Endoscopic Ultrasound Fine Needle Biopsy Research Articles

High Diagnostic Yield of Fine Needle Biopsy for Pancreatic Serous Cystadenomas - a Multi-Center Study.

Distinguishing serous cystadenoma, a benign pancreatic cyst, from potentially malignant mucinous pancreatic cystic lesions carries significant clinical and prognostic implications; and while endoscopic ultrasound-guided fine needle aspiration is the standard diagnostic tool, its low diagnostic yield often results in additional workup. This study evaluates diagnostic yield of fine needle biopsy (FNB) on lesions suggestive of serous cystadenoma on endoscopic ultrasound. Patients with microcystic EUS appearance were identified through retrospective chart review in two institutions. Prior cross sectional imaging diagnosis was also obtained. All microcystic lesions with classic "honeycomb" appearance for serous cystadenoma on EUS were targeted for FNB and their pathology evaluated. Patients were identified through database search from 2015 to 2022 and procedure information was obtained through a retrospective chart review from two large academic centers. Thirty-one patients with suspected serous cystadenoma who underwent EUS-FNB were included. EUS FNB was successful in obtaining diagnosis in 96.8% of patients. Serous cystadenoma was diagnosed via EUS FNB in 27 of 31 patients (87.1%). Of the remaining four patients, there was one invasive pancreatic ductal adenocarcinoma, one pancreatic neuroendocrine tumor, one intraductal papillary mucinous neoplasm, and one nondiagnostic sample. EUS-FNB sampling for histopathology is a safe and accurate diagnostic tool for pancreatic serous cystadenoma. When microcytic lesions are found on endoscopic ultrasound, our study results suggest that fine needle biopsy for histopathology should be considered as the initial diagnostic evaluation tool given the demonstrated improved diagnostic yield for serous cystadenoma.

MSI-H Detection by ddPCR in Endoscopic Ultrasound Fine Needle Biopsy (EUS-FNB) from Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive disease with limited survival. Curative opportunities are only available for patients with resectable cancer. Palliative chemotherapy is the current standard of care for unresectable tumors. Numerous efforts have been made to investigate new therapeutic strategies for PDAC. Immunotherapy has been found to be effective in treating tumors with high microsatellite instability (MSI-H), including PDAC. The ability of the Endoscopic Ultrasound Fine Needle Biopsy (EUS-FNB) to reliably collect tissue could enhance new personalized treatment by permitting genomic alterations analysis. The aim of this study was to investigate the feasibility of obtaining adequate DNA for molecular analysis from EUS-FNB formalin-fixed-paraffin-embedded (FFPE) specimens. For this purpose, FFPE-DNA obtained from 43 PDAC archival samples was evaluated to verify adequacy in terms of quantity and quality and was tested to evaluate MSI-H status by droplet digital PCR (ddPCR). All samples were suitable for ddPCR analysis. Unlike the 1–2% MSI-H frequency found with traditional techniques, ddPCR detected this phenotype in 16.28% of cases. This study suggests the ddPCR ability to identify MSI-H phenotype, with the possibility of improving the selection of patients who may benefit from immunotherapy and who would be excluded by performing traditional diagnostic methods.

A Preliminary Controlled Trial of Endoscopic Ultrasound-guided Fiducial Markers to Guide Pancreas Surgery.

Endoscopic ultrasound (EUS) is routinely used for fiducial marker placement (FMP) to guide stereotactic radiation of pancreatic tumors, but EUS-FMP explicitly to guide surgery has not been studied in a prospective, controlled manner. Multipurpose EUS systems have been developed that facilitate simultaneous EUS-FMP at the time of biopsy. We aimed to evaluate the feasibility of EUS-FMP to guide pancreatic resection. In this prospective trial, we enrolled patients with resectable pancreas masses undergoing tissue sampling and placed preloaded fiducials immediately after biopsy. Intraprocedure confirmation of carcinoma, neuroendocrine, and nonlymphomatous neoplasia by rapid on-site evaluation and lesion size <4 cm was required. The main outcomes were the feasibility and ease of preoperative placement and intraoperative detection of the markers using predefined Likert scales. In 20 patients, EUS-FMP was successful before planned surgery and placement was technically straightforward (Likert Scale: 9.1 ± 1.3; range: 1, most challenging to 10, most facile). Intraoperative detection was feasible and improved when compared with a pre-established comparator of 5 representing an equivalent lesion without a marker (Likert Scale: 7.8 ± 2.2; range: 1, most difficult to 10, most facile; P = 0.011). The mean tumor size on EUS was 1.7 ± 0.9 (range: 0.5 to 3.6) cm. EUS-FMP is feasible and safe for resectable pancreatic tumors before surgery and may assist in perioperative detection. Preloaded fiducials may be considered for placement at the time of initial referral for EUS-fine needle biopsy.

Multicenter, randomized controlled trial of EUS-guided fine-needle biopsy using a fork-tip needle with macroscopic or rapid on-site evaluation for pancreatic lesions (H2O trial)

ABSTRACT Background and Objectives According to previous reports, EUS–fine-needle biopsy (FNB) with or without rapid on-site evaluation (ROSE) showed the nonsuperiority of EUS-FNB + ROSE over EUS-FNB. However, previous studies included various kinds of FNB needle. This might be a critical limitation due to heterogeneity. Therefore, the aim of the present multicenter, randomized controlled trial was to compare the diagnostic accuracy of the fork-tip needle with or without ROSE for pancreatic lesions. Methods In the ROSE group, if an adequate sample was obtained to diagnose by on-site evaluation, EUS-FNB was stopped. If cytological results were insufficient or indeterminate, EUS-FNB was repeated. In the macroscopic on-site evaluation (MOSE) group, if a 4-mm length of visible core tissue was obtained, EUS-FNB was finished. If visible core tissue was not obtained or was less than 4 mm in length, a second puncture was attempted. Results One hundred seventy-one patients were randomized, 85 to the ROSE group and 86 to the MOSE group. In the MOSE group, diagnostic sensitivity and accuracy were 94.4% and 91.8%, respectively, for visible core tissue and 80.6% and 70.0%, respectively, for red tissue. Finally, overall diagnostic sensitivity and accuracy were 97.1% and 95.3%, respectively, in the ROSE group and 95.8% and 95.3%, respectively, in the MOSE group. Although there were no significant differences regarding adverse events between groups, the mean number of punctures was significantly lower in the MOSE group than in the ROSE group (1.47 vs. 1.20, P = 0.0171). Conclusions EUS-FNB using a fork-tip needle for pancreatic lesions has high diagnostic yield even without ROSE.

Endoscopic Ultrasound-Guided Fine-Needle Biopsy Versus Aspiration for Tissue Sampling Adequacy for Molecular Testing in Pancreatic Ductal Adenocarcinoma.

There is limited literature on sample adequacy for molecular testing in pancreatic ductal adenocarcinoma obtained via endoscopic ultrasound (EUS) fine-needle aspiration (FNA) versus EUS fine-needle biopsy (FNB). We aimed to compare these two modalities regarding sample adequacy for molecular and genomic sequencing. We reviewed all patients with pancreatic ductal adenocarcinoma who underwent EUS at Saint Luke's Hospital from 2018 to 2021. The patients were categorized based on the method of EUS tissue acquisition, specifically FNA or FNB. A comprehensive evaluation was conducted for all cases by cytotechnologists. Out of 132 patients who underwent EUS-guided biopsies, 76 opted for FNA, 48 opted for FNB, and 8 opted for a combination of both. The average number of passes required for FNB and FNA was 2.58 ± 1.06 and 2.49 ± 1.07, respectively (p = 0.704), indicating no significant difference. Interestingly, 71.4% (35) of FNB-obtained samples were deemed adequate for molecular testing, surpassing the 32.1% (26) adequacy observed with FNA (p < 0.001). Additionally, 46.4% (26) of FNB-obtained samples were considered adequate for genomic testing, a notable improvement over the 23.8% (20) adequacy observed with FNA (p = 0.005). Although the number of passes required for cytologic diagnosis did not differ significantly between EUS-FNB and EUS-FNA, the former demonstrated superiority in obtaining samples adequate for molecular testing. Tumor surface area and cellularity were crucial parameters in determining sample adequacy for molecular testing, irrespective of the chosen tissue acquisition modality.

Role of Endoscopic Ultrasound in Diagnosis of Pancreatic Ductal Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is the most common (90%) type of solid pancreatic neoplasm. Due to its late presentation and poor survival rate, early diagnosis and timely treatment is of utmost importance for better clinical outcomes. Endoscopic ultrasound provides high-resolution images of the pancreas and has excellent sensitivity in the diagnosis of even small (<2 cm) pancreatic lesions. Apart from imaging, it also has an advantage of tissue acquisition (EUS fine-needle aspiration, FNA; or fine-needle biopsy, FNB) for definitive diagnoses. EUS-guided tissue acquisition plays a crucial role in genomic and molecular studies, which in today's era of personalized medicine, are likely to become important components of PDAC management. With the use of better needle designs and technical advancements, EUS has now become an indispensable tool in the management of PDAC. Lastly, artificial intelligence for the detection of pancreatic lesions and newer automated needles for tissue acquisition will obviate observer dependency in the near future, resulting in the wider dissemination and adoption of this technology for improved outcomes in patients with PDAC.

Comparison of endoscopic ultrasound fine needle aspiration (FNA) vs fine needle biopsy (FNB) for preoperative grading of pancreatic neuroendocrine tumors: A systematic review and meta-analysis

Comparison of endoscopic ultrasound fine needle aspiration (FNA) vs fine needle biopsy (FNB) for preoperative grading of pancreatic neuroendocrine tumors: A systematic review and meta-analysis

Repeated endoscopic ultrasound-guided fine-needle biopsy of solid pancreatic lesions after previous nondiagnostic or inconclusive sampling.

Repeated endoscopic ultrasound (EUS)-guided tissue acquisition represents the standard practice for solid pancreatic lesions after previous nondiagnostic or inconclusive results. Since data are lacking, we aimed to evaluate the diagnostic performance of repeated EUS fine-needle biopsy (rEUS-FNB) in this setting. The primary outcome was diagnostic accuracy; sample adequacy, sensitivity, specificity, and safety were secondary outcomes. Consecutive patients undergoing rEUS-FNB for solid pancreatic lesions at 23 Italian centers from 2019 to 2021 were retrieved. Pathology on the surgical specimen, malignant histology together with ≥6-month follow-up, and benign pathology together with ≥12-month follow-up were adopted as gold standards. Among 462 patients, 56.5% were male, with a median age of 68 (59-75) years, malignancy prevalence 77.0%. Tumor size was 26 (20-35) mm. Second-generation FNB needles were used in 89.6% cases. Diagnostic accuracy, sensitivity, and specificity of rEUS-FNB were 89.2%, 91.4%, and 81.7%, respectively (19 false-negative and 12 false-positive results). On multivariate analysis, rEUS-FNB performed at high-volume centers (odds ratio [OR] 2.12; 95% confidence interval [CI] 1.10-3.17; P = 0.03) and tumor size (OR 1.03; 95% CI 1.00-1.06; P = 0.05) were independently related to diagnostic accuracy. Sample adequacy was 94.2%. Use of second-generation FNB needles (OR 5.42; 95% CI 2.30-12.77; P < 0.001) and tumor size >23 mm (OR 3.04; 95% CI 1.31-7.06; P = 0.009) were independently related to sample adequacy. Repeated EUS-FNB allowed optimal diagnostic performance after nondiagnostic or inconclusive results. Patients' referral to high-volume centers improved diagnostic accuracy. The use of second-generation FNB needles significantly improved sample adequacy over standard EUS-FNB needles.

Impact of biliary stent on endoscopic ultrasound fine needle biopsy (EUS-FNB) performance in pancreatic solid lesions diagnosis

Impact of biliary stent on endoscopic ultrasound fine needle biopsy (EUS-FNB) performance in pancreatic solid lesions diagnosis

CD24 and EpCAM expression on endoscopic ultrasound fine needle biopsy pancreatic ductal adenocarcinoma samples

CD24 and EpCAM expression on endoscopic ultrasound fine needle biopsy pancreatic ductal adenocarcinoma samples

S3368 Metastatic Breast Cancer to the Stomach Diagnosed With EUS Fine Needle Biopsy

S3368 Metastatic Breast Cancer to the Stomach Diagnosed With EUS Fine Needle Biopsy

S1994 Intra-Pancreatic Ectopic Adrenal Tissue Diagnosed on Endoscopic Ultrasound-Fine Needle Biopsy: First Report

S1994 Intra-Pancreatic Ectopic Adrenal Tissue Diagnosed on Endoscopic Ultrasound-Fine Needle Biopsy: First Report

Contrast-enhanced endoscopic ultrasound for swollen lymph nodes.

Endoscopic ultrasound (EUS) is an important tool for the evaluation of lymphadenopathy, especially in intra-thoracic or intra-abdominal regions. EUS also provides tissue diagnosis via EUS fine-needle aspiration or biopsy. To select the target for biopsy or aspiration, conventional B-mode images are used for the evaluation, but this approach still lacks diagnostic accuracy. Contrast-enhanced EUS has been used to evaluate the vascularity of lesions. Most malignant lymphadenopathy shows heterogenous enhancement or defect of enhancement, while quantitative studies using time-intensity curves in contrast-enhanced harmonic EUS show a rapid decline in enhancement pattern. These findings are useful as an auxiliary method for tissue diagnosis or in cases in which tissue diagnosis is contraindicated.

Diagnostic Accuracy and Safety of Endoscopic Ultrasound-Guided End-cutting Fine-needle Biopsy needles for tissue sampling of Abdominal and Mediastinal Lymphadenopathies: a prospective multicenter series.

The role of the newer EUS-fine needle biopsy (FNB) needles in lymphadenopathies (LA) is still under evaluation. We aimed to evaluate the diagnostic accuracy and the adverse event rate of EUS-FNB in diagnosing LA. From June 2015 to 2022, all patients referred to 4 institutions for EUS-FNB of mediastinal and abdominal LA were enrolled. 22G Franseen tip or 25G Fork tip needles were used. The gold standard for positive results was surgery or imaging and clinical evolution over a follow-up of at least one year. A total of 100 consecutive patients were enrolled, consisting of those with a new diagnosis of LA (40%), presence of LA with a previous history of neoplasia (51%), or suspected lymphoproliferative disease (9%). EUS-FNB was technically feasible in all LA patients with 2 to 3 passes (mean 2.62±0.93). The overall EUS-FNB sensitivity, positive predictive value (PPV), specificity, negative predictive value (NPV), and accuracy were 96.20%, 100%, 100%, 87.50%, and 97.00%, respectively. Histological analysis was feasible in 89% of cases. Cytological evaluation was performed in 67% of specimens. There was no statistical difference between the accuracy of the 22G or 25G needle (p=0.63). A sub-analysis on lymphoproliferative disease revealed a sensitivity and accuracy of 89.29% and 90.0%. No complications were recorded. EUS-FNB with new end-cutting needles is a valuable and safe method to diagnose LA. The high quality of histological cores and the good amount of tissue allowed a complete immunohistochemical analysis of metastatic LA and precise subtyping of the lymphomas.

Investigation into the content of red material in EUS-guided pancreatic cancer biopsies.

The red material occupying the larger portion of the acquired sample in EUS fine-needle biopsy (FNB) is seldom investigated. We aimed to evaluate the composition of the red material. Patients with a solid pancreatic mass who received EUS FNB from September 2020 to June 2021 were enrolled. The white or yellowish content with apparent bulk (white material) and the rest of pasta-like red content (red material) were separated immediately after puncture. Needle passes proceeded until 2 specimens with >4mm of white material were obtained. An extra needle pass was conducted for DNA collection. The DNA amount, Kirsten rat sarcoma virus (K-ras) mutation type, and mutation allele frequency were compared between the white and red material. Forty patients were enrolled with 68 paired white and red materials. The diagnostic accuracy was slightly higher in the white material (92.5% vs 82.5%, P= .219). On the histology slides, the area of the tumor gland was comparable in both materials, but the total tissue area was larger in the red material (9.74mm2 and 10.74mm2 larger according to generalized linear model and generalized estimating equation, respectively; both, P< .001). The amount of DNA was significantly higher in the red material (2.99 [interquartile range, 1.59-7.29] μg vs .70 [interquartile range, .27-1.24] μg; P< .001). Common pancreatic adenocarcinoma K-ras mutation was identified at a rate of 85% for the white material and 95% for the red material. Regardless of whether red or white material was used, there was a high concordance of K-ras mutation types (34 of 40 [85%]) and a high correlation of mutation allele frequency (ρ= .66, P< .001). In EUS FNB, the red material contains a higher amount of tumor DNA and can be an alternative source for tumor DNA analysis.

Sensitivity of endoscopic ultrasound-guided fine-needle aspiration cytology and biopsy for a diagnosis of pancreatic ductal adenocarcinoma: A comparative analysis.

The utility of endoscopic ultrasound fine-needle aspiration cytology (EUS-FNAC) or endoscopic ultrasound fine-needle aspiration biopsy (EUS-FNAB) for diagnosis of small and large pancreatic ductal adenocarcinomas (PDACs) remains in question. We addressed this by analyzing 97 definitively diagnosed cases of PDAC, for which both EUS-FNAC and EUS-FNAB had been performed. We subclassified the 97 solid masses into small (n = 35) or large (n = 62) according to the maximum tumor diameter (<24 mm or ≥24 mm) and compared the diagnostic sensitivity (truly positive rate) of EUS-FNAC and of EUS-FNAB for small and large masses. Diagnostic sensitivity of EUS-FNAC did not differ between large and small masses (79.0% vs. 60.0%; p = 0.0763). However, the diagnostic sensitivity of EUS-FNAB was significantly higher for large masses (85.5% vs. 62.9%; p = 0.0213). Accurate EUS-FNAC-based diagnosis appeared to depend on the degree of cytological atypia of cancer cells, which was not associated with quantity of cancer cells. The accuracy of EUS-FNAB-based diagnosis appeared to depend on cancer cell viability in large masses and cancer volume in small masses. Based on the advantages or disadvantages in each modality, both modalities play an important role in the qualitative diagnosis of PDAC as a complementary procedure.

Endoscopic ultrasound fine-needle biopsy to assess DAXX/ATRX expression and alternative lengthening of telomeres status in non-functional pancreatic neuroendocrine tumors

Background/objectivesDeath domain-associated protein (DAXX) and/or α-thalassemia/mental retardation X-linked (ATRX) chromatin remodeling genes mutations and alternative lengthening of telomeres (ALT) activation are associated with more aggressive behavior of non-functional pancreatic neuroendocrine tumors (NF-PanNETs). We aimed to evaluate the reliability of such markers on endoscopic-ultrasound fine-needle biopsy (EUS-FNB) specimens. MethodsPatients who underwent EUS-FNB and subsequent surgical resection for PanNETs between January 2017 and December 2019 were retrospectively identified. Immunohistochemistry (IHC) to evaluate DAXX/ATRX expression and fluorescence in situ hybridization (FISH) for ALT status were performed. Primary outcome was the concordance rate of markers expression between EUS-FNB and surgical specimens. Secondary aims were association between markers and lesion aggressiveness, their diagnostic performance in predicting aggressiveness, and agreement of preoperative and post-surgical Ki67-based grading. ResultsForty-one NF-PanNETs (mean diameter 36.1 ± 26.5 mm) were included. Twenty-four showed features of lesion aggressiveness. Concordance of expressions of DAXX, ATRX, and ALT status between EUS-FNB and surgical specimens were 95.1% (κ = 0.828; p < 0.001), 92.7% (κ = 0.626; p < 0.001), and 100% (κ = 1; p < 0.001), respectively. DAXX/ATRX loss and ALT-positivity were significantly (p < 0.05) associated with metastatic lymphnodes and lymphovascular invasion. The combination of all tumor markers (DAXX/ATRX loss + ALT-positivity + grade 2) reached an accuracy of 73.2% (95%CI 57.1–85.8) in identifying aggressive lesions. Pre- and post-operative ki-67-based grading was concordant in 80.5% of cases (k = 0.573; p < 0.001). ConclusionDAXX/ATRX expression and ALT status can be accurately evaluated in a preoperative setting on EUS-FNB samples, potentially improving the identification of patients with increased risk and poorer prognosis.

Solid Pseudopapillary Epithelial Neoplasm of the Pancreas: A Rare Entity with Diagnostic Dilemma

The solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas is a relatively uncommon entity. The aim of the present study was to summarize our experiences with regard to diagnostic dilemma, surgery, postoperative follow-up, and management. This retrospective data were collected during the period from January 1, 2018 to December 31, 2020. A total of four patients (three females and one male) were identified within an age range of 13 to 25 years. All the patients were presented with nonspecific symptoms such as abdomen lumps, swelling in the abdomen, and abdominal pain. To reach a definite diagnosis, imaging studies were conducted along with endoscopic ultrasound fine-needle aspiration (EUS-FNA) and biopsy. After confirmation of SPEN on biopsy, all the patients underwent surgery without any complications. Patients are on follow-up, and to date, no metastasis has been detected. SPEN is a rare pancreatic tumor with unusual pathological features leading to a diagnostic dilemma. The pathologist should be familiar with SPEN and its salient histological characteristics that differentiate it from other look-alike pancreatic tumors and can help in timely surgery and management.

Endoscopic Ultrasound in the Diagnosis of Extrahepatic Cholangiocarcinoma: What Do We Know in 2023?

Extrahepatic cholangiocarcinoma (CCA) is a rare and aggressive type of cancer, presenting as a mass or as a biliary stricture. This review summarizes the utility of endoscopic ultrasound (EUS) in the detection, staging, and determination of the differential diagnosis, especially when no cause of bile duct dilatation is revealed by cross-sectional imaging. The EUS detection rate for distal CCAs is higher than that for the proximal CCAs. The accuracy of T staging varies between 60 and 80%, and vascular involvement is correctly assessed by conventional EUS. EUS-tissue acquisition from the primary tumors is reserved for unresectable or metastatic CCA, especially in distal strictures or mass CCAs. For proximal lesions, EUS could be performed as an adjunctive to ERCP sampling when the latter is inconclusive. EUS is not appropriate for assessing the malignant features of lymph nodes in CCAs. Lymph node EUS-tissue acquisition should be performed only if it changes the surgical decision. Perhaps the development of EUS-fine needle biopsy and the detection of molecular genetic alteration will increase the diagnostic yield in CCAs.

Fluorescence confocal microscopy for rapid evaluation of EUS fine-needle biopsy in pancreatic solid lesions

Video 1EUS fine-needle biopsy of a pancreatic solid lesion evaluated with fluorescence confocal microscopy.