Performance of a new histology needle for EUS-guided fine needle biopsy: A retrospective multicenter study

Accuracy and clinical outcomes of pancreatic EUS-guided fine-needle biopsy in a consecutive series of 852 specimens

Background and Objectives:

Pancreatic EUS-guided fine needle biopsy (EUS-FNB) is increasingly used. Accuracy of EUS-FNB, particularly for benign diseases, utility of additional EUS-FNB if malignancy is suspected but initial diagnosis is inconclusive, and complication rate are not fully elucidated. We evaluated operating characteristics of EUS-FNB overall and for different diagnostic categories, value of additional EUS-FNB if malignancy is suspected but initial diagnosis is inconclusive, and frequency and type of complications.

Methods:

A retrospective tertiary single-center study including 852 consecutive pancreatic SharkCore EUS-FNBs from 723 patients between 2015 and 2020. EUS-FNB diagnoses were applied according to Papanicolaou Society's system and each category was further subcategorized.

Results:

Sufficient tissue cylinders for a histologic diagnosis were obtained in 93.4% (796/852). Accuracy was overall, for malignant, and benign entities 85.6% (confidence interval [CI]: 83.2%–87.9%), 88.3% (CI: 85.9%–90.4%), and 94% (CI: 92.2%–95.5%). Sensitivity and accuracy of EUS-FNB for autoimmune pancreatitis (AIP) (n = 15) was 83.3% (CI: 58.6%–96.4%) and 99.2% (CI: 98.3%–99.7%). Of patients in whom malignancy was suspected but initial EUS-FNB diagnosis was inconclusive, 7.3% (53/723) underwent one or two additional EUS-FNBs, and in 54.7% (29/53) of these, a malignant diagnosis was established. The frequency of hospitalization following EUS-FNB was 4.7%, with 0.2% (n = 2) incidents needing active intervention.

Conclusions:

We found a high accuracy of pancreatic EUS-FNB across all diagnostic categories including rare entities, such as AIP. In patients with a clinical suspicion of malignancy, additional EUS-FNB resulted in a conclusive diagnosis in more than half of cases. Complications necessitate hospitalization in almost 5%, but the majority are self-limiting.

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

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

Endoscopic Ultrasound-Guided Tissue Acquisition by 22-Gauge Franseen and Standard Needles for Solid Pancreatic Lesions

Background/Aims

Recently, a three-plane symmetric needle with Franseen geometry was developed for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). In this retrospective study, tissue acquisition per pass was compared between 22-gauge Franseen FNB and standard fine needle aspiration (FNA) needles in patients with solid pancreatic lesions.

Methods

Consecutive patients who underwent EUS-FNA or EUS-FNB for solid pancreatic lesions between October 2014 and March 2018 were retrospectively studied. The tissue acquisition rate and the diagnostic performance per session, per pass, and at first pass were compared.

Results

A total of 663 passes (300 by the FNB needle and 363 by the standard FNA needle) were performed in 154 patients (71 FNB and 83 FNA). The tissue acquisition rate per session and at first pass in the FNB and FNA groups was 100% and 95% (p=0.13) and 87% and 69% (p=0.007), respectively. The multivariate analysis revealed that among the patients, EUS-FNB (odds ratio, 3.07; p=0.01) was associated with a higher first-pass tissue acquisition rate. While the tissue acquisition rate reached a plateau after the 4th pass with FNA, it reached a plateau after the 2nd pass with FNB. Among the 129 malignant cases, the histological tissue acquisition rate per session was similar (100% and 94%), but the sensitivity by histology alone per session was higher for FNB than for FNA (93% and 73%, p<0.01).

Conclusions

The results of our retrospective analysis indicated that compared with a standard FNA needle, a 22-gauge Franseen FNB needle was associated with a higher first-pass tissue acquisition rate.

Comparison of fine-needle aspiration and fine-needle biopsy devices for endoscopic ultrasound-guided sampling of solid lesions: a systemic review and meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided tissue acquisition is extensively used, but the optimal sampling device is still a matter of debate. We performed meta-analyses on studies comparing fine-needle aspiration (FNA) with fine-needle biopsy (FNB) needles, and studies comparing different FNB needles.

METHODS

Online databases were searched for randomized controlled trials (RCTs) of at least 50 cases with a suspected solid pancreatic or nonpancreatic lesion that compared FNA with FNB needles. Outcome measures included diagnostic accuracy, adequacy, number of passes, presence of tissue cores, and adverse events. We also performed meta-regression analysis on the effect of FNB design on diagnostic accuracy. Quality was assessed using the QUADAS-2 tool.

RESULTS

18 RCTs comparing FNA with FNB needles were included. FNB provided a higher pooled diagnostic accuracy (87 % vs. 80 %; P = 0.02) and tissue core rate (80 % vs. 62 %; P = 0.002), and allowed diagnosis with fewer passes (P = 0.03), in both pancreatic and nonpancreatic lesions. A total of 93 studies were included comparing different FNB devices. Pooled diagnostic accuracy was higher for forward-facing bevel needles than for the reverse bevel needle. In this analysis, study quality was low and heterogeneity was high (I2  = 80 %).

CONCLUSION

FNB outperformed FNA when sampling pancreatic and nonpancreatic lesions. Forward-facing bevel FNB needles seemed to outperform the reverse bevel FNB needle, but the low quality of evidence prevents us from making strong recommendations on the optimal FNB design.

Endoscopic Ultrasound Quality Metrics in Clinical Practice

Recent advances in endoscopic ultrasound (EUS), particularly EUS-guided tissue acquisition, may have affected EUS procedural performance as measured by current American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) quality indicators. Our study aims to assess how these quality metrics are met in clinical practice. We retrospectively analyzed 732 EUS procedures; data collected were procedural indications, technical aspects and outcomes, completeness of documentation, and malignancy staging. EUS was performed in 660 patients for a variety of indications. All ASGE/ACG EUS procedural quality metrics were met or exceeded. Intervention was successful in 97.7% (715/732) of cases, with complication rate of 0.4% (3/732). EUS outcomes changed clinical management in 58.7% of all cases and in 91.2% of malignancy work-up cases; in 26.0% of suspected choledocholithiasis cases, endoscopic retrograde cholangiopancreatography (ERCP) was avoided after EUS. Locoregional EUS staging was accurate in 61/65 (93.8%) cases of non-metastatic disease and in 15/22 (68.2%) cases of metastatic disease. Pancreatic mass malignancy detection rate with EUS-guided fine needle aspiration (FNA) or fine needle biopsy (FNB) was 75.8%, with a sensitivity of 96.2%; a significant increase in detection rate from 46.2% (6/13) to 95.0% (19/20) (p = 0.0026) was observed with a transition to the predominant use of FNB for tissue acquisition. All ASGE/ACG EUS quality metrics were met or exceeded for EUS procedures performed for a wide variety of indications in a diverse patient population. EUS was instrumental in changing clinical management, with a low complication rate. The malignancy detection rate in pancreatic masses significantly increased with FNB use.

An exclusive fine-needle biopsy approach to sampling solid lesions under EUS guidance: a prospective cohort study

Background

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is increasingly utilized to enhance the cytological yield of sampling solid lesions, but its superiority over existing fine-needle aspiration (FNA) platforms has not been clearly demonstrated. The aim of our study was to compare the diagnostic accuracy and procedural outcomes of FNB using a new Franseen-tip needle to that of a traditional FNA in sampling solid lesions under EUS guidance.

Methods

Consecutive patients with solid lesions referred for EUS-FNB sampling were included. Procedure-related outcomes were collected prospectively including patient demographics, number of passes performed, diagnostic sample adequacy, adverse events, and recovery time. The Acquire needle was used to sample all lesions in the study group. Consecutive EUS-FNA procedures performed to sample solid lesions using the Expect needle were utilized as controls.

Results

There were 180 patients undergoing EUS-FNB compared to 183 patients undergoing EUS-FNA procedures for solid-lesion sampling. The procedure time was significantly shorter in patients who underwent FNB compared to FNA (mean: 37.4 vs 44.9 minutes, P < 0.001). Significantly fewer passes were performed in the FNB cohort compared to the FNA group (mean: 2.9 vs 3.8, P < 0.001). The cytologic diagnostic yield was significantly higher in the FNB group compared to the FNA group (98.3% vs 90.2%, P = 0.003). No significant difference in the incidence of adverse events was observed between the FNB and FNA groups (1.1% vs 0.5%, P = 0.564).

Conclusions

An FNB-exclusive approach to sampling solid lesions under EUS guidance is safe and feasible, and may result in fewer overall passes, shorter procedure time, and improved diagnostic adequacy. FNB may replace FNA as the primary sampling modality of choice in all solid lesions.

Factors associated with diagnostic accuracy, technical success and adverse events of endoscopic ultrasound-guided fine-needle biopsy: A systematic review and meta-analysis

BACKGROUND AND AIM

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is used to diagnose lesions within or adjacent to the digestive tract. However, there is no report on the overall diagnostic accuracy, technical success, and adverse events of FNB. The aims of this study were to conduct a systematic review and meta-analysis to comprehensively assess the diagnostic accuracy, technical success, and adverse events of FNB.

METHODS

Pubmed, Embase, and Cochrane Library databases were searched for relevant articles published in English from January 1998 to May 2019 (No. CRD42019141647). Primary outcomes were EUS-FNB related diagnostic accuracy rate, technical success rate, and adverse event rate.

RESULTS

A total of 51 articles including 5330 patients met our criteria. The overall EUS-FNB related diagnostic accuracy rate, technical success rate, and adverse event rate was 90.82% [95% confidence interval (CI) 88.69-92.76%], 99.71% [95% CI 99.35-99.93%], and 0.59% [95% CI 0.29-1.0%], respectively. Biopsy with 22G needle could increase the diagnostic accuracy rate and technical success rate to 92.17% [95% CI 89.32-94.61%] and 99.88% [95% CI 99.64-99.99%], respectively, and decrease the adverse event to 0.37% [95% CI 0.08-0.87%]. Moreover, it showed that 22G needle was an independent factor associated with a higher diagnostic accuracy rate and technical success rate and a lower adverse event rate (P = 0.04, P < 0.001, and P = 0.04, respectively) by univariate and multivariate meta-regression analyses.

CONCLUSION

Endoscopic ultrasound-guided fine-needle biopsy is a feasible and safe procedure for lesions within or adjacent to the digestive tract. Biopsy using 22G needle could increase the diagnostic accuracy rate and technical success rate and decrease adverse event rate during the FNB procedure.

Diagnostic efficacy of three suction techniques for endoscopic ultrasound-guided fine-needle biopsy of solid pancreatic lesions: protocol for a multicenter randomized cross-over clinical trial

BACKGROUND

How suction technique affects endoscopic ultrasound-guided tissue acquisition (EUS-TA) remains unclear. A standardized protocol is currently lacking, with most previous studies being restricted to EUS-guided fine-needle aspiration (EUS-FNA). The research related to EUS-guided fine-needle biopsy (EUS-FNB) is sparse.

AIMS

The aim of this study is to evaluate the diagnostic efficacy, cellularity, tissue acquisition, blood contamination and adverse event rate of three common suction techniques (standard suction, slow-pull, and wet suction) used for EUS-FNB of solid pancreatic masses.

METHODS

This is a multicenter single-blind randomized cross-over superiority trial. A total of 300 patients with suspected pancreatic malignancy will be enrolled from digestive endoscopic centers at five large tertiary hospitals in China. All three suction techniques will be performed on each patient using a 25G ProCore needle, with the sequence of suction techniques determined by randomization. Cytological and histological specimens obtained with each of the three techniques will be assessed independently. Outcomes among the three suction techniques will be compared.

DISCUSSION

To the best of our knowledge, this is the largest multicenter randomized cross-over trial designed to determine the optimal suction technique for the diagnosis of solid pancreatic masses. This study may contribute to standardizing the suction technique for EUS-FNB.

Endoscopic ultrasound-guided tissue acquisition of solid mass lesions of the pancreas: A retrospective comparison study of fine-needle aspiration and fine-needle biopsy

BACKGROUND

Although endoscopic ultrasound guided fine-needle biopsy (EUS-FNB) has emerged as an alternative to fine-needle aspiration (FNA) for the sampling of solid pancreatic mass lesions, it remains unclear which method is more effective. We compared the diagnostic yields of FNA, FNB, and combined FNA/FNB at a tertiary care institution.

METHODS

Specimens from EUS-FNA (04/2014-08/2017) and EUS-FNB (10/2015-08/2017) with SharkCore needle of pancreatic solid mass lesions were retrieved. Clinical, radiologic, and pathologic data was recorded. Pathology results of malignancy/neoplasms with uncertain malignant potential were considered as true positive. The "negative" cases included were with ≥6 months of follow-up. Nondiagnostic cases showed unremarkable pancreatic tissue, nonpancreatic elements, atypia, or features suspicious for malignancy. Diagnostic yield was defined as percentage of lesions sampled in which a benign or malignant tissue diagnosis, as defined above, was obtained. Statistical comparisons were performed using Fisher's exact test and univariable and multivariable logistic regression analysis.

RESULTS

The study cohort included 76 FNA only cases, 88 FNB only cases, and 40 combined FNA/FNB cases. Diagnostic yields were 70% (FNA), 70% (FNB), and 83% (FNA/FNB), which were not statistically different. Increase in lesion size and presence of ROSE were significantly associated with a diagnostic outcome on both univariable and multivariable analysis, unlike the number of passes.

CONCLUSION

Our results demonstrate that for solid pancreatic lesions, the diagnostic yields of FNA, FNB, and combined FNA and FNB are comparable. Presence of ROSE and increasing lesion size increased the diagnostic yield while the number of passes had no significant impact.

Comparison of the Diagnostic Performance of Newly Designed 21-Gauge and Standard 22-Gauge Aspiration Needles in Patients with Solid Pancreatic Masses

BACKGROUND

Although endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been widely used for the diagnosis of pancreatic tumors, the ability to obtain adequate pancreatic tumor tissue needs to be improved.

AIMS

This study was performed to compare a newly designed 21-gauge needle (EUS Sonopsy CY; Hakko Medical, Nagano, Japan) and a standard 22-gauge needle for tissue sampling of solid pancreatic masses.

METHODS

Consecutive patients with solid pancreatic masses who underwent EUS-FNA with either the EUS Sonopsy CY or the 22-gauge needle from June 2014 to December 2016 were enrolled. The primary outcome was comparison of the diagnostic yield of the FNA samples. The secondary outcomes were comparison of technical success, diagnostic ability for malignancy, and complications.

RESULTS

A total of 93 patients (40.9% female; mean age, 70.1 years) underwent EUS-FNA with the EUS Sonopsy CY (n = 47) or the standard 22-gauge needle (n = 46). The technical success rate was 100% in both groups, and the overall diagnostic accuracy for malignancy was similar between the groups (100% in the EUS Sonopsy CY group vs. 95.7% in the 22-gauge needle group, P = 0.242). Nevertheless, the EUS Sonopsy CY resulted in significantly higher scores for cellularity (P = 0.006) and lower scores for blood contamination (P < 0.001). The procedure-related complication rate was comparable between the groups (P = 0.148).

CONCLUSIONS

The EUS Sonopsy CY provided higher-quality specimens for histological evaluation in terms of both sample cellularity and blood contamination for the diagnosis of solid pancreatic masses.

TRIAL REGISTRATION

The study was registered in a clinical trial registry, No. UMIN000032598.

EUS-guided core biopsies of pancreatic solid masses using a new fork-tip needle: A multicenter prospective study

BACKGROUND AND AIM

Endoscopic ultrasound-guided sampling (EUS sampling) is a safe and effective technique. The study aim was to evaluate the presence of a histological core from pancreatic lesions using a new 25G fork-tip needle.

METHODS

Observational multicenter prospective and analytical study, including consecutive patients with solid pancreatic masses referred for EUS-guided sampling. At each needle pass, the endoscopist performed macroscopic on-site evaluation (MOSE). The primary outcome was the histological core procurement rates. Secondary outcomes were the evaluation of interobserver agreement between endoscopists and pathologists, adequacy of EUS samples for the diagnosis and post-procedure adverse events.

RESULTS

100 patients were enrolled in 3 centers. The mean size of the lesions was 28.5 mm (SD 11.7). Final diagnoses were adenocarcinoma (68%), neuroendocrine tumor (21%), inflammatory mass/benign lesions (8.0%), and pancreatic metastasis (3.0%). The pathologists described the presence of a core in 67 samples (67.0% of patients), with poor agreement with MOSE (kappa, 0. 12; 95% CI: 0.03-0.28). The diagnostic accuracy was 93%. We observed 6% of mild adverse events.

CONCLUSION

The new 25-gauge core needle showed good overall adequacy and a good rate of histological specimens during EUS sampling of solid pancreatic masses, with a minimum number of passes and no major complications. Clinicaltrial.gov number, NCT02946840.

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.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.

The difference in histological yield between 19G EUS-FNA and EUS-fine-needle biopsy needles

Background and Objective:

EUS-guided fine-needle biopsy (EUS-FNB) with acquisition of tissue core is possible with the use of 19G fine-needle aspiration (FNA) and dedicated biopsy needles. Published data of direct comparisons between biopsy needles are more limited compared to the abundant data comparing EUS-FNA with EUS-FNB. We performed a retrospective study to determine the difference in histologic yield between 19G FNA needle and EUS-FNB needles in patients with solid masses.

Materials and Methods:

Consecutive patients who underwent EUS-FNB of solid masses from January 2014 to July 2018 were identified from a database. The difference in histologic yield between needles was analyzed.

Results:

A total of 159 patients underwent 179 EUS-FNB procedures (median of 2 needle passes [range: 1–4]). The use of 19G FNA, 19G, 20G, and 22G FNB needles allowed acquisition of a histologic core in 67.4% (29/43), 72.5% (29/40), 82.1% (46/56), and 75.9% (22/29), respectively (P = 0.368). A significant difference in the yield of histologic core was detected when 19G FNA needle was compared with 22G Acquire™ FNB needle (67.4% [29/43] vs. 94.1% [16/17], P = 0.032). The presence of histologic core was significantly associated with a positive diagnosis (95.6% vs. 30.2%, P < 0.0001).

Conclusion:

EUS-FNB with acquisition of histologic core improved the diagnostic yield. Dedicated FNB needles appeared to achieve a higher yield of histologic core compared to 19G FNA needles.

Comparing endoscopic ultrasound-guided core biopsies of solid pancreatic and extrapancreatic lesions: a large single-operator experience with a new fine-needle biopsy needle

Background

There has been a paradigm shift in tertiary centers from endoscopic ultrasound (EUS) fine-needle aspiration to EUS fine-needle biopsy (EUS-FNB) for tissue acquisition in solid lesions. While data exists on the use of FNB needles in solid pancreatic lesions, very few studies looked at the utility of FNB in solid extrapancreatic lesions. Our aim was to study and compare the technical success and feasibility of EUS-FNB in evaluating solid pancreatic and extrapancreatic lesions using a novel FNB needle.

Methods

We performed a retrospective cohort study of patients with solid masses or lesions needing EUS-guided core biopsy at the University of Utah between May 2016 and November 2017. All core biopsies were obtained using an Acquire™Fine Needle Biopsy Device (Boston Scientific Corporation, Natick MA, USA). Rapid on-site evaluation was performed by a board-certified cytopathologist in all cases.

Results

One hundred thirty-two patients (87 male) were included. Ninety-nine (73.3%) of the lesions were located in the pancreas. All needle sizes (19 G, 22 G and 25 G) had similar yield. The mean number of passes needed was 2.28±0.7. EUS-FNB of the pancreatic lesions had a diagnostic accuracy of 97.9%, comparable to the 97.2% for the biopsied extra-pancreatic lesions. Only 3 of 132 cases needed re-biopsy at a later date. No immediate adverse events were reported.

Conclusion

In this large, single-center study, EUS-FNB with a novel Franseen-design needle was proven to be an effective modality for tissue acquisition from both pancreatic and extrapancreatic solid lesions.