1. Dr J King, Dr T Bracey Department of cellular pathology, Derriford Hospital May 2014

2. 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

3. RCPath Dataset 1  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

4. 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

5. 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

7. Standard  No published standards in datasets  Adequacy rate without ROSE 61%  Both mediastinal and pancreatic data 2  Mediastinal range 84 – 96%  With ROSE  Pancreatic range 67-86%  Without ROSE

8. Aim  Review all PMCB cases  Compare the outcome with conventional cytology methods  Provide recommendations from the results found

10. 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

11. 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

12. 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

13. Categories for cytology and PMCB results DiagnosisCytologyPMCB No sample takenC0PM0 InadequateC1PM1 BenignC2PM2 Atypical probably benignC3PM3 Suspicious of malignancyC4PM4 MalignantC5PM5

14. 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

15. Overall results  Of the total cytology samples, 67% were adequate (24/36)  Of the total PMCB samples, 78% were adequate (35/45)

16. Mediastinal cases C0C1C2C3C4C5Total PM0325 PM10 PM23811 PM30 PM40 PM55117 total831100123

17. 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

18. Mediastinal results...  One false negative  C2 no overt malignant cells  PM5 - metastatic moderately differentiated intestinal type adenocarcinoma  Remaining paired results correlated  No false positives

20. Retroperitoneal cases C0C1C2C3C4C5Total PM01236 PM14610 PM2112 PM311 PM41113 PM55112211 total129622233

21. 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

22. 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

24. How many used extra tests  16 of the PMCB had extra tests  Levels  Special stains  Immunohistochemistry

25. Discussion CytologyPMCB 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

26. 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

27. recommendations  Continue with PMCB  Review SOP for handling such specimens  Liase with operators  Re-audit with 2014 data

28. References 1. 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 Volume 41, Issue 12, 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)Clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of mediastinal and intra-abdominal lymphadenopathy 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) Comparison of 19- and 22-gauge needles in EUS-guided fine needle aspiration in patients with mediastinal masses and lymph nodes  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 Utility of liquid-based cytology in the evaluation of endoscopic ultrasound guided fine needle aspiration: Comparison with the conventional smears  Rapid on-site evaluation of EUS–FNA by cytopathologist: An experience of a tertiary hospital. R. Shafia Ecka; M. Sharma. Diagnostic Cytopathology. Oct 2013

29. 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) A 1 year audit of endoluminal ultrasound-guided fine needle aspiration cytology investigations (EUS-FNA) : Diagnostic efficacy and input of on-site cytological assessment  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 What is the impact of a one-week, intensive, hands-on eus training program on tissue acquisition?  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

30. Thank you