High and low negative pressure suction techniques in EUS-guided fine-needle tissue acquisition by using 25-gauge needles: a multicenter, prospective, randomized, controlled trial

The history of endoscopic ultrasound-guided fine-needle aspiration: development and progress

Endoscopic ultrasonography (EUS) is an important diagnostic technique to accurately diagnose diseases originating from organs near the gastrointestinal tract. EUS-guided fine-needle aspiration (FNA) has improved the histopathological diagnosis. EUS-FNA has been further developed over a long period of 40 years. The history of the development of endosonographic scopes, ultrasonographic observation systems, puncture needles, and puncture methods will provide a springboard for future development.

Consensus statements on endoscopic ultrasound-guided tissue acquisition. Guidelines from the Asian Endoscopic Ultrasound Group

OBJECTIVES

This consensus was developed by the Asian EUS Group (AEG), who aimed to formulate a set of practice guidelines addressing various aspects of endoscopic ultrasound-guided tissue acquisition (EUS-TA).

METHODS

The AEG initiated the development of consensus statements and formed an expert panel comprising surgeons, gastroenterologists, and pathologists. Three online consensus meetings were conducted to consolidate the statements and votes. The statements were presented and discussed in the first two consensus meetings and revised according to comments. Final voting was conducted at a third consensus meeting. The Grading of Recommendations, Assessment, Development, and Evaluation system was adopted to define the strength of the recommendations and quality of evidence.

RESULTS

A total of 20 clinical questions and statements regarding EUS-TA were formulated. The committee recommended that fine-needle biopsy (FNB) needles be preferred over conventional fine-needle aspiration (FNA) needles for EUS-TA of subepithelial lesions. For solid pancreatic masses, rapid on-site evaluation is not routinely recommended when FNB needles are used. For dedicated FNB needles, fork-tip and Franseen-tip needles have essentially equivalent performance.

CONCLUSION

This consensus provides guidance for EUS-TA, thereby enhancing the quality of EUS-TA.

Role of Endoscopic Ultrasound in Diagnosis of Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is the most common (90%) type of solid pancreatic neoplasm. Due to its late presentation and poor survival rate, early diagnosis and timely treatment is of utmost importance for better clinical outcomes. Endoscopic ultrasound provides high-resolution images of the pancreas and has excellent sensitivity in the diagnosis of even small (<2 cm) pancreatic lesions. Apart from imaging, it also has an advantage of tissue acquisition (EUS fine-needle aspiration, FNA; or fine-needle biopsy, FNB) for definitive diagnoses. EUS-guided tissue acquisition plays a crucial role in genomic and molecular studies, which in today's era of personalized medicine, are likely to become important components of PDAC management. With the use of better needle designs and technical advancements, EUS has now become an indispensable tool in the management of PDAC. Lastly, artificial intelligence for the detection of pancreatic lesions and newer automated needles for tissue acquisition will obviate observer dependency in the near future, resulting in the wider dissemination and adoption of this technology for improved outcomes in patients with PDAC.

Comparing fine needle biopsy techniques in solid pancreatic lesions: A prospective randomized study

INTRODUCTION

Endoscopic ultrasound-guided fine-needle biopsies (EUS-FNB) are the best technique for sampling solid pancreatic lesions. However, the most appropriate biopsy technique has not been standardized using Fine Needle Biopsy (FNB) needles. The aim of this work was to identify the best biopsy technique to achieve the best tissue integrity and cause the least blood contamination.

MATERIAL AND METHODS

Patients ≥18 years of age with solid pancreatic lesions who underwent EUS-FNB at our institution from January 2020 to May 2021 were consecutively selected. Three passes were performed with each of the threee techniques to obtain tissue: suction with 10 ml of vacuum, capillary, and wet. An independent pathologist evaluated the received tissue integrity and the degree of blood contamination of each sample according to scales.

RESULTS

Seventy-five patients were recruited for our study. A superior tissue integrity was observed using the wet-suction technique in lesions located in the body and/or tail of the pancreas, and an average score of 4.40 (p = 0.027) was assigned for this technique. Regarding the contamination of the sample in the whole cohort, the simple-suction technique shown a higher contamination, 1.55 (p < 0.001). There was no statistically significant difference among the techniques when evaluating tissue integrity or contamination in lesions larger or smaller than 3 cm.

CONCLUSION

When performing EUS-FNB for solid pancreatic lesions located in the head/uncinated process, the three methods provided similar diagnostic yields. The wet-suction technique had a higher score in tissue integrity when lesions were located in the body and/or tail of the pancreas.

Twenty versus 40 back-and-forth needle movements for endoscopic ultrasound-guided fine-needle biopsy of solid pancreatic masses: a prospective, crossover, randomized study

BACKGROUND AND AIMS

In endoscopic ultrasound (EUS)-fine-needle biopsy (FNB) of solid pancreatic mass lesions, the number of times the needle moves back and forth within the lesion might affect the collection of the sample and the subsequent diagnostic accuracy. Thus, this study was designed to compare the diagnostic adequacy between different numbers of back-and-forth movements in EUS-FNB.

METHODS

Fifty-five patients with solid pancreatic masses underwent EUS-FNB sampling with the needle (22-gauge) moved 20 times (MTT) and 40 times (MFT) randomly and sequentially for a total of four alternating passes. We compared the acquisition rate of appropriate and adequate specimens for histologic assessment and diagnostic accuracy.

RESULTS

Finally, 55 patients (35 men and 20 women) were included in the study. We found that 56.4% (31/55) and 60% (33/55) of the specimens obtained using MTT and MFT, respectively, could be adequately diagnosed histologically (P = 0.815, McNemar test). The diagnostic accuracy of MTT and MFT was 72.7% (40/55) and 80% (44/55), respectively (P = 0.289, McNemar test). The overall diagnostic accuracy was 89.1%.

CONCLUSION

There was no significant statistical difference between the histopathological diagnostic samples obtained in MTT and those obtained in MFT. Therefore, a large number of back-and-forth movements of the needle should be avoided during EUS-FNB, which can help reduce the operation time and may reduce the risk of intraoperative and postoperative complications (Clinical trial registration number: ChiCTR2000031106).

The Wet Suction Technique Enhances the Diagnostic Efficacy and Aspirate Quality of EUS-FNA for Solid Lesions: A Multicenter Retrospective Study in China

GOALS

To comprehensively compare the wet suction technique with the conventional dry suction technique for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in solid lesions.

BACKGROUND

Optimal suction techniques for EUS-FNA remain uncertain when approaching solid lesions.

STUDY

We performed a retrospective study of EUS-FNA at 3 medical centers in China. A total of 203 patients were enrolled who received 2 passes of EUS-FNA with 22-G needles. If the first pass underwent dry suction, the second pass was wet suction. Otherwise, the order of suction technique is opposite. Diagnostic accuracy, sample quality (including cellularity and blood contamination), and sample quantity (including specimen adequacy, the maximum intact specimen length, and the total specimen length) were compared between wet-suction and dry-suction techniques.

RESULTS

The patients included 143 pancreatic lesions and 60 nonpancreatic lesions. Compared with the dry suction technique, the wet suction technique yielded a significantly higher diagnostic accuracy (85.22% vs. 72.41%, P =0.002), better specimen adequacy score and cellularity score ( P <0.0001), and lower blood contamination score ( P <0.0001). In the subgroup analysis, wet suction provided significantly higher diagnostic accuracy in pancreatic cancer without chronic pancreatitis ( P <0.05), and better cellularity score and specimen adequacy score, lower blood contamination score, and longer maximum intact specimen length and total specimen length in various lesions than that in dry suction.

CONCLUSIONS

The wet suction technique resulted in significantly higher diagnostic accuracy in pancreatic cancer without chronic pancreatitis, and better cellularity and histologic specimen in most of solid lesions.

Comprehensive review on endoscopic ultrasound-guided tissue acquisition techniques for solid pancreatic tumor

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030, a high mortality rate considering the number of cases. Surgery and chemotherapy are the main treatment options, but they are burdensome for patients. A clear histological diagnosis is needed to determine a treatment plan, and endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding. With the development of personalized medicine and precision treatment, there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure, leading to the development of the fine-needle biopsy (FNB) needle. EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration (FNA) as the procedure of choice for EUS-TA of pancreatic cancer. However, EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions, so it is important clinicians are familiar with both. Given these recent dev-elopments, we present an up-to-date review of the role of EUS-TA in pancreatic cancer. Particularly, technical aspects, such as needle caliber, negative pressure, and puncture methods, for obtaining an adequate specimen in EUS-TA are discussed.

Actual pressure generated by various suction technique and suctioning liquid weight through endoscopic ultrasound-guided aspiration needles

OBJECTIVES

Suction pressure is one of the most important factors influencing the amount of tissue obtained during endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB). In this study we aimed to elucidate actual suction pressure generated by various suction methods and the weight of suctioning liquid.

METHODS

Different types of fine needles and suction techniques were used, including the slow pull technique (SPT), dry suction technique (DST), wet suction technique (WST), neutralizing negative pressure technique (NNPT), and residual negative pressure technique (RNPT). Actual suction pressure was measured and the amount of suctioning liquid was weighed.

RESULTS

Actual suction pressure and weight of the suctioning liquid were lower using SPT than using DST, while they were higher when using WST compared with those using DST. In general, the actual suction pressure increased and the weight of suctioning liquid decreased as the diameter of the FNA needles decreased. While weight of the suctioning liquid using FNB needles was significantly larger than that using FNA needles. In general, the actual suction pressure generated using RNPT was larger than that using NNPT.

CONCLUSIONS

WST is superior to SPT and DST in terms of actual suction pressure and weight of suctioning liquid. Diameter of the FNA needle was an important factor that may affect the actual suction pressure and weight of suctioning liquid. FNB needles are superior to FNA needles when it comes to the weight of suctioning liquid. Actual suction pressure obtained by novel suction methods (NNPT and RNPT) may provide a basis for future research.

Historical perspective on needle development: From the past to the future

With the introduction of EUS, endoscopy was no longer limited to luminal indications. However, the method was unable to distinguish malignant from benign lesions. Consequently, needles designed for tissue acquisition under EUS-guidance was designed. Initially, the needles were designed for fine needle aspiration (FNA); nevertheless, with increased requirement for the precured tissue in terms of quality and quantity, newly design needles aimed at obtaining tissue cores for histological assessment were developed. Recent studies demonstrate superiority of these fine needle biopsy needles (FNB) compared to FNA needles.

Cumulative sum learning curves guiding multicenter multidisciplinary quality improvement of EUS-guided tissue acquisition of solid pancreatic lesions

Background and study aims  In this study, we evaluated the performance of community hospitals involved in the Dutch quality in endosonography team regarding yield of endoscopic ultrasound (EUS)-guided tissue acquisition (TA) of solid pancreatic lesions using cumulative sum (CUSUM) learning curves. The aims were to assess trends in quality over time and explore potential benefits of CUSUM as a feedback-tool. Patients and methods  All consecutive EUS-guided TA procedures for solid pancreatic lesions were registered in five community hospitals between 2015 and  2018. CUSUM learning curves were plotted for overall performance and for performance per center. The American Society of Gastrointestinal Endoscopy-defined key performance indicators, rate of adequate sample (RAS), and diagnostic yield of malignancy (DYM) were used for this purpose. Feedback regarding performance was provided on multiple occasions at regional interest group meetings during the study period. Results  A total of 431 EUS-guided TA procedures in 403 patients were included in this study. The overall and per center CUSUM curves for RAS improved over time. CUSUM curves for DYM revealed gradual improvement, reaching the predefined performance target (70 %) overall, and in three of five contributing centers in 2018. Analysis of a sudden downslope development in the CUSUM curve of DYM in one center revealed temporary absence of a senior cytopathologist to have had a temporary negative impact on performance. Conclusions  CUSUM-derived learning curves allow for assessment of best practices by comparison among peers in a multidisciplinary multicenter quality improvement initiative and proved to be a valuable and easy-to-interpret means to evaluate EUS performance over time.

Endoscopic ultrasound-guided pancreatic sampling for the histopathological diagnosis of autoimmune pancreatitis

Autoimmune pancreatitis (AIP), which is characterized by pancreatic enlargement and irregular narrowing of the main pancreatic duct, is difficult to differentiate from malignancy. The irregular narrowing of the pancreatic duct, which can be detected via endoscopic retrograde cholangiopancreatography, is a characteristic feature of AIP; however, distinguishing between localized AIP and pancreatic cancer based on pancreatic duct imaging is difficult. This study overviews the efficacy of endoscopic ultrasound (EUS)-guided pancreatic sampling for the histopathological diagnosis of AIP. Recent enhancements in needle biopsy methodologies and technologies have contributed to improvement in the diagnostic efficacy of this technique. The guidance provided in this study for the histological diagnosis of AIP is anticipated to further advance in the histopathological diagnosis of AIP using EUS-guided pancreatic sampling.

Independent risk factors for true malignancy in atypical cytologic diagnostic category in EUS-FNA/FNB of the pancreas: A novel prediction model

Background and Objects:

Methods:

Results:

Conclusions:

A comparison between 25-gauge and 22-gauge Franseen needles for endoscopic ultrasound-guided sampling of pancreatic and peripancreatic masses: a randomized non-inferiority study

BACKGROUND

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) and fine-needle biopsy (FNB) are the current standard of care for sampling pancreatic and peripancreatic masses. Recently, a 22G EUS-FNB needle with Franseen geometry was developed, and this device was also introduced in a 25G platform. We compared the performance of the 25G and 22G Franseen needles for EUS-guided sampling of pancreatic and peripancreatic solid masses.

METHODS

We conducted a parallel-group randomized non-inferiority trial at a tertiary-care center from November 2018 to May 2019. The primary outcome was the quality of the histologic core assessed using the Gerke score. The optimal histologic core is indicated by a Gerke score of 4 or 5, which enables optimal histologic interpretation. The overall diagnostic accuracy and adverse event rate were also evaluated.

RESULTS

140 patients were enrolled and randomized (1:1) to the 25G and 22G groups. Tissue acquisition by EUS-FNB was successful in all patients. The optimal histologic core procurement rate was 87.1 % (61/70) for the 25G needle vs. 97.1 % (68/70) for the 22G; difference -10 % (95 % confidence interval -17.35 % to -2.65 %). High quality specimens were more frequently obtained in the 22G group than in the 25G group (70.0 % [49/70] vs. 28.6 % [20 /70], respectively; P < 0.001). The overall diagnostic accuracy did not differ between the groups (97.4 % for 25G vs. 100 % for 22G).

CONCLUSIONS

The 25G Franseen needle was inferior to the 22G needle in histologic core procurement. Therefore, for cases in which tissue architecture is pivotal for diagnosis, a 22G needle, which procures relatively higher quality specimens than the 25G needle, should be used.

A case of pancreatic endocrine carcinoma with a different clinical diagnosis before chemotherapy and pathological autopsy

We encountered a case of pancreatic neuroendocrine carcinoma (pNEC) diagnosed via pathological autopsy that was initially diagnosed clinically as G3 pancreatic neuroendocrine tumor (G3 pNET) and discussed the differences between these entities in the literature. A 76-year-old man was admitted to our department because of jaundice. Computed tomography revealed multiple round nodules in both lung fields, suggesting metastasis, and a mass lesion was detected in the head of the pancreas with poor contrast in the arterial phase and slight contrast enhancement in the equilibrium phase. Biopsy of the lungs and pancreas led to a diagnosis of multiple pulmonary metastases of G3 pNET. Because the lesions were unresectable, chemotherapy was administered. Treatment was started with everolimus for 5 weeks. However, the patient experienced severe loss of appetite and malaise, and the lung lesions progressed, prompting treatment discontinuation. Subsequently, the patient's disease progressed rapidly, and he died 99 days after the start of chemotherapy. We performed a pathological autopsy with the consent of the family because of the rapid tumor growth. A pathological autopsy revealed a final diagnosis of pNEC, which differed from the clinical diagnosis.

Diagnostic value of IMP3 and p53 immunohistochemical staining in EUS-guided fine-needle aspiration for solid pancreatic tumors

We previously identified insulin-like growth factor-II messenger ribonucleic acid-binding protein 3 (IMP3) as a valuable marker to distinguish malignant from benign lesions in pancreatic solid masses. The aim of this prospective study was to evaluate the usefulness of IMP3 and p53 immunohistochemical staining in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) samples for pancreatic solid masses. The study recruited 90 consecutive patients with pancreatic masses, including 62 pancreatic ductal adenocarcinomas (PDACs), 11 benign tumors, and 17 other tumors, who underwent EUS-FNA, and conducted IMP3 and p53 immunohistochemical staining. The main outcome measurement was improved diagnostic utility using IMP3 and p53 immunohistochemical staining. IMP3 and p53 expressions were detected in 60.8% and 49.4% of malignant lesions, 69.4% and 58.1% of PDACs, and 0% of benign lesions, respectively. In PDAC and benign tumors, the use of IMP3 and/or p53 immunostaining increased the sensitivity of cytohistological analysis from 88.7 to 93.5%, although the difference was not statistically significant. The sensitivity of histological analysis combined with that of IMP3 staining was 91.9%, which was significantly greater than that of histology alone (80.6%). The use of IMP3 and p53 immunohistochemical staining did not significantly improve the sensitivity of cytohistological analysis; however, IMP3 staining may be helpful for the histological analysis of malignant pancreatic tumors.

[Clinical and Technical Guideline for Endoscopic Ultrasound-guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy]

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in eight categories intended to help physicians make evidence- based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.

A Meta-analysis of Slow Pull versus Suction for Endoscopic Ultrasound-Guided Tissue Acquisition

Background/Aims

Endoscopic ultrasound (EUS)-guided tissue acquisition is widely utilized as a diagnostic modality for intra-abdominal masses, but there remains debate regarding which suction technique, slow pull (SP) or conventional suction (CS), is better. A meta-analysis of reported studies was conducted to compare the diagnostic yields of SP and CS during EUS-guided tissue acquisition.

Methods

We conducted a systematic electronic search using MEDLINE/PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials to identify clinical studies comparing SP and CS. We meta-analyzed accuracy, sensitivity, blood contamination and cellularity using the random-effects model.

Results

A total of 17 studies (seven randomized controlled trials, four prospective studies, and six retrospective studies) with 1,616 cases were included in the analysis. Compared to CS, there was a trend toward better accuracy (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.97 to 2.27; p=0.07) and sensitivity (OR, 1.67; 95% CI, 0.95 to 2.93; p=0.08) with SP and a significantly lower rate of blood contamination (OR, 0.48; 95% CI, 0.33 to 0.69; p<0.01). However, there was no significant difference in cellularity between SP and CS, with an OR of 1.28 (95% CI, 0.68 to 2.40; p=0.45). When the use of a 25-gauge needle was analyzed, the accuracy and sensitivity of SP were significantly better than those of CS, with ORs of 4.81 (95% CI, 1.99 to 11.62; p<0.01) and 4.69 (95% CI, 1.93 to 11.40; p<0.01), respectively.

Conclusions

Compared to CS, SP appears to provide better accuracy and sensitivity in EUS-guided tissue acquisition, especially when a 25-gauge needle is used.

Comparative diagnostic accuracy of EUS needles in solid pancreatic masses: a network meta-analysis

Background and study aims  Endoscopic ultrasound (EUS)-guided tissue sampling is the standard of care for diagnosing solid pancreatic lesions. While many two-way comparisons between needle types have been made in randomized controlled trials (RCTs), it is unclear which size and type of needle offers the best probability of diagnosis. We therefore performed a network meta-analysis (NMA) to compare different sized and shaped needles to rank the diagnostic performance of each needle. Methods  We searched MEDLINE, EMBASE and Cochrane Library databases through August, 2020 for RCTs that compared the diagnostic accuracy of EUS fine-needle aspiration (FNA) and biopsy (FNB) needles in solid pancreatic masses. Using a random-effects NMA under the frequentist framework, RCTs were analyzed to identify the best needle type and sampling technique. Performance scores (P-scores) were used to rank the different needles based on pooled diagnostic accuracy. The NMA model was used to calculate pairwise relative risk (RR) with 95 % confidence intervals. Results  Review of 2577 studies yielded 29 RCTs for quantitative synthesis, comparing 13 different needle types. All 22G FNB needles had an RR > 1 compared to the reference 22G FNA (Cook) needle. The highest P-scores were seen with the 22G Medtronic FNB needle (0.9279), followed by the 22G Olympus FNB needle (0.8962) and the 22G Boston Scientific FNB needle (0.8739). Diagnostic accuracy was not significantly different between needles with or without suction. Conclusions  In comparison to FNA needles, FNB needles offer the highest diagnostic performance in sampling pancreatic masses, particularly with 22G FNB needles.

Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE)

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a task force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in eight categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice. (Gut Liver 2021;15:-374)

Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE)

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in 8 categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.

Randomized controlled trial comparing a conventional needle and a novel needle for endoscopic ultrasound (EUS)-guided histology of peripancreatic masses

INTRODUCTION

Cytological study of samples obtained by Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) allows for recognition of clear signs of malignant transformation. However, certain neoplasms can be difficult to diagnose without histological analysis. Recently, a novel EUS-guided fine needle biopsy (EUS-FNB) needle was developed to increase tissue acquisition. This study set out to investigate the usefulness of this novel EUS-FNB needle (NEFN) in terms of obtaining a proper histology compared with a conventional EUS-FNA needle (CEFN).

METHODS

This investigation was a prospective, single-blind, randomized study in a single academic hospital. Primary outcome was the acquisition rate of an appropriate and sufficient specimen for histologic assessment. Secondary outcomes were diagnostic yield of peripancreatic masses using a CEFN and a NEFN. Furthermore, we assessed the feasibility of determining K-ras mutation status according to needle type.

RESULTS

The study enrolled 56 consecutive patients. Technical success rates were 96.6% (28/29) for the CEFN and 100% (27/27) for the NEFN (P = 1.000). No complications occurred during or after the procedure in either needle group. An adequate sample for cytologic diagnosis was obtained in 89.7% (26/29) of patients in the CEFN group vs 96.3% (26/27) of patients in the NEFN group (P = .612). For histologic diagnosis, a sample with a biopsy adequacy score of 2 or more was obtained in 41.4% (12/29) of CEFN-acquired samples vs 88.9% (24/27) of NEFN-acquired samples (P < .001). K-ras mutation analysis using histologic specimens was possible in 13 (44.8%) CEFN-acquired samples and 25 (92.6%) of NEFN-acquired samples. This difference was significant (P < .001).

CONCLUSIONS

The present study suggests that the NEFN is an effective and reliable alternative compared to a CEFN in terms of tissue acquisition rate and quality of histologic sampling.

IS THE NEW PROCORE 20G DOUBLE FORWARD-BEVEL NEEDLE CAPABLE TO OBTAIN BETTER HISTOLOGICAL SAMPLES BY ENDOSCOPIC ULTRASOUND FOR DIAGNOSING SOLID PANCREATIC LESIONS?

BACKGROUND

Fine needle biopsy (FNB) histological samples by endoscopic ultrasound. It is important to obtain representative histological samples of solid biliopancreatic lesions without a clear indication for resection. The role of new needles in such task is yet to be determined.

AIM

To compare performance assessment between 20G double fine needle biopsy (FNB) and conventional 22G fine needle aspiration (FNA) needles for endoscopic ultrasound (EUS)-guided biopsy.

METHODS

This prospective study examined 20 patients who underwent the random puncture of solid pancreatic lesions with both needles and the analysis of tissue samples by a single pathologist.

RESULTS

The ProCore 20G FNB needle provided more adequate tissue samples (16 vs. 9, p=0.039) with better cellularity quantitative scores (11 vs. 5, p=0.002) and larger diameter of the histological sample (1.51±1.3 mm vs. 0.94±0.55 mm, p=0.032) than the 22G needle. The technical success, puncture difficulty, and sample bleeding were similar between groups. The sensitivity, specificity, and diagnostic accuracy were 88.9%, 100%, and 90% and 77.8%, 100%, and 78.9% for the 20G and 22G needles, respectively.

CONCLUSIONS

The samples obtained with the ProCore 20G FNB showed better histological parameters; although there was no difference in the diagnostic performance between the two needles, these findings may improve pathologist performance.

The usefulness of EUS-FNA with contrast-enhanced harmonic imaging of solid pancreatic lesions: A prospective study

BACKGROUND AND AIM

Few studies have investigated endoscopic ultrasound-guided fine-needle aspiration with contrast-enhanced harmonic imaging (EUS-FNA-CHI) for diagnosing and adequately sampling pancreatic lesions. This study aimed to investigate the efficacy of EUS-FNA-CHI compared with that of endoscopic ultrasound-guided fine-needle aspiration with fundamental B mode imaging (EUS-FNA-FBI) for diagnosing solid pancreatic lesions.

METHODS

Consecutive patients with solid pancreatic lesions were enrolled prospectively (UMIN 000024467). Only samples obtained during the first needle pass (EUS-FNA-FBI) and second needle pass (EUS-FNA-CHI) were used to compare the accuracy rate for diagnosing pancreatic lesions and rate of adequate sampling for histological evaluation. In patients with hypo-enhancing lesions on contrast-enhanced harmonic EUS (CH-EUS), subgroup analyses were performed. Patients were classified into those with a heterogeneous area in the whole lesion (whole group), those with a heterogeneous area with a non-enhancing area (non-enhancing group), and those with a heterogeneous area with a homogeneous area (homogeneous group).

RESULTS

Ninety-three patients were enrolled. Overall, the rates of adequate sampling and sensitivity were significantly higher with EUS-FNA-CHI than with EUS-FNA-FBI (84.9% vs 68.8%, P = 0.003 and 76.5% vs 58.8%, P = 0.011, respectively). The adequate sampling rate and sensitivity were significantly higher with EUS-FNA-CHI than with EUS-FNA-FBI when the mass was > 15 mm. In the non-enhancing and homogeneous groups, the adequate sampling rate and sensitivity were significantly higher with EUS-FNA-CHI than with EUS-FNA-FBI.

CONCLUSIONS

CH-EUS enables improved observation of pancreatic lesions and helps identify the target of EUS-FNA among different pathological areas of the lesions particularly of > 15 mm.

The Diagnosis of Autoimmune Pancreatitis Using Endoscopic Ultrasonography

Autoimmune pancreatitis (AIP) is characterized by enlargement of the pancreas and irregular narrowing of the main pancreatic duct. It is often associated with IgG4-related sclerosing cholangitis (IgG4-SC), in which the bile duct narrows. Although characteristic irregular narrowing of the pancreatic duct caused by endoscopic retrograde cholangiopancreatography is noted in AIP, it is difficult to differentiate between localized AIP and pancreatic carcinoma based on imaging of the pancreatic duct. While stenosis of the bile duct in IgG4-SC is characterized by longer-length stenosis than in cholangiocarcinoma, differentiation based on bile duct imaging alone is challenging. Endoscopic ultrasound (EUS) can characterize hypoechoic enlargement of the pancreas or bile duct wall thickening in AIP and IgG4-SC, and diagnosis using elastography and contrast-enhanced EUS are being evaluated. The utility of EUS-guided fine needle aspiration for the histological diagnosis of AIP has been reported and is expected to improve diagnostic performance for AIP. Findings in the bile duct wall from endoscopic retrograde cholangiopancreatography followed by intraductal ultrasonography are useful in differentiating IgG4-SC from cholangiocarcinoma. Diagnoses based on endoscopic ultrasonography play a central role in the diagnosis of AIP.

Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS-FNA) with Image Enhancement

Although endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is useful in the differential diagnosis of solid pancreatic lesions, lymph nodes, and liver lesions, inadequate sampling may result in an incorrect pathological diagnosis. The accuracy of EUS for the evaluation of pancreatobiliary lesions may be increased by image enhancement technologies, including contrast-enhanced harmonic (CH)-EUS and EUS-elastography. These methods can provide information that complement EUS-FNA for the diagnosis and staging of pancreatobiliary cancer, and can help to identify the EUS-FNA target, reducing the requirement for repeat FNA.

Tissue acquisition and pancreatic masses: Which needle and which acquisition technique should be used?

Background and study aims  Pancreatic cancer represents the fourth most common cause of cancer-related deaths in Western countries and the need of a low-risk investigation to obtain an accurate histopathological diagnosis has become increasingly pressing. Endoscopic ultrasonography (EUS) with fine-needle aspiration (FNA) is the standard method for obtaining samples from pancreatic masses. In recent years, there has been an increasing need to obtain histological specimens during EUS procedures, rather than cytological ones, to guide oncological treatment options, leading to the so-call "FNB concept." Different needles have been developed for fine-needle biopsy (FNB) in recent years, enabling acquisition of larger specimens on which to perform histological and molecular analyses. The aim of this narrative review was to assess the role of EUS-guided FNA and FNB in patients with pancreatic masses, and to identify which needle and which acquisition technique should be used to improve tissue acquisition.

Comparison of smear cytology and liquid-based cytology in EUS-guided FNA of pancreatic lesions: experience from a large tertiary center

BACKGROUND AND AIMS

Studies comparing the diagnostic efficacy of liquid-based cytology (LBC) and smear cytology (SC) of pancreatic tissue sampling obtained via EUS-guided FNA (EUS-FNA) are still insufficient, mainly because results were controversial. We compared the diagnostic efficiency of LBC and SC of EUS-FNA of pancreatic lesions in one of the largest tertiary hospitals in China.

METHODS

A retrospective database search (January 2015 to January 2019) was performed for patients who underwent EUS-FNA with both LBC and SC. Demographic, cytologic, and endosonographic data were collected from 819 patients; 514 cases met the inclusion criteria. Diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were compared. Rapid on-site evaluation was not available in all cases.

RESULTS

Three hundred eighty-five cases (74.90%) had confirmed malignancy, and 40 cases (7.78%) confirmed benign neoplasm. Adequate tissue sampling rates showed no significant difference between the 2 groups. The sensitivity, accuracy, and negative predictive value (NPV) of LBC were higher than those of SC with statistical significance (71.4% vs 55.1%, 76.1% vs 61.6%, and 40.6% vs 27.7%, respectively). The sensitivity, accuracy, and NPV of combined SC and LBC were higher than those of LBC alone with statistical significance (83.9% vs 71.4%, 86.5% vs 76.1%, and 56.8% vs 40.6%, respectively). Multivariate analysis revealed that pancreatic neck/body/tail lesions (P = .003), solid lesions (P < .001), 22-gauge needle size (P < .001), and number of needle passage >3 (P = .041) were associated with higher diagnostic sensitivity in all participants using LBC, whereas number of needle passage >3 (P = .017) was associated with higher diagnostic sensitivity using SC.

CONCLUSIONS

LBC was more accurate and sensitive than SC in EUS-FNA of pancreatic lesions with higher NPV when rapid on-site evaluation is unavailable. Pancreatic neck/body/tail lesions, solid lesions, 22-gauge needle, and more than 3 passes were associated with higher sensitivity when using LBC. Performing more than 3 passes is associated with higher sensitivity when using SC.

Comparison of the Diagnostic Yield of the Standard 22-Gauge Needle and the New 20-Gauge Forward-Bevel Core Biopsy Needle for Endoscopic Ultrasound-Guided Tissue Acquisition from Pancreatic Lesions

Background/Aims

To compare the diagnostic yield of 20-gauge forward-bevel core biopsy needle (CBN) and 22-gauge needle for endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of solid pancreatic masses.

Methods

The use of 20-gauge CBN was prospectively evaluated for 50 patients who underwent EUS-FNA from June 2016 to December 2016. Data were compared with those obtained by a retrospective study of 50 consecutive patients who underwent EUS-FNA using standard 22-gauge needles between December 2016 and April 2017. At least two punctures were performed for each patient; the sample from the first pass was used for cytology with or without histology and that from the second pass was used for histology. Sample quantity was evaluated using the sample obtained from the second pass.

Results

There was no significant difference in the diagnostic accuracy rate between the first and second passes (20-gauge CBN: 96% [48/50]; standard 22-gauge needle: 88% [44/50]). Samples >10× power fields in length were obtained from 90% (43/48) and 60% (30/50) of patients using the 20-gauge CBN and standard 22-gauge needle, respectively (p=0.01). Technical failure occurred for two patients with the 20-gauge CBN.

Conclusions

Diagnostic accuracy of the 20-gauge CBN was comparable to that of the 22-gauge needle. However, two passes with the 20-gauge CBN yielded a correct diagnosis for 100% of patients when technically feasible. Moreover, the 20-gauge CBN yielded core tissue for 90% patients, which was a performance superior to that of the 22-gauge needle.

Safety and efficacy of endoscopic ultrasound-guided fine needle aspiration for pancreatic masses: A prospective multicenter study

OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions has high diagnostic yield. However, few prospective multicenter studies have been performed. We performed a prospective cohort study to evaluate the efficacy and safety of EUS-FNA for diagnosis of solid pancreatic lesions.

METHODS

This prospective cohort study involved five hospitals in Japan. The primary outcome was sensitivity of EUS-FNA for diagnosing malignant lesions. We also evaluated parameters of diagnostic sufficiency and the safety of EUS-FNA.

RESULTS

In total, 246 patients were enrolled. The absolute values of the parameters evaluated showed no significant differences; however, the percentage changes in the white blood cell counts and C-reactive protein levels after examination were significantly higher, and the percentage change in hemoglobin concentrations was significantly lower. The minor and major complication rates at the time of puncture, 24 h, 7 days and 28 days were 4.1%, 2.8%, 1.6%, and 0.0%, respectively. The true complication rate was 1.2%. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 97.2%, 88.0%, 96.2%, 100%, and 81.4%, respectively.

CONCLUSIONS

EUS-FNA for solid pancreatic lesions has high diagnostic yield and is safe, consistent with previously studies.

EUS tissue acquisition: From A to B

EUS-guided tissue acquisition (EUS-TA) has made rapid development since its introduction in the early 1990s. The technique is widely accepted and invaluable for staging and diagnosis of a variety of upper gastrointestinal and mediastinal lesions. Fine-needle aspiration (FNA) has long been the gold standard, but due to its limitations such as the inability to retain stroma and associated cellular architecture, novel biopsy needles (FNB) were designed. Overall, FNA and FNB needles perform seemingly equally in terms of diagnostic accuracy, however, the second-generation FNB needles require less passes. The third-generation FNB needles (crown-cut needle types) seem to be preferable to FNA needles as well as to the second-generation FNB needles, when larger histological specimens and preserved tissue architecture are required. EUS-TA is constantly under development, and new applications of this technique include tumor risk stratification according to its genetic profile as well as minimally invasive creation of patient-derived organoids, hallmarks of personized medicine. It remains yet to be shown, whether these applications will lead to a decisive shift from aspiration to biopsy, i.e., from A to B.

Present and Future of Endoscopic Ultrasound-Guided Tissue Acquisition in Solid Pancreatic Tumors

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is a well-established method for pathological diagnosis of solid pancreatic neoplasm. It can be performed either as EUS-guided fine-needle aspiration (EUS-FNA) or EUS-guided fine-needle biopsy (EUSFNB). The incidence of adverse events related to EUS-TA is less than 1%. The factors that affect the diagnostic accuracy and specimen adequacy include the techniques used, type and size of the needle, competency of endosonographers, presence of cytopathologists/ cytotechnologists, and rapid on-site examination. EUS-TA may contribute to precision medicine through obtaining tissue samples for next-generation sequencing. The current status, several clinical issues for diagnostic yield and adverse events, and future perspectives of EUS-FNA/FNB for diagnosing pancreatic neoplasm have been discussed in this review article.

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.

The diagnostic quality of needle brain biopsy specimens obtained with different sampling methods - Experimental study

The aim is to examine whether brain tissue samples obtained through needle biopsy are better for histopathological evaluation when obtained with defined vacuum pressure, a novel needle rotation method, and using different needle type - Laitinen or Nashold. Moreover the paper aims to answer the question: Does vacuum and mechanical injury resulting from different sampling methods damage the tissue specimen challenging the diagnosis?. Eight hundred biopsy specimens from fresh swine brains were obtained using Nashold and Laitinen brain biopsy needles through inner cannula cutting or needle rotation sampling at vacuum pressure, from 0 to 0.06 MPa. The specimen weight and tissue quality for microscopic assessment were evaluated using the Mair score. Rising aspiration pressure increased the biopsy sample weight. Needle rotation delivered larger biopsy samples than the standard method. Laitinen provided larger samples than the Nashold needle, with the same sampling method or vacuum pressure. A higher histopathological diagnostic quality of tissue was obtained with the Laitinen needle than with Nashold, with higher vacuum pressure than lower pressure and finally with needle rotation than the standard method. No tissue damage caused by higher suction pressure or method of tissue separation was documented. Brain tissue samples obtained through needle biopsy are better for histopathological evaluation when obtained with higher vacuum pressure, a novel needle rotation method and with Laitinen needle. Higher suction pressure and sampling methods did not cause tissue damage.

Diagnostic efficacy of smear plus liquid-based cytology for EUS-FNA of solid pancreatic lesions: A propensity-matched study

Liquid-based cytology (LBC) is a thin-layer slide preparation procedure that was developed to overcome the cell crowding and contamination associated with smear cytology (SC). The present study compared diagnostic efficacy between SC alone and SC combined with LBC (SLBC) using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) samples of pancreatic lesions.We retrospectively analyzed data derived from 311 consecutive patients. Specimens obtained via EUS-FNA from 179 patients between December 2011 and May 2016 were analyzed by SC, and those obtained from 132 patients between June 2016 and October 2017 were analyzed by SLBC. The 2 groups were compared in terms of adequate sample rate, diagnostic accuracy, sensitivity, and specificity using propensity score matching.SC and SLBC were compared using propensity score-matching in 204 patients (n = 102 per group). The adequate sample rate did not differ significantly between SLBC (100%) and SC (99.0%, P = 1). Diagnostic sensitivity, negative predictive value and accuracy were better for SLBC than for SC in terms of cytological (93.2% vs 67.4%, 68.4% vs 23.1%, and 94.1% vs 69.6%, P < .01 each, respectively) and cytohistological (95.5% vs 81.5%, 76.5% vs 34.6%, and 96.1% vs 82.4%, P < .01, P = .02, and P < .01, respectively) analyses.SLBC improves the diagnostic efficacy of EUS-FNA for pancreatic lesions compared to LBC.

Establishment of pancreatic cancer cell lines with endoscopic ultrasound-guided biopsy via conditionally reprogrammed cell culture

Recent studies have identified the mutational landscape of pancreatic cancer and suggested tumor‐specific subtypes. However, the major hurdle against personalized treatment is the difficulty to obtain sufficient cancer tissues from most inoperable cases. We investigated whether patient‐derived conditionally reprogrammed cells (CRCs) can be constructed using a small piece of tumor tissue using endoscopic ultrasound (EUS)‐guided fine needle biopsy (FNB). Thirty patients with pancreatic solid mass (mean size, 34.6 mm) were enrolled prospectively. Among 22 patients who were diagnosed with pancreatic ductal adenocarcinoma, we established patient‐derived pancreatic cancer cell lines from eight patients (36.4%). Immunofluorescence colony staining for CRCs showed that the cytoplasm of cancer cells was clearly stained with anti‐cytokeratin 19 monoclonal antibody. In the soft agar colony formation assay, CRCs formed colonies compared with the negative control by day 15. In vivo, implanted CRCs showed tumor engraftment and hematoxylin and eosin staining showed pancreatic cancer ductal structure. All established CRCs showed a KRAS mutation. In conclusion, we established patient‐derived pancreatic cancer cell lines with a small tumor tissue obtained by EUS‐FNB. With in vitro drug sensitivity and genomic studies, established patient‐derived cell lines can be used in identification of new targets for diagnosis and treatment of pancreatic cancer.

Efficacy of 3 fine-needle biopsy techniques for suspected pancreatic malignancies in the absence of an on-site cytopathologist

BACKGROUND AND AIMS

EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) has a high diagnostic accuracy for pancreatic tumors. Most reports have focused on the diagnostic yield of cytology or histology; the ability of various FNA/B techniques to obtain an adequate mass of cells or tissue has rarely been investigated.

METHODS

Patients with suspected pancreatic malignancy underwent EUS-FNB using a 22-gauge ProCore needle by either the stylet slow-pull-back technique (group A), conventional negative suction after stylet removal (group B), or non-suction after stylet removal (group C) in the absence of an on-site cytopathologist. The adequacy of the 3 techniques based on the diagnostic yield, cellularity, blood contamination, and core-tissue acquisition was evaluated.

RESULTS

A total of 50 patients (27 males) were analyzed. The mean tumor size was 21 to 40 mm in 54%. The rate of a good or excellent proportion of cellularity was highest in group A compared with groups B and C (72% vs 60% vs 50%, P = .049). A >25% rate of blood contamination was more prevalent in group B (30% vs 42% vs 10%, P = .009). The rate of adequate core-tissue acquisition was not different (52% vs 34% vs 50%, P = .140). Based on the multivariate generalized estimation equation, the stylet slow-pull-back technique and a tumor size >40 mm were favorable factors for diagnostic adequacy.

CONCLUSIONS

The stylet slow-pull-back technique might enable acquisition of tissue and assessment of cellularity for the diagnosis of pancreatic tumors suspected to be malignant. (Clinical trial registration number: KCT0002190.).

Prospective, multicenter, observational study of tissue acquisition through EUS-guided fine-needle biopsy using a 25G Franseen needle

Background:

Recently, EUS-guided fine-needle biopsy (EUS-FNB) using a Franseen needle was developed for histological tissue acquisition. However, the yield of a 25G Franseen needle when acquiring histological core tissue has been unclear.

Patients and Methods:

We performed a prospective, multicenter, and observational cohort study that included 100 solid lesions scheduled for EUS-FNB using a 25G Franseen needle at eight centers in Hokkaido, Japan. Only EUS-FNB specimens acquired at the first pass were evaluated without a rapid on-site evaluation. The tissue acquisition rate, acquisition rate of an adequate specimen for histological assessment, the quality of tissue sample, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, and adverse events were evaluated.

Results:

We analyzed a total of 100 solid lesions in 100 patients. The patients were 57 males and 43 females with a median age of 70 years. The technical success rate was 100%. The tissue acquisition rate was 95.0%. The acquisition rate of an adequate specimen for histological assessment was 82.0%. The sensitivity, specificity, PPV, NPV, and diagnostic accuracy were 87.0%, 100%, 100%, 40.0%, and 88.0%, respectively. The adverse event rate was 1.0%, and it was reported in only one patient who had a moderate pancreatic fistula.

Conclusions:

EUS-FNB using the 25G Franseen needle was feasible, and adequate histological core tissue samples were acquired with this method.

Benefit of high negative pressure during endoscopic ultrasound-guided fine-needle aspiration with standard 22-gauge needles for pancreatic lesions: a retrospective comparative study

OBJECTIVES

Few studies are available on high negative pressure (HNP) during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). This study compared the diagnostic yield between HNP and normal negative pressure (NNP) during EUS-FNA for solid pancreatic masses.

METHODS

Consecutive patients with pancreatic masses who underwent EUS-FNA using a 22-G needle with either HNP or NNP for both the first and second passes were retrospectively examined for diagnostic yield. Rapid on-site evaluation (ROSE) was unavailable at our center. The main outcome measures were the number of passes, diagnostic accuracy and quantity of histological samples.

RESULTS

Two hundred patients underwent EUS-FNA (n = 97, HNP; n = 103, NNP) over a 22-month period. A significantly lower median number of passes was required for HNP than for NNP (2 vs. 3; p < .001). There was no significant difference in diagnostic accuracy between the two groups. The rate of obtaining a histological sample larger than a 10× power field in length was significantly higher for HNP than for NNP (76.4% vs. 59.6%; p = .0019). In the multivariate analysis, a large tumor size (>20 mm) and HNP were identified as factors influencing the acquisition of a larger histological sample.

CONCLUSIONS

There was no significant difference in diagnostic accuracy between HNP and NNP. HNP required fewer passes without ROSE and was related to the acquisition of a larger histological sample. HNP may be useful when few samples are available for EUS-FNA with NNP or a larger histological sample is needed.

Gross visual inspection by endosonographers during endoscopic ultrasound-guided fine needle aspiration

BACKGROUND/OBJECTIVES

A clear criterion for terminating endoscopic ultrasound fine needle aspiration (EUS-FNA) without rapid on-site evaluation (ROSE) has not been established. However, a possible solution includes gross visual inspection (GVI) of the sample obtained with EUS-FNA. We performed a retrospective study to elucidate the efficacy of GVI for the diagnostic yield of EUS-FNA.

METHODS

Patients who underwent EUS-FNA of a pancreatic mass using a standard 22-G needle from January 2017 to December 2017 were included in the study. At least two punctures were performed for each patient, and GVI was performed for each pass by endoscopists. The correlation between GVI and pathological findings were investigated per needle pass for the first two passes. Regarding GVI, we evaluated the presence of a visible core (with or without) and the sample quantity (large or small).

RESULTS

We evaluated 126 EUS-FNA specimens and analyzed 252 needle passes. A final diagnosis of malignancy was made for 119 patients (94%). Accuracy rates were 92.5% with a visible core and 70.0% without a visible core (p < 0.01), and 85.2% for large sample quantities and 70.2% for small sample quantities (p < 0.01). Univariate analysis indicated that the presence of a visible core and large sample quantity were associated with accuracy. Multivariate analysis indicated that only the presence of a visible core was significant.

CONCLUSIONS

GVI can predict the correct diagnosis when ROSE is unavailable. Evaluating the presence of a visible core is more sensitive than assessing the quantity of the sample obtained.

Immunohistochemical analysis of IMP3 and p53 expression in endoscopic ultrasound-guided fine needle aspiration and resected specimens of pancreatic diseases

BACKGROUND

Insulin-like growth factor II messenger ribonucleic acid-binding protein 3 (IMP3) is a valuable marker that distinguishes malignant from benign lesions and predicts prognosis.

METHODS

First, we evaluated IMP3 expression in 77 resected specimens of pancreatic ductal adenocarcinoma (PDAC), intraductal papillary mucinous neoplasm (IPMN), and chronic pancreatitis (CP). Eleven PDAC patients preoperatively underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Survival analysis of IMP3 and clinicopathological factors was performed. IMP3 and p53 expression was evaluated in another 127 EUS-FNA samples of solid pancreatic masses to compare the diagnostic value of routine and immunohistochemical staining.

RESULTS

IMP3 expression was detected in 72.3%, 50%, 20%, and 0% of PDAC, malignant IPMN, benign IPMN, and CP, respectively. Evaluation of IMP3 expression in EUS-FNA specimens coincided with that in resected specimens in 10 of 11. IMP3 expression correlated with tumor differentiation in PDAC samples (p = .006) and with poor prognosis through univariate analysis (p = .045). Tumor differentiation and lymph node metastasis were significantly associated with poor prognosis through multivariate analysis. In EUS-FNA specimens, the sensitivity, specificity, and accuracy of cytohistological analysis were 80.8%, 100%, and 85.0%, respectively. IMP3 and p53 expression were detected in 80.8% and 44.9% of malignant and 0% and 5% of benign lesions. Combined with IMP3 immunostaining, the sensitivity, specificity and accuracy of cytohistological analysis significantly increased to 87.9%, 100%, and 90.8% (p = .016), respectively. Meanwhile, p53 staining had no impact on the results.

CONCLUSIONS

IMP3 immunohistochemical staining can improve the diagnostic accuracy of EUS-FNA for malignant pancreatic tumors.

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.

Pathological and Molecular Aspects to Improve Endoscopic Ultrasonography-Guided Fine-Needle Aspiration From Solid Pancreatic Lesions

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been applied to pancreatic lesions since the 1990s, and its use is now widespread. Improvements in endoscopic devices and sampling techniques have resulted in excellent diagnostic ability for solid pancreatic lesions. However, clinical improvements alone are not responsible for it; pathological aspects have also played important roles. Rapid on-site evaluation minimizes endoscopic procedures, although its value at improving the diagnostic ratio is still debated. Diagnostic efficacy differs by sample preparations (direct smear, cytospin, liquid-based cytology, cell block, and biopsy) and by staining methods (Papanicoloau, Diff-Quik, hematoxylin-eosin, and Giemsa). Several immunocytochemistry protocols aid in diagnosing epithelial components with cytological atypia and in differentiating various tumor types. One cytopathology diagnostic system is telecytology, which uses transmitted digital images and enables real-time diagnosis of EUS-FNA samples by expert cytologists at remote locations. However, EUS-FNA samples are useful for more than just diagnoses, as molecular analysis of these samples allows the identification of prognostic markers, such as genetic alterations in K-ras and EGFR. Expression of drug-metabolizing enzymes, human equilibrative nucleoside transporter 1, correlates with the response to gemcitabine-based chemotherapy. These pathology efforts have enhanced the diagnostic efficacy of EUS-FNA, thereby leading to better outcomes for patients with pancreatic diseases.

An animal experimental study to assess the core tissue acquisition ability of endoscopic ultrasound-guided histology needles

Background and Objectives:

Acquisition of core tissue on endoscopic ultrasound (EUS)-guided fine-needle aspiration has been regarded as important for establishing an accurate histological diagnosis. Recently, a new 20-gauge histology needle with reverse bevel (ProCore needle) and a 22-gauge needle with 3 novel symmetric heels (Acquire needle) have been developed. The aims of this animal experimental study were to assess the core tissue acquisition (TA) abilities of these new histology needles by comparing them with those of conventional 22-gauge needles and to evaluate the efficacy of suction for these needles.

Materials and Methods:

Three experienced echoendoscopists performed EUS-guided TA with and without suction using 43 types of needles. The amount of obtained tissue specimens and blood contamination was assessed using a scoring system, and the weight of the obtained tissue specimens was measured using an electronic balance.

Results:

The mean amount of core tissue score of the Acquire 22-gauge needle or ProCore 20-gauge needle was significantly higher than that of the conventional 22-gauge needles (Acquire 22-gauge needle vs. conventional 22-gauge needles: P = 0.024; ProCore 20-gauge needle vs. conventional 22-gauge needles: P = 0.001). There was no significant difference in the mean amount of core tissue score between the Acquire 22-gauge needle and the ProCore 20-gauge needle (P = 0.296). In the Acquire 22-gauge needle and ProCore 20-gauge needle, there was no significant difference between the mean amount of core tissue score with suction and that without suction (3.7 ± 0.4 vs. 3.5 ± 0.4, P = 0.734) although blood contamination increased (2.3 ± 0.7 vs. 1.6 ± 0.3, P = 0.061).

Conclusion:

The TA abilities of the ProCore 20-gauge needle and Acquire 22-gauge needle were better than those of the conventional 22-gauge needles. The efficacy of suction for the ProCore 20-gauge needle and Acquire 22-gauge needle was limited.

Clinical impact of endoscopic ultrasonography on the management of neuroendocrine tumors: lights and shadows

The incidence of gastroenteropancreatic neuroendocrine neoplasms has increased in the recent decades. An extensive bibliographical search was performed in PubMed to identify guidelines and primary literature (retrospective and prospective studies, systematic reviews, case series) published mostly between year 1997 and June 2017, using both medical subject heading (MeSH) terms and free-language keywords about the accuracy and diagnostic and therapeutic role of endoscopic ultrasound in the context of gastro-entero-pancreatic neuroendocrine neoplasms. Endoscopic ultrasound is the modality of choice for diagnosing pancreatic neuroendocrine neoplasms and for the locoregional staging of gastric, duodenal, pancreatic and rectal neuroendocrine neoplasms; in particular, in the setting of pancreatic neuroendocrine neoplasms it has demonstrated higher accuracy in tumor detection than other imaging modalities. Furthermore, the possibility of tattooing pancreatic lesions by endoscopic ultrasound fine needle aspiration may help surgeons to locate the tumor and avoid any demolition surgery. Finally, endoscopic ultrasound-guided therapies have been proposed and used in several studies for patients unsuitable for surgery, with good results on the control of symptoms and the reduction of tumor burden.