The diagnostic accuracy of 22-gauge and 25-gauge needles in endoscopic ultrasound-guided fine needle aspiration of solid pancreatic lesions: a meta-analysis

EUS-guided core biopsies of pancreatic solid masses using a new fork-tip needle: A multicenter prospective study

BACKGROUND AND AIM

Endoscopic ultrasound-guided sampling (EUS sampling) is a safe and effective technique. The study aim was to evaluate the presence of a histological core from pancreatic lesions using a new 25G fork-tip needle.

METHODS

Observational multicenter prospective and analytical study, including consecutive patients with solid pancreatic masses referred for EUS-guided sampling. At each needle pass, the endoscopist performed macroscopic on-site evaluation (MOSE). The primary outcome was the histological core procurement rates. Secondary outcomes were the evaluation of interobserver agreement between endoscopists and pathologists, adequacy of EUS samples for the diagnosis and post-procedure adverse events.

RESULTS

100 patients were enrolled in 3 centers. The mean size of the lesions was 28.5 mm (SD 11.7). Final diagnoses were adenocarcinoma (68%), neuroendocrine tumor (21%), inflammatory mass/benign lesions (8.0%), and pancreatic metastasis (3.0%). The pathologists described the presence of a core in 67 samples (67.0% of patients), with poor agreement with MOSE (kappa, 0. 12; 95% CI: 0.03-0.28). The diagnostic accuracy was 93%. We observed 6% of mild adverse events.

CONCLUSION

The new 25-gauge core needle showed good overall adequacy and a good rate of histological specimens during EUS sampling of solid pancreatic masses, with a minimum number of passes and no major complications. Clinicaltrial.gov number, NCT02946840.

New Era of Endoscopic Ultrasound-Guided Tissue Acquisition: Next-Generation Sequencing by Endoscopic Ultrasound-Guided Sampling for Pancreatic Cancer

Pancreatic cancer is a lethal cancer with an increasing incidence. Despite improvements in chemotherapy, patients with pancreatic cancer continue to face poor prognoses. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is the primary method for obtaining tissue samples of pancreatic cancer. Due to advancements in next-generation sequencing (NGS) technologies, multiple parallel sequencing can be applied to EUS-TA samples. Genomic biomarkers for therapeutic stratification in pancreatic cancer are still lacking, however, NGS can unveil potential predictive genomic biomarkers of treatment response. Thus, the importance of NGS using EUS-TA samples is becoming recognized. In this review, we discuss the recent advances in EUS-TA application for NGS of pancreatic cancer.

Comparison of specimen adequacy and diagnostic accuracy of a 25-gauge and 22-gauge needle in endobronchial ultrasound-guided transbronchial needle aspiration

Background

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the preferred diagnostic modality for sampling mediastinal and hilar lymph nodes (LNs). The conventional needle used for sampling is either a 21-gauge (21G) or 22-gauge (22G). A 25-gauge (25G) needle has recently been introduced with little known regarding its efficacy.

Methods

A retrospective study was conducted on patients referred for EBUS-TBNA who had LNs sampled using a 25G or 22G needle. A propensity score matching analysis was performed. After matching the groups, each LN was assessed for adequacy and final diagnosis. Non-diagnostic and benign lymphoid specimens were compared with repeat biopsy findings or long-term clinical and radiological follow-up.

Results

A total of 158 LNs were included. An adequate sample was obtained in 92.4% (73/79) in the 25G group and 92.4% (73/79) in the 22G group (P=1). The 25G group diagnosed benign lymphoid tissue in 82.3% (65/79), granuloma in 7.6% (6/79) and malignancy in 2.5% (2/79). Six lymph nodes in the 25G group were non-diagnostic (7.6%). The 22G group diagnosed benign lymphoid tissue in 83.5% (66/79), granuloma in 3.8% (3/79) and malignancy in 5.1% (4/79). Six lymph nodes in the 22G group were non-diagnostic (7.6%). The sensitivity, specificity, negative predictive value (NPV) and diagnostic accuracy in the 25G group was 88.9% (95% CI, 51.8-99.7%), 100% (95% CI, 92.1-100%), 97.8% (95% CI, 87.6-99.7%) and 98.2% (95% CI, 90.1-100%), respectively. The sensitivity, specificity, NPV and diagnostic accuracy in the 22G group was 77.8% (95% CI, 40-97.2%), 100% (95% CI, 86.8-100%), 92.9% (95% CI, 79.3-97.8%) and 94.3% (95% CI, 80.8-99.3%), respectively. The 25G and 22G group were comparable in diagnostic accuracy (P=0.7).

Conclusions

The 25G and 22G needle achieve comparable specimen adequacy and diagnostic accuracy in EBUS-TBNA.

Endoscopic ultrasound-guided fine-needle aspiration biopsy - Recent topics and technical tips

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is a useful procedure that enables reliable pathological diagnoses of pancreatobiliary diseases, subepithelial lesions, and swollen lymph nodes. In recent years, a pathological diagnosis based on EUS-FNA has made it possible to provide accurate treatment methods not only in these fields, but also in respiratory organs and otorhinolaryngology. This review discusses the latest topics pertaining to EUS-FNA as well as procedural tips.

Endoscopic ultrasonography in pancreatic diseases: advances in tissue acquisition

Background and study aims  Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) improved the diagnostic performance and upgraded the role of endoscopic ultrasonography (EUS) into an interventional modality, able to guide patient management and treatment.This review aimed to highlight the advances, emerging practices, procedural techniques and technological innovations in EUS tissue acquisition in pancreatic diseases. Methods  A thorough review of the literature was performed using PubMed to identify articles that describe techniques, advances, and practices in EUS tissue acquisition in gastrointestinal diseases. Conclusion  Since the first EUS-FNA procedure, EUS guided-tissue acquisition has been evolving continuously. Development of needles with innovative tip design enabled procurement of larger samples with preserved histological architecture. Moreover, sampling techniques and complementary methods, such as contrast harmonic imaging and EUS-elastography, have been introduced in an effort to improve diagnostic performance and sample adequacy.

Effect of Pancreatic Mass Size on Clinical Outcomes of Endoscopic Ultrasound-Guided Fine-Needle Aspiration

BACKGROUND

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has high diagnostic accuracy for pancreatic diseases. However, the effect of mass size on diagnostic accuracy has yet to be determined, especially for small pancreatic lesions. We aimed to determine the effect of pancreatic mass size on the diagnostic yield of EUS-FNA.

METHODS

We searched the database in Hokkaido University Hospital between May 2008 and December 2016 and identified solid pancreatic lesions examined by EUS-FNA. All lesions were stratified into five groups based on mass sizes: groups A (< 10 mm), B (10-20 mm), C (20-30 mm), D (30-40 mm) and E (≥ 40 mm). The sensitivity, specificity, diagnostic accuracy and adverse event rate were retrospectively evaluated.

RESULTS

We analyzed a total of 788 solid pancreatic lesions in 761 patients. The patients included 440 males (57.8%) with a mean age of 65.7 years. The sensitivities in groups A (n = 36), B (n = 223), C (n = 304), D (n = 147) and E (n = 78) were 89.3%, 95.0%, 97.4%, 98.5% and 98.7%, respectively, and they significantly increased as the mass size increased (P < 0.01, chi-squared test for trend). The diagnostic accuracies were 91.7%, 96.4%, 97.7%, 98.6% and 98.7%, respectively, and they also significantly increased as the mass size increased (P = 0.03). Multivariate analysis showed that pancreatic mass size was associated with diagnostic accuracy. The adverse event rates were not significantly different among the five groups.

CONCLUSIONS

The sensitivities and diagnostic accuracies of EUS-FNA for solid pancreatic lesions are higher for lesions ≥ 10 mm in size, and they are strongly correlated with mass size.

Fine-needle aspiration of cutaneous, subcutaneous, and intracavitary masses in dogs and cats using 22- vs 25-gauge needles

BACKGROUND

Fine-needle aspiration (FNA) is a common procedure as a diagnostic tool in veterinary medicine. However, it is unclear whether the gauge of the needle affects the quality of cytology.

OBJECTIVE

This study compared the quality of cytologic samples obtained via FNA using 22- or 25-gauge needles.

METHODS

Fine-needle aspiration was performed on 50 masses (cutaneous, subcutaneous, or intracavitary) obtained from client-owned animals. The size of the needle was randomly assigned using either of the following two sequences: 22-25-22 gauge or 25-22-25 gauge. Samples were evaluated by two board-certified clinical pathologists to assess cellularity, blood contamination, amount of cellular debris, degree of cellular trauma, and the overall ability to make a diagnosis for each sample.

RESULTS

No significant difference was detected between the 22- and 25-gauge needle samples for cellularity, whereas a significant difference was present for blood contamination, amount of cellular debris, and degree of cellular trauma. The overall ability to make a diagnosis was not significantly affected by the needle gauge. The degree of cellular trauma was significantly increased in intracavitary samples.

CONCLUSIONS AND CLINICAL RELEVANCE

Needle gauge is a contributing factor to FNA sample quality. However, it did not affect the overall ability to make a diagnosis. Samples obtained using 25-gauge needles resulted in less blood contamination yet increased cellular trauma compared to 22-gauge needle samples.

Diagnostic Endoscopic Ultrasound: Technique, Current Status and Future Directions

Endoscopic ultrasound (EUS) is now well established as an important tool in clinical practice. From purely diagnostic imaging, it has progressed to include tissue acquisition, which provided the basis for therapeutic procedures. Even as interventional EUS developed, there has been ongoing progress in EUS diagnostic capabilities due to improved imaging systems, better needles for tissue acquisition and development of enhanced imaging functions such as contrast harmonic EUS (CHEUS) and EUS elastography. EUS is well established for differentiation of subepithelial lesions, for T-staging of luminal gastrointestinal and pancreaticobiliary malignancies, for differentiation of benign pancreaticobiliary disorders and for diagnostic tissue acquisition, which can be achieved by EUS-guided fine needle aspiration or by EUS-guided fine needle biopsy using dedicated biopsy needles. This review briefly describes the technique of performing EUS and then discusses its clinical utility in terms of gastrointestinal cancer staging, the evaluation of pancreaticobiliary disorders and tissue acquisition. Enhanced imaging techniques such as CHEUS and EUS elastography are briefly reviewed.

A multicenter randomized trial comparing a 25-gauge EUS fine-needle aspiration device with a 20-gauge EUS fine-needle biopsy device

BACKGROUND AND AIMS

Several studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle.

METHODS

Consecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders.

RESULTS

A total of 608 patients were allocated to FNA (n = 306) or FNB (n = 302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (P = .043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, P < .001), accuracy for malignancy (87% vs 78%, P = .002) and Bethesda classification (82% vs 72%, P = .002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; P = .004), and did not differ among centers (P = .836).

CONCLUSION

The 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.).

Prospective comparison of slow-pull and standard suction techniques of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of solid pancreatic cancer

BACKGROUND

The usage of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the diagnosis of solid pancreatic cancer is increasing, however mainly retrospective studies are available about the detailed methods of sampling.

METHODS

To compare prospectively the diagnostic yield of EUS-FNA samples obtained with slow-pull (SP) and with standard suction technique (SS).

RESULTS

EUS-FNA sampling was diagnostic in 72 of 92 cases (78.3%). Diagnostic yield was 67.4% in the SS and 65.2% in the SP group. The number of smear pairs (1.84 vs. 3.56; p < 0.001) and blood contamination (1.50 vs. 2.19; p < 0.001) were significantly higher in the SS group, which resulted in lower rate of diagnostic samples (41.8% vs. 30.0%; p = 0.003). There was no difference in the cellularity (1.58 vs. 1.37; p = 0.2554), or in the sensitivity and specificity in the identification of malignancy between SP and SS subgroups (69.9, 100% vs. 73.5, 100%). Histological samples were obtained in 60 cases (with SP: 49 cases; with SS: 46 cases). There was no difference in the diagnostic yield of histological samples between the groups (63 and 58.7%).

CONCLUSION

The diagnostic yield, the cellularity of smears and the rate of acquiring sufficient histological material are similar in the SP and SS group, but due to lower bloodiness and decreased number of slides, the pathological diagnosis is faster and more cost-effective.

Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey

In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.

Instant evaluation of contrast enhanced endoscopic ultrasound helps to differentiate various solid pancreatic lesions in daily routine

BACKGROUND

Contrast enhanced harmonic endoscopic ultrasound (CEH-EUS) is a spreading technique; some studies have shown its value in the diagnosis of pancreatic adenocarcinoma using quantitative analysis.

AIM

To examine the value of CEH-EUS for differentiating various pancreatic lesions in everyday routine with qualitative and quantitative analysis.

METHODS

Data of 55 patients with pancreatic lesions who underwent CEH-EUS were analysed retrospectively. Perfusion characteristics were classified by the investigator qualitatively immediately upon investigation, quantitative analysis was performed later on. Samples from fine needle aspiration (EUS-FNA) or surgical specimen served as gold standard.

RESULTS

CEH-EUS showed 39 hypoenhanced lesions, 3 non-enhanced and 13 hyperenhanced lesions. Concordance of the investigators qualitative classification of peak contrast enhancement with quantitative analysis later on was 100%, while other parameters such as arrival time, time to peak or area under the curve did not show additional value. 34 of 39 hypoenhanced lesions were pancreatic adenocarcinoma; of the hyperenhanced lesions 4 were inflammatory, 3 neuroendocrine carcinomas, 1 lymphoma, 1 insulinoma and 4 metastases (2 of renal cell carcinoma, 2 of lung cancer). Non-enhanced lesions showed up as necroses. Sensitivity for the detection of pancreatic adenocarcinoma was 100%, specificity 87.2% for hypoenhancement alone; in otherwise healthy pancreatic tissue all hypoenhanced lesions were pancreatic adenocarcinoma (sensitivity and specificity 100%, PPV and NPV for adenocarcinoma 100%).

CONCLUSION

This study again shows the excellent value of CEH-EUS in everyday routine for diagnostics of various focal pancreatic lesions suggesting that qualitatively assessed hypoenhancement is highly predictive for adenocarcinoma. Additional quantitative analysis of perfusion parameters does not add diagnostic yield. In case of the various hyperenhanced pancreatic lesions in our data set, histologic sampling is essential for further treatment.

Endoscopic Ultrasound-Guided Tissue Acquisition: Techniques and Challenges

Endoscopic ultrasound-guided fine needle aspiration (EUS FNA) has made pathological diagnosis of pancreatic neoplasms, diseases involving lymph nodes at various mediastinal and abdominal sites, gastrointestinal submucosal lesions, perirectal lesions, adrenal lesions, and mediastinal masses easy. EUS-guided FNA is a multistep procedure that involves assessment of proper clinical indication, correct selection of FNA needles, and adoption of evidence-based techniques for tissue sampling. EUS FNA is done by needles that are available in different sizes, mainly 25, 22, and 19-gauge needle. The need of onsite cytopathologist, dependence on histology/core biopsy occasionally to get a diagnosis, and inability to reliably assess for molecular markers are important limitations of EUS FNA. EUS-guided fine needle biopsy (FNB) that samples the core of tissue is an exciting new development in the field of diagnostic EUS. FNB needles are expensive than FNA needles, and although the initial results are encouraging, more studies with robust evidence proving their superiority beyond any doubt are needed before they can be widely used.

Recent advancement in EUS-guided fine needle sampling

EUS-guided tissue acquisition technique plays an essential role for evaluation of gastrointestinal tumors. Several components affect the yield of EUS-guided tissue acquisition outcomes such as sampling techniques, use of ROSE (rapid onsite evaluation), training and experience, and needle designs. In this review we discuss advancement in EUS-guided fine needle sampling.

Systematic Review and Meta-Analysis of Diagnostic Accuracy of Endoscopic Ultrasound (EUS)-Guided Fine-Needle Aspiration (FNA) Using 22-gauge and 25-gauge Needles for Pancreatic Masses

BACKGROUND Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been used for detecting pancreatic cancer. We aimed to compare the diagnostic yield of both 22-gauge and 25-gauge EUS-FNA for the detection of pancreatic cancer. MATERIAL AND METHODS We searched the electronic databases including PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library up to June 13, 2017. Two reviewers independently screened studies and extracted data. RESULTS We analyzed data from 1824 patients from 16 included studies. The estimated pooled data for the 22-gauge needles reported sensitivity was 0.89 (0.83-0.93), specificity was 1.00 (0.74-1.00), positive LR was 485.28 (2.55-92 000) and negative LR was 0.11 (0.07-0.17). Results for the 25-gauge needles showed the pooled sensitivity, specificity, positive and negative LR was 0.90 (0.86-0.93), 0.99 (0.89-1.00), 59.53 (7.99-443.66), and 0.10 (0.07-0.14), respectively. The 25-gauge needle had significantly higher pooled sensitivity than the 22-gauge needle (0.90 vs. 0.87, χ²=5.26, P=0.02) while there was no difference in the pooled specificity (0.96 vs. 0.98, χ²=2.12, P=0.15). The quality of most studies was assessed favorable using QUADAS-2 (quality assessment of diagnostic accuracy studies-2). CONCLUSIONS Our findings revealed that the 25-gauge EUS-FNA used for pancreatic lesions could have a higher diagnostic yield than using 22-gauge EUS-FNA. Nevertheless, well-designed prospective studies recruiting more patients are needed.

Slow-Pull Using a Fanning Technique Is More Useful Than the Standard Suction Technique in EUS-Guided Fine Needle Aspiration in Pancreatic Masses

Background/Aims

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is useful for obtaining pancreatic mass samples. The combination of modified techniques (i.e., slow-pull technique and fanning technique) may improve the quality of the sample obtained by EUS-FNA. We investigated the effectiveness of a combined slow-pull fanning technique in EUS-FNA for pancreatic mass.

Methods

This prospective comparative study investigated EUS-FNA performed for pancreatic solid masses between August 2015 and July 2016. Pairwise specimens were alternately obtained using the following two techniques for targeted pancreatic lesions: standard suction or slow-pull with fanning. We compared the specimen quality, blood contamination, and diagnostic accuracy of these techniques.

Results

Forty-eight consecutive patients were included (29 men; mean age, 68.1±11.9 years), and 96 pancreatic mass specimens were obtained. The slow-pull with fanning technique had a significantly superior diagnostic accuracy than the suction technique (88% vs 71%, p=0.044). Furthermore, blood contamination was significantly reduced using the slow-pull with fanning technique (ratio of no or slight contamination, 77% vs 56%, p=0.041). No difference was observed in the acquisition of adequate cellularity between the groups. In the subgroup analysis, the tumor size and sampling technique were related to the EUS-FNA diagnostic accuracy.

Conclusions

The slow-pull with needle fanning technique showed a good diagnostic yield for EUS-FNA for pancreatic mass. This technique can be useful for performing EUS-guided sampling for diagnosing pancreatic disease.

Endoscopic Ultrasound-guided Specimen Collection and Evaluation Techniques Affect Diagnostic Accuracy

BACKGROUND & AIMS

Outcomes of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) evaluation vary with technique, needles, and methods of specimen evaluation. We performed a direct comparison of diagnostic yields of EUS-FNA samples collected using different gauge needles (22- vs 25-gauge), with or without suction.

METHODS

We performed a randomized controlled study of 352 patients with suspected pancreatic masses, referred for EUS-FNA at a tertiary referral center. Patients were randomly assigned to 22-gauge needles with or without suction or 25-gauge needles with or without suction. Specimens were evaluated offsite by cell block and rapid onsite cytologic evaluation (ROSE). Final diagnoses were made based on histologic analyses or 12-month follow-up evaluations. The primary outcome was diagnostic adequacy of cell blocks. Secondary outcomes were operating characteristics of ROSE and EUS-FNA, number of passes required for accurate onsite diagnosis, and amount of blood in specimens.

RESULTS

The final diagnoses were malignancy (81.5% of patients) and benign disease (17.0% of patients); 1.4% of patients were lost during follow up. Cell block, ROSE, and EUS-FNA led to diagnostic accuracies of 71.9%, 95.5%, and 96.6%, respectively. A 22-gauge needle with suction was associated with more passes for adequate onsite diagnosis (P = .003) and specimens contained more blood (P = .01). Diagnostic accuracy of specimens collected by transduodenal EUS-FNA was lower with 22-gauge needles with suction compared to other techniques (P = .004).

CONCLUSION

In a randomized trial of patients undergoing EUS-FNA for pancreatic masses, samples collected with 22-gauge vs 25-gauge needles performed equally well for offsite specimen evaluation. Use of suction appears to increase number of passes needed and specimen bloodiness. Specimen collection techniques should be individualized based on method of evaluation. ClinicalTrials.gov no: NCT02424838.

Endoscopic Ultrasound-Guided Tissue Acquisition Using Fork-Tip Needle Improves Histological Yield, Reduces Needle Passes, Without On-Site Cytopathological Evaluation

Background and Aim: Endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) and fine needle aspiration (FNA) are established methods in tissue acquisition. A new fork-tip FNB needle has been used to obtain core tissue samples. We compared the performance of the FNB using fork-tip needles with that of the FNA using conventional needles in patients who had solid neoplastic lesions within and around the upper gastrointestinal (GI) tract.

Methods: In this retrospective single-center study, patients who underwent EUS examinations for solid neoplastic lesions between October 2013 and February 2017 were included. The procedures were performed in the absence of an on-site cytologist. The main objectives were to compare the diagnostic yield and average number of passes of FNB using fork-tip needles versus those of FNA using conventional needles.

Results: EUS/FNA and EUS/FNB were performed on 181 solid neoplastic lesions primarily in the pancreas and GI tract walls. There was no significant difference in patient's age, gender, tumor location, or tumor size. The mean number of needle passes was significantly lower in the fork-tip needle group than in the conventional needle group (3.8 vs. 5.9; p < 0.0001). There was a trend toward higher sensitivity (89.9% vs. 81%) using the fork-tip needles than when using the conventional needles (p = 0.119). No significant difference in rates of adverse events between two groups was found.

Conclusions: Our study demonstrates that, compared with FNA using conventional needles, FNB using fork-tip needles required significantly fewer needle passes while achieving a relatively higher diagnostic yield due to its superior capacity in tissue acquisition from solid neoplastic lesions in and around GI tract walls without on-site cytological assessment.

Utility of Endoscopic Ultrasound-Guided Biopsy for Next-Generation Sequencing of Pancreatic Exocrine Malignancies

OBJECTIVES

Endoscopic ultrasound-guided fine-needle biopsy and aspiration (EUS FNB/A) are the standard diagnostic tests for pancreatic malignancies. Oncologists increasingly use tumor genomic analysis for management. Adequacy of FNB/A tissue for next-generation sequencing (NGS) has not been evaluated. This study examined FNB/A and other biopsy types for features that might predict adequacy for NGS.

METHODS

Seventy-six pancreatic exocrine malignancy biopsies submitted for NGS were assessed for adequacy, which was compared with other tumor/biopsy features.

RESULTS

Twenty-two (29%) of 76 samples were inadequate, including 16 (30%) of 54 FNBs and 4 (57%) of 7 FNAs. Larger-gauge needles were associated with adequacy in all samples (P = 0.0047) and in FNBs (P = 0.05). Metastatic samples were more likely to be adequate for NGS compared with pancreatic samples (P = 0.0357). Percutaneous biopsies were more likely to be adequate than EUS-guided FNB/As, although this trend was not significant (P = 0.0558). Other tumor/biopsy characteristics were not associated with adequacy.

CONCLUSIONS

Endoscopic US FNA and FNB provided similar NGS adequacy rates. Metastatic lesions accessible by percutaneous biopsy may be preferable to EUS FNB/A of primary lesions for obtaining tissue for NGS. All biopsies, including EUS FNB, were more likely to be successful using larger-gauge needles.

Comparison of Endoscopic Ultrasound-Fine-Needle Aspiration and Endoscopic Ultrasound-Fine-Needle Biopsy for Solid Lesions in a Multicenter, Randomized Trial

BACKGROUND & AIMS

Endoscopic ultrasound with fine-needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the gastrointestinal tract. Fine-needle biopsy (FNB) may provide higher diagnostic yield with fewer needle passes. The aim of this study was to assess the difference in diagnostic yield between FNA and FNB.

METHODS

This is a multicenter, prospective randomized clinical trial from 6 large tertiary care centers. Patients referred for tissue sampling of solid lesions were randomized to either FNA or FNB of the target lesion. Demographics, size, location, number of needle passes, and final diagnosis were recorded.

RESULTS

After enrollment, 135 patients were randomized to FNA (49.3%), and 139 patients were randomized to FNB (50.7%).The following lesions were sampled: mass (n = 210, 76.6%), lymph nodes (n = 46, 16.8%), and submucosal tumors (n = 18, 6.6%). Final diagnosis was malignancy (n = 192, 70.1%), reactive lymphadenopathy (n = 30, 11.0%), and spindle cell tumors (n = 24, 8.8%). FNA had a diagnostic yield of 91.1% compared with 88.5% for FNB (P = .48). There was no difference between FNA and FNB when stratified by the presence of on-site cytopathology or by type of lesion sampled. A median of 1 needle pass was needed to obtain a diagnostic sample for both needles.

CONCLUSIONS

FNA and FNB obtained a similar diagnostic yield with a comparable number of needle passes. On the basis of these results, there is no significant difference in the performance of FNA compared with FNB in the cytologic diagnosis of solid lesions adjacent to the gastrointestinal tract. ClinicalTrials.gov identifier: NCT01698190.

Suboptimal Agreement Among Cytopathologists in Diagnosis of Malignancy Based on Endoscopic Ultrasound Needle Aspirates of Solid Pancreatic Lesions: A Validation Study

BACKGROUND & AIMS

Despite the widespread use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to sample pancreatic lesions and the standardization of pancreaticobiliary cytopathologic nomenclature, there are few data on inter-observer agreement among cytopathologists evaluating pancreatic cytologic specimens obtained by EUS-FNA. We developed a scoring system to assess agreement among cytopathologists in overall diagnosis and quantitative and qualitative parameters, and evaluated factors associated with agreement.

METHODS

We performed a prospective study to validate results from our pilot study that demonstrated moderate to substantial inter-observer agreement among cytopathologists for the final cytologic diagnosis. In the first phase, 3 cytopathologists refined criteria for assessment of quantity and quality measures. During phase 2, EUS-FNA specimens of solid pancreatic lesions from 46 patients were evaluated by 11 cytopathologists at 5 tertiary care centers using a standardized scoring tool. Individual quantitative and qualitative measures were scored and an overall cytologic diagnosis was determined. Clinical and EUS parameters were assessed as predictors of unanimous agreement. Inter-observer agreement (IOA) was calculated using multi-rater kappa (κ) statistics and a logistic regression model was created to identify factors associated with unanimous agreement.

RESULTS

The IOA for final diagnoses, based on cytologic analysis, was moderate (κ = 0.56; 95% CI, 0.43-0.70). Kappa values did not increase when categories of suspicious for malignancy, malignant, and neoplasm were combined. IOA was slight to moderate for individual quantitative (κ = 0.007; 95% CI, -0.03 to -0.04) and qualitative parameters (κ = 0.5; 95% CI, 0.47-0.53). Jaundice was the only factor associated with agreement among all cytopathologists on multivariate analysis (odds ratio for unanimous agreement, 5.3; 95% CI, 1.1-26.89).

CONCLUSIONS

There is a suboptimal level of agreement among cytopathologists in the diagnosis of malignancy based on analysis of EUS-FNA specimens obtained from solid pancreatic masses. Strategies are needed to refine the cytologic criteria for diagnosis of malignancy and enhance tissue acquisition techniques to improve diagnostic reproducibility among cytopathologists.

How to measure quality in endoscopic ultrasound

Quality is a key focus for gastrointestinal endoscopy and main international gastroenterology societies instituted specific task forces focused on this issue. Endoscopic ultrasound (EUS) represents one of the most fascinating fields to explore in gastrointestinal endoscopy due to its relatively limited availability out of high-volume centers. This leads to a particular need to define widely accepted quality indicators (QIs) and the ways to measure them. The current manuscript reviews these indicators in light of their impact on common clinical practice.

Comparison of endoscopic ultrasound-guided fine-needle aspiration and biopsy with 22-gauge and 25-gauge needles for the "precision medicine" of pancreatic cancer: A retrospective study

We compared the sample volume of endoscopic ultrasound-guided fine-needle aspiration and biopsy (EUS-FNAB) specimens obtained by 22-gauge (22G) and 25-gauge (25G) needles, and the accuracy rate.This was a retrospective study in a single tertiary referral center. We investigated 153 patients with pancreatic ductal adenocarcinoma (PDAC) who underwent diagnostic EUS-FNAB before neoadjuvant gemcitabine-based chemoradiotherapy between October 2006 and November 2015. We performed immunohistochemical (IHC) analysis of human equilibrative nucleoside transporter 1 using the remnant cell blocks following pathological PDAC diagnosis. We compared the sampling rate, accuracy rate, and success rate of IHC analysis between 22G and 25G.There were 70 patients in the 22G group and 83 patients in the 25G group. The overall sampling rates on cytology and histology were 100% and 98.0%, respectively. The sampling rate did not differ between the 22G and 25G groups. The overall diagnostic accuracy rates on cytology and histology were 94.8% and 79.7%, respectively. The accuracy rates of 22G and 25G groups on cytology were 94.3% and 95.2%, respectively, whereas those on histology were 80.0% and 79.5%, respectively. The diagnostic accuracy on cytology and histology did not differ significantly between the 22G and 25G groups. Of 153 histology specimens, 69.3% of those with PDAC provided sufficient samples for IHC analysis. The success rate of IHC analysis did not differ significantly between the 22G (67.1%) and 25G (71.1%) groups (P = .60).Both 22G and 25G provided a high diagnostic yield with equivalent accuracy rates on histology. EUS-FNAB specimens obtained using 22G or 25G can be equally adequate for IHC analysis and may be suitable for diagnostic examination. Further investigations such as EUS-FNAB needle design and novel cell block preparation are needed to obtain adequate samples for use in "precision medicine."

EUS elastography (strain ratio) and fractal-based quantitative analysis for the diagnosis of solid pancreatic lesions

BACKGROUND AND AIMS

EUS elastography is useful in characterizing solid pancreatic lesions (SPLs), and fractal analysis-based technology has been used to evaluate geometric complexity in oncology. The aim of this study was to evaluate EUS elastography (strain ratio) and fractal analysis for the characterization of SPLs.

METHODS

Consecutive patients with SPLs were prospectively enrolled between December 2015 and February 2017. Elastographic evaluation included parenchymal strain ratio (pSR) and wall strain ratio (wSR) and was performed with a new compact US processor. Elastographic images were analyzed using a computer program to determine the 3-dimensional histogram fractal dimension. A composite cytology/histology/clinical reference standard was used to assess sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating curve.

RESULTS

Overall, 102 SPLs from 100 patients were studied. At final diagnosis, 69 (68%) were malignant and 33 benign. At elastography, both pSR and wSR appeared to be significantly higher in malignant as compared with benign SPLs (pSR, 24.5 vs 6.4 [P < .001]; wSR, 56.6 vs 15.3 [P < .001]). When the best cut-off levels of pSR and wSR at 9.10 and 16.2, respectively, were used, sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating curve were 88.4%, 78.8%, 89.7%, 76.9%, and 86.7% and 91.3%, 69.7%, 86.5%, 80%, and 85.7%, respectively. Fractal analysis showed a significant statistical difference (P = .0087) between the mean surface fractal dimension of malignant lesions (D = 2.66 ± .01) versus neuroendocrine tumor (D = 2.73 ± .03) and a statistical difference for all 3 channels red, green, and blue (P < .0001).

CONCLUSIONS

EUS elastography with pSR and fractal-based analysis are useful in characterizing SPLs. (Clinical trial registration number: NCT02855151.).

Endoscopic Ultrasound Imaging for Differential Diagnosis of Pancreatic Neoplasms: A 7-Year Study in a Chinese Population

Background

Currently, non-invasive methods for screening pancreatic cancer are lacking. There is little information regarding whether endoscopic ultrasound (EUS) imaging has a discriminatory ability for detecting benign and malignant pancreatic neoplasms. In this study, we retrospectively analyzed the demographic, clinicopathologic, and EUS features and follow-up information.

Material/Methods

A total of 58 patients with pancreatic neoplasms who underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) over a 7-year period (2009–2016) at our Department of Digestive Diseases were enrolled in our study.

Results

Of the 58 patients, 38 (65.5%) were diagnosed with malignant pancreatic neoplasms and 20 (34.5%) were benign ones. Of all the EUS findings, size of neoplasm (P=0.037) and regularity of margin (P=0.011) were significantly different between malignant and benign pancreatic neoplasms. However, age, sex, location, echo pattern, and dilation of main pancreatic duct did not show any significant difference (P>0.05). Size combined with regularity to detect malignant pancreatic neoplasms showed the following diagnostic values: sensitivity, 73.68%; specificity, 90%; positive predictive value, 76.60%; negative predictive value 81.82%; and area under the receiver operating characteristic curve, 0.887 (95% CI: 0.777–0.955, P<0.0001).

Conclusions

Our results showed the high value of EUS for differentiating malignant pancreatic neoplasms from benign ones. Due to this and its non-invasive nature, EUS should be the first-line method for detection of neoplastic pancreatic lesions.

Endobronchial Ultrasound-guided Transbronchial Needle Aspiration With a 19-G Needle Device

BACKGROUND

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration is a well-established first-line minimally invasive modality for mediastinal lymph node sampling. Although results are excellent overall, the technique underperforms in certain situations. We aimed to describe our results using a new 19-G EBUS-guided transbronchial needle aspiration device to determine safety and feasibility of this approach.

METHODS

We completed a retrospective chart review of all cases performed to the time of data analysis at each of 3 study sites.

RESULTS

A total of 165 procedures were performed with a total of 297 individual lymph nodes or lesions sampled with the 19-G device by 10 bronchoscopists. Relatively large targets were selected for sampling with the device (mean lymph node size: 20.4 mm; lung lesions: 33.5 mm). A specific diagnosis was obtained in 77.3% of cases with an additional 13.6% of cases with benign lymphocytes, for a procedural adequacy rate of 90.9%. Procedure sample adequacy was 88.6% in suspected malignant cases, 91.0% in suspected sarcoidosis/lymphadenopathy cases, and 85.7% of cases with suspected lymphoma. On a per-node basis, a specific diagnosis was noted in 191/280 (68.2%) of samples, with an additional 61 showing benign lymphocytes for a per-node sample adequacy rate of 90%. One case (0.6%) of intraprocedure bleeding was noted.

CONCLUSIONS

A new flexible 19-G EBUS needle was successfully and safely applied in a large patient cohort for sampling of lung and enlarged mediastinal lesions with high diagnostic rates across clinical indications.

A quarter century of EUS-FNA: Progress, milestones, and future directions

Tissue acquisition using EUS has considerably evolved since the first EUS-FNA was reported 25 years ago. Its introduction was an important breakthrough in the endoscopic field. EUS-FNA has now become a part of the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of the organs in its proximity, including lung diseases. This review aims to present the history of EUS-FNA development and to provide a perspective on the recent developments in procedural techniques and needle technologies that have significantly extended the role of EUS and its clinical applications. There is a bright future ahead for EUS-FNA in the years to come as extensive research is conducted in this field and various technologies are continuously implemented into clinical practice.

A Comparison of Endoscopic Ultrasound-Guided Fine-Needle Aspiration and Fine-Needle Biopsy in the Diagnosis of Solid Pancreatic Lesions

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is the method of choice for sampling pancreatic lesions. This study compares the diagnostic accuracy and safety of FNB using a novel core needle to FNA in solid pancreatic lesions.

METHODS

A retrospective review of patients in whom EUS FNA or FNB was performed for solid pancreatic lesions was conducted. Diagnostic performance was calculated based upon a dual classification system: classification 1, only malignant pathology considered a true positive, versus classification 2, atypical, suspicious, and malignant pathology considered a true positive.

RESULTS

43 patients underwent FNB compared with 51 FNA. Using classification 1, sensitivity was 74.0% versus 80.0%, specificity 100% versus 100%, and diagnostic accuracy 77.0% versus 80.0% for FNB versus FNA, respectively (all p > 0.05). Using classification 2, sensitivity was 97% versus 94.0%, specificity 100% versus 100%, and diagnostic accuracy 98.0% versus 94.0% for FNB versus FNA, respectively (all p > 0.05). FNB required significantly fewer needle passes (median = 2) compared to FNA (median = 3; p < 0.001). Adverse events occurred in two (4.5%) FNB patients compared with none in the FNA group (p > 0.05).

CONCLUSION

FNA and FNB have comparable sensitivity and diagnostic accuracy. FNB required fewer passes.

A 19-Gauge Histology Needle Versus a 19-Gauge Standard Needle in Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Solid Lesions: A Multicenter Randomized Comparison Study (GREATER Study)

BACKGROUND

The necessity of histological analysis is increasing. A 19-gauge histology needle (PC19) in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has recently been developed and has shown high yields of tissue acquisition and histological diagnosis.

AIMS

To compare the histological diagnostic yield in single-pass EUS-FNA for solid lesions using PC19 and a standard 19-gauge needle (EC19).

PATIENTS AND METHODS

Consecutive patients with solid lesions were enrolled and underwent one pass with each of PC19 and EC19 for EUS-FNA with the randomized order of the needles. The primary endpoint was the histological diagnostic accuracy. The secondary endpoints were the feasibility, yield of histological core, cytological and overall diagnostic accuracies, and adverse events. Subgroup analysis was performed for the optimal situation with PC19.

RESULTS

Of the 115 patients, 110 underwent EUS-FNA and five were excluded. EUS-FNA was performed from the esophagus in four, stomach in 80, or duodenum in 26. The final diagnosis was malignancy in 100 and benign in 10. The feasibility was 98.2 and 97.3% with PC19 and EC19, respectively (p = 1.00). The rate of presence of a histological core and the histological, cytological, and overall diagnostic accuracies for PC19 versus EC19 were 84.6 versus 80.9% (p = 0.593), 83.6 versus 73.6% (p = 0.099), 63.6 versus 56.4% (p = 0.335), and 90.0 versus 79.1% (p = 0.039), respectively. PC19 was favored in the trans-esophageal/gastric approaches to obtain a histological diagnosis (p = 0.013). Adverse events were observed in four patients.

CONCLUSION

Single-pass EUS-FNA with PC19 was feasible and showed significantly higher overall diagnostic accuracy and an increased tendency towards histological diagnostic accuracy, especially with trans-esophageal/gastric FNA.

Per-Pass Performance Characteristics of Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Malignant Solid Pancreatic Masses in a Large Multicenter Cohort

OBJECTIVES

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is widely performed for the evaluation of pancreatic masses. We evaluated the performance characteristics of EUS-FNA in obtaining a diagnosis of pancreatic malignancy.

METHODS

We performed a multicenter study of patients who underwent EUS-FNA for a solid pancreatic mass. Endoscopic ultrasound-guided FNA was standardized using a 25-gauge needle, slow-pull stylet technique for specimen acquisition, and on-site cytopathology. For the primary analysis, only malignant cytology was regarded as positive. A secondary analysis was performed in which malignant and/or suspicious cytology was regarded as positive.

RESULTS

A total of 138 patients underwent EUS-FNA. In the primary analysis, the sensitivity of EUS-FNA for malignancy was 56.7% on first pass, 73.3% on second pass, 83.3% on third pass, 89.2% on fourth pass, and 90.8% on fifth pass, with no increase beyond the fifth pass. In the secondary analysis, the sensitivity was 75.0% on first pass, 89.2% on second pass, 93.3% on third pass, and 95.8% on fourth pass, with no increase beyond the fourth pass. No significant relationship was seen between lesion size and diagnostic yield.

CONCLUSIONS

Using a 25-gauge needle, the maximal diagnostic yield of EUS-FNA for a solid pancreatic mass is reached after 4 needle passes.

Advanced EUS Guided Tissue Acquisition Methods for Pancreatic Cancer

Pancreas cancer is a lethal cancer as the majority patients are diagnosed at an advanced incurable stage. Despite improvements in diagnostic modalities and management strategies, including surgery and chemotherapies, the outcome of pancreas cancer remains poor. Endoscopic ultrasound (EUS) is an important imaging tool for pancreas cancer. For decades, resected pancreas cancer and other cancer specimens have been used to identify tissue biomarkers or genomics for precision therapy; however, only 20% of patients undergo surgery, and thus, this framework is not useful for unresectable pancreas cancer. With advancements in needle technologies, tumor specimens can be obtained at the time of tissue diagnosis. Tumor tissue can be used for development of personalized cancer treatment, such as performing whole exome sequencing and global genomic profiling of pancreas cancer, development of tissue biomarkers, and targeted mutational assays for precise chemotherapy treatment. In this review, we discuss the recent advances in tissue acquisition of pancreas cancer.

A comparison of the efficiency of 22G versus 25G needles in EUS-FNA for solid pancreatic mass assessment: A systematic review and meta-analysis

Our aim in this study was to compare the efficiency of 25G versus 22G needles in diagnosing solid pancreatic lesions by EUS-FNA. We performed a systematic review and meta-analysis. Studies were identified in five databases using an extensive search strategy. Only randomized trials comparing 22G and 25G needles were included. The results were analyzed by fixed and random effects. A total of 504 studies were found in the search, among which 4 randomized studies were selected for inclusion in the analysis. A total of 462 patients were evaluated (233: 25G needle/229: 22G needle). The diagnostic sensitivity was 93% for the 25G needle and 91% for the 22G needle. The specificity of the 25G needle was 87%, and that of the 22G needle was 83%. The positive likelihood ratio was 4.57 for the 25G needle and 4.26 for the 22G needle. The area under the sROC curve for the 25G needle was 0.9705, and it was 0.9795 for the 22G needle, with no statistically significant difference between them (p=0.497). Based on randomized studies, this meta-analysis did not demonstrate a significant difference between the 22G and 25G needles used during EUS-FNA in the diagnosis of solid pancreatic lesions.

Diagnostic yield of EUS-FNA of small (≤15 mm) solid pancreatic lesions using a 25-gauge needle

BACKGROUND

Early detection of small solid pancreatic lesions is increasingly common. To date, few and contradictory data have been published about the relationship between lesion size and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) diagnostic yield. The aim of this study was to assess the relation between the size of solid pancreatic lesions and the diagnostic yield of EUS-FNA using a 25-gauge needle in a center without available rapid on-site evaluation.

METHODS

In the retrospective cohort study, we selected patients who underwent EUS-FNA for solid pancreatic lesions with a 25-gauge needle from October 2014 to October 2015. Patients were divided into three groups (≤15 mm, 16-25 mm and >25 mm), and the outcomes were compared.

RESULTS

We analyzed 163 patients. Overall adequacy, sensitivity, specificity and accuracy were 85.2%, 81.8%, 93.7%, and 80.4%, respectively. When stratified by size, the sensitivity and accuracy correlated with size (P = 0.016 and P = 0.042, respectively). Multivariate analysis showed that lesion size was the only independent factor (P = 0.019, OR = 4.76) affecting accuracy. The role of size as an independent factor affecting accuracy was confirmed in a separate multivariate analysis, where size was included in the model as a covariate (P = 0.018, OR = 1.08).

CONCLUSION

Our study demonstrates that, in the absence of rapid on-site evaluation, mass size affects the accuracy of EUS-FNA of solid pancreatic lesions.

Impact of avascular areas, as measured by contrast-enhanced harmonic EUS, on the accuracy of FNA for pancreatic adenocarcinoma

BACKGROUND AND AIMS

EUS-guided FNA (EUS-FNA) is used for the diagnosis of pancreatic adenocarcinoma, but sometimes the method results in a false negative. Occasionally, an avascular area may be observed within the pancreatic adenocarcinoma tumor during contrast-enhanced harmonic EUS (CH-EUS). The aim of this study was to evaluate whether the diagnostic sensitivity of EUS-FNA for pancreatic adenocarcinoma was affected by the presence of avascularity on CH-EUS.

METHODS

Two hundred ninety-two patients with pancreatic adenocarcinoma who presented at Kindai University Hospital for EUS-FNA and CH-EUS between June 2009 and August 2013 were retrospectively evaluated. This was a single-center retrospective analysis of prospectively collected data held in a registry. The overall sensitivity of EUS-FNA for the diagnosis of pancreatic adenocarcinoma was calculated. The sensitivities of cytology, histology, and the combination of cytology and histology were also evaluated. These variables were individually evaluated according to the presence or absence of an avascular area on CH-EUS to assess whether the diagnostic sensitivity of EUS-FNA for pancreatic adenocarcinoma was related to the presence of an avascular area within the tumors.

RESULTS

The overall sensitivity of EUS-FNA was 90.8% (265/292). The sensitivities of EUS-FNA for lesions with and without an avascular area were 72.9% (35/48) and 94.3% (230/244), respectively, with the difference being statistically significant (P < .001).

CONCLUSIONS

EUS-FNA has lower sensitivity for pancreatic adenocarcinoma with avascular areas on CH-EUS.

A Multicenter comparative trial of a novel EUS-guided core biopsy needle (SharkCore™) with the 22-gauge needle in patients with solid pancreatic mass lesions

Background and Objectives:

The ability to obtain adequate tissue of solid pancreatic lesions by EUS-guided remains a challenge. The aim of this study was to compare the performance characteristics and safety of EUS-FNA for evaluating solid pancreatic lesions using the standard 22-gauge needle versus a novel EUS biopsy needle.

Methods:

This was a multicenter retrospective study of EUS-guided sampling of solid pancreatic lesions between 2009 and 2015. Patients underwent EUS-guided sampling with a 22-gauge SharkCore (SC) needle or a standard 22-gauge FNA needle. Technical success, performance characteristics of EUS-FNA, the number of needle passes required to obtain a diagnosis, diagnostic accuracy, and complications were compared.

Results:

A total of 1088 patients (mean age = 66 years; 49% female) with pancreatic masses underwent EUS-guided sampling with a 22-gauge SC needle (n = 115) or a standard 22-gauge FNA needle (n = 973). Technical success was 100%. The frequency of obtaining an adequate cytology by EUS-FNA was similar when using the SC and the standard needle (94.1% vs. 92.7%, respectively). The sensitivity, specificity, and diagnostic accuracy of EUS-FNA for tissue diagnosis were not significantly different between two needles. Adequate sample collection leading to a definite diagnosis was achieved by the 1^st, 2^nd, and 3^rd pass in 73%, 92%, and 98% of procedures using the SC needle and 20%, 37%, and 94% procedures using the standard needle (P < 0.001), respectively. The median number of passes to obtain a tissue diagnosis using the SC needle was significantly less as compared to the standard needle (1 and 3, respectively; P < 0.001).

Conclusions:

The EUS SC biopsy needle is safe and technically feasible for EUS-FNA of solid pancreatic mass lesions. Preliminary results suggest that the SC needle has a diagnostic yield similar to the standard EUS needle and significantly reduces the number of needle passes required to obtain a tissue diagnosis.

Utility of core biopsy with concurrent ROSE FNA in the diagnosis of pancreatic tumor-does the biopsy add any diagnostic benefit?

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic ultrasound-guided core-needle biopsy (EUS-CNB) are widely used for diagnosis of pancreatic tumors. The aim of our study was to compare the diagnostic performance of ROSE EUS-FNA and EUS-CNB for diagnosis of pancreatic malignancy during the same EUS.

METHODS

Patients who underwent both FNA and CNB during the same EUS for pancreatic solid lesion were reviewed retrospectively. Sample adequacy, diagnostic yield (defined as percentage of definitive diagnosis), sensitivity and specificity for malignancy were compared between FNA and CNB.

RESULTS

A total of 48 patients with solid pancreatic lesions were evaluated. The proportions of adequate samples were 48/48 (100%) for FNA and 45/48 (93.7%) for core biopsy (P = .24). The diagnostic yield was 42/48 (87.5%) and 33/48 (68.7%) for FNA and CNB respectively (P = .046). The incremental increase in diagnostic yield by combining both methods was 2/48 (4%). The diagnostic yield for malignancy was 30/32 (93.7%) for FNA and 23/32 (71.8%) for CNB (P = .043). The sensitivity for the diagnosis of malignancy for FNA and CNB were 90.6% and 69%, respectively (P = .045). The specificity was 100% for both methods. The sensitivity for diagnosing malignancy increased to 93.8% when the two methods were combined. The difference in diagnostic yield was not associated with lesion size or location.

CONCLUSION

EUS-guided FNA is a superior method of assessing solid pancreatic lesion and pancreatic malignancy with better diagnostic yield and higher sensitivity than EUS-CNB.

Endoscopic ultrasound-guided fine needle aspiration of pancreatic lesions with 22 versus 25 Gauge needles: A meta-analysis

BACKGROUND

Robust data in favour of a clear superiority of 22 versus 25 Gauge needles for endoscopic ultrasound-guided fine needle aspiration are still lacking.

OBJECTIVE

We aimed to compare the diagnostic sensitivity, specificity and safety of these two needles for endoscopic ultrasound-guided fine needle aspiration of solid pancreatic lesions.

METHODS

A computerized bibliographic search was restricted to randomized controlled trials only. Pooled effects were calculated using a random-effects model and expressed in terms of risk ratio and 95% confidence interval.

RESULTS

We analysed seven trials with 689 patients and 732 lesions (295 sampled with 22 Gauge needle, 309 with 25 Gauge needle, and 128 with both needles). A non-significant superiority of 25 Gauge in terms of pooled sensitivity (risk ratio: 0.93, 0.91-0.95 versus 0.89, 0.85-0.94 of 22 Gauge needle; p = 0.13) and no difference in terms of specificity (1.00, 0.98-1.00 in both groups; p = 0.85) were observed. Sample adequacy was similar between the two devices (risk ratio: 1.03, 0.99-1.06; p = 0.15). Very few adverse events were observed and did not impact on patient outcomes.

CONCLUSION

Our meta-analysis reveals non-superiority of 25 Gauge over 22 Gauge; hence no definitive recommendations over the use of one particular device can be made.

Endoscopic Ultrasonography with Fine-needle Aspiration: New Techniques for Interpretation of Endoscopic Ultrasonography Cytology and Histology Specimens

Significant advances have been made in the last few years in the technologies for sampling pancreatic masses, and in the understanding of the biology of pancreatic cancer. Better and more targeted treatments are likely to become available. Because most pancreatic cancers are likely to remain unresectable at diagnosis, high-quality, high-cellularity specimens are essential. A tailored approach that considers indication, location, and treatment possibilities needs to be taken before embarking on a pancreatic biopsy. Because the demand from oncologists and patients for increasingly personalized therapy is likely to grow, optimal sampling beyond diagnostic accuracy is likely to become increasingly critical.

New Developments in Endoscopic Ultrasound Tissue Acquisition

Endoscopic ultrasound (EUS)-guided tissue acquisition has greatly evolved since the first EUS-guided fine-needle aspiration was reported nearly 25 years ago. EUS-guided tissue acquisition has become the procedure of choice for sampling of the pancreas, subepithelial lesions, and other structures adjacent to the gastrointestinal tract. This review focuses on recent developments in procedural techniques and needle technologies for EUS-guided tissue acquisition.

Assessment of morbidity and mortality associated with endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: A systematic review and meta-analysis

BACKGROUND AND AIM

With increased availability of imaging technology, detection of pancreatic cystic lesions (PCL) is on the rise. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) improves the diagnosis accuracy of PCL. Systematic evaluation of morbidity and mortality associated with EUS-FNA for PCL has not been carried out. We conducted a systematic review and meta-analysis of morbidity and mortality associated with EUS-FNA.

METHODS

A literature search for relevant English-language articles was conducted on PubMed and EMBASE databases. Main outcome measures for this analysis were adverse effects of diagnostic EUS-FNA, and the associated morbidity and mortality, in patients with PCL.

RESULTS

Forty studies, with a combined subject population of 5124 patients with PCL, satisfied the inclusion criteria. Overall morbidity as a result of adverse events of EUS-FNA was 2.66% (95% confidence interval [CI]: 1.84-3.62%), and the associated mortality was 0.19% (95% CI: 0.09-0.32%). Common post-procedure adverse events included pancreatitis 0.92% (95% CI: 0.63-1.28%), hemorrhage 0.69% (95% CI: 0.42-1.02%), pain 0.49% (95% CI: 0.27-0.79%), infection 0.44% (95% CI: 0.27-0.66%), desaturation 0.23% (95% CI: 0.12-0.38%) and perforation 0.21% (95% CI: 0.11-0.36%). There was no peritoneal seeding in our study. Incidence of adverse events associated with prophylactic periprocedural antibiotic use was 2.77% (95% CI: 1.87-3.85%).

CONCLUSIONS

EUS-FNA is a safe procedure for diagnosis of PCL and is associated with a relatively low incidence of adverse events. Most adverse events were mild, self-limiting, and did not require medical intervention.

Comparison of endoscopic ultrasound guided fine needle aspiration and PET/CT in preoperative diagnosis of pancreatic adenocarcinoma

BACKGROUND

Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is the procedure of choice to investigate and sample pancreatic masses for the preoperative diagnosis of pancreatic ductal adenocarcinoma (PDAC). The role of 18fluoro-deoxyglucose positron emission tomography/computed tomography (PET/CT) in PDAC is debated. This study evaluates the role of EUS-FNA as compared to PET/CT in the preoperative evaluation of PDAC.

METHODS

Preoperative evaluation by PET/CT and EUS-FNA was performed on 25 patients with pancreatic solid lesions, who underwent a subsequent Whipple procedure or partial pancreatic resection.

RESULTS

This series included 19 PDACs and 6 non-PDACs including 1 metastatic breast ductal adenocarcinoma, 2 low grade neuroendocrine tumors, 2 chronic pancreatitis and 1 gastrointestinal tumor abutting the pancreas. EUS-FNA correctly diagnosed 18 of 19 PDACs, 1 metastatic breast ductal adenocarcinoma and all 5 of the other non-PDAC cases. One case of well differentiated PDAC was negative on EUS-FNA. PET/CT provided excellent size and was positive in 14 of 19 PDACs and the metastatic breast ductal adenocarcinoma. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for EUS-FNA in diagnosis of selected pancreatic tumors were 91%, 100%, 100%, 50% and 92%, respectively, while they were 65%, 100%, 100%, 20% and 68% for PET/CT, respectively.

CONCLUSIONS

Compared to PET/CT, EUS-FNA has a higher sensitivity and accuracy for preoperative diagnosis of PDAC. However, PET/CT provides excellent size, volume and stage information. A combination of both PET/CT and EUS will better help guide diagnosis and treatment of pancreatic adenocarcinoma.

Prospective randomized comparison of a 22G core needle using standard versus capillary suction for EUS-guided sampling of solid pancreatic masses

BACKGROUND AND STUDY AIMS

 The optimal technique for sampling pancreatic lesions with a 22 G Procore needle (pc) is unknown. The aims of this study were to evaluate the 22 Gpc using standard suction technique (SST) and capillary suction technique (CST) and compare diagnostic adequacy of 22 Gpc with the standard 25 G needle.

PATIENTS AND METHODS

 Sixty consecutive patients referred for EUS-FNA of a solid pancreatic mass were prospectively evaluated. All patients underwent 2 passes with a standard 25 G needle for cytologic analysis. The first group of 30 patients underwent a single pass with the 22 Gpc needle using SST for cytology and histology. The second group underwent a single pass with the 22 Gpc needle using CST. The sequence of passes was randomized. The diagnostic adequacy of each pass was graded by 2 cytopathologists blinded to technique and needle type for comparison.

RESULTS

 For a cytologic diagnosis with 22 Gpc, an adequate sample was obtained in 82.8 % SST vs. 80.0 % CST ( P  = 0.79). For a histologic diagnosis with 22 Gpc, an adequate sample was obtained in 70.4 % SST vs. 69.0 % CST ( P  = 0.91). A single pass with 22 Gpc provided comparable results to a single pass with the 25 G needle for a cytologic diagnosis; both were superior to a single 22 Gpc pass for a histologic diagnosis. Two passes with the 25 G needle provided a diagnostic specimen in 95.0 % vs 81.4 % with one pass using 22 Gpc ( P  = 0.01).

CONCLUSIONS

 No significant difference in diagnostic adequacy was observed between techniques for the 22 Gpc. Two passes with a 25 G needle performed better than 1 pass with 22 Gpc. (NCT01598194).

Endoscopic ultrasonography-guided tissue acquisition: How to achieve excellence

Endoscopic ultrasound (EUS)-guided tissue acquisition is a basic forte of an endosonographer. The multiple skills required to accomplish successful results include not only the puncture itself, but also proper lesion identification, correct puncture sequence, collaboration with the pathologist onsite or remotely, proper handling of the specimens, choosing one or more of cytology, cell-block, and/or tissue core preparation and, last, deciding the immunohistochemistry (IHC) panels and ancillary tests which may be needed for the current case. Error in any of these decisions may lead to incomplete or inconclusive information from the procedure, even if the aspirate is 'adequate.' In the present review, we will describe the technical aspects of EUS-guided tissue acquisition, current needles available and how to choose between them, and how to appropriately handle the specimen. We will also discuss the optimal approach to common targets including lymph nodes, pancreatic masses, pancreatic cysts, and subepithelial lesions.

"Clinical" cytology for endoscopists: A practical guide

Clinical cytology was originally used by clinicians to provide rapid diagnosis. However, with advancing medical subspecialization, few clinicians interpret cytology themselves these days, for example, gynecologists, hematologists, urologists, and occasional gastroenterologist (mainly in Asian countries). Cytological assessment enjoyed a renaissance with the development of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). Subsequently, pathologists, most of them more experienced in histology, had to take over. Recently, it has been shown that in-room cytology can be easily performed by the endoscopist themselves for initial evaluation of the quality of the EUS-FNA specimen and an initial diagnosis distinguishing benign or malignant cells. Bringing cytology back to the clinician has some advantages but does not substitute the professional cytopathologist. This report has written to lower the threshold for the clinician to find his way back to the microscope, which may improve both their diagnostic yield and assessment of EUS-FNA sample quality.