Comparison of 22-gauge standard and Franseen needles in EUS-guided tissue acquisition for diagnosing solid pancreatic lesions: a multicenter randomized controlled trial

Endoscopic ultrasound-guided pancreatic core-needle/microforceps biopsy is a valuable diagnostic tool for pancreatic lesions: Experience from a large academic institution

OBJECTIVE

Endoscopic ultrasound (EUS)-guided, fine-needle core biopsy (FNB), and through-the-needle microforceps biopsy (TTNB) are latest tools for evaluating pancreatic lesions. We aim to provide subspecialty surgical pathologists' experience with EUS-FNB/TTNB in diagnosing pancreatic lesions at a large academic center.

METHODS

A 3-year review identified 101 EUS pancreatic specimens submitted for surgical pathology: 87 biopsy specimens (FNB = 58, TTNB = 29) and 14 fine-needle aspirations (FNAs). Diagnoses were compared with cytology and resection specimens when available.

RESULTS

Of the 101 cases, 10 had previous EUS-FNA cytology with inconclusive diagnoses. Rebiopsy with EUS-FNB/TTNB provided definitive diagnoses in 9 cases. Thirty-five cases (18 cystic and 17 solid lesions) had concurrent surgical pathology and cytology specimens. The diagnostic yield of EUS-FNB/TTNB biopsy specimens (69%) was significantly higher than that of cytology specimens (26%, P = .0017), as was the diagnostic accuracy (P = .0012). This diagnostic advantage was statistically significant in cystic lesions (FNB/TTNB [83.3%] vs cytology [16.7%] for achieving a specific diagnosis, P = .0002) but not in solid lesions (61.5% vs 46.2%, P = .6951). Only in 1 case did cytology (adenocarcinoma) provide a more definitive diagnosis than surgical pathology (high-grade dysplasia cannot exclude adenocarcinoma).

CONCLUSIONS

The EUS-FNB/TTNB methods complement EUS-FNA cytology in diagnosing pancreatic lesions, and they often outperforms concurrent cytology specimens, particularly in cystic lesions.

Evaluation of the 22G Franseen needle and 22G Lancet needle for endoscopic ultrasonography-guided tissue acquisition sampling in solid pancreatic lesions: Propensity score weighting

BACKGROUND AND AIM

Advantages of endoscopic ultrasonography-guided tissue acquisition (EUS-TA) using a Lancet and Franseen needles have been evaluated and compared. However, little is known about the performance of each needle in diagnostic methods such as cytology and histology or the amount of blood contamination associated with each needle. This study aimed to compare the diagnostic yield and amount of blood contamination between two needles in patients with solid pancreatic lesions.

METHODS

We collected data of consecutive patients who underwent first time EUS-TA of solid pancreatic lesions at Osaka Metropolitan University between Jan 2006 and Jan 2021 from the electronic medical records. We compared the main outcomes (histological diagnostic accuracy) between the Lancet and Franseen needle groups. The amounts of core tissue and blood contamination were evaluated using a scoring system. This retrospective comparative study was conducted at a single center.

RESULTS

A total of 315 patients were divided into the Lancet (n = 200) and Franseen needle group (n = 115). The histological sensitivity and histological diagnostic accuracy of the Franseen needle was higher than that of Lancet needle (82.4% vs. 59.8%, respectively; odds ratio [OR], 2.29; 95% confidence interval [CI], 1.21-4.35; p = 0.011). Multivariate analysis using inverse probability of treat weighting method revealed that the diagnostic performance of the Franseen needle was the significantly higher than the Lancet needle (OR, 2.74; 95% CI, 1.31-5.74; p = 0.007). The core tissue score of 4 was achieved in 53.3% of the Franseen group and 3.3% of the Lancet group (p < 0.001), while high blood contamination was observed in 53.3% and 40%, respectively (p = 0.089).

CONCLUSION

The histological accuracy and the amount of tissue by the Franseen needle are higher than those of the Lancet needle. Franseen needle could achieve high histological diagnostic accuracy even with the same blood contamination rate as that in Lancet needle.

Adverse events of 20-22G second-generation endoscopic ultrasound-guided fine-needle biopsy needles for solid lesions in the upper gastrointestinal tract and adjacent organs: Systematic review and meta-analysis

OBJECTIVES

Previous research has conducted meta-analyses on the diagnostic accuracy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB). However, studies on adverse events (AEs) have been limited and sporadic and have included a highly diverse group of patients (with upper and lower gastrointestinal tract issues) and needles of varying sizes (19-22-25G). The purpose of this systematic review and meta-analysis was to determine the incidence of AEs related to the utilization of 20-22G second-generation EUS-FNB needles subsequent to puncture of the upper gastrointestinal tract and adjacent organs.

METHODS

We searched the PubMed, Embase, and SCIE databases from January 1, 2010, to December 31, 2023. The primary outcome was percentage of summary AEs. Subgroup analyses were based on needle type, needle size, and lesion site.

RESULTS

A total of 99 studies were included in the analysis, with 9303 patients. The overall AE rate for 20-22G second generation EUS-FNB needles in upper gastrointestinal EUS-FNB was 1.8% (166/9303), with bleeding being the most common AE at 44.0%. The percentages of pancreatitis, abdominal pain, and other AEs were 24.1%, 21.1%, and 10.8%, respectively. Patients undergoing hepatic EUS-FNB had the highest incidence of AEs at 14.0%, followed by submucosal lesions at 3.2% and pancreatic lesions at 2.6%.

CONCLUSION

EUS-FNB is a safe procedure with a relatively low risk of upper gastrointestinal AEs (1.8%) and no associated deaths. Postoperative bleeding and pancreatitis are the most common complications of EUS-FNB. Most AEs are mild and self-limiting in severity, and serious complications are very rare.

Endoscopic ultrasound-guided tissue sampling: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

This Technical and Technology Review from the European Society of Gastrointestinal Endoscopy (ESGE) represents an update of the previous document on the technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including the available types of needle, technical aspects of tissue sampling, new devices, and specimen handling and processing. Among the most important new recommendations are:ESGE recommends end-cutting fine-needle biopsy (FNB) needles over reverse-bevel FNB or fine-needle aspiration (FNA) needles for tissue sampling of solid pancreatic lesions; FNA may still have a role when rapid on-site evaluation (ROSE) is available.ESGE recommends EUS-FNB or mucosal incision-assisted biopsy (MIAB) equally for tissue sampling of subepithelial lesions ≥20 mm in size. MIAB could represent the first choice for smaller lesions (<20 mm) if proper expertise is available.ESGE does not recommend the use of antibiotic prophylaxis before EUS-guided tissue sampling of solid masses and EUS-FNA of pancreatic cystic lesions.

Updated techniques and evidence for endoscopic ultrasound-guided tissue acquisition from solid pancreatic lesions

Endoscopic ultrasound-guided tissue acquisition (EUS-TA), including fine-needle aspiration (EUS-FNA) and fine-needle biopsy (EUS-FNB), has revolutionized specimen collection from intra-abdominal organs, especially the pancreas. Advances in personalized medicine and more precise treatment have increased demands to collect specimens with higher cell counts, while preserving tissue structure, leading to the development of EUS-FNB needles. EUS-FNB has generally replaced EUS-FNA as the procedure of choice for EUS-TA of pancreatic cancer. Various techniques have been tested for their ability to enhance the diagnostic performance of EUS-TA, including multiple methods of sampling at the time of puncture, on-site specimen evaluation, and specimen processing. In addition, advances in next-generation sequencing have made comprehensive genomic profiling of EUS-TA samples feasible in routine clinical practice. The present review describes updates in EUS-TA sampling techniques of pancreatic lesions, as well as methods for their evaluation.

Dry Suction Versus Wet Suction of Endoscopic Ultrasound-Guided Fine-Needle Biopsy for Diagnosis of Solid Pancreatic Lesions: A Multicenter Randomized Controlled Noninferiority Trial

INTRODUCTION

Conclusions regarding the suction techniques of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) remain controversial. This study aimed to compare the diagnostic accuracy of the dry suction vs wet suction technique in solid pancreatic lesions (SPLs) and determine the optimal number of passes for EUS-FNB.

METHODS

This investigation was conducted as a multicenter, randomized, controlled, noninferiority trial. Patients with SPLs were randomly allocated to receive either the dry or wet suction technique. The primary outcome was diagnostic accuracy. The secondary outcomes included sensitivity, specificity, optimal number of needle passes, specimen quality, procedure time, and adverse events.

RESULTS

Of the 200 patients, 193 were included in the final analysis, with 96 in the dry suction group and 97 in the wet suction group. The diagnostic accuracies were 97.92% and 96.91% in the dry and wet groups, respectively, with a 1.01% difference between the study groups (2-sided 95% CI, -3.47% to 5.48%, P = 0.659). The overall adverse event rate was 2.6%. No significant differences were observed in sample adequacy (98.9% vs 98.9%, P = 1) or blood contamination ( P = 0.796). Regarding procedure time, there was no statistical difference (18.68 ± 8.03 minutes vs 19.36 ± 8.89 minutes, P = 0.626); however, more procedural steps were required in the wet suction technique. No significant difference was found between the cumulative diagnostic accuracy of each needle (first pass 93.78% vs second pass 95.34% vs third pass 97.41%, P = 0.225).

DISCUSSION

The dry suction technique is noninferior to the wet suction technique for EUS-FNB in SPLs. In the absence of rapid on-site evaluation, only one pass was required to achieve more than 90% diagnostic accuracy ( ClinicalTrial.gov number NCT05549856).

The correlation between tumoral CD8 expression and clinical course in patients with unresectable pancreatic cancer using tissue samples acquired by endoscopic ultrasound-guided tissue acquisition

BACKGROUND

The aim of this study was to evaluate the correlation between tumoral CD8 expression and the clinical course in patients with unresectable pancreatic ductal adenocarcinoma (PDAC) using tissue samples acquired by endoscopic ultrasound-guided tissue acquisition (EUS-TA).

METHODS

Patients with unresectable PDAC who underwent EUS-TA prior to treatment between September 2017 and October 2021 were included. The localization of the CD8-positive areas was qualitatively evaluated. We divided the patients into high and low groups based on the median percentage of CD8-positive areas. The correlation between the number of CD8-positive areas and overall survival was assessed. Furthermore, the response to chemotherapy was assessed in patients who underwent chemotherapy.

RESULTS

A total of 169 patients were included in the analysis. The median overall survival was 171 days (95% confidence interval [CI]: 86-401). The median CD8-positive area was 0.10% (95% CI: 0.05-0.26). The median overall survival in the high (≥0.1%) and low (<0.1%) CD8-positive groups were 156 and 213.5 days, respectively (p = .33). The number of CD8-positive areas was not correlated with the overall survival and response to chemotherapy (p = .69).

CONCLUSIONS

Tissue samples acquired using EUS-TA from patients with unresectable PDAC showed that CD8 expression did not affect the clinical course of patients.

Optimal tissue acquisition method for pancreatic mass

Pancreatic masses pose a diagnostic difficulty due to the technical complexities related to tissue acquisition. Endoscopic ultrasound (EUS)-guided tissue acquisition has transformed the field by allowing access to pancreatic lesions through fine-needle and biopsy. However, diagnostic accuracy differs based on tumor characteristics and procedural factors. This narrative review explores the nuances of tissue acquisition methods for pancreatic tumors, including factors such as tumor location, size, histological characteristics, and needle selection. It assesses the efficacy of different needle designs and maneuvers, including suction techniques and needle passes. Moreover, the diverse tissue preparation methods, including cytological smear, cell block, and direct histology, are discussed, highlighting the importance of tailored approaches based on tumor characteristics. Additionally, the roles of macroscopic on-site evaluation and rapid on-site evaluation in optimizing specimen adequacy are investigated. Furthermore, percutaneous ultrasound-guided biopsy is considered an alternative approach, particularly in settings where EUS is impractical. Additionally, the review emphasizes the emerging trend of using tissue for genetic testing and molecular analysis, requiring high-quality sample acquisition. Future directions in tissue acquisition techniques and their integration into clinical practice are discussed, providing promising avenues for pancreatic disease diagnosis and treatment.

Role of Liquid-Based Cytology in the Endoscopic Diagnosis of Pancreatic Ductal Adenocarcinoma

Recently, endoscopic ultrasound-guided tissue acquisition (EUS-TA) has been widely used to diagnose pancreatic ductal adenocarcinoma (PDAC). The histological examination of core tissues acquired using novel biopsy needles is the primary diagnostic approach for patients with PDAC. However, in patients with early-stage PDAC, such as Stages 0 and I, EUS-TA can be challenging, and its diagnostic accuracy may be limited. This presents a clinical dilemma: The earlier that clinicians attempt to accurately diagnose PDAC, the more difficult it becomes to do so using EUS-TA. Liquid-based cytology (LBC) is a technique for preparing pathological specimens from liquefied cytology specimens by placing the collected material in a special fixative preservative fluid. LBC offers advantages, such as specimen optimization with reduced blood interference, a high cell-collection rate, and the simplicity of the procedure in the endoscopy room. The use of LBC may improve diagnostic accuracy, particularly for early-stage PDAC. Therefore, we emphasize that cytology remains a valuable tool for the endoscopic diagnosis of PDAC. In this review, we discuss the role of LBC in the endoscopic diagnosis of PDAC.

Effect of the number of passes on diagnostic performance of EUS fine-needle biopsy of solid pancreatic masses: a systematic review and meta-analysis

BACKGROUND AND AIMS

The optimal number of passes to maximize the diagnostic ability of EUS fine-needle biopsy (FNB) of solid pancreatic masses (SPMs) is not well known. We conducted a systematic review to evaluate the impact of the incremental number of passes on diagnostic accuracy, tissue adequacy, and diagnostic yield for EUS-FNB of SPMs.

METHODS

We searched MEDLINE, Embase, Scopus, and Cochrane Central for randomized controlled trials comparing per-pass diagnostic outcomes of FNB needles in patients with SPMs. Meta-analysis was conducted using random-effects models. A separate analysis was performed on studies that used contemporary Franseen and fork-tip needles.

RESULTS

Overall, 19 randomized controlled trials (N = 3552) were identified. For EUS-FNB of SPMs, 3 passes with any FNB needle outperformed 2 passes for accuracy (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.20-2.09; I2 = 0%), adequacy (OR, 1.97; 95% CI, 1.30-2.83; I2 = 61%), and yield (OR, 2.12; 95% CI, 1.37-3.27; I2 = 14%). Adding a fourth or fifth pass resulted in no significant improvement in diagnostic parameters. When using contemporary FNB needles, adding a second to a single pass significantly improved accuracy (OR, 1.80; 95% CI, 1.23-2.63; I2 = 0%), adequacy (OR, 2.19; 95% CI, 1.65-2.90; I2 = 0%), and yield (OR, 2.72; 95% CI, 1.50-4.95; I2 = 0%). Adding a third pass to a second pass with contemporary needles improved adequacy (OR, 2.96; 95% CI, 1.97-4.46; I2 = 0%) but did not provide better diagnostic accuracy or yield.

CONCLUSIONS

Two passes with Franseen or fork-tip needles and 3 passes with any FNB needle suffice to provide optimal diagnostic performance for EUS-FNB of SPMs, without additional diagnostic benefits with more passes. Our results can inform future guidelines and quality benchmarks.

Endoscopic Ultrasound and Intraductal Ultrasound in the Diagnosis of Biliary Tract Diseases: A Narrative Review

Endoscopic ultrasound (EUS) and intraductal ultrasound (IDUS) play very important roles in the field of biliary tract disease. Because of their excellent spatial resolution, the detection of small lesions and T- or N-staging of tumors have become possible. Additionally, contrast-enhanced EUS and the new imaging technique of detective flow imaging are reported to be useful for differential diagnosis. Furthermore, EUS-guided tissue acquisition is used not only for pathological diagnosis but also to collect tissue samples for cancer genome profiling. This review provides an overview of diagnosis utilizing the features and techniques of EUS and IDUS.

Endoscopic ultrasound-guided radiofrequency ablation of pancreatic tumors

PURPOSE OF REVIEW

Surgery is a cornerstone in the management of pancreatic cancer and precancerous pancreatic lesions. However, many patients are not suitable candidates for surgery at the time of diagnosis for various reasons. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) appears to be a promising treatment option for patients who are ineligible for surgery for management of pancreatic adenocarcinoma (PDAC), and pancreatic neuroendocrine tumors (PNETs), and pancreatic cystic lesions (PCLs).

RECENT FINDINGS

EUS-RFA may serve as an adjunct to chemotherapy or palliative measures for inoperable cases of PDAC. Given its feasibility and efficacy, EUS-RFA has an evolving niche as a minimally invasive and potentially definitive treatment for PNETs and high-risk PCLs such as intraductal papillary mucinous neoplasms (IPMNs). EUS-RFA is a generally well tolerated procedure, with abdominal pain and acute pancreatitis being the most common adverse effects, though the risk can be mitigated through prophylactic measures.

SUMMARY

There is an increasing body of evidence to support the use of EUS-RFA in managing pancreatic lesions, either as definitive, adjunctive, or palliative treatment, depending on lesion type.

Comparison of 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma using endoscopic ultrasound fine-needle aspiration

BACKGROUND/AIMS

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using a 19-gauge needle is an efficient sampling method for the diagnosis of lymphadenopathy. This study compared 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma (ML).

METHODS

Patient characteristics, number of needle passes, puncture route, sensitivity, specificity, and accuracy of cytology/histology for lymphadenopathy were analyzed in patients diagnosed with lymphadenopathy by EUS-FNA using conventional or Franseen needles.

RESULTS

Between 2012 and 2022, 146 patients met the inclusion criteria (conventional [n=70] and Franseen [n=76]). The median number of needle passes was significantly lower in the conventional group than in the Franseen group (3 [1-6] vs. 4 [1-6], p=0.023). There were no significant differences in cytological/histological diagnoses between the two groups. For ML, the immunohistochemical evaluation rate, sensitivity of flow cytometry, and cytogenetic assessment were not significantly different in either group. Bleeding as adverse events (AEs) were observed in three patients in the Franseen group.

CONCLUSIONS

Both the 19-gauge conventional and Franseen needles showed high accuracy in lymphadenopathy and ML classification. Considering sufficient tissue collection and the avoidance of AEs, the use of 19-gauge conventional needles seems to be a good option for the diagnosis of lymphadenopathy.

Cutting edge of endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic lesions

This article provides an extensive review of the advancements and future perspectives related to endoscopic ultrasound-guided tissue acquisition (EUS-TA) for the diagnosis of solid pancreatic lesions (SPLs). EUS-TA, including fine-needle aspiration (EUS-FNA) and fine-needle biopsy (EUS-FNB), has revolutionized the collection of specimens from intra-abdominal organs, including the pancreas. Improvements in the design of needles, collection methods, and specimen processing techniques have improved the diagnostic performance. This review highlights the latest findings regarding needle evolution, actuation number, sampling methods, specimen evaluation techniques, application of artificial intelligence (AI) for diagnostic purposes, and use of comprehensive genomic profiling (CGP). It acknowledges the rising use of Franseen and fork-tip needles for EUS-FNB and emphasizes that the optimal number of actuations requires further study. Methods such as the door-knocking and fanning techniques have shown promise for increasing diagnostic performance. Macroscopic on-site evaluation (MOSE) is presented as a practical rapid specimen evaluation method, and the integration of AI is identified as a potentially impactful development. The study also underscores the importance of optimal sampling for CGP, which can enhance the precision of cancer treatment. Ongoing research and technological innovations will further improve the accuracy and efficacy of EUS-TA.

Methotrexate-associated lymphoproliferative disorder: A rare pancreatic tumor diagnosed via endoscopic ultrasound-guided fine-needle biopsy

A 73-year-old woman with a history of rheumatoid arthritis treated with methotrexate (MTX) for the last 10 years was referred to our hospital for a pancreatic tumor examination. Contrast-enhanced abdominal computed tomography revealed a 20-mm-diameter hypovascular tumor in the pancreatic tail. A hypoechoic mass with heterogeneous internal echo was found on an endoscopic ultrasound (EUS). An EUS-guided fine-needle biopsy (EUS-FNB) was performed with a 22-gauge Franseen-tip needle. Histologic examination of EUS-FNB specimens from the pancreatic tumor revealed the proliferation of atypical spindle cells. Immunohistochemical staining for CD20 and Ki-67 was positive in the atypical cells. Immunohistochemical staining for CD3 was partially positive in the atypical cells. Epstein-Barr virus-encoded RNA in situ hybridization showed positive staining. MTX-related lymphoproliferative disorder (MTX-LPD) with Epstein-Barr virus infection was diagnosed. MTX treatment was immediately discontinued, and treatment was initiated by a hematologist. However, her condition rapidly deteriorated, and she died of multiple organ failure 4 weeks after diagnosis. MTX-LPD can complicate gastrointestinal lesions. However, most lesions are localized in the stomach and rarely complicate pancreatic lesions. MTX-LPD is classified as an "iatrogenic" LPD. Therefore, immediate action, such as MTX discontinuation, is necessary. In conclusion, endoscopists should be aware that MTX-LPD lesions can occur in the pancreas and gastrointestinal tract. Moreover, EUS-FNB can be useful in the diagnosis of this rare pancreatic tumor.

Comprehensive review of pancreatic acinar cell carcinoma: epidemiology, diagnosis, molecular features and treatment

Pancreatic acinar cell carcinoma is a rare form (0.2-4.3%) of pancreatic neoplasm with unique clinical and molecular characteristics, which largely differ from pancreatic ductal adenocarcinoma. Pancreatic acinar cell carcinoma occurs more frequently in males and can occur in children. Serum lipase is elevated in 24-58% of patients with pancreatic acinar cell carcinoma. Pancreatic acinar cell carcinomas tend to be large at diagnosis (median tumour size: ~5 cm) and are frequently located in the pancreas head. Radiologically, pancreatic acinar cell carcinoma generally exhibits a solid appearance; however, necrosis, cystic changes and intratumoral haemorrhage can occur in larger lesions. Immunostaining is essential for the definitive diagnosis of pancreatic acinar cell carcinoma. Compared with pancreatic ductal adenocarcinoma, pancreatic acinar cell carcinoma has a more favourable prognosis. Although radical surgery is recommended for patients with pancreatic acinar cell carcinoma who do not have distant metastases, the recurrence rate is high. The effectiveness of adjuvant therapy for pancreatic acinar cell carcinoma is unclear. The response to FOLFIRINOX is generally favourable, and some patients achieve a complete response. Pancreatic acinar cell carcinoma has a different genomic profile compared with pancreatic ductal adenocarcinoma. Although genomic analyses have shown that pancreatic acinar cell carcinoma rarely has KRAS, TP53 and CDKN2A mutations, it has a higher prevalence of homologous recombination-related genes, including BRCA1/2 and ATM, than pancreatic ductal adenocarcinoma, suggesting high sensitivity to platinum-containing regimens and PARP inhibitors. Targeted therapies for genomic alternations are beneficial. Therefore, genetic testing is important for patients with pancreatic acinar cell carcinoma to choose the optimal therapeutic strategy.

22-gauge Co-Cr versus stainless-steel Franseen needles for endoscopic ultrasound-guided tissue acquisition in patients with solid pancreatic lesions

BACKGROUND/AIMS

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) using Franseen needles is reportedly useful for its high diagnostic yield. This study compared the diagnostic yield and puncturing ability of EUS-TA using 22-gauge cobalt-chromium (CO-Cr) needles with those of stainless-steel Franseen needles in patients with solid pancreatic lesions.

METHODS

Outcomes were compared between the 22-gauge Co-Cr Franseen needle (December 2019 to November 2020; group C) and stainless-steel needle (November 2020 to May 2022; group S).

RESULTS

A total of 155 patients (group C, 75; group S, 80) were eligible. The diagnostic accuracy was 92.0% in group C and 96.3% in group S with no significant intergroup differences (p=0.32). The rate of change in the operator (from training fellows to experts) was 20.0% (15/75) in group C and 7.5% (6/80) in group S. Stainless-steel Franseen needles showed less inter-operator difference than Co-Cr needles (p=0.03).

CONCLUSION

Both Co-Cr and stainless-steel Franseen needles showed high diagnostic ability. Stainless-steel Franseen needles are soft and flexible; therefore, the range of puncture angles can be widely adjusted, making them suitable for training fellows to complete the procedure.

K-ras gene mutation analysis to diagnosis pancreatic adenocarcinoma from endoscopic ultrasound-guided tissue acquisition; a systematic review and meta-analysis

BACKGROUND

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has high sensitivity for the pathological diagnosis of pancreatic masses, but also a high false-negative rate. K-ras gene mutations occur in over 75 % of pancreatic ductal adenocarcinomas (PDAC), and this meta-analysis evaluated the utility of detecting K-ras gene mutations from EUS-TA specimens for the diagnosis of PDAC.

METHODS

Relevant studies in PubMed, the Cochrane Library, and Web of Science were systematically searched. Meta-analysis was performed on data from the selected studies using a bivariate model to provide pooled values of sensitivity, specificity, and their 95 % confidence intervals (CIs).

RESULTS

This meta-analysis included 1521 patients (from 10 eligible studies) who underwent EUS-TA with K-ras gene mutation analysis for diagnosis of pancreatic solid masses. The pooled estimates of sensitivity and specificity were 76.6 % (95 % CI, 70.9-81.5 %) and 97.0 % (95 % CI, 94.0-98.5 %), respectively, for pathological diagnosis, 75.9 % (95 % CI 69.5-81.4 %) and 95.3 % (95 % CI, 92.3-97.2 %) for K-ras gene mutation analysis, and 88.7 % (95 % CI 87.1-91.7 %) and 94.9 % (95 % CI, 91.5-97.0 %) for pathological diagnosis in combination with K-ras gene mutation analysis. The sensitivity for diagnosis of PDAC was significantly higher for pathological diagnosis in combination with K-ras gene mutation analysis than for pathological diagnosis or K-ras gene mutation analysis alone (both, p < 0.001). There was no difference in specificity between pathological diagnosis in combination with K-ras gene mutation analysis and both either (p = 0.234, 0.945, respectively).

CONCLUSIONS

K-ras gene mutation analysis in combination with to pathological diagnosis of EUS-TA increases the accuracy of differential diagnosis of PDAC.

Therapeutic Endoscopic Ultrasound for Complications of Pancreatic Cancer

Progression of pancreatic adenocarcinoma can result in disease complications such as biliary obstruction and gastric outlet obstruction. The recent advances in endoscopic ultrasound (EUS) have transformed EUS from a purely diagnostic technology to a therapeutic modality, particularly with the development of lumen-apposing metal stents. In terms of biliary drainage, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy offer safe and effective techniques when conventional transpapillary stent placement via ERCP fails or is not possible. If these modalities are not feasible, EUS-guided gallbladder drainage offers yet another salvage technique when the cystic duct is non-involved by the cancer. Lastly, EUS-guided gastroenterostomy allows for an effective bypass treatment for cases of gastric outlet obstruction that enables patients to resume eating within several days. Future randomized studies comparing these techniques to current standard-of-care options are warranted to firmly establish therapeutic EUS procedures within the treatment algorithm for this challenging disease.

Dry suction versus wet suction technique of endoscopic ultrasound-guided fine-needle biopsy for diagnosis of solid pancreatic lesions: study protocol of a multicenter randomized controlled non-inferiority trial

BACKGROUND

Studies have shown that the wet suction technique in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) generates better histological diagnostic accuracy and specimen quality than the dry suction technique. However, conclusions of wet suction on the diagnostic accuracy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) are still controversial. Besides, the optimal number of passes for EUS-FNB has not been determined. We aimed to design a large multicenter randomized trial to compare the diagnostic accuracy of dry suction versus wet suction technique in solid pancreatic lesions (SPLs) using 22G Franseen needles and determine the optimal number of passes required for EUS-FNB.

METHODS

This is a multi-center open-label, randomized controlled non-inferiority trial with two parallel groups. Two hundred patients with SPLs will undergo EUS-FNB using 22G Franseen needles in 4 tertiary hospitals in China and will be randomly assigned to the dry suction group and wet suction group in a ratio of 1:1. The primary endpoint is diagnostic accuracy. Secondary endpoints include the optimal number of needle passes, sensitivity, specificity, specimen quality, cytological diagnoses, time of the procedure, and incidence of complications.

DISCUSSION

This study has been designed to determine (i) whether EUS-FNB using 22G Franseen needle with dry suction is non-inferior to wet suction in terms of diagnostic accuracy and (ii) the optimal number of passes during EUS-FNB of SPLs using 22G Franseen needle.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05549856. Registered on September 22, 2022.

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.

Risk Factors and Interpretation of Inconclusive Endoscopic Ultrasound-Guided Fine Needle Aspiration Cytology in the Diagnosis of Solid Pancreatic Lesions

BACKGROUND

The inconclusive cytological findings of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) remain a major clinical challenge and often lead to treatment delays.

METHODS

Patients who had undergone EUS-FNA sampling for solid pancreas lesions between 2014 and 2021 were retrospectively enrolled. The "atypical" and "non-diagnostic" categories of the Papanicolaou Society of Cytopathology System were considered inconclusive and the "negative for malignancy" category of malignancy was suspected clinically. We determined the frequency and predictors of inconclusive cytological finding.

RESULTS

A total of 473 first EUS-FNA samples were included, of which 108 cases (22.83%) were inconclusive. Significant increases in the odds of inconclusive cytological findings were observed for lesions with a benign final diagnosis (OR 11.20; 95% CI 6.56-19.54, p < 0.001) as well as with the use of 25 G FNA needles (OR 2.12; 95% CI 1.09-4.01, p = 0.023) compared to 22 G needles. Furthermore, the use of a single EUS-FNA technique compared to the combined use of slow-pull and standard suction techniques (OR 1.70; 95% CI 1.06-2.70, p = 0.027) and less than three punctures per procedure led to an elevation in the risk of inconclusive cytology (OR 2.49; 95% CI 1.49-4.14, p < 0.001). Risk reduction in inconclusive cytology findings was observed in lesions between 2-4 cm (OR 0.40; 95% CI 0.23-0.68, p = 0.001) and >4 cm (OR 0.16; 95% CI 0.08-0.31, p < 0.001) compared to lesions ≤2 cm.

CONCLUSIONS

The more than two punctures per EUS-FNA sampling with larger-diameter needle (19 G or 22 G) using the slow-pull and standard suction techniques in combination may decrease the probability of inconclusive cytological findings.

Current status of molecular diagnostic approaches using liquid biopsy

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive and lethal cancers, and developing an efficient and reliable approach for its early-stage diagnosis is urgently needed. Precancerous lesions of PDAC, such as pancreatic intraepithelial neoplasia (PanIN) and intraductal papillary mucinous neoplasms (IPMN), arise through multiple steps of driver gene alterations in KRAS, TP53, CDKN2A, SMAD4, or GNAS. Hallmark mutations play a role in tumor initiation and progression, and their detection in bodily fluids is crucial for diagnosis. Recently, liquid biopsy has gained attention as an approach to complement pathological diagnosis, and in addition to mutation signatures in cell-free DNA, cell-free RNA, and extracellular vesicles have been investigated as potential diagnostic and prognostic markers. Integrating such molecular information to revise the diagnostic criteria for pancreatic cancer can enable a better understanding of the pathogenesis underlying inter-patient heterogeneity, such as sensitivity to chemotherapy and disease outcomes. This review discusses the current diagnostic approaches and clinical applications of genetic analysis in pancreatic cancer and diagnostic attempts by liquid biopsy and molecular analyses using pancreatic juice, duodenal fluid, and blood samples. Emerging knowledge in the rapidly advancing liquid biopsy field is promising for molecular profiling and diagnosing pancreatic diseases with significant diversity.

Comparison between Target Sample Check Illuminator and White Light Observation in Discriminating the Presence of Target Specimen for Endoscopic Ultrasound-Guided Fine Needle Aspiration Sample

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an essential endoscopic tissue sampling method for diagnosing pancreatobiliary diseases; however, determining the presence of target specimens mixed in the blood by conventional observation is challenging due to the small size of the obtained sample. This study investigated the usefulness of a target sample check illuminator (TSCI) that emits a specific wavelength of light to determine the presence of target specimens. Twenty-seven patients who underwent EUS-FNA at our hospital were included. Conventional white light observation was performed for the collected samples, followed by TSCI; six people evaluated the presence of the target specimen on a 5-point scale. The target specimen discrimination score using TSCI (median: 5) was significantly higher than that using conventional white light observation (median: 1) (p < 0.001). No significant difference was observed in the discrimination score between the evaluator (novice vs. expert, p = 0.162) and puncture needle (22G vs. 25G, p = 0.196). The discriminability of TSCI in the samples obtained using EUS-FNA was significantly higher than that of conventional observation. TSCI does not depend on the evaluator or puncture needle for the identification of the target specimen; hence, it can provide a good pathological specimen and may contribute to the improvement of the diagnostic ability.

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.

The usefulness of liquid-based cytology for endoscopic ultrasound-guided tissue acquisition of solid pancreatic masses

Liquid-based cytology (LBC) is used primarily for cervical cytology, although it is also used for analyzing liquid samples such as urine and ascites specimens, as well as fine needle aspiration material, such as those obtained from breast and thyroid. The usefulness of the LBC method for endoscopic ultrasound-guided tissue acquisition (EUS-TA) of solid pancreatic masses was recently reported. The LBC method can produce multiple pathological slides and can be applied to immunocytochemistry and genetic analyses. In this article, we review the usefulness of LBC for EUS-TA of solid pancreatic masses.

Needle tract seeding after endoscopic ultrasound-guided tissue acquisition of pancreatic tumors: A nationwide survey in Japan

OBJECTIVES

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) plays a crucial role in the diagnosis of pancreatic tumors. The present study aimed to investigate the current status of needle tract seeding (NTS) after EUS-TA of pancreatic tumors based on a nationwide survey in Japan.

METHODS

Patients who underwent surgical resection of primary pancreatic tumors after EUS-TA performed between April 2010 and March 2018 were surveyed. The incidence rates of NTS were determined, and compared in patients with pancreatic ductal adenocarcinomas (PDACs) and other tumors, and in patients who underwent transgastric and transduodenal EUS-TA of PDACs. The detailed features and prognosis of patients with NTS were also assessed.

RESULTS

A total of 12,109 patients underwent surgical resection of primary pancreatic tumors after EUS-TA. The overall incidence rate of NTS was 0.330%, and the NTS rate was significantly higher in patients with PDAC than in those with other tumors (0.409% vs. 0.071%, P=0.004). NTS was observed in 0.857% of patients who underwent transgastric EUS-TA, but in none of those who underwent transduodenal EUS-TA. Of the patients with NTS of PDACs, the median time from EUS-TA to occurrence of NTS and median patient survival were 19.3 and 44.7 months, respectively, with 97.4% of NTS located in the gastric wall and 65.8% of NTS resected. The patient survival was significantly longer in patients who underwent NTS resection than in those without NTS resection (P=0.037).

CONCLUSIONS

NTS appeared only after transgastric not after transduodenal EUS-TA. Careful follow-up provides an opportunity to remove localized NTS lesions by gastrectomy.