Introduction: Despite advances in imaging techniques, the differentiation between pancreatic cancer and benign lesions remains difficult. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an effective method for providing tissue diagnosis, but problems occur when lesions are small or the cytological diagnosis is indeterminate. Aim: To prospectively evaluate the utility of EUS-FNA in patients with small solid pancreatic lesions and those with initial indeterminate or negative cytological diagnosis. Methods: During the study period we performed a total of 119 EUS-FNA procedures on 46 patients (mean age 56.3 years) for 47 small solid pancreatic lesions (range 7–30 mm, mean 17.2 mm in diameter). FNAs were performed in the presence of a cytopathologist. If cytological diagnoses were indeterminate, EUS-FNA was repeated within 3 weeks. Diagnoses were confirmed histologically or by follow-up (clinical and imaging: EUS +/– FNA and CT). Results: Localization of the lesions: head 28 (60%), uncinate process 4 (9%), body 11 (23%) and tail 4 (9%). On average, 3.7 passes were performed. We observed no complications. Initial cytological findings were: malignant 17 (36%), benign 21 (45%), and indeterminate 9 (19%). 8 (78%) of the indeterminate findings were confirmed to be malignant on repeated procedures. A diagnosis of pancreatic cancer was subsequently confirmed in 1 patient who had a benign cytological finding. 19 patients underwent surgery. Histology confirmed a neoplasm in all cases. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 68, 100, 100, 73 and 83%, respectively. After repeated EUS-FNAs of indeterminate findings sensitivity, negative predictive value and diagnostic accuracy rose to 92, 77 and 96%, respectively. Conclusion: EUS-FNA is a highly effective method for providing tissue diagnosis in patients with small solid pancreatic masses. Repeated procedures enhanced diagnostic accuracy in indeterminate findings, among which was high percentage of malignancies. EUS-FNA reduced the number of operations in patients with pancreatic solid masses.

The role of endoscopic ultrasound (EUS) in evaluating pancreatic pathology has been well documented from the beginning of its clinical use. High spatial resolution and the close proximity to the evaluated organs within the mediastinum and abdominal cavity allow detection of small focal lesions and precise tissue acquisition from suspected lesions within the reach of this method. Fine needle aspiration (FNA) is considered of additional value to EUS and is performed to obtain tissue diagnosis. Tissue acquisition from suspected lesions for cytological or histological analysis allows, not only the differentiation between malignant and non-malignant lesions, but, in most cases, also the accurate distinction between the various types of malignant lesions. It is well documented that the best results are achieved only if an adequate sample is obtained for further analysis, if the material is processed in an appropriate way, and if adequate ancillary methods are performed. This is a multi-step process and could be quite a challenge in some cases. In this article, we discuss the technical aspects of tissue acquisition by EUS-guided-FNA (EUS-FNA), as well as the role of an on-site cytopathologist, various means of specimen processing, and the selection of the appropriate ancillary method for providing an accurate tissue diagnosis and maximizing the yield of this method. The main goal of this review is to alert endosonographers, not only to the different possibilities of tissue acquisition, namely EUS-FNA, but also to bring to their attention the importance of proper sample processing in the evaluation of various lesions in the gastrointestinal tract and other accessible organs. All aspects of tissue acquisition (needles, suction, use of stylet, complications, etc.) have been well discussed lately. Adequate tissue samples enable comprehensive diagnoses, which answer the main clinical questions, thus enabling targeted therapy.

Gastric cancer remains the fourth leading cause of cancer-related mortality worldwide. Advanced disease is associated with a poor prognosis, emphasizing the critical importance of early diagnosis through endoscopy. In addition to prognosis, disease extent also plays a pivotal role in guiding management strategies. Therefore, accurate locoregional staging (T and N staging) is vital for optimal prognostic and therapeutic planning. Endoscopic ultrasound (EUS) has long been an essential tool in this regard, with computed tomography (CT) and, more recently, positron emission tomography–computed tomography (PET–CT) serving as alternative imaging modalities. EUS is particularly valuable in the assessment of early gastric cancer, defined as tumor invasion confined to the mucosa or submucosa. These tumors are increasingly managed by endoscopic resection techniques offering improved post-treatment quality of life. EUS has also recently been utilized in the restaging process after neoadjuvant chemotherapy, aiding in the evaluation of tumor resectability and prognosis. Its performance may be further enhanced through the application of emerging techniques such as contrast-enhanced endosonography, EUS elastography, and artificial intelligence systems. In advanced, unresectable disease, complications such as gastric outlet obstruction (GOO) severely impact patient quality of life. In this setting, EUS-guided gastroenterostomy (EUS-GE) offers a less invasive alternative to surgical gastrojejunostomy. This review summarizes and critically analyzes the role of EUS in the context of gastric cancer, highlighting its applications across different stages of the disease and evaluating its performance relative to other diagnostic modalities.

Current guidelines advocate 3–4 passes with a fine-needle aspiration (FNA) to achieve high rates of diagnostic samples for malignancy when performing endoscopic ultrasound (EUS)-guided sampling of solid pancreatic lesions, in the absence of on-site cytologic evaluation. The aim of this study is to compare 2 vs. 3 needle passes in EUS-FNA for solid pancreatic lesions in terms of incremental diagnostic yield and to identify factors associated with the procedure’s outcome. In this retrospective study, 2 passes of EUS-FNA were found to have similar diagnostic yield compared to 3 passes for the diagnosis of solid pancreatic masses, suggesting that there might be no significant incremental tissue yield when 3 passes are performed.

A 26-year-old woman presented with sharp pain in the upper abdomen. Elevated amylase and lipase levels suggested pancreatitis. Emergency computed tomography (CT) of the abdomen showed a cystic lesion with calcifications and lipid-like tissue located between the aorta and vena cava and compressing the pancreatic head and duodenum ([Fig. 1]). Teratoma was suspected. The patient had experienced acute idiopathic pancreatitis 4 years earlier, at which time CT had shown a pancreatic head pseudocyst, so it seemed that the appearance of the lesion had changed. The patient was referred for magnetic resonance imaging, which showed a cystic lesion with a thin capsule, septa, calcifications, and a solid part clearly not originating from the pancreatic head ([Fig. 2]). The patient then underwent endoscopic ultrasound (EUS) because of the suspicion of teratoma. EUS showed a well-delineated cystic lesion with hyperechoic septa and homogeneous, more solid parts. Calcifications were not seen on EUS ([Fig. 3]). EUS-guided fine-needle aspiration was performed with a 22-gauge needle (Expect; Boston Scientific, Natick, Massachusetts, USA). Chylous, milky white fluid was aspirated from the cyst. Biochemistry of the fluid showed a high level of triglycerides and low levels of carcinoembryonic antigen (CEA) and amylases, which definitely excluded pseudocyst from the differential diagnosis. Sediments of the fluid contained lymphocytes that were CD3+ on immunocytochemistry. The cytologic diagnosis was consistent with cystic lymphangioma. The patient refused surgical treatment. On follow-up, she was symptoms free and had serum values of amylase, lipase, cancer antigen (CA) 19-9, and CEA within normal range. This case is interesting because it shows lymphangioma as a rare cause of recurrent acute pancreatitis. Lymphangioma is a malformation of lymphatic vessels and should not be misinterpreted as a cystic or solid–cystic pancreatic tumor [1] [2]. Although it is benign, a compression effect on other organs can cause symptoms [3]. The patient had no other probable cause of acute pancreatitis, and we therefore concluded that in this case lymphangioma was the cause of pancreatitis. Endoscopy_UCTN_Code_CCL_1AF_2AF_3AC