Endoscopic ultrasound-guided fine-needle aspiration can target right liver mass

The outcomes of endoscopic ultrasound-guided tissue acquisition for small focal liver lesions measuring ≤2 cm

Objectives

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) for focal liver lesions has gained attention as an alternative to percutaneous biopsy. Although the outcomes of EUS-TA for focal liver lesions have been reported to be favorable, no studies have focused on small focal liver lesions (≤2 cm). The aim of this study was to evaluate the outcomes of EUS-TA for small focal liver lesions (≤2 cm).

Methods

The details of EUS-TA performed for focal liver lesions between 2016 and 2022 were retrospectively reviewed. The outcomes were compared between cases involving ≤2 cm lesions and those involving >2 cm lesions. The primary outcomes were diagnostic ability and adverse events.

Results

EUS-TA for focal liver lesions was performed in 109 cases. Of the 109 cases, 32 (29.3%) involved ≤2 cm lesions and 77 (70.6%) involved >2 cm lesions. Right lobe lesions and transduodenal puncture were significantly fewer in the ≤2 cm group. There were no significant differences in needle gauge, needle type, or number of punctures between the groups. The sensitivity, specificity, and accuracy rates were 96.8%, 100%, and 96.8%, respectively, in the ≤2 cm group and 97.4%, 100%, and 97.4%, respectively, in the >2 cm group, with no significant differences between the groups. There was no difference in adverse events between the groups (0% in the ≤2 cm group and 2.3% in the >2 cm group).

Conclusions

EUS-TA for small focal liver lesions measuring ≤2 cm has favorable outcomes, which are similar to those for lesions measuring >2 cm.

Endoscopic ultrasound-guided tissue acquisition for focal liver lesions in patients with a history of multiple primary malignant neoplasms

Objective

This study aimed to investigate the usefulness of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for diagnosing focal liver lesions in patients with a history of multiple primary malignant neoplasms.

Methods

Among patients who underwent EUS-TA for focal liver lesions between 2016 and 2022, those with a history of multiple malignant neoplasms were included. A histologically confirmed malignant tumor within the past 5 years before EUS-TA was defined as a history of malignant neoplasm. The primary outcomes were diagnostic ability and adverse events of EUS-TA.

Results

This study included 16 patients (median age, 73 [33-90] years), the median tumor size was 32 (6-51) mm, 14 had a history of double malignant neoplasms, whereas two had triple malignant neoplasms. Malignant neoplasms were detected histologically or cytologically in all cases. Immunohistochemistry was performed in 75% (12/16), and the final diagnosis of EUS-TA was metastatic liver tumor in 12 patients, and primary malignant liver tumor in four patients. The primary site could be identified in 11 of 12 metastatic tumor cases. The diagnostic yield of EUS-TA was 100% (16/16) for differentiating benign and malignant tumors and 94% (15/16) for confirming the histological type including the primary site of metastatic lesions. No adverse events were associated with the procedure.

Conclusion

EUS-TA is a useful diagnostic modality for focal liver lesions in patients with a history of multiple malignant neoplasms, allowing for the differential diagnosis of primary and metastatic tumors and identification of the primary site of metastatic lesions.

Endoscopic ultrasound-guided tissue acquisition for focal liver lesions can be safely performed in patients with ascites

Background and study aims In patients with ascites, percutaneous liver biopsy is generally contraindicated. Because endoscopic ultrasound-guided tissue acquisition (EUS-TA) allows tissue sample obtention from the digestive tract lumen, a biopsy without the intervention of ascites may prevent adverse events (AEs). This study aimed to evaluate the safety of EUS-TA for focal liver lesions in the presence of ascites. Patients and methods A retrospective study was conducted using medical records of cases in which EUS-TA was performed on focal liver lesions between 2016 and 2022. Study participants were classified into two groups: those with ascites and those without it, and the outcomes were compared. The primary outcome was AEs. Results We included 109 cases of EUS-TA for focal liver lesions. Ascites was present in 20.1% of cases (22/109) and absent in 79.8% of cases (87/109). There were no significant differences between the two groups in clinical backgrounds and EUS-TA procedure, although fine-needle biopsy needles were significantly more frequently used in patients without ascites. In the ascites group, puncture without intervening ascites was successful in 90.9% of cases (20/22). The incidence of AEs was 4.5% (1/22) in the ascites group and 1.1% (1/87) in the non-ascites group, showing no significant difference. The two AEs were mild self-limiting abdominal pain. Conclusions In focal liver lesions with ascites, EUS-TA allows biopsy without the intervention of ascites in most cases. The incidence of AEs did not differ significantly between patients with and without ascites.

Consensus statements on endoscopic ultrasound-guided tissue acquisition. Guidelines from the Asian Endoscopic Ultrasound Group

OBJECTIVES

This consensus was developed by the Asian EUS Group (AEG), who aimed to formulate a set of practice guidelines addressing various aspects of endoscopic ultrasound-guided tissue acquisition (EUS-TA).

METHODS

The AEG initiated the development of consensus statements and formed an expert panel comprising surgeons, gastroenterologists, and pathologists. Three online consensus meetings were conducted to consolidate the statements and votes. The statements were presented and discussed in the first two consensus meetings and revised according to comments. Final voting was conducted at a third consensus meeting. The Grading of Recommendations, Assessment, Development, and Evaluation system was adopted to define the strength of the recommendations and quality of evidence.

RESULTS

A total of 20 clinical questions and statements regarding EUS-TA were formulated. The committee recommended that fine-needle biopsy (FNB) needles be preferred over conventional fine-needle aspiration (FNA) needles for EUS-TA of subepithelial lesions. For solid pancreatic masses, rapid on-site evaluation is not routinely recommended when FNB needles are used. For dedicated FNB needles, fork-tip and Franseen-tip needles have essentially equivalent performance.

CONCLUSION

This consensus provides guidance for EUS-TA, thereby enhancing the quality of EUS-TA.

Endoscopic ultrasound-guided fine-needle aspiration in the diagnostic value of focal liver lesions: A systematic analysis of 88 cases (with video)

BACKGROUND AND AIMS

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions in the gastrointestinal tract and adjacent organs. Our study aimed to evaluate the safety and effectiveness of EUS-FNA in focal liver lesions (FLLs).

METHOD

Data from 88 patients diagnosed with FLLs by imaging who underwent EUS-FNA from 1 January 2017 to 31 August 2022 were reviewed in our retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of the School of Medicine of Shanghai Jiao Tong University. The EUS-FNA biopsy results were compared with the final diagnosis to evaluate diagnostic value. The relevant factors were analysed to determine their influence on EUS-FNA biopsy results.

RESULTS

The 88 patients analysed in this study resulted in a final diagnosis of 86 malignant and two benign cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18 % (82/88; 95 % Confidence Interval [CI], 87.9-98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02 % (80/86; 95 %CI, 87.6-98.4), 100 % (2/2; 95 %CI, 100-100), 100 % (80/80; 95 %CI, 100-100), and 25 % (2/8; 95 %CI, -5-55.0), respectively. The parameters related to lesion and procedure were not significantly different between these two groups (p > 0.05). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001).

CONCLUSION

Our data revealed that EUS-FNA is a safe and reliable diagnostic method for FLLs that shows high accuracy.

Endoscopic Ultrasound-Guided Fine Needle Biopsy of Focal Liver Lesions: An Effective Mini-Invasive Alternative to the Percutaneous Approach

Despite the introduction of serological neoplastic biomarkers and typical radiological characteristics in clinical practice, liver biopsy (LB) is often still necessary to establish a histological diagnosis, especially in ambiguous cases. Nowadays, LB via the percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonography (US) guidance, is the route of choice. However, certain focal liver lesions can be challenging to access percutaneously. In such cases, endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) may represent an attractive, minimally invasive alternative. This retrospective observational study aimed to evaluate the efficacy, diagnostic performance, and safety of EUS-FNB conducted on 58 focal liver lesions located in both liver lobes. The adequacy of FNB samples for focal liver lesions located in the left and right lobes was 100% and 81.2%, respectively, and the difference was statistically significant (p = 0.001). Technical success was 100% for both liver lobes. The overall sensitivity and specificity were 95% and 100%, respectively. EUS-FNB is effective in making an accurate diagnosis with an excellent safety profile for focal liver lesions located in both liver lobes.

Endoscopic Ultrasound-Guided Tissue Sampling for the Cytohistological Diagnosis of Focal Liver Lesions

BACKGROUND

Focal liver lesions (FLL) often require cytohistological evaluation. Endoscopic Ultrasound (EUS)-guided tissue acquisition (EUS-TA) is highly accurate in diagnosing pancreatic and gastrointestinal malignancies. The aim of our study was to evaluate the role of EUS-TA in the characterization of FLL.

METHODS

A retrospective analysis of a prospective database of patients who underwent EUS-TA for the evaluation of FLL. Diagnostic yield, adverse events and factors associated with diagnostic yield were evaluated as endpoints. The effect of variables such as needle size, lesion size, rapid on-site evaluation (ROSE) and the use of cytological or histological needles were analyzed.

RESULTS

A total of 114 cases were included (mean age 68.05 ± 11.35 years, 64 male). A correct diagnosis was made using EUS-TA in 100 of the 114 cases (diagnostic yield of 88%). The EUS-TA of additional extrahepatic lesions during the same EUS procedure increased the diagnostic yield to 94%. No adverse events were reported. Multivariate analysis did not identify any factor influencing the diagnostic yield.

CONCLUSIONS

EUS-TA is a highly accurate and safe technique for the differential diagnosis of FLL and could be considered as the primary approach in this setting.

Endoscopic ultrasound-guided tissue acquisition for focal liver lesions in the caudate lobe: a report of seven cases

The caudate lobe of the liver is located deep within the body and surrounded by major blood vessels, such as inferior vena cava, portal vein, and hepatic veins. Thus, percutaneous biopsy is technically challenging. Herein, we report seven patients with focal liver lesions in the caudate lobe who underwent endoscopic ultrasound-guided tissue acquisition (EUS-TA). Their median age was 56 (25-79) years, consisting five males and two females, and the median lesion size was 44 (19-77) mm. Transgastric EUS-TA was performed in all patients. The needles used were 22G and 25G in six patients and one patient, and the median procedure time was 18 (13-30) min. In all patients, adequate specimens were collected, and pathological diagnosis was possible (three intrahepatic cholangiocarcinoma, two metastatic tumors from pancreatic cancer, one hepatocellular carcinoma, and one focal nodular hyperplasia). No adverse events associated with the procedure were observed. EUS-TA can be the first choice for tissue acquisition of the caudate lobe lesions.

Endohepatology: The endoscopic armamentarium in the hand of the hepatologist

ABSTRACT

Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.

Distinct ways to perform a liver biopsy: The core technique setups and updated understanding of these modalities

There is dramatically increased incidence of several liver diseases worldwide; thus, an unmet need to diagnose and stage these pathological entities heralds the wide application of liver biopsy (LB) techniques. The ways of LB are versatile, including percutaneous LB, transjugular LB, and more recently an approach of minimal invasiveness, that is, EUS-guided LB (EUS-LB). In this review article, we come to the conclusion that EUS-LB may serve as a feasible, reliable, and safe alternative to percutaneous LB and transjugular LB in terms of improved diagnostic yield, excellent sampling performance, and controlled adverse events among patients with focal, infiltrative, and parenchymal liver diseases. Furthermore, extensive efforts have been made to optimize and refine several technical pillars within EUS-LB modality such as the selection of needle size/type, priming manner of biopsy needle, and choice of pass/actuation technique, all of which aim at obtaining better specimen quantity and quality. Another advantageous aspect and unique property pertinent to EUS-guided modality indicate that multiple screening, surveillance, and intervention procedures can be combined into one single endoscopic session. Accordingly, some pilot studies have clarified the clinical usefulness by integrating EUS-LB with simultaneous measurement of portal pressure gradient or examination of liver stiffness. However, more studies, in particular, randomized controlled trials or real-world evidence, are practically warranted to elucidate the validity and safety of EUS-LB as a regular/routine part of managing liver diseases.

Role of endoscopic ultrasound and endoscopic ultrasound-guided tissue acquisition in diagnosing hepatic focal lesions

BACKGROUND

Endoscopic ultrasonography (EUS) has become an established method in diagnostic and therapeutic procedures in gastroenterology; however, it has recently gained a growing role in hepatology.

AIM

To evaluate the role of EUS features, strain elastography (SE), and EUS-tissue acquisition in diagnosing hepatic focal lesions (HFLs) that could affect further management.

METHODS

This cross-sectional study included 215 patients with pancreatic, biliary, or gastrointestinal malignancies referred for EUS examination. HFLs were identified in 43 patients (20%), and EUS-guided tissue acquisition was performed from these lesions.

RESULTS

EUS features were highly sensitive (100%) but much less specific (57%) in diagnosing HFLs; the overall accuracy was 94%. Real-time elastography was also very sensitive (97%) but less specific (67%) in diagnosing HFLs; however, the overall accuracy was 92%. EUS tissue acquisition was extremely sensitive (100%) and specific (100%), with a 100% overall diagnostic accuracy.

CONCLUSION

The diagnostic utility of EUS-guided tissue acquisition was extremely accurate in diagnosing HFLs. EUS characteristics and real-time SE accurately predicted the histological diagnosis of both benign and malignant HFLs.

Outcome of Endoscopic Ultrasound-Guided Sampling of Mediastinal Lymphadenopathy

Methods

From May 2006 to January 2017, patients with mediastinal lymphadenopathy, who received an EUS-guided trucut biopsy or an FNA biopsy, were retrospectively reviewed. Demographic data, endosonographic characteristics of LNs including size, shape, border, echotexture, and echogenicity, diagnostic yield, and adverse events between the trucut needle group and aspiration needle group were compared.

Results

A total of 69 patients (trucut group, n = 33 vs. aspiration group, n = 36) were identified. There were no significant differences in demographic data, indication for an EUS-guided biopsy, location of LNs, number of needle passes, and endosonographic features of LNs between the two groups. The sizes of LNs were larger in the trucut group than in the aspiration group (28.9 ± 14.0 mm vs. 21.1 ± 8.8 mm, P = 0.007). However, there was no significant difference in the ratio of LNs that were ≥10 mm in both groups. The overall accuracy of the EUS-guided biopsy for the diagnosis of malignant lesions was 79.7% (55/69). There were no significant differences in the histological diagnostic yield of malignant LNs between the two groups. There were no significant procedure-related adverse events in both groups.

Conclusion

The EUS-guided biopsy can be a useful method for histologic evaluation of mediastinal nodal lesions.

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.

Role of EUS in detection of liver metastasis not seen by computed tomography or magnetic resonance imaging during staging of pancreatic, gastrointestinal, and thoracic malignancies

BACKGROUND AND OBJECTIVES

Liver metastases might not be detected by computed tomography (CT) and magnetic resonance imaging (MRI) due to their small size, but they can be detected by EUS. Furthermore, EUS-FNA has a significant impact on improving the diagnostic accuracy of EUS. The purpose of this study was to assess the feasibility of EUS in detection of occult small hepatic focal lesions at the time of primary tumor staging, not seen by CT or MRI.

METHODS

This prospective study included 730 patients who underwent EUS for staging or sampling of gastrointestinal, pancreatic, or thoracic malignancy. The liver was examined thoroughly for detection of occult lesions. CT or MRI was done within 1 week of EUS examination.

RESULTS

EUS examination of the liver detected focal lesions in 150 patients (20.5%) and metastases in 118 patients (16.2%); meanwhile, CT and MRI detected focal lesions in 99 patients (13.6%) and metastases in 82 patients (11.2%). EUS missed focal lesions in 7 patients, 6 of which were liver metastases (1.0% and 0.8%, respectively), while CT and MRI missed focal lesions in 58 patients, 42 of which were metastases (7.9% and 5.8%, respectively), which were detected by EUS.

CONCLUSION

Thorough dedicated EUS examination of the liver is a feasible useful tool for detection of small hepatic lesions missed by CT and MRI. It is not considered an extra financial burden to the patient or health-care system because those patients are indicated for EUS examination for evaluation of their original lesion in the first place. Furthermore, EUS-FNA can add another advantage in diagnosing the etiology of such lesions.

Hepatic Squamous Cell Carcinoma Diagnosed by Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Primary hepatic squamous cell carcinoma (SCC) is a rare malignancy with aggressive clinical features. This is the first case report of a primary hepatic SCC diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), which is a reliable and safe procedure for the histopathological diagnosis of liver lesions, even if the percutaneous approach is difficult due to ascites or hypervascularity at the puncture site. A 52-year-old man presented to the emergency department of a tertiary referral hospital with right upper quadrant abdominal pain and abdominal distention. Given the laboratory data, a diagnosis of spontaneous bacterial peritonitis (SBP) was made. Concurrently, an abdominal computed tomography (CT) scan revealed an 8 cm hypodense mass with delayed peripheral enhancement in the left hepatic lobe and paraaortic and perihepatic lymphadenopathy. As persistent ascites precluded percutaneous liver biopsy, we performed EUS-FNA of the liver mass, and the obtained specimen showed SCC. As otorhinolaryngological consultation and whole-body investigations, including chest CT, upper and lower endoscopy, and positron emission tomography CT, were all unremarkable except for the liver lesion and lymph nodes, a diagnosis of primary hepatic SCC with systemic lymph node metastasis was made. After treatment of SBP with antibiotics, we initiated chemotherapy concurrent with radiation therapy, adapted to his liver function. Radiation and three cycles of chemotherapy were not effective as the disease progressed, as seen on the follow-up CT scan, and the patient died of hepatic failure on the 134th day after diagnosis. In conclusion, EUS-FNA was a reliable method for tissue sampling in liver malignancies, particularly in selected patients with contraindications for percutaneous biopsy.

Endoscopic Ultrasound-Guided Fine Needle Aspiration Using a 22-G Needle for Hepatic Lesions: Single-Center Experience

BACKGROUND/AIMS

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been accepted as a reliable tool in diagnosing and staging intra-abdominal tumors. In this study, we aimed to investigate the performance of EUS-FNA in the evaluation of liver masses and its impact on patient management and procedure-related complications retrospectively.

METHODS

Data of patients who underwent EUS-FNA biopsies due to liver masses between November 2017 and July 2018 were retrieved retrospectively. Biopsies were performed using 22-G needles. The demographics, EUS-FNA results, sensitivity and specificity of the procedure, negative predictive value, positive predictive value, and specimen sufficiency rates were assessed.

RESULTS

A total of 25 patients (10 females) were included in the study. The mean age was 62.73±15.2 years. The mean size of the masses was 34.50±16.04 mm. The technical success rate was 88%. During the EUS-FNA procedure, each patient had only one pass with 94.45% of aspirate sufficiency rate and 86.3% of biopsy sufficiency rate. The diagnostic accuracy rate was 86.3%. There were no complications.

CONCLUSION

For the evaluation of liver masses, EUS-FNA using a 22-G needle with even one pass had high aspiration and biopsy success rates accompanied with high diagnostic accuracy rates.

The Evolving Role of Advanced Endoscopic Techniques in Hepatology

The role of advanced endoscopy in the field of hepatology has evolved rapidly over the last decade. Several novel diagnostic and therapeutic interventions can now be accomplished endoscopically both easily and safely in patients with liver disease; these include endoscopic ultrasound (EUS)-guided liver biopsy, EUS-guided measurement of the portal pressure gradient, EUS-guided therapy for gastric varices, and EUS elastography. This article highlights advances in endoscopic tools and techniques that can be applied in the field of hepatology.

Comparative Study of an Ultrasound-guided Percutaneous Biopsy and Endoscopic Ultrasound-guided Fine-needle Aspiration for Liver Tumors

Objective Both a percutaneous biopsy and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) have been widely performed for liver tumors. However, no studies have compared these two biopsy methods. Method A retrospective study was conducted using medical records for patients who underwent a liver tumor biopsy from 2012 to 2019. The cases were classified into two groups for a comparison: an ultrasound-guided percutaneous biopsy group (percutaneous group) and an EUS-FNA group (EUS group). Results A total of 106 patients (47 in the percutaneous group and 59 in the EUS group) were included. The final diagnosis was malignant in 100 cases and benign in the remaining 6 cases. While the median lesion diameter was 62 mm in the percutaneous group, it was significantly smaller (34 mm) in the EUS group (p <0.01). The EUS group had more left lobe tumors than right lobe tumors. All cases of caudate lobe tumor (four cases) underwent EUS-FNA. The sensitivity, specificity, and accuracy of the procedure were 95%, 100%, and 96% in the percutaneous group and 100%, 100%, and 100% in the EUS group, respectively showing no significant difference. Adverse events were reported in 17% of the percutaneous group, which was significantly lower than in the EUS group (2%; p <0.01). Conclusion A percutaneous biopsy and EUS-FNA have equivalent diagnostic qualities for liver tumors, although EUS-FNA tends to be associated with fewer adverse events. A complete understanding of the characteristics of each procedure is essential when choosing the best biopsy method for each particular case.

Endoscopic ultrasound guided hepatic interventions

Intervention for liver disease has predominantly been performed through the percutaneous approach. However, as endoscopic ultrasound (EUS) applications have expanded, there have emerged various EUS-guided interventions for liver disease, a space we call "Endo-Hepatology". EUS-guided liver biopsy can be considered the "forerunner" of Endo-Hepatology and has become a clinical option for patients requiring histologic diagnosis and staging of their liver disease. EUS also enables direct access to the portal vein. Subsequently, many procedures are being explored, such as angiography, measurement of the portosystemic pressure gradient, portal vein sampling to detect cancer cell or DNA, and EUS-guided transhepatic intrahepatic portosystemic shunt creation. Since the transducer is close to the liver, especially the left and caudate lobes, EUS can be used as a rescue when the percutaneous approach is not favorable and EUS-guided treatments of liver tumor, cyst and abscess have been reported. This review summarizes the available studies of EUS-guided intervention in the liver.

Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration: A Narrative Review

Considerable progress has been made recently in the use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to diagnose intra-luminal gastrointestinal lesions and extra-luminal lesions near the gastrointestinal tract. Numerous reports have indicated that EUS-FNA has high diagnostic performance and safety, which has led to the routine use of EUS-FNA and an increasing number of cases. Thus, while EUS-FNA has a low rate of complications, endoscopists may encounter these complications as the number of cases increases. Infrequent reports have also described life-threatening complications. Therefore, endoscopists should possess a comprehensive understanding of the complications of EUS-FNA, which include hemorrhage, perforation, infection, and acute pancreatitis, as well as their management. This review examines the available evidence regarding the complications associated with EUS-FNA, and the findings will be useful for ensuring that endoscopists perform EUS-FNA safely and appropriately.

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.

A Comprehensive Narrative Review on the Evolving Role of Endoscopic Ultrasound in Focal Solid Liver Lesions Diagnosis and Management

The implications of endoscopic ultrasound (EUS) have expanded considerably in recent years to cover more fields in invasive gastroenterology practice, as both an investigative and therapeutic modality. The utility of EUS in the diagnosis and management of focal liver lesions has gained a special attractiveness recently. The EUS probe proximity to the liver and its excellent spatial resolution enables real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS. Aside from its notable capability to execute targeted biopsies and therapeutic interventions, EUS has developed into a hopeful therapeutic tool for the management of solid liver lesions. Herein, we provide a comprehensive state-of-the-art review on the efficacy and safety of EUS in the diagnosis and management of focal solid liver lesions. Medline/PubMed and Embase database searches were conducted by two separate authors (T.K. and W.S.), all relevant studies were assessed, and relevant data was extracted and fully reported. EUS-guided diagnosis of focal liver lesions by sonographic morphologic appearance and cytological and histopathological finding of biopsies obtained via fine needle aspiration/biopsy have been shown to significantly improve the diagnosis of solid liver lesions compared with traditional imaging tools. Similarly, EUS-guided treatment has been shown to consistently have excellent technical success, high efficacy, and minor adverse events. The evolving valuable evidences of EUS utility might satisfy the unmet need of optimizing management of focal solid liver lesions.

A State-of-the-Art Review on the Evolving Utility of Endoscopic Ultrasound in Liver Diseases Diagnosis

Liver diseases are amongst the most common diseases worldwide and manifest as a parenchymatic and/or biliary injury due to several causes as well as focal liver lesions, ranging from benign to malignant ones. The diagnosis of liver diseases is based mainly on biochemical and advanced imaging studies and, when required, on liver biopsy. Endoscopic ultrasound (EUS), which combines endoscopy and ultrasonography, is one of the main examination techniques used in gastroenterology as it is applied to evaluate abnormalities in the lumen of the upper and lower gastrointestinal tract and to define pancreatic and hepato-biliary features, often in chronic patients. Given its high spatial resolution and its proximity to the liver, EUS is gaining popularity in the diagnostic work up of liver diseases. This is a comprehensive overview of the current literature on the diagnostic indications for EUS use in patients with liver diseases. We performed a MEDLINE\PubMed and Embase search, and all articles that were relevant, after reviewing abstracts, were assessed and the full text was analyzed to extract data regarding technical success, diagnostic yield, bioptic characteristics, and complications rate. EUS-guided imaging and biopsy techniques in liver diseases have shown consistent favorable promising results among the reports through the literature, with an excellent diagnostic yield and safety profile, especially in the context of focal lesions and portal hypertension. The application of EUS in the diagnosis of liver diseases is a promising technique and should be considered as a first-line therapeutic option in selected cases.

EUS-guided fine-needle core liver biopsy with a modified one-pass, one-actuation wet suction technique comparing two types of EUS core needles

Background and study aims  We compared the diagnostic yield and specimen adequacy in EUS-guided parenchymal biopsies between two types of EUS 19 G core needles. Patients and methods  This is a retrospective study of 420 patients at two tertiary medical centers in Florida with unexplained abnormal liver associated tests were referred for EUS evaluation of biliary obstruction and pancreatic pathology. EUS-guided liver biopsy (EUS-LB) was performed at the same session after biliary obstruction was excluded. We compared intact specimen length (ISL), total specimen length (TSL), complete portal triads (CPT) and adverse events (AE). Welch's T and Tukey tests were used for ISL, TSL and CPT. Results  A total of 210 patients underwent EUS-LB using a Franseen needle, 210 patients using a fork-tip needle. Median patient age was 52 years (15.63) and 238 (56.7 %) were female. The fork-tip needle had a mean ISL of 2.7 (1.1 SD) cm, TSL of 6 cm (2.1 SD), and mean 19.5 CPT (8.5 SD) Abdominal pain occurred in 35 patients (17 %) post-procedure and was managed with supportive care. Two patients required intravenous (IV) narcotic administration. Subcapsular hematomas occurred in 1 (0.5 %) patients. The Franseen needle had a mean ISL of 3.1 cm (1.3 SD), TSL of 6.5 cm (2.6 SD), and mean of 24 CPT (8.8 SD). Abdominal pain occurred in four patients (2 %) post-procedure, which resolved in all patients after IV narcotic administration. Subcapsular hematomas occurred in 1 (0.5 %) and bile leak in 1(0.4 %) patients. Conclusions  Use of the Franseen needle resulted in better liver core samples than that obtained with a fork-tip needle.

Endoscopic ultrasound guided liver biopsy: Recent evidence

Liver biopsy (LB) is an essential tool in diagnosing, evaluating and managing various diseases of the liver. As such, histopathological results are critical as they establish or aid in diagnosis, provide information on prognosis, and guide the appropriate selection of medical therapy for patients. Indications for LB include evaluation of persistent elevation of liver chemistries of unclear etiology, diagnosis of chronic liver diseases such as Wilson's disease, autoimmune hepatitis, small duct primary sclerosing cholangitis, work up of fever of unknown origin, amyloidosis and more. Traditionally, methods of acquiring liver tissue have included percutaneous LB (PCLB), transjugular LB (TJLB) or biopsy taken surgically via laparotomy or laparoscopy. However, traditional methods of LB may be inferior to newer methods. Additionally, PCLB and TJLB carry higher risks of adverse events and complications. More recently, endoscopic ultrasound guided LB (EUS-LB) has evolved as an alternative method of tissue sampling that has proven to be safe and effective, with limited adverse events. Compared to PC and TJ routes, EUS-LB may also have a greater diagnostic yield of tissue, be superior for a targeted approach of focal lesions, provide higher quality images and allow for greater patient comfort. These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue. Herein, we provide a review of the recent evidence of EUS-LB for liver disease.

The role of EUS in diagnosis and treatment of liver disorders

Background and aim  Transabdominal ultrasound (US), computed tomographic scanning (CT) and magnetic resonance imaging (MRI) are established diagnostic tools for liver diseases. Percutaneous transhepatic cholangiography is used to perform hepatic interventional procedures including biopsy, biliary drainage procedures, and radiofrequency ablation. Despite their widespread use, these techniques have limitations. Endoscopic ultrasound (EUS), a tool that has proven useful for evaluating the mediastinum, esophagus, stomach, pancreas, and biliary tract, has an expanding role in the field of hepatology complementing the traditional investigational modalities. This review aimed to assess the current scientific evidence regarding diagnostic and therapeutic applications of EUS for hepatic diseases.

Endoscopic resection of the pancreatic tail and subsequent wound healing mechanisms in a porcine model

BACKGROUND

Laparoscopic resection of the pancreatic body and tail is the predominant methodology to remove lesions in these locations; its safety and surgical planning are relatively mature, but it remains a complex and high-precision surgical operation, requiring abundant experience and skills in laparoscopic surgery, with a 10% rate of complications.

AIM

To verify the feasibility and safety, as well as to examine the complications of endoscopic pancreatectomy and healing mechanisms of pancreatic wounds after endoscopic resection.

METHODS

Transgastric endoscopic resections of varying sizes of pancreases were performed in 15 healthy Bama miniature pigs. The technical success rate, the incidence of serious complications, and the survival of the animals were studied. The healing of the wounds was evaluated by sacrificing the animals at various time points. Finally, the expression of transforming growth factor-β1 and Smad3/Smad7 in the surgical site was examined by immunohistochemistry to explore the role of these factors in wound healing of the pancreas.

RESULTS

Partial and total resections were successfully performed in two groups of animals, respectively. The technical success rate and the survival rate of the pigs were both 100%. We obtained 12 pancreatic tissue samples by endoscopic resection. The pancreatic wounds were closed with metal clips in one group and the wounds healed well by forming scars. There was a small amount of pancreatic leakage in the other group, but it can be fully encapsulated. The level of transforming growth factor-β1 (TGF-β1) in the wounds increased during the inflammatory and fibrous hyperplasia phases, and decreased in the scar phase. The expression of Smad3 paralleled that of TGF-β1, while the expression of Smad7 had an inverse relationship with the expression of TGF-β1.

CONCLUSION

Purely transgastric endoscopic resection of the pancreas is a safe, effective, and feasible procedure, but the incidence of pancreatic leakage in total pancreatic tail resection is high. The expression of TGF-β1 and Smad3/Samd7 is related to the progression of pancreatic wound healing.

Diagnostic yield of endoscopic ultrasound-guided biopsy of focal liver lesions

Endoscopic ultrasonography (EUS) has become an indispensable method for diagnosis and therapeutic procedures in gastroenterology. As experience with this technique grows, new indications continue to emerge. Due to the vicinity of the transducer to the liver, endoscopic ultrasonography provides detailed images of the liver segments and its vascular and biliary structures. Endosonographers have made an effort to define a clinical role for endoscopic ultrasound in liver diseases; however, not much is known about endoscopic ultrasound guided fine needle aspiration (EUS-FNA) in hepatic focal lesions. This review summarizes the available evidence regarding the usefulness of endoscopic ultrasound-guided fine needle aspiration in patients with focal liver lesions.

The usefulness of contrast-enhanced harmonic EUS-guided fine-needle aspiration for evaluation of hepatic lesions (with video)

BACKGROUND AND AIMS

Small hepatic masses often do not have distinct margins on B-mode EUS images. Contrast-enhanced harmonic EUS (CEH-EUS) is widely used for evaluating ambiguous pancreatic lesions. However, its role in detecting hepatic lesions and the use of EUS-guided FNA are not well evaluated. We investigated the usefulness of CEH-EUS-guided FNA for evaluating hepatic lesions.

METHODS

Thirty consecutive patients with hepatic masses underwent CEH-EUS and CEH-EUS-guided FNA between September 2010 and November 2016.

RESULTS

Twenty-eight patients (93.3%) had malignant tumors and 2 patients (6.7%) had benign hepatic masses. Before contrast enhancement, 73.3% of the hepatic lesions (22/30) in the patient cohort were visible on B mode. After contrast enhancement, 93.3% of these hepatic lesions (28/30) were distinguishable from the surrounding liver parenchyma. The technical success rate was 100%. The median tumor size on EUS and the number of needle passes were 24.5 mm (interquartile range [IQR], 14.5-40.8) and 2 (IQR, 2-3), respectively. The diagnostic accuracy of CEH-EUS-guided FNA was 86.7% (26/30 cases). There were no procedure-related adverse events.

CONCLUSIONS

CEH-EUS-guided FNA can be a safe and efficient method for the diagnosis of hepatic masses. It can result in high diagnostic accuracy in cases where the hepatic lesions are poorly visible on conventional EUS.

Quantitative assessment of hepatic fibrosis in chronic hepatitis B and C: T1 mapping on Gd-EOB-DTPA-enhanced liver magnetic resonance imaging

AIM

To assess the accuracy of Look-Locker on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) for staging liver fibrosis in chronic hepatitis B/C (CHB/C).

METHODS

We prospectively included 109 patients with CHB or CHC who underwent a 3.0-Tesla MRI examination, including T1-weighted and Look-Locker sequences for T1 mapping. Hepatocyte fractions (HeF) and relaxation time reduction rate (RE) were measured for staging liver fibrosis. A receiver operating characteristic analysis using the area under the receiver operating characteristic curve (AUC) was used to compare the diagnostic performance in predicting liver fibrosis between HeF and RE.

RESULTS

A total of 73 patients had both pathological results and MRI information. The number of patients in each fibrosis stage was evaluated semiquantitatively according to the METAVIR scoring system: F0, n = 23 (31.5%); F1, n = 19 (26.0%); F2, n = 13 (17.8%); F3, n = 6 (8.2%), and F4, n = 12 (16.4%). HeF by EOB enhancement imaging was significantly correlated with fibrosis stage (r = -0.808, P < 0.05). AUC values for diagnosis of any (≥ F1), significant (≥ F2) or advanced (≥ F3) fibrosis, and cirrhosis (F4) using HeF were 0.837 (0.733-0.913), 0.890 (0.795-0.951), 0.957 (0.881-0.990), and 0.957 (0.882-0.991), respectively. HeF measurement was more accurate than use of RE in establishing liver fibrosis staging, suggesting that calculation of HeF is a superior noninvasive liver fibrosis staging method.

CONCLUSION

A T1 mapping-based HeF method is an efficient diagnostic tool for the staging of liver fibrosis.

EUS anatomy of the liver segments

Clinical applications of EUS for the liver have been recently increasing. They include the screening and diagnosis of liver parenchymal disease and malignant tumors as well as EUS-guided interventions such as hepaticogastrostomy, tumor ablation therapy, and portal pressure gradient measurement. Although the segmental localization of the targeted tumor, bile duct, and vessel in the liver is important to complete these procedures, little information is available regarding hepatic segmental anatomy on EUS. The liver can be visualized with EUS by transgastric and transduodenal scanning, and the EUS determination of segmental location can be achieved using various anatomical landmarks. Identification of the right posterior segments is, however, technically difficult because they are located far from the stomach and duodenum. In the present review, we describe the normal anatomy of liver segments using linear EUS.