EUS-guided Sampling Research Articles

High Sensitivity of Endoscopic Ultrasound-Guided Fine-Needle Aspiration and Endoscopic Ultrasound-Guided Fine-Needle Biopsy in Lymphadenopathy Caused by Metastatic Disease: A Prospective Comparative Study.

Background/AimsThe diagnostic work-up of lymphadenopathy is challenging but important to determine the correct therapy. Nevertheless, few studies have addressed the topic of endosonography (EUS)-guided tissue acquisition in lymphadenopathy. Therefore, we aimed to evaluate the accuracy and safety of EUS-guided fine-needle biopsy sampling (EUS-FNB) in intrathoracic and intraabdominal lymphadenopathy. MethodsIn a tertiary care center, patients with lymphadenopathy referred for EUS-guided sampling were included prospectively from 2014 to 2019 (NCT02360839). In all cases, EUS-FNB (22 gauge) and EUS-guided fine-needle aspiration (EUS-FNA) (25 gauge) were performed. The patients were randomized to the first needle pass with FNB or FNA. Study outcomes were the diagnostic accuracy and adverse event rate. ResultsForty-eight patients were included (median age: 69 years [interquartile range, 59–76]; 24/48 females [50%]). The final diagnoses were metastasis (n=17), lymphoma (n=11), sarcoidosis (n=6), and inflammatory disease (n=14). The diagnostic performance of the two modalities was comparable, including a high sensitivity for metastatic nodes (EUS-FNB: 87% vs. EUS-FNA: 100%, p=0.5). The sensitivity for lymphoma was borderline superior in favor of EUS-FNB (EUS-FNB: 55% vs. EUS-FNA: 9%, p=0.06). No adverse events were recorded. ConclusionsIn lymphadenopathy, both EUS-FNB and EUS-FNA are safe and highly sensitive for metastatic lymph node detection. Lymphoma diagnosis is challenging regardless of the needle used.

Use of suction during endoscopic ultrasound-guided fine needle biopsy of solid pancreatic lesions with a Franseen-tip needle: a pilot comparative trial.

Background and study aims The utility of suction during endoscopic ultrasound (EUS) fine-needle biopsy (FNB) using Franseen-tip needle remains unclear and has not been evaluated in randomized trials. We designed a randomized crossover trial to compare the diagnostic yield during EUS-FNB using a 22G Franseen-tip needle, with and without standard suction. Patients and methods Consecutive patients undergoing EUS-guided sampling of solid pancreatic lesions were recruited. A minimum of two passes were performed for each case: one with 20-mL syringe suction (S+) and another without (S–). The order of passes was randomized and the pathologist blinded. The endpoints were the diagnostic yield and the impact of blood contamination in the diagnosis. Results Fifty consecutive patients were enrolled. The overall diagnostic accuracy was 84 %. A diagnosis of malignancy was obtained in 70 samples: 36 in the S+group and 34 in the S–group. A statistically significant difference was seen in the diagnostic accuracy (S+: 78 % vs. S–: 72 %, P < 0.01) and blood contamination (S+: 68 %; S–: 44 %, P < 0.01). The sensitivity, specificity, negative likelihood ratio and positive likelihood ratio for S+vs. S–samples were 76.6 % vs. 73.9 %, 100 % vs. 100 % and 0.23 vs. 0.26, NA vs NA, respectively. A negative impact of blood contamination in the overall diagnostic yield wasn’t seen, even in samples where suction was used (OR 0.36, P = 0.15) Conclusions We found a higher diagnostic yield with the use of suction. It was associated with a higher degree of sample blood contamination that did not affect the diagnostic performance.

Outcomes of endoscopic ultrasound and endoscopic resection of gastrointestinal subepithelial lesions: a single-center retrospective cohort study.

BackgroundEndoscopic resection (ER) is an emerging therapeutic alternative for subepithelial gastrointestinal lesions (SELs). We aimed to determine whether size, layer of origin, and histology based on endoscopic ultrasound (EUS) and EUS-guided sampling (EUS-GS) influenced the outcomes and selection of patients for ER.MethodsWe performed a retrospective review of patients who underwent EUS, EUS-GS and resection of SELs from 2012-2019. Two pathologists reviewed the histology and layer of origin of all resected specimens, serving as the criterion for EUS accuracy.ResultsSeventy-three patients were included, of whom 59 (81%) were gastric SELs. Per EUS, median lesion size was 21 mm (interquartile range 15-32), and 63 (86%) originated from the 4th layer. The overall accuracy of EUS and EUS-GS in predicting the layer of origin and histology was 88% (95% confidence interval [CI] 77-94%) and 96% (95%CI 87-98%), respectively. Based on EUS, 18 (25%) patients were referred for ER, 5 (7%) to laparoscopic-endoscopic cooperative surgery, and 50 (68%) to surgery. Size >20 mm was associated with the type of resection approach (P=0.005), while layer of origin and histology were not (P=0.06 and P=0.09, respectively). When SELs were inaccurately classified (n=4) there were no adverse events or revision of the resection approach.ConclusionsEUS plays an important role in the outcome of resection approach for SELs, with size significantly influencing the selection for ER. In patients undergoing ER, no revised resections were needed when EUS was inaccurate.

Early detection of pancreatic tumors by advanced EUS imaging.

The early detection of pancreatic ductal adenocarcinoma (PDAC) dramatically improves outcome. All available state-of-the-art imaging methods allow early detection with EUS being the best technique for exclusion of PDAC and detection of very early PDAC. Etiological differentiation of small SPL is important to guide individually tailored patients' management including radical surgery in resectable PDAC, medical (neoadjuvant or palliative intended) treatment in patients with non-resectable malignancy, pancreatic parenchyma saving strategies in some non-PDAC, and follow-up in particular in low-grade PanNEN or other small benign lesions. Multimodality EUS imaging including B-Mode assessment, elastography, contrast-enhancement and EUS-guided sampling is the most appropriate technique for diagnosis and risk assessment of small SPL. We present a review discussing modern (endoscopic) ultrasound imaging techniques including contrast enhanced ultrasound and elastography for the early detection and characterization of solid 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 diagnosis and management of gastric subepithelial lesions.

The purpose of this manuscript is to provide an in-depth review of gastric subepithelial lesions (SELs) and describe the current approach to endoscopic diagnosis and management of these lesions. Gastric SELs are a relatively frequent finding on routine endoscopy (incidence 0.2-3%). A systematic approach to diagnosis and management is key because many SELs are of little consequence, while others carry a high risk of malignant transformation. Because esophagogastroduodenoscopy (EGD) cannot delineate depth of invasion or subepithelial appearance, endoscopic ultrasound (EUS) should be considered a first-line modality. Recent data suggest EUS-guided fine needle biopsy (FNB) may be superior to traditional fine needle aspiration (FNA) for the diagnosis of gastric SELs due to its ability to obtain histologic specimens for immunohistochemical staining. Alternative techniques for tissue sampling (combined with simultaneous resection) include submucosal resection, endoscopic submucosal dissection (ESD), submucosal tunnelling with endoscopic resection (STER) or endoscopic full-thickness resection (EFTR). This review details the endoscopic diagnosis and management of gastric SELs. Although EUS-guided sampling remains a first-line strategy (preferably with FNB), recent techniques including ESD, STER and EFTR have the potential to provide additional diagnostic and therapeutic options.

EUS-through-the-needle microbiopsy forceps in pancreatic cystic lesions: A systematic review.

Pancreatic cystic lesions (PCLs) are being increasingly encountered in clinical practice, and sometimes, they can represent a diagnostic challenge. Recently, a through-the-needle micro forceps biopsy (MFB) device was introduced in the endosonography practice to facilitate EUS-guided sampling of PCLs. The aim was to perform a systematic review of studies evaluating the technical aspects, safety, and efficacy of the EUS-guided MFB for PCLs. A literature search was performed in three major databases, PubMed, Embase, and Web of Science in September 2019 using the search terms: “through-the-needle,” “biopsy forceps,” “microforceps,” “endoscopic ultrasound,” and “endosonography.” Case reports and case series with <10 patients were excluded from the analysis. Altogether nine studies reporting on 463 patients were included in our systematic review. The mean age of the patients was 68.3 years, with a slight female predominance (60.9%). Most of the cysts were located in the body/tail of the pancreas (61.2%), with an overall mean size of 33 mm. The technical success of EUS-guided MFB was reported in 98.5%. The tissue acquisition yield reported was 88.2%, and the diagnostic accuracy was 68.6%. Adverse events were reported in 9.7%. EUS-guided MFB is technically feasible, safe, and has a high diagnostic accuracy for PCLs.

57 THE ROLE OF EUS IN SELECTING ENDOSCOPIC VERSUS SURGICAL RESECTION OF SUBEPITHELIAL LESIONS: WALL LAYER AND HISTOLOGIC TYPE ANALYSIS

Gastrointestinal tract subepithelial lesions (SELs) are often incidentally found at endoscopy or radiologic exam. With the emerging role of endoscopic resection it is important for endosonographers to accurately determine layer of origin and histologic type of SELs to identify the optimal approach for resection. Not all SELs are amenable to endoscopic resection which is largely based on the deepest aspect of wall layer involvement. To our knowledge, there are no published data on utility and accuracy of EUS in selection of patients undergoing endoscopic versus surgical resection of SELs. To determine 1. Diagnostic accuracy of EUS and EUS-guided sampling in identifying the layer of origin and histologic SEL subtype prior to resection and 2. Patient outcomes when EUS incorrectly identified the layer of origin or lesion subtype. Retrospective single tertiary-center review (2012 to 2019) of patients with SELs identified from a procedure database and electronic medical records. Patients who had EUS, EUS-guided sampling and endoscopic or surgical resection were included. Two pathologists reviewed the histologic type and layer of origin of all resected specimens that served as the criterion standard to determine accuracy of EUS. Of 1,070 patients with SELs who had EUS, 73 (6.8%) were included in the study cohort. Per EUS, n=63 (86%) of SELs originated from the 4th layer of the GI tract, n=59 (81%) were gastric and n=71 (97%) were hypoechoic. Mean size of SELs at EUS was 25.4±15.34mm. Lymphadenopathy was present in 5 (7%) cases. Diagnosis was obtained in n=67 (92%) patients using FNA (29%), FNB (48%) and FNA+FNB (23%). A GIST was diagnosed in n=46 (62%) cases (Table 1). SELs were resected surgically, endoscopically or by combined approach in 68%, 25% and 7% of patients respectively. Diagnostic yield of EUS-guided sampling was 92%. Accuracy of EUS and EUS-guided sampling in predicting the layer of origin and histologic type were 88% and 96% respectively (Table 2). There were no adverse events or need for revised resection approach in patients whom SELs were inaccurately classified based on layer of origin, however 2 (3%) patients underwent surgical resection for benign lesions based on inaccurate histology by EUS. Adverse events were reported in n=2 (2.7%) cases following endoscopic resection. There were no EUS related adverse events. EUS plays a role in selecting patients best suited for endoscopic versus surgical resection of gastrointestinal SELs based on accuracy of EUS and EUS-guided sampling in identifying parameters of layer of origin and histologic type in this cohort of patients. However, preventable surgical resections occurred when EUS incorrectly predicted histologic type. No revisions of resection approach or adverse events occurred when EUS incorrectly predicted the layer of origin.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Su1306 DOES SIZE MATTER? COMPARISON OF 22G VERSUS 25G FINE NEEDLE ASPIRATION IN THE DIAGNOSIS OF SOLID LESIONS

While endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is considered a first-line strategy for sampling solid gastrointestinal tract lesions, choice of needle size remains highly variable. Therefore, the primary aim of this study was to compare the impact of needle size (22G versus 25G) in the diagnosis of solid lesions. This was a multi-center, retrospective observational study to evaluate the outcomes of EUS-guided FNA of solid lesions over a 3-year duration. Patient and lesion information as well as diagnostic test characteristics (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV] and diagnostic accuracy), as well as adverse events were analyzed. Specimens with rapid on-site evaluation (ROSE) were excluded to avoid over-estimation of diagnostic yield. Surgical resection pathology or immunohistochemistry were considered the reference standard for diagnostic yield. A bivariate model was used to compute diagnostic characteristics, and two-sample t-tests for binomial proportions were utilized to compare strategies. A total of 284 patients underwent EUS-guided sampling of solid lesions (22G: n=169 and 25G: n=115). Baseline lesion and sampling characteristics as well as diagnostic test results are shown in Table 1. Lymph nodes (31.34%), pancreatic lesions (24.65%), subepithelial lesions (31.34%), and other lesions (12.67%) were included. Mean age of all patients was 62.83±11.67 years with no difference between groups (P=0.90). Mean lesion size was also similar [20.08±12.62 versus 18.12±11.16; P=0.21] as was number of needle passes performed [2.55±1.25 versus 2.74±1.64; P=0.26]. Route of tissue acquisition was also not different between groups (P=0.75). Overall there was no difference in sensitivity, specificity, or diagnostic accuracy between 22G versus 25G needles (P>0.05). On subgroup analyses by type of lesion, there was no difference in diagnostic yield by needle size for pancreatic lesions and lymph nodes; however, larger 22G needles demonstrated a higher accuracy for subepithelial lesions [84.62% versus 62.50%; P=0.0246]. No adverse events occurred in either group. Based upon this study, 22G needle size outperformed 25G for accurate diagnosis of subepithelial lesions. Needle size did not impact sampling of pancreatic lesions or lymph nodes. These results suggest 22G be the preferred needle size for FNA of subepithelial lesions.

Evaluation of endoscopic ultrasound fine-needle aspiration versus fine-needle biopsy and impact of rapid on-site evaluation for pancreatic masses.

Background and study aims Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is traditionally considered a first-line strategy for diagnosing pancreatic lesions; however, given less than ideal accuracy rates, fine-needle biopsy (FNB) has been recently developed to yield histological tissue. The aim of this study was to compare diagnostic yield and safety between EUS-FNA and EUS-FNB in sampling of pancreatic masses. Patients and methods This was a multicenter retrospective study to evaluate efficacy and safety of EUS-FNA and EUS-FNB for pancreatic lesions. Baseline characteristics including sensitivity, specificity, and accuracy, were evaluated. Rapid on-site evaluation (ROSE) diagnostic adequacy, cell-block accuracy, and adverse events were analyzed. Subgroup analyses comparing FNA versus FNB route of tissue acquisition and comparison between methods with or without ROSE were performed. Multivariable logistic regression was also performed. Results A total of 574 patients (n = 194 FNA, n = 380 FNB) were included. Overall sensitivity, specificity, and accuracy of FNB versus FNA were similar [(89.09 % versus 85.62 %; P = 0.229), (98.04 % versus 96.88 %; P = 0.387), and 90.29 % versus 87.50 %; P = 0.307)]. Number of passes for ROSE adequacy and cell-block accuracy were comparable for FNA versus FNB [(3.06 ± 1.62 versus 3.04 ± 1.88; P = 0.11) and (3.08 ± 1.63 versus 3.35 ± 2.02; P = 0.137)]. FNA + ROSE was superior to FNA alone regarding sensitivity and accuracy [91.96 % versus 70.83 %; P < 0.001) and (91.80 % versus 80.28 %; P = 0.020)]. Sensitivity of FNB + ROSE and FNB alone were superior to FNA alone [(92.17 % versus 70.83 %; P < 0.001) and (87.44 % versus 70.83 %; P < 0.001)]. There was no difference in sensitivity though improved accuracy between FNA + ROSE versus FNB alone [(91.96 % versus 87.44 %; P = 0.193) and (91.80 % versus 80.72 %; P = 0.006)]. FNB + ROSE was more accurate than FNA + ROSE (93.13 % versus 91.80 % ; P = 0.001). Multivariate analysis showed ROSE was a significant predictor of accuracy [OR 2.60 (95 % CI, 1.41–4.79)]. One adverse event occurred after FNB resulting in patient death. Conclusion EUS-FNB allowed for more consistent cell-block evaluation as compared to EUS-FNA. EUS-FNA + ROSE was found to have a similar sensitivity to EUS-FNB alone suggesting a reduced need for ROSE as part of the standard algorithm of pancreatic sampling. While FNB alone produced similar diagnostic findings to EUS-FNA + ROSE, FNB + ROSE still was noted to increase diagnostic yield. This finding may favor a unique role for FNB + ROSE, suggesting it may be useful in cases when previous EUS-guided sampling may have been indeterminate.

Protocolo diagnóstico de las lesiones sólidas y quísticas pancreáticas

Solid Pancreatic Lesions (SPL) are usually symptomatic and mainly corresponding to a pancreatic cancer. CT scan and MR imaging are often performed as initial evaluation. Endoscopic Ultrasound (EUS) is the best technique for the differential diagnosis of a SPL. EUS allows the detection of small lesions, assess the resectability of the tumor and perform EUS-guided sampling for obtaining a final diagnosis in most cases. The vast majority of Cystic Pancreatic Lesions (CPL) are incidentally found. The main point is to distinguish benign from potential malignant lesions, as mucinous CPL (Intraductal Papillary Mucinous Neoplasm – IPMN and Mucinous Cystic Neoplasm). EUS and MRI with Cholangiopancreatography (MRCP) are the best techniques in the characterization. Therapeutic approach is mainly based on the presence of warning signs, being the international guidelines an important tool for the management. Age and comorbidities must be taken into account in therapeutic decision (surgical treatment vs surveillance).

Slow-pull compared to suction technique for EUS-guided sampling of pancreatic solid lesions: a meta-analysis of randomized controlled trials.

Background and study aims Current ESGE guidelines suggest employing the suction (SU) technique for endoscopic ultrasound (EUS)-guided sampling of pancreatic solid lesions. Nonetheless, recent randomized controlled trials (RCT) have reported that the slow-pull (SP) technique has similar diagnostic accuracy with possibly less blood contamination. However, these results are heterogeneous and limited to small cohorts. The aim of this meta-analysis was to compare adequacy, accuracy, sensitivity and specificity of the SU and SP techniques for EUS-guided sampling of solid pancreatic lesions. Methods A computerized bibliographic search was restricted to RCTs. Pooled effects were calculated using a random-effects model and expressed in terms of pooled sensitivity and specificity and OR (95 % CI) for adequacy and accuracy. Results Overall, seven RCTs were included, for a total of 475 patients (163 lesions sampled with SU, 164 with SP and 148 by both). The adequacy was similar (OR = 0.98) without heterogeneity (I 2 = 0 %), but a high degree of blood contamination was more common with SU than SP (pooled rate 27.6 % vs 19.7 %). A non-significant superiority of SP in terms of pooled accuracy (OR = 0.82; 95 % CI 0.36–1.85) was recorded, with moderate heterogeneity (I 2 = 52.4 %). The SP technique showed a slightly higher pooled sensitivity compared to SU (88.7 % vs 83.4 %), while specificity was similar (97.2 % SP vs 96.9 % SU), with considerable heterogeneity. Conclusion The current meta-analysis reveals non-superiority of SU over SP, while SP results in reduced blood contamination. If the 5 % accuracy difference favouring SP is true, with alfa error = 0.05 and beta = 0.20, a RCT of 982 patients per arm is needed to confirm significance.

Prospective evaluation of 25-gauge Franseen needles for endoscopic ultrasound-guided fine-needle biopsy of solid pancreatic masses.

Background and study aims The ideal puncture needle for endoscopic ultrasound (EUS)-guided sampling is maneuverable and easy to puncture with, and can obtain sufficient material in almost one pass. The novel 25-gauge Franseen needle may provide a good balance between maneuverability and sample yield. Patients and methods Between July 2017 and December 2018, 116 patients with solid pancreatic masses were prospectively enrolled and investigated. We evaluated the diagnostic yield associated with using the 25-gauge Franseen needle for EUS-guided sampling of pancreatic masses. Results The technical success rate was 100 % (116/116). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for malignancy were 98 % (105/107), 100 % (9/9), 100 % (105/105), 82 % (9/11), and 98 % (114/116), respectively. Cumulative sensitivities for malignancy were 87 % (93/107) on pass 1, 97 % (104/107) on pass 2, and 98 % (105/107) on pass 3, respectively, with no increase in sensitivity after 4 or more. An adequate specimen for histological assessment was obtained in 79 % (92/116) of cases. Multivariate logistic analyses showed that lesion size smaller than 13 mm was a risk factor for failure of obtaining an adequate specimen for histological assessment ( P = 0.010) Conclusions The novel 25-gauge Franseen needle showed excellent diagnostic yield for solid pancreatic masses. However, its ability to obtain an adequate specimen for histological assessment may still be insufficient, especially when dealing with small lesions.

Fork-tip needle biopsy versus fine-needle aspiration in endoscopic ultrasound-guided sampling of solid pancreatic masses: a randomized crossover study.

A novel fork-tip fine-needle biopsy (FNB) needle has recently been introduced for endoscopic ultrasound (EUS)-guided sampling. The aim of this study was to compare the performance of fork-tip FNB histology and standard fine-needle aspiration (FNA) cytology in the diagnosis of solid pancreatic masses. A randomized crossover study was performed in patients referred for EUS-guided sampling. Three passes were taken with each needle in a randomized order. Only samples reported as diagnostic of malignancy were considered positive. The primary end point was the sensitivity of diagnosis of malignancy. Secondary end points included the amount of sample obtained, ease of diagnosis, duration of tissue sampling, pathologist viewing time, and cost. 108 patients were recruited. Median age was 69 years (range 30 - 87) and 57 were male; 85.2 % had a final diagnosis of malignancy. There were statistically significant differences in sensitivity (82 % [95 % confidence interval (CI) 72 % to 89 %] vs. 71 % [95 %CI 60 % to 80 %]), accuracy (84 % [95 %CI 76 % to 91 %] vs. 75 % [95 %CI 66 % to 83 %]), proportion graded as a straightforward diagnosis (69 % [95 %CI 60 % to 78 %] vs. 51 % [95 %CI 41 % to 61 %]), and median pathology viewing time (188 vs. 332 seconds) (P < 0.001) between FNB and FNA needles, respectively. There was no significant difference in cost between an FNB or FNA strategy. The diagnostic performance of the fork-tip FNB needle was significantly better than that of FNA; it was associated with ease of diagnosis, shorter pathological viewing times, and was cost neutral.

EUS-guided fine-needle biopsy sampling versus FNA in the diagnosis of subepithelial lesions: a large multicenter study

Although conventional EUS-guided FNA (EUS-FNA) has previously been considered first-line for sampling subepithelial lesions (SELs), variable accuracy has resulted in increased use of fine-needle biopsy (FNB) sampling to improve diagnostic yield. The primary aim of this study was to compare FNA versus FNB sampling for the diagnosis of SELs. This was a multicenter, retrospective study to evaluate the outcomes of EUS-FNA and EUS-guided FNB sampling (EUS-FNB) of SELs over a 3-year period. Demographics, lesion characteristics, sensitivity, specificity, accuracy, number of needle passes, diagnostic adequacy of rapid on-site evaluation (ROSE), cell block accuracy, and adverse events were analyzed. Subgroup analyses were performed comparing FNA versus FNB sampling by location and diagnostic yield with or without ROSE. Multivariable logistic regression was also performed. Two hundred twenty-nine patients with SELs (115 FNA and 114 FNB sampling) underwent EUS-guided sampling. Mean patient age was 60.86 ± 12.84 years. Most lesions were gastric in location (75.55%) and from the fourth layer (71.18%). Cell block for FNB sampling required fewer passes to achieve conclusive diagnosis (2.94 ± 1.09 vs 3.55 ± 1.55; P= .003). The number of passes was not different for ROSE adequacy (P= .167). Immunohistochemistry was more able to be successfully performed in more FNB sampling samples (69.30% vs 40.00%; P< .001). Overall, sensitivity and accuracy were superior for FNB sampling versus FNA (79.41% vs 51.92% [P= .001] and 88.03% vs 77.19% [P= .030], respectively). On subgroup analysis, sensitivity and accuracy of FNB sampling alone was superior to FNA+ ROSE (79.03% vs 46.67% [P= .001] and 87.25% vs 68.00% [P= .024], respectively). There was no significant difference in diagnostic yield of FNB sampling alone versus FNB sampling+ ROSE (P > .05). Multivariate analysis showed no predictors associated with accuracy. One minor adverse event was reported in the FNA group. EUS-FNB was superior to EUS-FNA in the diagnosis of SELs. EUS-FNB was also superior to EUS-FNA alone and EUS-FNA+ ROSE. These results suggest EUS-FNB should be considered a first-line modality and may suggest a reduced role for ROSE in the diagnosis of SELs. However, a large randomized controlled trial is required to confirm our findings.

Endoscopic ultrasound-guided fine-needle aspiration vs fine-needle biopsy for the diagnosis of pancreatic neuroendocrine tumors.

Background and study aims Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as a method of obtaining preoperative diagnosis of pancreatic neuroendocrine tumors (PanNETs) has been reported in several series. Fine-needle biopsies (FNB) are increasingly employed to obtain core specimens during EUS. However, the differences in efficacy between these sampling methods in the diagnosis of PanNETs still needs to be defined. Patients and methods Over a 13-year period, all patients who underwent EUS-guided tissue sampling of suspicious pancreatic lesions with clinical, endoscopic and pathologic details were entered into an electronic database. Lesions underwent EUS-FNA or FNB sampling, or a combination of the two. The accuracy and safety of different EUS-guided sampling methods for confirmed PanNETs were investigated. Results A total of 91 patients (M/F: 42/49, median age: 57 years), who underwent 102 EUS procedures had a final diagnosis of PanNET. Both EUS-guided sampling modalities were used in 28 procedures, EUS-FNA alone was used in 61 cases, while EUS-FNB alone in 13 cases. Diagnostic yield of EUS-FNA and EUS-FNB alone, including the inadequate specimens, was 77.5 % (95 %CI: 68.9 – 86.2 %) and 85.4 % (95 %CI: 74.6 – 96.2 %), respectively. The combination of both sampling modalities established the diagnosis in 96.4 % of cases (27/28) (95 %CI: 89.6 – 100 %), significantly superior to EUS-FNA alone ( P = 0.023). Diagnostic sensitivity among the adequate samples for EUS-FNA, EUS-FNB and for the combination of the two methods was 88.4 % (95 %CI: 80.9 – 96.0 %), 94.3 % (95 %CI: 86.6 – 100 %) and 100 % (95 %CI: 100 – 100 %). There was one reported complication, a post-FNA bleeding, treated conservatively. Conclusions EUS-FNB improves diagnostic sensitivity and confers additional information to cytological assessment of PanNETs.

1416 Rare Presentation of Large Pancreatic Mass With Chylous Ascites

INTRODUCTION: Primary pancreatic lymphomas (PPL) are very rare and mimic pancreatic head cancer. We present a case of a man who presented with a pancreatic mass and chylous ascites, and was found to have PPL. CASE DESCRIPTION/METHODS: A 69-year-old man presented with 2 months of anorexia, abdominal pain and distension. He denied fever, chills or weight loss. Abdomen was distended, soft, non-tender with shifting dullness and fluid thrill. Laboratory tests were noncontributory except for mildly elevated LDH 254 U/L. Abdominal computed tomography (CT) showed a 20 × 10 × 17 cm soft tissue mass impinging the distal duodenum, replacing the proximal pancreatic parenchyma, encasing the celiac and superior mesenteric arteries; ascites, lymphadenopathy and multiple omental nodules were seen. No cirrhosis or hepatomegaly noted. 2.5 L of grossly chylous fluid was drained with lymphocytic predominance, high triglycerides 980 mg/dL and negative cytology. Endoscopic ultrasound (EUS) showed an irregular hypoechoic mass. Fine needle aspiration (FNA) showed lymphoid cells with irregular nuclear membrane contours strongly positive for CD20, consistent with B cell lymphoma. PET-CT scan confirmed a metabolically active pancreatic mass with inguinal, aortocaval, juxtadiaphrgamatic and inframammary lymphadenopathy. Diagnostic laparoscopic biopsy confirmed diffuse B-cell lymphoma of germinal center origin positive for CD10, BCL6, BCL2 and CD45. Patient received 6 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) which he tolerated well. Follow-up PET CT scan showed reduction in size of pancreatic mass and lymph nodes without areas of new/worsening lymphoma. DISCUSSION: PPLs comprise 0.5% of all pancreatic masses. Diagnostic criteria include dominant pancreatic mass, without superficial or mediastinal lymphadenopathy, absent hepatosplenic involvement and a normal blood leukocyte count. Clinical presentation is non-specific without classic symptoms of nodal lymphoma. Abdominal pain is the most common symptom (83%), followed by abdominal mass and weight loss. High tumor burden, β2-microglobulin levels &gt;2 mg/l and high LDH levels are poor prognostic markers. Definitive diagnosis requires histologic confirmation, EUS-guided sampling is highly accurate. Treatment options include surgery, chemotherapy, radiation, alone or in combination. Cure rates upto 30% have been reported. Long term remission can be obtained with CHOP chemotherapy alone in majority of patients. Addition of rituximab results in overall improvement in patient survival.

Comparison between fine-needle biopsy and fine-needle aspiration for EUS-guided sampling of subepithelial lesions: a meta-analysis

There is limited evidence on the diagnostic performance of EUS-guided fine-needle biopsy (FNB) sampling in patients with subepithelial lesions. The aim of this meta-analysis was to compare EUS-guided FNB sampling performance with FNA in patients with GI subepithelial lesions. A computerized bibliographic search on the main databases was performed through May 2019. The primary endpoint was sample adequacy. Secondary outcomes were diagnostic accuracy, histologic core procurement rate, and mean number of needle passes. Summary estimates were expressed in terms of odds ratio (OR) and 95% confidence interval (CI). Ten studies (including 6 randomized trials) with 669 patients were included. Pooled rates of adequate samples for FNB sampling were 94.9% (range, 92.3%-97.5%) and for FNA 80.6% (range, 71.4%-89.7%; OR, 2.54; 95% CI, 1.29-5.01; P= .007). When rapid on-site evaluation was available, no significant difference between the 2 techniques was observed. Optimal histologic core procurement rate was 89.7% (range, 84.5%-94.9%) with FNB sampling and 65% (range, 55.5%-74.6%) with FNA (OR, 3.27; 95% CI, 2.03-5.27; P< .0001). Diagnostic accuracy was significantly superior in patients undergoing FNB sampling (OR, 4.10; 95% CI, 2.48-6.79; P< .0001) with the need of a lower number of passes (mean difference, -.75; 95% CI, -1.20 to -.30; P= .001). Sensitivity analysis confirmed these findings in all subgroups tested. Very few adverse events were observed and did not impact on patient outcomes. Our results speak clearly in favor of FNB sampling, which was found to outperform FNA in all diagnostic outcomes evaluated.

Slow-pull compared to suction technique for EUS-guided sampling of pancreatic solid lesions: a meta-analysis of randomized controlled trials

Slow-pull compared to suction technique for EUS-guided sampling of pancreatic solid lesions: a meta-analysis of randomized controlled trials

Comparison between 22G aspiration and 22G biopsy needles for EUS-guided sampling of pancreatic lesions: A meta-analysis.

Robust data in favor of clear superiority of 22G fine-needle biopsy (FNB) over 22G FNA for an echoendoscopic-guided sampling of pancreatic masses are lacking. The objective of this study is to compare the diagnostic outcomes and sample adequacy of these two needles. Computerized bibliographic search on the main databases was performed and restricted to only randomized controlled trials. Summary estimates were expressed regarding risk ratio (RR) and 95% confidence interval. A total of 11 trials with 833 patients were analyzed. The two needles resulted comparable in terms of diagnostic accuracy (RR 1.02, 0.97–1.08; P = 0.46), sample adequacy (RR 1.01, 0.96–1.06; P = 0.61), and histological core procurement (RR 1.01, 0.89–1.15; P = 0.86). Pooled sensitivity in the diagnosis of pancreatic cancer was 93.1% (87.9%–98.4%) and 90.4% (86.3%–94.5%) with biopsy and aspirate, respectively, whereas specificity for detecting pancreatic cancer was 100% with both needles. Analysis of the number of needle passes showed a nonsignificantly positive trend in favor of FNB (mean difference: −0.32, −0.66–0.02; P = 0.07). Our meta-analysis stands for a nonsuperiority of 22G FNB over 22G FNA; hence, no definitive recommendations on the use of a particular device can be made.