Comparison of 22G reverse-beveled versus standard needle for endoscopic ultrasound-guided sampling of solid pancreatic lesions

Collaboration of community hospital endosonographers improves diagnostic yield of endoscopic ultrasonography guided tissue acquisition of solid pancreatic lesions

Background and study aims  Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is the method of choice for establishing a pathological diagnosis of solid pancreatic lesions. Data on quality and yield of EUS-guided TA performed in community hospitals are lacking. A study was performed to determine and improve the diagnostic yield of EUS-guided TA in a group of community hospitals. Methods  Following analysis of the last 20 EUS-guided TA procedures of solid pancreatic lesions performed in each of four community hospitals, a collaborative EUS interest group was formed and a prospective registry was started. During meetings of the interest group, feedback on results per center were provided and strategies for improvement were discussed. Results  In the BEFORE team formation cohort, 80 procedures were performed in 66 patients. In the AFTER team formation cohort, 133 procedures were performed in 125 patients. After team formation, the rate of adequate sample increased from 80 % (95 %CI [0.7 - 0.9]) to 95 % (95 %CI [0.9 - 1.0]) , diagnostic yield of malignancy improved from 28 % (95 %CI [0.2 - 0.4]) to 64 % (95 % CI [0.6 - 0.7]), and sensitivity of malignancy improved from 63 % (95 %CI [0.4 - 0.8]) to 84 % (95 %CI [0.8 - 0.9]). Multivariate regression analysis revealed team formation to be the only variable significantly associated with an increased rate of adequate sample. Conclusions  Formation of a regional EUS interest group with regular feedback on results per center, and discussions on methods and techniques used, significantly improved the outcome of EUS-guided TA procedures in patients with solid pancreatic lesions in community hospitals.

EUS-FNB with or without on-site evaluation for the diagnosis of solid pancreatic lesions (FROSENOR): Protocol for a multicenter randomized non-inferiority trial

BACKGROUND

Rapid on-site evaluation (ROSE) of cytological specimensacquired with EUS-guided fine needle aspiration (EUS-FNA) represents the most accurate available technique to reach a definitive diagnosis in patients with pancreatic solid masses. Recently, needles with high histological yield have been developed for EUS-guided fine needle biopsy (EUS-FNB), with which the need for ROSE can be potentially overcome.

AIMS

The primary aim is to compare the diagnostic accuracy of EUS-FNB with or without ROSE. The main endpoint will be measured against the gold standard diagnosis (surgical pathology whenever available or diagnostic work-up in agreement with a clinical course of at least six months). Secondary endpoints include: (a) safety; (b) presence of tissue core; (c) quality of specimens; (d) time of the sampling procedure. Reliability of macroscopic on-site evaluation (MOSE) by endosonographers will be also assessed.

METHODS

FROSENOR is an international randomized non-inferiority ongoing study at sixteen centers in four continents. Eight hundred patients will be randomized in two arms (EUS-FNB + ROSE vs. EUS-FNB alone) and outcomes compared. Sample size has been calculated in order to demonstrate the non-inferiority of FNB alone. Randomization and data collection will be performed online.

DISCUSSION

This study will ascertain if ROSE is still needed when performing EUS-FNB of solid pancreatic lesions.

Impact of endoscopic ultrasound-guided fine-needle biopsy on the diagnosis of subepithelial tumors: A propensity score-matching analysis

BACKGROUND AND AIM

Immunohistological evaluations are essential for diagnosing subepithelial tumors (SET). However, endoscopic ultrasound-guided sampling using fine-needle aspiration (FNA) needles is limited in its ability to procure core tissue for immunostaining. Fine-needle biopsy (FNB) needles may mitigate this limitation. The present study aimed to examine the efficacy of FNB needles for procuring samples that enable the diagnosis of SET.

METHODS

One hundred sixty patients were included in the study and separated into those whose samples were obtained using FNB needles (FNB group) and those whose samples were procured using FNA needles (FNA group). Groups were compared regarding the conclusive diagnosis rate and unwarranted resection rate. Propensity score matching was introduced to reduce selection bias.

RESULTS

Rates at which conclusive diagnoses were reached through adequate immunohistological evaluations were 82% and 60% in the FNB and FNA groups, respectively; this difference was significant (P = 0.013). Unwarranted resection rate was significantly lower in the FNB group (2%) than in the FNA group (14%; P = 0.032). Multivariate analyses showed that lesions ≤20 mm were a significant risk factor for lower conclusive diagnosis rates following the use of FNB needles (P = 0.017).

CONCLUSIONS

Fine-needle biopsy needles can be useful for obtaining samples that facilitate the diagnosis of SET and for avoiding unwarranted resections. However, FNB needles may be less advantageous for small SET.

A multicenter randomized trial comparing a 25-gauge EUS fine-needle aspiration device with a 20-gauge EUS fine-needle biopsy device

BACKGROUND AND AIMS

Several studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle.

METHODS

Consecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders.

RESULTS

A total of 608 patients were allocated to FNA (n = 306) or FNB (n = 302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (P = .043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, P < .001), accuracy for malignancy (87% vs 78%, P = .002) and Bethesda classification (82% vs 72%, P = .002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; P = .004), and did not differ among centers (P = .836).

CONCLUSION

The 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.).

Comparison between 22G aspiration and 22G biopsy needles for EUS-guided sampling of pancreatic lesions: A meta-analysis

Robust data in favor of clear superiority of 22G fine-needle biopsy (FNB) over 22G FNA for an echoendoscopic-guided sampling of pancreatic masses are lacking. The objective of this study is to compare the diagnostic outcomes and sample adequacy of these two needles. Computerized bibliographic search on the main databases was performed and restricted to only randomized controlled trials. Summary estimates were expressed regarding risk ratio (RR) and 95% confidence interval. A total of 11 trials with 833 patients were analyzed. The two needles resulted comparable in terms of diagnostic accuracy (RR 1.02, 0.97–1.08; P = 0.46), sample adequacy (RR 1.01, 0.96–1.06; P = 0.61), and histological core procurement (RR 1.01, 0.89–1.15; P = 0.86). Pooled sensitivity in the diagnosis of pancreatic cancer was 93.1% (87.9%–98.4%) and 90.4% (86.3%–94.5%) with biopsy and aspirate, respectively, whereas specificity for detecting pancreatic cancer was 100% with both needles. Analysis of the number of needle passes showed a nonsignificantly positive trend in favor of FNB (mean difference: −0.32, −0.66–0.02; P = 0.07). Our meta-analysis stands for a nonsuperiority of 22G FNB over 22G FNA; hence, no definitive recommendations on the use of a particular device can be made.

Recent advancement in EUS-guided fine needle sampling

EUS-guided tissue acquisition technique plays an essential role for evaluation of gastrointestinal tumors. Several components affect the yield of EUS-guided tissue acquisition outcomes such as sampling techniques, use of ROSE (rapid onsite evaluation), training and experience, and needle designs. In this review we discuss advancement in EUS-guided fine needle sampling.

22-Gauge biopsy needles have a better histological diagnostic yield in the discrimination of specific pancreatic solid neoplasms

BACKGROUND

To overcome the limitations of using cytological specimen alone for the diagnosis of challenging pancreatic lesions, biopsy needles have been developed to procure histological specimens during EUS, especially for the discrimination of several specific pancreatic tumors requiring adequate histological samples. The aim of this study was to compare the diagnostic yield of EUS-guided 22-gauge (G) fine needle aspiration (FNA) needles and 22G fine needle biopsy (FNB) needles for sampling pancreatic masses.

METHODS

We conducted a retrospective study of all EUS-guided sampling performed between November 2012 and April 2016. 422 cases sampled with a 22G FNA needle (N = 254) or a 22G FNB needle (N = 168) were recruited for this study. The specimen quality analyses, technical characteristics, accuracy, sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) for the pancreatic masses were reviewed and compared.

RESULTS

There was no significant difference in the procurement of adequate histological specimens (75.0% vs. 79.5%; p = .277) or the presence of diagnostic histological specimens (71.3% vs. 77.4%; p = .155) between FNA and FNB groups, respectively. There were also no significant differences in the accuracy, sensitivity, specificity, PPVs, or NPVs of the cytological, histological, and overall analyses for FNA and FNB groups in the diagnosis of pancreatic malignancy. However, 22G biopsy needles demonstrated a better histological diagnostic yield in the discrimination of pancreatic adenocarcinoma and non-adenocarcinoma pancreatic neoplasms than 22G FNA needles (69.8% vs. 57.9%, p = .033).

CONCLUSIONS

22G FNB needle demonstrated a better histological diagnostic yield in the differentiation between pancreatic adenocarcinoma and non-adenocarcinoma pancreatic neoplasms.

Touch imprint cytology on endoscopic ultrasound fine-needle biopsy provides comparable sample quality and diagnostic yield to standard endoscopic ultrasound fine-needle aspiration specimens in the evaluation of solid pancreatic lesions

OBJECTIVES

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the gold standard for the diagnosis of solid pancreatic lesions (SPLs). Cytological samples can also be obtained using touch imprint cytology (TIC) on EUS fine-needle biopsy (FNB) specimens. We aimed to compare sample quality and diagnostic yield of EUS-FNA-standard cytology (EUS-FNA-SC) to that of EUS-FNB-TIC in a series of patients with SPLs.

METHODS

Thirty-two consecutive patients referred for EUS-tissue acquisition of SPLs who underwent rapid on-site evaluation of both EUS-FNA-SC and paired EUS-FNB-TIC during the same endoscopic session were retrospectively identified. Sample quality (evaluated in terms of blood contamination, presence of clots, tissue casts, cellularity, and necrosis) and diagnostic yield were compared between the techniques.

RESULTS

The mean number of passes to reach diagnosis at rapid on-site evaluation was similar between EUS-FNA-SC and EUS-FNB-TIC (1.09 ± 0.3 vs 1.13 ± 0.34, P = .711). EUS-FNA-SC scores of sample quality were comparable to those of EUS-FNB-TIC (blood contamination, 2.47 ± 1.11 vs 2.25 ± 1.14, P = .109; clots, 1.25 ± 0.76 vs 1.19 ± 0.69, P = .624; tissue casts, 3.56 ± 0.88 vs 3.59 ± 1.09, P = .872; cellularity, 2.84 ± 1.11 vs 3.09 ± 1.09, P = .244; necrosis, 2.25 ± 1.08 vs 2.53 ± 1.02 P = .059; total score, 12.38 ± 2.88 vs 17.66 ± 2.38, P = .536). Adequacy, sensitivity and diagnostic accuracy of the two sampling techniques were equal (93.7%, 90.6% and 90.6%, respectively).

CONCLUSIONS

EUS-FNB-TIC provides comparable samples to those of EUS-FNA-SC and combines the benefits of cytology and histology for the evaluation of SPLs by employing a single needle during the same endoscopic procedure.

Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2: Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3: Bile duct cannulation rate (key performance measure, at least 90 %); 4: Tissue sampling during EUS (key performance measure, at least 85 %); 5: Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6: Bile duct stone extraction (key performance measure, at least 90 %); 7: Post-ERCP pancreatitis (key performance measure, less than 10 %). 8: Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.

Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at centre and endoscopist level: 1 Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90%); 2 antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95%); 3 bile duct cannulation rate (key performance measure, at least 90%); 4 tissue sampling during EUS (key performance measure, at least 85%); 5 appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95%); 6 bile duct stone extraction (key performance measure, at least 90%); 7 post-ERCP pancreatitis (key performance measure, less than 10%); and 8 adequate documentation of EUS landmarks (minor performance measure, at least 90%). This present list of quality performance measures for ERCP and EUS recommended by the ESGE should not be considered to be exhaustive; it might be extended in future to address further clinical and scientific issues.

Concise review on the comparative efficacy of endoscopic ultrasound-guided fine-needle aspiration vs core biopsy in pancreatic masses, upper and lower gastrointestinal submucosal tumors

Endoscopic ultrasound (EUS)-guided fine needle aspiration with or without biopsy (FNA/FNB) are the primary diagnostic tools for gastrointestinal submucosal tumors. EUS-guided fine needle aspiration (EUS-FNA) is considered a first line diagnostic method for the characterization of pancreatic and upper gastrointestinal lesions, since it allows for the direct visualization of the collection of specimens for cytopathologic analysis. EUS-FNA is most effective and accurate when immediate cytologic assessment is permitted by the presence of a cytopathologist on site. Unfortunately, the accuracy and thus the diagnostic yield of collected specimens suffer without this immediate analysis. Recently, a EUS-FNB needle capable of obtaining core samples (fine needle biopsy, FNB) has been developed and has shown promising results. This new tool adds a new dimension to the diagnostic and therapeutic utility of this technique. The aim of the present review is to compare the efficacy of EUS-FNA to that afforded by EUS-FNB in the characterization of pancreatic masses and of upper and lower gastrointestinal submucosal tumors.

Histologic retrieval rate of a newly designed side-bevelled 20G needle for EUS-guided tissue acquisition of solid pancreatic lesions

Background

Innovative approaches to improve diagnostic yield of endoscopic ultrasound-guided tissue acquisition (EUS-TA) have focused on needle design with development of fine-needle biopsy (FNB) needles with microcore-acquisition technology. Recently, a 20-gauge (20G) antegrade-cutting-side-bevelled biopsy needle (ProCore®) was developed for EUS-TA, but data about its diagnostic performance and histological capability are scant.

Objectives

We assessed the diagnostic performance and histologic retrieval rate of a new 20G antegrade-cutting-side-bevelled biopsy needle compared with a 22G reverse-side-bevelled needle for EUS sampling of solid pancreatic lesions.

Patients and methods

A retrospective analysis of 238 consecutively collected patients who underwent EUS-TA using a 20G or a 22G ProCore® needle, without rapid on-site evaluation (ROSE), was conducted at two centres.Sensitivity, specificity, positive predictive value and negative predictive value were calculated. Histologic tissue retrieval was evaluated applying a scoring system for each case.

Results

Sensitivity and specificity were estimated as 98.4-100% in the 20G-, and 94.9-100% in the 22G-needle groups, respectively (p > 0.99). The 20G procured more histologic-grade tissues (92.6% vs 49.5%, p < 0.0001) achieved by a lower number of passes (2.64 vs 3.44, p < 0.0001) compared to the 22G.

Conclusions

Both side-bevelled FNB needles achieved a high diagnostic sensitivity. The 20G-side-bevelled needle obtained a significantly higher microcore retrieval rate.

A Comparison of Endoscopic Ultrasound-Guided Fine-Needle Aspiration and Fine-Needle Biopsy in the Diagnosis of Solid Pancreatic Lesions

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is the method of choice for sampling pancreatic lesions. This study compares the diagnostic accuracy and safety of FNB using a novel core needle to FNA in solid pancreatic lesions.

METHODS

A retrospective review of patients in whom EUS FNA or FNB was performed for solid pancreatic lesions was conducted. Diagnostic performance was calculated based upon a dual classification system: classification 1, only malignant pathology considered a true positive, versus classification 2, atypical, suspicious, and malignant pathology considered a true positive.

RESULTS

43 patients underwent FNB compared with 51 FNA. Using classification 1, sensitivity was 74.0% versus 80.0%, specificity 100% versus 100%, and diagnostic accuracy 77.0% versus 80.0% for FNB versus FNA, respectively (all p > 0.05). Using classification 2, sensitivity was 97% versus 94.0%, specificity 100% versus 100%, and diagnostic accuracy 98.0% versus 94.0% for FNB versus FNA, respectively (all p > 0.05). FNB required significantly fewer needle passes (median = 2) compared to FNA (median = 3; p < 0.001). Adverse events occurred in two (4.5%) FNB patients compared with none in the FNA group (p > 0.05).

CONCLUSION

FNA and FNB have comparable sensitivity and diagnostic accuracy. FNB required fewer passes.

Prospective histological evaluation of a 20G core trap with a forward-cutting bevel needle for EUS-FNA of pancreatic lesions

BACKGROUND

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been established as a method to obtain tissues of various organs. To obtain sufficient tissue has clinical impact to facilitate the diagnosis by clinical pathologists, the assessment and subtyping of various neoplasms, and for further immunohistochemical investigations of tumor type. Recently, a novel 20G core trap with a forward-cutting beveled FNA needle (ProC-F) has become available. The aim of this prospective study was to evaluate the feasibility and diagnostic yield of EUS-FNA for pancreatic lesions using this needle.

PATIENTS AND METHOD

In this study, the first puncture was performed using the ProC-F. Only tissue obtained with the first puncture using the ProC-F was used to evaluate diagnostic yield of ProC-F. The second puncture was performed using a 22G standard FNA needle using the same technique as for the first puncture. Second puncture was performed if the endosonographer did not feel that sufficient tissue had not been obtained by first puncture.

RESULTS

Fifty-three consecutive patients who underwent EUS-FNA for pancreatic lesions were prospectively enrolled. The technical success rate of EUS-FNA using the ProC-F was 98.1% (52/53). The rate of adequate tissue obtained by ProC-F was 96.2% (50/52). On the other hand, the rate of adequate tissue obtained by the standard needle was 71.1%. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of the ProC-F and the standard needle were 92.5, 100, 100, 76.9, and 94.0%, and 85.2, 100, 100, 55.6, and 87.5%, respectively. Diagnostic yield of ProC-F about sensitivity (P = 0.027), NPV (P = 0.035), and accuracy (P = 0.004) was significantly higher than of standard needle. Adverse events were not seen in any patients.

CONCLUSIONS

Although only tissue obtained by the first puncture was evaluated, the rate of adequate tissue and the histologic diagnostic yield for pancreatic lesions were extremely high using the ProC-F.

Fine needle biopsy is superior to fine needle aspiration in endoscopic ultrasound guided sampling of pancreatic masses: A meta-analysis of randomized controlled trials

BACKGROUND

The comparison between endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) and EUS guided fine needle biopsy (FNB) in sampling pancreatic masses is still controversial.

METHODS

A systematic search was conducted in PubMed and Web of Science to identify all relevant randomized controlled trials (RCTs). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for dichotomous outcomes of interest (specimen adequacy, diagnostic accuracy, complications, and technical success), while mean difference (MD) and 95% CI were pooled for continuous variables (number of needle passes required for diagnosis).

RESULTS

Eleven RCTs were identified with a total of 694 EUS-FNA cases and 688 EUS-FNB cases. Compared with EUS-FNA, EUS-FNB had a better specimen adequacy (OR: 1.83, 95% CI: 1.27-2.64), higher diagnostic accuracy (OR: 1.62, 95% CI: 1.17-2.26), and fewer number of needle passes (MD: 0.69, 95% CI: 1.18 to 0.20). No significant difference was found in complications (OR: 1.01, 95% CI: 0.27-3.78) and technical success (OR: 0.13, 95% CI: 0.02-1.07).

CONCLUSION

EUS-FNB is superior to EUS-FNA in sampling pancreatic masses.

EUS-guided reverse bevel fine-needle biopsy sampling and open tip fine-needle aspiration in solid pancreatic lesions - a prospective, comparative study

OBJECTIVES

Different diagnostic entities can present as solid pancreatic lesions (SPL). This study aimed to explore the utility of endoscopic ultrasound-guided reverse bevel fine-needle biopsy sampling (EUS-FNB) in SPLs.

MATERIAL AND METHODS

In 2012-2015, consecutive patients with SPLs were prospectively included in a tertiary center setting and subjected to dual needle sampling with a 22 gauge reverse bevel biopsy needle and a conventional 25 gauge open tip aspiration needle (EUS-FNA). The outcome measures were the diagnostic accuracy of sampling, calculated for each modality separately and for the modalities combined (EUS-FNA + FNB), and the adverse event rate related to sampling.

RESULTS

In 68 unique study subjects, the most common diagnostic entities were pancreatic neuroendocrine tumor, PNET, (34%), pancreatic ductal adenocarcinoma, PDAC, (32%), pancreatitis (15%) and metastasis (6%). The overall diagnostic accuracy of EUS-FNB was not significantly different from that of EUS-FNA, (69% vs. 78%, p = .31). EUS-FNA + FNB, compared with EUS-FNA alone, had a higher sensitivity for tumors other than PDAC (89% vs. 69%, p = .02) but not for PDACs (95% vs. 85%, p = .5). No adverse event was recorded after the study dual-needle sampling procedures.

CONCLUSIONS

Endoscopic ultrasound-guided tissue acquisition performed with a 22 gauge reverse bevel biopsy needle is safe but not superior to conventional fine-needle aspiration performed with a 25 gauge open tip needle in diagnosing solid pancreatic lesions. However, the performance of both these modalities may facilitate the diagnostic work-up in selected patients, such as cases suspicious for pancreatic neuroendocrine tumors and metastases. NCT02360839.

Comparison of modified wet suction technique and dry suction technique in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for solid lesions: study protocol for a randomized controlled trial

Background

Several suction techniques have been developed recently to enhance tissue acquisition when sampling solid lesions using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The aim of this study is to determine whether a new modified wet suction technique (MWST) compared with the conventional dry suction technique (DRST) shall present better outcomes with respect to diagnostic yield and specimen quality of solid lesions in the intra-abdomen and mediastinum.

Methods/design

This is a single-blind, randomized, controlled, superiority trial conducted at four large tertiary care centers in China. Two hundred and ninety-six patients with solid lesions referred for EUS-FNA will be randomly assigned to group A, using DRST for the first pass, or group B, using MWST for the first pass in a ratio of 1:1. Following a 2 × 2 cross-over design, the pass sequence for group A is DRST, MWST, DRST, MWST. For group B, the pass sequence is MWST, DRST, MWST, DRST. All procedures will be performed by experienced echoendoscopists, and the patients and assessors (cytologists and pathologists) will be blinded during the entire study. The primary outcome measure is the diagnosis yield. Secondary outcome measures are specimen quality, including assessment of quantity of cell, tissue integrity, and blood contamination.

Discussion

To our knowledge, this is the first large-scale randomized controlled trial to compare MWST with DRST when sampling solid lesions in the intra-abdomen and mediastinum. The results may contribute to future multicenter clinical trials in standardizing suction techniques during EUS-FNA.

Trial registration

Clinical Trials.gov, NCT02789371. Retrospectively registered on 6 June 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2380-y) contains supplementary material, which is available to authorized users.

A comprehensive review of endoscopic ultrasound core biopsy needles

INTRODUCTION

Endoscopic ultrasound (EUS)-guided tissue acquisition by-fine needle biopsy (EUS-FNB) developed over the last two decades as an attempt to overcome the limitations of fine needle aspiration (FNA). There are now three commercially available second-generation FNB needles with different tip designs.

AREAS COVERED

In this review the roles of EUS-FNA and FNB, the history and evolution of the EUS core biopsy needle are addressed followed by a presentation of currently available needles. Literature search was conducted using MEDLINE, Controlled Trials Register, US Patent Registry, Google Scholar, and Conference Abstracts.

EXPERT COMMENTARY

While FNA remains the reference standard, it is limited by the inability to retain stroma and associated cellular architecture in biopsy samples. Histologic architecture is of paramount importance in providing a molecular diagnosis and for accurate tumor staging. FNB offers a superior diagnostic yield to FNA and initial experiences with the three commercially available second-generation FNB needles show highly promising results.

Comparison of 22-gauge standard fine needle versus core biopsy needle for endoscopic ultrasound-guided sampling of suspected pancreatic cancer: a randomized crossover trial

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is effective for tissue diagnosis of pancreatic mass. To improve diagnostic yield and drawbacks, 22-gauge (G) core biopsy (FNB) needle has been developed. This study aims to compare 22G FNA and FNB needles for EUS-guided sampling of suspected pancreatic cancer.

METHODS

This is a randomized controlled crossover trial. A total of 60 patients with suspected unresectable pancreatic cancer referred for EUS-guided sampling were randomly assigned to two groups. Both groups had 22G FNA and FNB needles performed in a randomized order. The primary endpoint was the cytological, histological and overall diagnostic accuracy of pancreatic cancer.

RESULTS

FNA and FNB needles reported similar level of diagnostic accuracy (FNA needle 95% vs. FNB needle 93.3%; p = .564), and it was not statistically different. However, cytological cellularity was significantly higher in the FNB needles compared to FNA needles (odds ratio 2.75, 95% confidence interval (CI)). There were no procedure-related complications in both needles.

CONCLUSIONS

The diagnostic accuracy of EUS-guided sampling for pancreatic cancer using 22G FNA is comparable to FNB needles. The cytological quality of specimen is better in the FNB needle.

Application of intraoperative transluminal core-biopsy for diagnosis of pancreatic head mass: A single center 15-year experience

BACKGROUND

Pathology is the gold standard for diagnosis of pancreatic cancer. Preoperative endoscopic ultrasound-guided biopsy is an expensive procedure that is not routine in developing countries, hence a cheap, reliable alternative is required.

AIM

To evaluate the effectiveness and safety of a new technique of intraoperative biopsy from pancreatic head mass.

METHODS

Patients undergoing intraoperative transluminal core-biopsy (TLCB) for pancreatic head mass from January 2000 to June 2015 were included in this study. Following Kocher's maneuver, a biopsy was taken from the mass through the duodenum transluminally, using a commercial 16G automatic core-biopsy needle. Multiple tissue specimens were obtained for intraoperative frozen section examination. Depending on the pathological results, a decision was taken to either perform pancreaticoduodenectomy, duodenum-preserving pancreatic head resection, bypass surgery, or to just terminate the operation. The malignancy status of the lesion was confirmed by postoperative pathological examination and/or long-term follow-up of the patients.

RESULTS

A total of 525 patients were included. Intraoperative pathological reports revealed 436 malignant cases and 89 cases without evidence of malignancy. The sensitivity, specificity, false positive rate, and false negative rate were 97.7%, 100%, 0%, and 2.3%, respectively. Complications occurred in 2 patients.

CONCLUSION

TLCB is a quick, safe, effective, and accurate method for intraoperative diagnosis method in patients with pancreatic head mass; it can provide reliable evidence for surgical decision-making.

Novel fork-tip needles versus standard needles for EUS-guided tissue acquisition from solid masses of the upper GI tract: a matched cohort study

BACKGROUND

There are very few available data on the novel SharkCore™ needles for EUS-FNB.

AIM

Comparison of the performance of the SharkCore™ needles with the standard EUS-FNA needles for the diagnosis of solid upper GI masses.

PATIENTS AND METHODS

Single-center, retrospective cohort study in an academic tertiary referral hospital. Patients were matched 1:1 for the site of the lesion and the presence or absence of rapid on-site evaluation (ROSE).

RESULTS

A total of 102 patients were included. There was no statistically significant difference in the mean number of passes (3.3 ± 1.3 versus 3.4 ± 1.5; p = .89). Similar results were observed at the subgroup with ROSE (4.3 ± 1.3 versus 3.7 ± 1.5; p = .26). More histological specimens were obtained with the SharkCore™ needles compared to standard needles (59 versus 5%; p < .001). Diagnostic test characteristics were not significantly different (sensitivity: 91.5 versus 85.7; specificity: 100 versus 100%; accuracy: 92.2 versus 85.4% for SharkCore™ versus standard needles, p > .05 in all cases). At multivariable analysis, there was no statistically significant difference in the mean number of passes in all patients (p = .23) and in the ROSE subgroup (p = .66). However, the SharkCore™ needle obtained significantly more histological material than the standard needle (odds ratio 66; 95% confidence interval: 11.8, 375.8, p < .001). There was no significant difference in complication rates (p = .5).

LIMITATIONS

Retrospective study, single-center.

CONCLUSION

The SharkCore needles were similar to standard FNA needles in terms of the number of passes to reach diagnosis, but obtained significantly more histological specimen.

Endoscopic ultrasound guided fine needle aspiration versus endoscopic ultrasound guided fine needle biopsy in sampling pancreatic masses: A meta-analysis

BACKGROUND

The comparison between endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and endoscopic ultrasound guided fine needle biopsy (EUS-FNB) for the diagnosis of pancreatic masses is still controversial. Many factors can affect the final results.

METHODS

Databases, such as PubMed, EMBASE, Cochrane Library, and Science Citation Index updated from 2000 to 2016 were searched to include eligible articles. In the meta-analysis, the main outcome measurements were the diagnostic accuracy, number of needle passes, specimen adequacy, the rate of complications, and technical success.

RESULTS

Eight randomized controlled trials (RCTs) were identified, and a total of 921 cases were included in the meta-analysis. The diagnostic accuracy was not significantly different between the FNA and FNB groups. The specimen adequacy was higher in the FNB group compared with the FNA group. The number of needle passes to obtain sufficient tissue was lower in the FNB group. The rate of adverse events and technical success did not significantly differ between the 2 groups. But, the forest plot showed a trend toward lower technical success rate and a trend toward higher diagnostic accuracy in the FNB group, compared with FNA.

CONCLUSION

We provide the evidence that FNB is comparable to FNA in terms of diagnostic accuracy, adverse events, and technical success. FNB gives higher specimen adequacy than that of FNA, despite performance of fewer needle passes.

A meta-analysis of endoscopic ultrasound-fine-needle aspiration compared to endoscopic ultrasound-fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment

Background The diagnostic yield of endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is variable, and partly dependent upon rapid onsite evaluation (ROSE) by a cytopathologist. Second generation fine-needle biopsy (FNB) needles are being increasingly used to obtain core histological tissue samples. Aims Studies comparing the diagnostic yield of EUS guided FNA versus FNB have reached conflicting conclusions. We therefore conducted a systematic review and meta-analysis to compare the diagnostic yield of FNA with FNB, and specifically evaluating the diagnostic value of ROSE while comparing the two types of needles. Methods We searched several databases from inception to 10 April 2016 to identify studies comparing diagnostic yield of second generation FNB needles with standard FNA needles. Risk ratios (RR) were calculated for categorical outcomes of interest (diagnostic adequacy, diagnostic accuracy, and optimal quality histological cores obtained). Standard mean difference (SMD) was calculated for continuous variables (number of passes required for diagnosis). These were pooled using random effects model of meta-analysis to account for heterogeneity. Meta-regression was conducted to evaluate the effect of ROSE on various outcomes of interest. Results Fifteen studies with a total of 1024 patients were included in the analysis. We found no significant difference in diagnostic adequacy [RR 0.98 (0.91, 1.06), (I² = 51 %)]. Although not statistically significant (P = 0.06), by meta-regression, in the absence of ROSE, FNB showed a relatively better diagnostic adequacy. For solid pancreatic lesions only, there was no difference in diagnostic adequacy [RR 0.96 (0.86, 1.09), (I² = 66 %)]. By meta-regression, in the absence of ROSE, FNB was associated with better diagnostic adequacy (P = 0.02). There was no difference in diagnostic accuracy [RR 0.99 (0.95, 1.03), (I² = 27 %)] or optimal quality core histological sample procurement [RR 0.97 (0.89, 1.05), (I² = 9.6 %)]. However, FNB established diagnosis with fewer passes [SMD 0.93 (0.45, 1.42), (I² = 84 %)]. The absence of ROSE was associated with a higher SMD, i. e., in the presence of an onsite pathologist, FNA required relatively fewer passes to establish the diagnosis than in the absence of an onsite pathologist. Conclusions There is no significant difference in the diagnostic yield between FNA and FNB, when FNA is accompanied by ROSE. However, in the absence of ROSE, FNB is associated with a relatively better diagnostic adequacy in solid pancreatic lesions. Also, FNB requires fewer passes to establish the diagnosis.

Is there a difference between 19G core biopsy needle and 22G core biopsy needle in diagnosing the correct etiology? - A meta-analysis and systematic review

AIM

To compare the accuracy of endoscopic ultrasonography (EUS) 19G core biopsies and 22G core biopsies in diagnosing the correct etiology for a solid mass.

METHODS

Articles were searched in Medline, PubMed, and Ovid journals. Pooling was conducted by both fixed and random effects models.

RESULTS

Initial search identified 4460 reference articles for 19G and 22G, of these 670 relevant articles were selected and reviewed. Data was extracted from 6 studies for 19G (n = 289) and 16 studies for 22G (n = 592) which met the inclusion criteria. EUS 19G core biopsies had a pooled sensitivity of 91.6% (95%CI: 87.1-95.0) and pooled specificity of 95.9% (95%CI: 88.6-99.2), whereas EUS 22G had a pooled sensitivity of 83.3% (95%CI: 79.7-86.6) and pooled specificity of 64.3% (95%CI: 54.7-73.1). The positive likelihood ratio of EUS 19G core biopsies was 9.08 (95%CI: 1.12-73.66) and EUS 22G core biopsies was 1.99 (95%CI: 1.09-3.66). The negative likelihood ratio of EUS 19G core biopsies was 0.12 (95%CI: 0.07-0.24) and EUS 22G core biopsies was 0.25 (95%CI: 0.14-0.41). The diagnostic odds ratio was 84.74 (95%CI: 18.31-392.26) for 19G core biopsies and 10.55 (95% CI: 3.29-33.87) for 22G needles.

CONCLUSION

EUS 19G core biopsies have an excellent diagnostic value and seem to be better than EUS 22G biopsies in detecting the correct etiology for a solid mass.

Endoscopic ultrasonography complements computed tomography in predicting portal or superior mesenteric vein resection in patients with borderline resectable pancreatic carcinoma

BACKGROUND

Current guidelines recommend computed tomographic (CT) scans for vascular staging of patients with pancreatic carcinoma; however, endoscopic ultrasonography (EUS) in these patients is not required and its utility in combination with CT scan is less well-defined. The purpose of this study is to explore the utility of EUS in addition to CT in identifying patients with borderline resectable pancreatic carcinoma (BRPC).

METHODS

We reviewed our database of patients with BRPC who went to surgery with curative intent. Inclusion criteria were preoperative staging with CT scan and EUS, completion of neoadjuvant chemotherapy and radiotherapy, and surgical resection.

RESULTS

We identified 62 patients (average age of 65 ± 9 years, 60% male); 97% of patients underwent R0 resections. We found that 29% of patients were classified as BRPC by EUS alone, 23% by CT alone, and 48% by both modalities. Of 34 patients who required vein resection, EUS alone preoperatively identified 88% of these patients while CT alone identified 67%. EUS identified 11 patients who required vein resection that CT did not identify as BRPC, whereas CT identified 4 patients that EUS did not identify as BRPC. On multivariate analysis, EUS was associated with vein resection (P < 0.02), but CT scan findings, tumor size, and CA19-9 values were not associated (each P > 0.1).

CONCLUSIONS

EUS complemented CT in identifying BRPC patients requiring vein resection, with nearly one-third of patients identified with EUS alone, supporting EUS use in addition to CT scan for vascular staging of patients with pancreatic carcinoma.

Impact of EUS-guided fine-needle biopsy sampling with a new core needle on the need for onsite cytopathologic assessment: a preliminary study

BACKGROUND AND AIMS

FNA is the primary method of EUS tissue acquisition. In an attempt to improve our yield of EUS-guided tissue acquisition, we compared fine-needle biopsy (FNB) sampling without rapid onsite evaluation (ROSE) with FNA with ROSE and assessed the concordance of FNA and FNB sampling.

METHODS

This was a retrospective review of prospectively collected data from consecutive patients. Patients underwent FNB sampling and FNA of the same single lesion, with the same needle gauge and number of passes. FNA with ROSE was performed with a standard FNA needle. FNB sampling was performed with a new dedicated core needle. FNA samples were assessed with ROSE, and a final interpretation was provided by cytopathology staff; FNB samples were analyzed by surgical pathologists, each not made aware of the other's opinion.

RESULTS

Thirty-three patients underwent 312 passes in 42 different lesions. A diagnosis of malignancy was more likely with FNB sampling than with FNA (72.7% vs 66.7%, P = .727), although statistical significance was not reached. FNA and FNB sampling had similar sensitivities, specificities, and accuracies for cancer (81.5% vs 88.9%, 100% vs 100%, and 84.8% vs 90.9%, respectively). FNB sampling provided qualitative information not reported on FNA, such as degree of differentiation in malignancy, metastatic origin, and rate of proliferation in neuroendocrine tumors.

CONCLUSIONS

FNB sampling without ROSE using a dedicated core needle performed as well as FNA with ROSE in this small cohort, suggesting that FNB sampling with this new core needle may eliminate the need for an onsite cytopathologic assessment, without loss of diagnostic accuracy.

22-gauge core vs 22-gauge aspiration needle for endoscopic ultrasound-guided sampling of abdominal masses

AIM

To compare the aspiration needle (AN) and core biopsy needle (PC) in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of abdominal masses.

METHODS

Consecutive patients referred for EUS-FNA were included in this prospective single-center trial. Each patient underwent a puncture of the lesion with both standard 22-gauge (G) AN (Echo Tip Ultra; Cook Medical, Bloomington, Indiana, United States) and the novel 22G PC (EchoTip ProCore; Cook Medical, Bloomington, Indiana, United States) in a randomized fashion; histology was attempted in the PC group only. The main study endpoint was the overall diagnostic accuracy, including the contribution of histology to the final diagnosis. Secondary outcome measures included material adequacy, number of needle passes, and complications.

RESULTS

Fifty six consecutive patients (29 men; mean age 68 years) with pancreatic lesions (n = 38), lymphadenopathy (n = 13), submucosal tumors (n = 4), or others lesions (n = 1) underwent EUS-FNA using both of the needles in a randomized order. AN and PC reached similar overall results for diagnostic accuracy (AN: 88.9 vs PC: 96.1, P = 0.25), specimen adequacy (AN: 96.4% vs PC: 91.1%, P = 0.38), mean number of passes (AN: 1.5 vs PC: 1.7, P = 0.14), mean cellularity score (AN: 1.7 vs PC: 1.1, P = 0.058), and complications (none). A diagnosis on the basis of histology was achieved in the PC group in 36 (64.3%) patients, and in 2 of those as the sole modality. In patients with available histology the mean cellularity score was higher for AN (AN: 1.7 vs PC: 1.0, P = 0.034); no other differences were of statistical significance.

CONCLUSION

Both needles achieved high overall diagnostic yields and similar performance characteristics for cytological diagnosis; histological analysis was only possible in 2/3 of cases with the new needle.

Endoscopic ultrasound-guided techniques for diagnosing pancreatic mass lesions: Can we do better?

The diagnostic approach to a possible pancreatic mass lesion relies first upon various non-invasive imaging modalities, including computed tomography, ultrasound, and magnetic resonance imaging techniques. Once a suspect lesion has been identified, tissue acquisition for characterization of the lesion is often paramount in developing an individualized therapeutic approach. Given the high prevalence and mortality associated with pancreatic cancer, an ideal approach to diagnosing pancreatic mass lesions would be safe, highly sensitive, and reproducible across various practice settings. Tools, in addition to radiologic imaging, currently employed in the initial evaluation of a patient with a pancreatic mass lesion include serum tumor markers, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). EUS-FNA has grown to become the gold standard in tissue diagnosis of pancreatic lesions.

The slow-pull capillary technique increases the quality of endoscopic ultrasound fine needle biopsy samples in solid pancreatic lesions

INTRODUCTION

Endoscopic ultrasound-guided sampling is used routinely for the diagnosis of solid pancreatic masses. We aimed to compare the standard suction technique with the recently described 'slow-pull' technique.

PATIENTS AND METHODS

Patients with a solid pancreatic mass of more than 2 cm undergoing endoscopic ultrasound-guided fine needle biopsy with the same endoscopist using a 22 G core biopsy needle were included in the study. Patients had a first suction pass, followed by either another suction pass or a slow-pull pass. The rate of samples contributive to the diagnosis, cellularity, presence of tissue microfragments, and blood contamination were assessed and compared between each pass and each technique.

RESULTS

A total of 98 patients with a lesion diameter of 33.1±10 mm were analyzed. Lesions were adenocarcinomas in 83%, neuroendocrine tumors in 6%, and benign lesions in 11% of the cases. The rate of contributive samples of the first suction pass, the slow-pull pass, and the second suction pass were 96.9, 97.9, and 90.2%, respectively (P=NS). The slow-pull capillary technique, compared with the suction technique, provided samples with better cellularity, higher proportion of representative and tumor cells, and more tissue microfragments (P=0.002, 0.0004, 0.006, and 0.005, respectively).

CONCLUSION

Endoscopic ultrasound-guided fine needle biopsy sampling of solid pancreatic lesions using the slow-pull technique yielded overall outcomes similar to the standard suction technique in terms of diagnostic performance. However, the slow-pull capillary technique improved the histological quality of the samples, mainly through a higher proportion of tissue microfragments and tumor cells.

Comparing endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) versus fine needle biopsy (FNB) in the diagnosis of solid lesions: study protocol for a randomized controlled trial

Background

Linear endoscopic ultrasonography (EUS) allows the visualization, identification, and characterization of the extent of lesions of the gastrointestinal (GI) tract and adjacent structures. EUS-guided fine-needle aspiration (EUS-FNA) facilitates a more accurate diagnosis of mediastinal, intra-abdominal, and pancreatic lesions through the collection of the cytological material under direct visualization. Recent reports suggest that histological samples can be obtained by EUS-FNA with a reverse, bevel-tipped needle (the ProCore needle) to collect the core samples (fine needle biopsy, FNB), thereby adding a new dimension to the diagnostic usefulness of this technique. Certain neoplasms, such as lymphoma and stromal tumors, can be assessed by EUS-FNB to confirm the diagnosis. Here, we aimed to carry out a prospective, multicenter, single-blind, randomized, controlled trial to compare EUS-FNB and EUS-FNA.

Methods/design

A total of 408 patients will be enrolled from five endoscopic centers. Patients will be divided into two groups: (1) group A, which is the EUS regular needle group (EUS-FNA) and (2) group B, which is the EUS ProCore needle group (EUS-FNB). Patients in group A will be examined with a 22G EchoTip Ultra needle, and patients in group B, with a 22G EchoTip ProCore needle. For all included patients, four EUS-guided passes will be made in each lesion. In the first and second pass, a slow-pull suction method of the stylet will be done. The third and fourth pass will use manual suction of 5 cc. The primary objective is to compare the diagnostic yield of malignancy by EUS-FNA versus EUS-FNB.

Discussion

The trial will compare samples obtained by EUS-FNA versus EUS-FNB for the diagnostic yield of solid lesions. The efficacy of these two sampling methods will be assessed on various lesions, which may provide insights into developing practice guidelines for their future indications.

Trial registration

Clinical Trials.gov, NCT02327065.

Mapping international practice patterns in EUS-guided tissue sampling: outcome of a global survey

BACKGROUND AND STUDY AIMS

Although Endoscopic Ultrasound (EUS)-guided tissue sampling is widely used, the optimal sampling strategy remains subject of debate. We evaluated practice patterns within the international endosonographic community.

PATIENTS AND METHODS

An online questionnaire was sent to 400 endosonographers from the United States, Europe, and Asia.

RESULTS

A total of 186 (47 %) endosonographers participated: United States 54 (29 %), Europe 85 (46 %), and Asia 47 (25 %). European (75 %) and Asian (84 %) respondents routinely check coagulation status, whereas US respondents only check on indication (64 %, P = 0.007). While propofol sedation is standard in the United States (83 %), conscious sedation is still widely used in Europe (52 %) and Asia (84 %, P < 0.001). Overall, the 22-gauge needle is most commonly used (52 %). For fine-needle aspiration (FNA) of solid pancreatic lesions, 22-gauge (45 %) and 25-gauge (49 %) needles are used equally. For fine-needle biopsy (FNB) of solid masses, the 25-gauge device is less favored than the 22-gauge FNA device (49 % versus 21 %). The 19-gauge needle is generally used for FNB of submucosal masses (62 %). Rapid on-site pathological evaluation (ROSE) is utilized more often by US (98 %) than by European and Asian respondents (51 %, P < 0.001). Cytolyt (52 %), formalin (15 %) and alcohol (15 %) are used for FNA specimen preservation in the United States and Europe, while saline (27 %) and alcohol (38 %) are widely used in Asia (P < 0.001).

CONCLUSIONS

EUS-guided tissue sampling practices vary substantially within the international endosonographic community and differ considerably from recommendations expressed in guidelines. Because the clinical relevance of these variations is largely unknown, the outcome of this survey suggests a need for further studies.