Patient and lesion characteristics
Forty-nine patients underwent EUS-FNA for pelvic lesions at our institution from January 2008 to December 2018; 28 via the upper GI approach and 21 via the lower GI approach. Basic characteristics of patients are shown in Table 1.
Table 1. Patient and lesion characteristics
|
Overall
|
Upper GI
|
Lower GI
|
Number of patients, n
|
49
|
28
|
21
|
Age, y.o., median (range)
|
69 (32-87)
|
68 (32-87)
|
72 (48-83)
|
Gender, male/female. n
|
28 / 21
|
12 / 16
|
16 / 5
|
Size of lesions, mm, median (range)
|
40 (13-135)
|
26 (32-87)
|
58 (13-135)
|
Target lesions, n (%)
|
|
|
|
Pelvic LN
|
33 (67.3)
|
23 (82.1)
|
10 (47.6)
|
Pelvic mass
|
7 (14.3)
|
2 (7.1)
|
5 (23.8)
|
Retroperitoneal mass
|
3 (6.1)
|
3 (10.7)
|
-
|
Submucosal tumor
|
6 (12.2)
|
-
|
6 (28.6)
|
LN, lymph node; GI, gastrointestinal tract
Final diagnosis
The final diagnoses in the upper GI group were malignancy in 24 patients (85.7%)—malignant lymphoma in 19, lymph node metastasis of malignant tumor in 4 (ovarian cancer in 2, gallbladder cancer in 1 renal cancer in 1), and carcinoma of unknown primary cancer in 1. In the remaining 4 patients (14.3%), the final diagnoses were benign—retroperitoneal fibrosis in 3 and lipoma in 1. The final diagnoses in the lower GI group were malignancy in 18 patients (85.7%)—malignant lymphoma in 6, lymph node metastasis of malignant tumor in 5 (bladder cancer recurrence after surgery in 2, rectal cancer recurrence after endoscopic treatment in 2, gallbladder cancer in 1), gastrointestinal stromal tumor in 4, carcinoma of unknown primary in 1, peritoneal mesothelioma in 1, and rectal invasion of bladder cancer in 1. In the remaining 3 patients (14.3%), the final diagnoses were benign—schwannoma in 1, Castleman disease in in 1, and nonspecific lymphadenopathy in in 1. The final diagnoses were obtained based on the surgical pathology in 12 patients, EUS-FNA results with the clinical course and median follow-up period of 27.2 (range, 6.3–103.3) months in 35 patients, the result of mucosal biopsy of the small intestinal lesion during double-balloon enteroscopy in 1 patient, and the imaging findings with the clinical course and follow up period of 41.3 months in 1 patient. (Table 2).
Table 2. Final diagnoses of the patients with pelvic lesions who underwent EUS-FNA
|
Overall
n=49
|
Upper GI n=28
|
Lower GI n=21
|
Malignant diseases, n (%)
|
42 (85.7)
|
24 (85.7)
|
18 (85.7)
|
Malignant lymphoma
|
25 (51.0)
|
19 (67.9)
|
6 (28.6)
|
LN metastasis of malignant tumor
|
9 (18.4)
|
4 (14.3)
|
5 (23.8)
|
Carcinoma of unknown primary
|
2 (4.1)
|
1 (3.6)
|
1 (4.8)
|
Gastrointestinal stromal tumor
|
4 (8.2)
|
-
|
4 (19.0)
|
Peritoneal mesothelioma
|
1 (2.0)
|
-
|
1 (4.8)
|
Rectal invasion of bladder cancer
|
1 (2.0)
|
-
|
1 (4.8)
|
Benign diseases, n (%)
|
7 (14.3)
|
4 (14.3)
|
3 (14.3)
|
Retroperitoneal fibrosis
|
3 (61.2)
|
3 (10.7)
|
-
|
Lipoma
|
1 (2.0)
|
1 (3.6)
|
-
|
Schwannoma
|
1 (2.0)
|
-
|
1 (4.8)
|
Castleman disease
|
1 (2.0)
|
-
|
1 (4.8)
|
Non-specific lymphadenopathy
|
1 (2.0)
|
-
|
1 (4.8)
|
EUS-FNA, endoscopic ultrasound-guided fine needle aspiration; LN, lymph node; GI, gastrointestinal tract
Technical performance
The technical success rates were 91.8% (45/49) in overall patients—89.3% (25/28) and 95.2% (20/21) with the upper and lower GI approaches, respectively. The FNA was unsuccessful via the upper GI approach because of the existence of vessels in the puncture route in 2 patients (1 in the aorta and 1 in the inferior vena cava), and the lesion was not detected in 1 patient via the upper GI approach. In the lower GI approach, FNA failed in 1 patient in whom the procedure was complicated by sigmoid colon perforation during the scope insertion. Emergent surgery was required in this patient. Among these 4 patients in whom FNA was unsuccessful, the final diagnoses were obtained based on the surgical pathology in 3 patients (renal cell carcinoma metastasis in 1, retroperitoneal fibrosis 1, and nonspecific lymphadenopathy in 1). In the remaining 1 patient, further imaging studies including CT, magnetic resonance imaging (MRI), and positron emission tomography CT (PET-CT) indicated suspicious of lipoma, and follow-up imaging studies showed no progression for 41.4 months. Regarding the type of needles, we used a 19-gauge FNA needle in 36 cases, 22-gauge FNA needle in 2 case, 25-gauge FNA needle in 1 case, 19-gauge FNB needle in 1 case and 22-gauge FNB needle in 5 cases. No AEs were observed, except for one, sigmoid colon perforation. Therefore, the AE rate was 2.0% (1/49). The location of the target lesions for EUS-FNA and the feasibility of EUS-FNA are shown in Figure 1 (Table 3).
Table 3. Procedure details and data related EUS-FNA
|
Overall
n=49
|
Upper GI
n=28
|
Lower GI
n=21
|
Technical success rate of EUS-FNA, n (%)
|
45 (91.8)
|
25 (89.3)
|
20 (95.2)
|
Reasons for unsuccessful cases, n
|
|
Existence of vessels in the puncture route, 2
The lesion was not detected, 1
|
Sigmoid colon perforation, 1
|
Type of needle, n (%)
|
|
|
|
19-gauge FNA needle
|
36 (73.5)
|
21 (75.0)
|
15 (71.4)
|
22-gauge FNA needle
|
2 (4.1)
|
1 (3.6)
|
1(4.8)
|
25-gauge FNA needle
|
1 (2.0)
|
1 (3.6)
|
-
|
19-gauge FNB needle
|
1 (2.0)
|
-
|
1 (4.8)
|
22-gauge FNB needle
|
5 (10.2)
|
2 (7.1)
|
3 (14.3)
|
Puncture site, n (%)
|
|
Duodenum, 23 (82.1)
Stomach, 2 (7.1)
|
Rectum, 17 (81.0)
Sigmoid colon, 3 (14.3)
|
The number of passes, n, median (IQR)
|
3 (2-3)
|
3 (2-3)
|
3 (2-3)
|
Adverse event, n (%)
|
1 (4.8)
|
-
|
Perforation, 1 (4.8)
|
EUS-FNA, endoscopic ultrasound-guided fine needle aspiration; GI, gastrointestinal tract; FNB, fine needle biopsy; IQR, interquartile range
Diagnostic capability of EUS-FNA
Among patients who achieved technical success with EUS-FNA, the histological evaluation was feasible in 97.8% (44/45), although the cytological material was obtained in all patients. The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA for malignancy were 97.6% (40/41; 95% CI 87.4–99.6%), 100% (4/4; 95% CI 51.0–100%), 100% (40/40; 95% CI 91.2–100%), 80.0% (4/5; 95% CI 37.6–96.4%), and 97.8% (44/45; 95% CI 88.4–99.6%), respectively (Table 4). The histological and cytological diagnostic capabilities for malignancy are shown in Tables 5 and 6. In 1 patient with false-negative FNA result, we performed double-balloon endoscopy because the wall thickening of the small intestine was detected by CT imaging. And then, the final diagnosis of malignant lymphoma was obtained with mucosal biopsy of the small intestinal lesion.
Table 4. The overall diagnostic capability for malignancy in EUS-FNA for pelvic lesions
|
All patients
% (n, 95%CI)
|
Upper GI
% (n, 95%CI)
|
Lower GI
% (n, 95%CI)
|
Sensitivity
|
97.6 (40/41, 87.4-99.6)
|
100 (23/23, 85.7-100)
|
94.4 (17/18, 74.2-99.0)
|
Specificity
|
100 (4/4, 51.0-100)
|
100 (2/2, 34.2-100)
|
100 (2/2, 34.2-100)
|
PPV
|
100 (40/40, 91.2-100)
|
100 (23/23, 85.7-100)
|
100 (17/17, 81.2-100)
|
NPV
|
80.0 (4/5, 37.6-96.4)
|
100 (2/2, 34.2-100)
|
66.7 (2/3, 20.8-93.9)
|
Accuracy
|
97.8 (44/45, 88.4-99.6)
|
100 (25/25, 86.7-100)
|
95.0 (19/20, 76.4-99.1)
|
EUS-FNA, endoscopic ultrasound-guided fine needle aspiration; GI, gastrointestinal tract; CI confidence interval, PPV positive predictive value, NPV negative predictive value
Table5. The histological diagnostic capability for malignancy in EUS-FNA for pelvic lesions
|
All patients
% (n, 95%CI)
|
Upper GI
% (n, 95%CI)
|
Lower GI
% (n, 95%CI)
|
Sensitivity
|
97.5 (39/40, 87.1-99.6)
|
100 (23/23, 85.7-100)
|
94.1 (16/17, 73.0-90.0)
|
Specificity
|
100 (4/4, 51.0-100)
|
100 (2/2, 34.2-100)
|
100 (2/2, 34.2-100)
|
PPV
|
100 (39/39, 91.0-100)
|
100 (23/23, 85.7-100)
|
100 (16/16, 80.6-100)
|
NPV
|
80.0 (4/5, 37.6-96.4)
|
100 (2/2, 34.2-100)
|
66.7 (2/3, 20.8-93.9)
|
Accuracy
|
97.7 (43/44, 88.2-99.6)
|
100 (25/25, 86.7-100)
|
94.7 (18/19, 75.4-99.1)
|
EUS-FNA, endoscopic ultrasound-guided fine needle aspiration; GI, gastrointestinal tract; CI confidence interval, PPV positive predictive value, NPV negative predictive value
Table6. The cytological diagnostic capability for malignancy in EUS-FNA for pelvic lesions
|
All patients
% (n, 95%CI)
|
Upper GI
% (n, 95%CI)
|
Lower GI
% (n, 95%CI)
|
Sensitivity
|
82.9 (34/41, 68.7-91.5)
|
78.3 (18/23, 58.1-90.3)
|
88.9 (16/18, 67.2-96.9)
|
Specificity
|
75.0 (3/4, 30.1-95.4)
|
100 (2/2, 34.2-100)
|
50.0 (1/2, 9.5-90.5)
|
PPV
|
97.1 (34/35, 85.5-99.5)
|
100 (18/18, 82.4-100)
|
94.1 (16/17, 73.0-99.0)
|
NPV
|
30.0 (3/10, 10.8-60.3)
|
28.6 (2/7, 8.2-64.1)
|
33.3 (1/3, 6.1-79.2)
|
Accuracy
|
82.2 (37/45, 68.7-90.7)
|
80.0 (20/25, 60.9-91.1)
|
85.0 (17/20, 64.0-94.8)
|
EUS-FNA, endoscopic ultrasound-guided fine needle aspiration; GI, gastrointestinal tract; CI confidence interval, PPV positive predictive value, NPV negative predictive value