Endoscopy 2020; 52(12): 1091-1092
DOI: 10.1055/a-1243-0687
Editorial

Tissue is the issue?

Referring to Seicean A et al. p. 1084–1090
Anthony Yuen Bun Teoh
Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
› Author Affiliations

In the randomized crossover study by Seicean et al., the authors compared endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) with or without contrast-enhanced harmonic imaging (CE-EUS) [1]. With the use of CE-EUS, the authors postulated that any necrotic area could be visualized and avoided during FNA, resulting in improved diagnostic accuracy. However, after completion of the study, the authors noted that the diagnostic accuracies were similar between the two groups and the combined diagnostic rate after two passes was 93.8 %. The results remained similar after subgroup analysis on mass location, presence of necrosis, portal hypertension, biliary stenting, and diagnosis.

“...newer adjuncts to further improve the diagnostic accuracy of EUS-FNA are currently being utilized and these adjuncts may be more important than contrast-enhanced EUS in improving outcomes. These include rapid on-site cytopathology, macroscopic on-site evaluation, and fine-needle biopsy needles.”

The results of this study contrast with those reported in two other studies assessing the role of CE-EUS-guided FNA. In a randomized trial that included 40 patients comparing EUS-FNA with or without contrast-enhanced harmonic imaging for solitary pancreatic lesions, the authors reported significantly fewer needle passes required to make a diagnosis with CE-EUS [2]. However, the reported first pass diagnostic rate was unusually low in both groups (CE-EUS vs. EUS: 60 % vs. 25 %, P = 0.03) and the diagnostic accuracy only reached 90 % after three or more passes in both groups. Similarly, in a prospective study that included 93 patients, the authors concluded that CE-EUS improved FNA outcomes compared with conventional EUS-FNA. However, the reported first pass rates of adequate sampling and sensitivity in the conventional arm was also low (CE-EUS vs. EUS: 84.9 % vs. 68.8 %, P = 0.003 and 76.5 % vs. 58.8 %, P = 0.01, respectively) [3]. Thus, the results of these studies may be misleading in suggesting the superiority of CE-EUS.

CE-EUS can produce interesting EUS images. The modality was reported to allow characterization of specific types of pathologies, including mural nodules in pancreatic cysts, neuroendocrine tumors, and malignant behavior of gastrointestinal tumors. However, the added value in EUS-FNA appears to be limited, according to the current study. This can be partly explained by the fact that both arms had obtained high diagnostic accuracies on the first pass and it was difficult to further improve this with the use of CE-EUS. In addition, newer adjuncts to further improve the diagnostic accuracy of EUS-FNA are now being utilized and these adjuncts may be more important than CE-EUS in improving outcomes. These include rapid on-site cytopathology (ROSE), macroscopic on-site evaluation (MOSE), and fine-needle biopsy (FNB) needles.

ROSE is commonly employed in North America and the practice was shown to be associated with almost 90 % diagnostic accuracy with reduced number of passes compared with conventional EUS-FNA [4]. However, in the rest of the world, ROSE is often not available and hence MOSE has been developed [5]. MOSE involves macroscopically identifying at least a 4-mm white core within the specimen obtained from EUS-FNA on a glass slide to confirm adequacy of the sample. In a randomized study involving 244 patients, MOSE had a 92.6 % diagnostic yield and required significantly fewer passes compared with conventional FNA. In the latest development, FNB needles that are designed with multiple cutting surfaces on the needle tip were shown by several studies to result in improved diagnostic accuracy, sensitivity, and specificity. Furthermore, histological cores for pathological assessments can be obtained in the majority of patients with the use of these needles [6] [7] [8]. The next research question will then be whether MOSE with FNB needles could achieve similar diagnostic accuracies compared with ROSE. Studies to address this question are currently under way.

In conclusion, although CE-EUS allows characterization of specific pathologies, the role in guiding EUS-FNA seems to be limited. Furthermore, newer adjuncts to EUS-FNA may be more important than CE-EUS in improving outcomes.



Publication History

Article published online:
25 November 2020

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  • References

  • 1 Seicean A, Samarghitan A, Bolboacă SD. et al. Contrast-enhanced harmonic versus standard endoscopic ultrasound-guided fine-needle aspiration in solid pancreatic lesions: a single-center prospective randomized trial. Endoscopy 2020; 52: 1084-1090
  • 2 Sugimoto M, Takagi T, Hikichi T. et al. Conventional versus contrast-enhanced harmonic endoscopic ultrasonography-guided fine-needle aspiration for diagnosis of solid pancreatic lesions: a prospective randomized trial. Pancreatology 2015; 15: 538-541
  • 3 Itonaga M, Kitano M, Kojima F. et al. The usefulness of EUS-FNA with contrast-enhanced harmonic imaging of solid pancreatic lesions: a prospective study. J Gastroenterol Hepatol 2020; DOI: 10.1111/jgh.15144.
  • 4 Hebert-Magee S, Bae S, Varadarajulu S. et al. The presence of a cytopathologist increases the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology for pancreatic adenocarcinoma: a meta-analysis. Cytopathology 2013; 24: 159-171
  • 5 Chong CCN, Lakhtakia S, Nguyen N. et al. Endoscopic ultrasound-guided tissue acquisition with or without macroscopic on-site evaluation: randomized controlled trial. Endoscopy 2020; DOI: 10.1055/a-1172-6027.
  • 6 Oppong KW, Bekkali NLH, Leeds JS. et al. Fork-tip needle biopsy versus fine-needle aspiration in endoscopic ultrasound-guided sampling of solid pancreatic masses: a randomized crossover study. Endoscopy 2020; 52: 454-461
  • 7 Crino SF, Le Grazie M, Manfrin E. et al. Randomized trial comparing the fork-tip and the side-fenestrated needles for EUS-guided fine-needle biopsy of solid pancreatic lesions. Gastrointest Endosc 2020; DOI: 10.1016/j.gie.2020.05.016.
  • 8 Karsenti D, Palazzo L, Perrot B. et al. 22G Acquire vs. 20G Procore needle for endoscopic ultrasound-guided biopsy of pancreatic masses: a randomized study comparing histologic sample quantity and diagnostic accuracy. Endoscopy 2020; DOI: 10.1055/a-1160-5485.