Absence Of Rapid On-site Evaluation Research Articles

Endobronchial ultrasound (EBUS)-guided transbronchial miniforceps biopsy an urban center experience.

The role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in staging mediastinal and hilar lymph nodes in non-small cell lung cancer (NSCLC) is well established. However, evidence of its diagnostic utility in other pathologies-such as lymphoma-remains inadequate. This retrospective observational study aims to determine the diagnostic yield of EBUS-guided miniforceps biopsy (EBUS-MFB) compared to EBUS-TBNA in both malignant and nonmalignant conditions. We conducted a retrospective cross-sectional chart review of all adult patients referred for EBUS at our institution between January 2019 and December 2022. All patients who underwent both EBUS-TBNA and EBUS-MFB were included, with some patients also undergoing transbronchial cryobiopsy. Patients without pathology reports available were excluded. The combination of EBUS-MFB and EBUS-TBNA had the highest percentage of diagnostic results both in the overall cohort (34.4%) and in patients who did not undergo transbronchial cryobiopsy (46.2%). EBUS-MFB alone yielded more diagnostic results compared to EBUS-TBNA. Transbronchial cryobiopsy was the sampling method with the highest percentage of diagnostic results in the cryobiopsy group (64.5%). Statistical analysis revealed a significant difference in diagnostic yield between EBUS-MFB and EBUS-TBNA (P<0.001), with EBUS-MFB showing a higher diagnostic yield overall. EBUS-MFB had a significantly higher diagnostic yield than EBUS-TBNA in benign cases, in patients diagnosed with sarcoidosis, but not in malignant disease. Our study suggests that combining EBUS-MFB with EBUS-TBNA can improve the diagnostic yield, particularly in benign cases and sarcoidosis. These findings support the potential superiority of adding EBUS-MFB over EBUS-TBNA alone and highlight the need for further randomized control trials to validate these results. The retrospective nature of this study and certain limitations, such as the lack of adequate longer-term follow-up, selection and operator biases, and the absence of rapid on-site evaluation (ROSE) in some cases, should be considered when interpreting the results. Nonetheless, this study contributes to the growing evidence for the utility of EBUS-MFB in improving the diagnostic yield of EBUS procedures in specific clinical scenarios.

Comparison of EUS-guided conventional smear and liquid-based cytology in pancreatic lesions: A systematic review and meta-analysis.

Background and study aims Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) has limitations of inadequate sampling and false-negative results for malignancy. It has been performed using conventional smear (CS) cytology with rapid on-site evaluation (ROSE) with reasonable diagnostic accuracy. An alternative to ROSE is liquid-based cytology (LBC). Commonly used LBC techniques include precipitation-based (SurePath™) and filtration-based (ThinPrep ® , CellPrep ® ). Data regarding the diagnostic efficacy of LBC compared with CS are limited. Methods Multiple databases were searched through March 2020 to identify studies reporting diagnostic yield of EUS-guided CS and LBC in pancreatic lesions. Pooled diagnostic odds and rates of performance for the cytologic diagnoses of benign, suspicious, and malignant lesions were calculated. Diagnostic efficacy was evaluated by pooled rates of accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results Nine studies with a total of 1308 patients were included in our final analysis. Pooled diagnostic odds of CS cytology were 1.69 (CI 1.02–2.79) and 0.39 (CI 0.19–0.8) for malignant lesions when compared to filtration-based and precipitation-based LBC techniques, respectively. For CS, precipitation-based and filtration-based LBC, pooled diagnostic accuracy was 79.7 %, 85.2 %, 77.3 %, sensitivity was 79.2 %, 83.6 %, 68.3 %, and specificity was 99.4 %, 99.5 %, 99.5 %, respectively. Conclusions The precipitation-based LBC technique (SurePath™) had superior diagnostic odds for malignant pancreatic lesions compared with CS cytology in the absence of ROSE. It showed superior accuracy and sensitivity, but comparable specificity and PPV. Diagnostic odds of CS cytology in the absence of ROSE were superior to the filtration-based LBC technique (ThinPrep ® , Cellprep ® ) for diagnosing malignant pancreatic lesions.

S0053 Comparison of EUS-Guided Conventional Smear Cytology and Liquid Based Cytology in Pancreatic Lesions: A Systematic Review and Meta-Analysis

INTRODUCTION: EUS guided fine needle aspiration (EUS-FNA) has limitations of inadequate sampling and false-negative results for malignancy. Traditionally it has been performed using conventional smear (CS) cytology with sub-optimal diagnostic accuracy. The addition of rapid on-site evaluation (ROSE) to CS has been shown to improve sensitivity and sample adequacy. However, ROSE is not available in all healthcare centers. An alternative to ROSE is liquid-based cytology (LBC). Commonly used LBC techniques include precipitation-based (SurePath™) and filtration-based (ThinPrep®, CellPrep®). Data regarding the diagnostic efficacy of LBC compared to CS without ROSE is limited. METHODS: Multiple databases were searched through March 2020 to identify studies reporting diagnostic yield of EUS-guided CS and LBC in pancreatic lesions. Pooled diagnostic odds and rates of performance for the cytologic diagnoses of benign, suspicious, and malignant lesions were calculated. Diagnostic efficacy was evaluated by pooled rates of accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: 9 studies with a total of 1308 patients were included in our final analysis. None of the included studies utilized rapid on-site evaluation (ROSE). CS cytology performed significantly better than filtration-based LBC technique in diagnosing suspicious, and malignant pancreatic lesions [OR = 1.69 (1.02–2.79); P = 0.04, OR = 0.47 (0.27–0.8); P = 0.006]. For benign lesions, outcomes of the two techniques were comparable. Precipitation-based LBC performed significantly better than CS cytology in diagnosing malignant pancreatic lesions [OR = 0.39 (0.19–0.8); P = 0.01], but this effect was not seen with respect to benign lesions. For CS, precipitation-based and filtration-based LBC, pooled diagnostic accuracy was 79.7%, 85.2%, 77.3%, sensitivity was 79.2%, 83.6%, 68.3%, and specificity was 99.4%, 99.5%, 99.5%, respectively. CONCLUSION: Precipitation-based LBC technique (SurePath™) had superior diagnostic odds for malignant pancreatic lesions compared to CS cytology in the absence of ROSE. It showed superior accuracy and sensitivity, but comparable specificity and PPV. Diagnostic odds of CS cytology in the absence of ROSE were superior to filtration-based LBC technique (ThinPrep®, Cellprep®) for diagnosing malignant pancreatic lesions. In the absence of ROSE, precipitation-based LBC should be preferred over conventional smear technique in EUS-guided sampling of pancreatic lesions.Figure 1.: Odds Ratio - Forest Plot.Figure 2.: Pooled Rate - Forest Plot.

Endoscopic ultrasound-guided tissue acquisition with or without macroscopic on-site evaluation: randomized controlled trial

The use of macroscopic on-site evaluation (MOSE) to estimate the adequacy of a specimen for histological diagnosis during endoscopic ultrasound (EUS)-guided fine-needle tissue acquisition (FNTA) has recently been advocated. This study aimed to evaluate the diagnostic yield of MOSE compared with conventional EUS-FNTA without rapid on-site evaluation (ROSE). This was an international, multicenter, prospective, randomized controlled study. After providing informed consent, consecutive adult patients referred for EUS-FNTA for solid lesions larger than 2 cm were randomized to a MOSE arm or to a conventional arm without ROSE. A designated cytopathologist from each center performed all cytopathological examinations for that center and was blinded to the randomization results. The primary outcome measure was the diagnostic yield, and the secondary outcomes included sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, and the rate of procedure-related complications. 244 patients (122 conventional, 122 MOSE) were enrolled during the study period. No significant differences between the two arms were found in procedure time or rate of procedure-related adverse events. The diagnostic yield for the MOSE technique (92.6 %) was similar to that for the conventional technique (89.3 %; P = 0.37), with significantly fewer passes made (median: conventional 3, MOSE 2; P < 0.001). EUS-FNTA with the MOSE technique provided a similar diagnostic yield to conventional EUS-FNTA technique in the absence of ROSE but with fewer passes. This technique can be used when ROSE is not available.

Diagnostic yield and agreement on fine-needle specimens from solid pancreatic lesions: comparing the smear technique to liquid-based cytology

Background and study aims The traditional “smear technique” for processing and assessing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is sensitive to artifacts. Processing and evaluation of specimens collected in a liquid medium, liquid-based cytology (LBC) may be a solution. We compared the diagnostic value of EUS-FNA smears to LBC in pancreatic solid lesions in the absence of rapid on-site evaluation (ROSE). Patients and methods Consecutive patients who required EUS-FNA of a solid pancreatic lesion were included in seven hospitals in the Netherlands and followed for at least 12 months. Specimens from the first pass were split into two smears and a vial for LBC (using ThinPrep and/or Cell block). Smear and LBC were compared in terms of diagnostic accuracy for malignancy, sample quality, and diagnostic agreement between three cytopathologists. Results Diagnostic accuracy for malignancy was higher for LBC (82 % (58/71)) than for smear (66 % (47/71), P = 0.04), but did not differ when smears were compared to ThinPrep (71 % (30/42), P = 0.56) or Cell block (62 % (39/63), P = 0.61) individually. Artifacts were less often present in ThinPrep (57 % (24/42), P = 0.02) or Cell block samples (40 % (25/63), P < 0.001) than smears (76 % (54/71)). Agreement on malignancy was equally good for smears and LBC (ĸ = 0.71 versus ĸ = 0.70, P = 0.98), but lower for ThinPrep (ĸ = 0.26, P = 0.01) than smears. Conclusion After a single pass, LBC provides higher diagnostic accuracy than the conventional smear technique for EUS-FNA of solid pancreatic lesions in the absence of ROSE. Therefore, LBC, may be an alternative to the conventional smear technique, especially in centers lacking ROSE.

Comparison of Number of Passes and Cytopathological Specimen Adequacy for Thyroid Fine-Needle Aspiration Biopsy in the Absence of an On-Site Pathologist

Aim: Ultrasound-guided fine-needle aspiration biopsy (FNAB) is a reliable, minimally invasive diagnostic method with high sensitivity and specificity in the evaluation of thyroid nodules. Our aim in this retrospective study was to determine if there was a difference in the adequacy ratio based on the number of needle passes in the thyroid FNABs in the absence of rapid on-site evaluation (ROSE) by the pathologist and to determine the optimal needle pass number for FNAB. Methods: Between November 2018 and February 2019, thyroid FNABs of 121 (99 female, 22 male) patients were evaluated retrospectively. Samples for each biopsy were numbered according to the order of retrieval, and 4 pairs of slides were prepared by the radiologist without on-site microscopic evaluation. Cytological results were determined according to the Bethesda classification. Results: The rate of adequacy in the first, second, third, and fourth passes were 76.0, 82.6, 77.7, and 71.2%, respectively. No statistically significant difference was found between these four groups in terms of adequacy (p = 0.21). The adequacy rates of the 1st, 1st+2nd, 1st+2nd+3rd, and cumulative evaluation of all four biopsies were 76.0, 87.6, 90.1, and 91.7%, respectively (p = 0.001). A statistically significant difference was found in the comparison of the 1st biopsy and the cumulative 1st+2nd biopsy in terms of adequacy rates (p = 0.019). However, there was no statistically significant difference between the cumulative 1st+2nd biopsy and the cumulative 1st+2nd+3rd biopsy in terms of adequacy rates (p = 0.54). Conclusions: In cases where ROSE cannot be performed, we recommend a minimum of 2 and a maximum of 3 needle entries for FNAB adequacy with the right technique and preparation.

Endoscopic ultrasound-guided sampling of solid pancreatic masses: the fine needle aspiration or fine needle biopsy dilemma. Is the best needle yet to come?

Fine needle aspiration (FNA) is currently the standard of care for sampling pancreatic solid masses by using endoscopic ultrasound (EUS). The accuracy of the technique is reported to be high, especially if coupled with the rapid on site evaluation (ROSE), and it has a high safety profile. However, FNA presents some limitations, such as the small amount of tissue that can be collected and the inability of obtaining a core tissue with intact histological architecture, which is relevant to perform immunohistochemical analysis, molecular profiling and, therefore, targeted therapies. Moreover, the presence of the ROSE by an expert cytopathologist is very important to maximize the diagnostic yield of FNA technique; however, it is not widely available, especially in small centers. Hence, the introduction of EUS fine needle biopsy (FNB) with a new generation of needles, which show a high safety profile too and a satisfying diagnostic accuracy even in the absence of ROSE, could be the key to overcome the limitations of FNA. However, FNB has not yet shown diagnostic superiority over FNA. Considering all the technical aspects of FNA and FNB, the different types of needle currently available, comparisons in term of diagnostic yield, and the different techniques of sampling, a tailored approach should be used in order to determine the needle that is most appropriate for the different specific scenarios.

Diagnostic yield of EUS-FNA of small (≤15 mm) solid pancreatic lesions using a 25-gauge needle

BackgroundEarly detection of small solid pancreatic lesions is increasingly common. To date, few and contradictory data have been published about the relationship between lesion size and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) diagnostic yield. The aim of this study was to assess the relation between the size of solid pancreatic lesions and the diagnostic yield of EUS-FNA using a 25-gauge needle in a center without available rapid on-site evaluation. MethodsIn the retrospective cohort study, we selected patients who underwent EUS-FNA for solid pancreatic lesions with a 25-gauge needle from October 2014 to October 2015. Patients were divided into three groups (≤15 mm, 16–25 mm and >25 mm), and the outcomes were compared. ResultsWe analyzed 163 patients. Overall adequacy, sensitivity, specificity and accuracy were 85.2%, 81.8%, 93.7%, and 80.4%, respectively. When stratified by size, the sensitivity and accuracy correlated with size (P = 0.016 and P = 0.042, respectively). Multivariate analysis showed that lesion size was the only independent factor (P = 0.019, OR = 4.76) affecting accuracy. The role of size as an independent factor affecting accuracy was confirmed in a separate multivariate analysis, where size was included in the model as a covariate (P = 0.018, OR = 1.08). ConclusionOur study demonstrates that, in the absence of rapid on-site evaluation, mass size affects the accuracy of EUS-FNA of solid pancreatic lesions.

Prospective Study of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-Small Cell Lung Cancer Stadification: How Many Passes Are Adequate for PET Positive and Negative Lymph Nodes?

SESSION TITLE: Rapid Session: Interventional Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 03:15 PM - 04:15 PM PURPOSE: It is recommended in the absence of rapid on-site evaluation (ROSE) in patients suspected of having lung cancer and undergoing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for diagnosis, that a minimum of 3 separate needle passes be performed per sampling site (Ungraded Consensus-Based Statement).1 However it is still unclear if there is a difference between PET-positive lymph nodes (LN) and those PET negative. The purpose of the present study was to elucidate the number of passes needed for PET positive or negative LN. METHODS: A prospective study was performed from 2012 to 2017 at the Bellvitge University Hospital, 103 patients with diagnosed NSCLC were recruited. The patients underwent 3 passes of EBUS-TBNA in 150 lymph nodes found during the procedure that were bigger than 5 mm. The 3 passes were studied by ROSE and by cell block, each pass separately. LN were divided by PET results. The results of the passes and the final diagnosis were analyzed. RESULTS: A total of 103 patients were selected, 85,7% of them were male with an average age of 66.9 years. All of them have been diagnosed of non-small cell lung cancer (NSCLC) prior to the test performance, 34,3% were adenocarcinoma and 65,7% squamous cell carcinoma. ROC analysis and Sensitivity has been assessed for each of the two groups of LN (PET + and PET-) and the results were compared for each pass. We observed that in PET positive LN there is a significant improvement in the sensitivity if 3 passes were performed, while in PET negative LN there is no significant difference in the diagnostic yield between one or three passes. There is no significant difference if the LN were <10 mm or >10 mm. There is neither significant difference if the tumor was an Adenocarcinoma. CONCLUSIONS: In NSCLC stadification by EBUS-TBNA, we recommend three passes in those PET-positive LN and only one in those PET-negative even if ROSE is available. CLINICAL IMPLICATIONS: This study suggest that three passes per PET-positive LN and one for PET-negative LN are necessary to obtain satisfactory results for NSCLC stratification with ROSE available. DISCLOSURE: The following authors have nothing to disclose: Noelia Cubero, Melisa Masis, Rosa Lopez Lisbona, Marta Diez-Ferrer, Antoni Rosell No Product/Research Disclosure Information

A meta-analysis of endoscopic ultrasound-fine-needle aspiration compared to endoscopic ultrasound-fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment.

Background The diagnostic yield of endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is variable, and partly dependent upon rapid onsite evaluation (ROSE) by a cytopathologist. Second generation fine-needle biopsy (FNB) needles are being increasingly used to obtain core histological tissue samples. Aims Studies comparing the diagnostic yield of EUS guided FNA versus FNB have reached conflicting conclusions. We therefore conducted a systematic review and meta-analysis to compare the diagnostic yield of FNA with FNB, and specifically evaluating the diagnostic value of ROSE while comparing the two types of needles. Methods We searched several databases from inception to 10 April 2016 to identify studies comparing diagnostic yield of second generation FNB needles with standard FNA needles. Risk ratios (RR) were calculated for categorical outcomes of interest (diagnostic adequacy, diagnostic accuracy, and optimal quality histological cores obtained). Standard mean difference (SMD) was calculated for continuous variables (number of passes required for diagnosis). These were pooled using random effects model of meta-analysis to account for heterogeneity. Meta-regression was conducted to evaluate the effect of ROSE on various outcomes of interest. Results Fifteen studies with a total of 1024 patients were included in the analysis. We found no significant difference in diagnostic adequacy [RR 0.98 (0.91, 1.06), (I 2 = 51 %)]. Although not statistically significant (P = 0.06), by meta-regression, in the absence of ROSE, FNB showed a relatively better diagnostic adequacy. For solid pancreatic lesions only, there was no difference in diagnostic adequacy [RR 0.96 (0.86, 1.09), (I 2 = 66 %)]. By meta-regression, in the absence of ROSE, FNB was associated with better diagnostic adequacy (P = 0.02). There was no difference in diagnostic accuracy [RR 0.99 (0.95, 1.03), (I 2 = 27 %)] or optimal quality core histological sample procurement [RR 0.97 (0.89, 1.05), (I 2 = 9.6 %)]. However, FNB established diagnosis with fewer passes [SMD 0.93 (0.45, 1.42), (I 2 = 84 %)]. The absence of ROSE was associated with a higher SMD, i. e., in the presence of an onsite pathologist, FNA required relatively fewer passes to establish the diagnosis than in the absence of an onsite pathologist. Conclusions There is no significant difference in the diagnostic yield between FNA and FNB, when FNA is accompanied by ROSE. However, in the absence of ROSE, FNB is associated with a relatively better diagnostic adequacy in solid pancreatic lesions. Also, FNB requires fewer passes to establish the diagnosis.

Endobronchial ultrasound-transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: variability of results and perspectives.

The remarkable value of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging of non-small cell lung cancer (NSCLC) is recognized worldwide. Reports from different centers however show considerable variation of EBUS-TBNA performance in terms of diagnostic yield, sensitivity and negative predictive value (NPV). Interpretation of EBUS-TBNA diagnostic efficacy requires clarifying whether the technique is used for purely diagnostic purpose or mediastinal staging, recognizing that different study groups may be inherently heterogeneous and that numerous factors may impact on the procedure outcomes. Review of these factors indicates that the prevalence of N2/N3 disease, the thoroughness of mediastinal sampling and >3 needle passes per target lymph node (LN) [in the absence of rapid on-site evaluation (ROSE)] influence the procedure outcomes, while many details in the sample preparation technique are unlikely to impact on the results and should be left to the proceduralists' preference. Generalized use of a standardized database for prospective collection of relevant EBUS-TBNA data would allow reporting institutional results by sub-groups of N2/N3 disease prevalence and thoroughness of staging, and would help establishing quality standards for the procedure.

Novel fork-tip needles versus standard needles for EUS-guided tissue acquisition from solid masses of the upper GI tract: a matched cohort study

Background: There are very few available data on the novel SharkCore™ needles for EUS-FNB.Aim: Comparison of the performance of the SharkCore™ needles with the standard EUS-FNA needles for the diagnosis of solid upper GI masses.Patients and methods: Single-center, retrospective cohort study in an academic tertiary referral hospital. Patients were matched 1:1 for the site of the lesion and the presence or absence of rapid on-site evaluation (ROSE).Results: A total of 102 patients were included. There was no statistically significant difference in the mean number of passes (3.3 ± 1.3 versus 3.4 ± 1.5; p = .89). Similar results were observed at the subgroup with ROSE (4.3 ± 1.3 versus 3.7 ± 1.5; p = .26). More histological specimens were obtained with the SharkCore™ needles compared to standard needles (59 versus 5%; p < .001). Diagnostic test characteristics were not significantly different (sensitivity: 91.5 versus 85.7; specificity: 100 versus 100%; accuracy: 92.2 versus 85.4% for SharkCore™ versus standard needles, p > .05 in all cases). At multivariable analysis, there was no statistically significant difference in the mean number of passes in all patients (p = .23) and in the ROSE subgroup (p = .66). However, the SharkCore™ needle obtained significantly more histological material than the standard needle (odds ratio 66; 95% confidence interval: 11.8, 375.8, p < .001). There was no significant difference in complication rates (p = .5).Limitations: Retrospective study, single-center.Conclusion: The SharkCore needles were similar to standard FNA needles in terms of the number of passes to reach diagnosis, but obtained significantly more histological specimen.

Endosonographer's macroscopic evaluation of EUS-FNAB specimens after interactive cytopathologic training: a single-center prospective validation cohort study.

In many centers, rapid on-site evaluation (ROSE) for the specimens obtained from endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) is not available. The aim of this study was to compare the diagnostic yields of EUS-FNAB in the presence or absence of ROSE. Seventy-five patients who underwent EUS-FNAB for the pancreatic, gastric subepithelial, and mesenteric mass lesions at our institution from November 2013 to August 2014 were included. For 20 patients in the pilot cohort, EUS-FNAB was performed with ROSE, and simultaneously, training of the staff endosonographer for tissue adequacy by an on-site cytopathologist was also performed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of EUS-FNAB in the pilot cohort were 91.7, 100.0, 100.0, 88.9, and 95.0%, respectively. The 3.2±0.8 [mean±standard deviation (SD)] needle passes were needed in this cohort. Fifty-five patients were enrolled as a validation cohort from April 2014 to August 2014, and tissue adequacies were assessed by an experienced endosonographer without ROSE in this cohort. The sensitivity, specificity, PPV, NPV, and accuracy of EUS-FNAB in this validation cohort were 92.1, 100.0, 100.0, 85.0, and 94.6%, respectively. The 4.5±0.6 (mean±SD) needle passes were needed in this cohort (p<0.01 compared to pilot cohort). Diagnostic accuracy of EUS-FNAB in which the adequacy of sample was assessed by an attending endosonographer was acceptable. This study suggests that on-site evaluation by a trained endosonographer may be an alternative tool to ROSE where ROSE is not available.

Tu1636 Prospective Evaluation of the Yield and Diagnostic Accuracy of Endoscopic Ultrasound-Guided Fine Needle Aspiration in the Absence of Rapid Onsite Evaluation

The studies for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) without rapid onsite evaluation (ROSE) were scarce. The aim of the current study was to compare the diagnostic yields of EUS-FNA in the presence or absence of ROSE, in cases without ROSE the adequacy of specimens was assessed by an attending endosonographer.

Mo1393 Prospective Evaluation of the Yield and Diagnostic Accuracy of Endoscopic Ultrasound Guided Fine Needle Aspiration and Biopsy in the Absence of Rapid Onsite Evaluation

Mo1393 Prospective Evaluation of the Yield and Diagnostic Accuracy of Endoscopic Ultrasound Guided Fine Needle Aspiration and Biopsy in the Absence of Rapid Onsite Evaluation

Is It Time to Take a Pass on the Increased Number of Passes in EUS-FNA?

Despite the extensive use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), there still exists a wide variation in the number of samples required to ensure acquisition of diagnostic material from pancreatic lesions. Although multiple passes can be performed during EUSFNA, prolonging the procedure likely increases risk, decreases procedural efficiency, and increases the probability of samples being tainted with blood. It has been 21 years since EUS-FNA was used to obtain pancreatic tissue for cytologic analysis [1, 2], 16 years since the publication of the first reports evaluating the clinical impact and staging of pancreatic lesions sampled by EUSFNA [3], and 14 years since the publication of the initial reports of the evaluation of the number of passes needed to obtain a diagnostic yield and the significance of on-site cytopathology during the procedure [4–7]. During this time, the focus has been on determining the necessity of on-site cytopathologic evaluation, the optimal number of needle passes, and the most effective needle type used for tissue acquisition. Despite numerous studies addressing these issues, many endoscopists are still perplexed about the nature of the best practices needed to ensure optimal results, in particular with regard to the need for on-site cytopathology for skilled and experienced endosonographers practicing at a high-volume center. To date, multiple meta-analyses have confirmed the diagnostic accuracy, cost-effectiveness, accuracy, and safety of EUS-FNA for solid pancreatic lesions [8–12]. Moreover, structured literature reviews have concluded that rapid on-site evaluation (ROSE) improves diagnostic accuracy [8, 9]. Notwithstanding these considerable successes, ongoing refinements to EUS-FNA continue to be explored. Regardless of the likelihood that increasing numbers of passes raises the risk of needle failure, tissue injury, postprocedural complications, and medical expenses, the endosonographer is caught between the need to provide adequate tissue needed to optimize diagnostic yield weighed against the cost and risk of making additional passes. Failed EUS-FNA often engenders additional risk and expense due to the need to repeat EUS or to obtain tissue with radiologic or surgical guidance. Moreover, as treatment options for pancreatic cancer advance, rendering an onsite diagnosis alone may not be adequate, since additional tissue may be required to perform ancillary studies and molecular mapping. Nevertheless, ROSE may not be financially viable due to excess time commitment, limited resources, relatively low reimbursements, and acceptable adequacy rates achieved by more experienced endosonographers. In order to have a sustainable EUS practice with optimal clinical outcomes, it may be beneficial to provide some degree of ROSE training for endosonographers incorporating the ‘‘fanning’’ FNA technique combined with an algorithmic approach to needle selection [13–15]. In this issue of Digestive Diseases and Sciences, Schmidt et al. [16] examined current practices of lesion sampling, weighing diagnostic accuracy against the probability of adverse events in the presence and absence of ROSE. The authors provide empirical data regarding the diagnostic yield and performance characteristics of EUS-FNA of solid pancreatic lesions using mathematical modeling to determine the likelihood of adverse events with a fixed number of passes (no-ROSE) versus a variable number of passes (ROSE) while controlling for other variables. Schmidt and colleagues used a discrete-event simulation model to conclude that ROSE reduces the number of passes, thereby reducing the S. Hebert-Magee R. H. Hawes S. Varadarajulu (&) Center for Interventional Endoscopy, Florida Hospital, 601 East Rollins Street, Orlando, FL 32803, USA e-mail: svaradarajulu@yahoo.com

Prospective evaluation of the yield and diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration and biopsy in the absence of rapid onsite evaluation

Prospective evaluation of the yield and diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration and biopsy in the absence of rapid onsite evaluation

Improving endoscopic ultrasound-guided fine needle aspiration specimens in the absence of rapid onsite evaluation: Does cytotechnologist training provide the solution?

Improving endoscopic ultrasound-guided fine needle aspiration specimens in the absence of rapid onsite evaluation: Does cytotechnologist training provide the solution?

Comparing endobronchial ultrasound-guided fine needle aspiration specimens with and without rapid on-site evaluation

Comparing endobronchial ultrasound-guided fine needle aspiration specimens with and without rapid on-site evaluation