EUS-guided Trucut Biopsy Research Articles

Outcome of Endoscopic Ultrasound-Guided Sampling of Mediastinal Lymphadenopathy.

Methods From May 2006 to January 2017, patients with mediastinal lymphadenopathy, who received an EUS-guided trucut biopsy or an FNA biopsy, were retrospectively reviewed. Demographic data, endosonographic characteristics of LNs including size, shape, border, echotexture, and echogenicity, diagnostic yield, and adverse events between the trucut needle group and aspiration needle group were compared. Results A total of 69 patients (trucut group, n = 33 vs. aspiration group, n = 36) were identified. There were no significant differences in demographic data, indication for an EUS-guided biopsy, location of LNs, number of needle passes, and endosonographic features of LNs between the two groups. The sizes of LNs were larger in the trucut group than in the aspiration group (28.9 ± 14.0 mm vs. 21.1 ± 8.8 mm, P = 0.007). However, there was no significant difference in the ratio of LNs that were ≥10 mm in both groups. The overall accuracy of the EUS-guided biopsy for the diagnosis of malignant lesions was 79.7% (55/69). There were no significant differences in the histological diagnostic yield of malignant LNs between the two groups. There were no significant procedure-related adverse events in both groups. Conclusion The EUS-guided biopsy can be a useful method for histologic evaluation of mediastinal nodal lesions.

How Can We Optimize Tools and Techniques for Endoscopic Ultrasound–Guided Liver Biopsy?

How Can We Optimize Tools and Techniques for Endoscopic Ultrasound–Guided Liver Biopsy?

Endoscopic ultrasound with tissue sampling is accurate in the diagnosis and subclassification of gastrointestinal spindle cell neoplasms.

Background and Objectives:Mesenchymal (spindle cell) neoplasms (SCN) of the gastrointestinal (GI) tract are an important subtype of subepithelial lesions that need subclassification to assess their malignant potential. Reported success rates of accurate subclassification with endoscopic ultrasound (EUS)-guided biopsies are variable. Our goal was to analyze our experience using EUS-guided TruCut biopsy (EUS-TCB) in the majority of patients.Methods:Retrospective analysis in patients who underwent EUS with biopsies for suspected SCN at our tertiary referral center between 2004 and 2013.Results:A total of 146 patients with suspected SCN underwent EUS with tissue acquisition. Thirteen patients were excluded from analysis because tissue acquisition established a definite diagnosis other than SCN. In the remaining 133 patients, tissue acquisition was diagnostic of SCN in 118 (88.7%) and nondiagnostic in 15 (11.3%). Subclassification based on immunohistochemistry (IHC) was possible in 109 of the 133 cases (81.9%). The final diagnosis was GI stromal tumor in 64, leiomyoma in 39, and schwannoma in 6 cases. The percentage of patients who were subclassified by the various EUS-guided techniques together was 72.18%, and the percentage of patients who were subclassified specifically with EUS-TCB was 61.65%. Tissue specimens that enabled a specific diagnosis based on histological or cytological characteristics in conjunctions with IHC were obtained with EUS core biopsy in 83 (TCB in 82 and ProCore needle biopsy in 1), fine-needle aspiration in 13, mucosal resection in 10, and forceps biopsies (bite-on-bite) in 3 cases.Conclusion:EUS with endoscopic tissue acquisition is accurate in the diagnosis and subclassification of SCN. In experienced hands, the EUS-TruCut needle is a valuable tool with a high success rate for this indication.

Endoscopic ultrasound making resonance in cancer research

Endoscopic ultrasound (EUS) is a novel technology that is being increasingly used for the diagnosis and management of cancers involving various organ systems. The technology was introduced three decades ago and its use has expanded exponentially in the past two decades. EUS-guided fine needle aspiration (FNA) is the best modality for tumor detection and tissue diagnosis even if the mass is weakly identified by other imaging modalities (1). EUS-FNA is capable of taking samples from masses that are not imaged by computed tomography or magnetic resonance imaging and lesions too deeply encased by adjacent vascular structures to allow percutaneous biopsy (2). EUS-guided FNA as well as EUS guided Trucut biopsy (TCB) has proven to be beneficial for benign and malignant diseases as well as staging of malignant tumors of the GI tract and adjacent structures (3). The application of EUS-guided therapy is especially appealing for malignancies because it provides accurate and effective palliative treatment. This is possible primarily due to two EUS characteristics: (I) its ability to deliver direct treatment to lesions unreachable by other means; and (II) the minimal invasiveness of EUS, which provides superior results with a low complication rate (4). EUS is being used to locally stage esophageal tumors (T staging), and it can be used for the assessment of esophageal submucosal tumors as well. Based on the EUS characteristics, we can positively identify the lesions that arise from exterior layers. This approach is particularly useful for evaluating invasion of local disease (especially esophageal cancer), tumor depth, nodal involvement, and detection of distant metastases (5). CT and magnetic resonance imaging lack the ability to differentiate the layers of the esophageal mucosa. Thus, these modalities cannot accurately discern the T stage of esophageal cancer (6). Therefore, EUS is a prerequisite before performing esophageal endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Esophageal leiomyomas, esophageal cancers, cystic lesions, lipomas, vascular lesions, and esophageal extraluminal compressions are some of the lesions that are commonly identified using EUS. EUS can be used to obtain cytology specimens from mediastinal nodal enlargement for the diagnosis and staging of bronchogenic carcinoma (7). EUS has a definitive role for evaluation of early gastric cancers and gastric submucosal lesions. Early gastric cancers can be staged using EUS and the feasibility of EMR or ESD can be determined. Gastrointestinal stromal tumors (GISTs) and other submucosal lesions can be diagnosed as well using EUS and their potential for ESD can be determined using EUS.

When to perform a pancreatoduodenectomy in the absence of positive histology? A consensus statement by the International Study Group of Pancreatic Surgery

Pancreatoduodenectomy (PD) provides the best chance for cure in the treatment of patients with localized pancreatic head cancer. In patients with a suspected, clinically resectable pancreatic head malignancy, the need for histologic confirmation before proceeding with PD has not historically been required, but remains controversial. An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature and worked together to establish a consensus on when to perform a PD in the absence of positive histology. The incidence of benign disease after PD for a presumed malignancy is 5-13%. Diagnosis by endoscopic cholangiopancreatography brushings and percutaneous fine-needle aspiration are highly specific, but poorly sensitive. Aspiration biopsy guided by endoscopic ultrasonography (EUS) has greater sensitivity, but it is highly operator dependent and increases expense. The incidence of autoimmune pancreatitis (AIP) in the benign resected specimens is 30-43%. EUS-guided Trucut biopsy, serum levels of immunoglobulin G4, and HISORt (Histology, Imaging, Serology, Other organ involvement, and Response to therapy) are used for diagnosis. If AIP is suspected but not confirmed, the response to a short course of steroids is helpful for diagnosis. In the presence of a solid mass suspicious for malignancy, consensus was reached that biopsy proof is not required before proceeding with resection. Confirmation of malignancy, however, is mandatory for patients with borderline resectable disease to be treated with neoadjuvant therapy before exploration for resection. When a diagnosis of AIP is highly suspected, a biopsy is recommended, and a short course of steroid treatment should be considered if the biopsy does not reveal features suspicious for malignancy.

Pediatric pancreatic endoscopic ultrasound guided trucut biopsy

s / Pancreatology 13 (2013) e1–e94 e26 were significantly more frequently observed in AZA+ compared to AZA-. In AZA+ group, relapse was observed in 16/17 (94%) before treatment and in 2/16 (12%) after treatment (mean follow-up 3 yrs range 1-8). Both AZA+ relapsing pts were treated with steroids, continuing AZA, and fully responded to therapy. 1 pts discontinued AZA for side effects (hepatitis). Conclusions: AZA seems to be an effective and safe treatment in AIP.

Gastric Schwannoma Diagnosed by Endoscopic Ultrasonography-Guided Trucut Biopsy

Schwannomas of the gastrointestinal (GI) tract are rare subepithelial tumors comprising approximately 3.3% to 12.8% of all mesenchymal tumors of the GI tract. On endoscopic ultrasound (EUS) they are seen as hypoechoic tumors arising most commonly from the 4th proper muscle layer. Although EUS helps to distinguish tumor characteristics, tissue sampling is required for differentiation with other more common tumors such as GI stromal tumors. Both EUS-guided fine needle aspiration and EUS-guided trucut biopsy (EUS-TCB) can be used for tissue sampling. However, only EUS-TCB allows core biopsy and a high yield of immunohistochemical staining. We report a case of a gastric schwannoma diagnosed by EUS-TCB.

Pediatric Pancreatic Endoscopic Ultrasound Guided Trucut Biopsy

Purpose: Pancreatic endoscopic ultrasound (EUS) guided trucut biopsy (TCB) obtains larger samples allowing histologic review, thereby increasing the diagnostic sensitivity compared to fine needle aspiration (FNA) particularly for autoimmune pancreatitis. There have been no reports describing the use of EUS TCB in pediatric patients. Therefore, our aim was to determine the diagnostic utility and safety of pancreatic EUS TCB in pediatric patients. Methods: A prospectively maintained EUS database was reviewed to identify all pediatric patients who had undergone pancreatic EUS TCB. Medical records were reviewed to obtain clinical, imaging, EUS and pathology data. Results: Eleven patients (5 males, mean age 14.6 years, range 9-19 years) were identified who underwent pancreatic TCB (19-guage, Quick-Core, Cook Medical) using a linear echoendoscope. A median of 2 (range 1-3) passes were obtained retrieving an average of 9.25 mm of tissue per pass (range 0-18 mm). EUS TCB was diagnostic (n=7) or partially diagnostic (n=1) in 8 of 9 (89%) patients with pancreatic pathology that included AIP type 2 (n=7) and lymphoma (n=1). In two patients with a final diagnosis of abdominal pain without evidence of pancreatic pathology, TCB revealed benign pancreatic tissue and one sample was inadequate revealing only fibrofatty tissue. No complications developed other that self-limited bleeding (n=2) without need for intervention.Table: [1805]Conclusion: Pancreatic EUS TCB appears to be safe and useful in diagnosing pancreatic disease in pediatric patients, although technical difficulties may limit tissue acquisition and prohibit diagnosis. In pediatric patients with pancreatic disease of unclear etiology, EUS TCB may be a useful diagnostic tool and should be considered for diagnosis and to allow timely and disease specific therapy.

Sa1537 Prospective Randomized Trial Comparing 19-G Tru-Cut Needle (TCB) and New 19-G Core Histology Needle (CHN) for Endoscopic Ultrasound (EUS) Guided Liver Biopsy in a Porcine Model

Histologic biopsy specimen is important for evaluating/staging liver disease. Non-operative liver tissue acquisition is usually obtained by percutaneous or transvascular routes. However, these have technical limitations and procedure-related complications. EUS-guided Trucut biopsy (TCB) has been proposed as an alternative because it may provide sufficient histologic diagnosis after a limited number of passes under real-time visualization. However, TCB also has been limited given the low core yield, need for multiple passes, and difficulty with angulation.

Best Practices in Endoscopic Ultrasound–Guided Fine-Needle Aspiration

Over the past 2 decades, endoscopic ultrasound-guided fine-needle aspiration has evolved to become an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. The technique is useful for biopsy of mucosal and submucosal lesions in which prior endoscopic biopsies have been nondiagnostic; to sample peri-intestinal structures such as lymph nodes; and to sample masses in the pancreas, liver, adrenal glands, gallbladder, and bile duct. Also, with the advent of neoadjuvant therapies for diseases such as pancreatic cancer, most patients require a tissue diagnosis before initiating treatment. This review provides a perspective on technical issues that are key for best practices in endoscopic ultrasound-guided fine-needle aspiration.

Signet-Ring Cell Carcinoma Mimicking Gastric Gastrointestinal Stromal Tumor Confirmed by Endoscopic Ultrasound-Guided Trucut Biopsy

A submucosal gastric adenocarcinoma, especially the signet ring cell type, is rare. The histologic evaluation techniques for this lesion has not been established; however, histologic confirmation is very important for decision of treatment method. Here, we report a 57-year-old man with a 12-cm gastric submucosal signet ring cell type adenocarcinoma, diagnosed by an endoscopic ultrasound-guided Trucut biopsy and immunochemical studies. This case suggests that the endoscopic ultrasound-guided Trucut biopsy might be a useful diagnostic method in cases of gastric adenocarcinoma with features of gastrointestinal stromal tumor.

A Case of Rectal Mucosa-associated Lymphoid Tissue Lymphoma Diagnosed by Endoscopic Unroofing Technique

Mucosa-associated lymphoid tissue (MALT) lymphoma is a typical primary gastrointestinal lymphoma, particularly in the stomach. Although primary rectal lymphoma is rare, it may present as a subepithelial tumor. Several techniques have been proposed for a tissue diagnosis in subepithelial tumor, including endoscopic ultrasonography (EUS)-guided fine needle aspiration (EUS-FNA), EUS-guided trucut biopsy (EUS-TCB), and tacked biopsy. However the diagnostic efficacy of these techniques appears to be limited. The unroofing technique involves removal of the overlying mucosa, thereby exposing the subepithelial lesion. It was originally reported as a method for endoscopic treatment of colorectal lymphangioma. In this case, a subepithelial tumor of the rectum was diagnosed using the endoscopic unroofing technique. This is a useful modality for the diagnosis of subepithelial tumor, because it provides histologic results in a safe and rapid manner.

Endoscopic Ultrasound-Guided Fine Needle Aspiration in Submucosal Lesion

A submucosal lesion, more appropriately a subepithelial lesion, is hard to diagnose. Endoscopic ultrasonography is good to differentiate the nature of submucosal lesion. For definite diagnosis, tissue acquisition from submucosal lesion is necessary, and many methods have been introduced for this purpose mainly by endoscopic ultrasonography, such as endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), EUS-guided Trucut Biopsy (TCB), and EUS-guided fine needle biopsy (FNB). For EUS-FNA, adequate processing of specimen is important, and for proper diagnosis of EUS-FNA specimen, both cytologic and histologic examinations, including immunohistochemical stains, are important. All gastrointestinal stromal tumors have some degree of malignant potential, so there have been a lot of efforts and methods to increase diagnostic yields of submucosal lesion. We herein review the current hot topics on EUS-FNA for submucosal tumor, such as needles, on-site cytopathologists, immunohistochemical stains, EUS-TCB, EUS-FNB, Ki-67 labelling index, DOG1, and combining EUS-FNA and EUS-TCB.

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.

Utility of EUS-guided biopsy of extramural pelvic masses

The diagnostic utility of EUS-guided FNA (EUS-FNA) and EUS-guided Trucut biopsy (EUS-TCB) of pelvic masses has not been well described. To evaluate the utility of EUS in the diagnosis of pelvic masses. Retrospective cohort study. Single tertiary referral hospital in Indianapolis, Indiana. Consecutive patients referred for EUS evaluation of pelvic mass from January 2002 to July 2009. Patients with newly diagnosed rectal cancer or a known/suspected intramural mass were excluded. EUS-FNA and/or EUS-TCB. Endosonographic features and cytological and pathological findings were evaluated. The final diagnosis was confirmed by surgical pathology or cytology and clinical follow-up. The sensitivities and specificities of EUS-TCB were calculated in a subset of patients with available surgical pathology. A total of 69 patients were identified, and 40 with intramural lesions (n = 36) or incomplete follow-up (n = 4) were excluded. The remaining 29 patients (15 men, mean age 58.5 ± 10.8 years) with pelvic masses (mean size 40.8 ± 20.1 mm) were evaluated. EUS-FNA or EUS-TCB helped to make the diagnosis in 25 of 29 patients (86%). Compared with surgical pathology (available in 17 patients), EUS-FNA had a sensitivity of 88% (95% CI, 53%-98%) and specificity of 100% (95% CI, 65%-100%) for malignancy. EUS-TCB alone had a sensitivity of 67% (95% CI, 21%-94%) and specificity of 100% (95% CI, 34%-100%) for malignancy, but the combination of EUS-FNA and EUS-TCB had a sensitivity of 100% (95% CI, 68%-100%) and a specificity of 100% (95% CI, 68%-100%). Complications after EUS-FNA included a pelvic abscess in 2 patients (7%) with a cystic pelvic mass. Single-center study. EUS-FNA and EUS-TCB are sensitive for the diagnosis of malignancy in pelvic masses. Sampling of cystic masses in this region is discouraged.

Clinical impact of EUS-guided Trucut biopsy results on decision making for patients with gastric subepithelial tumors ≥2 cm in diameter

Preoperative pathologic diagnosis of a gastric subepithelial tumor (SET) may improve clinical decision making. However, the clinical impact of EUS-guided Trucut biopsy (EUS-TCB) data on decision making in patients with a gastric SET has not been assessed. To evaluate the impact of EUS-TCB information on the clinical management of patients with a gastric SET. Retrospective review of prospectively collected data. Tertiary referral center. Sixty-five patients with gastric SETs 2 cm or larger in diameter. EUS-TCB. The number of patients for whom treatment plans were changed because of EUS-TCB results. Nine SETs were not punctured by the TCB needle because of technical problems, and we were unable to obtain adequate subepithelial tissue from 19 SETs. Treatment plans were changed for 18 of 65 patients (27.7%). The changes were avoiding unnecessary resection (7 benign SETs ≥ 3 cm in diameter), scheduling for definitive treatment (6 GI stromal tumors and 1 carcinoid tumor), and modifying the surgical field (3 large GI stromal tumors and 1 carcinoma). When we assessed treatment plans relative to tumor location, we found that avoiding unnecessary resection was associated with the presence of cardiac SETs. Retrospective study with a small number of patients. EUS-TCB changed or influenced management decisions in 18 of 65 patients (27.7%) with gastric SETs. Patients could receive proper and tailored surgery, medical treatment, or surveillance according to size and location of SETs with EUS-TCB.

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.

Mo1411 Feasibility, Specimen Adequacy, and Diagnostic Accuracy of a New EUS Guided Core Biopsy Needle: A Pilot Study

Endoscopic Ultrasound-guided fine needle aspiration (EUS-FNA) is an effective tool for tissue sampling of tumors within and adjacent to the gastrointestinal tract. While cytology obtained from FNA is generally adequate for diagnosis of malignancy, histology may be required for tumors such as lymphoma, gastrointestinal stromal tumor (GIST), and metastatic carcinoma. EUS-guided tru-cut biopsy using the currently available Quick-Core needle (Cook Medical, USA) has been suboptimal due to technical limitations.

Mo1379 Feasibility of Intra-Tumoral Confocal Microscopy Under EUS Guidance (EUS-CM)

2.3 respectively, while the mean number of passes with a standard FNA needle was 3.7. No complications occurred, however 100% of the 19 gauge stylets were difficult to remove once the needle was inserted into a target lesion. Conclusion: Our initial experience with this novel EUS-FNB device demonstrates promising results, with higher overall accuracy using fewer number of passes to achieve a diagnosis, and no additional complications noted. It also can obtain tissue from the periduodenal/pancreatic head region, which has been a limitation of traditional EUS guided trucut biopsy. Ongoing comparative data collection should be pursued to further delineate this device’s capacity to achieve complete histologic diagnosis, and its impact on clinical management/cost and need for onsite cytopathology interpretation.

Endoscopic ultrasound-guided Trucut biopsy of gastrointestinal mesenchymal tumor

Data on the utility of endoscopic ultrasound-guided Trucut biopsy (EUS-TCB) for suspected gastrointestinal mesenchymal tumor (GIMT) are limited. This study aimed to determine the diagnostic yield and complications from EUS-TCB for GIMT. Consecutive patients with suspected upper gastrointestinal or rectal GIMT from the muscularis propria with a maximal diameter of 20 mm or more were enrolled in a prospective, single-center cohort. An EUS-TCB was performed when on-site fine-needle aspiration (FNA) cytology review of the lesion was deemed suboptimal. Gastrointestinal stromal tumor (GIST) and leiomyoma were defined by the presence or absence of positive immunochemistry (IC) for c-kit, respectively. All GIMTs with a nondiagnostic IC were considered as unspecified. The outcomes assessed included diagnostic pathologic and IC yield (when tested) and procedural complications. In this study, 38 patients (24 women; median age, 62 years) with suspected GIMT (median maximal diameter, 42 mm; range, 20-120 mm) in the esophagus (n=6), stomach (n=28), duodenum (n=3), or rectum (n=1) underwent EUS-TCB without complications. Final diagnoses included GIST for 20 patients, leiomyoma for 13 patients, unspecified GIMT for 3 patients, and unknown disorder for 2 patients. An EUS-FNA was performed for 33 (87%) of the 38 patients, a diagnostic final cytology for 25 (76%) of 33 patients, and an FNA-IC for 12 (50%) of 24 patients. The EUS-TCB (median, 3 passes; range, 1-8 passes) obtained a visible tissue specimen in 37 (97%) of the 38 patients, with a median overall maximal fragment length of 3.5 mm (range, 0-15 mm). The diagnostic final TCB histology and TCB-IC were obtained, respectively, in 79 and 97% of the samples tested. In this cohort, EUS-TCB provided diagnostic histology and IC for 79 and 97% of the patients, respectively. For the initial biopsy of GIMT, EUS-TCB may be considered an acceptable alternative to EUS-FNA.