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

Immune Checkpoint Inhibitor-induced Pancreatitis with Pancreatic Enlargement Mimicking Autoimmune Pancreatitis: A Case Report and Review of the Literature

A 61-year-old woman was administered 35 cycles of pembrolizumab for the treatment of recurrent endometrial cancer, achieving a complete response. She presented with asymptomatic pancreatic enlargement and elevated hepatobiliary enzymes, but amylase and lipase levels were within the normal ranges. Intrapancreatic bile duct stenosis due to pancreatic enlargement was present, mimicking autoimmune pancreatitis on computed tomography performed before the onset of clinical manifestations. A histological examination of a biopsy specimen showed lymphocyte and plasma cell infiltration with dense fibrosis in the stroma. The patient was successfully treated with oral prednisolone. There were no manifestations of recurrent pancreatitis after tapering the prednisolone dose.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical value of endoscopic ultrasound sound speed in differential diagnosis of pancreatic solid lesion and prognosis of pancreatic cancer

BACKGROUND

Differential diagnosis of pancreatic solid lesion (PSL) and prognosis of pancreatic cancer (PC) is a clinical challenge. We aimed to explore the differential diagnostic value of sound speed (SS) obtained from endoscopic ultrasonography (EUS) in PSL and the prognostic value of SS in PC.

METHODS

Patients with PSL in The Third Xiangya Hospital of Central South University from March 2019 to October 2019 were prospectively enrolled, who obtained SS from PSL. Patients were divided into the PC group and the pancreatic benign lesion (PBL) group. SS1 is the SS of lesions and SS2 is the SS of normal tissues adjacent to lesions. Ratio1 is equal to SS1 divided by SS2 of PSL (ratio1 = SS1/SS2).

RESULTS

Eighty patients were enrolled (24 PBL patients, 56 PC patients). SS1 and ratio1 in PC group were higher compared with PBL group (SS1:1568.00 vs. 1550.00, Z = -2.066, p = 0.039; ratio1: 1.0110 vs. 1.0051, Z = -3.391, p = 0.001). The SS1 in PC (Z = -6.503, p < 0.001) was higher compared to SS2. In the nonsurgical group of PC, low ratio1 predicted high overall survival (OS) (7.000 months vs. 4.000 months; p = 0.039). In the surgical group of PC, low SS1 was associated with low median OS (4.000 months vs. 12.000 months; p = 0.033).

CONCLUSIONS

SS plays a vital role in distinguishing between PBL and PC. Higher SS1 and ratio1 obtained by EUS are more related to PC than PBL. In PC patients, high SS1 may predict pancreatic lesions. In the nonsurgical group of PC, low ratio1 may predict high OS. However, in the surgical group of PC, low SS1 may predict low OS.

Factors Influencing the Diagnostic Performance of Repeat Endoscopic Ultrasound-Guided Fine-Needle Aspiration/Biopsy after the First Inconclusive Diagnosis of Pancreatic Solid Lesions

Background/Aims

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) is essential in diagnosing solid pancreatic lesions (SPLs), but without rapid on-site evaluation (ROSE), a repeat EUS-FNA/B is crucial for clarifying an inconclusive diagnosis. We aimed to evaluate factors associated with improved diagnostic performance of repeat EUS-FNA/B for initially inconclusive SPL diagnoses without ROSE.

Methods

Of 5,894 patients subjected to EUS-FNA/B, 237 (4.0%) with an initially inconclusive diagnosis of SPLs were retrospectively enrolled from five tertiary medical centers between January 2016 and June 2021. Diagnostic performance and procedural factors of EUS-FNA/B were analyzed.

Results

The diagnostic accuracies of first and repeat EUS-FNA/B were 96.2% and 67.6%, respectively. Of 237 patients with an inconclusive diagnosis from initial EUS-FNA/B, 150 were pathologically diagnosed after repeat EUS-FNA/B. In multivariate analysis of repeat EUS-FNA/B, tumor location (body/tail vs head: odds ratio [OR], 3.74; 95% confidence interval [CI], 1.48 to 9.46), number of needle passes (≥4 vs ≤3: OR, 4.80; 95% CI, 1.44 to 15.99), needle type (FNB vs FNA: OR, 3.26; 95% CI, 1.44 to 7.36), needle size (22 gauge vs 19/20 gauge: OR, 2.35; 95% CI, 1.19 to 4.62), and suction method (suction vs others: OR, 5.19; 95% CI, 1.30 to 20.75) were associated with a significantly improved diagnostic performance.

Conclusions

Repeat EUS-FNA/B is essential for patients with an inconclusive EUS-FNA/B without ROSE. To improve the diagnostic performance of repeated EUS-FNA/B, it is recommended that 22-gauge FNB needles, ≥4 needle passes, and suction methods are used.

Role of Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) in the Diagnosis of Suspicious Malignant Esophageal Strictures

(1) Background: The accurate diagnosis of esophageal strictures is quite critical for optimizing medical intervention. However, the diagnosis of suspicious malignant esophageal strictures with intact mucosa appearance and negative biopsy results is challenging. This study aimed to evaluate the role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis of suspicious esophageal strictures. (2) Methods: We retrospectively analyzed the cases with suspicious malignant esophageal strictures that underwent EUS-FNA, with or without rapid on-site evaluation (ROSE), in our hospital from April 2017 to September 2022. Their clinical manifestations, imaging examinations, gastroscopic examinations, EUS-FNA results, and therapeutic strategies were retrospectively recorded and analyzed. (3) Results: A total of 23 patients (15 male and 8 female) were enrolled in this study. Based on EUS-FNA results, 18 patients were diagnosed with malignancies, including 16 cases of primary esophageal cancer (13 squamous carcinomas and 3 adenocarcinomas), 1 case of mediastinal cancer, and 1 case of metastatic esophageal cancer; 1 case of tuberculosis was also confirmed by EUS-FNA. Among 4 cases of ambiguous diagnosis with EUS-FNA, 1 was diagnosed with an esophageal glomus tumor after surgical removal, and 2 patients survived for several years without medical intervention, which hinted at the possibility of benign esophageal strictures. No major complications, including bleeding or perforation, were observed. (4) Conclusions: EUS-FNA may serve as a safe and effective diagnostic tool in suspicious malignant esophageal strictures with accurate specimen acquisition, especially for biopsy-negative cases.

Comparison between three types of needles for endoscopic ultrasound-guided tissue acquisition of pancreatic solid masses: a multicenter observational study

It is debatable which needle has clear superiority of diagnostic performance in endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) of solid pancreatic masses. This study aimed to compare the performance of three needles and determine the variables that affect diagnostic accuracy. From March 2014 to May 2020, 746 patients with solid pancreatic masses who underwent EUS-FNB using three types of needles (Franseen needle, Menghini-tip needle, and Reverse-bevel needle) were retrospectively reviewed. Multivariate analysis using a logistic regression model was used to identify factors related to diagnostic accuracy. There were significant differences between the groups regarding the procurement rate of the histologic and optimal quality cores (Franseen vs. Menghini-tip vs. Reverse-bevel: 98.0% [192/196] vs. 85.8% [97/113] vs. 91.9% [331/360], P < 0.001 and 95.4% [187/196] vs. 65.5% [74/113] vs. 88.3% [318/360], P < 0.001, respectively). The sensitivity and accuracy using histologic samples were 95.03% and 95.92% for Franseen, 82.67% and 88.50% for Menghini-tip, and 82.61% and 85.56% for Reverse-bevel needles, respectively. In direct comparison between the needles using histologic samples, the Franseen needle showed significantly superior accuracy than the Menghini-tip (P = 0.018) and Reverse-bevel needles (P < 0.001). Multivariate analysis indicated that tumor size ≥ 2 cm (odds ratio [OR] 5.36, 95% confidence interval [CI] 3.40-8.47, P < 0.001) and fanning technique (OR 1.70, 95% CI 1.00-2.86, P = 0.047) were significantly associated with an accurate diagnosis. EUS-FNB using the Franseen needle enables the acquisition of a larger and more adequate histologic core tissue and achieves an accurate histological diagnosis when using the fanning technique.

A Meta-Analysis Comparing Endoscopic Ultrasound-guided Fine-needle Aspiration With Endoscopic Ultrasound-guided Fine-needle Biopsy

BACKGROUND

The superiority between endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is still a debate. The purpose of this meta-analysis was to compare the diagnostic value and safety of these 2 needles in sampling of all solid lesions and separately pancreatic lesions.

MATERIALS AND METHODS

PubMed, EMBASE, and the Cochrane library were searched for randomized controlled studies that reported the comparison of FNA and FNB in solid mass. Outcome measures included diagnostic accuracy, number of needle passes, diagnostic adequacy, presence of tissue cores, and adverse events. Standard error, upper and lower confidence intervals at 95% confidence interval for the risk were obtained using Review Manager Version 5.3 which was also used to generate forest plots for pooled analysis. The random or fixed effect model was applied depending on the heterogeneity ( I2 ).

RESULTS

Eighteen randomized control trial studies with a total of 2718 patients (1141 patients with EUS-FNA, 1108 with EUS-FNB, and remaining 469 patients were sampled with both needles alternatively) were included in the meta-analysis.FNB group has relatively good diagnostic accuracy relative risk (RR): 0.94, 0.92-0.97; P =0.0002), diagnostic adequacy (RR: 0.95, 0.9-1.0; P =0.04) and high quality histologic yield compared (RR: 0.77, 0.64-0.93; P =0.007) with the FNA group in solid gastrointestinal lesions, and the number of needle passes to obtain sufficient tissue (mean difference: 0.54, 0.45-0.64; P <0.00001) was lower in the FNB group. For solid pancreatic disease only, there was no difference in diagnostic accuracy (RR: 0.97, 0.93-1.01, P =0.13) or quality histologic yield (RR: 0.60, 0.29-1.23; P =0.16). The rate of adverse events (RR: 1.04, 0.48-2.29; P =0.92) did not significantly differ between FNA and FNB groups.

CONCLUSIONS

In solid gastrointestinal lesions, FNB is associated with a relatively better diagnostic adequacy, diagnostic adequacy and tissue cores rates, and less number of needle passes. For solid pancreatic disease only, there is no difference in diagnostic accuracy or tissue cores rates.

Safety and efficacy of endoscopic ultrasound as a diagnostic and therapeutic tool in pediatric patients: a multicenter study

BACKGROUND

Despite the well-established diagnostic and therapeutic applications of endoscopic ultrasound (EUS) in adults, data about its use in children are limited. In this study, we tried to assess the feasibility, safety, and clinical impact of EUS in pediatric patients.

METHODS

Data of pediatric patients (<18 years) referred for EUS over a 3-year period to the endoscopy units of four Egyptian tertiary centers were retrospectively analyzed. Significant impact was defined as a new diagnosis or treatment attributed to the EUS procedure.

RESULTS

Twenty-four diagnostic and five therapeutic EUS procedures were conducted in 29 children with a median age of 9 years. Indications for EUS included assessment of solid pancreatic mass (n = 3), pancreatic cyst (n = 2), suspected chronic pancreatitis (n = 9), pancreatic pseudocyst (PPC) (n = 5), recurrent hypoglycemia (n = 1), bile duct mass (n = 1), subepithelial lesion (esophageal, duodenal or anorectal) (n = 4), mediastinal mass (n = 1), pelvic mass (n = 3), and mass at splenic hilum (n = 1). Therapeutically, five patients underwent cystogastrostomy for symptomatic PPC with 100% technical and clinical success. EUS was able to diagnose 21 out of the other 24 patients. EUS-guided tissue acquisition was performed in 11 patients with definitive histopathological diagnosis in 10 patients (91%). There was no procedure-related major complication, while minor complications occurred in two cases (transient pain in one case, temporary fever, and vomiting in two cases).

CONCLUSION

Standard linear EUS equipment and accessories can be used safely and effectively in selected pediatric patients for diagnostic and therapeutic purposes.

Managing adverse events after endoscopic ultrasound-guided drainage of the biliary tract and pancreatic fluid collections: Narrative review (with video)

Endoscopic ultrasound (EUS)-guided therapeutic procedures have become increasingly common in clinical practice. The development of EUS-guided fine needle aspiration cytology led to the concept of interventional EUS. However, it carries a considerable risk of adverse events (AEs), which occur in approximately 23% of the procedures performed for the drainage of pancreatic fluid collections and 2.5-37.0% of those performed for drainage of the biliary tract. Although the vast majority of AEs occurring after EUS-guided drainage are mild, a deep understanding of such events is necessary for their appropriate management. Because EUS-guided drainage is a novel procedure, there have been few studies of the topic. To our knowledge, this is the first narrative review that focuses on the management and resolution of AEs occurring after EUS-guided drainage of pancreatic fluid collections or the biliary tract. We also include an explanatory video.