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Luo P, Ma W, Jiao D. Thyroid fine needle aspiration specimen adequacy: a noninferiority study and cost-effectiveness comparison of puncture needles. Sci Rep 2024; 14:22554. [PMID: 39343786 PMCID: PMC11439899 DOI: 10.1038/s41598-024-74209-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 09/24/2024] [Indexed: 10/01/2024] Open
Abstract
Needle selection plays a pivotal role in determining the success of fine needle aspiration (FNA) procedures. Two commonly utilized puncture needles for thyroid FNA are the conventional syringe needle and the stylet needle. Syringe needles are known for their cost-effectiveness in comparison to stylet needles. This study aimed to determine if FNA with syringe needles is non-inferior to FNA with stylet needles in terms of specimen adequacy while also comparing the direct costs associated with both needle types. A total of 220 thyroid nodules from 185 patients were prospectively included in this study. The same operator performed a total of four punctures on the same nodule twice using a syringe and a stylet needle. The results of this study show that the utilization of syringe needles for thyroid FNA was non-inferior to the use of stylet needles in terms of specimen adequacy. Cost analysis revealed that syringe needle FNA was not only less expensive (CNY 500.9 versus CNY 780) but also more effective (adequacy 85.91% versus 84.55%). In summary, given the global prevalence of FNA procedures, the economic considerations are paramount, and our findings support the routine use of syringe needles in thyroid FNA.
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Affiliation(s)
- Pengfei Luo
- Department of General Surgery, Fuyang People's Hospital, 501 Sanqing Road, Fuyang, 236000, China.
| | - Wei Ma
- Department of General Surgery, Fuyang People's Hospital, 501 Sanqing Road, Fuyang, 236000, China
| | - Dahai Jiao
- Department of General Surgery, Fuyang People's Hospital, 501 Sanqing Road, Fuyang, 236000, China
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Chen D, Ren Y, Chen S, Jin Y, Xie H, Yu L, Peng K, Xia Y, Pan D, Lu J, Lu L, Wan X, Hu D, Li B. The Wet Suction Technique Enhances the Diagnostic Efficacy and Aspirate Quality of EUS-FNA for Solid Lesions: A Multicenter Retrospective Study in China. J Clin Gastroenterol 2023; 57:417-422. [PMID: 35389928 DOI: 10.1097/mcg.0000000000001700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 03/08/2022] [Indexed: 12/10/2022]
Abstract
GOALS To comprehensively compare the wet suction technique with the conventional dry suction technique for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in solid lesions. BACKGROUND Optimal suction techniques for EUS-FNA remain uncertain when approaching solid lesions. STUDY We performed a retrospective study of EUS-FNA at 3 medical centers in China. A total of 203 patients were enrolled who received 2 passes of EUS-FNA with 22-G needles. If the first pass underwent dry suction, the second pass was wet suction. Otherwise, the order of suction technique is opposite. Diagnostic accuracy, sample quality (including cellularity and blood contamination), and sample quantity (including specimen adequacy, the maximum intact specimen length, and the total specimen length) were compared between wet-suction and dry-suction techniques. RESULTS The patients included 143 pancreatic lesions and 60 nonpancreatic lesions. Compared with the dry suction technique, the wet suction technique yielded a significantly higher diagnostic accuracy (85.22% vs. 72.41%, P =0.002), better specimen adequacy score and cellularity score ( P <0.0001), and lower blood contamination score ( P <0.0001). In the subgroup analysis, wet suction provided significantly higher diagnostic accuracy in pancreatic cancer without chronic pancreatitis ( P <0.05), and better cellularity score and specimen adequacy score, lower blood contamination score, and longer maximum intact specimen length and total specimen length in various lesions than that in dry suction. CONCLUSIONS The wet suction technique resulted in significantly higher diagnostic accuracy in pancreatic cancer without chronic pancreatitis, and better cellularity and histologic specimen in most of solid lesions.
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Affiliation(s)
| | | | - Sumin Chen
- Department of Gastroenterology, Tongren Hospital
| | - Yubiao Jin
- Department of Pathology, Shanghai General Hospital
| | | | | | | | | | - Dan Pan
- Department of Gastroenterology, The Fifth People's Hospital of Zunyi, Guizhou
| | | | | | - Xinjian Wan
- Department of Gastroenterology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Duanmin Hu
- Department of Gastroenterology, The Second Hospital of Soochow University, Soochow, Jiangsu, China
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Luo P, Mu X, Ma W, Jiao D, Zhang P. Effect of a stylet on specimen sampling in thyroid fine needle aspiration: A randomized, controlled, non-inferiority trial. Front Endocrinol (Lausanne) 2023; 14:1062902. [PMID: 37033228 PMCID: PMC10076701 DOI: 10.3389/fendo.2023.1062902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
Background There is a cost advantage in using a needle without stylet over a needle with stylet in thyroid fine needle aspiration (FNA). This study aimed to elucidate the non-inferiority of thyroid FNA without a stylet (S-) to thyroid FNA with a stylet (S+) on specimen sampling. Methods In this study, patients with thyroid nodules undergoing FNA were consecutively enrolled between May 2022 and July 2022. One experienced operator performed two punctures of each nodule with a stylet and without a stylet. Specimen adequacy was the primary outcome. Wald test was used for statistical analysis of the primary outcome. The difference in specimen adequacy between the two methods was expressed as a two-sided 95% confidence interval (CI). The S- method was considered non-inferior to the S+ method if the lower bound of the 95% CI of the S- minus S+ adequacy difference was greater than a predetermined non-inferiority margin of -10%. Results A total of 149 patients (195 nodules) were enrolled in the study. A total of 167 of 195 nodules (85.64%) and 169 of 195 nodules (86.67%) were obtained adequate specimens using the S+ and S- methods, respectively. The difference in specimen adequacy (S- minus S+) between the two methods was 1.03% (95% CI, -5.83% to 7.88%). The lower bound 95% CI of the difference in specimen adequacy (-5.83%) was greater than the predetermined non-inferiority margin of -10%. The difference in the yield for malignancy was not significantly different between the two methods. Conclusion Thyroid FNA without a stylet is non-inferior to thyroid FNA with a stylet on specimen sampling.
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Affiliation(s)
- Pengfei Luo
- Department of General Surgery, Fuyang People’s Hospital, Fuyang, China
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Kassirian S, Mitchell MA, McCormack DG, Zeman-Pocrnich C, Dhaliwal I. Rapid On-site Evaluation (ROSE) in Capillary Pull Versus Suction Biopsy Technique With Endobronchial Ultrasound-transbronchial Needle Aspiration (EBUS-TBNA). J Bronchology Interv Pulmonol 2022; 29:48-53. [PMID: 34010221 DOI: 10.1097/lbr.0000000000000776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Suction and capillary pull are 2 biopsy techniques used in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Although these techniques have been shown to perform comparably in terms of overall diagnostic yield, we hypothesized that the capillary pull technique would be associated with improved rapid on-site evaluation (ROSE) adequacy rates thus allowing for a shorter procedure time. METHODS One hundred eighteen patients undergoing EBUS-TBNA for any indication were randomized to suction or capillary pull techniques for the first biopsy pass; the technique used for all subsequent passes was based on operator preference and was not recorded. The first pass was subjected to ROSE and an adequacy assessment was given. ROSE slides were also scored for cellularity of diagnostic/lesional cells and blood contamination. The overall procedure time was also recorded. RESULTS There were no significant differences between suction and capillary pull techniques in terms of ROSE adequacy rates. Cellularity of diagnostic/lesional cells and blood contamination scores were also comparable. There was no significant difference in procedure time for the 2 techniques. CONCLUSION This study suggests no differences in ROSE outcomes between suction and capillary pull techniques in EBUS-TBNA. The technique used should therefore be left to the discretion of the operator.
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Affiliation(s)
| | - Michael A Mitchell
- Departments of Medicine
- Division of Respirology, Schulich Faculty of Medicine and Dentistry, Western University, London, ON, Canada
| | - David G McCormack
- Departments of Medicine
- Division of Respirology, Schulich Faculty of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Inderdeep Dhaliwal
- Departments of Medicine
- Division of Respirology, Schulich Faculty of Medicine and Dentistry, Western University, London, ON, Canada
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Nakai Y, Hamada T, Hakuta R, Sato T, Ishigaki K, Saito K, Saito T, Takahara N, Mizuno S, Kogure H, Koike K. A Meta-analysis of Slow Pull versus Suction for Endoscopic Ultrasound-Guided Tissue Acquisition. Gut Liver 2021; 15:625-633. [PMID: 33592584 PMCID: PMC8283288 DOI: 10.5009/gnl20270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 12/29/2022] Open
Abstract
Background/Aims Endoscopic ultrasound (EUS)-guided tissue acquisition is widely utilized as a diagnostic modality for intra-abdominal masses, but there remains debate regarding which suction technique, slow pull (SP) or conventional suction (CS), is better. A meta-analysis of reported studies was conducted to compare the diagnostic yields of SP and CS during EUS-guided tissue acquisition. Methods We conducted a systematic electronic search using MEDLINE/PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials to identify clinical studies comparing SP and CS. We meta-analyzed accuracy, sensitivity, blood contamination and cellularity using the random-effects model. Results A total of 17 studies (seven randomized controlled trials, four prospective studies, and six retrospective studies) with 1,616 cases were included in the analysis. Compared to CS, there was a trend toward better accuracy (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.97 to 2.27; p=0.07) and sensitivity (OR, 1.67; 95% CI, 0.95 to 2.93; p=0.08) with SP and a significantly lower rate of blood contamination (OR, 0.48; 95% CI, 0.33 to 0.69; p<0.01). However, there was no significant difference in cellularity between SP and CS, with an OR of 1.28 (95% CI, 0.68 to 2.40; p=0.45). When the use of a 25-gauge needle was analyzed, the accuracy and sensitivity of SP were significantly better than those of CS, with ORs of 4.81 (95% CI, 1.99 to 11.62; p<0.01) and 4.69 (95% CI, 1.93 to 11.40; p<0.01), respectively. Conclusions Compared to CS, SP appears to provide better accuracy and sensitivity in EUS-guided tissue acquisition, especially when a 25-gauge needle is used.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Suction versus slow-pull for endoscopic ultrasound-guided fine-needle aspiration of pancreatic tumors: a prospective randomized trial. HPB (Oxford) 2020; 22:779-786. [PMID: 31677985 DOI: 10.1016/j.hpb.2019.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/11/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Suction (S) is commonly used to improve cell acquisition during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Slow-pull (SP) sampling is another technique that might procure good quality specimens with less bloodiness. We aimed to determine if SP improves the diagnostic yield of EUS-FNA of pancreatic masses. METHODS Patients with pancreatic solid masses were randomized to four needle passes with both techniques in an alternate fashion. Sensitivity, specificity, positive, and negative predictive values were calculated. Cellularity and bloodiness of cytological samples were assessed and compared according to the technique. RESULTS Sensitivity, specificity, and accuracy of suction vs. SP were 95.2% vs. 92.3%; 100% vs. 100; 95.7% vs. 93%, respectively. As to the association of methods, they were 95.6, 100 and 96%, respectively. Positive predictive values for S and SP were 100%. There was no difference in diagnostic yield between S and SP (p = 0.344). Cellularity of samples obtained with SP and Suction were equivalent in both smear evaluation (p = 0.119) and cell-block (0.980). Bloodiness of SP and suction techniques were similar as well. CONCLUSIONS S and SP techniques provide equivalent sensitivity, specificity, and accuracy. Association of methods seems to improve diagnostic yield. Suction does not increase the bloodiness of samples compared to slow-pull.
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Castellani D, Germani U, Bassotti G, Manta R. EUS Standard Devices. ENDOTHERAPY IN BILIOPANCREATIC DISEASES: ERCP MEETS EUS 2020:47-63. [DOI: 10.1007/978-3-030-42569-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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Landau MS, Pearce TM, Carty SE, Wolfe J, Yip L, McCoy KL, LeBeau SO, Tublin ME, Ohori NP. Comparison of the collection approaches of 2 large thyroid fine-needle aspiration practices reveals differing advantages for cytology and molecular testing adequacy rates. J Am Soc Cytopathol 2019; 8:243-249. [PMID: 31543223 DOI: 10.1016/j.jasc.2019.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/16/2019] [Accepted: 03/22/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION At our institution, almost all thyroid fine-needle aspiration (FNA) procedures are performed by either Endocrinology or Radiology personnel. In this study, we compared the cytology and molecular adequacy rates of these 2 thyroid FNA practices, which differ on several aspects of specimen procurement. MATERIALS AND METHODS All thyroid FNA specimens from Endocrinology and Radiology practices between September 2008 and December 2016 were included. Over this time frame, the molecular testing modality transitioned from polymerase chain reaction (PCR)-based (7-gene panel era) to next generation sequencing (NGS)-based (ThyroSeq era). In measuring cytology adequacy, the Bethesda System unsatisfactory rate was determined. Molecular adequacy was categorized as Optimal, Limited Thyroid Epithelial Cells, Limited Nucleic Acids, or Failed. These parameters were compared for the 2 practices. RESULTS The study cohorts comprised 5810 specimens from Endocrinology and 4597 from Radiology. More Endocrinology specimens were satisfactory for cytology diagnosis than those from Radiology (94.7% versus 90.0%, P < 0.001). For molecular adequacy, fewer Endocrinology specimens were optimal than specimens from Radiology for both the 7-gene panel era (76.2% versus 82.9%, P < 0.001) and the ThyroSeq era (88.1% versus 91.9%, P = 0.049). CONCLUSIONS The 2 thyroid FNA practices varied inversely in their adequacy rates for cytology and molecular testing. Had one practice been superior for both cytology and molecular adequacy, a recommendation for the method of choice would have been straightforward. However, our results show that optimization of FNA practice for the current practice of thyroid cytology requires further investigation due to the complex nature of specimen procurement.
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Affiliation(s)
- Michael S Landau
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Thomas M Pearce
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jenna Wolfe
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shane O LeBeau
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mitchell E Tublin
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - N Paul Ohori
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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10
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Pih GY, Kim DH. Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy in Gastrointestinal Subepithelial Tumors. Clin Endosc 2019; 52:314-320. [PMID: 31370379 PMCID: PMC6680013 DOI: 10.5946/ce.2019.100] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of asymptomatic and incidentally found upper gastrointestinal subepithelial tumors (SETs) is increasing with the implementation of national cancer screening and the development of high-resolution endoscopy in Korea. However, endoscopy alone cannot be used to determine whether SETs are benign or malignant. Endoscopic ultrasound (EUS) is used to further characterize these lesions through the examination of their layered structure, internal echogenicity, size, and relationship to the extramural structure. These provide additional information on whether the lesion is benign or malignant. Nevertheless, the sensitivity and specificity of EUS alone in predicting malignancy is unsatisfactory. Recent guidelines have recommended deciding the timing of EUS-fine needle aspiration and biopsy (EUS-FNA/B) for SETs based on tumor size, malignant features on endoscopy, and high-risk features on EUS. The diagnostic accuracy of EUS-FNA/B is reportedly influenced by factors including needle size, number of needle passes, use of suction, use of a stylet in the needle assembly, fanning technique, availability of an on-site cytopathologist, and experience of the endosonographer. Therefore, according to the characteristics of the SETs, various subsequent methods and techniques should be appropriately employed to improve the diagnostic yield of EUS-FNA/B.
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Affiliation(s)
- Gyu Young Pih
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Mitselos IV, Karoumpalis I, Theopistos VI, Tzilves D, Christodoulou DK. Endoscopic ultrasonography in pancreatic diseases: advances in tissue acquisition. Endosc Int Open 2019; 7:E922-E930. [PMID: 31304238 PMCID: PMC6624111 DOI: 10.1055/a-0915-9594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/09/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) improved the diagnostic performance and upgraded the role of endoscopic ultrasonography (EUS) into an interventional modality, able to guide patient management and treatment.This review aimed to highlight the advances, emerging practices, procedural techniques and technological innovations in EUS tissue acquisition in pancreatic diseases. Methods A thorough review of the literature was performed using PubMed to identify articles that describe techniques, advances, and practices in EUS tissue acquisition in gastrointestinal diseases. Conclusion Since the first EUS-FNA procedure, EUS guided-tissue acquisition has been evolving continuously. Development of needles with innovative tip design enabled procurement of larger samples with preserved histological architecture. Moreover, sampling techniques and complementary methods, such as contrast harmonic imaging and EUS-elastography, have been introduced in an effort to improve diagnostic performance and sample adequacy.
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Affiliation(s)
- Ioannis V. Mitselos
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Ioannis Karoumpalis
- Department of Gastroenterology, General National Hospital of Athens “G. Gennimatas”, Athens, Greece
| | - Vasileios I. Theopistos
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Dimitrios Tzilves
- Department of Gastroenterology, General Hospital of Thessaloniki “Theageneion”,Thessaloniki, Greece
| | - Dimitrios K. Christodoulou
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece,Corresponding author Dimitrios K. Christodoulou, MD, PhD University Hospital of IoanninaFaculty of MedicineUniversity of IoanninaPO Box 1186Ioannina, 45110Greece+30 265 100 7016
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Lee KY, Cho HD, Hwangbo Y, Yang JK, Han SJ, Choi HJ, Lee YN, Cha SW, Moon JH, Cho YD, Park SH, Lee TH. Efficacy of 3 fine-needle biopsy techniques for suspected pancreatic malignancies in the absence of an on-site cytopathologist. Gastrointest Endosc 2019; 89:825-831.e1. [PMID: 30403966 DOI: 10.1016/j.gie.2018.10.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/24/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) has a high diagnostic accuracy for pancreatic tumors. Most reports have focused on the diagnostic yield of cytology or histology; the ability of various FNA/B techniques to obtain an adequate mass of cells or tissue has rarely been investigated. METHODS Patients with suspected pancreatic malignancy underwent EUS-FNB using a 22-gauge ProCore needle by either the stylet slow-pull-back technique (group A), conventional negative suction after stylet removal (group B), or non-suction after stylet removal (group C) in the absence of an on-site cytopathologist. The adequacy of the 3 techniques based on the diagnostic yield, cellularity, blood contamination, and core-tissue acquisition was evaluated. RESULTS A total of 50 patients (27 males) were analyzed. The mean tumor size was 21 to 40 mm in 54%. The rate of a good or excellent proportion of cellularity was highest in group A compared with groups B and C (72% vs 60% vs 50%, P = .049). A >25% rate of blood contamination was more prevalent in group B (30% vs 42% vs 10%, P = .009). The rate of adequate core-tissue acquisition was not different (52% vs 34% vs 50%, P = .140). Based on the multivariate generalized estimation equation, the stylet slow-pull-back technique and a tumor size >40 mm were favorable factors for diagnostic adequacy. CONCLUSIONS The stylet slow-pull-back technique might enable acquisition of tissue and assessment of cellularity for the diagnosis of pancreatic tumors suspected to be malignant. (Clinical trial registration number: KCT0002190.).
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Affiliation(s)
- Ka Young Lee
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Hyun Deuk Cho
- Department of Pathology, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Young Hwangbo
- Department of Preventive Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Jae Kook Yang
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Su Jung Han
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Hyun Jong Choi
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Yun Nah Lee
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Sang-Woo Cha
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Seoul, Korea
| | - Jong Ho Moon
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Young Deok Cho
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Seoul, Korea
| | - Sang-Heum Park
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
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Ichim VA, Chira RI, Mircea PA. Diagnostic yield of endoscopic ultrasound-guided biopsy of focal liver lesions. Med Pharm Rep 2019; 92:15-20. [PMID: 30957081 PMCID: PMC6448489 DOI: 10.15386/cjmed-1066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/25/2018] [Accepted: 08/08/2018] [Indexed: 12/11/2022] Open
Abstract
Endoscopic ultrasonography (EUS) has become an indispensable method for diagnosis and therapeutic procedures in gastroenterology. As experience with this technique grows, new indications continue to emerge. Due to the vicinity of the transducer to the liver, endoscopic ultrasonography provides detailed images of the liver segments and its vascular and biliary structures. Endosonographers have made an effort to define a clinical role for endoscopic ultrasound in liver diseases; however, not much is known about endoscopic ultrasound guided fine needle aspiration (EUS-FNA) in hepatic focal lesions. This review summarizes the available evidence regarding the usefulness of endoscopic ultrasound-guided fine needle aspiration in patients with focal liver lesions.
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Affiliation(s)
- Vlad Andrei Ichim
- Department of Internal Medicine. Division of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Romeo Ioan Chira
- Department of Internal Medicine. Division of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Petru Adrian Mircea
- Department of Internal Medicine. Division of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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The Use of a Stylet in Endoscopic Ultrasound With Fine-Needle Aspiration: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2019. [PMID: 28644309 DOI: 10.1097/mcg.0000000000000867] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is the most efficacious way to collect specimens from a solid lesion adjacent to the gastrointestinal tract and is performed with an internal stylet during puncture. However, its reinsertion into the needle is time-consuming. Controversy surrounds whether quality of cytology specimen improves with stylet use. We performed a meta-analysis comparing the use of stylet versus no stylet with EUS-FNA of gastrointestinal-related masses. METHODS Multiple databases were searched from inception until April 28, 2016. Discordant findings from independent extractions were reviewed by at least 2 investigators. Methods were executed as per the standards of the Cochrane Collaboration. Primary outcomes assessed were diagnostic adequacy of individual specimen samples, accuracy, and yield. Secondary outcomes included overall diagnostic accuracy of per-malignant lesion, cellularity, contamination, and bloodiness of the sample, and adverse events. RESULTS Five randomized control trials were identified comparing stylet versus no stylet use, which enrolled 504 patients, evaluated 537 lesions, and 1914 distinct specimens. There was no difference in diagnostic adequacy [risk ratio (RR)=1.00; 95% confidence interval (CI), 0.95-1.07], accuracy (RR=0.98; 95% CI, 0.90-1.06), or yield (RR=0.96; 95% CI, 0.89-1.03). No stylet use was favored in per-lesion malignant diagnosis (RR=0.85; 95% CI, 0.76-0.96). There was no difference in representative cellularity, contamination, or bloodiness of specimens obtained with or without stylet use. CONCLUSIONS Stylet use confers no significant advantage in diagnostic adequacy, accuracy, yield, contamination, bloodiness, or cellularity over no stylet. We reinforce that no stylet use may be used preferentially in EUS-FNA as a more convenient technique and is favored with a higher per-lesion malignant diagnosis.
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Witt BL, Factor RE, Chadwick BE, Caron J, Siddiqui AA, Adler DG. Evaluation of the SharkCore ® needle for EUS-guided core biopsy of pancreatic neuroendocrine tumors. Endosc Ultrasound 2018; 7:323-328. [PMID: 29623910 PMCID: PMC6199904 DOI: 10.4103/eus.eus_51_17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 07/03/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES EUS guided core biopsy was once rarely performed but is now entering mainstream practice. Neuroendocrine tumors often warrant core biopsy as sufficient tissue must be obtained to allow for special staining to ensure a correct diagnosis. Traditionally these lesions were sampled with FNA needles. We performed a retrospective pilot study to evaluate the clinical value and efficacy of the a new EUS core needle biopsy needle as compared to a standard EUS FNA needle in the evaluation of patients with known or suspected neuroendocrine tumors. METHODS A retrospective analysis of the first 10 patients (between January 2015 and April 2016) to undergo EUS-FNA with the SharkCore® needle at the University of Utah School of Medicine/Huntsman Cancer Center with neuroendocrine tumors. Each case was retrospectively reviewed by a board certified cytopathologist (BLW) for the following cytologic parameters on the aspirate smears or touch/squash preparations: overall cellularity [1 (low) to 3 (high)], percentage of obtained cells that were lesional/representative (<25%, 26%-50%, and >50%), relative ease of interpretation [1 (difficult) to 3 (easy)]. Pathologic material and reporting records were also reviewed for each case to confirm the number of needle passes to achieve diagnostic adequacy, the presence or absence diagnostic material on H&E slide (from cell block, if prepared), whether a definitive diagnosis was able to be rendered, and the presence or absence of a true core/core fragments (within the cell block, if prepared). RESULTS A total of 20 patients underwent EUS-FNA for suspected neuroendocrine lesions. Ten patients underwent either transgastric or transduodenal EUS-FNA with the 22 gauge SharkCore® needle. The comparison cohort of 10 patients underwent either transgastric or transduodenal EUS-FNA with the standard 22 gauge Echotip® needle. The SharkCore® needle required a fewer mean number of needle passes to obtain diagnostic adequacy than the Echotip® (P=0.0074). For cases with cell blocks, the SharkCore® needle produced diagnostic material in 100% of cases, whereas Echotip® produced diagnostic material in 60% of cases. There was no significant difference between specimen cellularity, percentage of lesional material, or ease of interpretation between the two needle types. CONCLUSION Our pilot investigation targeting patients with known or suspected pancreatic NETs indicates that the SharkCore® needle shows promise in obtaining suitable tissue for ancillary testing that can allow for more definitive pathologic interpretations on EUS FNA specimens. Fewer passes were needed with the core needle when compared to a standard needle.
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Affiliation(s)
- Benjamin L. Witt
- Department of Pathology, School of Medicine, ARUP Laboratories, University of Utah, Salt Lake City, UT, USA
| | - Rachel E. Factor
- Department of Pathology, School of Medicine, ARUP Laboratories, University of Utah, Salt Lake City, UT, USA
| | - Barbara E. Chadwick
- Department of Pathology, School of Medicine, ARUP Laboratories, University of Utah, Salt Lake City, UT, USA
| | - Justin Caron
- Department of Pathology, School of Medicine, ARUP Laboratories, University of Utah, Salt Lake City, UT, USA
| | - Ali A. Siddiqui
- Division of Gastroenterology, School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Douglas G. Adler
- Division of Gastroenterology, School of Medicine, University of Utah, Salt Lake City, UT, USA
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Marshall C, Mounzer R, Hall M, Simon V, Centeno B, Dennis K, Dhillon J, Fan F, Khazai L, Klapman J, Komanduri S, Lin X, Lu D, Mehrotra S, Muthusamy VR, Nayar R, Paintal A, Rao J, Sams S, Shah J, Watson R, Rastogi A, Wani S. Suboptimal Agreement Among Cytopathologists in Diagnosis of Malignancy Based on Endoscopic Ultrasound Needle Aspirates of Solid Pancreatic Lesions: A Validation Study. Clin Gastroenterol Hepatol 2018; 16:1114-1122.e2. [PMID: 28911946 DOI: 10.1016/j.cgh.2017.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/17/2017] [Accepted: 09/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Despite the widespread use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to sample pancreatic lesions and the standardization of pancreaticobiliary cytopathologic nomenclature, there are few data on inter-observer agreement among cytopathologists evaluating pancreatic cytologic specimens obtained by EUS-FNA. We developed a scoring system to assess agreement among cytopathologists in overall diagnosis and quantitative and qualitative parameters, and evaluated factors associated with agreement. METHODS We performed a prospective study to validate results from our pilot study that demonstrated moderate to substantial inter-observer agreement among cytopathologists for the final cytologic diagnosis. In the first phase, 3 cytopathologists refined criteria for assessment of quantity and quality measures. During phase 2, EUS-FNA specimens of solid pancreatic lesions from 46 patients were evaluated by 11 cytopathologists at 5 tertiary care centers using a standardized scoring tool. Individual quantitative and qualitative measures were scored and an overall cytologic diagnosis was determined. Clinical and EUS parameters were assessed as predictors of unanimous agreement. Inter-observer agreement (IOA) was calculated using multi-rater kappa (κ) statistics and a logistic regression model was created to identify factors associated with unanimous agreement. RESULTS The IOA for final diagnoses, based on cytologic analysis, was moderate (κ = 0.56; 95% CI, 0.43-0.70). Kappa values did not increase when categories of suspicious for malignancy, malignant, and neoplasm were combined. IOA was slight to moderate for individual quantitative (κ = 0.007; 95% CI, -0.03 to -0.04) and qualitative parameters (κ = 0.5; 95% CI, 0.47-0.53). Jaundice was the only factor associated with agreement among all cytopathologists on multivariate analysis (odds ratio for unanimous agreement, 5.3; 95% CI, 1.1-26.89). CONCLUSIONS There is a suboptimal level of agreement among cytopathologists in the diagnosis of malignancy based on analysis of EUS-FNA specimens obtained from solid pancreatic masses. Strategies are needed to refine the cytologic criteria for diagnosis of malignancy and enhance tissue acquisition techniques to improve diagnostic reproducibility among cytopathologists.
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Affiliation(s)
- Carrie Marshall
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rawad Mounzer
- Digestive Institute, Banner - University Medical Center, Phoenix, Arizona
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Violette Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Barbara Centeno
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Katie Dennis
- Department of Pathology, University of Kansas School of Medicine, Kansas City, Kansas
| | | | - Fang Fan
- Department of Pathology, University of Kansas School of Medicine, Kansas City, Kansas
| | - Laila Khazai
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Jason Klapman
- Gastrointestinal Tumor Program, Moffitt Cancer Center, Tampa, Florida
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Xiaoqi Lin
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - David Lu
- Department of Pathology, University of California Los Angeles, Los Angeles, California
| | - Sanjana Mehrotra
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California
| | - Ritu Nayar
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - Ajit Paintal
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - Jianyu Rao
- Department of Pathology, University of California Los Angeles, Los Angeles, California
| | - Sharon Sams
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Janak Shah
- Division of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, Louisiana
| | - Rabindra Watson
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Yang MJ, Hwang JC, Yoo BM, Kim JH, Lee D, Lim H, Kim YB. A prospective randomized trial of EUS-guided tissue acquisition using a 25-gauge core biopsy needle with and without a stylet. Surg Endosc 2018; 32:3777-3782. [DOI: 10.1007/s00464-018-6166-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/21/2018] [Indexed: 02/07/2023]
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Bansal RK, Choudhary NS, Puri R, Patle SK, Bhagat S, Nasa M, Bhasin A, Sarin H, Guleria M, Sud R. Comparison of endoscopic ultrasound-guided fine-needle aspiration by capillary action, suction, and no suction methods: a randomized blinded study. Endosc Int Open 2017; 5:E980-E984. [PMID: 28983505 PMCID: PMC5628048 DOI: 10.1055/s-0043-116383] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/23/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND STUDY AIM Different types of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) techniques are used in clinical practice; the best method in terms of outcome has not been determined. The aim of the study was to compare the diagnostic adequacy of aspirated material, and the cytopathological and EUS morphological features between capillary action, suction, and no-suction FNA methods. PATIENTS AND METHODS This was a prospective, single-blinded, randomized study conducted at a tertiary care hospital. Patients were randomized to the three groups: capillary action, suction, and no suction. A total of 300 patients were included, with 100 patients in each arm. RESULTS A total of 300 patients (195 males) underwent EUS-FNA of 235 lymph nodes and 65 pancreatic masses (distribution not statistically different between the groups). The mean age was 52 ± 14 years. A 22 gauge needle was used in the majority (93 %) of procedures. There was no statistical difference between the three groups regarding lymph node size at the largest axis and ratio, type of needle, echo features, echogenicity, calcification, necrosis, shape, borders (lymph nodes), number of passes, and cellularity. Diagnostic adequacy of the specimen was 91 %, 91 %, and 94 % in the capillary, suction, and no suction groups, respectively ( P = 0.67). Significantly more slides and blood clots were generated by the suction method compared with the other methods. CONCLUSION The capillary action, suction, and no suction methods of EUS-FNA are similar in terms of diagnostic adequacy of the specimen. The suction method has the disadvantages of causing more bleeding and generating more slides.
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Affiliation(s)
- Rinkesh K. Bansal
- Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, India
| | - Narendra S. Choudhary
- Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, India
| | - Rajesh Puri
- Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, India,Corresponding author Rajesh Puri, MD Institute of Digestive and Hepatobiliary SciencesMedanta The Medicity, Sector 38GurugramDelhi NCRIndia, PIN 122001+91-012448-34111
| | - Saurabh K. Patle
- Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, India
| | - Suraj Bhagat
- Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, India
| | - Mukesh Nasa
- Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, India
| | - Amit Bhasin
- Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, India
| | - Haimanti Sarin
- Department of Cytopathology, Medanta the Medicity, Gurugram, India
| | - Mridula Guleria
- Department of Cytopathology, Medanta the Medicity, Gurugram, India
| | - Randhir Sud
- Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, India
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Xu Y, Lin J, Jin Y, Wu X, Zheng H, Feng J. Is endobronchial ultrasound-guided transbronchial needle aspiration with a stylet necessary for lymph node screening in lung cancer patients? ACTA ACUST UNITED AC 2017; 50:e6372. [PMID: 28832765 PMCID: PMC5561810 DOI: 10.1590/1414-431x20176372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/29/2017] [Indexed: 12/25/2022]
Abstract
During endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), a needle is commonly used with a stylet, although recently the stylet has been omitted. This prospective study aimed to compare the quality of specimens obtained by EBUS-TBNA performed with and without a stylet. Between November 2013 and November 2014, 131 patients with lung cancer underwent EBUS-TBNA, with a total of 148 mediastinal or hilar lymph nodes sampled both with and without an inner-stylet, yielding 296 cytological specimens. Specimens were scored cytologically using five parameters: background blood or clot, amount of cellular material, degree of cellular degeneration, degree of cellular trauma, and retention of appropriate architecture. The procedure with a stylet required significantly longer operation time than without a stylet (14.5±0.8 vs 12.7±1.1 min, P<0.001). Excellent specimens were obtained in 261/296 and 260/296 samples in the procedures with and without a stylet, respectively (P=0.9), while the remaining 35 and 36 samples, respectively, were adequate. The diagnosing and staging of lung cancer using EBUS-TBNA did not differ significantly between the groups. In conclusion, specimen collection by EBUS-TBNA without a stylet is easier and faster than the procedure using a stylet and absence of a stylet did not alter specimen quality or diagnostic accuracy.
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Affiliation(s)
- Y Xu
- Department of Respiratory Medicine, Tai Zhou Hospital of Zhejiang Province, LinHai, Zhejiang Province, China
| | - J Lin
- Department of Respiratory Medicine, Tai Zhou Hospital of Zhejiang Province, LinHai, Zhejiang Province, China
| | - Y Jin
- Department of Medical Record Library, Tai Zhou Hospital of Zhejiang Province, LinHai, Zhejiang Province, China
| | - X Wu
- Department of Respiratory Medicine, Tai Zhou Hospital of Zhejiang Province, LinHai, Zhejiang Province, China
| | - H Zheng
- Department of Pathology, Tai Zhou Hospital of Zhejiang Province, LinHai, Zhejiang Province, China
| | - J Feng
- Department of Respiratory Medicine, Tai Zhou Hospital of Zhejiang Province, LinHai, Zhejiang Province, China
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Mohamadnejad M, Mullady D, Early DS, Collins B, Marshall C, Sams S, Yen R, Rizeq M, Romanas M, Nawaz S, Ulusarac O, Hollander T, Wilson RH, Simon VC, Kushnir V, Amateau SK, Brauer BC, Gaddam S, Azar RR, Komanduri S, Shah R, Das A, Edmundowicz S, Muthusamy VR, Rastogi A, Wani S. Increasing Number of Passes Beyond 4 Does Not Increase Sensitivity of Detection of Pancreatic Malignancy by Endoscopic Ultrasound-Guided Fine-Needle Aspiration. Clin Gastroenterol Hepatol 2017; 15:1071-1078.e2. [PMID: 28025154 DOI: 10.1016/j.cgh.2016.12.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/10/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear exactly how many passes are required to determine whether pancreatic masses are malignant using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). We aimed to define the per-pass diagnostic yield of EUS-FNA for establishing the malignancy of a pancreatic mass, and identify factors associated with detection of malignancies. METHODS In a prospective study, 239 patients with solid pancreatic masses were randomly assigned to groups that underwent EUS-FNA, with the number of passes determined by an on-site cytopathology evaluation or set at 7 passes, at 3 tertiary referral centers. A final diagnosis of pancreatic malignancy was made based on findings from cytology, surgery, or a follow-up evaluation at least 1 year after EUS-FNA. The cumulative sensitivity of detection of malignancy by EUS-FNA was calculated after each pass; in the primary analysis, lesions categorized as malignant or suspicious were considered as positive findings. RESULTS Pancreatic malignancies were found in 202 patients (84.5% of the study population). EUS-FNA detected malignancies with 96% sensitivity (95% confidence interval [CI], 92%-98%); 4 passes of EUS-FNA detected malignancies with 92% sensitivity (95% CI, 87%-95%). Tumor size greater than 2 cm was the only variable associated with positive results from cytology analysis (odds ratio, 7.8; 95% CI, 1.9-31.6). In masses larger than 2 cm, 4 passes of EUS-FNA detected malignancies with 93% sensitivity (95% CI, 89%-96%) and in masses ≤2 cm, 6 passes was associated with 82% sensitivity (95% CI, 61%-93%). Sensitivity of detection did not increase with increasing number of passes. CONCLUSIONS In a prospective study, we found 4 passes of EUS-FNA to be sufficient to detect malignant pancreatic masses; increasing the number of passes did not increase the sensitivity of detection. Tumor size greater than 2 cm was associated with malignancy, and a greater number of passes may be required to evaluate masses 2 cm or less. ClinicalTrials.gov number, NCT01386931.
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Affiliation(s)
- Mehdi Mohamadnejad
- University of California, Los Angeles, Los Angeles, California; Liver and Pancreatobiliary Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Science, Tehran, Iran
| | - Daniel Mullady
- Washington University School of Medicine, St. Louis, Missouri
| | - Dayna S Early
- Washington University School of Medicine, St. Louis, Missouri
| | - Brian Collins
- Washington University School of Medicine, St. Louis, Missouri
| | - Carrie Marshall
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sharon Sams
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Roy Yen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mona Rizeq
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Maria Romanas
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | - Samia Nawaz
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ozlem Ulusarac
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | | | - Robert H Wilson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Violette C Simon
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Stuart K Amateau
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brian C Brauer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Srinivas Gaddam
- Washington University School of Medicine, St. Louis, Missouri
| | - Riad R Azar
- Washington University School of Medicine, St. Louis, Missouri
| | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Raj Shah
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona
| | | | | | - Amit Rastogi
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Bhatia V, Varadarajulu S. Endoscopic ultrasonography-guided tissue acquisition: How to achieve excellence. Dig Endosc 2017; 29:417-430. [PMID: 28140485 DOI: 10.1111/den.12823] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/25/2017] [Indexed: 02/08/2023]
Abstract
Endoscopic ultrasound (EUS)-guided tissue acquisition is a basic forte of an endosonographer. The multiple skills required to accomplish successful results include not only the puncture itself, but also proper lesion identification, correct puncture sequence, collaboration with the pathologist onsite or remotely, proper handling of the specimens, choosing one or more of cytology, cell-block, and/or tissue core preparation and, last, deciding the immunohistochemistry (IHC) panels and ancillary tests which may be needed for the current case. Error in any of these decisions may lead to incomplete or inconclusive information from the procedure, even if the aspirate is 'adequate.' In the present review, we will describe the technical aspects of EUS-guided tissue acquisition, current needles available and how to choose between them, and how to appropriately handle the specimen. We will also discuss the optimal approach to common targets including lymph nodes, pancreatic masses, pancreatic cysts, and subepithelial lesions.
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Affiliation(s)
- Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India
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Best LMJ, Rawji V, Pereira SP, Davidson BR, Gurusamy KS. Imaging modalities for characterising focal pancreatic lesions. Cochrane Database Syst Rev 2017; 4:CD010213. [PMID: 28415140 PMCID: PMC6478242 DOI: 10.1002/14651858.cd010213.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Increasing numbers of incidental pancreatic lesions are being detected each year. Accurate characterisation of pancreatic lesions into benign, precancerous, and cancer masses is crucial in deciding whether to use treatment or surveillance. Distinguishing benign lesions from precancerous and cancerous lesions can prevent patients from undergoing unnecessary major surgery. Despite the importance of accurately classifying pancreatic lesions, there is no clear algorithm for management of focal pancreatic lesions. OBJECTIVES To determine and compare the diagnostic accuracy of various imaging modalities in detecting cancerous and precancerous lesions in people with focal pancreatic lesions. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, and Science Citation Index until 19 July 2016. We searched the references of included studies to identify further studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA We planned to include studies reporting cross-sectional information on the index test (CT (computed tomography), MRI (magnetic resonance imaging), PET (positron emission tomography), EUS (endoscopic ultrasound), EUS elastography, and EUS-guided biopsy or FNA (fine-needle aspiration)) and reference standard (confirmation of the nature of the lesion was obtained by histopathological examination of the entire lesion by surgical excision, or histopathological examination for confirmation of precancer or cancer by biopsy and clinical follow-up of at least six months in people with negative index tests) in people with pancreatic lesions irrespective of language or publication status or whether the data were collected prospectively or retrospectively. DATA COLLECTION AND ANALYSIS Two review authors independently searched the references to identify relevant studies and extracted the data. We planned to use the bivariate analysis to calculate the summary sensitivity and specificity with their 95% confidence intervals and the hierarchical summary receiver operating characteristic (HSROC) to compare the tests and assess heterogeneity, but used simpler models (such as univariate random-effects model and univariate fixed-effect model) for combining studies when appropriate because of the sparse data. We were unable to compare the diagnostic performance of the tests using formal statistical methods because of sparse data. MAIN RESULTS We included 54 studies involving a total of 3,196 participants evaluating the diagnostic accuracy of various index tests. In these 54 studies, eight different target conditions were identified with different final diagnoses constituting benign, precancerous, and cancerous lesions. None of the studies was of high methodological quality. None of the comparisons in which single studies were included was of sufficiently high methodological quality to warrant highlighting of the results. For differentiation of cancerous lesions from benign or precancerous lesions, we identified only one study per index test. The second analysis, of studies differentiating cancerous versus benign lesions, provided three tests in which meta-analysis could be performed. The sensitivities and specificities for diagnosing cancer were: EUS-FNA: sensitivity 0.79 (95% confidence interval (CI) 0.07 to 1.00), specificity 1.00 (95% CI 0.91 to 1.00); EUS: sensitivity 0.95 (95% CI 0.84 to 0.99), specificity 0.53 (95% CI 0.31 to 0.74); PET: sensitivity 0.92 (95% CI 0.80 to 0.97), specificity 0.65 (95% CI 0.39 to 0.84). The third analysis, of studies differentiating precancerous or cancerous lesions from benign lesions, only provided one test (EUS-FNA) in which meta-analysis was performed. EUS-FNA had moderate sensitivity for diagnosing precancerous or cancerous lesions (sensitivity 0.73 (95% CI 0.01 to 1.00) and high specificity 0.94 (95% CI 0.15 to 1.00), the extremely wide confidence intervals reflecting the heterogeneity between the studies). The fourth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (dysplasia) provided three tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing invasive carcinoma were: CT: sensitivity 0.72 (95% CI 0.50 to 0.87), specificity 0.92 (95% CI 0.81 to 0.97); EUS: sensitivity 0.78 (95% CI 0.44 to 0.94), specificity 0.91 (95% CI 0.61 to 0.98); EUS-FNA: sensitivity 0.66 (95% CI 0.03 to 0.99), specificity 0.92 (95% CI 0.73 to 0.98). The fifth analysis, of studies differentiating cancerous (high-grade dysplasia or invasive carcinoma) versus precancerous (low- or intermediate-grade dysplasia) provided six tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing cancer (high-grade dysplasia or invasive carcinoma) were: CT: sensitivity 0.87 (95% CI 0.00 to 1.00), specificity 0.96 (95% CI 0.00 to 1.00); EUS: sensitivity 0.86 (95% CI 0.74 to 0.92), specificity 0.91 (95% CI 0.83 to 0.96); EUS-FNA: sensitivity 0.47 (95% CI 0.24 to 0.70), specificity 0.91 (95% CI 0.32 to 1.00); EUS-FNA carcinoembryonic antigen 200 ng/mL: sensitivity 0.58 (95% CI 0.28 to 0.83), specificity 0.51 (95% CI 0.19 to 0.81); MRI: sensitivity 0.69 (95% CI 0.44 to 0.86), specificity 0.93 (95% CI 0.43 to 1.00); PET: sensitivity 0.90 (95% CI 0.79 to 0.96), specificity 0.94 (95% CI 0.81 to 0.99). The sixth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (low-grade dysplasia) provided no tests in which meta-analysis was performed. The seventh analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) provided two tests in which meta-analysis was performed. The sensitivity and specificity for diagnosing cancer were: CT: sensitivity 0.83 (95% CI 0.68 to 0.92), specificity 0.83 (95% CI 0.64 to 0.93) and MRI: sensitivity 0.80 (95% CI 0.58 to 0.92), specificity 0.81 (95% CI 0.53 to 0.95), respectively. The eighth analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) or benign lesions provided no test in which meta-analysis was performed.There were no major alterations in the subgroup analysis of cystic pancreatic focal lesions (42 studies; 2086 participants). None of the included studies evaluated EUS elastography or sequential testing. AUTHORS' CONCLUSIONS We were unable to arrive at any firm conclusions because of the differences in the way that study authors classified focal pancreatic lesions into cancerous, precancerous, and benign lesions; the inclusion of few studies with wide confidence intervals for each comparison; poor methodological quality in the studies; and heterogeneity in the estimates within comparisons.
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Affiliation(s)
- Lawrence MJ Best
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
| | - Vishal Rawji
- University College London Medical SchoolLondonUK
| | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
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Wang R, Wang J, Li Y, Duan Y, Wu X, Cheng B. Diagnostic accuracies of endoscopic ultrasound-guided fine-needle aspiration with distinct negative pressure suction techniques in solid lesions: A retrospective study. Oncol Lett 2017; 13:3709-3716. [PMID: 28521473 DOI: 10.3892/ol.2017.5942] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 02/01/2017] [Indexed: 12/14/2022] Open
Abstract
Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) is highly accurate in obtaining specific diagnoses for various diseases. The present study aimed to evaluate the diagnostic yields, accuracies and sampling adequacies, of slow-pull, 5 ml suction and 10 ml suction techniques in EUS-FNA of solid lesions. The present study was a retrospective comparative study, which was performed in tertiary academic centers, recognized for their expertise in EUS and EUS-guided FNA. The present study involved 149 patients who underwent EUS-FNA of solid masses. A total of 34 (22.8%), 37 (24.8%) and 78 (52.4%) patients underwent EUS-FNA with slow-pull, 5 ml suction and 10 ml suction techniques, respectively. The EUS-FNA cytology and histology results were compared with those from the gold standard of surgical histopathology [hematoxylin-eosin staining; immunohistochemical test of cluster of differentiation (CD) 79a, CD20 and flow cytometry test] or long-term clinical follow-up. The present retrospective comparative study demonstrated that the diagnostic yields and accuracies of EUS-FNA with slow-pull (86.1%) were significantly superior to those achieved with 5 ml suction (83.3%) or 10 ml suction (69.9%; P<0.0001; χ2 test). Consistently, 86.5% (32/37) of the samples obtained from the 5 ml suction group were adequate for histological diagnosis. By contrast, 70.6 (24/34) and 85.9% (67/78) of samples from the slow-pull and 10 ml suction groups were adequate for histological diagnosis, respectively. The samples obtained using 10 ml suction contained more blood compared with those obtained via slow-pull and 5 ml suction (P=0.0056; χ2 test). No complications were noted in any of the three groups. The samples that were obtained for histopathological diagnosis using 5 ml suction were superior to those obtained using slow-pull or 10 ml suction. Additional multi-central prospective studies in which EUS-FNA is performed with variable negative pressures are required to improve the defining of the diagnostic roles of those techniques.
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Affiliation(s)
- Ronghua Wang
- Department of Gastroenterology and Hepatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China.,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Jinlin Wang
- Department of Gastroenterology and Hepatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Yawen Li
- Department of Gastroenterology and Hepatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Yaqi Duan
- Department of Pathology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Xiaoli Wu
- Department of Gastroenterology and Hepatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Bin Cheng
- Department of Gastroenterology and Hepatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
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Hwang JH, Aslanian HR, Thosani N, Goodman A, Manfredi M, Navaneethan U, Pannala R, Parsi MA, Smith ZL, Sullivan SA, Banerjee S, Maple JT. Devices for use with EUS. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2017; 2:35-45. [PMID: 29905238 PMCID: PMC5990542 DOI: 10.1016/j.vgie.2016.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Kim JH, Park SW, Kim MK, Lee J, Kae SH, Jang HJ, Koh DH, Choi MH. Meta-Analysis for Cyto-Pathological Outcomes in Endoscopic Ultrasonography-Guided Fine-Needle Aspiration With and Without the Stylet. Dig Dis Sci 2016; 61:2175-2184. [PMID: 27010546 DOI: 10.1007/s10620-016-4130-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 03/10/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Theoretically, use of the stylet during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) will prevent the tip of the needle from being blocked and the sample from being contaminated, improving the quality and diagnostic yield of specimens. AIM This meta-analysis aimed to evaluate any benefit from the use of a stylet during EUS-FNA. METHODS MEDLINE, EMBASE, WEB of SCIENCE, and the Cochrane Central Register of Controlled Trials were searched for articles published through October 2015. A fixed-effects model was used to calculate the pooled effects when there is no heterogeneity and a random-effects model was used in situations with significant heterogeneity. RESULTS Five prospective randomized controlled studies and two retrospective studies of a total of 5491 specimens (2504 specimens in the S+ group and 2987 specimens in the S- group) were included in this study. The pooled analysis demonstrated no significant differences in the adequate sample rate between the S+ group (2135/2504, 85.26 %) and S- group (2609/2987, 87.35 %) [odds ratio 0.94 (95 % confidence interval 0.79-1.11), p = 0.45]. Furthermore, the rate of cellularity > 50 %, the contamination rate, and the blood contamination rate were not significantly superior in the S+ group when compared with the S- group. CONCLUSIONS Whether the use of a stylet improves the proportion of adequate specimens or quality of the specimen is questionable. Our results suggest that the use of a stylet dose not guarantee any advantage during EUS-guided tissue sampling.
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Affiliation(s)
- Jae Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea.
| | - Mi Kang Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea
| | - Sea Hyub Kae
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea
| | - Hyun Joo Jang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea
| | - Min Ho Choi
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Korea
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26
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The slow-pull capillary technique increases the quality of endoscopic ultrasound fine needle biopsy samples in solid pancreatic lesions. Eur J Gastroenterol Hepatol 2016; 28:911-6. [PMID: 27140228 DOI: 10.1097/meg.0000000000000638] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Endoscopic ultrasound-guided sampling is used routinely for the diagnosis of solid pancreatic masses. We aimed to compare the standard suction technique with the recently described 'slow-pull' technique. PATIENTS AND METHODS Patients with a solid pancreatic mass of more than 2 cm undergoing endoscopic ultrasound-guided fine needle biopsy with the same endoscopist using a 22 G core biopsy needle were included in the study. Patients had a first suction pass, followed by either another suction pass or a slow-pull pass. The rate of samples contributive to the diagnosis, cellularity, presence of tissue microfragments, and blood contamination were assessed and compared between each pass and each technique. RESULTS A total of 98 patients with a lesion diameter of 33.1±10 mm were analyzed. Lesions were adenocarcinomas in 83%, neuroendocrine tumors in 6%, and benign lesions in 11% of the cases. The rate of contributive samples of the first suction pass, the slow-pull pass, and the second suction pass were 96.9, 97.9, and 90.2%, respectively (P=NS). The slow-pull capillary technique, compared with the suction technique, provided samples with better cellularity, higher proportion of representative and tumor cells, and more tissue microfragments (P=0.002, 0.0004, 0.006, and 0.005, respectively). CONCLUSION Endoscopic ultrasound-guided fine needle biopsy sampling of solid pancreatic lesions using the slow-pull technique yielded overall outcomes similar to the standard suction technique in terms of diagnostic performance. However, the slow-pull capillary technique improved the histological quality of the samples, mainly through a higher proportion of tissue microfragments and tumor cells.
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Adler DG, Witt B, Chadwick B, Wells J, Taylor LJ, Dimaio C, Schmidt R. Pathologic evaluation of a new endoscopic ultrasound needle designed to obtain core tissue samples: A pilot study. Endosc Ultrasound 2016; 5:178-83. [PMID: 27386475 PMCID: PMC4918301 DOI: 10.4103/2303-9027.183976] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Standard endoscopic ultrasound-fine-needle aspiration (EUS-FNA) needles are in widespread use. Meaningful differences between the available needles have been difficult to identify. Recently, a new EUS needle (Shark Core®, Covidien, Dublin, Leinster, Ireland), has been introduced in an attempt to improve diagnostic accuracy, tissue yield, and to potentially obtain a core tissue sample. We performed a pilot study prospectively to evaluate this new needle when compared to a standard EUS-FNA needle. MATERIALS AND METHODS Analysis of the first 15 patients undergoing EUS-FNA with the Shark Core needle was performed and it was compared to EUS-FNA in 15 patients who underwent EUS-FNA with a standard needle. RESULTS The Shark Core needle required fewer needle passes to obtain diagnostic adequacy than the standard needle [(χ(2)(1) = 11.3, P < 0.001]. The Shark Core needle required 1.5 passes to reach adequacy, whereas the standard needle required three passes. For cases with cell blocks, the Shark Core needle produced diagnostic material in 85% of cases [95% confidence interval (CI): 54-98], whereas the standard needle produced diagnostic material in 38% of the cases (95% CI: 9-76). The Shark Core needle produced actual tissue cores 82% of the time (95% CI: 48-98) and the standard needle produced no tissue cores (95% CI: 0-71) (P = 0.03). CONCLUSION This pilot study found that the Shark Core needle had a high rate of producing adequate cytologic material for the diagnosis of pancreatic and peri-pancreatic lesions sampled by EUS with fewer passes required to obtain a definitive diagnosis and with a high rate of tissue cores being obtained when compared to a standard FNA needle.
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Affiliation(s)
- Douglas G Adler
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Utah, USA
| | - Benjamin Witt
- Department of Pathology, ARUP Laboratories, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Barbara Chadwick
- Department of Pathology, ARUP Laboratories, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jason Wells
- Department of Pathology, ARUP Laboratories, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Linda Jo Taylor
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Utah, USA
| | - Christopher Dimaio
- Department of Gastroenterology and Hepatology, Mount Sinai School of Medicine, New York, USA
| | - Robert Schmidt
- Department of Pathology, ARUP Laboratories, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Mounzer R, Yen R, Marshall C, Sams S, Mehrotra S, Said MS, Obuch JC, Brauer B, Attwell A, Fukami N, Shah R, Amateau S, Hall M, Hosford L, Wilson R, Rastogi A, Wani S. Interobserver agreement among cytopathologists in the evaluation of pancreatic endoscopic ultrasound-guided fine needle aspiration cytology specimens. Endosc Int Open 2016; 4:E812-9. [PMID: 27556103 PMCID: PMC4993880 DOI: 10.1055/s-0042-108188] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 04/25/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound with fine needle aspiration (EUS-FNA) has become the standard of care in the evaluation of solid pancreatic lesions. Limited data exist on interobserver agreement (IOA) among cytopathologists in assessing solid pancreatic EUS-FNA specimens. This study aimed to evaluate IOA among cytopathologists in assessing EUS-FNA cytology specimens of solid pancreatic lesions using a novel standardized scoring system and to assess individual clinical and cytologic predictors of IOA. METHODS Consecutive patients who underwent EUS-FNA of solid pancreatic lesions at a tertiary care referral center were included. EUS-FNA slides were evaluated by four blinded cytopathologists using a standardized scoring system that assessed final cytologic diagnosis and quantitative (number of nucleated/diagnostic cells) and qualitative (bloodiness, inflammation/necrosis, contamination, artifact) cytologic parameters. Final clinical diagnosis was based on final cytology, surgical pathology, or 1-year clinical follow-up. IOA was calculated using multi-rater kappa (κ) statistics. Bivariate analyses were performed comparing cases with and without uniform agreement among the cytopathologists followed by logistic regression with backward elimination to model likelihood of uniform agreement. RESULTS Ninety-nine patients were included (49 % males, mean age 64 years, mean lesion size 26 mm). IOA for final diagnosis was moderate (κ = 0.45, 95 % confidence interval (CI) 0.4 - 0.49) with minimal improvement when combining suspicious and malignant diagnoses (κ = 0.54, 95 %CI 0.49 - 0.6). The weighted kappa value for overall diagnosis was 0.65 (95 %CI 0.54 - 0.76). IOA was slight to fair (κ = 0.04 - 0.32) for individual cytologic parameters. A final clinical diagnosis of malignancy was the most significant predictor of agreement [OR 3.99 (CI 1.52 - 10.49)]. CONCLUSIONS Interobserver agreement among cytopathologists for pancreatic EUS-FNA specimens is moderate-substantial for the final cytologic diagnosis. The final clinical diagnosis of malignancy was the strongest predictor of agreement. These results have significant implications for patient management and need to be validated in future trials.
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Affiliation(s)
- Rawad Mounzer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Roy Yen
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Carrie Marshall
- Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Sharon Sams
- Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Sanjana Mehrotra
- Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | | | - Joshua C. Obuch
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Brian Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Augustin Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Raj Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Stuart Amateau
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Matthew Hall
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Lindsay Hosford
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Robert Wilson
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Amit Rastogi
- Division of Gastroenterology, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA,Corresponding author Sachin Wani, MD Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CenterMail Stop F7351635 Aurora CourtRm 2.031AuroraCO 80045USA+1-720-848-2749
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Jani BS, Rzouq F, Saligram S, Lim D, Rastogi A, Bonino J, Olyaee M. Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Lesions: A Systematic Review of Technical and Procedural Variables. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2016; 8:1-11. [PMID: 27011940 PMCID: PMC4784176 DOI: 10.4103/1947-2714.175185] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Endoscopic ultrasound (EUS)-guided tissue acquisition has emerged over the last decade as an invaluable diagnostic tool in approaching the different pancreatic lesions. Given the safety and minimal invasiveness of this approach combined with the high diagnostic yield, it became the standard of care when dealing with different pancreatic pathologies. However, some variables regarding this procedure remain not fully understood. These can influence the diagnostic yield of the procedure and include the presence of the on-site cytopathologist, the type and size of the needle used as well as obtaining aspiration versus core biopsy, the number of passes and the sampling technique, and the role of suction and stylet use among others. We performed a comprehensive literature search using PubMed, Google Scholar, and Embase for studies that assessed these variables. Eligible studies were analyzed using several parameters such as technique and procedure, with the aim of reviewing results from an evidence-based standpoint.
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Affiliation(s)
- Bhairvi S Jani
- Department of Internal Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Fadi Rzouq
- Department of Internal Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shreyas Saligram
- Department of Internal Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Diego Lim
- Department of Internal Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Amit Rastogi
- Department of Internal Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - John Bonino
- Department of Internal Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Mojtaba Olyaee
- Department of Internal Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Abe Y, Kawakami H, Oba K, Hayashi T, Yasuda I, Mukai T, Isayama H, Ishiwatari H, Doi S, Nakashima M, Yamamoto N, Kuwatani M, Mitsuhashi T, Hasegawa T, Hirose Y, Yamada T, Tanaka M, Sakamoto N. Effect of a stylet on a histological specimen in EUS-guided fine-needle tissue acquisition by using 22-gauge needles: a multicenter, prospective, randomized, controlled trial. Gastrointest Endosc 2015; 82:837-844.e1. [PMID: 25936452 DOI: 10.1016/j.gie.2015.03.1898] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 03/05/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND EUS-guided FNA (EUS-FNA) has become the most efficacious way to obtain specimens from a solid lesion adjacent to the GI tract. Previous reports regarding the use of a stylet during EUS-FNA were all based on cytological diagnosis and have showed no significant superiority in terms of diagnostic yield. OBJECTIVE To clarify the noninferiority of EUS-FNA without a stylet (S-) compared with EUS-FNA with a stylet (S+) on histological assessment. DESIGN A prospective, single-blind, randomized, controlled crossover study. SETTING Five tertiary referral centers in Japan. PATIENTS Patients referred for EUS-FNA of a solid lesion. INTERVENTION EUS-FNA S+ and S- in a total of 4 alternate passes with randomization to S+ first or S- first. MAIN OUTCOME MEASUREMENTS The primary endpoint was the acquisition rate of an appropriate and sufficient specimen for histological assessment. The secondary endpoints were cellularity, contamination, bloodiness, diagnostic ability, and diagnostic accuracy. RESULTS We enrolled 107 patients (110 lesions) and analyzed 220 specimens each in the S+ and S- groups. The acquisition rate of appropriate and sufficient specimens in the S+ group was 121 of 220 (55.0%) and 122 of 220 (55.5%) in the S- group. The difference in the acquisition rate of the specimen (S- minus S+) based on the generalized estimating equation was 0.42% (95% confidence interval, -6.72% to 7.56%), which was less than 10% of the prespecified noninferiority margin of this study. With regard to cellularity, contamination, bloodiness score, diagnostic ability, and diagnostic accuracy, there were no significant differences between both groups. There were no dropouts in the study. LIMITATIONS A variety of target lesions, multiple pathologists, lack of an assessment of intraobserver and interobserver variability, and a single-blind study for the pathologists. CONCLUSION EUS-FNA S- is noninferior to EUS-FNA S+ on histological assessment. ( CLINICAL TRIAL REGISTRATION NUMBER UMIN000008695.).
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Affiliation(s)
- Yoko Abe
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Koji Oba
- Research and Clinical Trial Center, Hokkaido University Hospital, Sapporo, Japan
| | - Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University, Sapporo, Japan
| | - Ichiro Yasuda
- The First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, University of Tokyo, Tokyo, Japan
| | - Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, Sapporo Medical University, Sapporo, Japan
| | - Shinpei Doi
- The First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | | | - Natsuyo Yamamoto
- Department of Gastroenterology, University of Tokyo, Tokyo, Japan
| | - Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Tadashi Hasegawa
- Department of Surgical Pathology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoshinobu Hirose
- Department of Tumor Pathology, Gifu University Hospital, Gifu, Japan
| | - Tetsuya Yamada
- Department of Pathology, Gifu Municipal Hospital, Gifu, Japan
| | - Mariko Tanaka
- Department of Pathology, The University of Tokyo, Tokyo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
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The clinical impact of immediate on-site cytopathology evaluation during endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: a prospective multicenter randomized controlled trial. Am J Gastroenterol 2015; 110:1429-39. [PMID: 26346868 DOI: 10.1038/ajg.2015.262] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Observational data on the impact of on-site cytopathology evaluation (OCE) during endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic masses have reported conflicting results. We aimed to compare the diagnostic yield of malignancy and proportion of inadequate specimens between patients undergoing EUS-FNA of pancreatic masses with and without OCE. METHODS In this multicenter randomized controlled trial, consecutive patients with solid pancreatic mass underwent randomization for EUS-FNA with or without OCE. The number of FNA passes in the OCE+ arm was dictated by the on-site cytopathologist, whereas seven passes were performed in OCE- arm. EUS-FNA protocol was standardized, and slides were reviewed by cytopathologists using standardized criteria for cytologic characteristics and diagnosis. RESULTS A total of 241 patients (121 OCE+, 120 OCE-) were included. There was no difference between the two groups in diagnostic yield of malignancy (OCE+ 75.2% vs. OCE- 71.6%, P=0.45) and proportion of inadequate specimens (9.8 vs. 13.3%, P=0.31). Procedures in OCE+ group required fewer EUS-FNA passes (median, OCE+ 4 vs. OCE- 7, P<0.0001). There was no significant difference between the two groups with regard to overall procedure time, adverse events, number of repeat procedures, costs (based on baseline cost-minimization analysis), and accuracy (using predefined criteria for final diagnosis of malignancy). There was no difference between the two groups with respect to cytologic characteristics of cellularity, bloodiness, number of cells/slide, and contamination. CONCLUSIONS Results of this study demonstrated no significant difference in the diagnostic yield of malignancy, proportion of inadequate specimens, and accuracy in patients with pancreatic mass undergoing EUS-FNA with or without OCE.
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Alatawi A, Beuvon F, Grabar S, Leblanc S, Chaussade S, Terris B, Barret M, Prat F. Comparison of 22G reverse-beveled versus standard needle for endoscopic ultrasound-guided sampling of solid pancreatic lesions. United European Gastroenterol J 2015; 3:343-52. [PMID: 26279842 DOI: 10.1177/2050640615577533] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 11/18/2014] [Accepted: 02/22/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using standard needles has a high diagnostic value in the evaluation of solid pancreatic masses. Fenestrated needles have been developed to improve the quality of EUS-guided tissue sampling by providing core biopsies (FNB). METHODS Patients with solid pancreatic masses of >2 cm were prospectively included in our study and randomized to receive EUS sampling, using either a standard 22G FNA or a 22G Procore® FNB needle. The main study endpoint was the number of needle passes required to obtain a diagnosis in more than 90% of cases. RESULTS We included 100 patients (male = 63, female = 37; mean age = 68.4 years) in our study. We found that 88% of the lesions were malignant, with a mean size of 32 mm. A sample adequate for diagnosis was obtained in more than 90% of cases after the second needle pass in the FNB group, versus the third needle pass in the FNA group. Slide cellularity and presence of tissue microfragments were significantly higher in the FNB group. Sensitivity for the diagnosis of malignancy was 88.4% versus 97.8% for the EUS-FNA and EUS-FNB group, respectively, while specificity for both techniques was 100%. No complications were recorded. CONCLUSIONS Although the accuracy of both needle types for proving malignancy was similar, a lower number of passes was required with the FNB needles to achieve the same contributive sample rate as with the FNA needles. FNB also improved the histopathological quality of specimens, suggesting an overall superiority of FNB sampling.
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Affiliation(s)
- Abdullah Alatawi
- Department of Gastroenterology, Cochin Hospital, Groupe Hospitalier Paris Centre, Paris, France
| | - Frédéric Beuvon
- Department of Histopathology, Cochin Hospital, Groupe Hospitalier Paris Centre, Paris, France
| | - Sophie Grabar
- Department of Biostatistics and Epidemiology, Cochin Hospital, Groupe Hospitalier Paris Centre, Paris, France ; Paris-Descartes University, Paris, France
| | - Sarah Leblanc
- Department of Gastroenterology, Cochin Hospital, Groupe Hospitalier Paris Centre, Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology, Cochin Hospital, Groupe Hospitalier Paris Centre, Paris, France ; Paris-Descartes University, Paris, France
| | - Benoit Terris
- Department of Histopathology, Cochin Hospital, Groupe Hospitalier Paris Centre, Paris, France ; Paris-Descartes University, Paris, France
| | - Maximilien Barret
- Department of Gastroenterology, Cochin Hospital, Groupe Hospitalier Paris Centre, Paris, France ; Paris-Descartes University, Paris, France
| | - Frédéric Prat
- Department of Gastroenterology, Cochin Hospital, Groupe Hospitalier Paris Centre, Paris, France ; Paris-Descartes University, Paris, France
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Gonçalves B, Soares JB, Bastos P. Endoscopic Ultrasound in the Diagnosis and Staging of Pancreatic Cancer. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 22:161-171. [PMID: 28868399 PMCID: PMC5580187 DOI: 10.1016/j.jpge.2015.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/23/2015] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer is one of the digestive cancers with the poorest prognosis, so an early and correct diagnosis is of utmost importance. With the development of new therapeutic options an accurate staging is essential. Endoscopic ultrasonography (EUS) has a major role in all stages of the management of these patients. EUS has a high accuracy in the diagnosis of pancreatic adenocarcinoma and the possibility to perform fine-needle aspiration/biopsy (FNA/FNB) increases the diagnostic yield of EUS. There is still no consensus on the several technical aspects of FNA, namely on the rapid on-site evaluation (ROSE), the diameter and type of needle, the number of passes and the use of stylet and suction. Contrast-enhanced EUS (CE-EUS) and EUS elastography (EUS-E) have been used in recent years as an adjunct to EUS-FNA. Given the higher sensitivity of these techniques a negative cytology by EUS-FNA should not exclude malignancy when CE-EUS and/or EUS-E are suggestive of pancreatic neoplasia. EUS remains one of the main methods in the staging of pancreatic adenocarcinoma, namely to further evaluate patients with non-metastatic disease that appears resectable on initial imaging. EUS is crucial for an accurate preoperative evaluation of pancreatic cancer which is essential to choose the correct management strategy. The possibility to obtain samples from suspicious lesions or lymph nodes, by means of EUS-guided fine-needle aspiration as well as the use of contrast-enhanced and elastography, makes EUS an ideal modality for the diagnosis and staging of pancreatic cancer.
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Affiliation(s)
- Bruno Gonçalves
- Gastroenterology Department, Hospital de Braga, Braga, Portugal
| | | | - Pedro Bastos
- Gastroenterology Department, Hospital de Braga, Braga, Portugal
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EUS-guided tissue acquisition: an evidence-based approach (with videos). Gastrointest Endosc 2014; 80:939-59.e7. [PMID: 25434654 DOI: 10.1016/j.gie.2014.07.066] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 07/17/2014] [Indexed: 02/08/2023]
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Hammoud GM, Almashhrawi A, Ibdah JA. Usefulness of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of hepatic, gallbladder and biliary tract Lesions. World J Gastrointest Oncol 2014; 6:420-429. [PMID: 25400873 PMCID: PMC4229785 DOI: 10.4251/wjgo.v6.i11.420] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/17/2014] [Accepted: 10/27/2014] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of the liver is a safe procedure in the diagnosis and staging of hepatobiliary malignancies with a minimal major complication rate. EUS-FNA is useful for liver lesions poorly accessible to other imaging modalities of the liver. EUS-guided FNA of biliary neoplasia and malignant biliary stricture is superior to the conventional endoscopic brushing and biopsy.
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Tadic M, Stoos-Veic T, Kusec R. Endoscopic ultrasound guided fine needle aspiration and useful ancillary methods. World J Gastroenterol 2014; 20:14292-14300. [PMID: 25339816 PMCID: PMC4202358 DOI: 10.3748/wjg.v20.i39.14292] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/22/2014] [Accepted: 07/11/2014] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic ultrasound (EUS) in evaluating pancreatic pathology has been well documented from the beginning of its clinical use. High spatial resolution and the close proximity to the evaluated organs within the mediastinum and abdominal cavity allow detection of small focal lesions and precise tissue acquisition from suspected lesions within the reach of this method. Fine needle aspiration (FNA) is considered of additional value to EUS and is performed to obtain tissue diagnosis. Tissue acquisition from suspected lesions for cytological or histological analysis allows, not only the differentiation between malignant and non-malignant lesions, but, in most cases, also the accurate distinction between the various types of malignant lesions. It is well documented that the best results are achieved only if an adequate sample is obtained for further analysis, if the material is processed in an appropriate way, and if adequate ancillary methods are performed. This is a multi-step process and could be quite a challenge in some cases. In this article, we discuss the technical aspects of tissue acquisition by EUS-guided-FNA (EUS-FNA), as well as the role of an on-site cytopathologist, various means of specimen processing, and the selection of the appropriate ancillary method for providing an accurate tissue diagnosis and maximizing the yield of this method. The main goal of this review is to alert endosonographers, not only to the different possibilities of tissue acquisition, namely EUS-FNA, but also to bring to their attention the importance of proper sample processing in the evaluation of various lesions in the gastrointestinal tract and other accessible organs. All aspects of tissue acquisition (needles, suction, use of stylet, complications, etc.) have been well discussed lately. Adequate tissue samples enable comprehensive diagnoses, which answer the main clinical questions, thus enabling targeted therapy.
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Holt BA, Varadarajulu S, Hébert-Magee S. High-quality endoscopic ultrasound-guided fine needle aspiration tissue acquisition. Adv Ther 2014; 31:696-707. [PMID: 24958327 PMCID: PMC4115182 DOI: 10.1007/s12325-014-0129-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Indexed: 02/07/2023]
Abstract
Endoscopic ultrasound-guided fine needle aspiration is a multistep procedure that involves proper clinical indication, correct selection of needles, adapting evidence-based techniques such as the fanning maneuver and not routinely using suction or the stylet for tissue sampling, and establishing reliable cytopathology support. Integrating cytopathology in the training curriculum and developing a more flexible platform of needles and echoendoscopes are likely to further advance the field of endosonography. This review aims to summarize the technical issues that are key to performing high-quality endoscopic ultrasound-guided fine needle aspiration.
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Affiliation(s)
- Bronte A. Holt
- Center for Interventional Endoscopy, Florida Hospital, 601 East Rollins Street, Orlando, FL 32804 USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, 601 East Rollins Street, Orlando, FL 32804 USA
| | - Shantel Hébert-Magee
- Center for Interventional Endoscopy, Florida Hospital, 601 East Rollins Street, Orlando, FL 32804 USA
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Wani S. Basic techniques in endoscopic ultrasound-guided fine-needle aspiration: Role of a stylet and suction. Endosc Ultrasound 2014; 3:17-21. [PMID: 24949406 PMCID: PMC4063265 DOI: 10.4103/2303-9027.123008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 11/20/2013] [Indexed: 12/18/2022] Open
Abstract
There are several variables that have been studied to optimize various outcomes of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) such as quality and adequacy of specimens, diagnostic yield of malignancy, accuracy and overall efficiency. Using an evidence-based approach, the objectives of this review are to discuss two key aspects of EUS-FNA: (a) Use of a stylet and (b) use of suction. Level 1 evidence available from randomized controlled trials demonstrates that the use of a stylet during EUS-FNA has no impact on the diagnostic yield of malignancy or the quality of specimens. Air flushing in a slow, controlled fashion is superior to reinsertion of a stylet to express EUS-FNA aspirates. The use of suction should be considered during EUS-FNA of pancreatic masses. However, data from a randomized controlled trial suggest that suction should not be used during EUS-FNA of lymph nodes as it increases bloodiness of specimens obtained and has no impact on the overall diagnostic yield.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA ; Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Denver, CO, USA
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Salah W, Faigel DO. When to puncture, when not to puncture: Submucosal tumors. Endosc Ultrasound 2014; 3:98-108. [PMID: 24955339 PMCID: PMC4064168 DOI: 10.4103/2303-9027.131038] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 11/20/2013] [Indexed: 12/19/2022] Open
Abstract
Subepithelial masses of the gastrointestinal (GI) tract are a frequent source of referral for endosonographic evaluation. Subepithelial tumors most often appear as protuberances in the GI tract with normal overlying mucosa. When there is a need to obtain a sample of the mass for diagnosis, endoscopic ultrasound (EUS) - guided fine-needle aspiration (FNA) is superior to other studies and should be the first choice to investigate any subepithelial lesion. When the decision is made to perform EUS-guided FNA several technical factors must be considered. The type and size of the needle chosen can affect diagnostic accuracy, adequacy of sample size and number of passes needed. The use of a stylet or suction and a fanning or standard technique during EUS-guided FNA are other factors that must be considered. Another method proposed to improve the efficacy of EUS-guided FNA is having an on-site cytopathologist or cytotechnician. Large or well-differentiated tumors may be more difficult to diagnose by standard EUS-FNA and the use of a biopsy needle can be used to acquire a histopathology sample. This can allow preservation of tissue architecture and cellularity of the lesion and may lead to a more definitive diagnosis. Alternatives to FNA such as taking bite-on-bite samples and endoscopic submucosal resection (ESMR) have been studied. Comparison of these two techniques found that ESMR has a significantly higher diagnostic yield. Most complications associated with EUS-FNA such as perforation, infection and pancreatitis are rare and the severity and incidence of these adverse events is not known. Controversy exists as to the optimal method in which to perform EUS-FNA and larger prospective trials are needed.
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Affiliation(s)
- Wajeeh Salah
- Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
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Sahai AV. Endoscopic ultrasound-guided fine-needle aspiration studies: Fanning the flames. Endosc Ultrasound 2014; 3:68-70. [PMID: 24955335 PMCID: PMC4064164 DOI: 10.4103/2303-9027.131037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 04/05/2014] [Indexed: 12/26/2022] Open
Affiliation(s)
- Anand V Sahai
- Division of Gastroenterology, CHUM, Hospital Saint Luc, Quebec H2 X 3J4, Canada
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Kurtycz DFI, Field A, Tabatabai L, Michaels C, Young N, Schmidt CM, Farrell J, Gopal D, Simeone D, Merchant NB, Pitman MB. Post-brushing and fine-needle aspiration biopsy follow-up and treatment options for patients with pancreatobiliary lesions: The Papanicolaou Society of Cytopathology Guidelines. Cytojournal 2014; 11:5. [PMID: 25191519 PMCID: PMC4153339 DOI: 10.4103/1742-6413.133356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 02/06/2014] [Indexed: 12/28/2022] Open
Abstract
The Papanicolaou Society of Cytopathology (PSC) has developed a set of guidelines for pancreatobiliary cytology including indications for endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) biopsy, techniques of EUS-FNA, terminology and nomenclature for pancreatobiliary cytology, ancillary testing and post-procedure management. All documents are based on the expertise of the authors, a review of the literature and discussions of the draft document at several national and international meetings over an 18 month period and synthesis of online comments of the draft document on the PSC web site (www.papsociety.org). This document selectively presents the results of these discussions and focuses on the follow-up and treatment options for patients after procedures performed for obtaining cytology samples for the evaluation of biliary strictures and solid and cystic masses in the pancreas. These recommendations follow the six-tiered terminology and nomenclature scheme proposed by committee III.
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Affiliation(s)
| | - Andrew Field
- Department of Pathology, Saint Vincent's Hospital, Sydney, Australia
| | | | - Claire Michaels
- Department of Surgery, Case Western Reserve University, Philadelphia, PA
| | - Nancy Young
- Department of Surgery, Albert Einstein College of Medicine, Philadelphia, PA
| | | | | | - Deepak Gopal
- Department of Surgery, Division of Gastroenterology, University of Wisconsin, USA
| | | | - Nipun B. Merchant
- Department of Medicine, Division of Surgical Oncology, Vanderbilt University, USA
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Gimeno‐García AZ, Elwassief A, Paquin SC, Gariépy G, Sahai AV. Randomized controlled trial comparing stylet-free endoscopic ultrasound-guided fine-needle aspiration with 22-G and 25-G needles. Dig Endosc 2014; 26:467-73. [PMID: 24877242 DOI: 10.1111/den.12204] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Previous studies comparing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) results with different gauge needles have all been carried out with the stylet in place and show no clear advantage to the larger 22-G needle. Similar data for stylet-free EUS-FNA (SF-EUS-FNA) are unavailable. The aim of the present study was to determine whether diagnostic yield and specimen adequacy is superior with the 22-G needle as compared to the 25-G needle. METHODS All patients ≥ 18 years referred for solid-lesion EUS-FNA were eligible. Patients with suspected diagnosis of lymphoma, gastrointestinal stromal tumor, sarcoidosis, significant coagulopathy (international normalized ratio > 1.5 or platelets < 50000/mm(3)), use of clopidogrel within 7 days of EUS, and pregnancy were excluded. The two needles were compared regarding diagnostic yield, sample adequacy, bloodiness, ease of puncture, visibility, number of passes, failures, and complications. RESULTS One hundred and twenty consecutive patients were included and 126 lesions were sampled. Sensitivity, specificity, positive predictive value and negative predictive value for the 22-G SF-EUS-FNA were 83%, 100%, 100% and 56%, respectively, and for the 25-G SF-EUS-FNA were 88.8%, 100%, 100% and 76.5%, respectively (P=NS). There were no significant differences between the 22-G and the 25-G FNA needles in sample adequacy, bloodiness, ease of puncture, FNA failure, visibility, number of passes and complications; and no significant differences between either needle were found in relation to lesion site. CONCLUSION For SF-EUS-FNA, the larger 22-G needle offers no advantage over the smaller 25-G needle.
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Affiliation(s)
| | - Ahmed Elwassief
- Internal Medicine Department, Gastroenterology UnitAlhossien Hospital, Alazhar University Cairo Egypt
| | - Sarto C. Paquin
- Department of GastroenterologyCentre Hospitalier de l'Université de Montréal Montreal Canada
| | - Gilles Gariépy
- Department of PathologyCentre Hospitalier de l'Université de Montréal Montreal Canada
| | - Anand V. Sahai
- Department of GastroenterologyCentre Hospitalier de l'Université de Montréal Montreal Canada
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Kurtycz D, Tabatabai ZL, Michaels C, Young N, Schmidt CM, Farrell J, Gopal D, Simeone D, Merchant NB, Field A, Pitman MB. Postbrushing and fine-needle aspiration biopsy follow-up and treatment options for patients with pancreatobiliary lesions: The papanicolaou society of cytopathology guidelines. Diagn Cytopathol 2014; 42:363-71. [DOI: 10.1002/dc.23121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 01/15/2014] [Indexed: 12/28/2022]
Affiliation(s)
- Daniel Kurtycz
- Department of Pathology; University of Wisconsin, Wisconsin State Laboratory of Hygiene; Madison Wisconsin
| | | | - Claire Michaels
- Department of Pathology; Case Western Reserve University; Cleveland Ohio
| | - Nancy Young
- Department of Pathology; Albert Einstein College of Medicine; Bronx New York
| | - C. Max Schmidt
- Department of Surgery; Indiana University; Indianapolis Indiana
| | - James Farrell
- Department of Medicine; UCLA School of Medicine; Los Angeles California
| | - Deepak Gopal
- Division of Gastroenterology, Department of Medicine; University of Wisconsin; Madison Wisconsin
| | - Diane Simeone
- Department of Surgery; University of Michigan; Michigan
| | - Nipun B. Merchant
- Division of Surgical Oncology, Department of Medicine; Vanderbilt University, Vanderbilt; Nashville Tennessee
| | - Andrew Field
- Department of Pathology; St. Vincent's Hospital Sydney Australia
| | - Martha Bishop Pitman
- Department of Pathology, Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
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Karadsheh Z, Al-Haddad M. Endoscopic ultrasound guided fine needle tissue acquisition: Where we stand in 2013? World J Gastroenterol 2014; 20:2176-2185. [PMID: 24605016 PMCID: PMC3942822 DOI: 10.3748/wjg.v20.i9.2176] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/19/2013] [Accepted: 01/17/2014] [Indexed: 02/06/2023] Open
Abstract
Since its introduction, endoscopic ultrasound (EUS) guided fine needle aspiration and fine needle biopsy have become an indispensable tool for the diagnosis of lesions within the gastrointestinal tract and surrounding organs. It has proved to be an effective diagnostic method with high accuracy and low complication rates. Several factors can influence the accuracy and the diagnostic yield of this procedure including experience of the endosonographer, availability of onsite cytopathology services, the method of cytopathology preparation, the location and physical characteristics of the lesion, sampling techniques and the type and size of the needle used. In this review we will outline the recent studies evaluating EUS-guided tissue acquisition and will provide practical recommendations to maximize tissue yield.
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Karadsheh Z, Al-Haddad M. Endoscopic ultrasound-guided fine-needle aspiration needles: which one and in what situation? Gastrointest Endosc Clin N Am 2014; 24:57-69. [PMID: 24215760 DOI: 10.1016/j.giec.2013.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is increasingly used as a diagnostic and therapeutic tool for pancreatic and other gastrointestinal disorders. Several factors affect the outcome of EUS-FNA, one of which is needle size. The decision to use a specific needle depends on factors including location, consistency, and type of the lesion; presence of onsite cytopathologist; and need for additional tissue procurement for histology. This review provides a balanced perspective on the use of different needle sizes available, highlighting the differences among them and potential niche applications of each to maximize diagnostic yield of EUS-FNA.
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Affiliation(s)
- Zeid Karadsheh
- Department of Internal Medicine, Brockton Hospital, 680 Centre Street, Brockton, MA 02302, USA
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Varadarajulu S, Hasan MK, Bang JY, Hebert-Magee S, Hawes RH. Endoscopic ultrasound-guided tissue acquisition. Dig Endosc 2014; 26 Suppl 1:62-9. [PMID: 24033879 DOI: 10.1111/den.12146] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 06/13/2013] [Indexed: 02/08/2023]
Abstract
Endoscopic ultrasound (EUS) is an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. While fine-needle aspiration (FNA) has been routinely carried out for establishing tissue diagnosis, the emerging concept of tailoring chemotherapeutic agents based on molecular markers has increased the demand for core tissue procurement by means of EUS-guided fine-needle biopsy (EUS-FNB). In addition, FNB may offset the limitations of FNA wherein the diagnostic sensitivity is incumbent on the availability of an onsite cytopathologist. Given the increasing number of procedures being done, developing a unit-specific algorithmic approach for needle selection is important to improve the procedural efficiency and utilization of resources. Finally, the best outcomes can be attained only by practicing evidence-based techniques, procuring adequate quantity of sample for ancillary studies and processing the specimens appropriately.
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Affiliation(s)
- Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
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Vilmann P, Seicean A, Săftoiu A. Tips to overcome technical challenges in EUS-guided tissue acquisition. Gastrointest Endosc Clin N Am 2014; 24:109-24. [PMID: 24215763 DOI: 10.1016/j.giec.2013.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The diagnostic yield of EUS-FNA depends on several factors, such as the experience of the endosonographer, the characteristics of the lesion, the clinical status of the patient, the size and type of needles, the methods of specimen preparation, as well as cytopathologist expertise. The endosonographic technique can be improved when several tips and tricks useful to overcome challenges of FNA are known. Technical challenges of FNA are related to the characteristics of the lesion and its surroundings, sonographic imaging, and limitations related to the needle. Several tips and tricks necessary to overcome them are presented in this review.
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Affiliation(s)
- Peter Vilmann
- Department of Endoscopy, Gastrointestinal Unit, Copenhagen University Hospital, Herlev Ringvej 75, Herlev 2730, Denmark
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Kedia P, Gaidhane M, Kahaleh M. Technical Advances in Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition for Pancreatic Cancers: How Can We Get the Best Results with EUS-Guided Fine Needle Aspiration? Clin Endosc 2013; 46:552-62. [PMID: 24143320 PMCID: PMC3797943 DOI: 10.5946/ce.2013.46.5.552] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/13/2013] [Accepted: 08/19/2013] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.
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Affiliation(s)
- Prashant Kedia
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
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Abstract
The field of diagnostic and therapeutic endoscopic ultrasound (EUS) is growing rapidly. Although EUS has enhanced our ability to diagnose and treat a wide variety of GI conditions, there are many controversial issues regarding the appropriate application of EUS techniques. In this review we discuss five controversial topics in EUS: the utility of EUS in staging of esophageal and gastric cancer; selection of appropriate needle gauge for fine needle aspiration (FNA); use of the stylet in FNA; and the emerging role of contrast agents in endoscopic ultrasound.
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Affiliation(s)
| | - Tyler M. Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA., USA
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