Utility of EUS-guided biopsy of extramural pelvic masses

Antibiotic prophylaxis in digestive endoscopy: Guidelines from the French Society of Digestive Endoscopy

Digestive endoscopy is a highly dynamic medical discipline, with the recent adoption of new endoscopic procedures. However, comprehensive guidelines on the role of antibiotic prophylaxis in these new procedures have been lacking for many years. The Guidelines Commission of the French Society of Digestive Endoscopy (SFED) convened in 2023 to establish guidelines on antibiotic prophylaxis in digestive endoscopy for all digestive endoscopic procedures, based on literature data up to September 1, 2023. This article summarizes these new guidelines and describes the literature review that fed into them.

The Role of Endoscopic Ultrasound-guided Fine-needle Aspiration of Pelvic Lesions: A Meta-analysis

BACKGROUND AND AIMS

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a potentially valuable tool for the diagnosis of pelvic lesions. The aim of this meta‑analysis was to evaluate the efficacy and feasibility of EUS-FNA in the diagnosis of pelvic lesions.

METHODS

We performed a computerized search of PubMed, EMBASE, Cochrane Library, and Science Citation Index, through March 2023. The main outcome measures examined in the meta-analysis were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy.

RESULTS

We evaluated 22 trials that used surgical pathology or imaging follow-up results as the reference standard. The studies comprised 844 patients. The cumulative sensitivity, specificity, PPV, NPV, and accuracy were 94%, 100%, 100%, 89%, and 96%, respectively. In the subgroup analysis, the prospective studies revealed the cumulative sensitivity, specificity, PPV, NPV, and accuracy were 91%, 100%, 100%, 85%, and 93%, respectively.

CONCLUSIONS

In conclusion, we provide evidence that EUS-FNA is a qualitative diagnostic technique with high sensitivity, specificity, PPV, and accuracy. However, its NPV is slightly low, which does not exclude the risk of a missed diagnosis, and more randomized controlled trials or prospective studies are still needed in the future. EUS-FNA is effective and feasible for pelvic space-occupying lesions. This technique has high clinical application value for pelvic lesions.

Diagnosis by Endoscopic Ultrasonography-Guided Sampling through the Lower Gastrointestinal Tract

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) is very safe and has a high diagnostic rate for upper gastrointestinal lesions, especially pancreatic lesions, but its application in the lower gastrointestinal tract has rarely been reported. Due to the tortuous course of the colorectum, with the sigmoid colon particularly prone to perforation, most endoscopists are reluctant to perform lateral-sector endoscopic ultrasound scanning without a water-bag protection for the puncture. The ultrasonic endoscopy and flexible puncture needle techniques recently introduced into clinical practice have made ultrasound-guided puncture safer and more convenient. In addition, endoscopists have carefully tested various protective measures to improve the safety of the lower gastrointestinal puncture, substantially increasing its clinical feasibility. In this article, we review the iterations of endoscopic ultrasound equipment introduced in recent years and the many ingenious ideas proposed by endoscopists regarding lower gastrointestinal puncture.

Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration: A Narrative Review

Considerable progress has been made recently in the use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to diagnose intra-luminal gastrointestinal lesions and extra-luminal lesions near the gastrointestinal tract. Numerous reports have indicated that EUS-FNA has high diagnostic performance and safety, which has led to the routine use of EUS-FNA and an increasing number of cases. Thus, while EUS-FNA has a low rate of complications, endoscopists may encounter these complications as the number of cases increases. Infrequent reports have also described life-threatening complications. Therefore, endoscopists should possess a comprehensive understanding of the complications of EUS-FNA, which include hemorrhage, perforation, infection, and acute pancreatitis, as well as their management. This review examines the available evidence regarding the complications associated with EUS-FNA, and the findings will be useful for ensuring that endoscopists perform EUS-FNA safely and appropriately.

Gastrointestinal Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Assessing Suspected Deep Pelvic or Abdominal Recurrence in Gynecologic Cancer: A Feasibility Study

OBJECTIVES

To assess the feasibility of gastrointestinal endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for histologic confirmation of cancer recurrence in women with gynecologic cancer.

METHODS

This work was a retrospective cohort study comprising 46 consecutive women treated for gynecologic cancer and suspected of having a deep pelvic or abdominal recurrence on ultrasound imaging, computed tomography, positron emission tomography-computed tomography, or magnetic resonance imaging, evaluated at our institution from January 2010 to December 2017. Primary cancer was ovarian (n = 22), cervical (n = 13), endometrial (n = 4), sarcoma (n = 4), and other (n = 3). All women underwent EUS examinations for locating the lesion and guiding FNA. The results of FNA (benign/malignant) were assessed. Procedure-related complications were recorded.

RESULTS

The patients' mean age was 57.8 years. A total of 66 procedures were performed. Eleven women underwent 2 procedures; 2 women underwent 3 procedures; and 1 woman underwent 6 procedures at different times during the study period. In 1 case, no lesion was detected on the EUS assessment, and in 2 cases, FNA was not successful. Most lesions were located in the retroperitoneum or involved the intestine. Fine-needle aspiration could be performed in 63 cases (94.5%). Cytologic samples were adequate in 62 of 63 (98.4%). Recurrence was confirmed in 56 cases (90.3%) and ruled out in 6 (9.7%). No patient had any complication related to the procedure.

CONCLUSIONS

Endoscopic ultrasound-guided FNA is a minimally invasive, feasible, and safe technique for confirming pelvic/abdominal recurrence of gynecologic cancer.

Rectal ultrasound with fine needle aspiration: an underutilized modality for delineating and diagnosing perirectal, presacral, and pelvic lesions

Background and study aims  The merits of rectal ultrasound for rectal cancer staging are well documented. Conventional approaches to accessing perirectal and presacral lesions entail computed tomography guidance via a transgluteal approach or frank surgical exploration. We report on the safety and efficacy of performing rectal ultrasound with fine-needle aspiration (RUS-FNA) for evaluating perirectal, presacral, and pelvic abnormalities. Patients and methods  Patients who underwent RUS-FNA of perirectal, presacral, or pelvic lesions between August 2005 and September 2016 were identified using an institutional database. Subjects were all individuals treated at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, United States. Patient demographics and imaging characteristics were noted. Procedural details included lesion size, location, echo appearance, and technical information. Patients were given antibiotics prior to FNA attempt and for 3 days after. Diagnostic yield, clinical utility, and complications were noted. Results  Twenty-seven patients met criteria during the specified study time period. The cohort consisted of 12 males (44.4 %) and 15 females (55.5 %). RUS-FNA was diagnostic in 24 patients (88.8 %) and obviated the need for surgery in 14 patients (51.9 %). There were four complications (14.8 %): two perirectal and two presacral abscesses. Conclusion  While the diagnostic yield of RUS-FNA is high and the potential to affect clinical decision-making is substantial, risk of complication is not negligible. RUS-FNA should only be performed if the result will substantially alter clinical management, and the decision to perform RUS-FNA should be made with close consultation between the endosonographer, surgeon, and/or medical or radiation oncologist.

Endoscopic ultrasound-guided FNA of pelvic lesions: A large single-center experience

BACKGROUND

Pelvic endoscopic ultrasound-guided fine-needle aspiration (PEUS-FNA) of rectal or perirectal lesions is safe, minimally invasive, and well tolerated. It provides valuable information, which can greatly influence patient management. Herein, the authors present what to their knowledge is the largest series to date of PEUS-FNA.

METHODS

PEUS-FNA specimens were retrieved from the archives of the study institution from January 2001 to March 2015. Only patients with solid pelvic lesions were examined. The cytopathology findings, immunohistochemistry, corresponding histology, and clinical data were collected. For analysis of accuracy, atypical or suspicious results were classified as "negative." The sensitivity and specificity of PEUS-FNA were calculated in a subset of patients with available surgical pathology.

RESULTS

A total of 127 cases meeting the current study criteria were obtained from patients who underwent PEUS-FNA at the study institution between January 2001 and March 2015. The mean age of the patients was 60 years, and 53% were female. Pelvic lesions were comprised of 72% masses and 28% lymph nodes, with a mean mass diameter of 27.38 mm (range, 5-100 mm). PEUS-FNA was positive for malignancy in 45% of cases, atypical/suspicious in 4.7% of cases, and negative for malignancy in 50.3% of cases. Surgical pathology was available for 44 patients. PEUS-FNA demonstrated 89.3% sensitivity, 100% specificity, a diagnostic accuracy of 93.2%, a positive predictive value of 100%, and a negative predictive value of 84.2%. No complications were noted.

CONCLUSIONS

PEUS-FNA is safe and effective for the investigation of pelvic lesions. Cancer Cytopathol 2016;124:836-41. © 2016 American Cancer Society.

Endoscopic Ultrasonography-Guided Biopsy for Differentiation of Benign and Malignant Pelvic Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Preoperative diagnosis of pelvic lesions remains challenging despite advances in imaging technologies. Endoscopic ultrasonography (EUS)-guided biopsy is an effective diagnostic modality for sampling the digestive tract and surrounding areas. However, a meta-analysis summarizing the diagnostic efficacy of EUS-guided biopsy for pelvic lesions has not been published.

AIMS

We aimed to evaluate the utility of EUS-guided biopsy in the diagnosis of pelvic lesions.

METHODS

Articles were identified via structured database search; only studies where pelvic lesions were confirmed by surgery or clinical follow-up were included. Data extracted were selected with strict criteria. A fixed-effects model was used to estimate the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). A summary receiver operating characteristic curve (SROC) was also constructed.

RESULTS

Ten studies containing a total of 246 patients were included. The pooled sensitivity of EUS-guided biopsy for differential diagnosis of pelvic masses was 0.89 (95% CI 0.83-0.94), and the specificity was 0.93 (95% CI 0.86-0.97). The area under the SROC was 0.9631. The combined PLR, NLR, and DOR were 11.75 (95% CI 5.90-23.43), 0.12 (95% CI 0.07-0.20), and 100.06 (95% CI 37.48-267.10) respectively. There is potential presence of publication bias in this meta-analysis.

CONCLUSIONS

Our meta-analysis shows that EUS-guided biopsy is a powerful tool for differentiating pelvic masses with a high sensitivity and specificity. Furthermore, it is a safe procedure with low rate of complication, although more high-quality prospective studies are required to be done.

Usefulness of EUS-guided fine needle aspiration biopsy in the diagnosis of suspected or recurring lymphoproliferative disorders

BACKGROUND

EUS-guided fine needle aspiration biopsy (EUS-FNAB) of deep-seated lymphadenopathy is proposed to identify lymphoproliferative disorders when no superficial lesion is accessible.

METHODS

We analyzed prospectively collected data of 115 EUS-FNABs from 73 thoracic or abdomino-pelvic targets in 52 patients with suspected lymphoproliferative disorders (LPDs) between January 2005 and May 2011 from a single institution. Conventional histology and immunohistochemistry procedures were performed on samples.

RESULTS

No complications were recorded. An LPD was identified in 29 cases and ruled out in 21 cases. In 2 cases the analysis was negative, but an LPD was identified using a secondary procedure. For the identification of LPDs irrespective of subtype, this procedure has positive and negative predictive values of 100% and 91.3% respectively, with 93.6% sensitivity and 100% specificity. In 31 patients finally diagnosed with LPDs, an accurate diagnosis meeting the 2008 World Health Organization classification criteria was established in 21 (68%) cases, success being significantly associated with target size above 30 mm in multivariate analysis (odds ratio 7.47; p = 0.05).

CONCLUSION

EUS-FNAB of deep-seated lymphadenopathy with conventional morphological assessment appears to have a high diagnostic value for LPD identification and can obviate invasive surgery. A sub-classification was possible in two thirds of the cases.

Impact of endoscopic ultrasound-guided fine-needle aspiration and multidisciplinary approach in the management of abdominal or mediastinal mass

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a useful tool for the diagnosis of suspected abdominal or mediastinal neoplastic lesions.

AIM

To evaluate the impact of EUS-FNA and multidisciplinary approach on the diagnostic work-up and therapeutic management of patients with abdominal or mediastinal neoplastic lesions.

PATIENTS AND METHODS

One hundred and twenty patients (69 men, median age 65 years) with a suspected abdominal or mediastinal neoplastic mass at computed tomography or MRI underwent EUS-FNA. All EUS-FNA findings and clinical data were evaluated by a multidisciplinary team (oncologists, surgeons, and gastroenterologists). EUS-FNA findings were compared with the final diagnosis made by histological evaluation of the surgical specimen or clinical outcome at follow-up.

RESULTS

A correct diagnosis was obtained by EUS-FNA in 96/120 patients (80%), indicating benignancy of the lesion in 21 (18%) cases and confirming malignancy in 75 (62%). On the basis of EUS-FNA findings, chemotherapy was tailored in 57/75 (76%) patients with malignancy whereas the surgical strategy was changed in 21/120 (18%) of patients. Overall, the diagnostic accuracy of EUS-FNA was 85%. A multidisciplinary team approach enabled a correct diagnosis in patients in whom EUS-FNA was nondiagnostic and to identify five cases with false-negative EUS-FNA findings.

CONCLUSION

EUS-FNA has a relevant impact on the management of suspected abdominal or mediastinal neoplastic lesions. A multidisciplinary team approach enables to overcome the EUS-FNA methodological limitations. The combination of EUS-FNA and multidisciplinary team approach could help to diagnose and tailor therapeutic options in such patients.

Basic techniques in endoscopic ultrasound-guided fine needle aspiration for solid lesions: Adverse events and avoiding them

Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is often the preferred technique for tissue acquisition in the diagnosis of suspected intrathoracic and intraabdominal pathology. Although EUS FNA is a safe and accurate procedure, it has been associated with a low risk of adverse events. The unique properties of the echoendoscope and its ability to acquire tissue outside of the gastrointestinal lumen impart risks that are not associated with routine endoscopic procedures. In this review, we discuss the risk of perforation related to the echoendoscope itself and adverse events related to FNA of solid masses including infections, bleeding, pancreatitis and pancreatic duct leak, bile duct leak and tumor seeding. We also provide tips on how to avoid the most common adverse events related to EUS-FNA.

Prospective evaluation of adverse events following lower gastrointestinal tract EUS FNA

OBJECTIVES

There are virtually no data concerning the risk of adverse events (AEs) following lower gastrointestinal (LGI) endoscopic ultrasound (EUS). Our aim was to determine the incidence and factors associated with AEs following LGI EUS fine needle aspiration (FNA).

METHODS

We conducted a prospective cohort study at a tertiary referral center. Five hundred and sixty-three patients underwent LGI EUS FNA between 1 January 2004 and 1 January 2012. We analyzed the 502 patients who had complete follow-up. AE severity was graded (1-5) utilizing Common Terminology Criteria or Visual Analog Scale. AEs were assessed during the procedures, in clinical follow-up, during phone interviews conducted at 7-14 days, and final clinical and/or phone interviews at 2-4 months.

RESULTS

AEs developed in 103 (20.5%) patients and were classified as grade 1, 2, 3, or 4 in 34 (6.8%), 41 (8.2%), 23 (4.6%), and 5 (1.0%) patients, respectively. Bleeding and pain were the commonest AEs. No deaths occurred. On multivariate analysis, AEs were associated with prior pain (odds ratio (OR): 3.83, 95% confidence interval (CI): 2.35-6.25), FNA from a site other than a lymph node (LN) or gut wall (OR: 2.26, 95% CI: 1.10-4.70), and malignant FNA cytology (OR: 1.80, 95% CI: 1.10-2.97); serious (grade 3-4) AEs were associated with prior pain (OR: 15.21, 95% CI: 5.04-45.85) and FNA from a site other than a LN or gut wall (OR: 3.25, 95% CI: 1.15-9.20).

CONCLUSIONS

LGI EUS FNA is associated with a high rate of serious grades 3-4 AEs. This may reflect the total number of associated interventions and the frequency of underlying pathology and symptoms.

Beyond cytology: why and when does the oncologist require core tissue?

There are 2 main reasons why oncologists may require additional tissue and a histologic section in addition to cytopathology from FNA specimens: improved diagnostic accuracy and molecular characterization of tumors. Rather than mutually exclusive diagnostic procedures, EUS-FNA and EUS-CNB must be viewed as supplementary techniques and both approaches should be incorporated as essential tools in the current endoscopic armamentarium.

Techniques for endoscopic ultrasound-guided fine-needle biopsy

Although endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the method of choice to obtain samples to reach definitive diagnosis of lesions of the gastrointestinal tract and of adjacent organs, it cannot fully characterize certain neoplasms. The lack of cytology expertise has hindered the dissemination of EUS, limiting its widespread use. The obtainment of a tissue specimen through EUS fine-needle biopsy (EUS-FNB) may overcome the limitations of EUS-FNA. EUS-FNB is expected to move the practice of EUS from cytology to histology, expanding the use of EUS and facilitating targeted therapies and monitoring of treatment response in a more biologically driven manner.

Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications

Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.