In memoriam: Fine-needle aspiration, birth: Fine-needle biopsy: The changing trend in endoscopic ultrasound-guided tissue acquisition

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.

Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.

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.

Diagnostic Approach to Biliary Strictures

Biliary strictures represent a narrowing of the bile ducts, leading to obstruction that may result from benign or malignant etiologies. Accurate diagnosis is crucial but challenging due to overlapping features between benign and malignant strictures. This review presents a comprehensive diagnostic approach that integrates biochemical markers, imaging modalities, and advanced endoscopic techniques to distinguish between these causes. Imaging tools such as ultrasound, MRI/MRCP, and CECT are commonly used, each with distinct advantages and limitations. Furthermore, endoscopic procedures such as ERCP and EUS are key in tissue acquisition, enhancing diagnostic accuracy, especially for indeterminate or complex strictures. Recent innovations, including artificial intelligence and new endoscopic techniques, hold promise in enhancing precision and reducing diagnostic challenges. This review emphasizes a multidisciplinary strategy to improve diagnostic pathways, ensuring timely management for patients with biliary strictures.

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.

The World Health Organization Reporting System for Pancreaticobiliary Cytopathology: Overview and Summary

The recently published WHO Reporting System for Pancreaticobiliary Cytopathology (World Health Organization [WHO] System) is an international approach to the standardized reporting of pancreaticobiliary cytopathology, updating the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology (PSC System). Significant changes were made to the categorization of benign neoplasms, intraductal neoplasms, mucinous cystic neoplasms, and malignant neoplasms considered low grade. Benign neoplasms, such as serous cystadenoma, categorized as Neoplastic: benign in the PSC system, are categorized as Benign/negative for malignancy in the WHO system. Pancreatic neuroendocrine tumor, solid-pseudopapillary neoplasm, and gastrointestinal stromal tumor, categorized as Neoplastic: other in the PSC system, are categorized as Malignant in the WHO System in accord with their classification in the 5th edition WHO Classification of Digestive System Tumours (2019). The two new categories of Pancreaticobiliary Neoplasm Low-risk/grade and Pancreaticobiliary Neoplasm High-risk/grade are mostly limited to intraductal neoplasms and mucinous cystic neoplasms. Low-risk/grade lesions are mucinous cysts, with or without low-grade epithelial atypia. High-risk/grade lesions contain neoplastic epithelium with high-grade epithelial atypia. Correlation with clinical, imaging, and ancillary studies remains a key tenet. The sections for each entity are written to highlight key cytopathological features and cytopathological differential diagnoses with the pathologist working in low resource setting in mind. Each section also includes the most pertinent ancillary studies useful for the differential diagnosis. Sample reports are provided for each category. Finally, the book provides a separate section with risk of malignancy and management recommendations for each category to facilitate decision-making for clinicians.

Impact of biliary stents in the performance of the EUS-guided tissue acquisition: A systematic review and meta-analysis

INTRODUCTION AND AIM

Pancreatobiliary tumours are challenging to diagnose exclusively by imaging methods. Although the optimum moment for carrying out the EUS is not well defined, it has been suggested that the presence of biliary stents may interfere with the proper staging of tumours and the acquisition of samples. We performed a meta-analysis to evaluate the impact of biliary stents on EUS-guided tissue acquisition yield.

MATERIAL AND METHODS

We conducted a systematic review in different databases, such as PubMed, Cochrane, Medline, and OVID Database. A search was made of all studies published up to February 2022.

RESULTS

Eight studies were analyzed. A total of 3185 patients were included. The mean age was 66.9±2.7 years; 55.4% were male gender. Overall, 1761 patients (55.3%) underwent EUS guided tissue acquisition (EUS-TA) with stents in situ, whereas 1424 patients (44.7%) underwent EUS-TA without stents. The technical success was similar in both groups (EUS-TA with stents: 88% vs EUS-TA without stents: 88%, OR=0.92 [95% CI 0.55-1.56]). The type of stent, the needle size and the number of the passes were similar in both groups.

CONCLUSIONS

EUS-TA has similar diagnostic performance and technical success in patients with or without stents. The type of stent (SEMS or plastic) does not seem to influence the diagnostic performance of EUS-TA. Future prospectives and RCT studies are needed to strengthen these conclusions.

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.

EUS-FNA versus EUS-FNB in Pancreatic Solid Lesions ≤ 15 mm

A small tumor size may impact the diagnostic performance of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for diagnosing solid pancreatic lesions (SPLs). We aimed to compare the diagnostic yield of EUS-guided fine-needle aspiration (FNA) and biopsy (FNB) in SPLs with a diameter ≤ 15 mm. Consecutive patients who underwent EUS-TA for SPLs ≤ 15 mm between January 2015 and December 2022 in a tertiary referral center were retrospectively evaluated. The primary endpoint was diagnostic accuracy. The final diagnosis was based on surgical pathology or disease evolution after a minimum follow-up of 6 months. Inadequate samples were all considered false negatives for the study. Secondary outcomes included sample adequacy, factors impacting accuracy, and safety. We included 368 patients (52.4% male; mean age: 60.2 years) who underwent FNA in 72 cases and FNB in 296. The mean size of SPLs was 11.9 ± 2.6 mm. More than three passes were performed in 5.7% and 61.5% of patients in the FNB and FNA groups, respectively (p < 0.0001). FNB outperformed FNA in terms of diagnostic accuracy (89.8% vs. 79.1%, p = 0.013) and sample adequacy (95.9% vs. 86.1%, p < 0.001). On multivariate analysis, using FNA (OR: 2.10, 95% CI: 1.07-4.48) and a final diagnosis (OR: 3.56, 95% CI: 1.82-6.94) of benign conditions negatively impacted accuracy. Overall, the adverse event rate was 0.8%, including one pancreatitis in the FNA group and one pancreatitis and one bleeding in the FNB group, all mild and conservatively managed. EUS-TA for SPLs ≤ 15 mm has a high diagnostic yield and safety. This study suggests the superiority of FNB over FNA, with better performance even with fewer passes performed.

The yield of cytology and histology obtained by endoscopic ultrasound-guided fine needle aspiration and biopsy needles in the diagnosis of pancreatic adenocarcinoma

INTRODUCTION

Endoscopic ultrasound-guided fine needle aspiration and biopsy (EUS-FNA, -FNB) are the mainstay for tissue diagnosis of pancreatic lesions. Traditionally, FNA was performed for obtaining cytology and also histology if available from the puncture. Since their advent, however, FNB needles have been intended mainly to obtain core biopsies for histological specimens.

AIMS

We aimed to assess the yield of cytology obtained via both FNA and FNB needles.

METHODS

A retrospective study was performed including all patients who were diagnosed with pancreatic adenocarcinoma obtained via EUS-FNA/FNB needles.

RESULTS

Overall, 227 patients were included. Of them, 85 patients underwent FNB, versus 142 patients who had FNA. The average age in the FNB group was 70.46 ± 11.29 years, versus 71.44 ± 11.80 in the FNA group, P = 0.57. Notably, cytological analysis diagnosed malignancy equally in both groups (69.4% in the FNB group, vs. 65.5% in the FNA group). The compatibility rate of cytology with histology was 76.5% in the FNB group, versus 76.1% in the FNA group (P = 0.69). The agreement level between cytology obtained by FNA and FNB, versus histology obtained by both needles, was moderate (kappa = 0.48, 95% CI 0.39-0.57). Similarly, the agreement level between cytology and histology in the FNB group was moderate as well (kappa = 0.5, 95% CI 0.36-0.64).

CONCLUSION

Cytological assessment yielded an equal performance as compared to histological assessment with both needles. We recommend obtaining cytology specimens in pancreatic solid lesion puncture by FNB needle.

Diagnostic value of endoscopic ultrasound in groove pancreatitis

Aim: Groove pancreatitis (GP) is a rare type of chronic pancreatitis characterized by varying degrees of thickening and scarring of the duodenal wall, duodenal lumen stenosis, mucosal hypertrophy with plicae and cyst formation. GP is primarily observed in middle-aged male patients with a history of alcohol consumption. Clinical symptoms are usually non-specific, and there is currently no unified diagnostic standard. However, imaging methods, particularly endoscopic ultrasound (EUS), are useful for diagnosis. EUS-guided biopsy can provide a strong basis for the final diagnosis. This review summarizes the value of EUS and its derivative technologies in the diagnosis, differential diagnosis and treatment of GP.Methods: After searching in PubMed and Web of Science databases using 'groove pancreatitis (GP)' and 'endoscopic ultrasonography (EUS)' as keywords, studies related were compiled and examined.Results: EUS and its derivative technologies are of great significance in the diagnosis, differential diagnosis, and treatment of GP, but there are still limitations that need to be comprehensively applied with other diagnostic methods to obtain the most accurate results.Conclusion: EUS has unique value in both the diagnosis and treatment of GP. Clinicians need to be well-versed in the advantages and limitations of EUS for GP diagnosis to select the most suitable imaging diagnostic method for different cases and to reduce the unnecessary waste of medical resources.

Diagnostic accuracy of endoscopic ultrasonography-guided tissue acquisition prior to resection of pancreatic carcinoma: a nationwide analysis

INTRODUCTION

Endoscopic ultrasonography guided tissue acquisition (EUS + TA) is used to provide a tissue diagnosis in patients with suspected pancreatic cancer. Key performance indicators (KPI) for these procedures are rate of adequate sample (RAS) and sensitivity for malignancy (SFM).

AIM

assess practice variation regarding KPI of EUS + TA prior to resection of pancreatic carcinoma in the Netherlands.

PATIENTS AND METHODS

Results of all EUS + TA prior to resection of pancreatic carcinoma from 2014-2018, were extracted from the national Dutch Pathology Registry (PALGA). Pathology reports were classified as: insufficient for analysis (b1), benign (b2), atypia (b3), neoplastic other (b4), suspected malignant (b5), and malignant (b6). RAS was defined as the proportion of EUS procedures yielding specimen sufficient for analysis. SFM was calculated using a strict definition (malignant only, SFM-b6), and a broader definition (SFM-b5+6).

RESULTS

691 out of 1638 resected patients (42%) underwent preoperative EUS + TA. RAS was 95% (range 89-100%), SFM-b6 was 44% (20-77%), and SFM-b5+6 was 65% (53-90%). All centers met the performance target RAS>85%. Only 9 out of 17 met the performance target SFM-b5+6 > 85%.

CONCLUSION

This nationwide study detected significant practice variation regarding KPI of EUS + TA procedures prior to surgical resection of pancreatic carcinoma. Therefore, quality improvement of EUS + TA is indicated.

Fine needle biopsy versus fine needle aspiration in the diagnosis of immunohistochemistry-required lesions: A multicenter study with prospective evaluation

Objectives

The superiority of EUS-guided fine-needle biopsy (EUS-FNB) over fine-needle aspiration (FNA) remains controversial. This study aimed to compare the efficacy of FNB and FNA in immunohistochemistry (IHC)-required lesions, including, type 1 autoimmune pancreatitis (AIP), neuroendocrine tumor (NET), mesenchymal tumor, and lymphoma.

Methods

In this multicenter study, specimens from all eligible patients who underwent EUS-FNB/FNA with these specific lesions were prospectively evaluated. Demographics, adequacy of specimens for IHC, diagnostic accuracy, and integrity of tissue were analyzed. Subgroup analysis and multivariate logistic regression were also performed to control confounders.

Results

A total of 439 patients were included for analysis. Most lesion types were type 1 AIP (41.69%), followed by NET, mesenchymal tumor, and lymphoma. FNB yielded specimens with better adequacy for IHC (82.41% vs. 66.67%, P < 0.001) and higher diagnostic accuracy (74.37% vs. 55.42%, P < 0.001). The superiority of FNB over FNA in adequacy for IHC (odds ratio, 2.786 [1.515-5.291]) and diagnostic accuracy (odds ratio, 2.793 [1.645-4.808]) remained significant after control of confounders including needle size, lesion site, lesion size, and endoscopists. In subgroup analysis, FNB showed higher diagnostic accuracy in AIP and mesenchymal tumor, whereas no statistically significant difference was observed in NET and lymphoma.

Conclusions

FNB was superior to FNA needles in obtaining tissues with better adequacy and integrity. These results suggest that FNB should be considered a first-line modality in the diagnosis of IHC-required lesions, especially AIP and mesenchymal tumor. However, a randomized controlled trial with larger sample size is needed to further confirm our findings.

Mediastinal Abscess Formation after EUS-Guided Sampling in a Young Patient with Sarcoidosis: Be Aware of the Increased Risk!

International guidelines establish EUS-guided sampling as safe and accurate for the evaluation of mediastinal solid lesions, such as lymphadenopathies of unknown origin, and point out an increased risk of severe infectious complications induced by needle puncture in mediastinal cystic lesions. A retrospective case series and a systematic review documented an increased risk of mediastinal abscess formation after EUS-guided lymph nodes sampling in patients with sarcoidosis. The authors describe a case of a 38-year-old male patient with a final diagnosis of sarcoidosis, who developed a large mediastinal abscess after EUS-guided fine-needle biopsy of mediastinal lymphadenopathies. Endoscopists should be aware of the potential increased risk of severe infectious complications when sampling mediastinal lymph nodes in suspected sarcoidosis, and a strategy to minimize such risk should be pursued.

Surgical Diagnoses of Pancreatic Adenocarcinoma Not Found on Previous Endoscopic Ultrasound: A Case Series and Review of the Literature

INTRODUCTION

Pancreatic cancer is a leading cause of death in North America and Western Europe with rising rates in the developing world. Endoscopic ultrasound (EUS) with FNA (fine needle aspiration) is a critical component in the evaluation and diagnosis of pancreatic lesions with a high sensitivity and specificity. In this paper, we report patients at our center who eventually developed pancreatic cancer despite an early negative EUS, and identifying factors that may result in a missed diagnosis.

METHODS

The University of Louisville database was queried for patients who had a Whipple procedure for presumed benign disease and had a pre-operative EUS between 2008 and 2018. Patients who had pancreatic adenocarcinoma on final pathology were identified. Demographic, clinical, EUS, operative, and pathologic details were reviewed for each case in efforts to identify factors associated with failure to diagnose a pancreatic malignancy on EUS.

RESULTS

Five patients who had pancreatic adenocarcinoma on final pathology were reviewed in detail and their cases are presented in the paper. Four of the patients had dilation of the common bile duct, three had chronic pancreatitis. Two of them had previous surgery on the pancreas or bile ducts.

CONCLUSIONS

All of the patients presented in the paper had variables that made their EUS evaluation challenging. A high index of suspicion must be maintained in patients that do not improve after appropriate treatment of their strictures or pancreatic lesions. In the future, new techniques, such as fine needle biopsy and biomarker assays, may improve diagnosis accuracy.

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.

Current Practice Patterns of Endoscopic Ultrasound-Guided Tissue Sampling for Pancreatic Solid Mass in Korea: Outcomes of a National Survey

BACKGROUND/AIMS

Although endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and fine needle biopsy (FNB) are widely used for tissue acquisition of pancreatic solid mass, the optimal strategy of this procedure has not been established yet. The aim of this nationwide study was to investigate the current practice patterns of EUS-FNA/FNB for pancreatic solid mass in Korea.

METHODS

The Policy-Quality Management of the Korean Pancreatobiliary Association (KPBA) developed a questionnaire containing 22 questions. An electronic survey consisting of the questionnaire was distributed by e-mail to members registered to the KPBA.

RESULTS

A total of 101 respondents completed the survey. Eighty respondents (79.2%) performed preoperative EUS-FNA/FNB for operable pancreatic solid mass. Acquire needles (60.4%) were used the most, followed by ProCore needles (47.5%). In terms of need size, most respondents (>80%) preferred 22-gauge needles regardless of the location of the mass. Negative suction with a 10-mL syringe (71.3%) as sampling technique was followed by stylet slow-pull (41.6%). More than three needle passes for EUS-FNA/FNB was performed by most respondents (>80%). The frequency of requiring repeated procedure was significantly higher in respondents with a low individual volume (<5 per month, p=0.001). Prophylactic antibiotics were routinely used in 39 respondents (38.6%); rapid on-site pathologic evaluation was used in 6.1%.

CONCLUSIONS

According to this survey, practices of EUS-FNA/FNB for pancreatic solid mass varied substantially, some of which differed considerably from the recommendations present in existing guidelines. These results suggest that the development of evidence-based quality guidelines fitting Korean clinical practice is needed to establish the optimal strategy for this procedure.

The Rate of Avoidable Pancreatic Resections at a High-Volume Center: An Internal Quality Control and Critical Review

BACKGROUND

The incidence of benign diseases among pancreatic resections for suspected malignancy still represents a relevant issue in the surgical practice. This study aims to identify the preoperative pitfalls that led to unnecessary surgeries at a single Austrian center over a twenty-year period.

METHODS

Patients undergoing surgery for suspected pancreatic/periampullary malignancy between 2000 and 2019 at the Linz Elisabethinen Hospital were included. The rate of "mismatches" between clinical suspicion and histology was considered as primary outcome. All cases that, despite that, fulfilled the indication criteria for surgery were defined as minor mismatches (MIN-M). Conversely, the true avoidable surgeries were identified as major mismatches (MAJ-M).

RESULTS

Among the 320 included patients, 13 (4%) presented with benign lesions at definitive pathology. The rate of MAJ-M was 2.8% (n = 9), and the most frequent causes of misdiagnoses were autoimmune pancreatitis (n = 4) and intrapancreatic accessory spleen (n = 2). In all MAJ-M cases, various mistakes within the preoperative workup were detected: lack of multidisciplinary discussion (n = 7, 77.8%); inappropriate imaging (n = 4, 44.4%); lack of specific blood markers (n = 7, 77.8%). The morbidity and mortality rates for mismatches were 46.7% and 0.

CONCLUSION

All avoidable surgeries were the result of an incomplete pre-operative workup. The adequate identification of the underlying pitfalls could lead to minimize and, potentially, overcome this phenomenon with a concrete optimization of the surgical-care process.

The role of rectal endoscopic ultrasonography plus fine needle aspirartion and fine needle biopsy in pelvic masses

BACKGROUND AND AIM

The diagnostic role of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) and fine needle biopsy (FNB) of pelvic masses has not been well established. We aimed to evaluate the diagnostic accuracy of EUS plus FNA/FNB in suspected local recurrence of pelvic masses.

MATERIALS AND METHODS

All consecutive patients with a history of lower gastrointestinal and pelvic mass undergone EUS-FNA/FNB were included in the study.

RESULTS

In total 34 patients who underwent EUS-guided FNA or FNB of a perirectal mass were enrolled. The sampled lesion was a mass in 22 patients (64.7%) and a lymph node in 10 patients (29.4%). The univariate logistic regression analysis for diagnostic accuracy showed lesion size as a significant predictor of diagnostic accuracy [odds ratio (OR), 1.61; 1.08-2.27; P  = 0.02]. Diagnostic sensitivity was 100% (71.5-100%) with EUS-FNB and 75% (34.9-96.8%) with EUS-FNA ( P  = 0.12); specificity was 100% in both groups ( P  = 1.0). Sample adequacy was 94.1% in the whole cohort, with 20/20 adequacy rate (100%) in the EUS-FNB group and 12/14 (85.7%) in the EUS-FNA group ( P  = 0.28).

CONCLUSION

This is the first study demonstrating the diagnostic yield of EUS plus FNA/FNB in patients with pelvic masses comparing the two needles. Our results highlight the relevance of this technique, especially in undefined masses during oncological follow-up.

Endoscopic ultrasound fine-needle biopsy vs fine-needle aspiration for lymph nodes tissue acquisition: a systematic review and meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided tissue acquisition represents the choice of methods for suspected lymph nodes (LNs) located next to the gastrointestinal tract. This study aimed to compare the pooled diagnostic performance of EUS-guided fine-needle biopsy (EUS-FNB) and fine-needle aspiration (EUS-FNA) for LNs sampling.

METHODS

We searched PubMed/MedLine and Embase databases through August 2021. Primary outcome was diagnostic accuracy; secondary outcomes were sensitivity, specificity, sample adequacy, optimal histological core procurement, number of passes, and adverse events. We performed a pairwise meta-analysis using a random-effects model. The results are presented as odds ratio (OR) or mean difference along with 95% confidence interval (CI).

RESULTS

We identified nine studies (1,276 patients) in this meta-analysis. Among these patients, 66.4% were male; the median age was 67 years. Diagnostic accuracy was not significantly different between the two approaches (OR, 1.31; 95% CI, 0.81-2.10; P = 0.270). The accuracy of EUS-FNB was significantly higher when being performed with newer end-cutting needles (OR, 1.87; 95% CI, 1.17-3.00; P = 0.009) and in abdominal LNs (OR, 2.48; 95% CI, 1.52-4.05; P < 0.001) than that of EUS-FNA. No difference in terms of sample adequacy was observed between the two approaches (OR, 1.40; 95% CI, 0.46-4.26; P = 0.550); however, histological core procurement and diagnostic sensitivity with EUS-FNB were significantly higher than those with EUS-FNA (OR, 6.15; 95% CI, 1.51-25.07; P = 0.010 and OR, 1.87; 95% CI, 1.27-2.74, P = 0.001). The number of needle passes needed was significantly lower in the EUS-FNB group than in the EUS-FNA group (mean difference, -0.54; 95% CI, -0.97 to -0.12; P = 0.010).

CONCLUSIONS

EUS-FNA and EUS-FNB perform similarly in LN sampling; however, FNB performed with end-cutting needles outperformed FNA in terms of diagnostic accuracy.

Tumor Location in the Head/Uncinate Process and Presence of Fibrosis Impair the Adequacy of Endoscopic Ultrasound-Guided Tissue Acquisition of Solid Pancreatic Tumors

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) of solid pancreatic tumors shows optimal specificity despite fair sensitivity, with an overall suboptimal diagnostic yield. We aim to quantify the adequacy and accuracy of EUS-TA and assess predictive factors for success, focusing on the presence and degree of specimen fibrosis. All consecutive EUS-TA procedures were retrieved, and the specimens were graded for sample adequacy and fibrosis. The results were evaluated according to patients' and tumor characteristics and the EUS-TA technique. In total, 407 patients (59% male, 70 [63-77] year old) were included; sample adequacy and diagnostic accuracy were 90.2% and 94.7%, respectively. Fibrosis was significantly more represented in tumors located in the head/uncinate process (p = 0.001). Tumor location in the head/uncinate (OR 0.37 [0.14-0.99]), number of needle passes ≥ 3 (OR 4.53 [2.22-9.28]), and the use of cell block (OR 8.82 [3.23-23.8]) were independently related to adequacy. Severe fibrosis was independently related to false negative results (OR 8.37 [2.33-30.0]). Pancreatic tumors located in the head/uncinate process showed higher fibrosis, resulting in EUS-TA with lower sample adequacy and diagnostic accuracy. We maintain that three or more needle passes and cell block should be done to increase the diagnostic yield.

Diagnostic performance of endoscopic ultrasound-guided tissue acquisition by EUS-FNA versus EUS-FNB for solid pancreatic mass without ROSE: a retrospective study

BACKGROUND

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fine-needle aspiration (FNA) and fine-needle biopsy (FNB) remains unclear. We aimed to evaluate and compare the diagnostic yields between FNA and FNB using conventional FNA and Franseen needles of the same size 22-gauge needle, in patients with solid pancreatic mass who underwent EUS-TA without rapid onsite cytopathology evaluation (ROSE).

METHODS

All cases of EUS-TA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a single-centre university hospital were retrospectively reviewed. All procedures were performed without an onsite cytologist. Before the endoscopist finished the procedure, macroscopic onsite evaluation (MOSE) was confirmed. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared.

RESULTS

A total of 151 patients (FNA, n = 77; FNB, n = 74) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-TA. The mean age was 62.3 ± 12.8 years, with 88 (58.3%) males. Age, sex, mass location, tumour size and disease stage from imaging were not significantly different between the two groups. The diagnostic performance was higher in EUS-FNB (94.6%) than in EUS-FNA (89.6%). The mean number of needle passes was clearly fewer in FNB than in FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was shorter in FNB (34.7 min) than in FNA (41 min). The adverse event rate between FNB and FNA was not significantly different.

CONCLUSIONS

The diagnostic yield of solid pancreatic mass was higher in FNB using the Franseen needle than in FNA using the conventional FNA needle in a centre where ROSE is unavailable, without serious adverse event. In addition, FNB had fewer needle passes and shorter total procedure time.

Comparison between endoscopic ultrasound-guided fine-needle biopsy and bite-on-bite jumbo biopsy for sampling of subepithelial lesions

BACKGROUND AND AIMS

A direct comparison between endoscopic ultrasound (EUS) fine-needle biopsy (FNB) and current endoscopic biopsy techniques in patients with subepithelial lesions (SELs) is still lacking. Aim of this multicenter study was to compare the diagnostic performance and safety profile between EUS-FNB and bite-on-bite jumbo biopsy.

METHODS

Out of 416 patients undergoing endoscopic sampling of SELs between 2017 and 2021, after propensity score matching two groups were compared: 120 undergoing EUS-FNB and 120 sampled with bite-on-bite jumbo biopsy. Primary outcome was sample adequacy. Secondary outcomes were diagnostic accuracy, sensitivity, specificity, and adverse events.

RESULTS

Median age was 61 years and most patients were male in both groups. Final diagnosis was GIST in 65 patients (54.1%) in the EUS-FNB group and 62 patients in the bite-on-bite biopsy group (51.6%; p = 0.37). Sample adequacy was significantly higher in the EUS-FNB group as compared to the bite-on-bite biopsy group (94.1% versus 77.5%, p<0.001). EUS-FNB outperformed bite-on-bite biopsy also in terms of diagnostic accuracy (89.3% versus 67.1%, p<0.001) and sensitivity (89% vs 64.5%; p<0.001), whereas specificity was 100% in both groups (p = 0.89). These findings were confirmed in subgroup analysis according to SEL location, final diagnosis, and wall layers of the sampled SEL. Adverse event rate was 6.6% in the EUS-FNB group and 30% in the bite-on-bite biopsy group (p<0.001).

CONCLUSION

EUS-FNB outperforms bite-on-bite biopsy both in terms of diagnostic yield and safety profile.

Endoscopic ultrasonography‐guided tissue acquisition for small solid pancreatic lesions: Does the size matter?

Endoscopic ultrasonography‐guided tissue acquisition (EUS‐TA) is now an established technique to obtain the pathological diagnosis of solid pancreatic lesions (SPLs), but the diagnosis of small SPLS by EUS‐TA can still be difficult. We conducted a literature review and a meta‐analysis on the diagnostic yield of EUS‐TA according to the tumor size. In a meta‐analysis of 33 studies with 6883 cases, a pooled odds ratio (OR) of sensitivity was significantly higher in SPLs of >20 mm (OR 1.64, p = 0.02) and in SPLs of >10 mm (OR 3.05, p = 0.01), but not in SPLs of >30 mm (OR 1.18, p = 0.46). The meta‐analysis of accuracy also showed a similar trend: OR of 1.59 in SPLs of >20 mm (p < 0.01) and OR of 3.27 in SPLs of >10 mm (p < 0.01) and OR of 1.03 in SPLs of >30 mm (p = 0.87). The use of a 25‐gauge needle tended to improve sensitivity in small SPLs, though not statistically significant: OR of 1.25 and 2.82 in studies with and without a 25‐gauge needle (p = 0.08). The use of fine needle biopsy needles, slow pull method, and rapid on‐site evaluation did not significantly improve sensitivity in small SPLs. EUS‐TA for small SPLs, especially neuroendocrine neoplasms, is reported to have a high risk of adverse events. In summary, the diagnostic yield and safety of EUS‐TA for small (<20 mm) SPLs still needs improvement, and the best needle and technique for small SPLs should be further investigated.

Macroscopic visible core length can predict the histological sample quantity in endoscopic ultrasound-guided tissue acquisition: Multicenter prospective study

OBJECTIVES

Measurement of the macroscopic visible core (MVC) length during macroscopic on-site quality evaluation (MOSE) may allow estimation of sample adequacy for next-generation sequencing (NGS), and prediction of correct diagnosis in endoscopic ultrasound-guided tissue acquisition (EUS-TA) of pancreatic masses.

METHODS

This multicenter prospective study included consecutive patients who underwent EUS-TA for pancreatic masses using a 22-G Franseen needle. MVC length and pathological samples obtained from two needle passes were analyzed on a per-pass basis. Outcome measures included respective correlations of MVC length with histological sample quantity and diagnostic yields.

RESULTS

The analysis included 204 passes from 102 EUS-TAs. MVC length correlated positively with histological sample quantity (P < 0.01). On the receiver operating characteristic curve for MVC length, the cut-off value and area under the curve for obtaining a candidate sample for NGS were 30 mm and 0.74 (95% confidence interval [CI] 0.65-0.83), respectively. On multivariate analysis, MVC length ≥30 mm was a significant factor affecting suitability for NGS (odds ratio 6.19; 95% CI 2.72-14.10). Histologic diagnostic yield correlated positively with MVC length (P = 0.01); however, there was no positive correlation between MVC length and overall (histology plus cytology) diagnostic yield.

CONCLUSIONS

Measuring MVC length to predict histological sample quantity on MOSE may be of clinical significance during EUS-TA using a 22-G Franseen needle. It may be an effective method, particularly while submitting samples for NGS.

REGISTRATION

University Hospital Medical Information Network Trials Registry (UMIN000036528).

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy in solid lesions: A multi-center analysis

BACKGROUND

While endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is considered a preferred technique for tissue sampling for solid lesions, fine needle biopsy (FNB) has recently been developed.

AIM

To compare the accuracy of FNB vs FNA in determining the diagnosis of solid lesions.

METHODS

A retrospective, multi-center study of EUS-guided tissue sampling using FNA vs FNB needles. Measured outcomes included diagnostic test characteristics (i.e., sensitivity, specificity, accuracy), use of rapid on-site evaluation (ROSE), and adverse events. Subgroup analyses were performed by type of lesion and diagnostic yield with or without ROSE. A multivariable logistic regression was also performed.

RESULTS

A total of 1168 patients with solid lesions (n = 468 FNA; n = 700 FNB) underwent EUS-guided sampling. Mean age was 65.02 ± 12.13 years. Overall, sensitivity, specificity and accuracy were superior for FNB vs FNA (84.70% vs 74.53%; 99.29% vs 96.62%; and 87.62% vs 81.55%, respectively; P < 0.001). On subgroup analyses, sensitivity, specificity, and accuracy of FNB alone were similar to FNA + ROSE [(81.66% vs 86.45%; P = 0.142), (100% vs 100%; P = 1.00) and (88.40% vs 85.43%; P = 0.320]. There were no difference in diagnostic yield of FNB alone vs FNB + ROSE (P > 0.05). Multivariate analysis showed no significant predictor for better accuracy. On subgroup analyses, FNB was superior to FNA for non-pancreatic lesions; however, there was no difference between the techniques among pancreatic lesions. One adverse event was reported in each group.

CONCLUSION

FNB is superior to FNA with equivalent diagnostic test characteristics compared to FNA + ROSE in the diagnosis of non-pancreatic solid lesions. Our results suggest that EUS-FNB may eliminate the need of ROSE and should be employed as a first-line method in the diagnosis of solid lesions.

Predicting Malignancy of Biliary Stricture with a Nomogram in Patients with a Non-Malignant Endoscopic Tissue Diagnosis: A Retrospective Study

Purpose

The accurate differentiation between benign and malignant biliary stricture is significant but challenging. Tissue diagnosis of biliary stricture by endoscopy sampling can provide excellent specificity but insufficient sensitivity. For patients with suspected malignant biliary stricture (MBS) but non-malignant was reported in endoscopy tissue samples, we constructed a nomogram to predict malignancy and improve the overall diagnostic performance.

Patients and Methods

232 patients with suspected MBS and underwent endoscopy tissue sampling from January 2017 to December 2019 were included, among which 123 patients’ endoscopy tissue samples were classified as non-malignant (including atypical, negative for malignancy, and nondiagnostic). Demographics, serum markers, radiological and sampling results of these 123 patients were collected to construct a nomogram using multivariate analysis.

Results

The nomogram was developed based on bilirubin, CA19-9, radiological result, and atypical sampling results and provided an AUC of 0.863 (95% CI 0.795–0.930) for predicting MBS. The specificity, sensitivity, and accuracy of endoscopy tissue diagnosis were 100.00%, 59.90%, and 68.53%, respectively. With the nomogram added, the overall diagnosis specificity, sensitivity, and accuracy were 95.24%, 89.20%, and 90.23%, respectively.

Conclusion

The nomogram can predict malignancy in patients whose endoscopy tissue diagnoses were non-malignant. The overall diagnostic performance was improved with the nomogram added.

Endoscopic ultrasound-guided fine-needle biopsy histology with a 22-gauge Franseen needle and fine-needle aspiration liquid-based cytology with a conventional 25-gauge needle provide comparable diagnostic accuracy in solid pancreatic lesions

Background and Aim

Fine‐needle biopsy (FNB) needles obtain more core samples and support the shift from cytologic to histologic evaluation; however, recent studies have proposed a superior diagnostic potential for liquid‐based cytology (LBC). This study compared the diagnostic ability of endoscopic ultrasound (EUS)‐guided FNB histology with a 22‐gauge Franseen needle (22G‐FNB‐H) and fine‐needle aspiration (FNA) LBC with a conventional 25‐gauge needle (25G‐FNA‐LBC).

Methods

We analyzed 46 patients who underwent both 22G‐FNB‐H and 25G‐FNA‐LBC in the same lesion during the same endoscopic procedure. This study evaluated the diagnostic ability of each needle, diagnostic concordance between needles, and incremental diagnostic effect of both needles compared to using each needle alone.

Results

The agreement rate for malignancy between both techniques was 93.5% (kappa value = 0.82). There was no significant difference in the diagnostic ability of both methods. 22G‐FNB‐H and 25G‐FNA‐LBC provided an incremental diagnostic accuracy in two (4.3%) cases and one (2.2%) case, respectively.

Conclusion

Our study demonstrated that the diagnostic accuracy of 25G‐FNA‐LBC and 22G‐FNA‐H for solid pancreatic lesions were comparable. A conventional 25‐gauge needle that punctures lesions with ease can be used in difficult cases and according to the skill of the endoscopist.

EUS-Guided Biopsy with a Novel Puncture Biopsy Forceps Needle-Feasibility Study

Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) or biopsy (FNB) to diagnose lesions in the gastrointestinal tract is common. Demand for histology sampling to identify treatment-specific targets is increasing. Various core biopsy FNB needles to obtain tissue for histology are currently available, however, with variable (37-97%) histology yields. In this multicenter study, we evaluated performance, safety, and user experience of a novel device (the puncture biopsy forceps (PBF) needle). Twenty-four procedures with the PBF needle were performed in 24 patients with a suspected pancreatic lesion (n = 10), subepithelial lesion (n = 10), lymph node (n = 3), or pararectal mass (n = 1). In 20/24 (83%) procedures, the PBF needle yielded sufficient material for interpretation (sample adequacy). In 17/24 (71%), a correct diagnosis was made with the material from the PBF needle (diagnostic accuracy). All participating endoscopists experienced a learning curve. (Per)procedural technical issues occurred in four cases (17%), but there were no adverse events. The PBF needle is a safe and potentially useful device to obtain an EUS-guided biopsy specimen. As the design of the PBF needle is different to core biopsy FNB needles, specific training will likely further improve the performance of the PBF needle. Furthermore, the design of the needle needs further improvement to make it more robust in clinical practice.

Endoscopic Ultrasound-guided Fine-needle Biopsy With or Without Rapid On-site Evaluation for Diagnosis of Solid Pancreatic Lesions: A Randomized Controlled Non-Inferiority Trial

BACKGROUND AND AIMS

The benefit of rapid on-site evaluation (ROSE) on the diagnostic accuracy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) has never been evaluated in a randomized study. This trial aimed to test the hypothesis that in solid pancreatic lesions (SPLs), diagnostic accuracy of EUS-FNB without ROSE was not inferior to that of EUS-FNB with ROSE.

METHODS

A noninferiority study (noninferiority margin, 5%) was conducted at 14 centers in 8 countries. Patients with SPLs requiring tissue sampling were randomly assigned (1:1) to undergo EUS-FNB with or without ROSE using new-generation FNB needles. The touch-imprint cytology technique was used to perform ROSE. The primary endpoint was diagnostic accuracy, and secondary endpoints were safety, tissue core procurement, specimen quality, and sampling procedural time.

RESULTS

Eight hundred patients were randomized over an 18-month period, and 771 were analyzed (385 with ROSE and 386 without). Comparable diagnostic accuracies were obtained in both arms (96.4% with ROSE and 97.4% without ROSE, P = .396). Noninferiority of EUS-FNB without ROSE was confirmed with an absolute risk difference of 1.0% (1-sided 90% confidence interval, -1.1% to 3.1%; noninferiority P < .001). Safety and sample quality of histologic specimens were similar in both groups. A significantly higher tissue core rate was obtained by EUS-FNB without ROSE (70.7% vs. 78.0%, P = .021), with a significantly shorter mean sampling procedural time (17.9 ± 8.8 vs 11.7 ± 6.0 minutes, P < .0001).

CONCLUSIONS

EUS-FNB demonstrated high diagnostic accuracy in evaluating SPLs independently on execution of ROSE. When new-generation FNB needles are used, ROSE should not be routinely recommended. (ClinicalTrial.gov number NCT03322592.).

Endoscopic Ultrasound Fine-Needle Biopsy versus Fine-Needle Aspiration for Tissue Sampling of Abdominal Lymph Nodes: A Propensity Score Matched Multicenter Comparative Study

There is a paucity of evidence on the comparison between endoscopic ultrasound (EUS) fine-needle biopsy (FNB) and fine-needle aspiration (FNA) for lymph node (LNs) sampling. The aim of this study was to compare these two approaches in a multicenter series of patients with abdominal tumors. Out of 502 patients undergoing EUS sampling, two groups following propensity score matching were compared: 105 undergoing EUS-FNB and 105 undergoing EUS-FNA. The primary outcome was diagnostic accuracy. Secondary outcomes were diagnostic sensitivity, specificity, sample adequacy, optimal histological core procurement, number of passes, and adverse events. Median age was 64.6 years, and most patients were male in both groups. Final diagnosis was LN metastasis (mainly from colorectal cancer) in 70.4% of patients in the EUS-FNB group and 66.6% in the EUS-FNA group (p = 0.22). Diagnostic accuracy was significantly higher in the EUS-FNB group as compared to the EUS-FNA group (87.62% versus 75.24%, p = 0.02). EUS-FNB outperformed EUS-FNA also in terms of diagnostic sensitivity (84.71% vs. 70.11%; p = 0.01), whereas specificity was 100% in both groups (p = 0.6). Sample adequacy analysis showed a non-significant trend in favor of EUS-FNB (96.1% versus 89.5%, p = 0.06) whereas the histological core procurement rate was significantly higher with EUS-FNB (94.2% versus 51.4%; p < 0.001). No procedure-related adverse events were observed. These findings show that EUS-FNB is superior to EUS-FNA in tissue sampling of abdominal LNs.

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.

Utility of contrast-enhanced harmonic endoscopic ultrasonography for predicting the prognosis of pancreatic neuroendocrine neoplasms

BACKGROUND AND AIMS

Pancreatic neuroendocrine neoplasms (PanNENs), including Grade 1 (G1) or G2 tumors, can have a poor prognosis. This study investigated the value of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for predicting the prognosis of PanNENs.

METHODS

This single-center, retrospective study included 47 consecutive patients who underwent CH-EUS and were diagnosed with PanNEN by surgical resection or EUS-guided fine needle aspiration between December 2011 and February 2016. Patients were divided into aggressive and non-aggressive groups according to the degree of clinical malignancy. CH-EUS was assessed regarding its capacity for diagnosing aggressive PanNEN, the correspondence between contrast patterns and pathological features, and its ability to predict the prognosis of PanNEN.

RESULTS

There were 19 cases of aggressive PanNEN and 28 cases of non-aggressive PanNEN. The aggressive group included three G1, four G2, three G3 tumors, three mixed neuroendocrine non-neuroendocrine neoplasms, and six neuroendocrine carcinomas. CH-EUS was superior to contrast-enhanced computed tomography for the diagnosis of aggressive PanNEN (P < 0.001): hypo-enhancement on CH-EUS was an indicator of aggressive PanNEN, with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 94.7%, 100%, 100%, 96.6%, and 97.9%, respectively. Among G1/G2 PanNENs, cases with hypo-enhancement on CH-EUS had a poorer prognosis than those with hyper/iso-enhancement (P = 0.0009). Assessment of 36 resected specimens showed that hypo-enhancement on CH-EUS was associated with smaller and fewer vessels and greater degree of fibrosis.

CONCLUSION

Contrast-enhanced harmonic endoscopic ultrasonography may be useful for predicting the prognosis of PanNENs.

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.

The Impact of Recent Advances in Endoscopic Ultrasound-Guided Tissue Acquisition on the Management of Pancreatic Cancer

Over the last few decades, endoscopic ultrasound (EUS)-guided tissue acquisition has become the method of choice for the pathological diagnosis of solid pancreatic lesions. Due to its high diagnostic yield and low complication rate, EUS-guided tissue acquisition has surpassed percutaneous sampling techniques. For many years, EUS-guided fine-needle aspiration (EUS-FNA) was traditionally used to obtain cytological aspirates of solid pancreatic lesions, with sensitivity values ranging from 80 to 90% for the diagnosis of malignancy. Nevertheless, despite numerous technical advances, EUS-FNA still presents some limitations. Therefore, EUS-guided fine-needle biopsy (EUS-FNB) has been introduced to provide tissue core biopsies, allowing histological assessment. A newly developed generation of FNB needles has demonstrated an outstanding diagnostic accuracy of over 95% for solid pancreatic lesions and provides samples appropriate for ancillary testing, such as immunohistochemistry and tumour molecular profiling. As a result, EUS-FNB is rapidly replacing EUS-FNA and is now the recommended technique for EUS-guided tissue acquisition in pancreatic cancer. Furthermore, with the recent expansion of neoadjuvant treatment criteria and with the advent of novel and personalised anti-cancer therapies, EUS-FNB is gaining a pivotal role in pancreatic cancer management and might soon be generalised to all patients, independent of disease stage. In this article, the authors present an updated review of the role of EUS-guided tissue acquisition in pancreatic cancer. Current indications, several technical aspects and new applications of EUS-FNA and EUS-FNB are discussed.

Comparing Needles and Methods of Endoscopic Ultrasound-Guided Fine-Needle Biopsy to Optimize Specimen Quality and Diagnostic Accuracy for Patients With Pancreatic Masses in a Randomized Trial

BACKGROUND & AIMS

Given the lack of procedure standardization, findings vary from analyses of pancreatic tissues collected by endoscopic ultrasound-guided fine-needle biopsy. It is not clear which needle and technique yield the best specimen for analysis. We compared the specimen quality and accuracy of diagnoses made from samples collected by fine-needle biopsy needles using different collection techniques.

METHODS

Patients found to have pancreatic masses during imaging (n = 129) were assigned randomly to groups from whom pancreatic tissue samples were collected by reverse-bevel, Menghini-tip, franseen, or fork-tip needles. A second randomization determined the technical sequence of biopsies in each patient (suction, no suction, and stylet retraction). Two independent pathologists, blinded to the type of needle and sampling technique, analyzed all the samples. Final diagnoses of malignancy were made based on surgical resection, death from cancer progression, or findings from radiology or clinical follow-up evaluations (reference standard). The primary objective was to compare the cellularity of the samples collected, defined as the proportion of core tissue in the biopsy sample. Secondary objectives were to compare the accuracy of diagnoses made from biopsy samples and identify factors associated with high cellularity.

RESULTS

One-hundred and nine patients had a final diagnosis of malignancy (84.5%) and 20 patients had benign disease (15.5%). Samples collected by fork-tip or franseen needles had significantly higher cellularity than samples collected by reverse-bevels or Menghini-tip needles (P < .001). Neoplasias were identified with greater than 90% accuracy using samples collected by fork-tip or franseen needles (P < .001 compared with other needles). On multivariable regression analysis, use of franseen needles (odds ratio [OR], 4.42; 95% CI, 2.58-7.58; P < .001) or fork-tip needles (OR, 3.86; 95% CI, 2.24-6.64; P < .001), stylet retraction (OR, 2.13; 95% CI, 1.21-3.72; P = .008), no suction (OR, 2.74; 95% CI, 1.57-4.80; P < .001), and pancreatic mass larger than 3 cm (OR, 1.92; 95% CI, 1.21-3.05; P = .005) were associated with high cellularity of the sample.

CONCLUSIONS

In patients with suspected pancreatic cancer, samples with the highest degree of cellularity in a single biopsy, resulting in a diagnostic accuracy of 90% of higher, were collected by fine-needle biopsy using the franseen or fork-tip needle. Clinicaltrials.gov no: NCT04085055.

Comparison of Endoscopic Ultrasound-Guided Tissue Acquisition Using a 20-Gauge Menghini Needle with a Lateral Forward Bevel and a 22-Gauge Franseen Needle: A Single-Center Large Cohort Study

Background/Aims

Several fine-needle biopsy (FNB) needles are available for endoscopic ultrasound (EUS)-guided tissue acquisition. However, there is disagreement on which type of needle has the best diagnostic yield. The aim of this study was to compare the performance and safety of two commonly used EUS-FNB needles.

Methods

We retrospectively analyzed consecutive patients who underwent EUS-FNB between June 2016 and March 2020 in our hospital. Two types of needles were evaluated: a 20-gauge Menghini needle with a lateral forward bevel and a 22-gauge Franseen needle. Rapid on-site evaluation was performed in all the cases. A multivariate analysis was performed to clarify the negative predictive factors for obtaining a histological diagnosis. Propensity score matching was performed to compare the diagnostic yields of these two needles.

Results

We analyzed 666 patients and 690 lesions. The overall diagnostic rate of histology alone was 88.8%, and the overall adverse event rate was 1.5%. Transduodenal access and small lesions (≤2 cm) were identified as negative predictive factors for obtaining a histological diagnosis. After propensity score matching, 482 lesions were analyzed. The diagnostic accuracy rates of histology in the M and F needle groups were 89.2% and 88.8%, respectively (p=1.00).

Conclusions

Both the needles showed high diagnostic yield, and no significant difference in performance was observed between the two.

The Role of Endoscopic Ultrasound in Pancreatic Cancer Staging in the Era of Neoadjuvant Therapy and Personalised Medicine

Precise staging of pancreatic cancer is crucial for treatment choice. In clinical practice, this includes the TNM staging and determination of tumour resectability, based on a multimodality imaging workup. International guidelines recommend multi-detector computed tomography (CT), with a dedicated pancreatic protocol, as the first-line tool for TNM staging and evaluation of tumour-vessel relationships. In non-metastatic disease upon initial CT assessment, both magnetic resonance imaging and endoscopic ultrasound (EUS) may add relevant information, potentially changing treatment sequence. EUS may have distinct advantages in pancreatic cancer diagnosis and staging when compared with other modalities, being particularly valuable in the determination of portal venous confluence involvement (particularly in small and ill-defined/isoattenuating tumours on CT), in locoregional nodal staging and in the detection of ascites. As we step forward to a more frequent use of neoadjuvant chemotherapy and to personalised medicine, the importance of EUS-guided fine-needle biopsy (EUS-FNB) also increases. The recent availability of third-generation biopsy needles significantly increased the diagnostic yield of EUS-guided tissue acquisition, providing diagnostic cell blocks in approximately 95% of cases with only two dedicated passes and allowing ancillary testing, such as immunohistochemistry and molecular profiling of the tumour. In this article, the authors present an updated perspective of the place of EUS and EUS-FNB in the staging algorithm of pancreatic cancer. Data supporting the increasing role of neoadjuvant therapy and the importance of a patient-tailored treatment selection, based on tumoural subtyping and molecular profiling, are also discussed.

Endoscopic ultrasound-guided fine-needle aspiration of pelvic lesions via the upper and lower gastrointestinal tract approaches

BACKGROUND

Combining upper and lower gastrointestinal tract (GI) approaches allows expansion of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) indications for pelvic lesions. The upper GI approach has been used for pelvic lesions around the level of the aortoiliac bifurcation in our institution. The aim of this study is to evaluate the feasibility and safety of EUS-FNA for pelvic lesions via the upper and lower GI approaches.

METHODS

All consecutive patients who underwent EUS-FNA for the pelvic lesion between January 2008 and December 2018 were retrospectively analyzed. Pelvic lesions were defined as lesions located around and below the aortoiliac bifurcation level. The primary outcome was technical success rate, and the secondary outcomes were the diagnostic capability of EUS-FNA for malignancy and the safety.

RESULTS

EUS-FNA for pelvic lesions was performed in 49 patients: upper and lower GI approaches were used in 28 and 21 patients, respectively. The technical success rates were 91.8% (45/49) in all patients: 89.3% (25/28) and 95.2% (20/21) with the upper and lower GI approaches, respectively. Among patients who achieved technical success, the diagnostic accuracy for malignancy was 97.8% (44/45) in all patients: 100% (25/25) and 95.0% (19/20) with the upper and lower GI approaches, respectively. One (2.0%) patient developed an adverse event of sigmoid colon perforation.

CONCLUSIONS

EUS-FNA for pelvic lesions via the upper and lower GI approaches was a safe, feasible, and effective method, although careful endoscopic manipulation is required to avoid perforation, especially with the lower GI approach. Further large-scale, well-designed studies are needed to validate our findings.

Diagnostic Fine-Needle Biopsy of Small Solid Pancreatic Lesions Using a Franseen Needle during Endoscopic Ultrasound Examination

BACKGROUND AND AIM

During endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNB), Franseen needles can help collect sufficient tissue to permit histopathological assessment. However, its efficacy might be limited by the size of the targeted lesion. This study aimed to evaluate the feasibility of histopathological assessment of small solid pancreatic lesions using a 22-gauge Franseen needle during EUS-FNB.

METHODS

This retrospective study evaluated data from all patients who underwent EUS-FNB using a Franseen needle for solid pancreatic lesions at the University of Toyama Hospital between June 2018 and April 2020.

RESULTS

The study included 159 patients who had 152 malignant lesions and 7 benign lesions. The malignant lesions included pancreatic cancers (n = 134), neuroendocrine neoplasms (n = 15), metastatic tumors (n = 2), and a solid pseudopapillary neoplasm (n = 1). The diagnostic accuracy of EUS-FNB (combining histology and cytology) was 98.7%. However, the histopathological diagnosis was only confirmed for 64.3% of small lesions (<10 mm), relative to 97.2% for larger lesions. Multivariate analysis also revealed that lesion size of <10 mm predicted a less accurate histopathological diagnosis (odds ratio: 6.97, 95% confidence interval: 1.02-47.67; p = 0.041). Further analyses revealed a failed histological diagnosis in 4 patients with lesions of <5 mm in size and accurate diagnoses in 9 out of 10 patients with lesions of 5-10 mm in size.

CONCLUSIONS

The diagnostic accuracy for small lesions (<10 mm), especially for lesions of <5 mm, based on histological examination alone, was significantly lower than that for others (>10 mm). Furthermore, multivariate analysis revealed that only lesion size was an independent predictor of histopathological diagnosis accuracy.

Endoscopic diagnosis and management of gastric subepithelial lesions

PURPOSE OF REVIEW

The purpose of this manuscript is to provide an in-depth review of gastric subepithelial lesions (SELs) and describe the current approach to endoscopic diagnosis and management of these lesions.

RECENT FINDINGS

Gastric SELs are a relatively frequent finding on routine endoscopy (incidence 0.2-3%). A systematic approach to diagnosis and management is key because many SELs are of little consequence, while others carry a high risk of malignant transformation. Because esophagogastroduodenoscopy (EGD) cannot delineate depth of invasion or subepithelial appearance, endoscopic ultrasound (EUS) should be considered a first-line modality. Recent data suggest EUS-guided fine needle biopsy (FNB) may be superior to traditional fine needle aspiration (FNA) for the diagnosis of gastric SELs due to its ability to obtain histologic specimens for immunohistochemical staining. Alternative techniques for tissue sampling (combined with simultaneous resection) include submucosal resection, endoscopic submucosal dissection (ESD), submucosal tunnelling with endoscopic resection (STER) or endoscopic full-thickness resection (EFTR).

SUMMARY

This review details the endoscopic diagnosis and management of gastric SELs. Although EUS-guided sampling remains a first-line strategy (preferably with FNB), recent techniques including ESD, STER and EFTR have the potential to provide additional diagnostic and therapeutic options.

Fine Needle Aspiration versus Fine Needle Biopsy of Biliopancreatic Lesions: Are They Really Opposing Techniques or Can They Be Complementary? Our Experience in a Large Cohort of Cases from a Single Institution

INTRODUCTION

Nowadays, endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA), and fine needle biopsy (FNB) are considered the best procedures for the diagnosis of biliopancreatic lesions. These methods represent a milestone since they proved to be both safe for the patient and useful to achieve diagnostic material useful to plan the best treatment strategy.

OBJECTIVE

Since in the literature, a debate between cytology and histology supporters is still ongoing and the trend is changing in favor of FNB, we would like to present our experience about the diagnostic yield of FNA and FNB. The aim of our study is to highlight FNA versus FNB diagnostic role of biliopancreatic lesions, highlight advantages, and drawbacks of these procedures, and our view on these 2 procedures and whether they should still be considered complementary or opposing techniques.

METHODS

We retrospectively reviewed our hospital series of 469 EUS diagnostics procedures of biliopancreatic lesions performed in 419 patients, between 2015 and 2019.

RESULTS

The overall adequacy rates of FNA and FNB were, respectively, 98.9 and 100%. Stratifying cases according to anatomic location of the mass (pancreas vs. biliary system), we detected 168 malignancies out of 349 pancreatic lesions (168/349; 48.1%), while biliary system cases positive for malignancy represented 33.8% (23/68 cases) (p value = 0.045, χ2 test). As for concomitant FNB, our series displayed a high rate of diagnostic concordance (88.8%).

CONCLUSIONS

Despite numerous data published, it is still unclear which is the most feasible method to use; therefore, we compared FNA, FNB, or their combination to understand the best applicable technique. Our experience confirmed that FNA is extremely efficient in the diagnosis of biliopancreatic lesions, especially in the hands of expert endoscopists and pathologists. Considering anatomic location, EUS-FNA is more accurate for mass-forming neoplasms in the pancreatic parenchyma rather than for lesions of the biliary system. Moreover, concomitant FNB usually confirmed the cytological diagnosis, allowing a deeper immunohistochemical characterization of the neoplasia. This proves that a "pure" cytology and "pure" histology approach should be looked differently since these are complementary techniques especially if we can obtain a cellblock from FNA.

Endoscopic ultrasound-fine needle biopsies of pancreatic lesions: Prospective study of histology quality using Franseen needle

BACKGROUND

The introduction of fine needle biopsies (FNB) to clinical practice presents a changing trend towards histology in the endoscopic ultrasound-guided tissue acquisition (EUS-TA).

AIM

To evaluate the clinical performance of a new FNB needle, the 22-gauge (22G) Franseen needle, when sampling pancreatic solid lesions.

METHODS

Consecutive patients with an indication for EUS-TA for the assessment of pancreatic solid lesions were included in this prospective, single-center, single-arm trial. Each patient underwent a puncture of the lesion two times using the 22G Franseen needle and the obtained samples were directly placed into formalin for histological analysis. The primary study endpoint was the rate of high-quality obtained specimen. Secondary endpoints included the length and diameter of the core specimen, the diagnostic accuracy and the complication rate.

RESULTS

From June 2017 to December 2018, forty patients with pancreatic solid lesions (22 females; mean age 67.2 years) were enrolled. Tissue acquisition was achieved in all cases. High-quality histology, rated with Payne score 3, was obtained in 37/40 cases (92.5%) after two needle passes. The mean size of the acquired histological core tissue was 1.54 mm × 0.39 mm. The diagnostic accuracy for the correct diagnosis was 85% (34/40). Only one adverse event was occurred, consisting of a self-limiting bleeding in the puncture site.

CONCLUSION

The 22G Franseen needle achieved according to our standardized protocol a high rate of histological core procurement, and a high diagnostic accuracy, with one minor adverse event reported.

Diagnostic yield of endoscopic ultrasound-guided tissue acquisition for small solid pancreatic lesions

Background and study aims  Endoscopic ultrasound (EUS)-guided tissue acquisition is sometimes required to diagnose small solid pancreatic lesions. The aim of this study was to evaluate the diagnostic yield of EUS-guided tissue acquisition for small solid pancreatic lesions and the differences in diagnostic yield among different needles. Patients and method  We retrospectively analyzed consecutive patients who had undergone EUS-guided tissue acquisition for solid pancreatic lesions less than 2 cm between November 2012 and June 2019. Three types of needles were evaluated in this study: a 22-gauge fine-needle aspiration (FNA) Lancet needle, a 20-gauge fine-needle biopsy (FNB) Menghini needle with a lateral forward bevel, and a 22-gauge FNB Franseen needle. We evaluated the diagnostic yield and safety of the procedure using these needles. Results  We analyzed 160 patients with 163 lesions. The overall sensitivity, specificity, and accuracy were 92.0 %, 100 %, and 92.6 %, respectively. In the histological plus cytological diagnosis, accuracies of the Lancet, Menghini, and Franseen needles were 92.7 %, 97.0 %, and 85.7 %, respectively ( P  = 0.10). In the histological diagnosis alone, the negative predictive values (NPVs) of the Lancet, Menghini, and Franseen needles were 13.3 %, 53.3 %, and 27.3 %, respectively ( P  = 0.08). Adverse events occurred in four cases (2.5 %): one postprocedural bleeding, two cases of pancreatitis, and one pancreatic abscess. Conclusions  EUS-guided tissue acquisition for small solid pancreatic lesions has a high diagnostic yield and safety. This study suggested a difference in the diagnostic yield of each needle for small solid pancreatic lesions.

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.

Endoscopic ultrasound-guided tissue acquisition with or without macroscopic on-site evaluation: randomized controlled trial

BACKGROUND

The use of macroscopic on-site evaluation (MOSE) to estimate the adequacy of a specimen for histological diagnosis during endoscopic ultrasound (EUS)-guided fine-needle tissue acquisition (FNTA) has recently been advocated. This study aimed to evaluate the diagnostic yield of MOSE compared with conventional EUS-FNTA without rapid on-site evaluation (ROSE).

METHODS

This was an international, multicenter, prospective, randomized controlled study. After providing informed consent, consecutive adult patients referred for EUS-FNTA for solid lesions larger than 2 cm were randomized to a MOSE arm or to a conventional arm without ROSE. A designated cytopathologist from each center performed all cytopathological examinations for that center and was blinded to the randomization results. The primary outcome measure was the diagnostic yield, and the secondary outcomes included sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, and the rate of procedure-related complications.

RESULTS

244 patients (122 conventional, 122 MOSE) were enrolled during the study period. No significant differences between the two arms were found in procedure time or rate of procedure-related adverse events. The diagnostic yield for the MOSE technique (92.6 %) was similar to that for the conventional technique (89.3 %; P  = 0.37), with significantly fewer passes made (median: conventional 3, MOSE 2; P  < 0.001).

CONCLUSIONS

EUS-FNTA with the MOSE technique provided a similar diagnostic yield to conventional EUS-FNTA technique in the absence of ROSE but with fewer passes. This technique can be used when ROSE is not available.

An international, multi-institution survey on performing EUS-FNA and fine needle biopsy

BACKGROUND AND OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and fine needle biopsy (FNB) are effective techniques that are widely used for tissue acquisition. However, it remains unclear how to obtain high-quality specimens. Therefore, we conducted a survey of EUS-FNA and FNB techniques to determine practice patterns worldwide and to develop strong recommendations based on the experience of experts in the field.

METHODS

This was a worldwide multi-institutional survey among members of the International Society of EUS Task Force (ISEUS-TF). The survey was administered by E-mail through the SurveyMonkey website. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. Another questionnaire about the level of recommendation was designed to assess the respondents' answers.

RESULTS

ISEUS-TF members developed a questionnaire containing 17 questions that was sent to 53 experts. Thirty-five experts completed the survey within the specified period. Among them, 40% and 54.3% performed 50-200 and more than 200 EUS sampling procedures annually, respectively. Some practice patterns regarding FNA/FNB were recommended.

CONCLUSION

This is the first worldwide survey of EUS-FNA and FNB practice patterns. The results showed wide variations in practice patterns. Randomized studies are urgently needed to establish the best approach for optimizing the FNA/FNB procedures.