Published online Sep 14, 2026. doi: 10.3748/wjg.118873
Revised: February 13, 2026
Accepted: April 13, 2026
Published online: September 14, 2026
Processing time: 218 Days and 9.7 Hours
Pancreatic cancer has one of the highest mortality rates among malignant tumors, with increasing prevalence and ranking sixth as the leading cause of cancer death worldwide. Histological diagnosis is made preferably by using tissue samples obtained with endoscopic ultrasound, using fine-needle aspiration (FNA) or fine-needle biopsy (FNB) needles. Currently, there are no studies comparing the sen
To compare the diagnostic yield for suspected solid pancreatic malignancies using 22-gauge FNA and FNB needles between general pathologists and experts in pancreaticobiliary cytology focus on positive detection rate.
Thirty patients were selected and underwent endoscopic ultrasound-guided punctures using FNA and FNB needles, for a total of 4 punctures per patient. All samples were analyzed by a general pathologist and an expert pathologist. Sensitivity was the diagnostic parameter evaluated.
Overall, 100 slides [83.3%, 95% confidence interval (CI): 75.9%-89.2%] were considered positive by general pathologists, while 95 slides (79.2%, 95%CI: 71.3%-85.7%) were considered positive by expert pathologists. General pathologists from the Hospital das Clínicas of the Medical School of the University of São Paulo and Hospital das Clínicas of the Medical School of Ribeirão Preto centers (high-volume centers) concluded that 90% of the samples (95%CI: 78%-96.5%) were positive, whereas those from the Hospital Geral de Fortaleza center (low-volume center) considered 70% of the samples positive (95%CI: 54.8%-82.4%). When comparing sensitivity between different needles and centers, and controlling for the expertise of the pathologist, FNB showed significantly superior performance for general pathologists (FNB: 85%, 95%CI: 62.1%-96.8% vs FNA: 55%, 95%CI: 31.5%-76.9%; P = 0.042).
In low-volume centers, the use of FNB may help improve the diagnostic sensi
Core Tip: The diagnostic yield of endoscopic ultrasound-guided tissue acquisition for solid pancreatic lesions is influenced by needle design, pathologist expertise, and institutional volume. This study shows that fine-needle biopsy provides superior diagnostic sensitivity compared with fine-needle aspiration when specimens are assessed by general pathologists, particularly in low-volume centers. These findings support fine-needle biopsy as a practical strategy to improve diagnostic reliability and reduce dependence on specialized cytopathology in routine clinical practice.
- Citation: Miranda Neto AA, Brunaldi VO, da Ponte Neto AM, Kemp R, dos Santos JS, Pádua JDB, Brunaldi MO, Oliveira FAA, Herculano Júnior JRL, Chacon DA, de Oliveira GHP, Ribeiro IB, Matuguma SE, de Moura EGH. Diagnostic performance of fine-needle aspiration vs fine-needle biopsy in solid pancreatic lesions based on pathologist expertise: A prospective multicenter trial. World J Gastroenterol 2026; 32(34): 118873
- URL: https://www.wjgnet.com/1007-9327/full/v32/i34/118873.htm
- DOI: https://dx.doi.org/10.3748/wjg.118873
Pancreatic cancer, an invasive malignant tumor with a higher prevalence in adult and older patients (aged 60 years to 85 years), carries a high morbidity and mortality rate[1]. Most tumors present at advanced stages, with ductal adenocarcinoma being the most common histological subtype (> 90% of cases)[2,3]. The histological diagnosis of suspected pancreatic malignancies is essential for planning cancer treatment. Among current diagnostic methods, endoscopic ultrasound (EUS) is preferred for its efficacy and safety in tissue sampling for histocytological diagnosis, using either fine-needle aspiration (FNA) or fine-needle biopsy (FNB)[4]. While FNA has demonstrated satisfactory diagnostic sensitivity and specificity[4-6], immediate on-site evaluation of samples by a cytopathologist can increase the diagnostic yield by up to 15%[4,7]. However, this practice is not feasible in most centers, potentially reducing diagnostic accuracy[8].
FNB can increase diagnostic accuracy by providing histological core samples for both cytological and architectural (histological) analysis[8]. Although preliminary studies did not demonstrate the superiority of FNB over FNA in determining the etiology of solid pancreatic lesions[9-12], recent research suggests that FNB may offer higher accuracy while requiring fewer needle passes[5,8,13,14], indicating superior tissue acquisition.
It is important to note that most published studies on this topic originate from highly specialized, high-volume centers, and pathologist expertise is known to be crucial for a high accuracy and diagnostic yield[7,15]. Current literature lacks data on the diagnostic performance of these needles by pathologists who are not experts in cytopathology. We hypo
This is a multicenter prospective trial designed in accordance with the updated CONSORT guidelines[16]. The participating centers were Hospital das Clínicas of the Medical School of the University of São Paulo (HC-FMUSP), Hospital das Clínicas of the Medical School of Ribeirão Preto (HC-FMRP), and Hospital Geral de Fortaleza (HGF). The study protocol was approved by the Research Ethics Committee of each participating center: HC-FMUSP, No. 37048419.6.1001.0068; HC-FMRP, No. 37048419.6.2002.5440; and HGF, No. 37048419.6.2001.5040. Each participant or accompanying person provided written informed consent prior to any procedures. The trial was registered at the Bra
Eligible participants were patients aged ≥ 18 years with a diagnosis of solid pancreatic lesions visualized on previous abdominal imaging (ultrasound, nuclear magnetic resonance, or computed tomography), and without a prior cytological or histological diagnosis. Patients were excluded from the study if they had suspected cystic lesions, tumors of the major duodenal papilla, or distal cholangiocarcinoma.
Patients were placed in the left lateral decubitus position and monitored with cardiovascular support, pulse oximetry, and oxygen inhalation via nasal catheter. Following deep sedation, a curved linear array echoendoscope (Olympus GF-UCT 180 or Pentax EG-3870UTK, Japan) was used to visualize and characterize the lesion. Subsequently, four EUS-guided punctures were performed per patient: Two using a 22-gauge FNA needle (22-gauge EUS-FNA ECO Needle, Micro-Tech Endoscopy, China) and two using a 22-gauge FNB needle (22-gauge FNB TridentTM EUS-FNB Needle, Micro-Tech Endoscopy, China). The first puncture in each set was performed as specified in the randomization sequence. A 20-mL vacuum pressure syringe technique was used for each puncture, and the needle was moved back and forth within the lesion at least 20 times. No pathologist was present in the endoscopy suite during the procedures.
The anatomopathologic examination of a complete specimen obtained after surgical intervention was considered the gold standard. Alternatively, patients were followed for up to 6 months, and their outcomes, such as distant metastases, palliation, or death, were monitored, as previously described in the literature[17,18].
Samples obtained through EUS-guided puncture were fixed in 10% buffered formalin and subdivided according to their macroscopic dimensions, as follows: Biopsies ≥ 1 mm underwent standard histological processing with paraffin embedding. The residual fixative medium from these vials was submitted for cytological processing, including preparation of agarose cell blocks for embedding. Biopsies < 1 mm underwent exclusively cytological processing, together with the fixative medium, for the preparation of agarose cell blocks.
All samples and the remaining fixative media were centrifuged at 1500 rpm for 10 minutes. The supernatant was discarded, and the cell pellet was transferred to Eppendorf tubes containing 1.5 mL of 3% agarose. The samples were centrifuged again at 1500 rpm for 10 minutes. The agarose-embedded cell pellet was cooled to 4 °C. After solidification, it was sectioned, placed into cassettes, and sent for standard histological processing with paraffin embedding[19].
Semi-serial 3-μm-thick sections were cut from each biopsy and paraffin-embedded specimen, at three different depth levels and stained with hematoxylin and eosin. The samples were evaluated by two independent pathologists: One specialized in pancreatic pathology and one general pathologist. The general pathologist receives broad training in anatomical pathology and is qualified to evaluate a wide variety of tissues and organs in common diseases. This professional plays an essential role in the daily diagnostic workflow and laboratory management. In contrast, the specialist pathologist has specific training in a particular area, a longer period of specialization, and dedicates much of their daily practice to a defined field of pathology; therefore, specialists are fewer in number compared to generalists.
Thirty participants were recruited from the three participating centers, with each center sequentially selecting ten individuals. Each patient underwent four punctures, two performed with an FNA needle and two with an FNB needle, resulting in 40 punctures per center. Each pass (puncture) was placed into a separate formalin-containing flask, yielding four slides per patient and a total of 120 slides. Each slide was evaluated by two pathologists, resulting in 240 analyses in total (Figure 1).
Individuals were recruited consecutively between March 2021 and July 2022, according to the demand at each center, with two patients scheduled for EUS-guided puncture on the same day. Before the study began, an independent researcher with no involvement in the trial created a complete randomization list using online software (http://www.random.org). The researcher prepared sealed, opaque envelopes containing the letters A, B, C, or D (block sizes of four), with a 1:1 allocation ratio. Each center received a copy of this complete list.
During the procedure, an independent researcher opened two sealed envelopes in the procedure room immediately before the first puncture. Each envelope contained a letter from A to D. The first envelope identified the flasks for the first needle, and the second envelope identified the flasks for the second needle. As predetermined, the FNA needle was used first, alternating with the FNB needle for the subsequent patient (randomized on a first-come, first-served basis). For example, in patient “1”, the FNA needle was used initially, with two flasks extracted (e.g., FA1 and FA2), followed by two flasks with the FNB needle (e.g., FB1 and FB2). Patient “2” followed the reverse order, using the FNB needle first (e.g., flasks FC1 and FC2) and the FNA needle used next (e.g., flasks FD1 and FD2) (Figure 2). Both patients and pathologists were blinded to the allocation and puncture sequences.
The eight flasks (four pairs) obtained were sent together to the pathology department for processing and analysis. Each pathologist independently evaluated each pair of flasks (considered one case) and issued a signed and dated diagnostic report (for example: Flasks A = ductal adenocarcinoma; flasks B = ductal adenocarcinoma; flasks C = chronic pancreatitis; flasks D = chronic pancreatitis). These reports were then forwarded to the endoscopy team (not blinded), which com
When the diagnoses were concordant, the pathology team was notified to officially release the report in the electronic medical record. In case of discordance, the blinding code was broken, due to ethical and clinical care considerations, to allow discussion between the pathologists and reach a final diagnosis. For the evaluation of diagnostic performance, however, the initial independent assessments were used. This methodology was adopted to prevent impressions derived from the analysis of material obtained with one needle from influencing the interpretation of the comparator needle.
After the procedures, patients were followed 24 hours, 7 days, and 6 months via telephone contact using their previously registered numbers. Relevant information for clinical evaluation and follow-up was recorded in spreadsheets created with Google Forms.
For descriptive analysis, qualitative variables were presented as absolute and relative frequencies with 95% confidence intervals (CIs). Quantitative continuous variables were presented as mean ± SD, whereas quantitative discrete variables were presented as median (interquartile range). Sensitivity, defined as the probability of a positive result in the presence of the disease (true positive rate), was the only diagnostic parameter evaluated. Sensitivity values were expressed as percentages with 95%CI, calculated using the exact Clopper-Pearson method. The absence of “non-diseased” individuals in the study precluded the evaluation of additional diagnostic parameters.
To test the hypothesis of equality between the observed sensitivities, a two-sample (binomial) proportion test based on normal approximation was performed. This is a nonparametric tool used to determine whether the observed proportion of successes in a sample differs significantly from an expected or hypothetical population proportion. This test provides test statistics, P value, and 95%CI. Diagnostic performance was further assessed according to needle type, pathologist expertise, and study center. All analyses were conducted with a two-sided α of 0.05 and 95%CI, using IBM SPSS 27, R Core Team (2023), and Excel 2022® (Microsoft Office, WA, United States).
Of the 30 participants included in the study, 63.3% (95%CI: 45.5%-78.7%) were women, with an age of 65 ± 12 years. The most common comorbidities were hypertension (53.3%, 95%CI: 35.9%-70.2%), type 2 diabetes (50%, 95%CI: 32.8%-67.2%), and overweight/obesity (23.3%, 95%CI: 11.1%-40.4%). Regarding imaging, computed tomography accounted for most suspected malignant lesions (66.7%, 95%CI: 48.9%-81.4%), while nuclear magnetic resonance corresponded to 30% (95%CI: 16%-47.7%). The lesions were mainly located in the pancreatic head and neck (70%, 95%CI: 52.3%-84%). Other characteristics are shown in Table 1.
| Variable | n (%) | 95%CI/mean ± SD |
| Sex | ||
| Male | 11 (36.7) | 21.3-54.5 |
| Female | 19 (63.3) | 45.5-78.7 |
| Age (years) | 65.0 ± 12.0 | |
| Comorbidities | ||
| Systemic arterial hypertension | 16 (53.3) | 35.9-70.2 |
| Type 2 diabetes mellitus | 15 (50.0) | 32.8-67.2 |
| Dyslipidemia | 3 (10.0) | 2.9-24.3 |
| Overweight or obesity | 7 (23.3) | 11.1-40.4 |
| Liver disease | 2 (6.7) | 1.4-19.7 |
| Pancreas disease | 1 (3.3) | 0.4-14.5 |
| Other1 | 14 (46.7) | 29.8-64.1 |
| Imaging | ||
| Suspicious lesion (NMR) | 9 (30.0) | 16.0-47.7 |
| Suspicious lesion (CT) | 20 (66.7) | 48.9-81.4 |
| Suspicious lesion (USG) | 1 (3.3) | 0.4-14.5 |
| Pancreatic lesion (head/neck) | 21 (70.0) | 52.3-84.0 |
| Pancreatic lesion (body/tail) | 9 (30.0) | 16.0-47.7 |
| Pancreatic lesion > 3 cm | 21 (70.0) | 52.3-84.0 |
| Dilated pancreatic duct | 13 (43.3) | 26.9-61.0 |
| Doppler signal | ||
| Hypervascularization | 13 (43.3) | 26.9-61.0 |
| Hypovascularization | 17 (56.7) | 39.0-73.1 |
| Post-procedure adverse events | ||
| Self-limiting bleeding | 2 (6.7) | 1.4-19.7 |
| Self-limiting pain | 2 (6.7) | 1.4-19.7 |
| Total examination duration (minutes) | 49.0 ± 18.0 | |
| Laboratory findings | ||
| Hemoglobin (g/dL) | 12.0 ± 2.1 | |
| Alkaline phosphatase (U/L) | 815.5 ± 1011.9 | |
| Gamma-GT (U/L) | 851.4 ± 895.6 | |
| Total bilirubin (mg/dL) | 9.5 ± 11.9 | |
| Direct bilirubin (mg/dL) | 6.9 ± 9.9 |
At the 6-month follow-up, 20 patients (66.6%) had died, 9 (30.0%) had initiated palliative care or had distant metastases, and 1 (3.3%) had undergone a surgical procedure (body-tail pancreatectomy) (Figure 3). Table 2 summarizes the findings of the analyses performed by both general and expert pathologists.
| Total sample | n (%) | 95%CI |
| General pathologist | ||
| Negative | 8 (6.7) | 3.2-12.2 |
| Positive | 100 (83.3) | 75.9-89.2 |
| Inconclusive | 12 (10.0) | 5.6-16.3 |
| Expert pathologist | ||
| Negative | 12 (10.0) | 5.6-16.3 |
| Positive | 95 (79.2) | 71.3-85.7 |
| Inconclusive | 13 (10.8) | 6.2-17.3 |
| HC-FMUSP sample | ||
| General pathologist | ||
| Negative | 0 | |
| Positive | 36 (90.0) | 78-96.5 |
| Inconclusive | 4 (10.0) | 3.5-22 |
| Expert pathologist | 0 | |
| Negative | 0 | |
| Positive | 35 (87.5) | 74.8-95.1 |
| Inconclusive | 5 (12.5) | 4.9-25.2 |
| HC-FMRP sample | ||
| General pathologist | ||
| Negative | 4 (10.0) | 3.5-22 |
| Positive | 36 (90.0) | 78-96.5 |
| Inconclusive | 0 | |
| Expert pathologist | ||
| Negative | 4 (10.0) | 3.5-22 |
| Positive | 36 (90.0) | 78-96.5 |
| Inconclusive | 0 | |
| HGF sample | ||
| General pathologist | ||
| Negative | 4 (10.0) | 3.5-22.0 |
| Positive | 28 (70.0) | 54.8-82.4 |
| Inconclusive | 8 (20.0) | 9.9-34.2 |
| Expert pathologist | ||
| Negative | 8 (20.0) | 9.9-34.2 |
| Positive | 24 (60.0) | 44.6-74.1 |
| Inconclusive | 8 (20.0) | 9.9-34.2 |
In the overall analysis, which included samples from all centers, 100 slides (83.3%, 95%CI: 75.9%-89.2%) were considered positive by general pathologists, while 95 slides (79.2%, 95%CI: 71.3%-85.7%) were considered positive by expert pathologists (Table 2). Figure 4A presents the sensitivity results; no statistically significant differences were observed between the 3 comparisons made.
In the stratified analysis, general pathologists from the HC-FMUSP and HC-FMRP centers concluded that 90% of the samples (95%CI: 78%-96.5%) were positive, whereas those from the HGF center considered 70% of the samples positive (95%CI: 54.8%-82.4%). Expert pathologists rated the samples as positive in 87.5% of cases (95%CI: 74.8%-95.1%) at the HC-FMUSP center, 90% (95%CI: 78%-96.5%) at the HC-FMRP center, and 60% (95%CI: 44.6%-74.1%) at the HGF center (Table 2).
As shown in Figure 4B, the sensitivity of the HGF center was significantly lower among general pathologists when compared to both the HC-FMRP (P = 0.045) and HC-FMUSP (P = 0.049) centers. This difference was slightly more pronounced among expert pathologists (HC-FMRP, P = 0.004; and HC-FMUSP, P = 0.011). Figure 4C illustrates the comparison between the different needles. FNB demonstrated significantly higher sensitivity (90%, 95%CI: 79.5%-96.2%) than FNA (76.7%, 95%CI: 63.9%-86.6%) (P = 0.020).
When comparing sensitivity between different needles and centers, and controlling for the expertise of the pathologist, FNB showed significantly superior performance at the HGF center for general pathologists (FNB: 85%, 95%CI: 62.1%-96.8% vs FNA: 55%, 95%CI: 31.5%-76.9%; P = 0.042). No significant difference was found in the other comparisons (Figure 4D). Regarding the histological diagnoses obtained by punctures per patient, 26 individuals (87%) were diagnosed with adenocarcinoma, 3 (10%) with neuroendocrine tumors, and 1 (3%) with solid pseudopapillary tumor (Frantz tumor).
The histopathological diagnosis of solid pancreatic lesions is crucial for tissue sampling that will ensure an accurate diagnosis and, consequently, proper management, especially when samples are obtained in the early stages of cancer, which correlate closely with prognosis[5]. High-quality samples increase diagnostic accuracy and prevent unnecessary surgery due to the invasive and potentially complicating nature of pancreatic cancer[5,20]. In this context, EUS plays a key role in tissue acquisition through EUS-guided punctures, combined with a subsequent careful evaluation by a pathologist.
The combination of EUS-guided punctures and pathological analysis is crucial for rapid and accurate diagnosis. Ensuring the best tools for this purpose is therefore essential. Effective diagnosis depends on a process that involves puncture technique, needle type, the method of tissue sampling and preparation, slide analysis, and pathologist expertise. This comprehensive approach distinguishes our research from previously published studies, which have focused primarily on the role of pathologist.
In our study, most slides were assessed as positive for malignancy by both general pathologists (83.3%) and expert pathologists (79.2%). Despite these numerical differences, the results were not statistically significant (P = 0.508), indicating no difference between the groups of pathologists. While this result is a limiting factor for the analysis, it is expected due to the epidemiological predominance of malignant tumors in solid pancreatic lesions. However, other benign conditions, such as chronic pancreatitis, autoimmune pancreatitis, and paraduodenal pancreatitis, may also be present (less frequently) and mimic tumors[21,22].
Regarding needle use, the literature indicates that FNA and FNB have similar sensitivity and specificity[9-12]. However, recent studies suggest that FNB may provide greater diagnostic accuracy and higher quality cytological samples with fewer needle passes[5,8,13,14]. Our study supports these findings, as we observed, in the overall analysis, a significantly higher sensitivity for FNB needles compared to FNA needles. However, a detailed analysis between needle types, pathologist expertise, and participating centers revealed that this difference in sensitivity was significant only at the HGF center, for the evaluation by general pathologists (85% vs 55%, P = 0.042).
The FNB provides a more intact tissue architecture, which facilitates material interpretation for non-specialists by preserving histology closer to the appearance of whole tissue. With FNA, however, cells are loose and disorganized, making analysis more challenging for non-specialists, who are generally more accustomed to evaluating structured tissue samples.
The classification of centers as “high- volume” or “low-volume” lacks supporting quantitative metrics. Differences in operators, equipment, or patient populations beyond pathologist expertise could confound the inter center comparisons. Heterogeneity among centers may influence comparative outcomes. The lower diagnostic yield at the HGF center may be associated with its status as a non-specialized center for pancreaticobiliary diseases and the resulting lower volume of examinations and procedures in this field. This leads to less experience in analysis among on-site pathologists, including experts. In contrast, high-volume centers such as HC-FMUSP and HC-FMRP have greater experience in analyzing solid pancreatic lesions, even among non-expert pathologists. This experience results in no statistically significant differences between needle types or pathologists at these centers. This finding is important as it supports the increased use of biopsy needles in centers with less expertise. By obtaining higher quality specimens and samples, less experienced pathologists could improve their diagnostic yield/performance in pancreaticobiliary cytology.
This study highlights the crucial, yet often underrecognized, role of the pathologist in the diagnostic algorithm for solid pancreatic lesions, particularly with regard to the analysis resulting from EUS-guided punctures of these lesions. While many studies focus on the comparison between FNB and FNA needles as the sole determinants of diagnostic yield, this study emphasizes that it is the pathologist’s diagnostic expertise, particularly in pancreaticobiliary pathology, that is ultimately crucial for establishing the correct diagnosis.
While the results of this study are encouraging, it is important to acknowledge its limitations. The small sample size, despite the increased power offered by four punctures per patient (totaling 120 punctures and 240 analyses), impacts the strength of our conclusions. Future studies with a larger number of patients may provide more robust results to support our findings. All patients included in the study had a confirmed diagnosis of malignancy, which aligns with existing literature. However, the absence of a “non-diseased” control group limited our analysis to sensitivity, which is consistent with the positive predictive value. Because we did not have any non-diseased patients in this study, it was not possible to assess the true accuracy of these professionals in diagnosing equivocal cases. For non-specialized pathologists, the lack of experience in evaluating this type of lesion may contribute to false alarms. This factor, potentially compounded by the limited number of patients and centers involved, also impacts the final evaluation.
Another limiting factor is the use of clinical follow-up of up to 6 months as a surrogate gold standard for the diagnosis of solid pancreatic neoplasms in patients with advanced disease and no curative treatment option, given the impossibility of obtaining a surgical specimen. Although this approach has been described in the literature[17,18], it is not equivalent to histological confirmation and, in some cases, may be insufficient for indolent tumors. Despite these limitations, we believe this work represents a promising foundation for future research. The inclusion of additional centers and patients may enrich literature with data on the role of the pathologist in the diagnostic algorithm for solid pancreatic lesions and may even corroborate or expand our current findings.
In low-volume centers, the use of FNB may help improve the diagnostic sensitivity of general pathologists. Further studies with a larger sample size are needed to confirm these findings.
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