This guideline is being co-published in
Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in 8 categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.
Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) plays an essential role in the establishment of an accurate tissue diagnosis and tailored treatment plan for pancreatic solid tumors, and is associated with few major adverse events [
Our purpose was to establish a practical guideline for EUS-guided tissue acquisition that applies to the current medical practice. The target for this guideline includes patients with pancreatic solid tumor requiring tissue diagnostic confirmation. We aimed to provide a suitable framework for making decisions regarding the appropriate and accurate diagnosis for preoperative evaluation and postoperative management of patients with pancreatic solid tumors. The target audience for this guideline includes clinicians who perform EUS-guided tissue acquisition ranging from general clinicians to physicians that specialize in pancreatology, clinical researchers, and health policymakers involved in the diagnosis and treatment of pancreatic solid tumors. A summary of the evidence statement and recommendations is provided at the end of this paper.
The Korean Society of Gastrointestinal Endoscopy (KSGE) Task Force on Guideline for EUS-guided tissue acquisition of pancreatic solid tumor comprised a development panel of 16 endosonographers, who were experts in this field, and an expert in methodology for guideline development. Conflicts of interest were disclosed according to the guideline of the KSGE. During the development of this guideline, no members of the Task Force were solicited or asked about the development activities by other stakeholders. There was also an internal evaluation panel within members of the committee comprising six gastroenterologists, one pathologist, and one statistician in charge of methodology for guideline development. Six external validation panel members were also asked to conduct a full evaluation (
The members of the Committee set up the following eight items: indication of EUS-guided tissue acquisition of pancreatic solid tumor; selection of the appropriate needle; the optimal number of needle passes; strategy for inadequate or inconclusive pathological results; specific endoscopic techniques; methods of specimen processing; adverse events and their prevention; and learning-related issues. Because the definition of pancreatic solid tumor and the significance of diagnosing pancreatic solid tumor by image modalities represents the major premise on which this guideline is formulated, we did not handle this item as a statement. Therefore, key questions (KQs) were prepared for the other eight items, and modifications were made based on opinions of the internal evaluation panel such that there were 12 statements in total. The KQs were established through the PICO process; P (population) represents patients with pancreatic solid tumors; I (intervention) represents main therapeutic interventions including EUS-guided tissue acquisition; C (comparison) represents main alternative therapeutic interventions to compare with the interventions; and O (outcome) represents the usefulness of diagnostic performance.
For each KQ, a systematic literature search was conducted until December 2017 using PubMed and the Cochrane database. A detailed description of keywords and search formulas were given for each statement. In addition, a manual search was conducted when there were insufficient research results to refer to. The literature search was performed by members of the team of experts for clinical practice guideline development who suggested search queries and presented search results in collaboration with the committee members. We searched the Cochrane Library, EMBASE, KoreaMed, MEDLINE, and the Guideline International Network in July 2019. Keywords related to the pancreatic solid tumor ([“pancreatic” OR “pancreas” OR “pancreato”] AND [“cancer” OR “tumor” OR “carcinoma” OR “adenocarcinoma” OR “neoplasm”]), and endoscopic ultrasound (EUS)-guided tissue acquisition ([“endoscopic ultrasound” OR “EUS” OR “Echoendoscopic”] AND [“aspiration” OR “biopsy” OR “histologic” OR “pathologic” OR “cytologic” ]) were used. Different keywords or different combinations of keywords were also used based on each key question.
The exclusion criteria were as follows: 1) studies not involving human subjects or the target populations of the guideline’s KQs; 2) studies that did not perform an intervention related to the KQs and intervention for comparison; 3) studies that were case reports, unpublished studies, abstract-only publications, or review articles; 4) studies that were published in a language other than English; and 5) the original full-text could not be found. In the first stage of study selection, duplicate studies were removed. For each KQ, titles and abstracts of articles returned from our keyword search were examined independently by two assigned committee members to exclude irrelevant articles. The entire contents of all selected full-texts were then screened as per our inclusion and exclusion criteria [
Qualitative systematic reviews were conducted to evaluate the risk of biases and heterogeneity of each study. The domains of risk of bias included performance bias, selection bias, attrition bias, detection bias, and other biases. The revised Cochrane Risk of Bias Tool was used to evaluate randomized controlled trials [
The strength of recommendations was graded with reference to (1) the quality of the evidence, (2) the homogeneity of the study population, (3) risks-benefits analysis, and (4) cost analysis. Regarding consensus establishment, a total of 12 committee members voted for each proposed statement according to the modified Delphi method, which uses a scoring system (sum of the score 1-2: non-consensus, 3: dissatisfaction, 4-5: consensus). The options were adopted as confirmative statements if any of the statements achieve a consensus of 2/3 agreement or higher as agree or agree strongly (as point 4 or 5). If the proposed statements had an agreement <2/3 among 12 committee members, either it had to be modified or the strength of recommendation had to be amended through discussion within the committee; subsequently, voting was repeated until a higher agreement above 2/3 was achieved. According to the sum of the score, the grading of recommendations was divided into two categories, “1: Strong Recommendations” and “2: Weak Recommendations”, which are described as “recommendations” and “suggestions”, respectively [
For an internal review by the KSGE, a total of 34 members of the KSGE Steering Committee and 14 members from the Insurance Committee of KSGE reviewed the first draft using open questions and provided comments. The draft was revised according to the comments to ensure balance and completeness of the guideline. Furthermore, for an external review of the guideline, a modified e-Delphi mechanism process such as employing the online platform was then used for 11 expert panels to produce an evidence-based consensus. This consensus consisted of two main rounds of web-based voting, using a custom-built online voting platform scoring each using a 5-point scale with updated iterations of the statements and evaluative text based on feedback after each round. Following the first round of voting, the statements that achieved a consensus of 2/3 agreement or higher as agree or agree strongly (as point 4 or 5) were accepted as final statements and recommendations. The statements that did not achieve 2/3 were entered into the second round of voting after appropriate revision based on discussions during the e-Delphi mechanism process. The statements and recommendations that did not reach the 2/3 consensus agreement following two rounds of voting were removed.
For universal provision and distribution of the practical guideline, we plan to publish the guideline in
It is not anticipated that treatment decisions will be made using this practical guideline without first considering the specific conditions of individual patients. Medical conditions such as demographic background, underlying comorbidities, clinical stage, and economic environment vary among individuals. Furthermore, this guideline is not intended to establish an absolute diagnostic or therapeutic standard that physicians should use to manage patients in real clinical settings but aims to assist physicians in making evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. It is impossible for the guideline development committee to consider the specific conditions of each individual patient when formulating recommendations. Thus, this practical guideline should not be used to support legal judgments in the assessment of the appropriateness of individual medical practice.
It is essential that the indications for EUS-guided tissue acquisition can provide information on the potential treatment strategy of patients with pancreatic solid tumor. Furthermore, endoscopists should consider the technical feasibility in terms of the distance from the echoendoscope to the target lesion as well as blood vessel location during needle puncture. In some countries, tissue confirmation of specific cell types is mandatory before anti-tumor therapy such as chemotherapy or radiotherapy to ensure effective response as well as conformance with the policy of the country’s national health insurance system. Recently, the European Society of Gastrointestinal Endoscopy (ESGE) guidelines [
① Unresectable pancreatic tumor
② Resectable/borderline resectable pancreatic tumor
③ Autoimmune pancreatitis or mass forming chronic pancreatitis
④ Neuroendocrine pancreatic tumors and other pancreatic tumors
There are various types and diameters of needle used in EUS-guided tissue acquisition for solid pancreatic tumors in the market. Furthermore, a new type of needle specially designed to procure histologic core preserving intact histologic architecture for suitable pathological evaluation has been introduced recently. These devices, collectively called FNB needles, has the unique feature of a needle tip which has either a side-slot (core trap) or a special geometry of the cutting tip (
EUS-guided tissue acquisition for cytopathologic evaluation through FNA or FNB using specially designed core needles has become a key technique in the diagnosis of solid pancreatic tumors [
In regard to sample adequacy, 22-gauge FNB had significantly better sample adequacy than 25-gauge FNA (RR, 0.79; 95% CI, 0.68-0.92) in the direct meta-analysis, whereas 22-gauge FNA was more likely to obtain an adequate sample compared with 19-gauge FNA needles (RR, 1.13; 95% CI, 1.00-1.28). However, the results of network meta-analyses did not indicate that any of the tested needles were superior to another in terms of obtaining an adequate sample.
In regard to histologic core procurement rate, 25-gauge FNB had a significantly superior outcome than 25-gauge FNA (RR, 1.17; 95% CI, 1.00-1.36) according to a direct meta-analysis [
The optimal number of needle passes for accurate diagnosis of solid pancreatic tumors has been the subject of debate. The execution of more needle passes than necessary may cause potential procedure-related adverse events and also a longer procedure time [
Per-pass analyses from recent prospective trials [
The Papanicolaou Society of Cytopathology developed a set of guidelines for standardized terminology and nomenclature of pancreatobiliary cytology specimens in 2014 (
Furthermore, K-ras mutation analysis can be another useful option for differentiation of pancreatic mass lesions and may complement other diagnostic tools, especially when the results of EUS-FNA are inconclusive. In one meta-anlaysis [
The diagnostic accuracy of EUS-guided tissue acquisition under ROSE is reported to be higher than 90% in most studies [
However, for a given sample adequacy rate and the number of needle passages, ROSE is expected to have higher per-case accuracy than sampling without ROSE [
Regarding sample adequacy, the pooled data from a recent meta-analysis [
Theoretically, the application of suction on the needle mount was a standard practice based on the understanding that negative pressure would increase cellularity. One RCT [
As an alternative to suction, the slow-pull-back technique was recently introduced for EUS-FNA or FNB of solid pancreatic lesions [
Since its introduction in 2013 [
Seeking another maneuver with equal or superior diagnostic outcomes as the fanning technique without its limitations, Park et al. invented an alternative and similar technique called the “torque technique.” Torque is applied by twisting the body of the echoendoscope to the right (clockwise) or left (counter-clockwise) without using the left/right control knob. In that study [
Diagnostic performance differs by cytologic or histologic sample preparations (smear, rapid cytology, liquid-based cytology, cell block, and histology) and by staining methods [
Direct smear facilitates rapid staining and cytological diagnosis; thus, is an essential step in processing EUS-FNA specimens from pancreatic tumors. The assistant nurse places the stylet into the needle channel to extrude the aspirated sample onto the slide. Appropriate quantities of acquired sample material should be mounted on the slide for inspection of optical properties of the optimal specimen. Applying large quantities of the sample at once can lead to thick smears (with cells obscured within clusters) or clotting artifacts, while watery or small quantities of sample do not smear well on the slide causing air-drying artifacts [
When smear specimens are made using two slide glasses, usually one slide is prepared using the conventional air-dried method for rapid cytology with Diff-Quik, whereas the other slide is fixed in ethanol for later staining using Papanicolaou and HE stain [
Almost all false-negative cytologic results are due to errors in sampling, preparation of the sample, and interpretation of the sample. For this reason, liquid-based cytology (LBC) is an effective technique for sample preparation which can be manipulated automatically within only 2-4 minutes per sample after the acquisition of cytologic materials [
The cell block is an effective technique that overcomes the disadvantages of conventional smear cytology and can lead to a definite diagnosis through IHC and molecular assays. Various cell block techniques have been developed over time: the traditional manual, involving rinsing the sample with 50% ethanol; the sodium alginate method, involving fixing the sample in 10% formalin and 1% sodium alginate; and the novel Cellient Automated Cell Block System (Hologic Inc, Marlborough, MA, Mass). All methods involve embedding the collected cell pellets in paraffin and cutting thin 3-5 µm sections before staining [
Recent technical and instrumental improvements in EUS-FNB for pancreatic solid tumors have enabled adequate histologic sampling, even using 22- or 25-gauge needles. According to a recent network meta-analysis [
IHC staining focuses on the diagnosis of epithelial components with histological atypia and differential diagnosis of various tumors such as mass-forming chronic pancreatitis, pancreatic neuroendocrine tumor (PNET), and autoimmune pancreatitis through preserving histologic architecture. Genetic analysis can aid in tailored treatment in individuals with pancreatic cancer and prediction of prognosis. Telecytology, which is a remote cytopathology diagnostic system based on online transmitted microscope images, enables real-time diagnosis of the samples by expert cytopathologists.
IHC can be applied to histologic cores from EUS-FNB, cell block, and even liquid-based cytology. It can differentiate benign and malignant lesions and reduces false negatives by staining for tumor suppressor gene proteins (e.g., TP53 or E-cadherin) [
The most ideal system for the rapid cytological diagnosis of samples from EUS-FNA is ROSE. As mentioned earlier, however, the usefulness of the ROSE system is limited both in terms of time required and availability of technology, even in an experienced tertiary hospital. As a substitute for ROSE, telecytology was introduced in 1997 by the International Academy of Cytology Task Force Summary to save time and labor of cytopathologists and to enable real-time analysis of samples from EUS-FNA performed at remote locations, even at field hospitals [
Many molecular analyses for the detection of epigenetic and genetic alterations have been conducted using samples from EUS-guided tissue acquisition for a pancreatic tumor [
Many molecular abnormalities based on DNA, RNA, or proteins in pancreatic tumor tissues have been evaluated and determined to be indicators for prognosis [
Wang et al. [
Among 4,909 EUS-FNA samples analyzed in a multicenter United States survey of solid pancreatic tumors, acute pancreatitis was identified in 14 (0.29%) [
According to multivariate logistic regression risk factor analysis for acute pancreatitis [
The incidence of bacteremia or even infection after EUS-guided tissue acquisition is very low, usually insignificant, and similar to that of diagnostic endoscopy including EUS without tissue acquisition [
In conclusion, current guidelines [
Intraluminal bleeding following EUS-guided tissue acquisition is typically mild and self-limiting without clinical consequences. Significant bleeding is very rare, but possible if large or major vasculatures are punctured or if patients have a coagulopathy [
Extra-luminal bleeding manifests as visibly expanding echopoor regions near the target area, or confirmation of blood flow under color-doppler ultrasonography, and has been reported to occur in 1.3-2.6% of all cases [
Needle tract seeding after EUS-guided tissue acquisition has been considered to be an extremely rare adverse event [
The relationship between the incidence of adverse events after EUS-guided tissue acquisition and needle size is an important issue. Theoretically, the incidence of adverse events with a larger diameter needle was expected to be higher than that using needles that were smaller in diameter.
There is little available evidence regarding the minimal average number of performed procedures required to achieve competency in endoscopy. Several trials [
Recent guidelines [
A more recent study [
This guideline proposes a standard process for physicians who perform EUS-guided tissue acquisition based on the available evidence at the time of preparation in order to prevent unnecessary or unsuitable medical treatments and to facilitate appropriate and practical recommendations for the tissue confirmation of solid pancreatic tumors. We aim to provide a suitable decision-making framework for the accurate diagnosis and appropriate management of patients with solid pancreatic tumors. This guideline is not intended to establish an absolute standard that physicians should use to manage patients in real clinical settings but aims to assist physicians in making evidence-based judgments for the diagnosis of pancreatic solid tumors. Therefore, this guideline should not be used to support legal judgments, establish a legal standard of care or to encourage, advocate, require, or discourage any particular treatment. EUS-guided tissue acquisition has clearly been established as the first-line procedure for the diagnosis of solid pancreatic tumors and will continue to be improved as further research is conducted.
Endoscopic ultrasound image of different solid pancreatic tumors. (A) Solid lesion located in the pancreatic head, corresponding to pancreatic ductal adenocarcinoma. (B) Pancreatic neuroendocrine tumor located in the pancreatic tail. (C) Insulinoma located in the pancreatic tail. (D) Solid pseudopapillary tumor located in the pancreatic tail. (E) Mass forming chronic pancreatitis located in the pancreatic neck. (F) Mass forming autoimmune pancreatitis located in the pancreatic head with bile duct obstruction. CBD, common bile duct; PV, portal vein.
Task Force Team for the Guideline for Endoscopic Ultrasound-Guided Tissue Acquisition of Pancreatic Solid Tumor
KSGE Clinical Practice Guideline Committee | |
---|---|
President | Hoon Jai Chun (in November 2017) |
Joo Young Cho (present) | |
Congress chairman | Soo Teik Lee (in November 2017) |
Ho Gak Kim (in November 2018) | |
Chan Guk Park (present) | |
Director and chairperson of the KSGE Task Force | Jeong-Sik Byeon |
Director | Se Woo Park |
Development panel director | Se Woo Park, Moon Jae Chung |
Development panel members | Seong Hun Kim, Chang Min Cho, Jun Ho Choi, Eun Kwang Choi, Tae Hoon Lee, Eunae Cho |
Evaluation panel director | Jun Kyu Lee |
Evaluation panel members | Tae Jun Song, Jae Min Lee, Jun Hyuk Son, Jin Suk Park, Chi Hyuk Oh |
External evaluation panel members | Dong-Ah Park and her team |
Korean Society of Gastroenterology | |
Korean Pancreatobiliary Association |
EUS, endoscopic ultrasound; KSGE, Korean Society of Gastrointestinal Endoscopy.
Summary and Strength of Recommendations for EUS-Guided Tissue Acquisition of Pancreatic Solid Tumor
2-1. For routine EUS-guided tissue acquisition of pancreatic solid tumors, FNA and FNB needles are equally recommended. When the pri- mary aim of sampling is to obtain a histologic core tissue specimen (e.g., focal autoimmune pancreatitis or neuroendocrine tumors), KSGE recommends using FNB needles (level of evidence: moderate, grade of recommendation: strong). |
2-2. Our group suggests that no specific type or diameter of needle has a higher diagnostic accuracy than others in EUS-guided tissue acqui- sition for solid pancreatic tumors. However, 22-gauge needles tended to have superior outcomes compared to 19-gauge or 25-gauge needles in terms of optimal histologic core procurement and sample adequacy (level of evidence: low, grade of recommendation: weak). |
5-1. Our group suggests that routine application of ROSE cannot guarantee an improvement in diagnostic accuracy and performance in terms of sensitivity and specificity. Nevertheless, application of ROSE is expected to achieve higher per-case accuracy than non-application (level of evidence: low, grade of recommendation: weak). |
5-2. The use of a stylet during EUS-guided tissue acquisition does not appear to guarantee any advantages with regards to the adequacy of the specimen, diagnostic yield, nor regarding prevention of needle clogging by gut wall tissue (level of evidence: moderate, grade of recommen- dation: weak). |
5-3. Our group suggests that routine application of suction is recommended in cases where cellularity is poor, such as fibrotic lesions in chronic pancreatitis, whereas it is discouraged in non-fibrotic lesions which may contain necrosis and blood to minimize contamination of the cellular sample (level of evidence: moderate, grade of recommendation: weak). Also, the slow-pull-back technique may be more effective in terms of adequate tissue acquisition and require fewer needle passes for solid pancreatic tumors (level of evidence: low, grade of recom- mendation: weak). |
5-4. Our group suggests that the fanning technique for EUS-guided tissue acquisition offers technically acceptable feasibility and superior diagnostic performance, including fewer needle passes required to establish the definite diagnosis, than the standard technique (level of evidence: moderate, grade of recommendation: strong). Furthermore, the torque technique, similar to the fanning technique, also showed better outcomes regarding optimal histologic core procurement and diagnostic accuracy in comparison with the standard technique (Level of evidence: low, grade of recommendation: weak). |
CT, computed tomography; EUS, endoscopic ultrasound; FNA, fine-needle aspiration; FNB, fine needle biopsy; KSGE, Korean Society of Gastrointestinal Endoscopy; ROSE, rapid on-site evaluation.
Available Needles in the Market of Korea for EUS-Guided Tissue Acquisition of Pancreatic Solid Tumors [
Manufacturer | Model | Needle type | Needle diameter |
---|---|---|---|
Boston Scientific | ExpectTM Slimline (SL) | Aspiration needle | 19G, 22G, 25G |
AcquireTM Flex | Biopsy needle | 22G, 25G | |
Cook | EchoTip Ultra | Aspiration needle | 19G, 22G, 25G |
EchoTip ProCore | Biopsy needle | 19G, 22G, 25G | |
EchoTip ProCore | Biopsy needle | 20G |
|
Olympus | EZ-shot 3 | Aspiration needle | 19G, 22G, 25G |
EZ-shot 3 with sideport | Aspiration needle | 19G, 22G, 25G | |
MediGlobe | SonoTip Pro Control | Aspiration needle | 19G, 22G, 25G |
FineMedix | ClearTip | Aspiration needle | 19G, 22G, 25G |
ClearTip | Biopsy needle | 19G, 22G, 25G |
A newly marketed needle designed with a core trap and bevel system to increase diagnostic yield and enhance procurement of histologic core, while other gauge needles (19, 22, and 25 gauge) have a reversed bevel system.
A newly marketed needle designed with a core trap and bi-bevel system to increase diagnostic yield and enhance procurement of histologic core.
Standardized Terminology and Nomenclature of Pancreatobiliary Cytology Specimens in 2014 [
Category | Nomenclature | Definition | |
---|---|---|---|
Category I | Non-diagnostic | A non-diagnostic cytology specimen is one that provides no diagnostic or useful information about the solid or cystic lesion sampled; for example, an acellular aspirate of a cyst without evidence of a mucinous etiology such as thick colloid-like mucus, elevated CEA or KRAS/GNAS mutation (see Category IV). Any cellular atypia precludes a non-diagnostic report. | |
Category II | Negative (for malignancy) | A negative cytology sample is one that contains adequate cellular and/or extracellular tissue to evaluate or define a lesion that is identified on imaging. When using the negative category one should give a specific diagnosis when practical, including: | |
Benign pancreatobiliary tissue in the setting of vague fullness and no discrete mass | |||
Acute pancreatitis | |||
Chronic pancreatitis | |||
Autoimmune pancreatitis | |||
Pseudocyst | |||
Lymphoepithelial cyst | |||
Splenule/accessory spleen. | |||
Category III | Atypical | The category of atypical should only be applied when there are cells present with cytoplasmic, nuclear, or architectural features that are not consistent with normal or reactive cellular changes of the pancreas or bile ducts and are insufficient to classify them as a neoplasm or suspicious for a high-grade malignancy. The findings are insufficient to establish an abnormality explaining the lesion seen on imaging. Follow-up evaluation is warranted. | |
Category IV | Neoplastic: Benign | This interpretation category connotes the presence of a cytological specimen that is sufficiently cellular and representative, with or without the context of clinical, imaging, and ancillary studies, to be diagnostic of a benign neoplasm. | |
Neoplastic: Other | This interpretation category defines a neoplasm that is either premalignant such as intraductal papillary neoplasm of the bile ducts, intraductal papillary mucosal neoplasms, or mucinous cystic neoplasm with low, intermediate, or high-grade dysplasia by cytological criteria, or a low-grade malignant neoplasm such as well-differentiated primitive neuroectodermal tumor or solid-pseudopapillary neoplasm. While mucinous epithelium in biliary brushing specimens may indeed represent a neoplastic change, given the lack of evidence-based literature on the cytological interpretation, histology and management of these lesions, low-grade mucinous change of biliary epithelium will remain in the “atypical” rather than “neoplastic” category. | ||
Category V | Suspicious (for malignancy) | A specimen is suspicious for malignancy when some, but an insufficient number of the typical features of a specific malignant neoplasm are present; mainly pancreatic adenocarcinoma. The cytological features raise a strong suspicion for malignancy, but the findings are qualitatively and/or quantitatively insufficient for a conclusive diagnosis, or tissue is not present for ancillary studies to define a specific neoplasm. The morphologic features must be sufficiently atypical that malignancy is considered more probable than not. | |
Category VI | Positive for malignancy | A group of neoplasms that unequivocally display malignant cytologic characteristics and include pancreatic ductal adenocarcinoma and its variants; cholangiocarcinoma, acinar cell carcinoma, high-grade neuroendocrine carcinoma (small cell and large cell), pancreatoblastoma, lymphomas, sarcomas and metastases to the pancreas. |
CEA, Carcinoembryonic antigen; GNAS, guanine nucleotide-binding protein/α-subunit; KRAS, Kirsten rat sarcoma viral oncogene homolog.
Specific Indicators of Immunohistochemistry Staining [
Marker for Immunohistochemistry | Target tumor |
---|---|
Cytokeratin (CK) | Epithelial cell tumors |
Mucin core protein (MUC) | |
Cytokeratin (CK) 7 and 20 | Gastrointestinal tract adenocarcinoma (especially biliary tract cancer) |
HepPar 1 | Hepatocellular carcinoma |
Glypican 3 | |
AFP | |
CD10 | Solid pseudopapillary tumors |
β-catenin | |
Chromogranin A | Neuroendocrine tumors |
Synaptophysin | |
trypsin | Acinar cell carcinoma |
lipase | Intraductal tubular or |
BCL10 | tubulo-papillary neoplasms |
MUC6 | |
L26 | B cell marker |
UCHL1 | T cell marker |
LCA | Malignant lymphoma |
IgG4 subtype | Autoimmune pancreatitis |
Ziehl-Neelsen | Peripancreatic tuberculous lymphadenopathy |
Procedure-Related Adverse Events from EUS-Guided Tssue Acquisition for Pancreatic Lesions
Overall pancreatic lesions ( |
Pancreatic solid tumors ( |
Pancreatic cyst ( |
|
---|---|---|---|
Abdominal pain | 31 (0.38%) | 24 (0.33%) | 7 (0.77%) |
Pancreatitis | 36 (0.44%) | 26 (0.36%) | 10 (1.10%) |
Fever | 7 (0.08%) | 4 (0.05%) | 3 (0.33%) |
Bleeding | 8 (0.10%) | 5 (0.07%) | 3 (0.33%) |
Infection | 2 (0.02%) | 0 (0%) | 2 (0.22%) |
Perforation | 1 (0.01%) | 1 (0.01%) | 0 (0%) |
Bile leakage | 0 (0%) | 0 (0%) | 0 (0%) |
Total | 85 (1.03%) | 60 (0.81%) | 25 (2.75%) |
EUS, endoscopic ultrasound.