Slow-pull and different conventional suction techniques in endoscopic ultrasound-guided fine-needle aspiration of pancreatic solid lesions using 22-gauge needles

Comparation of 5 ml and 10 ml Negative Pressures with Wet-suction Techniques for EUS-FNA of Solid Lesions: A Single-center Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

The negative pressure selectable for the wet-suction technique remains uncertain. The aim was to investigate the quality of sampling and diagnostic accuracy with solid lesions by 5 mL and 10 mL negative pressure with wet-suction techniques.

METHODS

This is a single-center, crossover, randomized controlled trial conducted with a random sampling technique. In all, 160 patients consecutively undergoing EUS-FNA for solid lesions were randomized in a ratio of 1:1 into 2 groups, the 5 mL and 10 mL negative pressure wet-suction group. The main outcome was to compare the sample quality between the 2 groups. The secondary outcome was to compare the histologic and cytologic diagnostic accuracy of solid lesions.

RESULTS

Pancreatic (n=129) and nonpancreatic (n=27) lesions from 156 lesions were examined. The sample quality concluding cellularity, adequacy, integrity, and blood contamination were comparable between the 2 groups. However, in subgroup analysis, we found 19G FNA provided more integrity of specimen in 5 mL than in 10 mL group (100% vs. 82.9%, P=0.025). In contrast, this benefit was not noteworthy in the 22G FNA subgroup. And there was no statistically significant in histologic (87.82% vs. 87.18%, P=1.000) and cytologic (78.85% vs. 80.77%, P=0.778) accuracy between 5 mL and 10 mL groups.

CONCLUSION

When using the wet-suction technique, 5 mL and 10 mL negative pressure offer equivalent sample quality and diagnostic accuracy. However, the 19G FNA can obtain better sample quality with 5 mL negative pressure than 10 mL negative pressure.

Wet-suction versus slow-pull technique for endoscopic ultrasound-guided fine-needle biopsy: a multicenter, randomized, crossover trial

BACKGROUND : It is unknown whether there is an advantage to using the wet-suction or slow-pull technique during endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) with new-generation needles. We aimed to compare the performance of each technique in EUS-FNB.

METHODS

 This was a multicenter, randomized, single-blind, crossover trial including patients with solid lesions of ≥ 1 cm. Four needle passes with 22 G fork-tip or Franseen-type needles were performed, alternating the wet-suction and slow-pull techniques in a randomized order. The primary outcome was the histological yield (samples containing an intact piece of tissue of at least 550 μm). Secondary end points were sample quality (tissue integrity and blood contamination), diagnostic accuracy, and adequate tumor fraction.

RESULTS

 Overall, 210 patients with 146 pancreatic and 64 nonpancreatic lesions were analyzed. A tissue core was retrieved in 150 (71.4 %) and 129 (61.4 %) cases using the wet-suction and the slow-pull techniques, respectively (P = 0.03). The mean tissue integrity score was higher using wet suction (P = 0.02), as was the blood contamination of samples (P < 0.001). In the two subgroups of pancreatic and nonpancreatic lesions, tissue core rate and tissue integrity score were not statistically different using the two techniques, but blood contamination was higher with wet suction. Diagnostic accuracy and tumor fraction did not differ between the two techniques.

CONCLUSION

 Overall, the wet-suction technique in EUS-FNB resulted in a higher tissue core procurement rate compared with the slow-pull method. Diagnostic accuracy and the rate of samples with adequate tumor fraction were similar between the two techniques.

Optimal sampling technique for EUS-guided fine-needle biopsy of solid pancreatic lesions using a 25-gauge ProCore needle: A multicenter randomized crossover superiority study

Background and Objectives

It remains unclear whether the use of the stylet slow-pull (SP) and wet suction (WS) can improve the yield of endoscopic ultrasound-guided fine-needle biopsy compared to standard suction (SS). The aim of this study was to compare the diagnostic efficacy of the three sampling techniques when using 25G ProCore needles for solid pancreatic lesions.

Materials and Methods

This multicenter single-blind randomized crossover superiority trial enrolled patients with solid pancreatic lesions (n = 300) from four digestive endoscopic centers in China. All three sampling techniques were performed on each patient using a 25G ProCore needle in a randomized sequence. The diagnostic efficacy, the specimen yield, and quality of each technique, the overall technical success rate and diagnostic yield of the 25G ProCore needle, and rate of adverse events were evaluated.

Results

A total of 291 patients were analyzed. No significant difference was found in diagnostic efficiency among the three techniques (sensitivity, 82.14% vs. 75.00% vs. 77.86, P = 0.1186; accuracy, 82.82% vs. 75.95% vs. 78.69%, P = 0.1212). The SP had an inferior tissue integrity compared to the SS and WS techniques (71.82% vs. 62.55% vs. 69.76%, P = 0.0096). There was no significant difference in the degree of blood contamination among the three groups (P = 0.2079). After three passes, the overall sensitivity was 93.93%, and the accuracy was 94.16%.

Conclusions

SS and WS techniques are better choices than SP technique for 25G ProCore needle, for they could provide higher specimen adequacy without increasing the amount of blood contamination. The 25G ProCore needle can provide a satisfactory diagnostic yield for solid pancreatic lesions.

Fine Needle Biopsies of Solid Pancreatic Lesions: Tissue Acquisition Technique and Needle Design Do Not Impact Specimen Adequacy

BACKGROUND AND AIMS

Data on adequacy of EUS guided biopsies using different tissue acquisition techniques and fine needle aspiration needle designs have been inconclusive. Data on newer fine needle biopsy (FNB) needles are scarce. This study compared the performance of 3 acquisition techniques and 2 fine needle biopsy designs in solid pancreatic lesions.

METHODS

Single-center, randomized, pilot clinical trial (Trial registration number NCT03264092). Patients undergoing EUS biopsy of pancreatic lesions were randomized to 1 of 3 acquisition techniques (dry suction, wet suction, slow pull) and 1 of 2 22G FNB needle designs. The primary outcome was specimen cellularity. Secondary outcomes included blood contamination and number of passes needed for diagnosis.

RESULTS

A total of 52 (35.3%), 49 (33.3%) and 46 (31.3%) specimens were obtained with slow pull, dry suction and wet suction, respectively. A total of 56 (38%) and 91 (62%) specimens were obtained with each needle, respectively. No difference in cellularity scores was identified by technique (3.28 vs 3.55 vs 2.94; p = 0.081) or needle type (3.45 vs 3.15; p = 0.19). The same was true for blood contamination and diagnostic pass. A diagnosis was reached after 3 passes in 51 patients (93%). Histological diagnosis was possible in 45 specimens (82%). No severe adverse events occurred.

CONCLUSIONS

Cellularity of pancreatic specimens obtained with FNB needles via EUS was not influenced by technique and needle design. Three passes were enough to obtain a histological diagnosis in most patients. Larger clinical trials are required to validate the results of this study.

Establishment of Patient-Derived Pancreatic Cancer Organoids from Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsies

Background/Aims

Three-dimensional cultures of human pancreatic cancer tissue also known as "organoids" have largely been developed from surgical specimens. Given that most patients present with locally advanced and/or metastatic disease, such organoids are not representative of the majority of patients. Therefore, we used endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to collect pancreatic cancer tissues from patients with advanced pancreatic cancer to create organoids, and evaluated their utility in pancreatic cancer research.

Methods

Single-pass EUS-FNA samplings were employed to obtain the tissue for organoid generation. After establishment of the organoid, we compared the core biopsy tissues with organoids using hematoxylin and eosin staining, and performed whole exome sequencing (WES) to detect mutational variants. Furthermore, we compared patient outcome with the organoid drug response to determine the potential utility of the clinical application of such organoid-based assays.

Results

Organoids were successfully generated in 14 of 20 tumors (70%) and were able to be passaged greater than 5 times in 12 of 20 tumors (60%). Among them, we selected eight pairs of organoid and core biopsy tissues for detailed analyses. They showed similar patterns in hematoxylin and eosin staining. WES revealed mutations in KRAS, TP53, CDKN2A, SMAD4, BRCA1, and BRCA2 which were 93% homologous, and the mean nonreference discordance rate was 5.47%. We observed moderate drug response correlations between the organoids and clinical outcomes in patients who underwent FOLFIRINOX chemotherapy.

Conclusions

The established organoids from EUS-FNA core biopsies can be used for a suitable model system for pancreatic cancer research.

Comparison of specimen quality among the standard suction, slow-pull, and wet suction techniques for EUS-FNA: A multicenter, prospective, randomized controlled trial

Background and Objectives

Standard suction technique (SST), slow-pull technique (SPT), and wet suction technique (WEST) of EUS-FNA are designed to improve the diagnostic yields of solid and solid-cystic lesions. We conducted a multicenter, prospective, randomized crossover trial to compare SST, SPT, and WEST on specimen quality and diagnostic accuracy using a 22G needle.

Methods

Patients with solid or solid-cystic lesions referred for EUS-FNA at four tertiary hospitals from December 2017 to August 2019 were considered eligible. All lesions were sampled using a 22G needle by the three techniques performed consecutively in a randomized order. The primary outcome was quality of the specimen acquired by each technique regarding blood contamination, tissue integrity and cellularity for diagnosis, graded on a predefined scale. The secondary outcomes were the diagnostic yield of EUS-FNA and the incidence of adverse events. ClinicalTrial. gov registration number: NCT03567863.

Results

A total of 300 patients (mean age, 60.6 years, 188 men) were enrolled. WEST was superior (mean score 4.02 ± 1.51) over SST (3.67 ± 1.57, P = 0.018), but comparable to SPT (3.83 ± 1.55, P = 0.370) in overall specimen quality evaluation. WEST produced better tissue integrity (1.42 ± 0.74) and higher cellularity (1.32 ± 0.80) than SST and SPT. SPT (1.43 ± 0.69) was superior to SST (1.27 ± 0.72, P = 0.004) and WEST (1.28 ± 0.71, P = 0.006) in avoiding blood contamination. WEST achieved a diagnostic accuracy of 74.7%, higher than SST (64.4%, P = 0.007) and SPT (65.0%, P = 0.012). One bleeding event occurred with a pancreatic lesion.

Conclusions

WEST was comparable to SPT and superior to SST in the overall quality of the specimen and achieved highest diagnostic yield.

Endoscopic ultrasonography‐guided tissue acquisition for small solid pancreatic lesions: Does the size matter?

Endoscopic ultrasonography‐guided tissue acquisition (EUS‐TA) is now an established technique to obtain the pathological diagnosis of solid pancreatic lesions (SPLs), but the diagnosis of small SPLS by EUS‐TA can still be difficult. We conducted a literature review and a meta‐analysis on the diagnostic yield of EUS‐TA according to the tumor size. In a meta‐analysis of 33 studies with 6883 cases, a pooled odds ratio (OR) of sensitivity was significantly higher in SPLs of >20 mm (OR 1.64, p = 0.02) and in SPLs of >10 mm (OR 3.05, p = 0.01), but not in SPLs of >30 mm (OR 1.18, p = 0.46). The meta‐analysis of accuracy also showed a similar trend: OR of 1.59 in SPLs of >20 mm (p < 0.01) and OR of 3.27 in SPLs of >10 mm (p < 0.01) and OR of 1.03 in SPLs of >30 mm (p = 0.87). The use of a 25‐gauge needle tended to improve sensitivity in small SPLs, though not statistically significant: OR of 1.25 and 2.82 in studies with and without a 25‐gauge needle (p = 0.08). The use of fine needle biopsy needles, slow pull method, and rapid on‐site evaluation did not significantly improve sensitivity in small SPLs. EUS‐TA for small SPLs, especially neuroendocrine neoplasms, is reported to have a high risk of adverse events. In summary, the diagnostic yield and safety of EUS‐TA for small (<20 mm) SPLs still needs improvement, and the best needle and technique for small SPLs should be further investigated.

A Meta-analysis of Slow Pull versus Suction for Endoscopic Ultrasound-Guided Tissue Acquisition

Background/Aims

Endoscopic ultrasound (EUS)-guided tissue acquisition is widely utilized as a diagnostic modality for intra-abdominal masses, but there remains debate regarding which suction technique, slow pull (SP) or conventional suction (CS), is better. A meta-analysis of reported studies was conducted to compare the diagnostic yields of SP and CS during EUS-guided tissue acquisition.

Methods

We conducted a systematic electronic search using MEDLINE/PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials to identify clinical studies comparing SP and CS. We meta-analyzed accuracy, sensitivity, blood contamination and cellularity using the random-effects model.

Results

A total of 17 studies (seven randomized controlled trials, four prospective studies, and six retrospective studies) with 1,616 cases were included in the analysis. Compared to CS, there was a trend toward better accuracy (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.97 to 2.27; p=0.07) and sensitivity (OR, 1.67; 95% CI, 0.95 to 2.93; p=0.08) with SP and a significantly lower rate of blood contamination (OR, 0.48; 95% CI, 0.33 to 0.69; p<0.01). However, there was no significant difference in cellularity between SP and CS, with an OR of 1.28 (95% CI, 0.68 to 2.40; p=0.45). When the use of a 25-gauge needle was analyzed, the accuracy and sensitivity of SP were significantly better than those of CS, with ORs of 4.81 (95% CI, 1.99 to 11.62; p<0.01) and 4.69 (95% CI, 1.93 to 11.40; p<0.01), respectively.

Conclusions

Compared to CS, SP appears to provide better accuracy and sensitivity in EUS-guided tissue acquisition, especially when a 25-gauge needle is used.

Comparison between modified wet suction and dry suction technique for endoscopic ultrasound-guided fine-needle biopsy in pancreatic solid lesions

BACKGROUND AND AIM

Although endoscopic ultrasound-guided fine-needle biopsy is widely applied, there is no clear consensus on the optimal biopsy technique. We described a modified wet suction technique (MWEST) with the aim to compare the efficacy and safety between MWEST and the dry suction technique (DST).

METHODS

In this prospective, randomized, crossover, single-blinded study, patients with suspected pancreatic malignancy were randomized to the DST (group A) or MWEST (group B) for the first pass, and the two techniques were performed alternately. The primary outcome was the comparison of specimen adequacy and diagnostic yield between the techniques. Secondary outcomes included the macroscopic visible core length, blood contamination of specimens, and adverse events of both techniques.

RESULTS

From January 2019 to September 2019, 216 passes were performed in 50 patients. The specimen adequacy was significantly higher in "per-lesion" (P = 0.026), "per-pass" (cytology: P = 0.034; histology: P = 0.042), and first-pass analysis (P = 0.034) for MWEST than for DST. In diagnostic yield, MWEST showed significantly superior histological yield (P = 0.014) and first-pass analysis (κ: MWEST: 0.743 and DST: 0.519) compared with DST. The median macroscopic visible core lengths were 8 mm (interquartile range: 3.25-15 mm) and 10 mm (interquartile range: 5.25-15 mm) for DST and MWEST, respectively (P = 0.036). Blood contamination was significantly more serious in DST than in MWEST (cytology: P = 0.021; histology: P = 0.042).

CONCLUSIONS

Endoscopic ultrasound-guided fine-needle biopsy with MWEST resulted in significantly better quality of specimen, histological, and first-pass diagnostic yields and comparable safety compared with the DST. MWEST is preferred for endoscopic ultrasound-guided fine-needle biopsy in pancreatic solid lesions.

Slow-pull capillary technique versus suction technique in endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing diseases involving hilar and mediastinal lymph node enlargement

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a widely used, safe, and accurate technique for obtaining pathological specimens to be used in the diagnosis of diseases involving lung hilar and mediastinal lymph node (LN) enlargement. However, application of the suction technique during EBUS-TBNA remains controversial. In addition, the effectiveness of the slow-pull capillary technique for the diagnosis of pancreatic masses was recently reported. The aim of this study was to compare the diagnostic accuracy of EBUS-TBNA using these two techniques.

METHODS

The accuracy, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and availability of tissue cores of the suction and slow-pull capillary techniques were studied retrospectively in patients who underwent EBUS-TBNA for the diagnosis of diseases involving lung hilar and mediastinal LN enlargement.

RESULTS

A total of 97 patients with hilar and mediastinal LN enlargement underwent EBUS-TBNA; 30 patients underwent the suction technique, 56 patients underwent the slow-pull capillary technique, 5 patients underwent both techniques, and 6 patients had failed operations. The accuracy, sensitivity, specificity, NPV, PPV, and the number of tissue cores obtained with the suction and slow-pull capillary techniques were 66.67% versus 85.71% (p = 0.039), 43.75% versus 85.42% (p < 0.001), 92.86% versus 87.5% (p > 0.05), 59.09% versus 50% (p > 0.05), 87.5% versus 97.62% (p > 0.05), and 19 versus 50 (p = 0.004), respectively. In both univariate and multivariate analyses, the acquisition of tissue core was significantly associated with the diagnostic accuracy of EBUS-TBNA. Moreover, the slow-pull capillary technique was significantly associated with the acquisition of tissue core in EBUS-TBNA. There were no significant differences between the two groups in the blood contamination of samples.

CONCLUSIONS

Use of the slow-pull capillary technique in EBUS-TBNA can significantly increase the accuracy related to the diagnosis of diseases involving hilar and mediastinal LN enlargement by improving the acquisition of tissue core. The reviews of this paper are available via the supplemental material section.

Intermittent endoscopic ultrasound guided fine-needle aspiration for the diagnosis of solid pancreatic lesions. Pilot study

Background and purpose of the study: endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) is the method of choice for sampling pancreatic solid lesions. However, there is significant heterogeneity in terms of the technique used. Intermittent aspiration has not been evaluated in pancreatic solid lesions and could improve the diagnostic performance.

METHODS

Single-blind, non-inferiority pilot study. Patients with solid pancreatic lesions and indication for EUS-FNA were prospectively included. Patients were randomly assigned to intermittent (IS) or continuous (CS) suction techniques. Diagnostic performance, cellularity, blood contamination and number of passes required to reach diagnosis were evaluated.

MAIN RESULTS

33 patients were assigned to CS (16 patients) or IS (17 patients). Diagnostic performance was 87.5% for CS and 94.1% for IS (OR 2.29, 95%CI 0.19-27.99, p = 0.51). In the IS group samples had higher cellularity (OR 1.83, 95%CI 0.48-6.91, p = 0.37) and lower blood contamination (OR 0.38, 95%CI 0.09-1.54, p = 0.18). The number of passes required to reach diagnosis was 2.12 for CS and 1.94 for IS (p = 0.64). Liquid cytology was obtained in 73.3% of IS and 61.5% of CS (OR 1.72, 95%CI 0.35-8.50).

CONCLUSIONS

The IS technique was not inferior to CS in terms of diagnostic accuracy in the evaluation of pancreatic solid lesions, with a tendency to obtain higher cellularity, lower blood contamination and frequent presence of cell block.

Stylet Slow-pull Versus Standard Suction for Endoscopic Ultrasound-guided Fine-needle Aspiration/Biopsy of Pancreatic Solid Masses: A Meta-Analysis

BACKGROUND AND STUDY AIM

There is limited evidence on the diagnostic performance of the stylet slow-pull (SP) method for endoscopic ultrasound-guided fine-needle aspiration/biopsy. The aim of this study was to compare the SP method with standard suction (SS) for endoscopic ultrasound-guided fine-needle aspiration/biopsy of solid pancreatic masses.

METHODS

A computerized bibliographic search of the main databases, including PubMed, EMBASE, Cochrane Library, and Science Citation Index, was performed through February 2020. The main outcome measurements were diagnostic accuracy, cellularity, low blood contamination, adequate core tissue acquisition, and technical success rate.

RESULTS

Eleven studies (including 6 randomized trials) were included, with a total of 504 patients who underwent SP and 551 who underwent SS. Diagnostic accuracy was significantly superior in the SP group, compared with the SS group [odds ratio (OR)=1.60; 95% confidence interval (CI), 1.14-2.26]. The SP group had higher pooled rates of low blood contamination (OR=1.93; 95% CI, 1.29-2.87) and adequate core tissue acquisition (OR=1.91; 95% CI, 1.11-3.26) than the SS group. There was no significant difference between groups in the adequacy of cellularity (OR=0.99; 95% CI, 0.63-1.57; P=0.98) or technical success rate (OR=0.38; 95% CI, 0.13-1.15; P=0.09).

CONCLUSIONS

The authors provide evidence that SP is superior to SS in diagnostic accuracy, low blood contamination, and adequate core tissue acquisition, without reducing adequacy of cellularity or technical success rate.

Optimal number of needle passes during EUS-guided fine-needle biopsy of solid pancreatic lesions with 22G ProCore needles and different suction techniques: A randomized controlled trial

Background and Objectives:

The sensitivity of EUS-guided fine-needle biopsy (EUS-FNB) varies considerably. The optimal number of passes through a solid pancreatic lesion with a 22G FNB needle during EUS-FNB is controversial. This prospective randomized controlled study aimed to determine the optimal number of needle passes during EUS-FNB of solid pancreatic lesions, with 22G FNB needles and different sampling techniques.

Methods:

Pancreatic masses were sampled using 22G FNB needles with either the stylet slow-pull (SP) technique or the standard-suction (SS) technique. We determined the number of needle passes required to obtain a diagnostic accuracy of >90%. Differences between the two techniques in terms of technical success rate, cytological acquisition, core tissue acquisition, sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and complications were analyzed.

Results:

A total of 120 patients were randomly assigned to either SP or SS group. Three patients who were lost to follow-up and one who did not complete 5 passes due to bent needle head were excluded from the study. Fifty-six cases in the SP group and 60 cases in the SS group were included in the analysis. For SP technique, the cumulative accuracy of passes 1, 2, 3, 4, and 5 was 44.83%, 76.79%, 87.50%, 92.86%, and 94.64%, respectively. For SS technique, the cumulative accuracy of passes 1, 2, 3, 4, and 5 was 71.67%, 85.0%, 90.0%, 93.33%, and 95.0%, respectively. For each group, there was no statistically significant difference in accuracy after 3 and 4 passes. After 4 passes, the pooled sensitivity (92.59% vs. 93.10%), accuracy (92.86% vs. 93.10%), and specificity (100% vs. 100%) were similar (P > 0.05) in the SP and SS groups, respectively. In addition, positive cytological diagnoses (83.9% vs. 85.0%) and positive histological diagnoses (71.4% vs. 78.3%) were comparable (P > 0.05) in the SP and SS groups, respectively. No statistically significant factor was found associated with diagnostic sensitivity for each group.

Conclusion:

When on-site cytological evaluation is unavailable, we recommend that at least 3 passes with 22G ProCore needles be performed during EUS-FNB using the SS technique, at least 4 passes when using SP technique. The SS technique showed potential advantages over SP technique in tissue acquisition and diagnostic capabilities.

Slow-pull technique yields better quality smears: prospective comparison of slow-pull and standard suction techniques of endoscopic ultrasound-guided fine-needle aspiration

BACKGROUND

Diagnostic accuracy and quality of smears obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are influenced by characteristics of suction and examined organ.

AIMS AND METHODS

Efficiency of EUS-FNA and quality of smears obtained by slow-pull (SP) and standard suction (SS) techniques was prospectively compared in the sampling of pancreatic (N = 56) and extrapancreatic (N = 145) tumors.

RESULTS

SS technique resulted in a higher number of smear pairs both in pancreatic (1.74 vs. 3.19; p < 0.001) and extrapancreatic tumors (1.62 vs. 3.28; p < 0.001); however, it decreased the proportion of diagnostic smears (46.69% vs. 36.52%; p = 0.002 and 49.17% vs. 30.67%; p < 0.001) and increased the bloodiness (1.51 vs. 2.07; p < 0.001 and 1.48 vs. 2.05; p < 0.001). In pancreatic cancers, no difference was observed in terms of diagnostic accuracy (81.38% vs. 83.45%) and cellularity (1.44 vs. 1.27; p = 0.067); however, they were substantially higher in extrapancreatic tumors using SP technique (71.41% vs. 60.71% and 1.34 vs. 0.77; p < 0.001). Only SP technique resulted in a significant difference between examiners in terms of technical success rate and quality of smears without any decrease of diagnostic accuracy.

CONCLUSIONS

SP technique yields better quality smears independently from tumors characteristics; however, it shows significant examiner-dependency. SS technique reduces the diagnostic accuracy of sampling in extrapancreatic tumors.

Tissue acquisition and pancreatic masses: Which needle and which acquisition technique should be used?

Background and study aims  Pancreatic cancer represents the fourth most common cause of cancer-related deaths in Western countries and the need of a low-risk investigation to obtain an accurate histopathological diagnosis has become increasingly pressing. Endoscopic ultrasonography (EUS) with fine-needle aspiration (FNA) is the standard method for obtaining samples from pancreatic masses. In recent years, there has been an increasing need to obtain histological specimens during EUS procedures, rather than cytological ones, to guide oncological treatment options, leading to the so-call "FNB concept." Different needles have been developed for fine-needle biopsy (FNB) in recent years, enabling acquisition of larger specimens on which to perform histological and molecular analyses. The aim of this narrative review was to assess the role of EUS-guided FNA and FNB in patients with pancreatic masses, and to identify which needle and which acquisition technique should be used to improve tissue acquisition.

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.

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.

Comparison between Conventional Smear and Liquid-Based Preparation in Endoscopic Ultrasonography-Fine Needle Aspiration Cytology of Pancreatic Lesions

The present study aimed to compare the diagnostic accuracy between conventional smear (CS) and liquid-based preparation (LBP) in endoscopic ultrasonography-fine needle aspiration cytology (EUS-FNAC) of pancreatic lesions. Using 31 eligible studies, the diagnostic accuracy of cytologic examination in CS and LBP was evaluated through a conventional meta-analysis and diagnostic test accuracy review. Overall concordance rates were 82.8% (95% confidence interval [CI], 79.8–85.5%) and 94.0% (95% CI, 84.4–97.8%) in CS and LBP, respectively. CS with rapid on-site evaluation (ROSE) showed a higher concordance rate than CS without ROSE. In CS, the pooled sensitivity and specificity were 89.8% (95% CI, 85.2–93.1%) and 95.0% (95% CI, 90.0–97.6%), respectively. The diagnostic odds ratio (OR) and area under curve (AUC) of the summary receiver operating characteristic (SROC) curve were 90.32 (95% CI, 43.85–147.11) and 0.945, respectively. In LBP, the pooled sensitivity and specificity were 80.9% (95% CI, 69.7–88.7%) and 99.9% (95% CI, 1.5–100.0%), respectively. The diagnostic OR and AUC of the SROC curve were 57.21 (95% CI, 23.61–138.64) and 0.939, respectively. Higher concordance rates were found in CS with ROSE and LBP in EUS-FNAC of pancreatic lesions. Regardless of the cytologic preparation method, EUS-FNAC is a useful and accurate diagnostic tool for pancreatic lesions.

Suction versus slow-pull for endoscopic ultrasound-guided fine-needle aspiration of pancreatic tumors: a prospective randomized trial

BACKGROUND

Suction (S) is commonly used to improve cell acquisition during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Slow-pull (SP) sampling is another technique that might procure good quality specimens with less bloodiness. We aimed to determine if SP improves the diagnostic yield of EUS-FNA of pancreatic masses.

METHODS

Patients with pancreatic solid masses were randomized to four needle passes with both techniques in an alternate fashion. Sensitivity, specificity, positive, and negative predictive values were calculated. Cellularity and bloodiness of cytological samples were assessed and compared according to the technique.

RESULTS

Sensitivity, specificity, and accuracy of suction vs. SP were 95.2% vs. 92.3%; 100% vs. 100; 95.7% vs. 93%, respectively. As to the association of methods, they were 95.6, 100 and 96%, respectively. Positive predictive values for S and SP were 100%. There was no difference in diagnostic yield between S and SP (p = 0.344). Cellularity of samples obtained with SP and Suction were equivalent in both smear evaluation (p = 0.119) and cell-block (0.980). Bloodiness of SP and suction techniques were similar as well.

CONCLUSIONS

S and SP techniques provide equivalent sensitivity, specificity, and accuracy. Association of methods seems to improve diagnostic yield. Suction does not increase the bloodiness of samples compared to slow-pull.

Slow-pull compared to suction technique for EUS-guided sampling of pancreatic solid lesions: a meta-analysis of randomized controlled trials

Background and study aims  Current ESGE guidelines suggest employing the suction (SU) technique for endoscopic ultrasound (EUS)-guided sampling of pancreatic solid lesions. Nonetheless, recent randomized controlled trials (RCT) have reported that the slow-pull (SP) technique has similar diagnostic accuracy with possibly less blood contamination. However, these results are heterogeneous and limited to small cohorts. The aim of this meta-analysis was to compare adequacy, accuracy, sensitivity and specificity of the SU and SP techniques for EUS-guided sampling of solid pancreatic lesions. Methods  A computerized bibliographic search was restricted to RCTs. Pooled effects were calculated using a random-effects model and expressed in terms of pooled sensitivity and specificity and OR (95 % CI) for adequacy and accuracy. Results  Overall, seven RCTs were included, for a total of 475 patients (163 lesions sampled with SU, 164 with SP and 148 by both). The adequacy was similar (OR = 0.98) without heterogeneity (I 2  = 0 %), but a high degree of blood contamination was more common with SU than SP (pooled rate 27.6 % vs 19.7 %). A non-significant superiority of SP in terms of pooled accuracy (OR = 0.82; 95 % CI 0.36-1.85) was recorded, with moderate heterogeneity (I 2  = 52.4 %). The SP technique showed a slightly higher pooled sensitivity compared to SU (88.7 % vs 83.4 %), while specificity was similar (97.2 % SP vs 96.9 % SU), with considerable heterogeneity. Conclusion  The current meta-analysis reveals non-superiority of SU over SP, while SP results in reduced blood contamination. If the 5 % accuracy difference favouring SP is true, with alfa error = 0.05 and beta = 0.20, a RCT of 982 patients per arm is needed to confirm significance.

Endoscopic ultrasound-guided tissue sampling of pancreatic lesions

Important advancements in endoscopic ultrasound-guided tissue sampling techniques and development of new needle designs have improved the diagnostic yield of pancreatic lesions. This innovation in endoscopic ultrasound has also opened the door for early diagnosis and precision therapy in the management of cancer patients. Endoscopic ultrasound fine needle biopsy is an invaluable tool and newer biopsy designs will probably play a pivotal role in the management of pancreatic lesions in the next future. Aim of the current review was to provide an overview on the available techniques and devices for the endoscopic ultrasound-guided sampling of pancreatic solid and cystic lesions.

Stylet slow-pull vs. standard suction technique for endoscopic ultrasound-guided fine needle biopsy in pancreatic solid lesions using 20 Gauge Procore™ needle: A multicenter randomized trial

BACKGROUND

Standard suction and slow-pull techniques have been utilized during endoscopic ultrasound-guided fine needle aspiration of pancreatic solid lesions, but the correct sampling technique remains unclear. New needles designed to obtain samples suitable for histological evaluation have become available. We performed a study comparing the two sampling methods during endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) in patients with pancreatic solid lesions.

METHODS

We performed EUS-FNB with a 20 Gauge FNB needle using slow-pull or standard suction techniques in a prospective, randomized, multicenter study. The primary aim was bloodiness of the collected specimens. Secondary aims were technical success and performance of the two techniques.

RESULTS

110 patients were included (55 per group). No difference in blood contamination was observed (slow-pull 80% vs. suction 74%, p = 0.917). Technical success was 95% (96% vs. 94%, p = 0315). Sensitivity (96% vs. 93%), specificity (100% vs. 100%), positive likelihood ratio (NA), negative likelihood ratio (0.04 vs. 0.07), diagnostic accuracy (96 vs. 93%) did not differ between the two groups.

CONCLUSION

EUS-FNB with slow-pull and standard suction techniques are comparable in terms of blood contamination providing similar high diagnostic sensitivity and accuracy in pancreatic solid lesions. The use of the new generation FNB needle allows to reach such high level of diagnostic adequacy regardless of the technique utilized.

The Feasibility and Histological Diagnostic Accuracy of Novel Menghini Needle (EUS Sonopsy CY™) for Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy of Solid Pancreatic Masses: A Prospective Crossover Study Comparing Standard Biopsy Needles

Background and Objectives

Recently, a 21G Menghini-type needle for EUS-guided fine-needle aspiration biopsy (EUS-FNAB) has been developed. The stylet of the EUS Sonopsy CY™ remains inside the needle during aspiration. Therefore, it is expected to obtain higher-quality histological core specimens without crushing the material or blood contamination. The aim of this study is to evaluate the feasibility and diagnostic accuracy of EUS-FNAB of solid pancreatic masses with this new biopsy needle.

Methods

A total of 30 patients with solid pancreatic masses who underwent EUS-FNAB with two different types of needles, EUS Sonopsy™ and ProCore™, were included in a prospective, randomized, controlled, crossover study. All the pancreatic masses were punctured with the two needles and were randomized regarding the order of the needle to be used. The primary outcome was to compare the diagnostic accuracy and the rates of tissue acquisition of the two needles.

Results

The tissue acquisition rate was not significantly different between the EUS Sonopsy CY™ needle and the ProCore™ needle (78.6% vs. 82.1%, P = 1.00). The histological diagnostic accuracy was also similar between the two needles (73% vs. 80%, P = .63). There was also no difference regarding the accuracy of cytology alone and the combination of both histological and cytological assessments between the EUS Sonopsy CY™ needle and the ProCore™ needle (90% vs. 87%, P = 1.00 and 90% vs. 90%, P = 1.00, respectively).

Conclusions

EUS Sonopsy CY™ is a reliable device for EUS-FNAB of solid pancreatic masses.

New Era of Endoscopic Ultrasound-Guided Tissue Acquisition: Next-Generation Sequencing by Endoscopic Ultrasound-Guided Sampling for Pancreatic Cancer

Pancreatic cancer is a lethal cancer with an increasing incidence. Despite improvements in chemotherapy, patients with pancreatic cancer continue to face poor prognoses. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is the primary method for obtaining tissue samples of pancreatic cancer. Due to advancements in next-generation sequencing (NGS) technologies, multiple parallel sequencing can be applied to EUS-TA samples. Genomic biomarkers for therapeutic stratification in pancreatic cancer are still lacking, however, NGS can unveil potential predictive genomic biomarkers of treatment response. Thus, the importance of NGS using EUS-TA samples is becoming recognized. In this review, we discuss the recent advances in EUS-TA application for NGS of pancreatic cancer.

Endoscopic ultrasonography in pancreatic diseases: advances in tissue acquisition

Background and study aims  Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) improved the diagnostic performance and upgraded the role of endoscopic ultrasonography (EUS) into an interventional modality, able to guide patient management and treatment.This review aimed to highlight the advances, emerging practices, procedural techniques and technological innovations in EUS tissue acquisition in pancreatic diseases. Methods  A thorough review of the literature was performed using PubMed to identify articles that describe techniques, advances, and practices in EUS tissue acquisition in gastrointestinal diseases. Conclusion  Since the first EUS-FNA procedure, EUS guided-tissue acquisition has been evolving continuously. Development of needles with innovative tip design enabled procurement of larger samples with preserved histological architecture. Moreover, sampling techniques and complementary methods, such as contrast harmonic imaging and EUS-elastography, have been introduced in an effort to improve diagnostic performance and sample adequacy.

The diagnostic quality of needle brain biopsy specimens obtained with different sampling methods - Experimental study

The aim is to examine whether brain tissue samples obtained through needle biopsy are better for histopathological evaluation when obtained with defined vacuum pressure, a novel needle rotation method, and using different needle type - Laitinen or Nashold. Moreover the paper aims to answer the question: Does vacuum and mechanical injury resulting from different sampling methods damage the tissue specimen challenging the diagnosis?. Eight hundred biopsy specimens from fresh swine brains were obtained using Nashold and Laitinen brain biopsy needles through inner cannula cutting or needle rotation sampling at vacuum pressure, from 0 to 0.06 MPa. The specimen weight and tissue quality for microscopic assessment were evaluated using the Mair score. Rising aspiration pressure increased the biopsy sample weight. Needle rotation delivered larger biopsy samples than the standard method. Laitinen provided larger samples than the Nashold needle, with the same sampling method or vacuum pressure. A higher histopathological diagnostic quality of tissue was obtained with the Laitinen needle than with Nashold, with higher vacuum pressure than lower pressure and finally with needle rotation than the standard method. No tissue damage caused by higher suction pressure or method of tissue separation was documented. Brain tissue samples obtained through needle biopsy are better for histopathological evaluation when obtained with higher vacuum pressure, a novel needle rotation method and with Laitinen needle. Higher suction pressure and sampling methods did not cause tissue damage.

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.

A "Back Light System" for Identification of Sites for Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Solid Pancreatic Masses: A Prospective, Randomized Study with a Crossover Design

Background/Aims

We applied a back light system (BLS) with a magnifying glass to improve the ability to assess the adequacy of specimen sampling using endosonography. We conducted this study to evaluate the efficacy of the BLS in sampling of specimens by endoscopic ultrasound-guided fine needle aspiration of solid pancreatic masses.

Methods

This was a prospective, randomized, crossover, single-center clinical trial. An endosonographer evaluated adequacy on gross visual inspection and identified whitish specimen sampling sites with and without the BLS according to a randomization sequence in the first and second passes with a 25-G needle. On cytological evaluation, the presence of well-defined pancreatic ductal epithelium was evaluated by a cytopathologist who was blinded to any clinical information.

Results

A total of 80 consecutive patients were eligible during the study period. Adequacy was observed for 52 specimens (65%) with the BLS and 54 (68%) without the BLS (p=0.88). In assessment of specimen adequacy on gross examination, only fair agreement was observed both with and without BLS (kappa score 0.40 and 0.29, respectively).

Conclusions

The BLS did not influence the ability to identify specimen sampling sites or reliable assessment of specimen site adequacy using gross visual inspection.

Efficacy of 3 fine-needle biopsy techniques for suspected pancreatic malignancies in the absence of an on-site cytopathologist

BACKGROUND AND AIMS

EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) has a high diagnostic accuracy for pancreatic tumors. Most reports have focused on the diagnostic yield of cytology or histology; the ability of various FNA/B techniques to obtain an adequate mass of cells or tissue has rarely been investigated.

METHODS

Patients with suspected pancreatic malignancy underwent EUS-FNB using a 22-gauge ProCore needle by either the stylet slow-pull-back technique (group A), conventional negative suction after stylet removal (group B), or non-suction after stylet removal (group C) in the absence of an on-site cytopathologist. The adequacy of the 3 techniques based on the diagnostic yield, cellularity, blood contamination, and core-tissue acquisition was evaluated.

RESULTS

A total of 50 patients (27 males) were analyzed. The mean tumor size was 21 to 40 mm in 54%. The rate of a good or excellent proportion of cellularity was highest in group A compared with groups B and C (72% vs 60% vs 50%, P = .049). A >25% rate of blood contamination was more prevalent in group B (30% vs 42% vs 10%, P = .009). The rate of adequate core-tissue acquisition was not different (52% vs 34% vs 50%, P = .140). Based on the multivariate generalized estimation equation, the stylet slow-pull-back technique and a tumor size >40 mm were favorable factors for diagnostic adequacy.

CONCLUSIONS

The stylet slow-pull-back technique might enable acquisition of tissue and assessment of cellularity for the diagnosis of pancreatic tumors suspected to be malignant. (Clinical trial registration number: KCT0002190.).

A multicenter evaluation of a new EUS core biopsy needle: Experience in 200 patients

Background and Objectives:

We present a multicenter study of a new endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) needle (Acquire, Boston Scientific, Natick, MA). The aim of the study was to analyze the needle's clinical performance when sampling solid lesions and to assess the safety of this device.

Methods:

We performed a multicenter retrospective study of patients undergoing EUS-FNB during July 1–November 15, 2016.

Results:

Two hundred patients (121 males and 79 females) underwent EUS-FNB of solid lesions with the Acquire needle. Lesions included solid pancreatic masses (n = 109), adenopathy (n = 45), submucosal lesions (n = 34), cholangiocarcinoma (n = 8), liver lesions (n = 6), and other (n = 8). Mean lesion size was 30.6 mm (range: 3–100 mm). The mean number of passes per target lesion was 3 (range: 1–7). Rapid onsite cytologic evaluation (ROSE) by a cytologist was performed in all cases. Tissue obtained by EUS-FNB was adequate for evaluation and diagnosis by ROSE in 197/200 cases (98.5%). Data regarding the presence or absence of a core of tissue obtained after EUS-FNB were available in 145/200 procedures. In 131/145 (90%) of cases, a core of tissue was obtained. Thirteen out of 200 patients (6.5%) underwent some form of repeat EUS-based tissue acquisition after EUS-FNB with the Acquire needle. There were no adverse events.

Conclusion:

Overall, this study showed a high rate of tissue adequacy and production of a tissue core with this device with no adverse events seen in 200 patients. Comparative studies of different FNB needles are warranted in the future to help identify which needle type and size is ideal in different clinical settings.

Slow-Pull Using a Fanning Technique Is More Useful Than the Standard Suction Technique in EUS-Guided Fine Needle Aspiration in Pancreatic Masses

Background/Aims

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is useful for obtaining pancreatic mass samples. The combination of modified techniques (i.e., slow-pull technique and fanning technique) may improve the quality of the sample obtained by EUS-FNA. We investigated the effectiveness of a combined slow-pull fanning technique in EUS-FNA for pancreatic mass.

Methods

This prospective comparative study investigated EUS-FNA performed for pancreatic solid masses between August 2015 and July 2016. Pairwise specimens were alternately obtained using the following two techniques for targeted pancreatic lesions: standard suction or slow-pull with fanning. We compared the specimen quality, blood contamination, and diagnostic accuracy of these techniques.

Results

Forty-eight consecutive patients were included (29 men; mean age, 68.1±11.9 years), and 96 pancreatic mass specimens were obtained. The slow-pull with fanning technique had a significantly superior diagnostic accuracy than the suction technique (88% vs 71%, p=0.044). Furthermore, blood contamination was significantly reduced using the slow-pull with fanning technique (ratio of no or slight contamination, 77% vs 56%, p=0.041). No difference was observed in the acquisition of adequate cellularity between the groups. In the subgroup analysis, the tumor size and sampling technique were related to the EUS-FNA diagnostic accuracy.

Conclusions

The slow-pull with needle fanning technique showed a good diagnostic yield for EUS-FNA for pancreatic mass. This technique can be useful for performing EUS-guided sampling for diagnosing pancreatic disease.

Clinical update on the management of pseudopapillary tumor of pancreas

Solid pseudopapillary neoplasm (SPN) is a rare tumor with malignant potential which is generally located in the tail of pancreas. The prevalence of SPN has increased with widespread use of cross sectional imaging. SPN is often misdiagnosed due to nonspecific clinical presentation and accurate diagnosis is essential for optimal management. Endoscopic ultrasound-FNA with immunohistochemistry can help in preoperative diagnosis. Surgery is the treatment of choice and a successful R0 resection is curative. Overall, SPN has a good prognosis. This review article focuses on pathogenesis, diagnosis and management of SPN.

Challenges in diagnosis of pancreatic cancer

Pancreatic cancer is a growing source of cancer related death, yet has poor survival rates which have not improved in the last few decades. Its high mortality rate is attributed to pancreatic cancer biology, difficulty in early diagnosis and the lack of standardised international guidelines in assessing suspicious pancreatic masses. This review aims to provide an update in the current state of play in pancreatic cancer diagnosis and to evaluate the benefits and limitations of available diagnostic technology. The main modalities discussed are imaging with computed tomography, magnetic resonance imaging, endoscopic ultrasound and positron emission tomography and tissue acquisition with fine needle aspiration. We also review the improvements in the techniques used for tissue acquisition and the opportunity for personalised cancer medicine. Screening of high risk individuals, promising biomarkers and common mimickers of pancreatic cancer are also explored, as well as suggestions for future research directions to allow for earlier detection of pancreatic cancer. Timely and accurate diagnosis of pancreatic cancer can lead to improvements in the current poor outcome of this disease.

Postoperative recurrence from tract seeding after use of EUS-FNA for preoperative diagnosis of cancer in pancreatic tail

A 50-year-old male underwent abdominal computed tomography at a city hospital in Japan, which revealed a tumor 38 mm in diameter in the tail of the pancreas. Based on findings from endoscopic ultrasonography-guided fine needle aspiration using a 22-gauge needle with a side hole, the tumor was diagnosed as an invasive ductal carcinoma. The patient was referred to our hospital and underwent a distal pancreatectomy. Esophagogastroduodenoscopy performed as part of a medical checkup at another hospital 2 years later revealed a 20-mm-sized submucosal tumor in the posterior wall of the upper body of the stomach. Examination of a biopsy specimen obtained from the top of the lesion revealed adenocarcinoma. Partial resection of the stomach was performed and pathological findings showed an adenocarcinoma in all layers of the stomach wall, consistent with recurrence derived from needle tract seeding of the previously excised cancerous tumor from the pancreatic tail. Additional experimentation performed for confirmation with an agar model showed that agar on the deep side leaked to the shallow side following puncture with a needle with a side hole used with a slow-pull technique.

Clinical impact of endoscopic ultrasonography on the management of neuroendocrine tumors: lights and shadows

The incidence of gastroenteropancreatic neuroendocrine neoplasms has increased in the recent decades. An extensive bibliographical search was performed in PubMed to identify guidelines and primary literature (retrospective and prospective studies, systematic reviews, case series) published mostly between year 1997 and June 2017, using both medical subject heading (MeSH) terms and free-language keywords about the accuracy and diagnostic and therapeutic role of endoscopic ultrasound in the context of gastro-entero-pancreatic neuroendocrine neoplasms. Endoscopic ultrasound is the modality of choice for diagnosing pancreatic neuroendocrine neoplasms and for the locoregional staging of gastric, duodenal, pancreatic and rectal neuroendocrine neoplasms; in particular, in the setting of pancreatic neuroendocrine neoplasms it has demonstrated higher accuracy in tumor detection than other imaging modalities. Furthermore, the possibility of tattooing pancreatic lesions by endoscopic ultrasound fine needle aspiration may help surgeons to locate the tumor and avoid any demolition surgery. Finally, endoscopic ultrasound-guided therapies have been proposed and used in several studies for patients unsuitable for surgery, with good results on the control of symptoms and the reduction of tumor burden.

Present status and perspectives of endosonography 2017 in gastroenterology

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.

Randomized crossover trial comparing EUS-guided fine-needle aspiration with EUS-guided fine-needle biopsy for gastric subepithelial tumors

AIM

The purpose of this study is to compare the diagnostic yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) and EUS-guided fine-needle biopsy (EUS-FNB) for gastric subepithelial tumors (SET).

METHODS

Patients diagnosed SET derived from fourth layer of the stomach were prospectively enrolled and randomly assigned to undergo both EUS-FNA using standard needle and EUS-FNB using a core biopsy needle alternatively to the same lesion a total of four times per session. The specimen was carefully examined for the presence of a macroscopic visible core, appearing as threadlike yellowish or bloody pieces of tissue and blinded histocytologic analyses were conducted. For spindle cell lesions by hematoxylin and eosin staining (H&E) on histologic evaluation, immunohistochemical staining was performed in all cases to confirm the pathological diagnosis.

RESULTS

A total of 23 patients were enrolled and underwent paired EUS-FNA and -FNB sampling. The diagnostic rate due to immunohistochemical staining was 73.9% and 91.3%, respectively (P = .120). The rate of obtaining specimens with a macroscopic yellowish core and only a bloody core among the tissue specimens were respectively 43.5% and 52.2% for EUS-FNA and 69.6% and 30.4% for EUS-FNB. The diagnostic rate for a yellowish core (84.6%) and a bloody core (84.2%, P = .971) did not differ significantly.

CONCLUSION

Both techniques were equivalently safe and successful in terms of a high diagnostic yield for gastric SET. And the tissue that can be immunohistochemically stained is present even in the specimens that appear to be a macroscopically bloody core.

New Developments in Endoscopic Ultrasound Tissue Acquisition

Endoscopic ultrasound (EUS)-guided tissue acquisition has greatly evolved since the first EUS-guided fine-needle aspiration was reported nearly 25 years ago. EUS-guided tissue acquisition has become the procedure of choice for sampling of the pancreas, subepithelial lesions, and other structures adjacent to the gastrointestinal tract. This review focuses on recent developments in procedural techniques and needle technologies for EUS-guided tissue acquisition.