Dr J King, Dr T BraceyDepartment of cellular pathology, Derriford HospitalMay 2014

Introduction

EUS-FNA facilitates the diagnosis of medistinal lymph node disease and retropertioneal lesions

May be the only method of diagnosing pancreatic carcinomas

Go on to have major surgery

RCPath Dataset1

FNA pancreas – Aspiration of pancreatic masses

requires appropriate image guidance. An effective team including the radiology and endoscopy units is thus essential. The effectiveness of the technique is improved by immediate on site assessment of adequacy, which may be performed either by a suitably trained BMS or pathologist. Staff time spent on this activity must be included in job planning

RCPath B7 F N A of lymph node B7.1 Staffing and workload FNA of palpable lymph nodes may be

taken by a variety of clinicians, or by Cytopathologists working in a clinic setting. In this instance, medical and BMS staffing calculations must take this into account. FNA of deep nodes, e.g. Para-aortic nodes, will usually be taken under radiological control. In this instance,it is advantageous for a BMS to attend to prepare the slides and to provide an immediate assessment of adequacy

Introduction ...

Since 2011, introduced poor man cell pellet (PMCB)

Upside down universal container, formalin soaked gauze within the tube and put the sample on the inside of the lid

Formalin vapour fixes the sample overnight

Processed as histology specimen

Standard

No published standards in datasets Adequacy rate without ROSE 61%

Both mediastinal and pancreatic data2

Mediastinal range 84 – 96% With ROSE

Pancreatic range 67-86% Without ROSE

Aim

Review all PMCB cases Compare the outcome with

conventional cytology methods Provide recommendations from the

results found

Method

Searches on the pathology database were made: T-C4360 – mediastinal lymph node T-D3300 – mediastinum NOS T-65000 – pancreas NOS T-EA539 – pancreatic cytologic material T-65010 – pancreatic duct NOS

Method ...

Each patient was then looked up on the pathology system in order to retrieve the report.

Data from the reports were inputted into an Excel Spreadsheet

Results were analysed

Data collected:

Site of aspiration operator cytology result PMCB result If any further work was performed on

the cell pellet Date received in the department Date the report was authorised

Categories for cytology and PMCB results

Diagnosis Cytology PMCB

No sample taken C0 PM0

Inadequate C1 PM1

Benign C2 PM2

Atypical probably benign C3 PM3

Suspicious of malignancy C4 PM4

Malignant C5 PM5

Results

A total of 69 cases 13 were excluded 56 cases suitable

23 mediastinal 33 retroperitoneal

PMCB 18 mediastinal 27 retroperitoneal TAT – 2-13 days – includes weekend

days

Overall results

Of the total cytology samples, 67% were adequate (24/36)

Of the total PMCB samples, 78% were adequate (35/45)

Mediastinal casesC0 C1 C2 C3 C4 C5 Total

PM0 3 2 5

PM1 0

PM2 3 8 11

PM3 0

PM4 0

PM5 5 1 1 7

total 8 3 11 0 0 1 23

Mediastinal cases

Total 23 patients 15 had cytology 18 had PMCB 10 had both Cytology – 80% (12/15) were

adequate PMCB – 100% (18/18) were adequate

61% (11/18) benign 39% (7/18) malignant

Mediastinal results ...

One false negative C2 no overt malignant cells PM5 - metastatic moderately

differentiated intestinal type adenocarcinoma

Remaining paired results correlated No false positives

Retroperitoneal casesC0 C1 C2 C3 C4 C5 Total

PM0 1 2 3 6

PM1 4 6 10

PM2 1 1 2

PM3 1 1

PM4 1 1 1 3

PM5 5 1 1 2 2 11

total 12 9 6 2 2 2 33

Retroperitoneal cases

Total 33 patients 21 had cytology 27 had PMCB 16 had both Cytology – 57% (12/21) were

adequate PMCB – 63% (17/27) were adequate

11/27 PM5 3/27 PM4

Retroperitoneal lesions

Comparing the cytology and PMCB: Cytology – inadequate ; PM – spindle cell

GIST 2 false negatives on cytology:

C2 and PM4 – suspicious of adenocarcinoma

C2 and PM5 – well differentiated endocrine lesion

Limitation on paired samples as all of the diagnostic material may have been put into the PMCB

How many used extra tests

16 of the PMCB had extra tests Levels Special stains Immunohistochemistry

Discussion

Cytology PMCB

Overall - 61% 67% 78%

Mediastinal 84-96%

80% 100%

Pancreatic 67-86%

57% 63%

•Small numbers•We hope to add with time•Operators and pathologists are becoming more experienced

Discussion

Overall PMCB greater diagnostic rate 100% in mediastinal nodes

Ability to maintain structure in PMCB Can perform further ancillary tests to

aid diagnosis Potential all histopathologists can

report – not just cytopathologists Technique could be useful elsewhere

- EBUS

recommendations

Continue with PMCB Review SOP for handling such

specimens Liase with operators Re-audit with 2014 data

References1. RCPath . Tissue Pathways for exfoliative cytology and FNA cytology. Jan 2010

2. Rapid on-site evaluation of EUS–FNA by cytopathologist: An experience of a tertiary hospital. R. Shifa Ecka; M. Sharma. Diagnostic Cytopathology. Volume 41, Issue 12, pages 1075–1080, December 2013

3. Clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of mediastinal and intra-abdominal lymphadenopathy. Mehmood S., Loya A., Yusuf M.A. Acta Cytologica, September 2013, vol./is. 57/5(436-442)

4. Comparison of 19- and 22-gauge needles in EUS-guided fine needle aspiration in patients with mediastinal masses and lymph nodes. Songur N., Songur Y., Bircan S., Kapucuoglu N. Turkish Journal of Gastroenterology, October 2011, vol./is. 22/5(472-478)

Utility of liquid-based cytology in the evaluation of endoscopic ultrasound guided fine needle aspiration: Comparison with the conventional smearsMoon S.-H., Seo D.W., Kim J.W., Gong G., Eum J., Song T.J., Park D.H., Lee S.S., Lee S.K., Kim M.-H. Gastrointestinal Endoscopy, April 2010, vol./is. 71/5

Rapid on-site evaluation of EUS–FNA by cytopathologist: An experience of a tertiary hospital. R. Shafia Ecka; M. Sharma. Diagnostic Cytopathology. Oct 2013

references

A 1 year audit of endoluminal ultrasound-guided fine needle aspiration cytology investigations (EUS-FNA) : Diagnostic efficacy and input of on-site cytological assessment. Hegarty S., Lioe T., Mitchell M., McNeice A., Mainie I. Gut, August 2013, vol./is. 62/(A34-A35)

What is the impact of a one-week, intensive, hands-on eus training program on tissue acquisition? Piramanayagam P., Bang J.Y., Varadarajulu S., Palaniswamy K.R. Gastrointestinal Endoscopy, May 2014, vol./Is. 79/5

Endoscopic ultrasound-guided fine-needle aspiration. KJ Chang; KD Katz; TE Durbin et al. Gastrointest Endosc. 1994; 40:694-699

Impact of on-site adequacy assessment for EUS FNA of solid pancreatic lesions. S Chatterjee.; V Wadehra; J Cunningham et al. Gut 2011 239301

Thank you