusions Both the needles showed high diagnostic yield, and no significant difference in performance was observed between the two.

Background/Aims The diagnostic work-up of lymphadenopathy is challenging but important to determine the correct therapy. Nevertheless, few studies have addressed the topic of endosonography (EUS)-guided tissue acquisition in lymphadenopathy. Therefore, we aimed to evaluate the accuracy and safety of EUS-guided fine-needle biopsy sampling (EUS-FNB) in intrathoracic and intraabdominal lymphadenopathy. Methods In a tertiary care center, patients with lymphadenopathy referred for EUS-guided sampling were included prospectively from 2014 to 2019 (NCT02360839). In all cases, EUS-FNB (22 gauge) and EUS-guided fine-needle aspiration (EUS-FNA) (25 gauge) were performed. The patients were randomized to the first needle pass with FNB or FNA. Study outcomes were the diagnostic accuracy and adverse event rate. Results Forty-eight patients were included (median age: 69 years [interquartile range, 59–76]; 24/48 females [50%]). The final diagnoses were metastasis (n=17), lymphoma (n=11), sarcoidosis (n=6), and inflammatory disease (n=14). The diagnostic performance of the two modalities was comparable, including a high sensitivity for metastatic nodes (EUS-FNB: 87% vs. EUS-FNA: 100%, p=0.5). The sensitivity for lymphoma was borderline superior in favor of EUS-FNB (EUS-FNB: 55% vs. EUS-FNA: 9%, p=0.06). No adverse events were recorded. Conclusions In lymphadenopathy, both EUS-FNB and EUS-FNA are safe and highly sensitive for metastatic lymph node detection. Lymphoma diagnosis is challenging regardless of the needle used.

A 57-year-old woman with epigastric pain was diagnosed with a 6-cm abdominal cystic lesion of unclear origin on cross-sectional imaging. Endoscopic ultrasound (EUS) demonstrated a unilocular cyst located between the pancreas, gastric wall, and left adrenal gland, with a regular wall filled with dense fluid with multiple hyperechoic floating spots. A 19-G needle was used to puncture the cyst, but no fluid could be aspirated. Therefore, EUS-guided through-the-needle biopsy (EUS-TTNB) was performed. Histological analysis of the retrieved fragments revealed a fibrous wall lined by “respiratory-type” epithelium with ciliated columnar cells, consistent with the diagnosis of a bronchogenic cyst. Laparoscopic excision was performed, and the diagnosis was confirmed based on the findings of the surgical specimen. Abdominal bronchogenic cysts are extremely uncommon, and a definitive diagnosis is commonly obtained after the examination of surgical specimens due to the lack of pathognomonic findings on cross-sectional imaging and poor cellularity on EUS-guided fine-needle aspiration cytology. EUS-TTNB is useful for establishing a preoperative histological diagnosis, thus supporting the decision-making process.

Adrenal gland infection is a clinical entity of great importance, but it is a largely unrecognized pathology. Immunosuppressed individuals are at a higher risk of presentation. Herein, we describe a young female patient, recently diagnosed with HIV, who presented with severe sepsis due to methicillin-resistant Staphylococcus aureus, associated with a left adrenal abscess. She was initially treated with antibiotics; however, due to the persistence of the systemic inflammatory response and bacteremia, endoscopic ultrasound-guided drainage was performed. This procedure was successful in resolving the clinical situation. Endoscopic ultrasound-guided adrenal gland drainage can be a safe, efficacious, and minimally invasive option for managing antibiotic-refractory adrenal abscesses in immunosuppressed patients.

Abstract Background and Aim The success rate of microsatellite instability (MSI) examination in biliary tract cancer (BTC) and the treatment outcomes of pembrolizumab in patients with MSI‐high (MSI‐H) BTC have not been fully investigated. We examined the success rate of MSI examination and the rate of MSI‐H status in patients with BTC as well as the treatment outcomes of patients with MSI‐H status who underwent pembrolizumab treatment. Methods We retrospectively reviewed 60 consecutive patients with unresectable or postoperative recurrent BTC who underwent MSI examination in a Japanese cancer referral center between January 2019 and September 2020. Results The study included 24 intrahepatic cholangiocarcinomas, 12 hilar cholangiocarcinomas, 4 distal cholangiocarcinomas, 16 gallbladder carcinomas, and 4 ampullary carcinomas. The methods of cancer tissue sampling were percutaneous liver tumor biopsy in 26 cases, surgery in 15 cases, endoscopic ultrasound fine‐needle aspiration in 12 cases, transpapillary bile duct biopsy in 5 cases, and others in 2 cases. The success rate of MSI examination was 98.3% (59 of 60). MSI examination failed in only one case using a surgical specimen due to time‐dependent degradation of DNA. The frequency of MSI‐H BTC was 3.3% (2 of 60 cases). One patient with MSI‐H intrahepatic cholangiocarcinoma achieved a complete response with pembrolizumab treatment. Conclusions MSI examinations in BTC were successful in almost all cases, regardless of tissue sampling methods. We experienced a case in which pembrolizumab resulted in a complete response to MSI‐H BTC. Since pembrolizumab for MSI‐H BTC could prolong survival time, MSI examination should be performed proactively to increase treatment options.

Primary pancreatic lymphomas (PPLs) are rare, and the histological classification of these tumors is difficult. To accurately diagnose and determine the appropriate treatment for PPLs, sufficient sample amounts are necessary. Here, we report a 73-year-old man with a primary pancreatic mantle cell lymphoma. Histological samples were obtained via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The tumor cells predominantly composed of atypical small to medium round cells, with diffuse immunoreactivity of CD20 and cyclin D1. In addition, immunoglobulin gene H chain rearrangement was detected. The patient underwent chemotherapy, resulting in complete remission. Eight years after the initiation of chemotherapy, the patient was still alive. EUS-FNA could be a useful and safe diagnostic modality for PPLs by providing enough samples for testing.

Abstract Background Primary squamous cell carcinoma (SCC) of the pancreas with pseudocysts, especially diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), is extremely rare. Case presentation A 64-year-old man was admitted to our department for abdominal distension. Two months ago, he experienced abdominal pain for 1 day and was diagnosed with acute pancreatitis in another hospital. After admission, laboratory tests showed the following: amylase 400 U/L, lipase 403 U/L, and carbohydrate antigen 19–9 (CA19-9) 347 U/mL. Abdominal computed tomography (CT) revealed pancreatitis with a pseudocyst with a diameter measuring 7 cm. During linear EUS, a large pseudocyst (5.4 × 5.2 cm) was observed in the pancreatic body. EUS-FNA was performed. We obtained specimens for histopathology and placed a plastic stent through the pancreas and stomach to drain the pseudocyst. Puncture fluid examination revealed the following: CA19-9 > 12,000 U/mL carcinoembryonic antigen (CEA) 7097.42 ng/ml, amylase 27,145.3 U/L, and lipase > 6000 U/L. Cytopathology revealed an abnormal cell mass, and cancer was suspected. Furthermore, with the result of immunohistochemistry on cell mass (CK ( +), P40 ( +), p63 ( +), CK7 (−) and Ki-67 (30%)), the patient was examined as squamous cell carcinoma (SCC). However, the patient refused surgery, radiotherapy and chemotherapy. After drainage, the cyst shrank, but the patient died 3 months after diagnosis due to liver metastasis and multiple organ failure. Conclusion For patients with primary pancreatic pseudocysts with elevated serum CEA and CA19-9 levels, we should not rule out pancreatic cancer, which may also be a manifestation of primary pancreatic SCC. EUS-FNA is helpful for obtaining histopathology and cytology and thus improving diagnostic accuracy.