Background and Objectives: Prognosis of pancreatic neuroendocrine neoplasms (PanNENs) mostly depend on tumor stage and grade, determined by Ki-67 labeling index. EUS-FNA is considered the gold-standard technique to obtain it. The aims of our study were to establish diagnostic accuracy of preoperative EUS-FNA Ki-67 evaluation considering final pathological assessment on surgical specimen as gold standard and to investigate the possible impact on prognosis of misclassification. Methods: This is a retrospective study from a prospectively collected database. EUS-FNA grading (eG) and surgical one (sG) measured according to Ki-67 proliferative index values, according to 2017 WHO classification, were compared. eG-sG correlation was evaluated by Spearman index. Logistic regression investigated factors associated with misclassification. Prognostic difference in terms of progression-free survival was evaluated by Kaplan Meier method. Results: One hundred and twelve PanNENs patients enrolled. In 13.4% of patients (15/112) EUS-FNA “undergraded” patients (eG1 vs. sG2), while in 12.5% (n = 14) it “overgraded” PanNENs (eG2 to sG1). No misclassifications in G3 patients. In patients with tumors <20 mm (n = 44), 2 (4.5%) eG1 and 10 (22.7%) eG2 were finally classified respectively as G2 and G1 at surgical histology. No factors, as i.e. the lesions' size or their morphological aspect, were associated with misclassification. In overgraded PanNENs, no progression occurred, while in patients correctly classified/undergraded the progression rate was 14.3%. Conclusions: This is the largest cohort of surgical PanNENs with preoperative EUS-FNA grading evaluation. Despite an acceptable eG-sG correlation, about 25% of patients are misclassified. Clinical impact of misclassification should be carefully considered especially in small tumors undergoing observation.

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Background and Objectives: Patients with locally advanced or metastatic pancreatic ductal adenocarcinoma (A-PDAC) are not candidates for surgical resection and are often offered palliative chemotherapy. The ready availability of a safe and effective tumor sampling technique to provide material for both diagnosis and comprehensive genetic profiling is critical for informing precision medicine in A-PDAC, thus potentially increasing survival. The aim of this study is to examine the feasibility and benefits of routine comprehensive genomic profiling (CGP) of A-PDAC using EUS-FNA material. Methods: This is a prospective cohort study to test the clinical utility of fresh frozen or archival EUS-FNA samples in providing genetic material for CGP. The results of the CGP will be reviewed at a molecular tumor board. The proportion of participants that have a change in their treatment recommendations based on their individual genomic profiling will be assessed. Correlations between CGP and stage, prognosis, response to treatment and overall survival will also be investigated. This study will open to recruitment in 2020, with a target accrual of 150 A-PDAC patients within 36 months, with a 2-year follow-up. It is expected that the majority of participants will be those who have already consented for their tissue to be biobanked in the Victorian Pancreatic Cancer Biobank at the time of diagnostic EUS-FNA. Patients without archival or biobanked material that is suitable for CGP may be offered a EUS-FNA procedure for the purposes of obtaining fresh frozen material. Discussion: This trial is expected to provide crucial data regarding the feasibility of routine CGP of A-PDAC using EUS-FNA material. It will also provide important information about the impact of this methodology on patients' survival.

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The optimal sampling techniques for EUS-FNA remain unclear and have not been standardized. To improve diagnostic accuracy, suction techniques for EUS-FNA have been developed and are widely used among endoscopists. The aim of this study was to compare wet-suction and dry-suction EUS-FNA techniques for sampling solid lesions. We performed a comprehensive literature search of major databases (from inception to June 2020) to identify prospective studies comparing wet-suction EUS-FNA and dry-suction EUS-FNA. Specimen adequacy, sample contamination, and histologic accuracy were assessed by pooling data using a random-effects model expressed in terms of odds ratio (OR) and 95% confidence interval (CI). Six studies including a total of 418 patients (365 wet suction vs. 377 dry suction) were included in our final analysis. The study included a total of 535 lesions (332 pancreatic lesions and 203 nonpancreatic lesions). The pooled odds of sample adequacy was 3.18 (CI: 1.82–5.54, P = 0.001) comparing wet- and dry-suction cohorts. The pooled odds of blood contamination was 1.18 (CI: 0.75–1.86, P = 0.1). The pooled rate for blood contamination was 58.33% (CI: 53.65%–62.90%) in the wet-suction cohort and 54.60% (CI 49.90%– 59.24%) in the dry-suction cohort (P = 0.256). The pooled odds of histological diagnosis was 3.68 (CI 0.82–16.42, P = 0.1). Very few adverse events were observed and did not have an impact on patient outcomes using either method. EUS-FNA using the wet-suction technique offers higher specimen quality through comparable rates of blood contamination and histological accuracy compared to dry-suction EUS-FNA.

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Accurate staging of non-small cell lung cancer (NSCLC) is crucial for allocation to surgical, medical or multimodal treatment. EUS and endobronchial ultrasound (EBUS) have gained ground in the diagnosis and staging of lung cancer in addition to radiological imaging (e.g., computed tomography, fluoroscopy, and magnetic resonance imaging), nuclear medicine techniques (e.g. positron emission tomography, PET), combined techniques (e.g., fluorodesoxyglucosepositron emission tomography scanning), and sonographic imaging including conventional transcutaneous mediastinal and lung ultrasound. By using one single echoendoscope in both the trachea and the esophagus, surgical staging procedures (e.g. mediastinoscopy and video assisted thoracoscopy) can be avoided in a considerable proportion of patients with NSCLC.

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Background and Objectives: Cholecystectomy is the gold standard for most gallbladder-related disease. However, many patients with gallbladder disease are poor surgical candidates. Current nonsurgical gallbladder drainage (GBD) methods include percutaneous cholecystostomy and endoscopic ultrasound-guided transluminal GBD (EUS-GBD). Outcomes for EUS-GBD for the treatment of noncholecystitis (NC) gallbladder disease have not been defined. Materials and Methods: Cases were identified using procedural data from a quaternary academic hospital for endoscopic procedures from 2015 to 2020. Patients who underwent EUS-GBD for acute cholecystitis, biliary colic, gallstone pancreatitis, and secondary prevention of gallstone disease were included. Results: Fifty-five cases of EUS-GBD were identified over the 5-year study period. Forty-one cases were performed for acute cholecystitis, and 15 were performed for other NC indications. Indications for NC drainage included primary treatment of symptomatic biliary colic and secondary prevention of gallstone pancreatitis and choledocholithiasis. There was no statistically significant difference in complications, mortality, or reintervention requirements. There was a 13.3% rate of immediate complications in the NC group, which were all medically managed. Conclusions: EUS-GBD appears to be a safe and effective way to manage gallstone disease in nonsurgical candidates with NC gallbladder-related disease. Overall complications and readmissions were infrequent. Complication rates were similar to those published in patients who underwent EUS-GBD for acute cholecystitis.

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Background and Objectives: Liver metastases might not be detected by computed tomography (CT) and magnetic resonance imaging (MRI) due to their small size, but they can be detected by EUS. Furthermore, EUS-FNA has a significant impact on improving the diagnostic accuracy of EUS. The purpose of this study was to assess the feasibility of EUS in detection of occult small hepatic focal lesions at the time of primary tumor staging, not seen by CT or MRI. Methods: This prospective study included 730 patients who underwent EUS for staging or sampling of gastrointestinal, pancreatic, or thoracic malignancy. The liver was examined thoroughly for detection of occult lesions. CT or MRI was done within 1 week of EUS examination. Results: EUS examination of the liver detected focal lesions in 150 patients (20.5%) and metastases in 118 patients (16.2%); meanwhile, CT and MRI detected focal lesions in 99 patients (13.6%) and metastases in 82 patients (11.2%). EUS missed focal lesions in 7 patients, 6 of which were liver metastases (1.0% and 0.8%, respectively), while CT and MRI missed focal lesions in 58 patients, 42 of which were metastases (7.9% and 5.8%, respectively), which were detected by EUS. Conclusion: Thorough dedicated EUS examination of the liver is a feasible useful tool for detection of small hepatic lesions missed by CT and MRI. It is not considered an extra financial burden to the patient or health-care system because those patients are indicated for EUS examination for evaluation of their original lesion in the first place. Furthermore, EUS-FNA can add another advantage in diagnosing the etiology of such lesions.

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Background and Objectives: Adverse events (AEs) such as bile peritonitis or pneumoperitoneum might occur during procedural steps for EUS-guided hepaticogastrostomy (HGS), such as during device exchange and after fistula dilation until stent deployment. Reducing the steps to the EUS-HGS procedure might therefore be ideal to prevent the occurrence of AEs. Recently, a novel, fully covered self-expandable metal stent (FCSEMS) has become available. Because of the fine-gauge stent delivery system (5.9Fr), fistula dilation might not be needed before stent deployment during EUS-HGS. The aim of this pilot study was to evaluate the technical feasibility and safety of one-step EUS-HGS using a novel 8-mm diameter FCSEMS. Patients and Methods: The primary outcome in this study was technical success, and the secondary outcomes were procedure- and stent-related AEs and clinical success. The technical success of one-step EUS-HGS was defined as successful FCSEMS deployment without any fistula dilation. Procedure time was measured from scope insertion to successful FCSEMS deployment. Results: One-step EUS-HGS using the novel FCSEMS was attempted on 14 patients. Technical success with a short procedure time (median: 7 min) and clinical success were obtained in all patients. In addition, procedure-related AEs such as bleeding, bile peritonitis, and stent migration during the procedure were not observed in any patients. Conclusions: One-step EUS-HGS using the novel FCSEMS with a fine-gauge stent delivery system is technically feasible and shortens the procedure time with no requirement for additional fistula dilation, resulting in a potential reduction in procedure-related AEs.

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Background and Objectives: Along with the rapid improvement of imaging technology, convex probe endobronchial ultrasound (CP-EBUS) sonographic features play an increasingly important role in the diagnosis of intrathoracic lymph nodes (LNs). Conventional qualitative and quantitative methods for EBUS multimodal imaging are time-consuming and rely heavily on the experience of endoscopists. With the development of deep-learning (DL) models, there is great promise in the diagnostic field of medical imaging. Materials and Methods: We developed DL models to retrospectively analyze CP-EBUS images of 294 LNs from 267 patients collected between July 2018 and May 2019. The DL models were trained on 245 LNs to differentiate benign and malignant LNs using both unimodal and multimodal CP-EBUS images and independently evaluated on the remaining 49 LNs to validate their diagnostic efficiency. The human comparator group consisting of three experts and three trainees reviewed the same test set as the DL models. Results: The multimodal DL framework achieves an accuracy of 88.57% (95% confidence interval [CI] [86.91%–90.24%]) and area under the curve (AUC) of 0.9547 (95% CI [0.9451–0.9643]) using the three modes of CP-EBUS imaging in comparison to the accuracy of 80.82% (95% CI [77.42%–84.21%]) and AUC of 0.8696 (95% CI [0.8369–0.9023]) by experts. Statistical comparison of their average receiver operating curves shows a statistically significant difference (P < 0.001). Moreover, the multimodal DL framework is more consistent than experts (kappa values 0.7605 vs. 0.5800). Conclusions: The DL models based on CP-EBUS imaging demonstrated an accurate automated tool for diagnosis of the intrathoracic LNs with higher diagnostic efficiency and consistency compared with experts.

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