EUS-guided tissue sampling: comparison of "dual sampling" (Trucut biopsy plus FNA) with "sequential sampling" (Trucut biopsy and then FNA as required)

The additional value of EUS-guided Tru-cut biopsy to EUS-guided FNA in patients with mediastinal lesions

BACKGROUND AND OBJECTIVE

EUS-guided FNA is a sensitive method to obtain cytologic specimens from solid lesions in close proximity to the GI tract. Although FNA provides cells for analysis, large-caliber Tru-cut biopsy (EUS-TCB) needles obtain samples that can be used for additional histopathologic analysis. We assessed the additional diagnostic yield of EUS-TCB in patients with solid mediastinal lesions in whom EUS-FNA was performed.

PATIENTS AND DESIGN

In the period from July 2003 to July 2007, all patients with mediastinal lesions accessible to EUS-FNA and EUS-TCB were evaluated. In all patients, a mean of 3 passes of EUS-FNA was followed by EUS-TCB. Cytologic and histologic specimens were evaluated by 2 pathologists blinded for patient condition. A final diagnosis was obtained by combining all information present (EUS-FNA and EUS-TCB results, mediastinoscopy, bronchoscopy [if performed], and other investigations).

RESULTS

The diagnostic accuracy of EUS-FNA, EUS-TCB, and the combination of both techniques was 93%, 90%, and 98%, respectively (not significant). In EUS-FNA-negative patients, EUS-TCB provided a final diagnosis in an additional 3 patients (5%). Malignant disease found by EUS-FNA could be specified by EUS-TCB in 15 patients (25% of patients). The granulomatous disease established by cytologic samples of clinically suspected tuberculosis could be specified by EUS-TCB in 2 patients (3%). In 1 patient (2%), both FNA and TCB were inconclusive.

LIMITATIONS

Retrospective study.

CONCLUSIONS

The diagnostic yield of EUS-FNA and EUS-TCB is comparable. We recommend limiting the use of EUS-TCB to specific cases in which EUS-FNA is not conclusive.

Does onsite cytotechnology evaluation improve the accuracy of endoscopic ultrasound-guided fine-needle aspiration biopsy?

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the preferred modality for the cytological diagnosis of various cancers. Onsite cytopathology interpretation is not available in most centres.

OBJECTIVE

To assess whether the the adequacy of tissue sampling assessed by an onsite cytotechnologist improves the diagnostic accuracy of EUS-FNA.

METHODS

The present study is a retrospective review of all patients undergoing solid mass EUS-FNA between September 2005 and August 2007. Patients in group I (September 2005 to August 2006) had cytology slides prepared by an endoscopy nurse. Patients in group II (September 2006 to August 2007) had cytology slides prepared, stained and assessed for adequacy of tissue sampling by a cytotechnologist in the endoscopy suite. The final cytopathological diagnosis (definitely positive, definitely negative or inconclusive) was compared between the two groups.

RESULTS

A total of 49 EUS-FNA procedures were performed in 47 patients in group I and 60 EUS-FNA procedures in 55 patients in group II. Pancreatic masses were the most common target site in both groups. The total number of needle passes was 105 in group I (mean 2.14 passes per patient; range one to five needle passes) and 158 in group II (mean 2.63 passes per patient; range one to four needle passes). The difference in the number of needle passes was not statistically significant between groups. The final diagnosis was definite in 53% in group I compared with 77% in group II (P=0.01). The percentage of inconclusive diagnoses was 47% in group I and 23% in group II (P=0.001).

CONCLUSION

Onsite cytotechnologist interpretation of adequacy of tissue sampling significantly improves the diagnostic yield of EUS-FNA. This appears to be independent of the total number of needle passes undertaken for tissue sampling.

EUS-guided Trucut needle biopsies as first-line diagnostic method for patients with intestinal or extraintestinal mass lesions

INTRODUCTION

Fine-needle aspiration (FNA) is a well-established technique to obtain cytological specimens, but it does not permit the extraction of histological tissue-core samples, which, if available, may increase the yield and accuracy of the histopathological diagnosis. This prospective study was designed to assess the yield and diagnostic accuracy of endoscopic ultrasound (EUS)-guided Trucut needle biopsy (TNB) as first-line diagnostic method for suspected malignant lesions identified by upper gastrointestinal EUS.

METHODS

In a prospective case series, 24 consecutive patients (14 women; median age, 68 (range, 38-84) years) with suspected malignancy underwent EUS-TNB with a 19-gauge needle. EUS was performed with a linear scanning echo endoscope. When the EUS-TNB device did not collect adequate samples, subsequent EUS-FNA was performed. The presence or absence of malignancy was confirmed by postoperative histopathology or diagnostic imaging follow-up for at least 9 months.

RESULTS

Adequate tissue specimens were obtained in 20 of 24 (83%) patients by TNB. An accurate diagnosis was achieved in 19 of 20 (95%) patients in whom TNB was successful with a sensitivity and specificity of 93% and 100%, respectively. In 11 patients malignant disease was found, whereas 8 patients showed benign lesions on TNB-obtained histopathology. Thirteen patients underwent additional EUS-FNA. The diagnosis by TNB was confirmed in seven of nine (78%) patients with additional FNA. In three of four patients with inadequate TNB, the diagnosis was established by FNA. The overall accuracy of EUS-TNB was 79% (19/24) for all patients and 92% (22/24) with subsequent FNA. The positive and negative predictive values for the diagnosis of a malignant lesion by EUS-TNB were 57.9% and 88.9%, respectively. Neither method had any procedure-related complications.

CONCLUSIONS

EUS-guided TNB is a safe and accurate technique to obtain core specimen for histopathologic diagnosis in patients with suspected malignancies on upper gastrointestinal EUS. FNA can serve as rescue technique and should be performed if TNB fails to obtain adequate tissue samples.

Initial experience with EUS-guided Tru-cut biopsy of benign liver disease

BACKGROUND

Histologic biopsy of the liver is often essential for diagnosing hepatic parenchymal disease. Tissue acquisition is traditionally obtained by a surgical, transvascular, or percutaneous route.

OBJECTIVE

To describe our initial experience with EUS-guided Tru-cut biopsy (EUS-TCB) of benign liver disease.

DESIGN

A prospective case series.

SETTING

A tertiary-referral hospital in Indianapolis, Indiana.

PATIENTS

Consecutive subjects undergoing EUS with suspected hepatic parenchymal disease.

INTERVENTIONS

EUS-TCB of the liver.

MAIN OUTCOME MEASUREMENTS

Liver biopsy specimen yield, diagnosis, and procedural complications. Specimens were routinely stained with hematoxylin and eosin and with special stains for reticulin, iron, and trichome. Each case was reviewed by a single experienced pathologist for the number of portal spaces, total specimen length, and final diagnosis. An adequate specimen was defined as 6 or more complete portal tracts.

RESULTS

Between February 2007 and March 2008, 21 consecutive patients (mean age 45 years; 13 women) were evaluated. The most common indications for liver biopsy were suspected nonalcoholic steatohepatitis (n = 9), intrahepatic cholestasis (n = 4), and suspected cirrhosis (n = 3). Transgastric biopsy (median 3 passes, range 1-4) into the left lobe (n = 18) or both the left and caudate lobe (n = 3) yielded a median total specimen length of 9 mm (range 1-23 mm). The median total number of portal tracts in the specimen was 2 complete (range 0-10) plus 3 partial (range 0-8) tracts. Six or more complete portal tracts were present in 6 of 21 (29%). A histologic diagnosis was obtained in 19 of 21 (90%). There were no complications.

LIMITATIONS

The small sample size and low-risk population.

CONCLUSIONS

In our initial experience, transgastric EUS-TCB of suspected benign liver disease by using a 19-gauge needle appears safe and feasible. Samples obtained are usually smaller than those traditionally considered adequate for histologic assessment. Further refinement of this technique appears indicated.

Efficacy, safety, and predictive factors for a positive yield of EUS-guided Trucut biopsy: a large tertiary referral center experience

OBJECTIVES

Endoscopic ultrasound-guided trucut biopsy (EUS-TCB) technique has the advantage of obtaining tissue for histological examination rather than for cytology alone. However, the diagnostic yield may depend on factors related to both technical aspects and the lesions sampled. Safety of EUS-TCB is yet to be established in a large number of procedures. The aim of the study was to determine factors predicting a positive diagnostic yield, and safety for EUS-TCB in a large tertiary referral center-based service.

METHODS

All patients were referred for EUS-guided tissue sampling as a part of their diagnostic workup. Linear-array echoendoscope (GF-2000-OL5, KeyMed) with a 19-gauge trucut needle (Quick-Core, Wilson-Cook) was used by two operators to obtain tissue samples. Clinical data, details of the EUS-TCB, post-procedure complications, and histology were prospectively collected between May 2002 and February 2008.

RESULTS

In total, 247 patients (143 men) aged 57-73 (median 66) had EUS-TCB performed. Lesions sampled were in the pancreas (113), esophagogastric wall (34), and extra-pancreatic areas (100) (lymph nodes: 52). The maximum diameter of the lesion/wall thickness ranged from 0.6 to 5.4 cm (median 3). One to five passes were made (median 3) to obtain tissue cores 2-18 mm (median 10) in length. The procedure failed in 6% of cases. The overall diagnostic accuracy was 75%. The overall complication rate was 2% (bronchopneumonia, minor hemoptysis, minor hematemesis, mucosal tear, retropharyngeal abscess) with no procedure-related deaths. Site of lesion (pancreatic vs. extra-pancreatic, P<0.032), site of biopsy (stomach vs. duodenum vs. esophagus, P<0.001), and number of passes (< or =2 vs.>2, P<0.013) were predictors of a positive diagnostic yield in univariate analysis. However, only the site of biopsy (P<0.001, 95% CI: 0.58-2.32) and number of passes (P=0.05) were independent predictors in multinominal logistic regression.

CONCLUSIONS

Diagnostic yield of EUS-TCB is higher when lesion is approached through the stomach and better when more than two passes were made. In this large series, the complication rate of 2% associated with EUS-TCB was similar to that reported with EUS-fine needle aspiration technique.

Preoperative tissue diagnosis for tumours of the pancreas

BACKGROUND

Preoperative biopsy of pancreatic lesions suspected of malignancy is controversial.

METHODS

A systematic Medline literature search was carried out. Diagnostic studies reporting quantitative preoperative pancreatic biopsy data were evaluated.

RESULTS

The analysis included 53 studies, mostly of a retrospective nature. Despite acceptable rates for sensitivity and specificity, the negative predictive value of percutaneous and endoscopic ultrasonography-guided biopsies was 60-70 per cent. Biopsy results were considered to be essential for directing non-surgical therapy in advanced disease. However, they were of limited value in planning the treatment of resectable solid or cystic tumours, or focal lesions in the setting of chronic pancreatitis.

CONCLUSIONS

Biopsy of suspected pancreatic malignancies with systemic spread or local irresectability is indicated for planning palliative or neoadjuvant therapy. Preoperative biopsy of potentially resectable pancreatic tumours is not generally advisable, as malignancy cannot be ruled out with adequate reliability.

Adequacy of endoscopic ultrasound core needle biopsy specimen of nonmalignant hepatic parenchymal disease

BACKGROUND & AIMS

The adequacy and diagnostic yield of hepatic parenchymal disease Trucut biopsy have not been determined. Therefore, our aim was to determine the adequacy of endoscopic ultrasound (EUS)-guided Trucut liver biopsy for histopathologic evaluation to include the number of complete portal tracts contained per millimeter of acquired tissue.

METHODS

A single institution retrospective review was made of 9 prospectively identified patients who underwent a transgastric left liver lobe EUS-guided Trucut biopsy during a 36-month period.

RESULTS

Adequate diagnostic material, to include complete portal tract number evaluation (median, 7) and connective tissue staining, was acquired to establish a histopathologic diagnosis in all 9 cases. Sixty-three complete portal tracts were established, resulting in 0.4 portal tracts per millimeter of tissue acquired. Findings established by EUS Trucut left liver lobe biopsy included mild steatosis (n = 4), cryptogenic cirrhosis (n = 2), chronic ductopenic biliary tract disease (n = 1), portal fibrosis with ductular proliferation (n = 1), and alcoholic cirrhosis with hemosiderosis (n = 1).

CONCLUSIONS

EUS-guided Trucut left liver lobe biopsy yields suitable aggregate tissue for diagnostic purposes to establish the presence of chronic liver disease.