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

Outcomes of Endoscopic Ultrasound-guided Fine Needle Biopsy Using a Novel Hydrostatic Stylet Tissue Acquisition Technique

BACKGROUND

Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) is frequently used to obtain core samples of solid lesions. Here, we describe and evaluate a novel hydrostatic stylet (HS) technique designed to optimize core sample acquisition, reporting diagnostic yield, efficacy, and safety relative to the conventional stylet slow-pull (SP) technique.

METHODS

A novel HS technique was developed and validated retrospectively. Consecutive patients who underwent EUS-FNB with core biopsy of solid lesions through either the HS or SP technique between January 2020 and April 2022 were included. Exclusion criteria included cystic lesions, nonlesional liver biopsies, and specimens sent for cytologic analysis only. Patient and lesion characteristics, number of passes, sample adequacy, and adverse events were compared between the two techniques.

RESULTS

A total of 272 patients were included with 138 in the HS group and 134 in the SP group. Lesion size and anatomic distribution were similar in both groups. Compared with the SP approach, the HS technique demonstrated significantly higher sample adequacy (97.8% vs 83.6%, P < 0.001), higher sensitivity (97.1% vs 89.7%, P = 0.03), and lower mean number of passes (1.2 vs 3.3, P < 0.001). Rates and severity of adverse events in the HS group were comparable to the SP group and existing literature. Similar associations were observed in pancreatic and nonpancreatic lesion subanalyses.

CONCLUSIONS

The novel HS technique demonstrated excellent biopsy sample adequacy and diagnostic yield while requiring fewer passes to obtain diagnostic specimens compared with a conventional EUS-FNB approach. Further prospective evaluation is needed to confirm these pilot findings and optimize EUS-FNB acquisition techniques.

Performance of EUS-FNB in solid pancreatic masses: a lesson from 463 consecutive procedures and a practical nomogram

The study's main goal was the diagnostic adequacy of pancreatic endoscopic ultrasonographic (EUS) fine-needle biopsy (FNB) and associated predictive factors. The secondary objective was to define the diagnostic accuracy of EUS-FNB in the diagnosis of pancreatic masses and pancreatic malignancies. None of the studies reported the diagnostic adequacy and accuracy of EUS. We retrospectively identified patients with solid pancreatic lesions that underwent EUS-FNB between 2013, and 2018. We calculated diagnostic adequacy and related factors. Using definitive histology on the surgically resected specimen as the gold standard, we calculated diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of EUS-FNB. We identified a total of 463 procedures. Diagnostic specimens were adequate in 436 procedures (94.1%), while 27 biopsies provided insufficient samples (5.9%). The multivariate analysis showed that lesion size and needle caliper were the only factors influencing diagnostic adequacy. The use of a biopsy needle (OR 0.69, 95% CI 0.30-0.1.63, P 0.400) did not improve sample adequacy. We calculated sensitivity (100%), specificity (93.2%), diagnostic accuracy (93.2%), positive predictive value (97.1%), and negative predictive value (100%) using resected specimen as the gold standard. We found no significant complications. EUS-FNB is a reliable technique for the histological characterization of solid pancreatic masses.

Endoscopic ultrasonography-fine needle aspiration of solid pancreatic masses: Do we need the fourth pass? A prospective study

BACKGROUND

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is important for the differential diagnosis of solid pancreatic lesions. Sample adequacy is related to the number of needle passes, and European guidelines recommend three to four needle passes with a standard EUS-FNA needle. We aimed to evaluate the optimal number of passes with standard EUS-FNA needles in solid pancreatic lesions.

METHODS

Patients with solid pancreatic masses without cystic component >20% on computed tomography scan, and without biliary metallic stents, or coagulation problems were included prospectively. Standard 22G needles were used (maximum four passes); each sample was paraffin-embedded and analyzed separately. Final diagnosis was established by EUS-FNA, repeat EUS-FNA, surgery, or follow-up.

RESULTS

Sixty-one of 65 patients were included. The final diagnoses were adenocarcinoma (n = 44, 72%), neuroendocrine tumor (NET) (n = 10, 16%), metastasis (n = 1, 4%) and nonmalignant lesion (n = 6, 10%). Immunohistochemical staining was possible in 17 cases. The diagnosis was established by the first pass in 62% of cases (n = 38), by the second in 15% (n = 9), by the third in 15% (n = 9), and by the fourth in 3% (n = 2). The diagnostic accuracy for all four passes compared to the first three passes was 95% vs 92% (P = .5). The contribution of the fourth pass was not different between adenocarcinoma and NET (2% vs 10%, respectively; P = .667).

CONCLUSION

Three passes with standard EUS-FNA was optimal for a specific diagnosis of solid pancreatic masses, regardless of the histological type of the lesion.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of the reverse bevel versus Franseen type endoscopic ultrasound needle

BACKGROUND

Reverse bevel (RB) needle is widely used for endoscopic ultrasound fine needle biopsy (EUS-FNB). A 3-plane symmetrical needle with Franseen geometry (FG) has recently become available.

AIM

To compare the clinical efficacy of FG to that of RB needle.

METHODS

A retrospective cohort study of all adult patients who underwent EUS-FNB for solid and mixed lesions either with 22G RB needle or 22G FG needle between January 2016 and February 2019 was undertaken. All cytology slides were reviewed by an independent gastrointestinal cytopathologist blinded to the needle used and the initial cytology report. The primary and secondary outcomes were to assess the sample adequacy using Euro-cytology criteria and the number of cell clusters, respectively.

RESULTS

Two hundred and twenty six procedures were included in the study. RB needle was used in 128 procedures and FG needle in 98 procedures. The baseline characteristics of both groups were comparable. On multivariable analysis, FG needle (P = 0.02) and location of the lesion (P < 0.01) were independently associated with adequate tissue. Further, the use of FG needle (P = 0.04) and the size of the lesion (P = 0.02) were independently associated with acquisition of increased number of cell clusters.

CONCLUSION

FG needle is superior to RB needle in acquiring adequate tissue and attaining higher number of cell clusters for solid and mixed 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.

Factors affecting the accuracy of endoscopic ultrasound-guided fine needle aspiration for the diagnosis of small (≤20 mm) pancreatic lesions

To explore the diagnostic value of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for small, solid or semi-solid pancreatic lesions (≤20 mm) and the factors affecting its accuracy.

METHODS

Altogether 92 patients with small, solid or semi-solid pancreatic lesions who underwent EUS-FNA at the Nanjing Drum Tower Hospital from November 2009 to January 2019 were retrospectively analyzed. Univariate and multivariate analyses were used to determine the factors affecting the accuracy of EUS-FNA for detecting these lesions.

RESULTS

Among the 92 cases, 56 (60.9%) were diagnosed as having malignant lesions and 36 (39.1%) as benign lesions, respectively. The overall sensitivity, specificity and accuracy of EUS-FNA for the diagnosis of small, solid or semi-solid pancreatic lesions were 71.4%, 100% and 82.6%, respectively. When considering the impact of the presence of a tissue core on the diagnosis, the sensitivity, specificity, and accuracy of EUS-FNA with tissue core compared with those based on cytology alone were 77.3% vs 50.0%; 100% vs 100%; and 86.8% vs 62.5%, respectively. The multivariate analysis showed that larger tumor size (>15-20 mm) (odds ratio [OR] 4.200, 95% confidence interval [CI] 1.21-14.53, P = 0.023) and histologic diagnosis based on tissue core (OR 4.593, 95% CI 1.03-20.47, P = 0.046) were related to a higher accuracy of EUS-FNA. Adverse events were observed in three patients, all were treated conservatively and recovered within 3 days.

CONCLUSIONS

EUS-FNA is effective and safe for diagnosing small pancreatic lesions. Tumor size and presence of tissue core are related to higher accuracy of the EUS-FNA.

Evaluation of Pancreatic Lesions With Endoscopic Ultrasound and Fine Needle Aspiration

Background. Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are commonly used for assessing pancreatic lesions. This study aimed to evaluate the diagnostic yield and accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in a single tertiary institution. Methods. Consecutive patients who underwent EUS-FNA of the pancreas at Queen Mary Hospital, Hong Kong, from January 2015 to March 2016 were retrospectively reviewed. Endoscopic findings and FNA results were analysed. For patients who subsequently underwent surgical resection of pancreatic lesion, EUS-FNA diagnoses were compared to histopathological findings of surgical specimens to determine its diagnostic accuracy. Results. One hundred twelve EUS-FNA were performed in 99 patients within the study time period and were included for analysis. Sixty-six (66.7%) pancreatic lesions were solid in nature and 33 (33.3%) were cystic. The overall diagnostic yield of EUS-FNA was 70.5% (n = 79). On multivariate analysis, more passes of needle were associated with a higher diagnostic yield (odds ratio = 2.000, P = .049). 57.1% (n = 64) of EUS-FNA results had an impact on management. Sixteen patients with diagnostic EUS-FNA subsequently underwent surgery for resection of the pancreatic lesion. Upon correlation to the histopathological findings of surgical specimens, there were 12 true-positive, 2 true-negative, 0 false-positive, and 2 false-negative cases. Sensitivity was 85.7%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 50%. The diagnostic accuracy of EUS-FNA was 87.5%. Conclusion. EUS-FNA is accurate and reliable for diagnosing pancreatic lesions.

The Diagnostic Dilemma of Malignant Biliary Strictures

The differential diagnosis for biliary strictures is broad. However, the likelihood of malignancy is high. Determining the etiology of a biliary stricture requires a comprehensive physical exam, laboratory evaluation, imaging, and ultimately tissue acquisition. Even then, definitive diagnosis is elusive, and many strictures remain indeterminant in origin. This literary review examines the diagnostic dilemma of biliary strictures and presents innovations in both histochemical and endoscopic techniques that have increased the diagnostic power of differentiating benign and malignant strictures. The field of tissue biopsy is revolutionizing with the advent of free DNA mutation profiling, fluorescence in situ hybridization (FISH), and methionyl t-RNA synthetase 1 (MARS 1), which allow for greater testing sensitivity. Endoscopic ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy, confocal laser endomicroscopy, and intraductal ultrasound build upon existing endoscopic technology to better characterize strictures that would otherwise be indeterminate in etiology. This review uses recent literature to insert innovative technology into the traditional framework of diagnostic methods for malignant biliary strictures.

Small but powerful: the promising role of small specimens for biomarker testing

Emphasis on the use of small specimens for biomarker testing to provide prognostic and predictive information for guiding clinical management for patients with advanced-stage cancer has been increasing. These biomarker tests include molecular analysis, cytogenetic tests, and immunohistochemical assays. Owing to the limited nature of the cellular material procured in these small specimens, which are collected using minimally invasive techniques (ie, fine needle aspiration and core needle biopsy), pathologists have been required to triage these samples judiciously and provide the clinically relevant genomic information required for patient care. Awareness of the advantages and limitations of these specimen preparations and the specific preanalytic requirements for the testing methods will help pathologists to develop optimal strategies to maximize the chances of effectively using these samples for comprehensive diagnostic and relevant biomarker testing.

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.

Present and Future of Endoscopic Ultrasound-Guided Tissue Acquisition in Solid Pancreatic Tumors

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is a well-established method for pathological diagnosis of solid pancreatic neoplasm. It can be performed either as EUS-guided fine-needle aspiration (EUS-FNA) or EUS-guided fine-needle biopsy (EUSFNB). The incidence of adverse events related to EUS-TA is less than 1%. The factors that affect the diagnostic accuracy and specimen adequacy include the techniques used, type and size of the needle, competency of endosonographers, presence of cytopathologists/ cytotechnologists, and rapid on-site examination. EUS-TA may contribute to precision medicine through obtaining tissue samples for next-generation sequencing. The current status, several clinical issues for diagnostic yield and adverse events, and future perspectives of EUS-FNA/FNB for diagnosing pancreatic neoplasm have been discussed in this review article.

Comparison of Franseen and fork-tip needles for EUS-guided fine-needle biopsy of solid mass lesions: A systematic review and meta-analysis

Franseen-tip and Fork-tip needles have been widely used in EUS guided fine-needle biopsy (FNB) of solid organs. There is conflicting data on the performance of these needles and unanswered questions on the ideal number of needle-passes and the requirement of an onsite cytopathologist (ROSE). We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through July 2018) to identify studies that reported on the use of Forktip and Franseen-tip needles in EUS-FNB of solid organs. The primary outcome was to estimate and compare the pooled rates of diagnostic-yield. A subgroup analysis compared the outcomes based on the number of needle-passes and the availability of ROSE. A total of 23 study-arms were available for analysis. The pooled rate of diagnostic yield with Fork-tip needle was 92.8% (95% CI 85.3 - 96.6, I² = 73.1) and the pooled rate of diagnostic yield with Franseen-tip needle was 92.7% (95% CI 86.4 - 96.2, I² = 88.4).