Accuracy of visual on-site evaluation (Vose) In predicting the adequacy of Eus-guided fine needle biopsy: A single center prospective study

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.

Endoscopic Ultrasound armamentarium for precise and early diagnosis of biliopancreatic lesions

The diagnostic paradigm for biliopancreatic lesions has been revolutionized by continuous advancements in endoscopic ultrasound (EUS) technologies and techniques. This review examines the expanding diagnostic toolkit available to clinicians, emphasizing innovations that have significantly enhanced precision and early detection capabilities. One of the most transformative advancements is the development of fine-needle biopsy (FNB) needles. Modern designs, including Franseen, and fork-tip configurations, have optimized tissue sampling, achieving diagnostic accuracies exceeding 90 % while minimizing the number of needle passes required. These innovations facilitate the acquisition of high-quality histological specimens suitable for comprehensive molecular profiling, paving the way for personalized therapeutic approaches. Concurrent advancements in sampling techniques have bolstered these needle design improvements. The fanning technique has been particularly effective, increasing diagnostic yields from 71 % to 88 %. Wet suction methods preserve tissue integrity better than traditional approaches, while standardized protocols for needle passes enhance procedural efficiency. For specimen evaluation, Rapid On-Site Evaluation (ROSE) offers 93 % sensitivity, while alternatives like Macroscopic On-Site Evaluation (MOSE) provide comparable accuracy while reducing dependency on specialized personnel and resources. Image enhancement technologies have markedly improved the ability to characterize lesions. Contrast Harmonic EUS (CH-EUS) is particularly effective in differentiating pancreatic cancer from other solid lesions, with meta-analyses confirming sensitivity and specificity of 94 % and 89 %, respectively. Its ability to detect lesions as small as 15 mm makes it invaluable for early diagnosis. In cystic lesions, CH-EUS excels in identifying malignant mural nodules, with diagnostic accuracies reaching 96 %. The integration of elastography and advanced digital imaging technologies has further expanded diagnostic capabilities. Strain elastography provides qualitative insights into tissue characteristics, while shear wave elastography offers quantitative measurements of stiffness, adding diagnostic precision. Similarly, technologies like detective flow imaging match the accuracy of contrast-enhanced techniques in pancreatic cancer detection and enhance vascular assessment. For cystic lesions, diagnostics have progressed beyond traditional fluid analysis. Techniques such as through-the-needle biopsy (TTNB) have improved diagnostic yields to 74 %, albeit with a modest risk of complications. Incorporating molecular markers and next-generation sequencing allows differentiation between cystic lesion subtypes and more accurate assessment of malignant potential. This array of diagnostic tools offers unprecedented potential for early and precise diagnosis of biliopancreatic lesions. Integrating these innovations into clinical practice requires careful consideration of their strengths and limitations. Future research should aim to standardize protocols and establish evidence-based algorithms for their combined use, with the ultimate goal of improving patient outcomes through earlier detection and tailored management of biliopancreatic pathologies.

EUS-guided transesophageal fine-needle biopsy sampling of lung masses: diagnostic performance and safety

BACKGROUND AND AIMS

Pulmonary masses are a diagnostic challenge in the field of EUS tissue acquisition, especially through transesophageal EUS-guided fine-needle biopsy sampling (EUS-FNB). Our study evaluated the feasibility, diagnostic performance, and safety of EUS-FNB of pulmonary lesions.

METHODS

Fifty-three patients were enrolled in a prospective registry. All EUS procedures were performed by experienced endosonographers. Outcomes were specimen adequacy, diagnostic accuracy, diagnostic sensibility, diagnostic specificity, and safety.

RESULTS

The mean patient age was 70 ± 10.4 years, and 71.7% were men. The mean lesion size was 52.4 ± 23.3 mm, and patients mostly had a single lesion (86.8%). Most patients had an advanced stage at diagnosis (stage IV, 41.82%), and the most common lung cancer was non-small cell lung carcinoma (69.4%). The diagnostic adequacy rate was 92.86%, and diagnostic accuracy was 87.5%. Adverse events were reported in 3 procedures.

CONCLUSIONS

Transesophageal EUS-FNB is a feasible and safe diagnostic method of tissue sampling for lung masses reachable by EUS.

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.

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.

Endoscopic Ultrasound-Guided Pancreatic Tissue Sampling: Lesion Assessment, Needles, and Techniques

Endoscopic ultrasound (EUS)-guided tissue sampling includes the techniques of fine needle aspiration (FNA) and fine needle biopsy (FNB), and both procedures have revolutionized specimen collection from the gastrointestinal tract, especially from remote/inaccessible organs. EUS-FNB has replaced FNA as the procedure of choice for tissue acquisition in solid pancreatic lesions (SPLs) across various society guidelines. FNB specimens provide a larger histological tissue core (preserving tissue architecture) with fewer needle passes, and this is extremely relevant in today's era of precision and personalized molecular medicine. Innovations in needle tip design are constantly under development to maximize diagnostic accuracy by enhancing histological sampling capabilities. But, apart from the basic framework of the needle, various other factors play a role that influence diagnostic outcomes, namely, sampling techniques (fanning, aspiration or suction, and number of passes), collection methods, on-site evaluation (rapid, macroscopic, or visual), and specimen processing. The choice taken depends strongly on the endoscopist's preference, available resources at the disposal, and procedure objectives. Hence, in this review, we explicate in detail the concepts and available literature at our disposal on the topic of EUS-guided pancreatic tissue sampling to best guide any practicing gastroenterologist/endoscopist in a not-to-ideal set-up, which EUS-guided tissue acquisition technique is the "best" for their case to augment their diagnostic outcomes.

Endoscopic Ultrasound-Guided Fine Needle Biopsy of Focal Liver Lesions: An Effective Mini-Invasive Alternative to the Percutaneous Approach

Despite the introduction of serological neoplastic biomarkers and typical radiological characteristics in clinical practice, liver biopsy (LB) is often still necessary to establish a histological diagnosis, especially in ambiguous cases. Nowadays, LB via the percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonography (US) guidance, is the route of choice. However, certain focal liver lesions can be challenging to access percutaneously. In such cases, endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) may represent an attractive, minimally invasive alternative. This retrospective observational study aimed to evaluate the efficacy, diagnostic performance, and safety of EUS-FNB conducted on 58 focal liver lesions located in both liver lobes. The adequacy of FNB samples for focal liver lesions located in the left and right lobes was 100% and 81.2%, respectively, and the difference was statistically significant (p = 0.001). Technical success was 100% for both liver lobes. The overall sensitivity and specificity were 95% and 100%, respectively. EUS-FNB is effective in making an accurate diagnosis with an excellent safety profile for focal liver lesions located in both liver lobes.

Diagnostic significance of clay-like materials aspirated from thyroid nodules

Objective

The simplest way to determine the adequacy of aspirated materials is the on-site gross visual assessment of aspirated materials. However, few studies have examined the gross findings of thyroid aspirates. This study aimed to clarify the diagnostic significance of clay-like material aspirated from thyroid nodules.

Material and Methods

We reviewed 69,848 thyroid nodules that underwent aspiration cytology at Kuma Hospital between January 2007 and August 2021. Among them, 355 (0.5%) nodules with aspirated materials described as clay-like materials were retrospectively examined.

Results

Among 355 nodules, 322 (90.7%) were categorized as cystic fluid or benign. The aspirated materials were mainly composed of non-epithelial components, including colloid or proteinaceous materials, foamy histiocytes, and degenerative red blood cells. In original ultrasound reports, the incidence of intermediate and high suspicion was 11.0%. Malignant cells were observed in 21 nodules (5.9%), one-third of which were papillary thyroid carcinomas. The materials aspirated from papillary and follicular thyroid carcinomas exhibited necrotic carcinoma cells derived from infarcted areas. The overall risk of malignancy was 3.9%. The risk of malignancy in nodules interpreted as highly suspicious on ultrasound examination was 37.5%.

Conclusion

As clay-like materials aspirated from thyroid nodules were considered sufficient specimens, the recognition contributes to avoiding unnecessary second punctures. The presence of clay-like materials was indicative of the colloid and/or blood components of benign cystic lesions, or, more rarely, of infarcted carcinoma. The ultrasound examination results tended to overestimate nodules. We should reaffirm that on-site gross visual assessment of aspirated materials is a fast and reasonably accurate predictor of the on-site adequacy of the samples.

Endoscopic ultrasound-guided fine-needle aspiration for gastrointestinal subepithelial lesions

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the first-choice procedure for obtaining pathological tissue samples from gastrointestinal (GI) subepithelial lesions (SELs). However, its diagnostic accuracy is lower than that for pancreatic masses owing to puncture difficulty and the need for immunostaining for definitive diagnosis. The advent of fine-needle biopsy needles, which have become well known in recent years, improves the diagnostic accuracy of EUS-FNA for GI SELs. The forward-viewing echoendoscope and rapid on-site evaluation (ROSE) have also helped to improve diagnostic accuracy. Furthermore, in facilities where ROSE is not available, endosonographers perform a macroscopic on-site evaluation. With these procedural innovations, EUS-FNA is now performed aggressively even for SELs smaller than 20 mm. The incidence of procedure-related adverse events such as bleeding and infection is low, and thus, EUS-FNA can be safely performed to diagnose SELs.

Advances and efficacy in specimen handling for endoscopic ultrasound-guided fine needle aspiration and biopsy: A comprehensive review

Endoscopic ultrasound-guided fine needle aspiration and biopsy have significantly evolved since they offer a minimally invasive approach for obtaining pathological specimens from lesions adjacent to or within the intestine. This paper reviews advancements in endoscopic ultrasound-guided fine needle aspiration and biopsy techniques and devices, emphasizing the importance of handling specimens for diagnostic accuracy. Innovations of fine needle biopsy needles with features like side holes and Franseen shapes have enhanced histological sampling capabilities. Techniques for specimen handling, including rapid on-site evaluation and macroscopic on-site evaluation, play pivotal roles in assessing sample adequacy, thereby influencing diagnostic outcomes. The utility of artificial intelligence in augmenting rapid on-site evaluation and macroscopic on-site evaluation, although still in experimental stages, presents a promising avenue for improving procedural efficiency and diagnostic precision. The choice of specimen handling technique is dependent on various factors including endoscopist preference, procedure objectives, and available resources, underscoring the need for a comprehensive understanding of each method's characteristics to optimize diagnostic efficacy and procedural safety.

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.

Macroscopic qualitative evaluation of solid pancreatic lesion specimens from endoscopic ultrasound-guided fine needle aspiration/biopsies

OBJECTIVES

To pathologically clarify the macroscopic features of endoscopic ultrasound-guided fine needle aspiration/biopsy (EUS-FNA/B) specimens in representative pancreatic diseases and establish tissue-handling standards based on the macroscopic findings.

METHODS

We gathered EUS-FNA/B specimens of cases at our institution with the final diagnoses of pancreatic ductal adenocarcinoma (PDAC, n = 172), neuroendocrine tumor (NET, n = 19), and chronic inflammatory lesion (CIL, n = 24) including autoimmune pancreatitis. We classified the specimens' macroscopic features in five categories (red strings, mixed-red-and-white strings, white cores, gray tissues, gelatinous tissues) and compared the specimens' features on cytological and histological slides.

RESULTS

All five macroscopic categories were observed in variable combinations in the PDACs; red strings and white cores predominated in the NETs and CILs. White cores represented neoplastic (PDAC, NET) or lesion (CIL) tissues. Mixed-red-and-white strings were unique to PDACs and contained cancerous cells. Neoplastic cells were numerous in red strings in NETs but not the other groups. Gray and gelatinous tissues represented necrosis and mucin, respectively, and the former were almost exclusively observed in PDACs. Red strings, mixed-red-and-white strings, and white cores were suitable for histological examination, whereas gray and gelatinous tissues were suitable for cytological examination. The white cores, mixed-red-and-white strings, and gelatinous tissues may be composed of non-neoplastic tissues such as contaminated gastrointestinal epithelium. In seven PDACs, although white cores were obtained, a histological diagnosis was not established.

CONCLUSIONS

Macroscopic evaluations of EUS-FNA/B can enable the identification of specimen components and a possible diagnosis. They also contribute to the selection of the optimal tissue-handling methods.

Macroscopic on‑site quality evaluation of biopsy specimens to improve the diagnostic accuracy of endoscopic ultrasound‑guided fine needle aspiration using a 22‑gauge needle for solid lesions: A single‑center retrospective study

The present study aimed to evaluate the clinical value of macroscopic on-site evaluation (MOSE) of solid masses by endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) using a standard 22-gauge needle and to explore the cut-off length of macroscopic visible core (MVC) required to obtain an accurate histopathological diagnosis. In total, 119 patients who satisfied the inclusion and exclusion criteria and underwent EUS-FNA were divided into conventional FNA and FNA combined with MOSE groups. In the MOSE group, the presence of MVC was examined and its total length measured, after which the pathological results of FNA were compared with the final diagnosis. The diagnostic sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of FNA in the two groups were calculated and the effect of MOSE on the FNA result was analyzed. The MOSE group had a higher diagnostic sensitivity (75.0% vs. 89.8%; P=0.038) and accuracy (74.5% vs. 90.6%; P=0.026). MVC was observed in 98.4% (63/64) of patients in the MOSE group. The median length of MVC was 15 mm. The optimal cut-off length of MVC for obtaining an accurate histological diagnosis was 13 mm, with a sensitivity of 90.2%. No statistically significant significance was observed in the specificity, PPV and NPV between the groups. Thus, MOSE helps to improve the diagnostic ability of FNA for solid masses and may be a useful alternative to assess the adequacy of puncture specimens in units where rapid on-site evaluation cannot be performed.