Endoscopic ultrasound (EUS) provides detailed, high-resolution images of the pancreas. However, whether a lesion is malignant or benign cannot be diagnosed solely from its imaging features on EUS. The introduction of EUS-guided fine needle aspiration (EUS-FNA) offers the possibility to obtain a cytological or histological diagnosis of pancreatic lesions with a high sensitivity and specificity. Although the clinical utility of EUS-FNA for pancreatic diseases is widely accepted, the indication for preoperative tissue diagnosis of pancreatic lesions suspected to be malignant is still controversial. This review highlights the diagnostic potential of EUS-FNA, as well as its current indications and contraindications, complications, and techniques.

1.
Kloppel G: Pancreatic biopsy; in Kloppel G, Heitz PU (eds): Pancreatic Pathology. Edinburgh, Churchill Livingstone, 1984, pp 114–122.
2.
Hajdu SI, Ehya H, Frable WJ, Geisinger KR, Gompel CM, Kern WH, Lowhagen T, Oertel YC, Ramzy I, Rilke FO, et al: The value and limitations of aspiration cytology in the diagnosis of primary tumors. A symposium. Acta Cytol 1989;33:741–790.
3.
Goodale RL, Gajl-Peczalska K, Dressel T, Samuelson J: Cytologic studies for the diagnosis of pancreatic cancer. Cancer 1981;47:1652–1655.
4.
Osnes M, Serck-Hanssen A, Kristensen O, Swensen T, Aune S, Myren J: Endoscopic retrograde brush cytology in patients with primary and secondary malignancies of the pancreas. Gut 1979;20:279–284.
5.
Vilmann P, Jacobsen GK, Henriksen FW, Hancke S: Endoscopic ultrasonography with guided fine needle aspiration biopsy in pancreatic disease. Gastrointest Endosc 1992;38:172–173.
6.
Hawes RH: Indications for EUS-directed FNA. Endoscopy 1998;30(suppl 1):A155–A157.
7.
Erickson RA: EUS-guided FNA. Gastrointest Endosc 2004;60:267–279.
8.
Yamao K, Sawaki A, Mizuno N, Shimizu Y, Yatabe Y, Koshikawa T: Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB): past, present, and future. J Gastroenterol 2005;40:1013–1023.
9.
Chang KJ, Nguyen P, Erickson RA, Durbin TE, Katz KD: The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma. Gastrointest Endosc 1997;45:387–393.
10.
Eloubeidi MA, Tamhane A, Varadarajulu S, Wilcox CM: Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006;63:622–629.
11.
Eloubeidi MA, Gress FG, Savides TJ, Wiersema MJ, Kochman ML, Ahmad NA, Ginsberg GG, Erickson RA, Dewitt J, Van Dam J, Nickl NJ, Levy MJ, Clain JE, Chak A, Sivak MV Jr, Wong R, Isenberg G, Scheiman JM, Bounds B, Kimmey MB, Saunders MD, Chang KJ, Sharma A, Nguyen P, Lee JG, Edmundowicz SA, Early D, Azar R, Etemad B, Chen YK, Waxman I, Shami V, Catalano MF, Wilcox CM: Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States. Gastrointest Endosc 2004;60:385–389.
12.
Jenssen C, Dietrich CF: Endoscopic ultrasound-guided fine-needle aspiration biopsy and trucut biopsy in gastroenterology – an overview. Best Pract Res Clin Gastroenterol 2009;23:743–759.
13.
Doi S, Yasuda I, Iwashita T, Ibuka T, Fukushima H, Araki H, Hirose Y, Moriwaki H: Needle tract implantation on the esophageal wall after EUS-guided FNA of metastatic mediastinal lymphadenopathy. Gastrointest Endosc 2008;67:988–990.
14.
Shah JN, Fraker D, Guerry D, Feldman M, Kochman ML: Melanoma seeding of an EUS-guided fine needle track. Gastrointest Endosc 2004;59:923–924.
15.
Paquin SC, Gariepy G, Lepanto L, Bourdages R, Raymond G, Sahai AV: A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma. Gastrointest Endosc 2005;61:610–611.
16.
Hirooka Y, Goto H, Itoh A, Hashimoto S, Niwa K, Ishikawa H, Okada N, Itoh T, Kawashima H: Case of intraductal papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination. J Gastroenterol Hepatol 2003;18:1323–1324.
17.
Micames C, Jowell PS, White R, Paulson E, Nelson R, Morse M, Hurwitz H, Pappas T, Tyler D, McGrath K: Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percutaneous FNA. Gastrointest Endosc 2003;58:690–695.
18.
Itoi T, Itokawa F, Sofuni A, Nakamura K, Tsuchida A, Yamao K, Kawai T, Moriyasu F: Puncture of solid pancreatic tumors guided by endoscopic ultrasonography: a pilot study series comparing Trucut and 19- and 22-gauge aspiration needles. Endoscopy 2005;37:362–366.
19.
Sakamoto H, Kitano M, Komaki T, Noda K, Chikugo T, Dote K, Takeyama Y, Das K, Yamao K, Kudo M: Prospective comparative study of the EUS guided 25-gauge FNA needle with the 19-gauge Trucut needle and 22-gauge FNA needle in patients with solid pancreatic masses. J Gastroenterol Hepatol 2009;24:384–390.
20.
Levy MJ: Endoscopic ultrasound-guided trucut biopsy of the pancreas: prospects and problems. Pancreatology 2007;7:163–166.
21.
Mizuno N, Bhatia V, Hosoda W, Sawaki A, Hoki N, Hara K, Takagi T, Ko SB, Yatabe Y, Goto H, Yamao K: Histological diagnosis of autoimmune pancreatitis using EUS-guided trucut biopsy: a comparison study with EUS-FNA. J Gastroenterol 2009;44:742–750.
22.
Levy MJ, Smyrk TC, Reddy RP, Clain JE, Harewood GC, Kendrick ML, Pearson RK, Petersen BT, Rajan E, Topazian MD, Wang KK, Wiersema MJ, Yusuf TE, Chari ST: Endoscopic ultrasound-guided trucut biopsy of the cyst wall for diagnosing cystic pancreatic tumors. Clin Gastroenterol Hepatol 2005;3:974–979.
23.
Erickson RA, Sayage-Rabie L, Beissner RS: Factors predicting the number of EUS-guided fine-needle passes for diagnosis of pancreatic malignancies. Gastrointest Endosc 2000;51:184–190.
24.
Klapman JB, Logrono R, Dye CE, Waxman I: Clinical impact of on-site cytopathology interpretation on endoscopic ultrasound-guided fine needle aspiration. Am J Gastroenterol 2003;98:1289–1294.
25.
Wiersema MJ, Norton ID: Endoscopic ultrasound-guided fine-needle aspiration biopsy in the gastrointestinal tract. UpToDate, 18.2.2010, http://www.uptodate.com/patients/content/topic.do?topicKey=~iIxncz_GU9HgNi.
26.
Hartwig W, Schneider L, Diener MK, Bergmann F, Buchler MW, Werner J: Preoperative tissue diagnosis for tumours of the pancreas. Br J Surg 2009;96:5–20.
27.
Takahashi K, Yamao K, Okubo K, Sawaki A, Mizuno N, Ashida R, Koshikawa T, Ueyama Y, Kasugai K, Hase S, Kakumu S: Differential diagnosis of pancreatic cancer and focal pancreatitis by using EUS-guided FNA. Gastrointest Endosc 2005;61:76–79.
28.
Gleeson FC, Kipp BR, Caudill JL, Clain JE, Clayton AC, Halling KC, Henry MR, Rajan E, Topazian MD, Wang KK, Wiersema MJ, Zhang J, Levy MJ: False positive endoscopic ultrasound fine needle aspiration cytology: incidence and risk factors. Gut 2010;59:586–593.
29.
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™). Pancreatic Adenocarcinoma, v 1. 2010, www.nccn.org.
30.
Bhutani MS: Interventional endoscopic ultrasonography: state of the art at the new millenium. Endoscopy 2000;32:62–71.
31.
Saftoiu A, Vilmann P: Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer. J Clin Ultrasound 2009;37:1–17.
32.
Hosoda W, Takagi T, Mizuno N, Shimizu Y, Sano T, Yamao K, Yatabe Y: Diagnostic approach to pancreatic tumors with the specimens of endoscopic ultrasound-guided fine needle aspiration. Pathol Int 2010;60:358–364.
33.
Imaoka H, Yamao K, Bhatia V, Shimizu Y, Yatabe Y, Koshikawa T, Kinoshita Y: Rare pancreatic neoplasms: the utility of endoscopic ultrasound-guided fine-needle aspiration – a large single center study. J Gastroenterol 2009;44:146–153.
34.
Yamao K, Nakamura T, Suzuki T, Sawaki A, Hara K, Kato T, Okubo K, Matsumoto K, Shimizu Y: Endoscopic diagnosis and staging of mucinous cystic neoplasms and intraductal papillary-mucinous tumors. J Hepatobiliary Pancreat Surg 2003;10:142–146.
35.
Brugge WR, Lewandrowski K, Lee-Lewandrowski E, Centeno BA, Szydlo T, Regan S, del Castillo CF, Warshaw AL: Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004;126:1330–1336.
36.
Tanaka M, Chari S, Adsay V, Fernandez-del Castillo C, Falconi M, Shimizu M, Yamaguchi K, Yamao K, Matsuno S: International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 2006;6:17–32.
37.
Abraham SC, Wilentz RE, Yeo CJ, Sohn TA, Cameron JL, Boitnott JK, Hruban RH: Pancreaticoduodenectomy (Whipple resections) in patients without malignancy: are they all ‘chronic pancreatitis’? Am J Surg Pathol 2003;27:110–120.
38.
Weber SM, Cubukcu-Dimopulo O, Palesty JA, Suriawinata A, Klimstra D, Brennan MF, Conlon K: Lymphoplasmacytic sclerosing pancreatitis: inflammatory mimic of pancreatic carcinoma. J Gastrointest Surg 2003;7:129–137, discussion 137–139.
39.
Ko SB, Mizuno N, Yatabe Y, Yoshikawa T, Ishiguro H, Yamamoto A, Azuma S, Naruse S, Yamao K, Muallem S, Goto H: Corticosteroids correct aberrant CFTR localization in the duct and regenerate acinar cells in autoimmune pancreatitis. Gastroenterology 2010;138:1988–1996.
40.
Okazaki K, Kawa S, Kamisawa T, Naruse S, Tanaka S, Nishimori I, Ohara H, Ito T, Kiriyama S, Inui K, Shimosegawa T, Koizumi M, Suda K, Shiratori K, Yamaguchi K, Yamaguchi T, Sugiyama M, Otsuki M: Clinical diagnostic criteria of autoimmune pancreatitis: revised proposal. J Gastroenterol 2006;41:626–631.
41.
Otsuki M, Chung JB, Okazaki K, Kim MH, Kamisawa T, Kawa S, Park SW, Shimosegawa T, Lee K, Ito T, Nishimori I, Notohara K, Naruse S, Ko SB, Kihara Y, Research Committee of Intractable Pancreatic Diseases provided by the Ministry of Health, Labour and Welfare of Japan and the Korean Society of Pancreatobiliary Diseases: Asian diagnostic criteria for autoimmune pancreatitis: consensus of the Japan-Korea Symposium on Autoimmune Pancreatitis. J Gastroenterol 2008;43:403–408.
42.
Chari ST, Takahashi N, Levy MJ, Smyrk TC, Clain JE, Pearson RK, Petersen BT, Topazian MA, Vege SS: A diagnostic strategy to distinguish autoimmune pancreatitis from pancreatic cancer. Clin Gastroenterol Hepatol 2009;7:1097–1103.
43.
Hamano H, Kawa S, Horiuchi A, Unno H, Furuya N, Akamatsu T, Fukushima M, Nikaido T, Nakayama K, Usuda N, Kiyosawa K: High serum IgG4 concentrations in patients with sclerosing pancreatitis. N Engl J Med 2001;344:732–738.
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