Endoscopic ultrasound-through-the-needle biopsy in pancreatic cystic lesions: A large single center experience

Value of EUS-guided through-the-needle biopsy in the diagnosis of pancreatic cystic neoplasms: An 8-year experience

Background and Objectives

An accurate diagnosis is crucial for the clinical management of pancreatic cystic neoplasm (PCN). EUS-guided through-the-needle biopsy (EUS-TTNB) is a novel technique for improving the accuracy of PCN diagnosis. There is insufficient evidence about the efficacy of EUS-TTNB. This study aims to evaluate the feasibility and diagnostic performance of EUS-TTNB for PCN.

Methods

Between June 2015 and July 2023, we prospectively enrolled 454 patients with a clinical concern for PCN in our database. After excluding those diagnosed with pancreatic cancer, pseudocysts, or other no-neoplasms, we assessed 326 patients with 329 cysts undergoing EUS-guided fine-needle-aspiration (EUS-FNA) or EUS-TTNB for evaluation. The primary indicators were tissue acquisition yield and diagnostic yield. The cyst characteristics (size, location, the presence of septation, mural nodule, and solid mass) and the number of biopsy samples were chosen for the analysis of factors associated with diagnostic performance.

Results

There were 220 (67.5%) females and 106 (32.5%) males, and the median patient age was 50 years (range, 18-88). There were 329 cysts sampled by FNA and 143 by TTNB. The median cyst size was 31.5 mm (range, 6.9-114.0). The diagnostic yields of FNA and TTNB were 35.7% (112/314) and 57.5% (73/127), respectively (P < 0.001). Special cyst types were diagnosed by TTNB in 58 (45.7%, 58/127) cysts, 19 of which had surgical pathology. Fifteen of 19 TTNB diagnoses were concordant with the surgical pathology.

Conclusion

EUS-TTNB is an option to improve the diagnosis of PCN. Standardized procedures and appropriate indications for TTNB need to be studied.

Risk of Pancreatitis After Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is frequently used to risk-stratify pancreatic cystic lesions (PCLs). Rising PCL incidence and developments in tissue acquisition and specimen analysis necessitate updated appraisal of EUS-FNA safety, particularly the risk of postprocedure pancreatitis, the most common EUS-FNA-related adverse event. Our systematic review aims to accurately quantify the risk of EUS-FNA-related pancreatitis to best inform decisions regarding EUS-FNA's optimal role in PCL workup.

METHODS

We performed systematic searches in 4 databases from inception to April 2024 for original English-language studies investigating EUS-FNA-related pancreatitis. We extracted data on demographics and EUS-FNA-related pancreatitis risk, severity, and risk factors. These were meta-analyzed through the DerSimonian Laird Method using a random-effects model. Meta-regression of pancreatitis risk was performed to delineate associations with clinical and procedural characteristics.

RESULTS

Sixty-four studies comprised 8,086 patients and reported 110 EUS-FNA-related pancreatitis events. Pooled risk of EUS-FNA-related pancreatitis was 1.4% (95% confidence intervals, -0.8% to 3.5%; I2 = 0.00), which was predominantly of mild severity (67%) and uniformly nonfatal. Pancreatitis risk lacked significant association with sample size, age, sex, cyst size, needle caliber, or passes, although we noted trends toward higher risk in studies published after 2015, those using higher gauge needles (19 G vs 22 G/25 G), and those performing EUS-guided through-the-needle biopsy.

DISCUSSION

We note with high certainty that pancreatitis after EUS-FNA of PCLs is infrequent and mild in severity with no mortality in the included cohort. EUS-guided through-the-needle biopsy may serve as a significant risk factor for EUS-FNA-related pancreatitis risk; however, further studies are needed to delineate other predisposing characteristics.

Endoscopic Ultrasound-Guided Through-the-Needle Biopsy: A Narrative Review of the Technique and Its Emerging Role in Pancreatic Cyst Diagnosis

Pancreatic cystic lesions (PCLs) pose a diagnostic challenge due to their increasing incidence and the limitations of cross-sectional imaging and endoscopic-ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-guided through the needle biopsy (EUS-TTNB) has emerged as a promising tool for improving the accuracy of cyst type determination and neoplastic risk stratification. EUS-TTNB demonstrates superior diagnostic performance over EUS-FNA, providing critical preoperative information that can significantly influence patient management and reduce unnecessary surgeries. However, the procedure has risks, with an overall adverse event rate of approximately 9%. Preventive measures and further prospective studies are essential to optimize its safety and efficacy. This review highlights the potential of EUS-TTNB to enhance the diagnostic and management approaches for patients with PCLs. It examines the current state of EUS-TTNB, including available devices, indications, procedural techniques, specimen handling, diagnostic yield, clinical impact, and associated adverse events.

Value of Endoscopic Ultrasound-Guided Through-the-Needle Biopsy in Pancreatic Cystic Lesions. A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) has been used over the past few years to increase diagnostic accuracy for pancreatic cystic lesions (PCLs). However, many concerns remain regarding its widespread use. This systematic review and meta-analysis aimed to pool the data from high-quality studies to evaluate the utility of EUS-TTNB in diagnosing PCLs.

METHODS

Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the diagnostic performance of EUS-TTNB in the diagnosis of pancreatic cystic lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models.

RESULTS

The initial search identified 635 studies, of which 35 relevant articles were reviewed. We extracted data from 11 studies that met the inclusion criterion, comprising a total of 575 patients. Mean patient age was 62.25 years ± 6.12 with females constituting 61.39% of the study population. Pooled sensitivity of EUS-TTNB in differentiating a PCL as neoplastic or non-neoplastic was 76.60% (95% CI = 72.60-80. 30). For the same indication, EUS TTNB had a pooled specificity of 98.90% (95% CI = 93.80-100.00). The positive likelihood ratio was 10.28 (95% CI = 4.77-22.15), and the negative likelihood ratio was 0.26 (95% CI = 0.22-0.31). The pooled diagnostic odds ratio for EUS-TTNB in diagnosing PCLs as malignant/pre-malignant vs. non-malignant was 41.34 (95% CI = 17.42-98.08). Pooled adverse event rates were 3.04% (95% CI = 1.83-4.54) for pancreatitis, 4.02% (95% CI = 2.61-5.72) for intra-cystic bleeding, 0.94% (95% CI = 0.33-1.86) for fever, and 1.73% (95% CI = 0.85-2.91) for other minor events.

CONCLUSIONS

EUS-TTNB has good sensitivity with excellent specificity in accurately classifying PCLs as neoplastic or non-neoplastic. Adding EUS-TTNB to EUS-FNA increases the accuracy of EUS-guided approach in diagnosing PCLs. However, it could significantly increase the risk of post-procedural pancreatitis.

Rare Pancreatic/Peripancreatic Cystic Lesions Can Be Accurately Characterized by EUS with Through-the-Needle Biopsy-A Unique Pictorial Essay with Clinical and Histopathological Correlations

Due to their aspecific macroscopic appearance, uncommon pancreatic cystic lesions (PCLs) are often misdiagnosed as mucinous lesions and improperly resected. We aimed to evaluate the endoscopic ultrasound (EUS)-guided through-the-needle biopsy (TTNB) capacity of the preoperative diagnosis of uncommon PCLs. Overall, 136 patients with PCLs who underwent EUS-TTNB between 2016 and 2022 were retrospectively identified. Common histotypes (e.g., IPMN, serous cystadenoma, and mucinous cystadenoma) were excluded and 26 (19.1%) patients (15 female, mean age 52.9 ± 10.4) were analyzed. The EUS findings, adverse events (AEs), and TTNB outcomes in uncommon PCLs were evaluated. The cysts histotype was accurately diagnosed by TTNB in 24/26 (92.3%) cases (seven cystic neuroendocrine tumors, four squamoid cysts, three acinar cells cystadenomas, two lymphoepithelial cysts, two mucinous non-neoplastic cysts, two bronchogenic cysts, two cystic lymphangiomas, one solid-pseudopapillary neoplasm, and one schwannoma). In the remaining two cases, lymphangioma was eventually diagnosed after resection. Surgery was performed in 15/26 (57.7%) patients. The mean follow-up of non-surgical patients was 32.5 months. One severe acute case of pancreatitis (3.8%) that required surgery occurred after EUS-TTNB. Uncommon pancreatic/peripancreatic lesions represent the 19.1% of PCLs in our series, with mainly benign histotypes. TTNB demonstrated a high diagnostic performance with a low rate of AEs in this setting, representing a reliable tool with which to avoid useless surgery.

Clinical Characteristics of Patients With Surgically Resected Pancreatic Cysts: A Retrospective Analysis of 136 Patients

OBJECTIVES

To retrospectively analyze the characteristics of pancreatic cysts with respect to histopathological diagnosis and various diagnostic imaging tools.

METHODS

The clinical features of 136 patients and characteristics of histopathologically diagnosed cysts were retrospectively assessed. The diagnostic accuracy of endoscopic ultrasound (EUS), computed tomography (CT), and magnetic resonance imaging (MRI) for pancreatic cysts was compared. Risk factors for high-grade dysplasia/invasive cancer in patients with intraductal papillary mucinous neoplasms (IPMNs) were also determined.

RESULTS

The final analysis included 30 serous cystic neoplasms (SCNs) (21.6%), 13 mucinous cystic neoplasms (MCNs) (9.4%), 65 IPMNs (46.8%), and 13 solid pseudopapillary neoplasms (SPNs) (9.4%). The percentage of women with MCNs, SPNs, SCNs, and IPMNs was 100.0, 76.9, 73.3, and 47.7%, respectively (P < .001). The percentages of patients over 60 years of age with IPMNs, SCNs, MCNs, and SPNs were 73.9, 23.3, 0, and 0%, respectively (P < .001). The percentage of cysts located in the body and tail of the pancreas in MCNs, SCNs, SPNs, and IPMNs was 100, 70, 53.9, and 46.2%, respectively (P < .001). A unique honeycomb appearance was observed in 26.7% of SCNs. The overall diagnostic accuracy of EUS, CT, and MRI for pancreatic cysts was 82.6, 72.5, and 73.9%, respectively. Lesion size and presence of solid components were independent predictors of high-risk IPMNs.

CONCLUSIONS

Patient characteristics and cyst features can help to differentiate pancreatic cyst types and identify high-risk IPMNs. The diagnostic accuracy of EUS for pancreatic cysts is superior to that of CT and MRI.

Pancreatic lymphoepithelial cyst with concurrent HIV infection: A case report and review of the literature

Pancreatic lymphoepithelial cysts are rare, benign, non-neoplastic unilocular or multilocular cystic lesions. These circumscribed pancreatic lesions are filled with keratinous material grossly and exhibit distinct microscopic features. Pancreatic lymphoepithelial cysts are like the more common lymphoepithelial cysts of the parotid glands, which have been associated with the diffuse infiltrative lymphocytosis syndrome often seen in patients with HIV infection. However, pancreatic lymphoepithelial cysts are rare and their association with HIV infection has not been established. The presence of secondary changes in non-neoplastic cysts such as goblet cell metaplasia that was present in our case is an important feature to be included in the differential diagnosis and not to be interpreted as a mucinous neoplasm, particularly on fine-needle aspiration specimen microscopic evaluation that would impact further management. Here we describe the diagnosis and treatment of lymphoepithelial cysts in a patient who was on highly active antiretroviral therapy for HIV infection and we provide a brief literature review. Defining the clinical characteristics of lymphoepithelial cysts in patients with HIV and determining accurate preoperative diagnostic procedures will be critical for establishing effective surgical and medical approaches to treating these cysts, which differ substantially from other more serious pancreatic cystic lesions.

Endoscopic ultrasound-guided through-the-needle microforceps biopsy and needle-based confocal laser-endomicroscopy increase detection of potentially malignant pancreatic cystic lesions: A single-center study

BACKGROUND

Currently, there is insufficient data about the accuracy in the diagnosing of pancreatic cystic lesions (PCLs), especially with novel endoscopic techniques such as with direct intracystic micro-forceps biopsy (mFB) and needle-based confocal laser-endomicroscopy (nCLE).

AIM

To compare the accuracy of endoscopic ultrasound (EUS) and associated techniques for the detection of potentially malignant PCLs: EUS-guided fine needle aspiration (EUS-FNA), contrast-enhanced EUS (CE-EUS), EUS-guided fiberoptic probe cystoscopy (cystoscopy), mFB, and nCLE.

METHODS

This was a single-center, retrospective study. We identified patients who had undergone EUS, with or without additional diagnostic techniques, and had been diagnosed with PCLs. We determined agreement among malignancy after 24-mo follow-up findings with detection of potentially malignant PCLs via the EUS-guided techniques and/or EUS-guided biopsy when available (EUS malignancy detection).

RESULTS

A total of 129 patients were included, with EUS performed alone in 47/129. In 82/129 patients, EUS procedures were performed with additional EUS-FNA (21/82), CE-EUS (20/82), cystoscopy (27/82), mFB (36/82), nCLE (44/82). Agreement between EUS malignancy detection and the 24-mo follow-up findings was higher when associated with additional diagnostic techniques than EUS alone [62/82 (75.6%) vs 8/47 (17%); OR 4.35, 95%CI: 2.70-7.37; P < 0.001]. The highest malignancy detection accuracy was reached when nCLE and direct intracystic mFB were both performed, with a sensitivity, specificity, positive predictive value, negative predictive value and observed agreement of 100%, 89.4%, 77.8%, 100% and 92.3%, respectively (P < 0.001 compared with EUS-alone).

CONCLUSION

The combined use of EUS-guided mFB and nCLE improves detection of potentially malignant PCLs compared with EUS-alone, EUS-FNA, CE-EUS or cystoscopy.

Endoscopic ultrasound-guided through-the-needle microforceps biopsy and needle-based confocal laser-endomicroscopy increase detection of potentially malignant pancreatic cystic lesions: A single-center study

BACKGROUND

Currently, there is insufficient data about the accuracy in the diagnosing of pancreatic cystic lesions (PCLs), especially with novel endoscopic techniques such as with direct intracystic micro-forceps biopsy (mFB) and needle-based confocal laser-endomicroscopy (nCLE).

AIM

To compare the accuracy of endoscopic ultrasound (EUS) and associated techniques for the detection of potentially malignant PCLs: EUS-guided fine needle aspiration (EUS-FNA), contrast-enhanced EUS (CE-EUS), EUS-guided fiberoptic probe cystoscopy (cystoscopy), mFB, and nCLE.

METHODS

This was a single-center, retrospective study. We identified patients who had undergone EUS, with or without additional diagnostic techniques, and had been diagnosed with PCLs. We determined agreement among malignancy after 24-mo follow-up findings with detection of potentially malignant PCLs via the EUS-guided techniques and/or EUS-guided biopsy when available (EUS malignancy detection).

RESULTS

A total of 129 patients were included, with EUS performed alone in 47/129. In 82/129 patients, EUS procedures were performed with additional EUS-FNA (21/82), CE-EUS (20/82), cystoscopy (27/82), mFB (36/82), nCLE (44/82). Agreement between EUS malignancy detection and the 24-mo follow-up findings was higher when associated with additional diagnostic techniques than EUS alone [62/82 (75.6%) vs 8/47 (17%); OR 4.35, 95%CI: 2.70-7.37; P < 0.001]. The highest malignancy detection accuracy was reached when nCLE and direct intracystic mFB were both performed, with a sensitivity, specificity, positive predictive value, negative predictive value and observed agreement of 100%, 89.4%, 77.8%, 100% and 92.3%, respectively (P < 0.001 compared with EUS-alone).

CONCLUSION

The combined use of EUS-guided mFB and nCLE improves detection of potentially malignant PCLs compared with EUS-alone, EUS-FNA, CE-EUS or cystoscopy.

Intracystic Glucose and Carcinoembryonic Antigen in Differentiating Histologically Confirmed Pancreatic Mucinous Neoplastic Cysts

INTRODUCTION

Differentiating mucinous neoplastic pancreatic cysts (MNPC) from cysts without malignant potential can be challenging. Guidelines recommend using fluid carcinoembryonic antigen (CEA) to differentiate MNPC; however, its sensitivity and specificity vary widely. Intracystic glucose concentration has shown promise in differentiating MNPC, but data are limited to frozen specimens and cohorts of patients without histologic diagnoses. This study aimed to compare glucose and CEA concentrations in differentiating MNPC using fresh fluid obtained from cysts with confirmatory histologic diagnoses.

METHODS

This multicenter cohort study consisted of patients undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic cysts during January 2013-May 2020. Patients were included if the cyst exhibited a histologic diagnosis and if both CEA and glucose were analyzed from fresh fluid. Receiver operating curve (ROC) characteristics were analyzed, and various diagnostic parameters were compared.

RESULTS

Ninety-three patients, of whom 59 presented with MNPC, met the eligibility criteria. The area under the receiver operating curve (AUROC) was 0.96 for glucose and 0.81 for CEA (difference 0.145, P = 0.003). A CEA concentration of ≥192 ng/mL had sensitivity of 62.7% and specificity of 88.2% in differentiating MNPC, whereas glucose concentration of ≤25 mg/dL had sensitivity and specificity of 88.1% and 91.2%, respectively.

DISCUSSION

Intracystic glucose is superior to CEA concentration for differentiating MNPC when analyzed from freshly obtained fluid of cysts with histologic diagnoses. The advantage of glucose is augmented by its low cost and ease of implementation, and therefore, its widespread adoption should come without barriers. Glucose has supplanted CEA as the best fluid biomarker in differentiating MNPC.

Efficacy and safety of EUS-guided through-the-needle microforceps biopsy sampling in categorizing the type of pancreatic cystic lesions

BACKGROUND AND AIMS

EUS-guided through-the-needle biopsy sampling (EUS-TTNB) using microbiopsy forceps is performed for the accurate diagnosis of pancreatic cystic lesions (PCLs). However, there are no standardized protocols for this procedure, and the amount of data on its efficacy is limited. Here, we evaluated the feasibility, efficacy, and safety of EUS-TTNB in categorizing the types of PCLs and identified the factors associated with diagnostic failure.

METHODS

The prospectively collected and maintained EUS-TTNB database at Asan Medical Center was reviewed to identify patients with PCLs who underwent EUS-TTNB between January 2019 and January 2021. The primary outcomes were technical success, diagnostic yield, and adverse events. Factors contributing to diagnostic failure and the discrepancies in the diagnosis made by conventional modalities (ie, EUS morphology, cross-sectional imaging, and cystic fluid analysis) were also evaluated.

RESULTS

Forty-five patients were analyzed. EUS-TTNB was successfully performed in all patients (technical success, 100%). Histologic diagnosis of PCLs was made in 37 patients (diagnostic yield, 82%). When comparing EUS-TTNB with a presumptive diagnosis, EUS-TTNB changed the diagnosis in 10 patients in terms of the categorization of the types of PCLs. The diagnostic yield was significantly higher in those who had 4 or more visible biopsy specimens per session (93%) than in those with fewer than 4 visible biopsy specimens per session (67%; P = .045). During follow-up, 3 patients (7%) experienced adverse events (2 acute pancreatitis, 1 intracystic bleeding), and no life-threatening adverse event occurred.

CONCLUSIONS

EUS-TTNB showed high technical feasibility, diagnostic yield, and good safety profile. EUS-TTNB may improve the categorization of the types of PCLs. Studies with standardized procedure protocols are needed to reduce the diagnostic failure for the types of PCLs.

Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know

The prevalence of pancreatic cysts has increased significantly over the last decade, partly secondary to increased quality and frequency of cross-sectional imaging. While the majority never progress to cancer, a small number will and need to be followed. The management of pancreatic cysts can be both confusing and intimidating due to the multiple guidelines with varying recommendations. Despite the differences in the specifics of the guidelines, they all agree on several high-risk features that should get the attention of any clinician when assessing a pancreatic cyst: presence of a mural nodule or solid component, dilation of the main pancreatic duct (or presence of main duct intraductal papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology on pancreatic cyst fluid aspiration. Other important criteria to consider include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9 levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related to the cystic lesion.

Diagnostic accuracy of EUS-guided through-the-needle-biopsies and simultaneously obtained fine needle aspiration for cytology from pancreatic cysts: A systematic review and meta-analysis

OBJECTIVES

To address the diagnostic accuracy of endoscopic ultrasound guided through-the-needle-biopsies (TTNBs) and simultaneously obtained cytology samples from pancreatic cysts compared to the final histopathological diagnosis of the surgical specimen, and to give an overview of ancillary tests performed on TTNBs.

METHODS

A literature search was conducted in MEDLINE, Embase and Scopus. Studies were included in the meta-analysis, if they had data for TTNB, cytology and a surgical specimen of pancreatic cysts as reference standard. The assessment of the risk of bias and quality of the included studies was conducted using the modified QUADAS-2 tool.

RESULTS

Ten studies with 99 patients were included in the meta-analysis. Data regarding study design and clinicopathological features were extracted systematically. For TTNB, pooled sensitivity was 0.86 (95 % CI 0.62-0.96), specificity 0.95 (95 % CI 0.79-0.99) and area under the curve (AUC) 0.86 for the diagnosis of a mucinous cyst and pooled sensitivity was 0.78 (95 % CI 0.61-0.89), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.92 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.69 (95 % CI 0.50-0.83), specificity 0.47 (95 % CI 0.28-0.68) and AUC 0.49. For cytology performed simultaneously, pooled sensitivity was 0.46 (95 % CI 0.35-0.57), specificity 0.90 (95 % CI 0.46-0.99) and AUC 0.64 for the diagnosis of mucinous cysts, and pooled sensitivity was 0.38 (95 % CI 0.23-0.55), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.84 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.29 (95 % CI 0.21-0.39), specificity 0.45 (95 % CI 0.25-0.66) and AUC 0.30. Furthermore, immunohistochemical stains can be useful to establish the specific cyst subtype.

CONCLUSIONS

TTNBs have a higher sensitivity and specificity than cytology for the diagnosis of mucinous cyst and high- risk cysts of the pancreas.

EUS-guided biopsy versus confocal laser endomicroscopy in patients with pancreatic cystic lesions: A systematic review and meta-analysis

Background and Objectives:

Pancreatic cystic lesions (PCLs) are frequent incidental findings on cross-sectional imaging and represent a diagnostic challenge as different kinds of PCLs harbor a dissimilar risk of malignancy. Two diagnostic tools have recently been developed and introduced: through-the-needle biopsy (TTNB) and needle-based confocal laser endomicroscopy (nCLE). The aim of this meta-analysis was to compare the diagnostic yield and performance, as well as the safety profile of the two methods.

Methods:

This meta-analysis was performed in accordance with the PRISMA statement. Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies with five or more patients undergoing either endoscopic ultrasound (EUS)-TTNB or EUS-nCLE for a PCL. Reviews, case reports, editorials, conference abstracts, and studies on exclusively solid pancreatic lesions were excluded. Outcomes of interest were diagnostic yield and performance, safety, and technical success.

Results:

Twenty studies with 1023 patients were included in the meta-analysis. Pooled diagnostic yield of EUS-nCLE was higher compared to EUS-TTNB (85% vs. 74%, P < 0.0001), while diagnostic performance was high and comparable for both methods (pooled sensitivity: 80% vs. 86% and pooled specificity: 80% vs. 83% for TTNB and nCLE, respectively, P > 0.05). Pooled estimate of total adverse event (AE) rate was 5% in the TTNB group and 3% in the nCLE group, P = 0.302. Technical success rates were high and comparable (94% and 99% for EUS-TTNB and nCLE, respectively; P = 0.07).

Conclusion:

EUS-TTNB and EUS-nCLE have a similar safety profile with a relatively low number of AEs. Technical success, sensitivity, and specificity are comparable; however, EUS-nCLE seems to have a slightly higher diagnostic yield.

Endoscopic ultrasound-guided through-the-needle microforceps biopsy improves diagnostic yield for pancreatic cystic lesions: a systematic review and meta-analysis

Background and study aims  Given variable diagnostic yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for pancreatic cystic lesions (PCLs), a through-the-needle (TTN) microforceps biopsy device passed through a 19-gauge FNA needle has been devised to improve tissue sampling. This was a systematic review and meta-analysis to evaluate the feasibility, diagnostic yield, and safety of EUS-guided TTN microforceps biopsy for diagnosis of PCLs. Methods  Individualized searches were developed in accordance with PRISMA and MOOSE guidelines. This was a cumulative meta-analysis performed by calculating pooled proportions with rates estimated using random effects models. Measured outcomes included pooled technical success, diagnostic yield, accuracy, and procedure-associated adverse events (AEs) as well as comparison to conventional FNA. Results  Eleven studies (n = 518 patients; mean age 64.13 ± 5.83 years; 58.19 % female) were included. Mean PCL size was 33.39 ± 3.72 mm with the pancreatic head/uncinate (35.50 %) being the most common location. A mean of 2.47 ± 0.92 forceps passes were performed with a mean of 2.79 ± 0.81 microbiopsies obtained per lesion. Pooled technical success was 97.12 % (95 % CI, 93.73-98.71; I ²  = 34.49) with a diagnostic yield of 79.60 % (95 % CI, 72.62-85.16; I ²  = 56.00), and accuracy of 82.76 % [(95 % CI, 77.80-86.80; I ²  = 0.00). The pooled serious adverse event rate was 1.08 % (95 % CI, 0.43-2.69; I ²  = 0.00). Compared to conventional FNA, TTN microforceps biopsy resulted in significant improvement in diagnostic yield [OR 4.79 (95 % CI: 1.52-15.06; P  = 0.007)] and diagnostic accuracy [OR 8.69 (95 % CI, 1.12-67.12; P  = 0.038)], respectively. Conclusions  EUS-guided TTN microforceps biopsy appears to be safe and effective for diagnosis of PCLs with improvement in diagnostic yield and accuracy when compared to FNA alone.

EUS-guided through-the-needle microbiopsy of pancreatic cysts: Technical aspects (with video)

Pancreatic cystic lesions are frequently encountered and diagnostically challenging as some of the cysts may have malignant potential (mucinous) while others are completely benign (serous). EUS-guided through-the-needle biopsy (EUS-TTNB) of the cyst wall has recently been introduced as an alternative to cyst fluid cytology. Several studies have shown that microbiopsies outperform cytology in terms of distinction between mucinous and nonmucinous lesions, but also in determining the specific cyst diagnosis. However, little is known about the technical aspects of tissue sampling with TTNB. Herein, we summarize our experience with the procedure in a tertiary referral center and discuss indications, technical aspects, and safety of the procedure. Most adverse events (AEs) associated with the procedure are mild, but there is emerging evidence that the rate of postprocedural pancreatitis is higher compared to standard fine-needle aspiration. The added diagnostic yield should therefore be placed in perspective with an increased risk of AEs. Prospective studies are warranted to fully identify which patient groups could benefit from EUS-TTNB.