Download PDF
Endosc Int Open 2016; 04(07): E812-E819
DOI: 10.1055/s-0042-108188
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Interobserver agreement among cytopathologists in the evaluation of pancreatic endoscopic ultrasound-guided fine needle aspiration cytology specimens[*]

Rawad Mounzer
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Roy Yen
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Carrie Marshall
2   Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Sharon Sams
2   Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Sanjana Mehrotra
2   Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Mohamed Sherif Said
3   Department of Pathology, Denver Health Medical Center, Denver, CO, USA
,
Joshua C. Obuch
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Brian Brauer
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Augustin Attwell
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Norio Fukami
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Raj Shah
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Stuart Amateau
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Matthew Hall
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Lindsay Hosford
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Robert Wilson
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
,
Amit Rastogi
4   Division of Gastroenterology, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MO, USA
,
Sachin Wani
1   Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
› Author Affiliations
Further Information

Publication History

submitted: 30 July 2015

accepted after revision: 25 April 2016

Publication Date:
21 June 2016 (online)

Also available at
   Permissions and Reprints

Background and aims: Endoscopic ultrasound with fine needle aspiration (EUS-FNA) has become the standard of care in the evaluation of solid pancreatic lesions. Limited data exist on interobserver agreement (IOA) among cytopathologists in assessing solid pancreatic EUS-FNA specimens. This study aimed to evaluate IOA among cytopathologists in assessing EUS-FNA cytology specimens of solid pancreatic lesions using a novel standardized scoring system and to assess individual clinical and cytologic predictors of IOA.

Methods: Consecutive patients who underwent EUS-FNA of solid pancreatic lesions at a tertiary care referral center were included. EUS-FNA slides were evaluated by four blinded cytopathologists using a standardized scoring system that assessed final cytologic diagnosis and quantitative (number of nucleated/diagnostic cells) and qualitative (bloodiness, inflammation/necrosis, contamination, artifact) cytologic parameters. Final clinical diagnosis was based on final cytology, surgical pathology, or 1-year clinical follow-up. IOA was calculated using multi-rater kappa (κ) statistics. Bivariate analyses were performed comparing cases with and without uniform agreement among the cytopathologists followed by logistic regression with backward elimination to model likelihood of uniform agreement.

Results: Ninety-nine patients were included (49 % males, mean age 64 years, mean lesion size 26 mm). IOA for final diagnosis was moderate (κ = 0.45, 95 % confidence interval (CI) 0.4 – 0.49) with minimal improvement when combining suspicious and malignant diagnoses (κ = 0.54, 95 %CI 0.49 – 0.6). The weighted kappa value for overall diagnosis was 0.65 (95 %CI 0.54 – 0.76). IOA was slight to fair (κ = 0.04 – 0.32) for individual cytologic parameters. A final clinical diagnosis of malignancy was the most significant predictor of agreement [OR 3.99 (CI 1.52 – 10.49)].

Conclusions: Interobserver agreement among cytopathologists for pancreatic EUS-FNA specimens is moderate-substantial for the final cytologic diagnosis. The final clinical diagnosis of malignancy was the strongest predictor of agreement. These results have significant implications for patient management and need to be validated in future trials.

* Results of this study were presented in part at Digestive Disease Week 2015, Washington, DC, USA.


 

  • References

  • 1 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015; 65: 5-29
    CrossrefPubMedGoogle Scholar
  • 2 Smith BD, Smith GL, Hurria A et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009; 27: 2758-2765
    CrossrefPubMedGoogle Scholar
  • 3 Tempero MA, Malafa MP, Behrman SW et al. Pancreatic adenocarcinoma, version 2.2014: featured updates to the NCCN guidelines. J Natl Compr Canc Netw 2014; 12: 1083-1093
    CrossrefPubMedGoogle Scholar
  • 4 Sun H, Ma H, Hong G et al. Survival improvement in patients with pancreatic cancer by decade: a period analysis of the SEER database, 1981–2010. Sci Rep 2014; 4: 6747
    CrossrefPubMedGoogle Scholar
  • 5 Rosch T, Lorenz R, Braig C et al. Endoscopic ultrasound in pancreatic tumor diagnosis. Gastrointest Endosc 1991; 37: 347-352
    CrossrefPubMedGoogle Scholar
  • 6 Owens DJ, Savides TJ. Endoscopic ultrasound staging and novel therapeutics for pancreatic cancer. Surg Oncol Clin N Am 2010; 19: 255-266
    CrossrefPubMedGoogle Scholar
  • 7 Eloubeidi MA, Jhala D, Chhieng DC et al. Yield of endoscopic ultrasound-guided fine-needle aspiration biopsy in patients with suspected pancreatic carcinoma. Cancer 2003; 99: 285-292
    CrossrefPubMedGoogle Scholar
  • 8 Eloubeidi MA, Tamhane A. Prospective assessment of diagnostic utility and complications of endoscopic ultrasound-guided fine needle aspiration. Results from a newly developed academic endoscopic ultrasound program. Dig Dis 2008; 26: 356-363
    CrossrefPubMedGoogle Scholar
  • 9 Adler DG, Jacobson BC, Davila RE et al. ASGE guideline: complications of EUS. Gastrointest Endosc 2005; 61: 8-12
    CrossrefPubMedGoogle Scholar
  • 10 Ngamruengphong S, Swanson KM, Shah ND et al. Preoperative endoscopic ultrasound-guided fine needle aspiration does not impair survival of patients with resected pancreatic cancer. Gut 2015; 64: 1105-1110
    CrossrefPubMedGoogle Scholar
  • 11 Hewitt MJ, McPhail MJ, Possamai L et al. EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis. Gastrointest Endosc 2012; 75: 319-331
    CrossrefPubMedGoogle Scholar
  • 12 Fisher L, Segarajasingam DS, Stewart C et al. Endoscopic ultrasound guided fine needle aspiration of solid pancreatic lesions: Performance and outcomes. J Gastroenterol Hepatol 2009; 24: 90-96
    CrossrefPubMedGoogle Scholar
  • 13 Shin HJ, Lahoti S, Sneige N. Endoscopic ultrasound-guided fine-needle aspiration in 179 cases: the M.D. Anderson Cancer Center experience. Cancer 2002; 96: 174-180
    CrossrefPubMedGoogle Scholar
  • 14 Weynand B, Borbath I, Bernard V et al. Pancreatic neuroendocrine tumour grading on endoscopic ultrasound-guided fine needle aspiration: high reproducibility and inter-observer agreement of the Ki-67 labelling index. Cytopathology 2014; 25: 389-395
    PubMedGoogle Scholar
  • 15 Larghi A, Correale L, Ricci R et al. Interobserver agreement and accuracy of preoperative endoscopic ultrasound-guided biopsy for histological grading of pancreatic cancer. Endoscopy 2015; 47: 308-314
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Pitman MB, Centeno BA, Ali SZ et al. Standardized terminology and nomenclature for pancreatobiliary cytology: the Papanicolaou Society of Cytopathology guidelines. Diagn Cytopathol 2014; 42: 338-350
    CrossrefPubMedGoogle Scholar
  • 17 Rastogi A, Wani S, Gupta N et al. A prospective, single-blind, randomized, controlled trial of EUS-guided FNA with and without a stylet. Gastrointest Endosc 2011; 74: 58-64
    CrossrefPubMedGoogle Scholar
  • 18 Wani S, Gupta N, Gaddam S et al. A comparative study of endoscopic ultrasound guided fine needle aspiration with and without a stylet. Dig Dis Sci 2011; 56: 2409-2414
    CrossrefPubMedGoogle Scholar
  • 19 Wani S, Early D, Kunkel J et al. Diagnostic yield of malignancy during EUS-guided FNA of solid lesions with and without a stylet: a prospective, single blind, randomized, controlled trial. Gastrointest Endosc 2012; 76: 328-335
    CrossrefPubMedGoogle Scholar
  • 20 Downs-Kelly E, Mendelin JE, Bennett AE et al. Poor interobserver agreement in the distinction of high-grade dysplasia and adenocarcinoma in pretreatment Barrett’s esophagus biopsies. Am J Gastroenterol 2008; 103: 2333-2340; quiz 2341
    CrossrefPubMedGoogle Scholar
  • 21 Skacel M, Petras RE, Gramlich TL et al. The diagnosis of low-grade dysplasia in Barrett’s esophagus and its implications for disease progression. Am J Gastroenterol 2000; 95: 3383-3387
    CrossrefPubMedGoogle Scholar
  • 22 Wang KK, Sampliner RE. Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 2008; 103: 788-797
    CrossrefPubMedGoogle Scholar
  • 23 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174
    CrossrefPubMedGoogle Scholar
  • 24 Gonzalo-Marin J, Vila JJ, Perez-Miranda M. Role of endoscopic ultrasound in the diagnosis of pancreatic cancer. World J Gastrointest Oncol 2014; 6: 360-368
    CrossrefPubMedGoogle Scholar
  • 25 Chang KJ, Nguyen P, Erickson RA et al. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma. Gastrointest Endosc 1997; 45: 387-393
    CrossrefPubMedGoogle Scholar
  • 26 Wani S, Mathur SC, Curvers WL et al. Greater interobserver agreement by endoscopic mucosal resection than biopsy samples in Barrett’s dysplasia. Clin Gastroenterol Hepatol 2010; 8: 783-788
    CrossrefPubMedGoogle Scholar
  • 27 Kaye PV, Haider SA, Ilyas M et al. Barrett’s dysplasia and the Vienna classification: reproducibility, prediction of progression and impact of consensus reporting and p53 immunohistochemistry. Histopathology 2009; 54: 699-712
    CrossrefPubMedGoogle Scholar
  • 28 Montgomery E, Bronner MP, Goldblum JR et al. Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation. Hum Pathol 2001; 32: 368-378
    CrossrefPubMedGoogle Scholar
  • 29 Kerkhof M, van Dekken H, Steyerberg EW et al. Grading of dysplasia in Barrett’s oesophagus: substantial interobserver variation between general and gastrointestinal pathologists. Histopathology 2007; 50: 920-927
    CrossrefPubMedGoogle Scholar
  • 30 Tanaka M, Masuda T, Yao T et al. Observer variation of diagnoses based on simple biopsy criteria differentiating among Crohn’s disease, ulcerative colitis, and other forms of colitis. J Gastroenterol Hepatol 2001; 16: 1368-1372
    CrossrefPubMedGoogle Scholar
  • 31 Geboes K, Riddell R, Ost A et al. A reproducible grading scale for histological assessment of inflammation in ulcerative colitis. Gut 2000; 47: 404-409
    CrossrefPubMedGoogle Scholar
  • 32 Osmond A, Li-Chang H, Kirsch R et al. Interobserver variability in assessing dysplasia and architecture in colorectal adenomas: a multicentre Canadian study. J Clin Pathol 2014; 67: 781-786
    CrossrefPubMedGoogle Scholar
  • 33 Karadsheh Z, Al-Haddad M. Endoscopic ultrasound-guided fine-needle aspiration needles: which one and in what situation?. Gastrointest Endosc Clin N Am 2014; 24: 57-69
    CrossrefPubMedGoogle Scholar
  • 34 Chen J, Yang R, Lu Y et al. Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic lesion: a systematic review. J Cancer Res Clin Oncol 2012; 138: 1433-1441
    CrossrefPubMedGoogle Scholar
  • 35 Lee LS, Nieto J, Watson RR et al. Randomized noninferiority trial comparing diagnostic yield of cytopathologist-guided versus 7 passes for EUS-FNA of pancreatic masses. Dig Endosc 2015; [Epub ahead of print] DOI: 10.1111/den.12594.
    PubMedGoogle Scholar
  • 36 Savides TJ, Donohue M, Hunt G et al. EUS-guided FNA diagnostic yield of malignancy in solid pancreatic masses: a benchmark for quality performance measurement. Gastrointest Endosc 2007; 66: 277-282
    CrossrefPubMedGoogle Scholar
  • 37 Bergeron JP, Perry KD, Houser PM et al. Endoscopic ultrasound-guided pancreatic fine-needle aspiration: potential pitfalls in one institution's experience of 1212 procedures. Cancer Cytopathol 2015; 123: 98-107
    CrossrefPubMedGoogle Scholar
  • 38 Madhoun MF, Wani SB, Rastogi A et al. The diagnostic accuracy of 22-gauge and 25-gauge needles in endoscopic ultrasound-guided fine needle aspiration of solid pancreatic lesions: a meta-analysis. Endoscopy 2013; 45: 86-92
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Wani S, Muthusamy VR, Komanduri S. EUS-guided tissue acquisition: an evidence-based approach (with videos). Gastrointest Endosc 2014; 80: 939-959 e7
    CrossrefPubMedGoogle Scholar
  • 40 Larghi A, Capurso G, Carnuccio A et al. Ki-67 grading of nonfunctioning pancreatic neuroendocrine tumors on histologic samples obtained by EUS-guided fine-needle tissue acquisition: a prospective study. Gastrointest Endosc 2012; 76: 570-577
    CrossrefPubMedGoogle Scholar