Adequate Tissue Acquisition Research Articles

Adequacy, safety, and technical determinants of a modified EUS-guided liver biopsy sampling technique in patients with or without cirrhosis: a pilot study

Background and AimsEndoscopic ultrasound-guided liver biopsy (EUS-LB) technique-related factors as a determinant of specimen yield have not been studied. We used a modified technique to study adequacy, safety and technical determinants in patients with or without cirrhosis. MethodsEUS-LB was performed with a 19G Franseen tip needle by wet heparinized suction. One or two passes with a variable number of actuations were taken, the end-point being the aspiration of blood. Primary outcomes were tissue core adequacy and definitive histologic diagnosis. Secondary outcomes were a correlation between the number and depth of actuations with total specimen length (TSL), longest specimen length (LSL) and adverse events (AE). Early and late adverse events (AE) were also accessed. ResultsAdequate samples were seen in 48/50 and histologic diagnosis could be achieved in 49/50 patients. Mean TSL, LSL and depth of actuation were 7.98±3.74cm, 1.89±0.80cm and 4.29±0.98cm, respectively. The median complete portal tracts(CPT) were 23 (range, 7-50) and number of actuations was 7 (range, 4-12) The correlation between TSL with number and depth of actuation was r=0.71 vs 0.53 & r=0.55 vs 0.51 and for LSL were r=0.28 vs 0.11 & r=0.74 vs 0.55 in non-cirrhotic and cirrhotic patients respectively. No major and 7(14%) minor adverse events were observed. ConclusionsThis modified EUS-LB technique results in adequate tissue acquisition and is safe in non-cirrhotic and cirrhotic patients. Technical factors like the number and depth of actuations determine specimen yield.

WHEN CANCERS COLLIDE: A COLLISION TUMOR OF ADENOCARCINOMA AND SMALL CELL CARCINOMA OF THE LUNGS

WHEN CANCERS COLLIDE: A COLLISION TUMOR OF ADENOCARCINOMA AND SMALL CELL CARCINOMA OF THE LUNGS

Comparison of diagnostic performances of slow-pull suction and standard suction in endoscopic ultrasound-guided fine needle biopsy for gastrointestinal subepithelial tumors.

Background/AimsEndoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is integral to the diagnosis of gastrointestinal (GI) subepithelial tumors (SETs). The impact of different EUS-FNB tissue sampling techniques on specimen adequacy and diagnostic accuracy in SETs has not been fully evaluated. This study aimed to compare the diagnostic outcomes of slow-pull (SP) and standard suction (SS) in patients with GI SETs. MethodsIn this retrospective comparative study, 54 patients were enrolled. Medical records were reviewed for location and size of the target lesion, FNB needle type/size, technical order, specimen adequacy, diagnostic yield, and adverse events. The acquisition rate of adequate specimens and diagnostic accuracy were compared according to EUS-FNB techniques. ResultsThe mean lesion size was 42.6±36.4 mm, and most patients were diagnosed with GI stromal tumor (75.9%). The overall diagnostic accuracies of the SP and SS techniques were 83.3% and 81.5%, respectively (p=0.800). The rates of obtaining adequate core tissue were 79.6% and 75.9%, respectively (p=0.799). No significant clinical factors affected the rate of obtaining adequate core tissue, including lesion location and size, FNB needle size, and final diagnosis. ConclusionsSP and SS had comparable diagnostic accuracies and adequate core tissue acquisition for GI SETs via EUS-FNB.

Comparison of tube-assisted mapping biopsy with digital single-operator peroral cholangioscopy for preoperative evaluation of biliary tract cancer.

Background/AimsDigital single-operator cholangioscopy (DSOC)-guided mapping biopsy (DMB) and tube-assisted mapping biopsy (TMB) are two techniques used for preoperative evaluation of biliary tract cancer (BTC). However, data regarding the diagnostic performance of these techniques are limited. MethodsWe retrospectively examined consecutive patients with BTC who underwent either technique at our institution between 2018 and 2020. We evaluated the technical success rate, adequate tissue acquisition rate, and diagnostic performance of these techniques for the evaluation of lateral spread of BTC. ResultsA total of 54 patients were included in the study. The technical success rate of reaching the target sites was 95% for DMB and 100% for TMB. The adequate tissue acquisition rate was 61% for DMB and 69% for TMB. The adequate tissue acquisition rate was low, especially for target sites beyond the secondary biliary radicles. The sensitivity of DMB alone was 39%, which improved to 65% when combined with visual impression. Experts demonstrated a higher negative predictive value and diagnostic accuracy with respect to both DSOC visual impression and DMB for the evaluation of lateral spread of BTC compared to trainees. ConclusionsAdequate tissue acquisition rates were similar between the two techniques. Since DMB requires expertise, TMB may be an acceptable option when DSOC is unavailable or when DSOC expertise is limited.

S2511 Spindle Cell Neoplasms of the Upper Gastrointestinal Tract, Adequate Tissue Acquisition and Histomorphologic Analysis by Using EUS-Guided Low Cost Multilayer Coil Sheathed Nitinol-Based FNA Needle: Review of Five Cases

S2511 Spindle Cell Neoplasms of the Upper Gastrointestinal Tract, Adequate Tissue Acquisition and Histomorphologic Analysis by Using EUS-Guided Low Cost Multilayer Coil Sheathed Nitinol-Based FNA Needle: Review of Five Cases

Randomized trial comparing the 25G and 22G Franseen needles in endoscopic ultrasound-guided tissue acquisition from solid pancreatic masses for adequate histological assessment.

The effects of the Franseen needle size in endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) of solid pancreatic masses remain unclear. This study aimed to compare 25G and 22G Franseen needles in terms of adequate tissue acquisition from solid pancreatic masses. In this single-center, crossover, randomized noninferiority trial, eligible patients underwent EUS-FNB with both 25G and 22G Franseen needles in a randomized order between November 2018 and August 2020. Tissue specimens from each pass were separately evaluated based on the cellularity scoring system. The primary outcome was the proportion of acquired specimens allowing adequate histological assessment (cellularity score ≥3). A -15% noninferiority margin was assumed. Data from 88 patients were analyzed, which showed malignant and benign lesions in 84 (95.5%) and four (4.5%) patients, respectively. Of the 88 specimens, 62 (70.5%) and 69 (78.4%) acquired using 25G and 22G needles, respectively, allowed adequate histological assessment. The adjusted proportion difference was -6.6% (95% confidence interval -8.8% to -4.5%), indicating noninferiority of the 25G Franseen needle (P < 0.001). The diagnostic accuracies of the 25G and 22G needles were 86.4% and 89.8%, respectively, with no significant difference (P = 0.180). Adverse events occurred in one patient. The 25G Franseen needle showed a noninferior adequate tissue acquisition and similar diagnostic performance compared to that of the 22G Franseen needle. However, a 15% noninferiority margin was high for clinical use; thus, further consideration is needed (Clinical Trial Registry no. UMIN000034596).

Biopince Full Core Biopsy Device for Percutaneous Lung Biopsy: A Retrospective Analysis of 184 Procedures Analyzing Complication Rates and Procedure Success

Background: Unlike fine needle aspiration, core needle biopsies allow the collection of intact tissue for pathological and molecular evaluation. In outpatient clinical practice, full core needle lung biopsy may be underused because of concerns that it might be too dangerous. We describe our experience using a full core device for percutaneous lung biopsy in a large cohort of patients. Research Question: Is percutaneous full core needle lung biopsy effective and safe in the outpatient setting? Study Design and Methods: The analyzed population comprised patients with lung masses &gt;1.1 cm who underwent percutaneous lung biopsy with a full core device. Analyzed data included core mass dimensions, distance from pleural edge to mass, lobe location, type, outcomes, and complications. Biopsy success was defined as adequate tissue acquisition for pathological evaluation that yielded a diagnosis. Biopsy procedures with incomplete data were excluded from this analysis. Results: We analyzed data from 184 lung biopsies performed on 182 patients (mean age, 70±11.7 years). Most biopsies were parenchymal (54.9%). The overall diagnostic success rate was 98.4%. No complications were reported for 77.2% of biopsies. Minor complications occurred during 39 biopsies (21.2%) and were primarily pneumothorax (16.8%). Major complications occurred during 4 biopsies (2.1%): 3 patients with pneumothorax required emergency department (ED) management and 1 patient went to the ED for severe pain. All complications resolved within 24 hours without hospitalization or transfusion. Crosstabulation analyses showed no significant differences between the lung lobe locations in terms of rates of disposition and complications, and between the lesion types in terms of rates of disposition and complications. Interpretation: Percutaneous lung biopsy performed using a full core biopsy device demonstrated a high rate of diagnostic success and a low risk of clinically significant procedural complications in an outpatient setting.

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

There is limited evidence on the diagnostic performance of the stylet slow-pull (SP) method for endoscopic ultrasound-guided fine-needle aspiration/biopsy. The aim of this study was to compare the SP method with standard suction (SS) for endoscopic ultrasound-guided fine-needle aspiration/biopsy of solid pancreatic masses. A computerized bibliographic search of the main databases, including PubMed, EMBASE, Cochrane Library, and Science Citation Index, was performed through February 2020. The main outcome measurements were diagnostic accuracy, cellularity, low blood contamination, adequate core tissue acquisition, and technical success rate. Eleven studies (including 6 randomized trials) were included, with a total of 504 patients who underwent SP and 551 who underwent SS. Diagnostic accuracy was significantly superior in the SP group, compared with the SS group [odds ratio (OR)=1.60; 95% confidence interval (CI), 1.14-2.26]. The SP group had higher pooled rates of low blood contamination (OR=1.93; 95% CI, 1.29-2.87) and adequate core tissue acquisition (OR=1.91; 95% CI, 1.11-3.26) than the SS group. There was no significant difference between groups in the adequacy of cellularity (OR=0.99; 95% CI, 0.63-1.57; P=0.98) or technical success rate (OR=0.38; 95% CI, 0.13-1.15; P=0.09). The authors provide evidence that SP is superior to SS in diagnostic accuracy, low blood contamination, and adequate core tissue acquisition, without reducing adequacy of cellularity or technical success rate.

Adequate tissue acquisition rate of peroral cholangioscopy-guided forceps biopsy.

BackgroundPeroral cholangioscopy (POCS)-guided forceps biopsy is a method for diagnosing indeterminate biliary strictures and for the preoperative identification of the exact perihilar and distal margins of biliary tract cancer (BTC). However, POCS-guided forceps biopsy may result in an insufficient amount of specimen at times. Therefore, we evaluated the adequate tissue acquisition rate and the factors affecting the adequate tissue acquisition of POCS-guided forceps biopsy for the biliary tract.MethodsPatients who underwent POCS-guided forceps biopsy for biliary disease between September 2016 and October 2018 at our hospital were enrolled retrospectively. We evaluated the adequate tissue acquisition rate of POCS-guided forceps biopsy for the biliary lesion and that for non-stenotic bile duct. In addition, the factors affecting the adequate tissue acquisition rate of POCS-guided forceps biopsy were evaluated.ResultsWe enrolled 47 patients with biliary disease and performed POCS-guided forceps biopsy for biliary lesion and POCS-guided forceps mapping biopsy for non-stenotic bile duct in 40 and 36 patients, respectively. The adequate tissue acquisition rates of POCS-guided forceps biopsy for biliary lesions and that for non-stenotic bile duct were 86.4%, and 68.9%, respectively. In the multivariate logistic regression analyses, age, and previous biliary stenting before POCS were factors affecting the adequate tissue acquisition rate of POCS-guided forceps biopsy for the biliary lesion. For non-stenotic bile duct, the location of the biliary lesion, endoscopic sphincterotomy (EST), and procedure time of POCS were factors affecting the adequate tissue acquisition rate of POCS-guided forceps mapping biopsy.ConclusionsPrevious biliary stenting was a factor affecting a low tissue acquisition rate of POCS-guided forceps biopsy for the biliary lesion. In the POCS-guided forceps mapping biopsy, the location of the biliary lesion, EST, and procedure time were factors affecting tissue acquisition rates.

Prospective comparative study of endoscopic ultrasonography-guided fine-needle biopsy and unroofing biopsy.

38 Background: Adequate tissue acquisition is important in making treatment decisions for patients with upper gastrointestinal subepithelial tumors (SETs). This study aimed to compare the outcomes of endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) with those of the unroofing biopsy technique. Methods: This study was a single-center, prospective comparative study conducted at Severance Hospital, Yonsei University College of Medicine. A total of 39 patients with SETs ≥15 mm were enrolled between January 2016 and August 2017. Results: Of the 39 patients, 28 underwent biopsy with both techniques (4 underwent only unroofing and 7 underwent only EUS-FNB). The mean tumor size was 21.0 mm (median, 19.0 mm; 15.0–45.0 mm). Histological diagnosis was made with EUS-FNB in 64.3% and with unroofing biopsy in 78.6% (p = 0.344), and immunohistochemical diagnosis was made with EUS-FNB in 46.4% and unroofing biopsy in 67.9% (p = 0.180). In the subgroup analysis (28 patients), there was no significant difference in diagnostic yield between the 2 methods. The mean procedural time with EUS-FNB was shorter than that with unroofing biopsy (p &lt; 0.001). The larger SET (≥ 20 mm) (p = 0.035) and satisfaction of procedure (p = 0.019) were positively associated with successful histological diagnosis by EUS-FNB. No complications were reported with both methods. Conclusions: There was no significant difference in the histological diagnostic yield for SETs between the EUS-FNB and unroofing biopsy techniques. Further study is needed to confirm the efficacy of EUS-FNB and unroofing biopsy in a larger study population. Clinical trial information: NCT02646241.

Initial Experience With Endoscopic Ultrasound-Guided Fine Needle Biopsy in a Safety Net Patient Population

Introduction: EUS-guided fine needle biopsy (EUS-FNB) has emerged as a novel alternative to EUS-guided fine needle aspiration (EUS-FNA) by providing tissue amendable for histologic evaluation with preserved cell morphology and architecture. Recent technologies have focused on modified bevel design to improve EUS-FNB tissue acquisition. Our goal was to evaluate the performance of EUS-FNB with new generation biopsy needles in a safety net patient population. Methods: Electronic database of endoscopic procedures was retrospectively queried for all procedures performed with EUS-FNB needles (Acquire, Boston Scientific or Shark Core, Medtronic) from 5/2016 to 5/2017. A standard technique was used with an average of 2-5 passes and 10 to-and-fro movements per pass; all procedure were performed by 3 experienced endoscopists. All specimens were collected, fixed in formalin, and were processed as histology. Data extraction was performed for patient demographics, target lesion, diagnostic adequacy, diagnostic accuracy, and complications. Diagnostic accuracy was assessed based on clinical follow-up in thirty-five cases, surgical follow-up in three cases and repeat biopsy in two cases. Results: 40 biopsies were performed with the following target sites: pancreatic lesions (53%), liver parenchyma (15%), abdominal mass (7.5%), submucosal lesions (7.5%), lymph nodes (7%), gastric mass (5%), hilar (2.5%) and ampulla masses (2.5%). Of the pancreatic lesions, 33% displayed a cystic component. Overall diagnostic adequacy of EUS-FNB was 32/40 (80%). Overall diagnostic accuracy was 29/38 (76%), with 2 patients pending follow-up at this time. Diagnostic adequacy and accuracy for pancreatic lesions was 15/21 (71%) and 13/20 (65%), respectively. Of non-cystic pancreatic lesions 12/14 (86%) were diagnostically adequate while 11/14 (79%) were diagnostically accurate. Diagnostic adequacy and accuracy for liver parenchymal, abdominal and submucosal mass biopsy were 12/12 (100%). Diagnostic accuracy for adequate specimens was 31/32 (97%). There were no procedural complications. Conclusion: Our data suggests that EUS-FNB is a safe alternative to EUS-FNA with adequate and accurate core tissue acquisition while used in a complex patient population with a variety of target lesions.

Comparison of FNA and fine-needle biopsy for EUS-guided sampling of suspected GI stromal tumors

Subepithelial lesions are found in about 1% of all EGD procedures, and GI stromal tumors are a type of subepithelial lesion commonly encountered. Although the majority of subepithelial lesions are benign, GI stromal tumors have malignant potential, making a definitive diagnosis important. Currently, the criterion standard for the diagnosis of GI stromal tumors is EUS-directed FNA (EUS-FNA). The definitive diagnosis of GI stromal tumors relies on immunohistochemical staining, which depends on enough tissue being submitted to the pathologist. Achieving adequate tissue acquisition from suspected GI stromal tumors by EUS-FNA remains a limitation. Advancements in needle design, however, have improved tissue acquisition and therefore may improve the definitive diagnosis of GI stromal tumors by EUS-FNA. The goal of this study is to compare a fine-needle biopsy (FNB) needle (SharkCore, Medtronics) with FNA needles in definitively diagnosing suspected GI stromal tumors. This is a retrospective, single-center study of consecutive patients with suspected GI stromal tumors by EUS characterization who underwent EUS-FNA or EUS-FNB. A total of 106 patients (53 men, mean [± standard deviation {SD}] age 62.19 ± 16.33 years) were included in the study undergoing EUS-FNA or EUS-FNB of suspected GI stromal tumors. The needle size that was used most often was 22 gauge in both groups. The average size of the lesions was 27.68 ± 15.70mm; 71.7% of lesions were located in stomach, 19.8% in the esophagus, 5.7% in the duodenum, and 2.8% in the rectosigmoid colon. Ninety-one patients underwent EUS-FNA and 15 patients underwent EUS-FNB. Adequate tissue was procured, allowing immunohistochemical staining in 59 (64.8%) patients in the FNA group and 15 (100%) patients in the FNB group; P= .006. A diagnosis was reached by immunohistochemical staining in 48 (52.7%) patients in the FNA group and 13 (86.7%) patients in the FNB group; P= .01. Tissue was insufficient to make a cytologic diagnosis in 22 (24.2%) patients in the FNA group compared with none in the FNB group; P= .03. Adequate tissue was procured on the first pass of the FNB needle in the majority of patients (83.3%), whereas only 23.5% of patients had adequate tissue on the first pass by the FNA needle, with a median of 3 passes; P= .00. Tissue was insufficient to perform immunohistochemical staining, and thus a diagnosis could not be confirmed before surgery in 8 of the 34 surgical patients in the FNA group. Ten of 15 patients in the EUS-FNB group underwent surgery, all of whom were correctly diagnosed by FNB. There were no reported immediate adverse events or technical difficulties in either group. EUS-FNB by using a SharkCore needle for suspected GI stromal tumors is technically similar and equally safe as FNA, with better tissue acquisition, which was achieved with fewer needle passes and an improved diagnostic yield by immunohistochemical staining.

Repeat biopsy in epidermal growth factor receptor mutation-positive nonsmall cell lung cancer: Feasibility, limitations, and clinical utility in Indian patients.

The feasibility and success rate of repeat biopsy for epidermal growth factor receptor (EGFR) mutation-positive lung cancers that have progressed on tyrosine kinase inhibitors (TKIs) are varied and merits further assessment. EGFR mutation-positive lung cancers were offered repeat biopsy upon progression on TKIs. Two groups of patients, first one on a clinical trial and second one from a database, were included for analysis. The feasibility to perform a repeat biopsy was analyzed in the first group. Success rate of biopsy and tissue adequacy for molecular testing was analyzed in both groups. Descriptive statistics were used for analyzing the demography, EGFR mutation type, tissue adequacy, and molecular profile at repeat biopsy. Kolmogorov-Smirnov test was used to assess normality of data. Two sample t-tests were used for comparison of proportions. The feasibility of undergoing repeat biopsy was 77% (95% confidence interval [CI] of 69.4%-83.5%) in the first group (114/148 patients). Feasibility was not analyzed in the second group of patients. Out of 196 patients who underwent a repeat biopsy, 154 patients (78.6%; 95% CI: 72.2%-84.1%) had tumor tissue adequate for performing molecular testing. 27/196 (13.8%) patients did not have any evidence of malignancy on repeat biopsy whereas 15/196 (7.6%) patients had scanty tissue on repeat biopsy prohibiting molecular testing. Six patients (3.06%; 95% CI: 1.1%-6.5%) had small cell transformation. T790M mutation was detected in 12 out of the 42 patients (28.6%; 95% CI: 15.7-44.6) in whom EGFR testing was performed on repeat biopsy specimen. Repeat biopsy was able to provide adequate tissue acquisition in only two-thirds of the patients. Liquid biopsy represents an important tool to bridge this gap.

Bench-top testing of suction forces generated through endoscopic ultrasound-guided aspiration needles.

Adequate needle size and tissue acquisition techniques for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) need further elucidation. Moreover, the actual negative pressure and suction forces of FNA needles remain unknown. We evaluated the suction forces of 19-gauge, 22-gauge, and 25-gauge conventional FNA needles and side hole aspiration needles using conventional negative pressure and the slow pull technique. Using a manometer, we determined the mean (SD) negative pressure and suction force for needle gauge, aspiration volume, and aspiration technique. We also evaluated the time to reach the maximum negative pressure. Suction force was comparatively higher in the 19-gauge needle when 50 ml of negative pressure was applied. Suction force using the slow pull method was very weak at 5% of pressure found with conventional methods. With the use of a 20-ml syringe, the time to reach the maximum negative pressure was 4 s in the 19-gauge needle, 11 s in the 22-gauge needle, and 80 s in the 25-gauge needle. Bench-top testing showed that suction force increases with a larger gauge needle and larger aspiration volume. The slow pull method produces a very weak suction force. The time to reach the maximum negative pressure was longest in the 25-gauge needle.

“Tissue is the Issue”: Circulating Tumor Cells in Pancreatic Cancer

Pancreatic cancer (PCa) is the fourth most common cause of all cancer-related deaths in the USA. Currently, the overall median survival is less than 1 year and 5-year survival rate is about 5 % [1]. The poor outcome for PCa is largely due to the fact that the vast majority of patients (pts) are diagnosed at an advanced disease stage or with occult metastases that soon reveal themselves despite no clinical or radiographic clues. Therefore, early and accurate diagnosis is critical to appropriately risk stratify and intervene to improve the clinical outcomes of pts with PCa. Diagnostic modalities in current use include cross-sectional imaging and the use of the non-specific serum biomarker carbohydrate antigen 19-9 (CA-19-9) and occasionally carcinoembryonic antigen (CEA). Radiographic imaging of PCa can be challenging due to the potential absence of a discrete pancreatic mass or presence of alternate symptom etiologies including pancreatic inflammation. Even in the setting of an appropriate clinical context with supportive imaging and serum biomarkers, assurance of histological or cytological confirmation of PCa is directly related to adequate tissue acquisition [2]. Methodologies for pancreatic tissue acquisition are invasive, of relative low diagnostic yield, and associated with potential complications such as pancreatitis, bleeding, duodenal perforations, and infections [3]. Therefore, novel non-invasive or minimally invasive methods of accurate PCa cell acquisition represent a clinical unmet need. Progression of most solid cancers is associated with intravasation of cancer cells into the pt’s circulatory system with dissemination to metastatic sites. These circulating tumor cells (CTCs), measured by collection and detection of epithelial cells in the peripheral circulation, are known to be detectable in pts with solid tumors from early through advanced disease [4]. In addition to diagnostic sampling, CTCs have many potential clinical applications in the management of patients with solid tumors. These include, but are not limited to, risk stratification/prognostication, monitoring of response to therapy, characterizing the tumor’s molecular alterations, screening for early relapse, and other potential ways to personalize therapy [5–9]. In this brief report, we describe the successful isolation and molecular characterization of CTCs from a pt with PCa in whom traditional acquisition of tissue for diagnosis and management was unsuccessful despite multiple traditional attempts.

Tissue Acquisition and Specimen Processing in the Diagnosis of NSCLC

The current management of non-small cell lung cancer (NSCLC) requires pathological differentiation between adenocarcinoma and squamous cell carcinoma using immunohistochemistry and morphological analysis. Additionally, as novel therapies for specific genetic mutation and chromosomal rearrangement profiles in patients with adenocarcinoma are becoming more numerous and clinically available, adequate tissue acquisition and specimen processing have become crucial. Historically, tissue was obtained via mediastinoscopy or video-assisted thoracoscopy (VATS). However, 80% of patients with lung cancer are ultimately found to be nonsurgical candidates. More recently, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to be a safe and potentially superior modality to obtain tissue for diagnosis, staging, and molecular profiling. The preparation of tissue specimens has also been the subject of study as different methods have been shown to increase cellular yield. This is of particular importance as the number of clinically significant targetable mutations and chromosomal rearrangements continues to grow and the need for more tissue increases.

Establishing the Diagnosis of Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer. To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article "Methodology for Development of Guidelines for Lung Cancer" in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians. Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions &lt; 2 or &gt; 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions &lt; 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs. The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions &lt; 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.

Diagnostic yield of a novel jumbo biopsy “unroofing” technique for tissue acquisition of gastric submucosal masses

Adequate tissue acquisition for the diagnosis of gastric submucosal masses (GSMs) has been challen ging for gastroenterologists. The use of standard biopsy forceps generally recovers non-diagnostic overlying mucosa. Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) provides a significant improvement, but is often still inadequate for diagnosis. The aim of the current study was to assess the efficacy of a novel jumbo biopsy unroofing technique (JUT) for tissue acquisition in GSM. This prospective study recruited patients who were referred for EUS for the evaluation of GSM between 2006 and 2009. All patients underwent EUS with FNA when feasible followed by JUT. The primary outcome was diagnostic yield of JUT. A total of 93 patients were enrolled, 72 of whom were included in the investigation; 16 patients were excluded with no evidence of a submucosal mass or extrinsic compression, and five patients were further excluded by pathology confirming mucosal lesions. Of the 72 jumbo biopsies 66 (92%) provided diagnostic tissue without significant complications and 42 (58%) had lesions amenable to FNA. Although 34 of the 42 lesions were deemed adequate at the time of on-site cytological evaluation, only 28 (67%) provided sufficient tissue for final diagnosis. More importantly, only 37/72 (52%) of all patients had lesions that required any further intervention. Utilization of JUT is safe and effective for diagnosis of GSM. The data suggest that the jumbo biopsy unroofing technique should be considered as an initial diagnostic strategy for GSMs found during upper endoscopy.

Comparison of coronary plaque rupture between stable angina and acute myocardial infarction: A three-vessel intravascular ultrasound study in 235 patients

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article “Methodology for Development of Guidelines for Lung Cancer” in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions < 2 or > 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.