Contrast-Enhanced Harmonic Endoscopic Ultrasound-Guided Fine-Needle Aspiration versus Standard Fine-Needle Aspiration in Pancreatic Masses: A Propensity Score Analysis

Contrast-enhanced endoscopic ultrasound likely does not improve diagnostic adequacy during endoscopic ultrasound guided tissue acquisition: A systematic review and meta-analysis

BACKGROUND AND AIMS

Solid pancreatic masses are sampled through tissue acquisition by endoscopic ultrasound (EUS). Inadequate samples may significantly delay diagnosis, increasing costs and carrying risks to the patients.

AIM

assess the diagnostic adequacy of tissue acquisition using contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) compared to conventional EUS.

METHODS

Five databases (PubMed, Embase, CENTRAL, Scopus and Web of Science) were searched in November 2023. Studies comparing diagnostic adequacy, accuracy and safety using CEH-EUS versus conventional EUS for tissue acquisition of solid pancreatic masses were included. Risk of bias was assessed using the Risk of Bias tool for randomized controlled trials (RoB2) and the Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tool for non-randomized studies, level of evidence using the GRADE approach, Odds Ratios (RR) with 95 % Confidence Intervals (CI) calculated and pooled using a random-effects model. I2 quantified heterogeneity.

RESULTS

The search identified 3858 records; nine studies (1160 patients) were included. OR for achieving an adequate sample was 1.467 (CI: 0.850-2.533), for randomized trials 0.902 (CI: 0.541-1.505), for non-randomized 2.396 (CI: 0.916-6.264), with significant subgroup difference. OR for diagnostic accuracy was 1.326 (CI: 0.890-1977), for randomized trials 0.997 (CI: 0.593-1.977) and for non-randomized studies 1.928 (CI: 1.096-3.393), significant subgroup difference (p = 0.0467). No differences were observed for technical failures or adverse events. Heterogeneity was low, risk of bias "low" to "some concerns" for most outcomes, mostly moderate for non-randomized studies.

CONCLUSION

Non-randomized studies indicated differences in favor of contrast-enhanced EUS, randomized studies showed no difference in diagnostic adequacy, accuracy or sensitivity when using CEH-EUS.

Contrast-enhanced guided endoscopic ultrasound procedures

Contrast-enhanced endoscopic ultrasound (CH-EUS) can overcome the limitations of endoscopic ultrasound-guided acquisition by identifying microvessels inside inhomogeneous tumours and improving the characterization of these tumours. Despite the initial enthusiasm that oriented needle sampling under CH-EUS guidance could provide better diagnostic yield in pancreatic solid lesions, further studies did not confirm the supplementary values in cases of tissue acquisition guided by CH-EUS. This review details the knowledge based on the available data on contrast-guided procedures. The indications for CH-EUS tissue acquisition include isoechoic EUS lesions with poor visible delineation where CH-EUS can differentiate the lesion vascularisation from the surrounding parenchyma and also the mural nodules within biliopancreatic cystic lesions, which occur in select cases. Additionally, the roles of CH-EUS-guided therapy in patients whose pancreatic fluid collections or bile ducts that have an echogenic content have indications for drainage, and patients who have nonvisualized vessels that need to be highlighted via Doppler EUS are presented. Another indication is represented if there is a need for an immediate assessment of the post-radiofrequency ablation of pancreatic neuroendocrine tumours, in which case CH-EUS can be used to reveal the incomplete tumour destruction.

Endoscopic Contrast-Enhanced Ultrasound and Fine-Needle Aspiration or Biopsy for the Diagnosis of Pancreatic Solid Lesions: A Systematic Review and Meta-Analysis

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) are currently recommended for the pathologic diagnosis of pancreatic solid lesions (PSLs). The application of contrast-enhanced endoscopic ultrasound (ECEUS) could aid the endoscopist during an FNA and/or FNB procedure. CEUS is indeed able to better differentiate the pathologic tissue from the surrounding healthy pancreatic parenchyma and to detect necrotic areas and vessels.

OBJECTIVES

Our objective was to evaluate if ECEUS could reduce the number of needle passes and side effects and increase the diagnostic efficacy of FNA and/or FNB.

METHODS

A comprehensive literature search of clinical studies was performed to explore if ECEUS-FNA or FNB could increase diagnostic accuracy and reduce the number of needle passes and adverse effects compared to standard EUS-FNA or FNB. In accordance with the study protocol, a qualitative and quantitative analysis of the evidence was planned.

RESULTS

The proportion of established diagnoses of ECEUS was 90.9% compared to 88.3% of EUS, with no statistically significant difference (p = 0.14). The diagnosis was made through a single step in 70.9% of ECEUS patients and in 65.3% of EUS patients, without statistical significance (p = 0.24). The incidence of adverse reactions was substantially comparable across both groups (p = 0.89).

CONCLUSION

ECEUS-FNA and FNB do not appear superior to standard EUS-FNA and FNB for the diagnosis of pancreatic lesions.

Methods to increase the diagnostic efficiency of endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic lesions: An updated review

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a means to procure adequate specimens for histological and cytologic analysis. The ideal EUS-FNA should be safe, accurate, and have a high sample adequacy rate and low adverse events rate. In recent years, many guidelines and trials on EUS-FNA have been published. The purpose of this article is to provide an update on the influence of some of the main factors on the diagnostic efficiency of EUS-FNA as well as a rare but serious complication known as needle tract seeding.

A review of contrast-enhanced harmonic endoscopic ultrasonography for pancreatic solid tumors

Endoscopic ultrasonography (EUS) is superior to other imaging modalities in the detection of pancreatic masses, although differentiating the types of pancreatic masses detected on EUS remains challenging. However, the value of contrast-enhanced harmonic EUS (CH-EUS) using ultrasound contrast agents for this differentiation has been reported. CH-EUS plays a pivotal role in analysis of small lesions that can only be detected with EUS. Recently, CH-EUS was used for staging and/or determining the resectability of pancreatic cancer in several clinical trials. In addition, it is used to estimate the response of pancreatic cancer to chemotherapy and to determine the prognosis in cases of pancreatic cancer and pancreatic neuroendocrine neoplasms. It is also postulated that CH-EUS improves the diagnostic performance of endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) through complementary diagnoses using CH-EUS and EUS-FNAB, or CH-EUS-guided EUS-FNAB. Thus, CH-EUS has been employed for various qualitative diagnoses, including differentiation of pancreatic masses. Second-generation contrast agents such as Sonazoid are used clinically for ultrasound diagnostic imaging of liver and breast disease. The positioning of CH-EUS with Sonazoid as a test for the diagnosis of solid pancreatic tumors is an issue for further studies.

Enhanced ultrasound-guided versus non-enhanced ultrasound-guided percutaneous needle biopsy in tissue cellularity of lung malignancies: a propensity score matched study

BACKGROUND

Though ultrasound-guided percutaneous lung needle biopsy (US-PLNB) is a first-line small biopsy method for peripheral lung lesions, quality of cellularity in specimens obtained via US-PLNB is uncertain. This study investigated the accuracy, sensitivity, and cellularity of US-PLNB. It examined the ability of contrast-enhanced ultrasound (CEUS) to improve the effectiveness of US-PLNB.

METHODS

We retrospectively analyzed all data of patients with subpleural lung lesions who underwent US-PLNB. The cellularity of US-PLNB from malignant lesions included the tumor cell number and proportion. The definition of high-quality cellularity (HQC) was concurrently achieving a tumor cell number ≥400 and a proportion ≥20%. The sensitivity, the actual numbers of tumor cell number/proportion, and the rate of HQC were calculated and compared between the CEUS and non-enhanced US groups after propensity score matching (PSM) with subgroup analyses by lesion size (small lesion ≤30 mm and large lesion >30 mm).

RESULTS

A total of 345 patients undergoing 345 US-PLNBs were evaluated, with 3.7±1.1 of punctures on average. There were 201 malignant and 144 benign lesions with a mean size of 43.8±24.1 mm. Among the 201 malignant lesions, 124 cases underwent CEUS and 77 underwent non-enhanced US. The quantity of tumor cells, the proportion of tumor cells, and the rate of HQC in 201 cases of US-PLNB from malignant lesions were 2,862.1±2,288.0, 44.6%±24.5%, and 82.1% [95% confidence interval (CI): 76.6% to 87.1%], respectively. The quantity of tumor cells, the proportion of tumor cells, and rate of HQC were significantly higher in the CEUS group than that in the non-enhanced US group, both in the analysis of overall malignant lesions and in large malignant lesions (all P<0.05).

CONCLUSIONS

The US-PLNB has high sensitivity and thereby obtains HQC samples for subpleural lung malignant lesions. The CEUS helps improve the rate of HQC and tissue cellularity of lung malignancies.

Artificial intelligence in endoscopy: More than what meets the eye in screening colonoscopy and endosonographic evaluation of pancreatic lesions

Artificial intelligence (AI)-based tools have ushered in a new era of innovation in the field of gastrointestinal (GI) endoscopy. Despite vast improvements in endoscopic techniques and equipment, diagnostic endoscopy remains heavily operator-dependent, in particular, colonoscopy and endoscopic ultrasound (EUS). Recent reports have shown that as much as 25% of colonic adenomas may be missed at colonoscopy. This can result in an increased incidence of interval colon cancer. Similarly, EUS has been shown to have high inter-observer variability, overlap in diagnoses with a relatively low specificity for pancreatic lesions. Our understanding of Machine-learning (ML) techniques in AI have evolved over the last decade and its application in AI–based tools for endoscopic detection and diagnosis is being actively investigated at several centers. ML is an aspect of AI that is based on neural networks, and is widely used for image classification, object detection, and semantic segmentation which are key functional aspects of AI-related computer aided diagnostic systems. In this review, current status and limitations of ML, specifically for adenoma detection and endosonographic diagnosis of pancreatic lesions, will be summarized from existing literature. This will help to better understand its role as viewed through the prism of real world application in the field of GI endoscopy.

The Utility of Endoscopic-Ultrasonography-Guided Tissue Acquisition for Solid Pancreatic Lesions

Endoscopic-ultrasonography-guided tissue acquisition (EUS-TA) has been widely performed for the definitive diagnosis of solid pancreatic lesions (SPLs). As the puncture needles, puncture techniques, and sample processing methods have improved, EUS-TA has shown higher diagnostic yields and safety. Recently, several therapeutic target genomic biomarkers have been clarified in pancreatic ductal carcinoma (PDAC). Although only a small proportion of patients with PDAC can benefit from precision medicine based on gene mutations at present, precision medicine will also be further developed for SPLs as more therapeutic target genomic biomarkers are identified. Advances in next-generation sequencing (NGS) techniques enable the examination of multiple genetic mutations in limited tissue samples. EUS-TA is also useful for NGS and will play a more important role in determining treatment strategies. In this review, we describe the utility of EUS-TA for SPLs.

Contrast-enhanced harmonic endoscopic ultrasound-guided fine-needle aspiration versus standard fine-needle aspiration in pancreatic masses: a meta-analysis

OBJECTIVES

It is still unclear whether endoscopic ultrasound (EUS) contrast-enhanced fine-needle aspiration (CH-EUS-FNA) determines superior results in comparison to standard EUS-FNA in tissue acquisition of pancreatic masses. Aim of this meta-analysis was to compare the diagnostic outcomes of these two techniques.

METHODS

We searched the PubMed/Medline and Embase database through October 2020 and identified 6 studies, of which 2 randomized controlled trials (recruiting 701 patients). We performed pairwise meta-analysis through a random effects model and expressed data as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Pooled diagnostic sensitivity was 84.6% (95% CI 80.7%-88.6%) with CH-EUS-FNA and 75.3% (67%-83.5%) with EUS-FNA, with evidence of a significant superiority of the former (OR 1.74, 95% CI 1.26-2.40; p < 0.001). Subgroup analysis confirmed the superiority of CH-EUS-FNA over EUS-FNA only in larger lesions. Pooled diagnostic accuracy was 88.8% (85.6%-91.9%) in CH-EUS-FNA group and 83.6% (79.4%-87.8%) in EUS-FNA group (OR 1.52, 1.01-2.31; p = 0.05). Pooled sample adequacy was 95.1% (91.1%-99.1%) with CH-EUS-FNA and 89.4% (81%-97.8%) with EUS-FNA (OR 2.40, 1.38-4.17; p = 0.02).

CONCLUSION

CH-EUS-FNA seems to be superior to standard EUS-FNA in patients with pancreatic masses. Further trials are needed to confirm these results.

Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS-FNA) with Image Enhancement

Although endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is useful in the differential diagnosis of solid pancreatic lesions, lymph nodes, and liver lesions, inadequate sampling may result in an incorrect pathological diagnosis. The accuracy of EUS for the evaluation of pancreatobiliary lesions may be increased by image enhancement technologies, including contrast-enhanced harmonic (CH)-EUS and EUS-elastography. These methods can provide information that complement EUS-FNA for the diagnosis and staging of pancreatobiliary cancer, and can help to identify the EUS-FNA target, reducing the requirement for repeat FNA.