Welcome to ASG Endo Hangout with GI Fellows, Luminal EUS Part 2. We have attendees joining us from all over the world, and the American Society for Gastrointestinal Endoscopy greatly appreciates your participation. My name is Ellie Vergara, and I will be the facilitator for this presentation. Before we get started, there are a few housekeeping items. We want this presentation to be interactive, so you are encouraged to submit your questions at any time online by clicking the chat feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to send the message. Please note that this presentation is being recorded and will be posted in the Fellows Corner section on GILeap, ASGE's online learning management platform, within a week. Now it is my pleasure to introduce our two moderators, Dr. Paula Adamson and Dr. Jordan Orr, who will help facilitate the incoming questions. I will now hand over the presentation to them. Hello, everyone. I want to thank ASG for hosting this webinar, our panelists for their dedication to Fellow education, and to all of you for joining us. I am Paula Adamson, and I am currently a third-year Fellow at the University of Louisville. And it is my pleasure today to co-moderate with Paula and help facilitate passing the questions along. My name is Jordan Orr. I'm the Advanced Endoscopy Fellow at Vanderbilt University Medical Center. So we have the pleasure of introducing our panelists for today. First, we have Dr. Ashley Faux, who is a Professor of Medicine at Case Western Reserve University School of Medicine, where she is an Advanced Therapeutic Endoscopist. She is on faculty at University Hospital Cleveland Medical Center, and serves as a Director of Endoscopy at the Cleveland VA Medical Center. She is a Counselor on the ASGE Governing Board. Dr. Girish Mishra is a Professor and Chief of GI and Hepatology, and Executive Director of the Digestive Health Service Line at Wake Forest Baptist Medical Center. His research interests are in US GI cancers, US training and curriculum, and has been very active with the ASGE, having served as the Chair of the Publications Committee a few years ago. Dr. Vanessa Shami is a Professor of Medicine and Director of Endoscopic Ultrasound in the Division of Gastroenterology and Hepatology at the University of Virginia Medical Center. She completed her gastrointestinal fellowship at the University of Virginia, and her interventional training at the University of Chicago. She served as a Counselor for the American Society for Gastrointestinal Endoscopy, and is actively involved in national education in endoscopy. Dr. Chalk is the current Secretary-Elect of ASGE. He is one of our Advanced Endoscopists at Case Western Reserve University, and he has served in various positions with ASGE and GIE Journal. And currently, he is the Director of Advanced Technology and Innovation Center of Excellence at UH Cleveland Medical Center. Dr. Chalk, we hand it over to you. Great. Thanks, Jordan. I hope those of you who have joined us have had a good day and are looking forward to this endo-hangout. For those of you who aren't familiar with this, this is a format of really a hangout where we discuss various cases and techniques and aspects. It's meant for trainees, but we invite people who are not trainees. And most of all, we want you to send questions to our co-moderators, Paula and Jordan. Even as we go through the cases and quiz our panelists to send those questions, please use your Q&A. I do want to thank ASGE for hosting this event and adding it to today. And most of all, our moderators are going to help us think about pancreatic EUS. So without further ado, a 43-year-old female comes in with acute abdominal pain. She denies any weight loss or other symptoms. And as is part of our want these days, part of the physical exam includes getting a CT scan. And on the CT scan, this is a cut. We see this lesion in the pancreas. Vanessa, I'm not going to ask you, but let me ask Ashley and Garish who hopefully haven't gone beyond this slide. Ashley, when you see this lesion, what do you think is going on? What do you think that is? So I think it looked sort of sense that maybe there's a little bit of a cystic component to it, maybe a part cystic, part solid thing. You know, when we think of a 43-year-old who's asymptomatic, you know, as much as we see a lot of pancreas cancer, we like to think of things that, you know, perhaps are not, you know, something like a pancreas cancer, and this looks more cystic. My guess, given her age and just where this is, this may be sort of something unusual, like a solid pseudopapillary pancreatic lesion or something that even though she just developed acute abdominal pain, it may just be sort of non-related, and this may be something that's been there for a while. The rest of the pancreas there looked kind of normal on that cut. Garish, any other thoughts? Yeah, no, thanks, Amanda. I'd also like to thank the ASG and for you and Vanessa and Ashley and others for inviting me to participate. If you go back to the slide, there are a couple of features on that CAT scan that I think need to be highlighted. We can't really see the pancreatic duct there, and in general, if we were dealing with a pancreatic cancer, often the duct gets dilated, and I think that's an important point to keep in mind, especially when you see that, think of things outside of adenocarcinomas such as lymphomas. And so as Ashley and others have pointed out, for the most part, this looks pretty cystic. I think an EUS will be helpful because whether it's totally anechoic versus a mixed type of heterogeneous, but the other thing, if you look at this, the borders are pretty well demarcated. So this argues against something very aggressive as a malignancy. Her demographics do favor a solid cystic pseudopapillary neoplasm, and you've not given us the history of pancreatitis, so this should not be a pseudocyst, but that's kind of the thought process just based on that imaging. The only other thought, just one more comment, was there is some density in there, and you sort of wonder maybe is there a little blood density, hard to tell, but another thing you can think of something acutely happens is was there a lesion that got bled into by this, but it's sort of hard to tell based on that one image. And you know, you guys, and I'm intervening even though it says Vanessa, I won't ask you. You know, I mean, MCNs would be a mucinous cystic neoplasms, obviously also in the differential, and the common things being common, that's kind of what our leading thought was in terms of diagnosis at this point. But, you know, in a woman, and what looks like a unilocular thing. So Lyle, can we get a poll? What would be your next step? A, listen for the audience, A, resection, since she has pain, would you go directly, ablate the cyst with alcohol injection, repeat CT imaging, everyone's here for U.S., so U.S. with selective FNA, or if it's cystic, would you leave it alone and not cause an infection? So everyone wanted the FNA, and anyone have hesitancy in FNA-ing this? Would you make a decision based on what you see, or would you be prepared to FNA? I mean, I think you need to have communication with your surgeons. I mean, I don't know how you guys, our surgeons want tissue, so I think it's very reasonable to do fine needle aspiration. I don't know, Ashley and Girish, if it's different at your institution? Yeah, no, it's, even when, you know, there are cases where it's overtly malignant, our oncologists and surgeons do want tissue. I think the risk of infecting this lesion is very, very low. I mean, I think maybe later on we'll talk about FNAs and the risk of infection and, you know, prophylactic antibiotics and things of that nature, but, and I think in this situation, I mean, I do think the U.S. is going to be helpful, and whether it's totally anechoic versus not. So thanks, I mean, I've been looking at this, this is a lesion that's predominantly solid with some, you know, at the upper pole of this lesion, those look like anechoic structures. So you know, you can make a case to do a core biopsy. I think that would probably give you a better yield and more tissue. I would do a core on this as my next step. So if you were doing a core, any tips as to where you would, what you would try to do technically to get a good core? Sure. I mean, I tend to fan the lesion and avoid the necrotic portions here. I mean, I think there's good meaty tissue throughout, short of those anechoic areas at the upper area of the lesion. So I would just try to get good tissue and fan, and I think we should have an answer with that. I usually use your 22. So fine needle, you'd try to get a biopsy and put it in formant, do cytology with 22? I know, I would just do a core because I'd like to see the architecture, especially given that our differential diagnosis here is a solid cystic papillary tumor, having architecture would be helpful. In the days before core, FNA often yielded a good result, and probably will tell you that there's some neuroendocrine type look in cells or so, but I would do a core biopsy. I do a touch prep. We do have a rose on site where they look at the specimen. I look at it. I look at every specimen under the microscope along with the folks. But so again, that varies, depends on where you're at, whether you'd have rose or not. But I would do a core biopsy on this. Anyone do any different? Anyone want to take any of that fluid out for analysis or just put it in formant? Yeah, I don't think the fluid's going to yield anything. What are you going to get out of it? First of all, those cystic components are so tiny. You've got to really get a few millimeters in order to send off CEA, and cytology is not all that we know in terms of cystic lesions. The yield is pretty poor. So as Girish was mentioning, where you really want to go is where it's meaty, where there's density. So you always want to go for the solid portion. And I agree. I mean, we FNA'd in this case, but absolutely at this point, we have so much more FNB. We do a lot more FNB. Ashley, I don't know which needle you use. I've really moved to using the FNB needle for almost everything except cysts. And so I actually call it the cheap needle and the expensive needle. So I use the Olympus, that's the one that we happen to use, just the inexpensive, old, good, old, easy shot for fluid. But for everything else, you just get better tissue with the FNB needle. I don't know that I designate it as FNB versus not. I kind of do a little of everything. I do a touch prep. I put some in Cytolite. I put some, depending informally. And I don't know that I necessarily would with this case, but I might just put it in for cell block. But yeah, definitely going for the solid and void the mushy cystic part. So Vanessa, you're the pathologist here, cytopathologist. So these are just to show, yeah, I mean, this is to show an H&E, there's a bland epithelial cells. And really, you know, so it's not adenocarcinoma. So that makes everybody feel a little bit better. And then they went beyond that. And if you go to the next slide, they did a beta-catenin stain. And what you can see is that it turned brown. And that is indicative of a solid pseudopapillary neoplasm. And so, you know, here, fine needle aspiration was diagnostic, but I agree completely with the, you know, Ashley and Girish probably at this point would go for an FNB if I had a do-over. But we had diagnostic tissue. If this was a serous cyst, what would you expect? I get blood on serous cyst adenomas. They're hypervascular, but you usually will get more cuboidal cells if you're lucky. I don't know if you guys have better luck than I do with serous cyst adenomas. I don't, I, you know, I think Amit that might be the senior person here, but doing this for about 23 years, it's like you can walk in a room and spot a serous cyst adenoma. I don't even FNA as what looks like a serous cyst adenoma. We've had one case of a serous cyst adenoma in the 20 years that I've been here at Wake Forest that had malignant progression. So it's rare to have, so if I think it's a serous cyst adenoma, I don't FNA. Yeah, I agree. I mean, if there's anything that I'm concerned about, like maybe some upstream duct dilation or just something that doesn't seem right, I might consider it, but I agree. But it definitely takes a couple of years of comfort of having seen enough of them, or you send one to the surgeon who resects it and then is not too happy with you. So I agree, I try to avoid it. But when I do FNA it, I usually get a little sort of thin blood looking stuff and it's usually not useful. Yeah, I agree. Thanks, Vanessa, for this specimen. Just to show grossly what you look at, because so often in the U.S. we're looking at things, but actually seeing gross specimens is instructive. So what would you tell the patients about this mask? The audience, most commonly affects women over 40 years. Referral to oncology for chemotherapy is recommended. Surgery is recommended. Probably acquired during pregnancy. It's a benign lesion without premalignant potential. It's a little bit harder question, Vanessa. Go to the front. Well, you saw the specimen, so. It's a tough question to ask after showing the specimen. I didn't know if it was a trick question, but no. Yeah, surgery is, you know, these are usually slow growing. They're very curative if you operate. And so surgical resection, especially a lot of them are young. So typically in their 20s. So, you know, you're not gonna watch a solid pseudopapillary, you know, tumor grow over time. So surgical resection is standard of care. And sometimes these can be quite large. I mean, 10, you know, centimeters. You rarely will ever see a 10 centimeter pancreatic adenocarcinoma, but these solid cystic can be extremely large. So questions now for those who have not attended these endo hangouts, do keep sending questions to Paula and Jordan. Paula, any questions from the audience? Any thing fellows wanna know? No, actually I think you guys just covered one of the questions that came through. Okay, Jordan? Yep, no questions yet. Yeah, send us a question and then we'll keep questions at the end and really grow the panel. Okay, let me see if I can get out of this. Let's move on to the next. So question for you, Gary. So you can tell a cyst, serocyst versus solid pseudopapillary. So can you point out the subtle differences? Yeah, I knew you were gonna put me on the spot because the classic is the microcystic or multiple cysts, but I think there's a couple of things if you look at the two different images and I think you have the pointer up. So on the left, look at the posterior aspect of that lesion. There's not what we call that cyst through transmission underneath there, whereas contrast that to the right, where if you look there, all that bright hyper-echoic rim. So to me, that's something that you'll see with a lot of cysts and it can help you distinguish a vascular lesion from, say, a cystic lesion. I agree, this particular lesion on the right has more of a solid component to it with several small cysts. So looking at the two, this one, they do look quite similar. On the left, the solid part's quite homogeneous and smooth sort of echo architecture, whereas the cirrhosis adenoma, there's some bright sort of hyper-echoic areas and with small cysts. And I think if you rotate your transducer more, you'll see more small cysts. But that cyst through transmission to me, I would say that's probably a cirrhosis adenoma. On the right, often they have imaging and often patients with cirrhosis adenomas are asymptomatic unless they're really large or they have prior imaging where the cyst size hasn't changed any. And sometimes a CT scan, they'll read as a multi-cystic complex lesion and you do an EUS and it's pretty classic for a cirrhosis adenoma. Thanks for pointing that out. Thanks, Vanessa, for that shot. I thought that was great, but it's subtle, but you do them and you can tell a difference and like Raisha was saying, this little bit of cystic, even in the solid portion, whereas you don't see that in this side. So next case, a pancreatic head mass, 81-year-old woman who presented, sorry, let me try to go back a little bit. 81-year-old woman presented with a history of back pain and right upper quadrant pain for several months. Unintentional weight loss of 10 pounds. Labs show a little bit of obstructive pattern with jaundice. Cross-sectional imaging showed dilated bile duct and pancreatic duct. Head appears enlarged concerning for mass and so she sent for EUS and ERCP. Sorry about that. So there's the history. And here's a CAT scan showing a dilated gallbladder, something in the pancreatic head. This is what you see on the endoscopic ultrasound. So take it away, Garish, Vanessa, what do you see? Oh, hey, you know, first of all, you can notice the bile duct, which he's pointing out now is dilated. And you can see if you follow it down, it kind of ends into a darker area. We call it hypoechoic and that is the mass. You can see, like Garish said, the other one was, it has no borders. The borders are really irregular and you can see the lesion before that. It was very regular. So this is more concerning for an adenocarcinoma. In addition to the... Go ahead. I was going to ask you, how did you know that was the bile duct? Very good. It just location wise. So I can see the common bile duct and I can also see the portal vein next to it. And by EUS, the nice thing is we have the evidence. We have a way of telling what has blood flow and what doesn't by using Doppler. And so it's just repetition, image repetition. And I know that we're in the head of the pancreas. So again, you can see the mass down there. You can see the common bile duct and the portal vein. The other way you can tell, and I'm not sure if there's some advanced fellows probably on the call, is if you look at the sort of the angle or the relationship of the bile duct with the portal vein versus if it was more horizontal, if you had an anechoic structure that was more horizontal, then that would suggest more of the gastrodenal artery that the bile duct almost never will be seen in a horizontal plane. It's always going to be in that anterior posterior, just very similar to the portal vein. And I think that might be the hepatic artery below posterior to the portal vein, but I can't tell. But yeah, I mean, that's the bile duct. That's the way. So again, looking at the relationships and that's because in the old days, the radial scopes didn't have Doppler capability. I know, Vanessa, I'm aging myself, but yeah, the original radial scopes had no Doppler. So you really had to not rely on relationships and angles and what the takeoffs were. That wasn't that long ago. And do you tell your surgeon that this is not resectable or how do you, how much do you rely on looking at your portal vein and the vascularity? Go ahead, Ashley or Vanessa. No, it's fine. I always like to look. So I always look at the portal vein. I like to see how much, if the portal vein is thrombosed, whether there's tumor compressing it. Obviously here it looks somewhat compressed on this one view, but again, EUS is dynamic. I tell them not only if the portal vein is involved, but how I even measure the number of centimeters, you can look at SMV, which is usually below the tumor on this shot. I can't see it right now. And then you can even see SMA. So, but ultimately the surgeons, at least at the University of Virginia rely on cross-sectional imaging. They rely on an MRI actually for staging. Right, what we can't tell by the EUS is sort of the degree of involvement. You can tell the length, but you can't tell the circumferential degree. And then if I don't see the SMA, I really worry that it's involved. So often I'll say there's a buttman or there's a faceman. I just can't see the SMA, which really suggests that there's involvement. So I definitely want to comment on the portal vein, the SMV and the SMA and the celiac when it's relevant. So Ashley, when you decide to take the needle out and sample this once you're done labeling, how are you gonna move that needle back and forth, quick, fast? Sure, so I like to, after I get the needle in, sort of figure out the distance that I need to go that's not too far and not too shallow. It's always tempting to go in the big meaty center part of it, but a lot of times if they're big they can be necrotic so you may not get diagnostic material. So I sort of try to go somewhat on an edge if I can, and you know the needle is sort of jab forward and slowly pull back. We do the the stylet withdrawal method now. We used to put suction on, but we really don't do that so much anymore, and so it's a jab forward and pull the needle back slowly. One of my attendings who I trained with, you know, was sort of anti the fan method because, you know, patients breathe, things move. You're never really sticking the needle in the same place, and that's what Dr. Chok taught me. So I don't hugely fan. In fact, I usually try and undo the elevator, loosen it, because it makes the needle move back and forth easier, and it also doesn't bend the needles much. So that's sort of my method that I use. You can also drop down to change your position. I do fan, and we don't use suction hardly for anything. I mean, I can't recall when we do suction at all, and I do think fanning gets different parts of the lesion, but I use mostly my up-down and my shoulder movement to get in and out of different planes of the lesion. Yeah, we slow pull as well. And what would you do? Do we all FNA now and send a sample, or could you make a argument if it's resectable to send them to surgery? So, you know, we've really changed the way we kind of approach pancreatic cancers. The majority of these patients are now going to undergo upfront chemotherapy, so we, our oncologists and surgeons, do want tissue. They'll get Folfax or Gemma Braxane, so we would get tissue. There's only a minority of tumors, T1 tumors, which are extraordinarily rare, that go right to surgery. Let's go. Any questions, Jordan? Questions from the audience? Yeah, we had, well, we had a few questions about the first case, which we can discuss now. And it really, it really pertains to the, to surveillance, and specific to cirrhosis adenoma. One, one participant mentioned would watchful, watchful observation be an option for this patient, so I guess that speaks to kind of the surveillance protocol people undergo with these, these cysts that, you know, may be indeterminate, or may be deemed to be cirrhosis adenoma. Do you do any surveillance for that? The question is for cirrhosis adenoma, or for a solid cystic? For cirrhosis adenoma, if you know, if you can tell it's a cirrhosis, what do you tell people? Right, yeah. Microcystically. Mm-hmm. Yeah, if you be five, five centimeter big cirrhosis, micro. Right, so we would all agree. Yeah, the whole context of the patient, you have a, let's just say, a 40 year old with a cirrhosis adenoma, I think that's a different than, you know, someone who's 80 years old. And then if you have no prior imaging, I'd probably, in their lifetime, get some imaging, whether it's CUS or a repeat CT in a 40 year old with a cirrhosis adenoma. I just wouldn't say you can't, you shouldn't surveil at all in their lifetime. So we tend to, we do the same. I mean, it's rare that we find a young person with a cirrhosis adenoma, but if they were older, there's no, there's actually no need to follow up unless they're symptomatic. Unless you have any doubt that it's a cirrhosis adenoma. Other questions? Yeah, we have another question for the solid pseudopapillary lesions, like lymphoma and autoimmune pancreatitis, usually doesn't seem to cause any peripheral pancreatic dilation. Have you ever seen a case in which the head, involving the head of the pancreas presenting with CBD obstruction and jaundice? I'm trying to think, I think I have, but I'm not sure. I've had a lymphoma cause biliary obstruction. The solid pseudopapillary neoplasms that I've had, have all been body tail. I don't know, Girish, if you've had any. Yeah, I've not had, I mean, again, they're rare. And now with, you know, four endosynographers here, I don't see all of them, like I used to when I first got here. But they're, I've seen about five ish. And I can't recall of a biliary obstruction. And you're right there. They're pretty large. I mean, it's almost like they take up the entire body and half of the tail. And the lymphomas, again, I've seen a fair bit. I've seen a lot of renal cells go into the pancreas. And they also don't cause much ductal dilation. So whenever you don't see the PD dilate, think of something outside of an adenocarcinoma. Good point. Keep those questions coming in. We'll try to get to as many of them at the end as we can. So let's go to the next case. 68 year old has this lesion. I forget whose case this is. Ashley, what do you think? So again, this looks like a cystic, well circumscribed lesion. It doesn't particularly look scary. The PD you can see towards the tail, I think, and it looks non dilated. So again, you know, is this some cystic neoplasm? And do we worry about it or not worry about it? Not sure. We always worry when people are older and we find things, but not on this one. I did have a glimpse of the history. If we can go to the prior slide. I don't want to. The patient had a history of prostate cancer, which is rare to go to the pancreas, but nonetheless, kind of adds to your differential. If you want to make it interesting. Never seen 68 surgical size wise. How many would vote to do in a US and how many would say radiologic image? Now you can US this and potentially sample and make sure it's not doesn't have solid components to it. I mean, renal cells, we've talked about ampullae, you know, go to the ampullae. This isn't the ampullae per se, but prostate, I've seen some urethelial cancers go some GYN malignancy. So just about everything. I think we've all seen some melanomas go to the pancreas, small cells. So I, I would feel uncomfortable just observing this, I would want to do in the US and potentially sample this. Let's ask the audience. What do you think? Pseudocystic met from prostate branch duct IPM and serous cyst epithelial cyst. So they're split, which sounds like everyone agrees we don't know what this is. So if you do do a US on this, your reach, how are you going to tell by us what what you're looking at? Or what are you going to be looking for with the US besides looking for solid component? Are you going to be sampling it? Or what are your thoughts before starting your exam? Sure. No, I mean, I think we know this is not going to be a pseudocyst, but those are fairly, you know, anechoic, there might be some debris. And so, so that will help us there. A cystic met from prostate cancer. I mean, I think the only time when you have a small cyst, say you have a 70 year old with a very small cyst, like a one centimeter, you know, it's probably not going to amount to much, but we've all seen those cystic islet cell tumors. So that's my rationale for doing an US on something really small. Usually, they're pretty well demarcated. I think neuroendocrine tumors, most endosynographers, you can just look at the US image and almost say this is a neuroendocrine tumor, obviously, you're going to have to do sampling. But so I don't think this is a cystic met from prostate cancer. Obviously, branched duct. And we talked about a cirrhosis. We didn't talk too much about the CT findings. But you know, you have the classic sort of stars starry sky or the honeycomb appearance with the central stellate scar, which we didn't see any of that feature. epithelial cysts tend not to be this big. I think the only other thing I've put on this differential is maybe a lymphangioma. I think we've seen those. They can be pretty large. In my experience, epithelial cysts tend to be pretty small and closer to the gastric wall as more in the body area. But but certainly, so I don't think it's a pseudocyst. I don't think it's a cystic met from prostate. So and I probably just looking at the imaging, I think it's probably a branched duct IPM med. So the endosynographer who did this did see something cystic and wasn't comfortable. How many of you are doing trying to biopsy the cyst wall? And would you consider doing it in this patient? I would FNA and send certainly send up for CEA on this cyst fluid. It's I missed it was at one point, what was the dimensions, Ashton? I went by I think it was over two and a half. Okay. This is interesting because it says pancreatic cysts with cyst wall biopsy, but you can't clearly see a wall completely around this. So I personally don't have much experience with cyst wall biopsies. I think when the the forceps first came out, we tried it. I wasn't all that excited. It's teeny, teeny tiny. And so I think I would just take fluid out of this and, you know, do my little string sign, see if it's mucinous looking and send it for for analysis and probably not cytology. Yeah, I agree. We do the same. We usually will send for fluid. And only if you're really, really unsure what it is, and it's going to make a difference in what you do, then put a put a forceps down. And remember, the forceps requires a 19 gauge needle. So the cyst has to be a certain size in order to get the needle in there and actually work the biopsy forceps. That was actually a picture that that that I think this is Greg's that you could see the PD come down and around and I think it looked like it connected. So sometimes we can't see that very easily, but there are times that we can. And that makes us a little more convinced. And the other thing is that the duct was not dilated. So and there is a little bit of chronicity. I've seen, you know, one of the things that perhaps in the other images is if you see a lot of chronic pancreatitis like changes, to me, that suggests some degree of obstruction and and long standing. So it always raises, you know, sort of my suspicion here, the duct was not dilated. So that favors more of a benign type of process or not a overt malignancy. I would do a cyst fluid analysis. And, you know, I'm also the area where we used to do those brushes through the if you can recall through a 19 gauge that we have that we don't use that anymore. I would probably just do an FNA of the cyst fluid and send off for analysis and we send cytology but I know it's I mean, it's you can count on your finger how many times you've gotten a malignant diagnosis from cytology, innocuous looking cyst. So what is your criteria for aspirating these cysts? And when do you decide to needle them? When do you leave them alone? Well, I think sorry, yeah, go ahead. The comment that I always make, you know, that I really impressed upon the fellows is you have to decide how it's going to change management or if it is, and you know what you're willing, you know, patient comes in asymptomatic, and it's an unscented process cyst that you have to go through normal, normal looking pancreas to get there and it's really small and they're 75 and have metastatic prostate cancer, that is probably not the person to aspirate on. I think you can look at it and say there's no concerning features and it may be a benign cyst, it may be an IPMN, but something to just watch. So for the times that I've given patients pancreatitis from I think going through their duct into a cyst, I'm a little more hesitant to do it unless I really think it's going to change what I do. So it may, you know, if it if you can't tell whether it's mucinous or not, yes, that might change, you know, how often you scan them or if you scan them again, but I do a little bit think more after I've, you know, caused a patient is asymptomatic to get pancreatitis about sticking a needle in everything. Yeah, actually, I think you raise a great point. I mean, you know, just because you can't, you know, we're all told that just because you can do something, I mean, you should do it. And then all of us have had pancreatitis in patients with something as simple as a small cyst. I mean, and I think, you know, if we look at our practice, there's no rhyme or reason I think we've given pancreatitis with the 25 gauge versus a 19 gauge, although intuitively you'd think there'd be less pancreatitis with the 19 gauge. Sorry, there'd be less with a smaller size needle. So I practice the same. You know, often we have the luxury of some prior imaging, what scan and if it hasn't changed, and it's, you know, kind of one to two centimeters, and then I look at the features as well. So, Girish, what is your criteria for putting a needle in? Is there a size? Is there a feature? When do you aspirate? Yeah, all the above. I mean, day of the week? No, no, that doesn't matter. I just thinking, I mean, I, but you know, this, this clearly is a cystic discussion we're having. I had a seven millimeter sort of neuroendocrine tumor, where the first FNA in an elderly where I didn't think it was going to make a difference, but the family was, you know, adamant that they wanted some tissue diagnosis. In that case, we were able to successfully get a diagnosis. I would not FNA a seven millimeter cystic lesion, I would say about somewhere between one to two centimeters. And if there's some septation in there, obviously, if there's some nodularity or anything that I would, but if it's less than one centimeter, I would not. Vanessa, when do you decide to send someone to surgery? Oh, you know, if you look at the guidelines, you know, we've got so many of them, if you kind of put them all together, dilated pancreatic duct, never a good sign. Any nodule or solid component, not a good thing. Obviously, cytology, if cytology is positive, you send them to surgery. And then the simple one is if they're symptomatic from it. So if it's obstructing the duct, and they're getting recurrent pancreatitis, or it's causing jaundice. So that would be sort of how I approach and how I decide to send patients for surgery. And honestly, size, I mean, age plays a role in this as well. So if it's a 30 year old with a pancreatic cyst, which is unusual, they're going to have to undergo potentially surveillance for decades. So I like to have that conversation with them before deciding but those are kind of my thoughts of when to send people for surgery. Awfully difficult size wise, what do you do if it's three and a half, four centimeters? And a certain patient who otherwise would be surgical? Do you think about sending them to surgery? Do you wait? Do you monitor? Do you look at increase in size? So you asking me or Ashley? Asking you, Ashley. Oh, okay. Okay. Yeah, I mean, you know, if you look at the European guidelines, I say, I think it's over three to four centimeters. And if you look at the other guidelines, for me, it's more, you know, if it's a four centimeter cystic lesion and they're 90 years old, I'm not sending them to surgery. But yeah, so you want to look at size. If it's over three centimeters, then it starts raising a red flag. The other thing is if it grows over time, that's not, that's never, that's kind of a red flag of, you know, is this progressing? So again, there's no clear cut size for me, but, you know, over three centimeters, you start thinking the chance of it having neoplastic or converting to a, you know, more aggressive neoplasia is higher. So the cyst biopsy showed IPMN actually, was that, now you know it's an IPMN, was that helpful? Well, I think if you looked at the EOS and you saw that it connected to the main PD, you know, it looked pretty otherwise, nothing concerning about it. I don't know that it necessarily changed, but it's helpful, I guess, for all of us to just say, okay, even if we didn't do the biopsy, if it was mucinous, I don't think the biopsy probably changes anything. So, you know, I don't typically do that. And I would have just taken some fluid off and proved that it was mucinous. And then it kind of sends you down the path of sort of how you're going to monitor this that you probably need to monitor this. So, you know, the thing I would just impress upon the fellows is all these things we were talking about are guidelines. They're not, you know, it's all about the patient, right? Every patient is different. There are patients who, you know, are absolutely no matter what you do, they're not getting surgery, they're not getting this and that. So, you know, you need to change what you do based on patients. Some patients, especially young ones, very anxious. They want to have an answer for exactly what this is. They can't tolerate, you know, lack of clarity, not that we can always give it to them. But I just think the important thing is, you know, every patient is a little bit different and the guidelines will help you. But in the end, the decisions you make are really based on the discussion you have with the patient. You give them as much information as you have and sort of the data that you know, and then you go from there. So it's challenging. These cysts are really challenging. And Ashley, you raised two great points that I just reiterate is, you know, that was my whole sort of problem with Red Path. I know they changed their name and nothing against the company. I think the idea was great with doing molecular analysis. But whenever you have a algorithm or a nomogram to say, this is what you should do or not do for a cyst, then, you know, I don't need a $5,000 or whatever test to say this is a mucin cyst or how am I gonna manage the patient? I put it all in context, like you just said, Ashley. So that's why I feel like, you know, as long as I can tell it's a mucinous cyst and with the CEA now, I look at big numbers. Is the CEA, you know, 250 or is it 2,500? You know, so big numbers to me matter. The difference between 300 and 500 to me doesn't really matter. The other point to make is, you know, the biopsies, if you look at the data, and I think Dennis Yang at Florida, when he was with Chris DiMaio, you know, he's done some really nice work on the forceps biopsies. It's useful in telling you if you have a mucinous versus not mucinous, which I think we can kind of get without the biopsies. The complication rate, it's not trivial. I mean, I'm sure the more you do the less complications, but about 7% in the literature and you can get pancreatitis. I do think the risk with a forceps biopsy is greater than with an FNA. Let's get some questions from the audience. Jordan, Paula? Yeah, we have quite a few questions about cyst fluid analysis. So Paula, go ahead. So we actually, our first question here. While Paula's getting the question, I'll also throw out a glucose measurement. Any of you throwing, using that? One of our fellows- That's a great question right now. Is that it? All right. Amit, we're a lot to discuss things that have been accepted in abstract. Yeah, so I think the abstract that scored really well had a, it might be from your center. I don't know, Amit, that went out. It is from our center. Okay, well, I'm not trying to, this isn't a- To kind of make you feel good, or I'm trying to schmooze a brown nose here, but it was rated as our top abstract for the session. It scored really highly. Well, and I won't say much more than that. But it's really interesting that if you look at the glucose for, I mean, our current standard is CEA, but if you look at glucose in the aspirin, and it was a multi-center, I want to say close to 500 patients were enrolled. The sensitivity and specificity for glucose and the cost, I think, let's validate it, but I think that's going to be the paradigm because it's so cheap and it performed better than CEA. So after that abstract, or your abstract, and Ashley's, I'm sure you were involved- It's actually Zach Smith's brainchild and Sagarika the fellow who- So, but right now we use CEA because glucose is not, hasn't been validated or we don't know about it yet. So I don't do glucose. I may in the very near future, we do a lot of CEA and things. I like question. Sure, so which cysts do you consider doing advanced imaging such as confocal microscopy? So I can answer that. So we don't use confocal microscopy for the cysts in general. You know, we haven't, I'm not sure. I mean, the data is out there, but I'm not sure that it would necessarily influence what I did. And I'd like to hear from the other panelists if I'm just obsolete or whether you guys feel like confocal helps in this instance. Yeah, we don't do confocal either. I think it's a neat concept. And if you look at the images and their studies, just trying to get, you know, a trainer set just to get inner observer agreement on what you're seeing on CLE, that takes, it takes a fair bit of practice. It can be taught and learned. Will you not biopsy and rely strictly on your imaging from NCLE? And I don't think we're there. I know that at Ohio State, Krishnan has done a lot of work. I don't know if it's a federally funded study, but he's got a multi-center study. So perhaps once the results come out that, how great, you know, how useful it is, then we could, the equipment's expensive. I mean, it's, you gotta pick and choose where your capital equipment is being spent. So if you have it as a research tool, great. As a clinical method, we don't use CLE. No, we don't, just can't afford it. Okay, let's move on. I'm sure there's more questions, but in the interest of time, great discussion. 47-year-old with acute pancreatitis had an outside CT, which revealed a pancreatic head mass. The RCP revealed mild bile duct dilation and cytologic brushing showed some atypia. This is what the lesion looks like. Any thoughts, Girish? It's pretty large. I don't have the measurements. The question is, did this mass cause the acute pancreatitis? Is there any other cause? Obviously, I'm gonna wanna EUS this because I think an EUS can give great information for a lot of abnormalities. So I'm just guessing this measures about five centimeters or so roughly with some duct dilation. So I'd EUS and see what the characteristics look like. I would not do a wiggle on this patient, sorry. And I wouldn't observe. Okay, so here's the EUS you asked for. What do you think? It's a mass and there's a CBD dilation. I think the portal vein is involved right there. And per Vanessa, you can probably measure that. It's gonna be about three centimeters of portal vein. I mean, just looking at the EUS image, I think it's hard to distinguish what it is. I'd probably FMB this lesion. You saw the gastroduodenal artery just on top. That does not make someone on resectable if that's involved. And you can pretty much skate around the GDA to get into the mass. That's usually not a problem. The pancreatic duct seems very dilated here. Oh, that's a vessel there. And the PD, it looks like it's just below. So that's probably the splenic artery up top and the vein and the PD is mildly dilated. The other aspects of the whole parenchyma of the body is really not much different than what you showed me in the head mass. So then when that echo pattern, when I see that echo pattern, I think that could this be chronic pancreatitis? Could this be autoimmune pancreatitis? Just based on the echo pattern that you're showing me there. And I think that brings a good point. I mean, I always like to look at the parenchyma, not only of the mass, but I also like to look quickly at the body and tail because that does help us understand because that does help you, especially if you have an unusual case and saying, is it hypoechoic all over? Is it a dark pancreas? Does it have chronic features, chronic features of chronic pancreatitis? So that was the reason to look at the rest of the parenchyma in this case. Right, because when you first look at it, you're like, ooh, that looks terrible. And then you start scanning the rest of the pancreas. You're like, oh, that looks terrible too. Oh wait, that looks terrible too. So, you know, sometimes you can be fooled into thinking it's a mass. And then, you know, you may biopsy that and while you're waiting, you look at the rest of the pancreas. You're like, oh, well, kind of all looks similar, but certainly- What do you think about the borders? A little different from your normal adenocia? I mean, it's still irregular though. I think the borders by themselves don't tell me too much. I would still, I would do a core on this because I've been fooled before thinking something was chronic pancreatitis and had to bring them back because I didn't biopsy thinking it was chronic pancreatitis and now with the core biopsy, I think it's, I mean, this is a large mass. I would do a core biopsy of this lesion right there in the head. I mean, the other important thing is, you know, other history. Does the patient have any other autoimmune diseases that might lead you down that path? He's 47, so not that old, but you know, I did an ERCP yesterday on a 42-year-old with metastatic pancreas. So you do see it, but it's just certainly less common in the younger set, which I am officially no longer part of. So the fine needle aspiration is done. It's non-diagnostic. Now, what would you do? I would have gone straight to FNB. Now, it's easier to say now and if the case was say three or four years ago when FNB wasn't as, you know, it was just coming out. So no fault there because that's all we had was the FNA, but, and we used to try to do ITG4 staining just on FNA specimens. And there are studies, but I would go straight to FNB and just stay. So are you just doing FNB and no aspiration at all or? Something that looks like that, I would go straight to FNB because I have autoimmune pancreatitis in my differential and I think an FNA would be really hard to make that distinction, FNB helps. So this case was about five years ago and I'm sorry to interject Amitabh, but the patient- Oh, you're asking, yeah. Yeah, we were gonna re-actually FNA and you know, the surgeons took the patient to the OR and unfortunately or fortunately it was after a Whipple, it was consistent with autoimmune pancreatitis. Always hard. Yeah. It just reminds me, I mean, poor, you know, John Bailey, he was on faculty here at Wake Forest. So John, you know, is in heaven. I think he passed from a brain tumor, but he would always, you know, bring cases, you know, from Duke when he spoke, when he was at Duke, it wasn't Duke, it was Duke, but he would describe a legal case actually where a very similar, but this was about 20 years ago when we didn't know as much about autoimmune pancreatitis. So I don't think we are afraid of a legal matter, but if we can provide our patients with the diagnosis so they don't have to go to surgery for that because I think, you know, that these are totally, you know, a lot of times curable just with steroids. So that would be a reason now I think all of us would do a core biopsy and not, or repeat the biopsy. And I think it's important to look at these cases and to bring forward cases, you know what I mean? Like this where, and it was very frustrating that the patient underwent a Whipple the next day, but, you know. Hopefully the patient did okay and got the steroids out. Did fine, yeah. And that's where if they don't do well, then that's when we feel, and no one's gonna be too upset about not having cancer after surgery, but if they don't do well and develop a leak or something, then it's a problem. A whole disaster. Yeah. Yeah, about eight years ago, I had a patient at the VA and you know, we just see so much cancer that we always think cancer. And this was sort of before auto-immune was really truly appreciated as such a thing that we see, we feel like we see more, or at least we think about more. And he went to surgery and, you know, the good news is, sir, I know you had a Whipple, but you don't have cancer. So. Jordan, any questions we should answer before we move on to the next case? Yeah, one participant mentioned, do you not routinely do F and B now? So I guess if that's an available option, are you also sending tissue for cytology and also SurgePath with your needles? I think most of us on that panel would at this point do F and B. I do, again, what Girish said, touch prep and actually send the core off. You know, with COVID hit, I started putting things in formalin and not asking for cytologists to come. I've been on a run with formalin that I've actually stopped asking for the cytologists. You're a patient, man. I like to know what's on. I need an immediate satisfaction. Well, I also like to be able to talk to the patient face-to-face. I don't really like calling on the phone three days later, be like, hi, remember we met for five minutes? You know, you have cancer. So I like to at least get a, even if I know in my gut that I think that's what it is, I like to have a prelim so that I can do the face-to-face. So do you do F and B and touch prep with the cytologists there? Yes. I think that was the question someone was asking. Let's do one more case and then we'll just turn it over to questions. Let me see if I can go, sorry. My stomach hurts. 66 year old male, had diabetes, presents with abdominal pain for four days with nausea, loss of appetite, weight loss for six months, has dark urine, pale stools, jaundice with a total billy of 9.6. Pancreatic enzyme is normal. This is a cut from his CAT scan. And the MRCP shows obstruction, not much dilation. Well, how would you approach this patient? Refer him for surgical resection? Do an ERCP and place a stent? USFNA and metal stent? If cytology positive? Or do USFNA followed by ERCP with metal stent regardless of onsite cytology? So, most people want to do FNA and then the RCP with metal if cytology is positive and plastic if not. Some want to do just the RCP and brush and place a stent and one person would metal stent regardless of on-site. Panel? Metal stent, plastic stent? I mean, I think in this case, since you, again, that's the advantage of having on-site cytopathology is that if you do the fine needle aspiration first, you're going to know whether you're dealing with a, usually you'll know whether you're dealing with a malignant process or not and that, you know, if it is an adenocarcinoma, then you're wanting to put a stent that's going to stay patent longer, potentially, and if it's not, if there's anything that suggests another process, then you may think plastic stent. Yeah, I like that rationale. I think that's, yeah, I agree. I think if you've put a metal stent in someone who you wish you hadn't later, it's really, it's a bad feeling and then it's a problem to get out. So sorry, don't have video, but here's the US with a lymph node mass and ERCP shows the double duck sign. So this is many years ago, I think we're all saying F and B these days, but this was on-site cytology and fine cytology aspiration with a 22 gauge needle did not give anything diagnostic and we got nothing on-site cytology. So elected to place a plastic stent because we didn't have a diagnosis. So the patient gets a CAT scan and the CAT scan for staging shows mets. So clearly not a surgical candidate. And a PET scan also shows that lighting up. But the biopsies are done then on the lung lesion and they show inflammatory changes with plasmacytic infiltrate. So now what would you do? That's pretty bizarre. I mean, I, now if today I'd go back and do a core biopsy of that head lesion and see if it looks like it's autoimmune. Sometimes you can, the diagnoses from talking about from the pathologist, it can be challenging at times to distinguish autoimmune from malignancy. So there's features that cytologists will tell you that the plasmacytic infiltrate. I guess the other thing is, could this patient have some sort of autoimmune involvement in the lung and in the pancreas? So and that's what we're seeing here because obviously autoimmune pancreatitis can affect other organs, salivary, I mean, just about anything, but salivary glands, the kidneys. So I guess you can go ahead. I think lymphoma is also on the differential when you see a pet light up in multiple places. But yeah, I think you gave it away since historology. The CA99 is 205 and IgG levels because of that autoimmune condition shows a little bit of elevation of IgG4. I think the key is don't, you know, the CA99 can be helpful when it's mildly elevated like that. I mean, I would call that mild versus, you know, the patients that have 10,000, 20,000, you know, you've got to be really careful. And you know, he's already had two biopsies that have been negative, but you just have to be a little bit careful about labeling someone with weight loss and who's older with autoimmune until you know, you've got enough. So now what would you do next? I would buy, I would do a core biopsy, just like you're saying, you're asking me, I mean, I think they're all going to be equally well, I use the shark horror a fair bit. In fact, I find great results with the shark horn, but you know, you might choose the Boston product or the cook product, I think whatever. And I don't want to answer all the questions. So I'll just hush right there. Well, no, go ahead and describe your technique and I'll ask Vanessa and Ashley. I mean, yeah, no, I use, I use the slow pull with the core, a shark 22, unless there's some genetics and research studies where they want more of a core, some of the NIH studies for metastatic lung cancer, for mediastinals up there, they ask for a larger core needle. So I use the 19 gauge there and the mediastinum and, and find that very helpful, easy because there's no torque on the scope. In general, the core biopsies, the larger needles, when you're, you've got to bend in the onsen, it, then it's a little bit harder, but not, not impossible. So my default core biopsy is the shark or 22, I use the slope pull. And then, you know, I, I get made fun of just for about anything in life anyways, my kids make fun of me and then fellows make fun of me, but the nurses, but I process my own slides on every single case. I actually, after I do the FN, FNA or FNB, I go over and you know, a tactical push. So I look at what the slide looks like for every single case and they make fun of me about that, but I've been doing it for 23 years and I don't think I'm going to change, but just looking at it, I mean, you can tell a fibrin clot, a clot versus a core piece of tissue. The cores are very almost clear looking. Whereas the clot is red. I mean, a good core, the color is not as red. It's, it's a very you know, not pinkish, but more of a clear gelatinous look. And that's a good one. It makes you feel better. I do the same thing because I, you can tell the difference. You can tell if you have good tissue. I mean, I can do one pass and be like, I'm done. You know, there was initial needle that came out after just the FNA needle called a core needle and the reps would try and tell you, look, look, can't you see? And you can, it just looked like a big thing of blood. Yeah. I couldn't see. With these new needles, I mean, you can do a biopsy. I mean, you just know, I mean, you're doing far fewer passes. As soon as you see it, you can just say, that's it. And I will, if I'm doing an FNA ERCP, I sometimes just do one pass, done, smear it, put some in cell block and go on to the ERCP because you really can be, I think these new needles are such game changers and you can tell the difference between. I had one case that was really frustrating and it was probably a retroperitoneal liposarcoma, which I just, you would think a huge mass that you could get it with the core. And it was just total fragment, no good tissue to, and I could get a core into it, but when you put it on the slide and then, and the formalin, the pathologist couldn't tell. So other than that, the core, and then, you know, we talked about foundation one or genetic testing. So much of our oncology colleagues asked for that. And so I do think, you know, maybe a little bit bigger cores for some of those studies, but I use a default, you know, my default is a 22 core. Yeah. I use a 22 core as well. You guys, I caution you about sticking, you know, the 19 gauge, I mean, there's no great data saying a 19 gauge is more likely to do harm than the 22, but I mean, first of all, Trying to use a 19 gauge needle, especially in the pancreatic head is close to, I don't know, maybe I'm just not good. It's hard to get down. So you have to get it down in the stomach and then push it down with the needle loaded. So it's not that easy. I tend to use a 22 gauge needle and this is a beautiful biopsy. I don't know who did it, but. And I had one bleed in that same patient, that liposarcoma to where I had to clip, you know, after the core biopsy, because with the FNA needles, you, I mean, I don't know if you have bleeds. I mean, it's so rare with the core. I think you do have to respect, especially if they're on eloquence and other things that you can have bleeding. So I actually had to put a clip up because it was actively bleeding. You can see that similar infiltrate here with IgG4 staining and then CD3 positive T cells. So now what would you do with this guy? Well now, now you know, you now have serology that maybe is consistent. It doesn't look like anything we've biopsied is a mass. You've got to put autoimmune pancreatitis higher on your differential diagnoses. And in this case, I mean, a trial of steroids, usually people with autoimmune get better quickly. So we would. Within days, within days, they're like within a week, it's like their obstruction's gone. They're feeling better. And just the fact that if they have response with steroids, don't think that they can't have cancer. I mean, so you really have to follow them closely with your surgeon if you're going to treat somebody with autoimmune, especially if you don't have good tissue like this. That's a good point. And remember 15% of people with pancreatic cancer actually can have an elevated IgG4. So that's something to keep in mind. So we're, you know, we're all very cautious and very hands-on on these patients and really follow them closely. As usual, the pathologist wouldn't. But our features are not diagnostic and are also not inconsistent with the clinical diagnosis of autoimmune pancreatitis. So anyway, what we did do is, and someone in the audience was asking about the high SOAR criteria. So just to remind people, it's histology differentiating between lymphoplasmic cystic sclerosing pancreatitis and IDCP or idiopathic duct-centric pancreatitis like the prior case. And want to look at imaging, look at the pancreatic parenchyma and also the duct. And then serology can be helpful, but not always elevated in this case. But if you have other organ involvement, as you did in this, in the lungs, which is really what took us in this direction. But the last part is to look for response to therapy, which consisted of a steroid trial. And remember, they're type 1s, which are the elderly males who had the lymphoplasmic cystic type, and type 2 or young, IDD4, maybe normal. It wasn't really that elevated that tend to be duct-centric as the previous case. So the patient had a dramatic improvement in IV steroids, as Girish mentioned, nearly complete resolution in pain and nausea after just three days and was discharged on oral steroids in three days and on the taper. And then came back, because what you really want to see is that stricture in the pancreatic duct. There's a little bit left there, but it really had dramatically resolved. And we were able to take the plastic stent out, unfortunately did not put a metal stent in retrospect. So I think we'll end there. There's about 13 minutes left, and we'll open this up to questions. Lyle, can we go to the last slide, then? Jordan? Yeah. Any questions for that? Yeah. Yes, sir. Yeah. you know, kind of a few questions scattered throughout one of the questions when we were talking about CIS fluid analysis and elevated CEA levels, obviously if it's if it's not dramatically higher low it really doesn't give you a lot of information but one comment was if the CEA is super elevated greater than 1500 what is your plan for those patients? I'm going to cheat a little bit and say if it's over 1500, you know, obviously it's a red flag. I'm also going to look, you know, do they have other things is the fluid viscous when you aspirate a mucinous cyst. Sometimes it's so viscous you can't even get it through the needle. So you know what I do is I pull the needle out and I kind of push push air and it kind of globs on the slide. So yeah, I mean usually somebody with CEA of 1500 especially if it looks viscous, you know that kind of prompts you to saying yes, it's a mucinous cyst and when it's 1500 then you've got to think does it have any neoplastic changes and I don't think a number alone is going to make me send a patient to surgery, but I would look at the whole picture, you know, is the patient symptomatic do they have a dilated pancreatic duct how old are they how large is the size. So it's one piece of the puzzle. Yeah, so we have another question. Do you routinely give antibiotics when you do an FNA on these pancreatic cysts? I mean the current guidelines suggest so we do I think there was just a study that was published that randomized over 500 I want to I can't remember Vanessa if it was in gastro Yeah, it was gastro 2020. Yeah, it was just a few months ago. And there was no difference in and so you didn't, you know, perhaps that'll change your practice again and interestingly I think Mike Levy had published a paper about 10-15 years gone rectal FNAs now I do feel I mean I give antibiotics for all the cysts and certainly all the rectal FNAs and we published our series on rectal FNAs of you know nodes presacral masses and the risk of infection with rectal FNAs despite using antibiotics is about 20% so much much higher with transrectal FNAs. I mean I so I know I'm kind of going from cyst to rectal FNAs but I think it's an important teaching point I will biopsy solid masses I will I will not biopsy a cystic lesion transrectal because so for suspected you know cysts or you know in that case we thought it was a gist tumor but so I do give antibiotics before the procedure and for three days after on cystic lesions only although I'm beginning to think that maybe I should rethink my my approach. I do think that for the audience especially if you guys are starting out I would follow the guidelines I completely agree I mean Girish and we were talking about this at the other endo hangout I just would follow the guidelines for now I do think those are going to change. I used to do three days of antibiotics now I just do one dose of IV so you can tell the experts were kind of evolving as the data comes out there and I'm starting to get more you know more bold as time goes on but I would recommend some antibiotics for the audience unless Amitabh and Ashley disagree and Girish. I'm totally with you. I do one dose like you do Vanessa. I do one dose if I collapse the cyst completely I often don't give any I don't know it's a little all over the place for me. And Ashley brings a great point that you you don't want to introduce the needle multiple times so you go in and collapse the best that you can rather than coming back whereas with solid masses you're you're doing you know two or three or four passes with cysts you shouldn't do but more than one pass and get the fluid that you need. And don't fan this is the one time not to fan there's no role you're just going in once and pulling fluid out because you really don't want to cause a leak you can have pretty bad pancreatitis. I mean my rationale despite a gastro study a randomized controlled trial or whatever is we know with mediastinal cysts you cause infection with rectal cysts you cause infection. So there has to be a low rate of infection with cysts and when we started these there were a couple of cases which is why Bill Briggie did a study where you know that multi-center study where everyone aspirated and everyone got antibiotics and we did a couple hundred and there were no infections. So why would I want to go back one dose of antibiotic rate may be low but there is some rate of getting infection and even if you did 500 patients you're not going to convince me that the study had enough power to pick up a small rate of infection. There has to be some rate of infection. More questions Paula? Sure we have another question. Are rectal FNAs done after a colon prep or is just an enema sufficient? Yeah that's a great question. We do a lot of rectal ultrasound here. Again I was trained in Charleston and we so I do anal ultrasounds for incontinence as well and we tried very early on thinking gosh can we get by with just an enema and it's woeful because what happens is all this because we use water right to get for rectal cancer staging the water you know water to to get great coupling and to visualize the wall layers and it's really important if you're trying to distinguish a a t2 versus a t3 lesion or t1 versus t2 and and what we found is the stool from above would just come and mix them with the water that I'm putting on the water pedal. It was just awful so we do a full colon prep for all of our rectals. Yeah we have a little bit of I guess mercy for the patients. I don't know we actually don't we don't use a full colon prep but Grish is completely right. Sometimes I regret it. I say oh especially when the stool pours down so I think it's a you know it's a preference. It is definitely easier if you have the patient do a full prep you know but I don't know if Ashley and Amitabh do something different. Just one last most of those I do unsedated unless it's a rectal left and a then obviously we use sedation or I tried to come up with a half prep you know half of go lightly and a couple enemas but I don't think they hand out those instructions anymore. Yeah I am you know we actually at the VA if I'm available and there's a rectal mass though usually get staging scans first just because of the prep. I try and run over and do the EOS before the patient goes but for FNA which I don't do very often you know I've had a couple patients with anal cancers with nodes that they asked me to FNA. I do usually do a full prep because it just seems like a good idea not to stick a needle where there's stool into the perirectal space. So one other caution with the rectal FNAs I mean before I was bolder and I'd go straight with the linear because that's kind of what we do with the you know we rarely do a radial first and then go with the linear to do a biopsy but in rectal cases and you know Jason Conway one of my partners here it does help you I mean there's so many organs and structures there that just doing a radial scope to get a better I mean unless it's just right there that you could avoid but I so I've kind of gone backwards just with the rectals. I almost never do a radial exam prior for with the pancreas mass I mean I go straight with linear just about everything. Which reminds me of early on of doing a FNA rectal and the cytologist who was on site said he saw semen so yeah radial might be a good idea before you stick what you think is a node. And seminal vesicles look like lymph nodes honestly. And that's happened to me I'm at that once and I said I won't do this again I mean I hopefully that won't happen again and that's why I you know I like to use a rectal I mean a radial on the rectal FNAs. We published in Endoscopy International about you know 50-60 rectal FNAs so I mean I think that's an excellent point though you know for any part of the body when you guys are starting if you know you're you have a pancreatic lesion and you're more comfortable with cross-sectional imaging you would be more comfortable conceptually with radial EUS. There is nothing wrong with starting with a radial scope and then going to linear after that. Actually that's how I was trained everybody got radial followed by linear. I do what Grish does and most of us do just go right to linear except for rectal. I do do radial first for rectal even if I'm going to FNA something because conceptually I think I'm just so much more comfortable with the upper tract than rectal than lower. And the seminal vesicles will get you every time they look like lymph nodes with little tails on either end. Yeah Jordan one final question and didn't even realize the time is almost up it's gone so fast. Yeah the time flies while we're having fun. Let me look at our list here going back to the using on-site cytopathology and the usefulness of that. Are any of you using the the rows for F and B samplings? Can they prepare that in the room and give you a a determination on the adequate sample? So touch prep. Vanessa go ahead. No it's okay all they do is they do a little touch prep so they touch it onto a slide and then we look under the microscope. There's actually there's going to be an interesting multi-center trial that we're actually part of. Alberto Larghi is going to publish to see many European centers in a couple of the U.S. where they're going to compare doing rows versus no rows for pancreatic masses and so that data is still pending but it's going to be really interesting. We're going to answer finally whether we really truly need on-site cytopathology but right now what I do is I do look under the slide. It's always nice to to know you know I've gotten the lesion in where you are. Grace final thought. No just on that alone at first I was skeptical that how can you just touch something on the slide and put everything in formula and get an answer and I'll tell you I mean you can see the entire gland of a pancreatic mass just with the touch prep so it can be done and yeah that's what we do. Well I want to thank Ashley, Vanessa, and Garish for a pleasant evening or pleasant afternoon or wherever you are in the world hanging out with us and especially Paula and Jordan for fielding all the questions and keeping us on track and finally ASG for fellows. The next endo hangout will be in April and Dr. Praline Chahal from the Cleveland Clinic is going to talk about interventional endoscopy fellowship and give some advice so look forward to that. Great panel as always. Take care everyone. Have a great weekend. If you are a trainee please join ASGE and become a member trainee member. Afternoon. Thanks everyone. Thanks. Jordan and Paula. Ashley. Absolutely. Thank you all. Thank you. Bye. We would like to thank our panelists Dr. Chuck, Dr. Pho, Dr. Shammi, Dr. Mishra, and our GI fellow moderators Dr. Adamson and Dr. Orr for this excellent presentation and thank you for your participation. We hope this information has been useful to you and your practice. This concludes our presentation.

Luminal EUS Part 2

ASG Endo Hangout

GI Fellows

endoscopic ultrasound

fine needle aspiration

adenocarcinoma

pancreatic cysts

differential diagnosis

CEA levels

antibiotics

colon prep

autoimmune pancreatitis