EUS-guided Sampling Research Articles

A Comparative study between a 22-gauge Aspiration needle and a 25-gauge biopsy needle for EUS-guided sampling of pancreatic mass lesions

A Comparative study between a 22-gauge Aspiration needle and a 25-gauge biopsy needle for EUS-guided sampling of pancreatic mass lesions

Mo1415 Randomizied Trial Comparing 22 and 25 Gauge Core Biopsy Needles for EUS-FNA of Solid Pancreatic and Peripancreatic Mass

A new core biopsy needle was developed to enable the acquisition of core specimens for histologic analysis and the additional diagnostic study such as immunohistochemical staining (IHC). There are limited data on the differences in diagnostic accuracy and histology core yield between a 22-gauge (PC22) and 25-gauge core biopsy needle (PC25). This prospective study compared the difference in diagnostic accuracy between a PC22 and PC25 when performing EUS-guided sampling without on-site cytopathologist.

Endoscopic ultrasound-guided sampling of a metastatic mucinous adenocarcinoma mimicking a gastric subepithelial tumor.

Metastatic mucinous adenocarcinoma of appendix origin and mimicking a gastric subepithelial tumor (SET) is very rare. Endoscopic ultrasound (EUS)-guided sampling is a useful diagnostic method for SETs. However, the cytologic findings of metastatic mucinous adenocarcinoma are unfamiliar to many pathologists and gastroenterologists. These findings present a diagnostic challenge because the introduction of gastric epithelium and mucin into the specimen during the procedure can be misleading. This is the first reported experience of an EUS-guided sampling of a gastric SET in a patient with suspected appendiceal tumor, to make the diagnosis of a mucinous adenocarcinoma.

Feasibility and efficiency of a new 22G core needle: a prospective comparison study

Histological examination of core tissue samples may have advantages over cytology in endoscopic ultrasound (EUS)-guided sampling. We aimed to evaluate the feasibility and efficiency of a new 22G core biopsy needle. Consecutive patients with a pancreatic mass lesion or peri-intestinal lymphadenopathy sequentially underwent fine needle biopsy with both a newly developed 22G core needle (the FNB needle) and a standard 22G fine needle aspiration (FNA) needle, in randomized order. In 144 patients, mean age 48 years (± standard deviation [SD] 14; range 18 - 82), with 145 lesions (mean lesion size 39 ± 15 mm, range 15 - 99), EUS-guided sampling was technically feasible with both needles in all patients. Mean number of passes to obtain sufficient tissue was 1.2 ± 0.5 with the core needle vs. 2.5 ± 0.9 with the standard needle (P < 0.001). FNB specimens were adequate for evaluation in 125 (86.2 %) vs. 127 (87.6 %) with FNA (P = 0.72). Among 139 patients available for follow-up, FNB provided a correct diagnosis in 110 (79.1 %) and FNA in 112 (80.6 %) (P = 0.73). Sensitivity, specificity, positive and negative predictive values, and accuracy for diagnosis of malignancy were 90 %, 100 %, 100 %, 93 %, 96 % for FNB and 77 %, 100 %, 100 %, 85 %, 92 % for FNA, respectively (P > 0.05). FNB with the new 22G core needle was technically feasible, efficient and comparable to FNA with a standard needle. The core needle required fewer passes to provide an adequate sample, offering potentially shorter procedure time.

Histology Combined with Cytology by Endoscopic Ultrasound-Guided Fine Needle Aspiration for the Diagnosis of Solid Pancreatic Mass and Intra-Abdominal Lymphadenopathy

Background/AimsSmall core biopsy samples can occasionally be obtained with conventional endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Although most studies have focused on the cytological analysis of specimens, data regarding histological assessment is scarce. The aim of this study was to determine whether core biopsies by conventional EUS-FNA could increase the accuracy of EUS-guided sampling when combined with cytology in the absence of an on-site cytopathologist.MethodsIn the 95 consecutive patients (98 lesions) undergoing EUS-FNA of solid pancreatic masses and intra-abdominal lymphadenopathy, tissue coils from the needle were harvested for histology, and residual tissue was examined by cytology.ResultsAdequate samples were obtained by EUS-FNA cytology, histology, and combined cytology-histology in 91.8%, 65.3%, and 94.8% of patients, respectively. From the pancreas (n=67), adequate samples for histology were obtained by EUS-FNA in 68.7% of cases, compared with 58.0% from non-pancreatic cases (n=31), respectively (p>0.05). The overall sensitivity and accuracy of EUS-FNA was 78.0% and 81.6% for cytology alone, 63.4% and 69.4% for histology alone, and 84.1% and 86.7% for combined cytology-histology, respectively.ConclusionsCombined cytology and histology analysis for diagnosing pancreatic masses and intra-abdominal lymphadenopathy may increase the diagnostic yield of conventional EUS-FNA without on-site cytology.

Su1549 EUS-Guided Needle Sampling for Gastric Subepithelial Tumors: Factors Associated With Higher Diagnostic Yield

EUS-guided sampling is an indispensible procedure for tissue diagnosis of gastric subepithelial tumors (SETs). Studies evaluating the factors associated with higher diagnostic yield of gastric SETs are limited.

Continuing Medical Education Exam: August 2012

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely on-line. To complete do the following: 1. Read the CME article in this issue carefully and complete the activity: Buchner AM, Guarner-Argente C, Ginsberg GG. Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center. Gastrointest Endosc 2012;76:255-63. Regunathan R, Woo J, Pierce MC, et al. Feasibility and preliminary accuracy of high-resolution imaging of the liver and pancreas using FNA-compatible microendoscopy (with video). Gastrointest Endosc 2012;76:293-300. Bang JY, Hebert-Magee S, Trevino JM, et al. Randomized, controlled trial comparing the 22-gauge aspiration and 22-gauge biopsy needles for EUS-guided sampling of solid pancreatic mass lesions. Gastrointest Endosc 2012;76:321-7. Daram SR, Lahr C, Tang S-j. Anorectal bleeding: etiology, evaluation, and management (with videos). [Technical Review] Gastrointest Endosc 2012;76:406-17. 2. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College and have provided a welcome opportunity for the ACC to cultivate leadership and engage members. Visit the journals Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College. Exams can be saved to be acessed at a later date. ou may create a free personal account to save and return to your work in progress, as well as save and track your completed activities o that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME ctivities can also be found at this site.

Randomized trial comparing the 22-gauge aspiration and 22-gauge biopsy needles for EUS-guided sampling of solid pancreatic mass lesions

To overcome limitations of cytology, biopsy needles have been developed to procure histologic samples during EUS. To compare 22-gauge (G) FNA and 22G biopsy needles (FNB) for EUS-guided sampling of solid pancreatic masses. Randomized trial. Tertiary-care medical center. This study involved 56 patients with solid pancreatic masses. Sampling of pancreatic masses by using 22G FNA or 22G FNB devices. Compare the median number of passes required to establish the diagnosis, diagnostic sufficiency, technical performance, complication rates, procurement of the histologic core, and quality of the histologic specimen. A total of 28 patients were randomized to the FNA group and 28 to the FNB group. There was no significant difference in median number of passes required to establish the diagnosis (1 [interquartile range 1-2.5] vs 1 [interquartile range 1-1]; P = .21), rates of diagnostic sufficiency (100% vs 89.3%; P = .24), technical failure (0 vs 3.6%; P = 1.0), or complications (3.6% for both) between FNA and FNB needles, respectively. Patients in whom diagnosis was established in passes 1, 2, and 3 were 64.3% versus 67.9%, 10.7% versus 17.9%, and 25% versus 3.6%, respectively, for FNA and FNB cohorts. There was no significant difference in procurement of the histologic core (100% vs 83.3%; P = .26) or the presence of diagnostic histologic specimens (66.7% vs 80%; P = .66) between FNA and FNB cohorts, respectively. Only pancreatic masses were evaluated. Diagnostic sufficiency, technical performance, and safety profiles of FNA and FNB needles are comparable. There was no significant difference in yield or quality of the histologic core between the 2 needle types.

Tu1555 Impact of Needle Type and Gauge on the Performance of Endoscopic Ultrasound-Guided Sampling: A Meta-Analysis

Impact of Needle Type and Gauge on the Performance of Endoscopic Ultrasound-Guided Sampling: A Meta-Analysis Young Oh*, Jeffrey L. Jackson Medical College of Wisconsin, Milwaukee, WI; Clement J. Zablocki VA Medical Center, Milwaukee, WI Background: There has been discordant data in the literature regarding which type and size of needle used for endoscopic ultrasound (EUS)-guided sampling has superior performance characteristics. AIM: The aim of this study was to comprehensively review and summarize the available literature on the performance of EUS-guided sampling based on the type and size of needle (19 gauge Trucut as well as 19, 22, and 25 gauge fine needle aspiration [FNA] needles) as well as sampling location. Methods: Published manuscripts until September 2011 regarding the use of EUS FNA or Trucut needles were identified in PubMed using relevant search terms. A review of the references from retrieved articles and abstracts from gastrointestinal meetings was also performed. Only studies that were published in English and compared two or more needles were included. Two reviewers independently reviewed each study for suitability to be included in the analysis. Data was pooled using a random effects model with variance based on exact binomial methods. Accuracy, sensitivity and specificity with 95% confidence intervals were calculated. Results: Forty-one articles and abstracts that included 3905 patients were identified that met the inclusion criteria. The combination of the Trucut needle and 22 gauge needle if necessary yielded the highest accuracy (0.95, 95% CI 0.93-0.97, p 0.03) and the 22 gauge needle alone yielded the lowest accuracy (0.76, 95% CI 0.72-0.80, p 0.001). A trend toward higher accuracies with the 25 gauge needle was observed, which did not reach statistical significance. The sensitivity using the Trucut needle was statistically worse than others (0.68, 95% CI 0.60-0.78, p 0.001) and no significant differences in specificity were observed with any of the needles. There appeared to be no differences by specific site of biopsy. Conclusions: The use of the Trucut needle in combination with the 22 gauge needle if necessary yielded the highest accuracy. For the use of single needles, a trend toward the highest accuracy was observed with the 25 gauge needle but this did not reach statistical significance.

Sa1523 Randomized Trial Comparing the Biopsy and Aspiration Needles for EUS-Guided Sampling of Solid Pancreatic Masses

Sa1523 Randomized Trial Comparing the Biopsy and Aspiration Needles for EUS-Guided Sampling of Solid Pancreatic Masses

Learning, techniques, and complications of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline

This article is the second of a two-part publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided Trucut biopsy. The first part (the Clinical Guideline) focused on the results obtained with EUS-guided sampling, and the role of this technique in patient management, and made recommendations on circumstances that warrant its use. The current Technical Guideline discusses issues related to learning, techniques, and complications of EUS-guided sampling, and to processing of specimens. Technical issues related to maximizing the diagnostic yield (e.g., rapid on-site cytopathological evaluation, needle diameter, microcore isolation for histopathological examination, and adequate number of needle passes) are discussed and recommendations are made for various settings, including solid and cystic pancreatic lesions, submucosal tumors, and lymph nodes. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling. A two-page executive summary of evidence statements and recommendations is provided.

Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB), of submucosal tumors, diffuse esophageal/gastric wall thickening, pancreatic solid masses and cystic-appearing lesions, mediastinal lesions unrelated to lung or esophageal cancer, cancer of the esophagus, stomach, and rectum, lymph nodes of unknown origin, adrenal gland masses, and focal liver lesions. False-positive cytopathological results and needle tract seeding are also discussed. The present Clinical Guideline describes the results of EUS-guided sampling in the different clinical settings, considers the role of this technique in patient management, and makes recommendations on circumstances that warrant its use. A two-page executive summary of evidence statements and recommendations is provided. A separate Technical Guideline describes the general technique of EUS-guided sampling, particular techniques to maximize the diagnostic yield depending on the nature of the target lesion, and sample processing. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling.

Endoscopic ultrasound in cystic pancreatic lesions: operator training needs to be improved, EUS-guided sampling should be standardized, and decision-making should be multidisciplinary and evidence-based

Management strategies for cystic pancreatic lesions (CPLs) currently present a real challenge as the number of incidentally discovered lesions appears be increasing in parallel with improvements in and greater use of modern imaging methods [1]. The accompanying advances of expertise in pancreatic medicine and surgery have identified the basic criteria for categorizing CPLs into two distinct groups. Group 1 are malignant or premalignant CPLs, and are mucinous (mucinous cystadenomas or intraductal papillary mucinous neoplasms [IPMNs]), or nonmucinous (essentially comprising cystic neuroendocrine tumors and rare papillary cystic neoplasms). Group 2 are benign CPLs, and include pseudocysts, serous cystadenomas (the macrocystic type can pose diagnostic challenges [2]), cystic lymphangiomas, mesenteric/peritoneal cysts, lymphoepithelial cysts, and rare benign pancreatic cysts (isolated or associated with polycystic pancreatic disorders).

Su1391 Value of Cytology Combined With Histology by EUS-FNA in the Solid Pancreatic Mass and Intra-Abdominal Lymphadenopathy

Endoscopic ultrasound - guided fine-needle aspiration (EUS- FNA) is a safe and accurate technique for diagnosing pancreatic tumor. Small core biopsies can be obtained with conventional EUS-FNA. Although most studies have concentrated on the cytology of specimen, few data existed on the histologic assessment. The aim of this study were to determine whether core biopsies by conventional EUS-FNA can increase the accuracy of EUS-guided sampling when combined with cytology when no on-site cytopathologist is present.

Diagnosis of mediastinal tuberculosis by using EUS-guided needle sampling in a geographic region with an intermediate tuberculosis burden

EUS-guided FNA (EUS-FNA) or trucut biopsy (TCB) is indispensible in the diagnosis of mediastinal malignancies. Less is known, however, about the usefulness of EUS-guided sampling for nonmalignant, mediastinal tuberculosis (TB), despite the increase in the incidence of TB. To assess the diagnostic yields of EUS-FNA/TCB in patients with mediastinal TB. Retrospective study. Tertiary-care referral hospital in a geographic region with an intermediate TB burden. This study involved 24 consecutive patients with mediastinal TB, who underwent EUS-FNA/TCB from July 2005 to September 2008. EUS-FNA/TCB. Technical success and diagnostic yields of EUS-FNA/TCB. Mediastinal lesions (mean diameter, 28.6 mm; range 17.0-49.5 mm) were targeted by using 22-gauge-needle FNA in 10 patients and 19-gauge-needle TCB in 14 patients. Before EUS, only 10 of the 24 patients had a presumptive diagnosis of mediastinal TB, whereas 11 patients were suspected of having malignancies. Six patients showed mass-like lung parenchymal lesions mimicking lung cancer, and 7 patients had a history of malignancy. Pathologic examination showed granulomatous inflammation in 16 patients (66.7%), including 10 patients with caseating granulomas. Positive microbiologic results were obtained in 10 patients (41.7%): 3 by Ziehl-Neelsen staining, 5 by Mycobacterium tuberculosis culture, and 5 by TB polymerase chain reaction (PCR) assay. EUS-FNA/TCB confirmed mediastinal TB in 20 of the 24 patients and directed 11 patients clinically suspected of having malignancies to anti-TB treatment. The diagnostic yields of FNA and TCB were similar (90.0% vs 78.6%). Retrospective design in a tertiary-care referral hospital. EUS-FNA/TCB is sufficiently useful to confirm mediastinal TB and can exclude suspected malignancies in TB patients.

T1461: Diagnostic Accuracy of Pancreatic Cyst Fluid Tumor Markers Obtained by EUS-Guided Sampling

Mucinous pancreatic cystic lesions (MPCLs) are premalignant but can be difficult to diagnose preoperatively. Pancreatic cyst fluid tumor markers and molecular analyses obtained by EUS-FNA have been increasingly utilized and may complement cytopathology.

EUS-guided sampling of suspected GI stromal tumors

The diagnostic yield of EUS-guided FNA (EUS-FNA) of suspected GI stromal tumors (GIST) has not been assessed in large series. Our purpose was to determine the diagnostic yield of EUS-FNA of subepithelial lesions with EUS features suggestive of GIST. Retrospective database review. Tertiary care referral center and an urban Veterans Administration hospital. Consecutive patients referred for EUS evaluation of upper GI subepithelial lesions of the fourth endosonographic layer who underwent EUS-FNA. Proportion of patients whose cytopathologic examination was diagnostic (immunohistochemical stains establish a specific diagnosis), suspicious (spindle cells identified, quantity not sufficient for specific stains), or nondiagnostic. A total of 112 patients (45.5% female, mean age 61.6 years) underwent EUS-FNA (mean number of FNA passes 5.3). Tumor location was as follows: stomach 62.5%, esophagus 30.4%, and duodenum 7.1%. EUS-FNA was diagnostic in 61.6%, suspicious (spindle cells) in 22.3%, and nondiagnostic in 16.1%. The histologic results were 31.3% GIST, 26.8% leiomyomas, 22.3% spindle cell neoplasms, 3.5 % neural tumors, and 16.1% nondiagnostic. Fifteen (12.5%) patients also underwent EUS-guided core needle biopsy needle sampling; 7 were diagnostic, 2 suspicious, and 6 nondiagnostic. Twenty-four (20.0%) patients underwent jumbo forceps sampling; 5 were diagnostic, 1 suspicious, and 18 nondiagnostic. There were no cases of diagnostic core needle biopsy after nondiagnostic FNA core needle biopsy. Jumbo forceps biopsy of ulcerated masses was diagnostic in 3 GISTs in which FNA was nondiagnostic. Univariate and multivariate analyses showed that no variable was associated with an increased diagnostic yield. EUS-FNA sampling of subepithelial lesions was diagnostic in 61.6% and showed a spindle cell neoplasm ("suspicious") in another 22.3% (diagnostic yield 83.9%). Core needle biopsy needle sampling did not increase the yield, but in the setting of an ulcerated mass, forceps biopsy may be diagnostic.

Endoscopic-ultrasound-guided mural trucut biopsy in the investigation of unexplained thickening of esophagogastric wall

Esophageal and/or gastric wall thickening raises the possibility of malignancy. Endoscopic-ultrasound-(EUS-)guided targeted biopsy of the thickened wall is possible. We aimed to evaluate the efficacy and safety of EUS-guided mural trucut biopsies (TCB) in detecting underlying malignancy in patients with thickened esophagogastric wall and negative mucosal biopsies. Patients with alarm symptoms referred for EUS-guided sampling after negative endoscopy and mucosal biopsy were included in the study. All patients had radial EUS reporting abnormal thickening of the esophageal/gastric wall. A linear-array echoendoscope and a 19-gauge trucut needle were used for sampling. Clinical and investigatory data were collected prospectively between 2004 and 2008. Thirty-one patients (20 men) aged 60 - 74 years (median 67 years) were included. All patients had thickened esophageal wall (n = 10), gastric wall (n = 21), or both on radial EUS. Prior to EUS, patients had undergone 1 - 5 endoscopies (median 1.2) and 2 - 8 mucosal biopsies (median 4). The median esophageal and gastric wall thicknesses were 12 and 18 mm respectively. During sampling 1 - 5 needle punctures (median 3) were made. On EUS-TCB, an adequate specimen for histology was obtained in 28/31 patients (90 %). The size of the tissue cores was 4 - 10 mm (median 6mm). Malignancy was confirmed in 16/31 patients (54 %) on histology, and in 11/31 patients (35.4 %) an underlying malignancy was excluded. There was no significant correlation between wall thickness and biopsy size (rho = 0.11, 95 %CI- 0.25 to - 0.45, two-sided P = 0.53). EUS-TCB had sensitivity, specificity, and positive and negative predictive values of 85 %, 100 %, 100 %, and 74 % respectively. There were no immediate or late complications. EUS-guided mural TCB is a safe and effective technique in the investigation of esophagogastric wall thickening in patients with alarm symptoms and has high sensitivity and specificity for the diagnosis of a cancer.

Randomized controlled trial of endoscopic ultrasound-guided fine-needle sampling with or without suction for better cytological diagnosis

Objective. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a highly accurate method to obtain specific diagnosis in various diseases. The optimal method of EUS-guided sampling of material for pathologic diagnosis has not been clearly established. The aim of our study was to compare two different techniques of EUS-guided sampling of solid masses, using either non-suction or suction with a 10-ml syringe. Material and methods. Patients assessed during a 6-month period were randomized to three passes of EUS-guided sampling with suction (26 patients) or non-suction (26 patients). The samples were characterized for cellularity and bloodiness, with a final cytology diagnosis established blindly. The final diagnosis was reached either by EUS-FNA if malignancy was definite, or by surgery and/or clinical follow-up of a minimum of 6 months in the cases of non-specific benign lesions. Results. EUS-guided fine-needle sampling with suction of solid masses increased the number of pathology slides (17.8±7.1 slides for suction as compared with 10.2±5.5 for non-suction, p=0.0001), without increasing the overall bloodiness of each sample. Sensitivity and the negative predictive values were higher when suction was applied, as compared to the non-suction group (85.7% as compared with 66.7%, p=0.05). Conclusions. This prospective randomized study showed that EUS-guided fine-needle sampling of solid masses using suction yields a higher number of slides without increasing bloodiness. Although, the proportion of target cells was relatively similar between the suction and non-suction sampling techniques, the sensitivity and negative predictive values of the procedure were significantly higher when suction was added.

EUS-guided tissue sampling: comparison of ”dual sampling” (Trucut biopsy plus FNA) with ”sequential sampling” (Trucut biopsy and then FNA as required)

Both endoscopic ultrasound- (EUS-) guided tissue sampling techniques, fine-needle aspiration (FNA) and Trucut biopsy, have advantages and limitations. The aim of this study was to develop a strategy of combining these two EUS-guided sampling techniques in order to maximize the diagnostic accuracy and minimize duplication. In this multicenter study we performed "dual sampling" (i. e. with both FNA and Trucut biopsy) in 95 patients during phase 1 of the study and "sequential sampling" (i. e. performing FNA only when Trucut biopsy tissue cores were macroscopically inadequate) in 72 patients during phase 2. During the study period, 167/401 patients referred for EUS-guided sampling were eligible for the study; only solid lesions were included. In 143/167 patients (86 %), sampling was performed via the transesophageal or transgastric routes. When the dual sampling strategy was used, an accurate diagnosis was achieved in 78/95 patients by FNA, compared with 85/95 by Trucut biopsy ( P = 0.21). The combined accuracy of the dual sampling strategy was higher than FNA alone (88/95 vs. 78/95, P = 0.048), but was not significantly higher than Trucut biopsy alone (88/95 vs. 85/95, P = 0.61). Using the sequential sampling strategy, an accurate diagnosis was achieved in 66/72 patients (92 %) compared with 88/95 (93 %) for dual sampling ( P = 1.0), and 8/72 patients (11 %) had to undergo FNA after Trucut biopsy failed to obtain an adequate sample. One patient with mediastinal tuberculosis developed a cold abscess following Trucut biopsy. A sequential sampling strategy, in which EUS-guided Trucut biopsy is attempted first, and FNA performed only when Trucut biopsy fails to obtain a macroscopically adequate sample, achieves a diagnostic accuracy of 92 %, with 11 % of patients requiring both sampling procedures.