Comparison of diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration with 22- and 25-gauge needles in the same patients

Endoscopic ultrasound-guided fine-needle aspiration for gastrointestinal subepithelial lesions

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the first-choice procedure for obtaining pathological tissue samples from gastrointestinal (GI) subepithelial lesions (SELs). However, its diagnostic accuracy is lower than that for pancreatic masses owing to puncture difficulty and the need for immunostaining for definitive diagnosis. The advent of fine-needle biopsy needles, which have become well known in recent years, improves the diagnostic accuracy of EUS-FNA for GI SELs. The forward-viewing echoendoscope and rapid on-site evaluation (ROSE) have also helped to improve diagnostic accuracy. Furthermore, in facilities where ROSE is not available, endosonographers perform a macroscopic on-site evaluation. With these procedural innovations, EUS-FNA is now performed aggressively even for SELs smaller than 20 mm. The incidence of procedure-related adverse events such as bleeding and infection is low, and thus, EUS-FNA can be safely performed to diagnose SELs.

Endoscopic ultrasound-guided tissue acquisition beyond the pancreas

Endoscopic ultrasound (EUS) offers the ability to obtain tissue material via a fine needle under direct visualization for cytological or pathological examination. Prior studies have looked at EUS tissue acquisition; however, most reports have been centered around lesions of the pancreas. This paper aims to review the literature on EUS tissue acquisition in other organs (beyond the pancreas) such as the liver, biliary tree, lymph nodes, and upper and lower gastrointestinal tracts. Furthermore, techniques for obtaining tissue samples under EUS guidance continue to evolve. Specifically, some of the techniques that endoscopists employ are suction techniques (i.e., dry heparin, dry suction technique, wet suction technique), the slow pull technique, and the fanning technique. Apart from acquisition techniques, the type and size of the needle utilized play a major role in the quality of samples. This review describes the indications for tissue acquisition for each organ, and also describes and compares the various tissue acquisition techniques, as well as the different needles used according to their shape and size.

Prospective comparison of slow-pull and standard suction techniques of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of solid pancreatic cancer

Background

The usage of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the diagnosis of solid pancreatic cancer is increasing, however mainly retrospective studies are available about the detailed methods of sampling.

Methods

To compare prospectively the diagnostic yield of EUS-FNA samples obtained with slow-pull (SP) and with standard suction technique (SS).

Results

EUS-FNA sampling was diagnostic in 72 of 92 cases (78.3%). Diagnostic yield was 67.4% in the SS and 65.2% in the SP group. The number of smear pairs (1.84 vs. 3.56; p < 0.001) and blood contamination (1.50 vs. 2.19; p < 0.001) were significantly higher in the SS group, which resulted in lower rate of diagnostic samples (41.8% vs. 30.0%; p = 0.003). There was no difference in the cellularity (1.58 vs. 1.37; p = 0.2554), or in the sensitivity and specificity in the identification of malignancy between SP and SS subgroups (69.9, 100% vs. 73.5, 100%). Histological samples were obtained in 60 cases (with SP: 49 cases; with SS: 46 cases). There was no difference in the diagnostic yield of histological samples between the groups (63 and 58.7%).

Conclusion

The diagnostic yield, the cellularity of smears and the rate of acquiring sufficient histological material are similar in the SP and SS group, but due to lower bloodiness and decreased number of slides, the pathological diagnosis is faster and more cost-effective.

Comparison of endoscopic ultrasound-guided fine-needle aspiration and biopsy with 22-gauge and 25-gauge needles for the "precision medicine" of pancreatic cancer: A retrospective study

We compared the sample volume of endoscopic ultrasound-guided fine-needle aspiration and biopsy (EUS-FNAB) specimens obtained by 22-gauge (22G) and 25-gauge (25G) needles, and the accuracy rate.This was a retrospective study in a single tertiary referral center. We investigated 153 patients with pancreatic ductal adenocarcinoma (PDAC) who underwent diagnostic EUS-FNAB before neoadjuvant gemcitabine-based chemoradiotherapy between October 2006 and November 2015. We performed immunohistochemical (IHC) analysis of human equilibrative nucleoside transporter 1 using the remnant cell blocks following pathological PDAC diagnosis. We compared the sampling rate, accuracy rate, and success rate of IHC analysis between 22G and 25G.There were 70 patients in the 22G group and 83 patients in the 25G group. The overall sampling rates on cytology and histology were 100% and 98.0%, respectively. The sampling rate did not differ between the 22G and 25G groups. The overall diagnostic accuracy rates on cytology and histology were 94.8% and 79.7%, respectively. The accuracy rates of 22G and 25G groups on cytology were 94.3% and 95.2%, respectively, whereas those on histology were 80.0% and 79.5%, respectively. The diagnostic accuracy on cytology and histology did not differ significantly between the 22G and 25G groups. Of 153 histology specimens, 69.3% of those with PDAC provided sufficient samples for IHC analysis. The success rate of IHC analysis did not differ significantly between the 22G (67.1%) and 25G (71.1%) groups (P = .60).Both 22G and 25G provided a high diagnostic yield with equivalent accuracy rates on histology. EUS-FNAB specimens obtained using 22G or 25G can be equally adequate for IHC analysis and may be suitable for diagnostic examination. Further investigations such as EUS-FNAB needle design and novel cell block preparation are needed to obtain adequate samples for use in "precision medicine."

Comparison of two different size needles in endoscopic ultrasound-guided fine-needle aspiration for diagnosing solid pancreatic lesions: A meta-analysis of prospective controlled trials

BACKGROUND

This meta-analysis aimed to provide a pooled analysis of prospective controlled trials comparing the diagnostic accuracy of 22-G and 25-G needles on endoscopic ultrasonography (EUS-FNA) of the solid pancreatic mass.

METHODS

We established a rigorous study protocol according to Cochrane Collaboration recommendations. We systematically searched the PubMed and Embase databases to identify articles to include in the meta-analysis. Sensitivity, specificity, and corresponding 95% confidence intervals were calculated for 22-G and 25-G needles of individual studies from the contingency tables.

RESULTS

Eleven prospective controlled trials included a total of 837 patients (412 with 22-G vs 425 with 25-G). Our outcomes revealed that 25-G needles (92% [95% CI, 89%-95%]) have higher sensitivity than 22-G needles (88% [95% CI, 84%-91%]) on solid pancreatic mass EUS-FNA (P = 0.046). However, there were no significant differences between the 2 groups in overall diagnostic specificity (P = 0.842). The pooled positive and negative likelihood ratio of the 22-G needle were 12.61 (95% CI, 5.65-28.14) and 0.16 (95% CI, 0.12-0.21), respectively. The pooled positive likelihood ratio was 12.61 (95% CI, 5.65-28.14), and the negative likelihood ratio was 0.16 (95% CI, 0.12-0.21) for the 22-G needle. The pooled positive likelihood ratio was 8.44 (95% CI, 3.87-18.42), and the negative likelihood ratio was 0.13 (95% CI, 0.09-0.18) for the 25-G needle. The area under the summary receiver operating characteristic curve was 0.97 for the 22-G needle and 0.96 for the 25-G needle.

CONCLUSION

Compared to the study of 22-G EUS-FNA needles, our study showed that 25-G needles have superior sensitivity in the evaluation of solid pancreatic lesions by EUS-FNA.

Clinical implications of doubling time of gastrointestinal submucosal tumors

AIM

To evaluate the efficacy of doubling time (DT) of gastrointestinal submucosal tumors (GIST).

METHODS

From April 1987 through November 2012, a total of 323 patients were given a final histopathological diagnosis of GISTs on surgical resection or endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in Kitasato University East Hospital or Kitasato University Hospital. We studied 53 of these patients (34 with resected tumors and 19 with unresected tumors) whose tumors could be measured on EUS on at least two successive occasions. The histopathological diagnosis was GIST in 34 patients, leiomyoma in 5, schwannoma in 3, ectopic pancreas in 1, hamartoma in 1, cyst in 1, Brunner’s adenoma in 1, and spindle-cell tumor in 7. We retrospectively calculated the DT of GISTs on the basis of the time course of EUS findings to estimate the growth rate of such tumors.

RESULTS

The DT was 17.2 mo for GIST, as compared with 231.2 mo for leiomyoma, 104.7 mo for schwannoma, 274.9 mo for ectopic pancreas, 61.2 mo for hamartoma, 49.0 mo for cyst, and 134.7 mo for Brunner’s adenoma. The GISTs were divided into risk classes on the basis of tumor diameters and mitotic figures (Fletcher’s classification). The classification was extremely low risk or low risk in 28 patients, intermediate risk in 3, and high risk in 3. DT of GIST according to risk was 24.0 mo for extremely low-risk plus low-risk GIST, 17.1 mo for intermediate-risk GIST, and 3.9 mo for high-risk GIST. DT of GIST was significantly shorter than that of leiomyoma plus schwannoma (P < 0.05), and DT of high-risk GIST was significantly shorter than that of extremely low-risk plus low-risk GIST (P < 0.05).

CONCLUSION

For GIST, a higher risk grade was associated with a significantly shorter DT. Small SMTs should initially be followed up within 6 mo after detection.

Role of Endoscopic Ultrasonography in Guiding Treatment Plans for Upper Gastrointestinal Subepithelial Tumors

Gastrointestinal (GI) subepithelial tumors (SETs) are usually observed incidentally by endoscopy and have diverse prognoses, varying from benign to potentially malignant. When a GI SET is suspected, endoscopic ultrasonography (EUS) is the most accurate diagnostic method to differentiate it from extraluminal compression. To determine the nature of GI SETs, EUS is also the most accurate diagnostic method, and reveals the precise sonographic nature of the lesion. There are some SETs with typical EUS findings of GI SETs, but most hypoechoic lesions are difficult to diagnose based on EUS images alone. EUS is also helpful to determine GI wall involvement in SETs and optimal treatment methods. For the diagnosis of GI SETs, obtaining a proper specimen is essential. EUS-guided cytology or biopsy methods such as fine-needle aspiration, Tru-Cut biopsy, and the newly introduced fine-needle biopsy (FNB) provide good results. To increase the diagnostic yield for GI SETs, cytology with immunocytochemical staining is used for cytological interpretation, resulting in good diagnostic yields. Recently, EUS-FNB using cheese slicer technology has been introduced, and has been reported to provide good diagnostic results for GI SETs.

Prospective Study for Comparison of Endoscopic Ultrasound-Guided Tissue Acquisition Using 25- and 22-Gauge Core Biopsy Needles in Solid Pancreatic Masses

Background and Aims

Although thicker needles theoretically allow more tissue to be collected, their decreased flexibility can cause mechanical damage to the endoscope, technical failure, and sample blood contamination. The effects of needle gauge on diagnostic outcomes of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) of pancreatic mass lesions remain unknown. This study compared procurement rates of histologic cores obtained from EUS-FNB of pancreatic masses using 25- and 22-gauge core biopsy needles.

Patients and Methods

From March 2014 to July 2014, 66 patients with solid pancreatic mass underwent EUS-FNB with both 25- and 22-gauge core biopsy needles. Among them, 10 patients were excluded and thus 56 patients were eligible for the analyses. Needle sequences were randomly assigned, and two passes were made with each needle, consisting of 10 uniform to-and-fro movements on each pass with 10 mL syringe suction. A pathologist blinded to needle sequence evaluated specimens for the presence of histologic core.

Results

The mean patient age was 65.8 ± 9.5 years (range, 44–89 years); 35 patients (62.5%) were men. The mean pancreatic mass size was 35.3 ± 17.1 mm (range 14–122.3 mm). Twenty-eight patients (50%) had tumors at the pancreas head or uncinate process. There were no significant differences in procurement rates of histologic cores between 25-gauge (49/56, 87.5%) and 22-gauge (46/56, 82.1%, P = 0.581) needles or diagnostic accuracy using only histologic cores (98% and 95%). There were no technical failures or procedure-related adverse events.

Conclusions

The 25-gauge core biopsy needle could offer acceptable and comparable outcomes regarding diagnostic performance including histologic core procurement rates compared to the 22-gauge core biopsy needle, although the differences were not statistically significant.

Trial Registration

ClinicalTrials.gov NCT01795066

The diagnostic value of endoscopic ultrasonography and contrast-enhanced harmonic endoscopic ultrasonography in gastrointestinal stromal tumors

Objective:

To evaluate the diagnostic value of endoscopic ultrasonography (EUS) and contrast-enhanced harmonic (CEH) EUS in patients with gastrointestinal stromal tumors (GISTs).

Patients and Methods:

About 19 patients with suspected GISTs underwent EUS and CEH-EUS before tumor resection. The malignant potential was assessed according to the modified Fletcher classification system. Patients were divided into lower (Group I) and higher (Group II) malignant potential group. The clinical characteristics and EUS/CEH-EUS features were compared between two groups.

Results:

The tumor size in Group II was significantly larger than that in Group I (14.6 ± 5.8 mm vs. 32.1 ± 8.4 mm, P < 0.05). Heterogeneous echogenicity was observed in 4 (4/8) cases in Group II and none in Group I (P < 0.05). Irregular intratumoral vessels were detected in 6 cases in Group II and none in Group I (P < 0.05). The sensitivity and specificity of irregular vessel detection for discriminating higher from lower malignant potential GISTs were 75% and 100%, respectively. The positive predictive value and negative predictive value of detection of irregular vessels to high malignant potential GISTs were 33% and 100%, respectively.

Conclusion:

Detection of irregular intratumoral vessels can predict higher malignant potential before tumor resection. The tumor size and echogenicity are assistant factors for malignant potential assessment. Endoscopic resection is an efficacious treatment with good security for appropriate patients.

Needle size has only a limited effect on outcomes in EUS-guided fine needle aspiration: a systematic review and meta-analysis

BACKGROUND

Several recent studies have investigated the utility of 19-, 22-, and 25-gauge needles in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic and peri-pancreatic tumors.

AIM

The objective of this study was to summarize data from these studies and estimate the effect of needle size on reported outcomes such as accuracy, adequacy, and complications.

METHODS

Systematic review and meta-analysis comparing the effect of needle size (19, 22, and 25G) on diagnostic accuracy, adequacy, number of needle passes, and complications.

RESULTS

25G appear to confer an advantage in adequacy rates relative to 22G needles (risk difference = 0.12 %, 95 % CI 0.01, 0.25). There was no significant difference in accuracy with an overall sensitivity and specificity for 22G being 0.78 (95 % CI 0.74-0.81) and 1.00 (95 % CI 0.98-1.00) and an overall sensitivity and specificity for 25G being 0.91 (95 % CI 0.87-0.94) and 1.00 (95 % CI 0.97-1.00). There was no difference in number of passes or complications between 25 and 22G. The limited data available regarding 19G needles do not show evidence of improved outcomes with these devices.

CONCLUSIONS

In the evaluation of pancreatic and peri-pancreatic lesions by EUS-FNA, 25G needles may confer an advantage in adequacy relative to 22G needles but confer no advantages with respect to accuracy, number of passes, or complications.

Rapid on-site evaluation increases endoscopic ultrasound-guided fine-needle aspiration adequacy for pancreatic lesions

BACKGROUND

Rapid on-site evaluation (ROSE) has the potential to improve adequacy rates and affect other outcomes; however, there have been few comparative studies to assess the impact of ROSE in the setting of ultrasound-guided endoscopic fine-needle aspiration cytology for pancreatic lesions.

AIMS

To determine whether ROSE improves adequacy rates of endoscopic fine-needle aspiration cytology for pancreatic lesions.

METHODS

Systematic review and meta-analysis of studies reporting a head-to-head comparison of adequacy or diagnostic accuracy (with ROSE vs. without ROSE) at a single site.

RESULTS

ROSE was associated with a statistically significant (p < 0.001) improvement in the adequacy rate (average 10 %, 95 % CI: 5-24 %). The impact of ROSE depends on the per-pass adequacy rate without ROSE. ROSE had no impact on diagnostic yield (p < 0.76).

CONCLUSIONS

ROSE is associated with an improvement in adequacy rates when implemented at sites where the per-case adequacy rate without ROSE is low (<90 %). It is unclear whether the type of assessor (pathologist vs. non-pathologist) has a significant impact on the success rate of ROSE. ROSE has no impact on diagnostic yield. Studies should employ head-to-head comparisons of cohorts with and without ROSE at a single location.

Endoscopic ultrasound-guided fine needle aspiration in submucosal lesion

A submucosal lesion, more appropriately a subepithelial lesion, is hard to diagnose. Endoscopic ultrasonography is good to differentiate the nature of submucosal lesion. For definite diagnosis, tissue acquisition from submucosal lesion is necessary, and many methods have been introduced for this purpose mainly by endoscopic ultrasonography, such as endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), EUS-guided Trucut Biopsy (TCB), and EUS-guided fine needle biopsy (FNB). For EUS-FNA, adequate processing of specimen is important, and for proper diagnosis of EUS-FNA specimen, both cytologic and histologic examinations, including immunohistochemical stains, are important. All gastrointestinal stromal tumors have some degree of malignant potential, so there have been a lot of efforts and methods to increase diagnostic yields of submucosal lesion. We herein review the current hot topics on EUS-FNA for submucosal tumor, such as needles, on-site cytopathologists, immunohistochemical stains, EUS-TCB, EUS-FNB, Ki-67 labelling index, DOG1, and combining EUS-FNA and EUS-TCB.