Journal of Clinical and Experimental Gastroenterology

ISSN : 2833-1133

ISSN : 2833-1133

Mini Review | Open Access | Volume 3 | Issue 1 | 2024 | DOI No.: 10.46439/gastro.3.019

A comparison of endoscopic ultrasoundguided fine needle aspiration and fine needle biopsy for pancreatic masses, gastrointestinal subepithelial lesions, and lymph nodes

Patrick Yang1,Shireen Pais1, Zhongren Zhou2,*

1Westchester Medical Center / New York Medical College, Department of Internal Medicine, Valhalla, NY 10595, USA

2Robert Wood Johnson Medical School,Department of Pathology & Laboratory Medicine , Rutgers University, New Brunswick NJ 08903, USA

*Corresponding Author:
Zhongren Zhou
Robert Wood Johnson Medical School
Department of Pathology & Laboratory
Medicine , Rutgers University, New
Brunswick NJ 08903, USA
E-mail: zz442@rwjms.rutgers.edu

Received date: July 23, 2024; Accepted date: August 20, 2024

Citation: Yang P, Pais S, Zhou Z. A comparison of endoscopic ultrasoundguided fine needle aspiration and fine needle biopsy for pancreatic masses, gastrointestinal subepithelial lesions, and lymph nodes. J Clin Exp Gastroenterol. 2024;3(1):16-20.

Copyright: © 2024 Yang P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Abstract

Background: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is a well-established diagnostic tool to obtain tissue from solid pancreatic masses, gastrointestinal subepithelial lesions, lymph nodes, liver as well as other neighboring organs. EUS-TA has proven to have a major clinical impact in diagnosis and staging, decreasing the need for invasive diagnostic procedures, such as thoracoscopy, mediastinoscopy, laparoscopy and open surgery. EUS-TA includes endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and endoscopic ultrasound guided fine-needle biopsy (EUS-FNB). Both procedures are safe and yield high diagnostic value. Despite its high diagnostic yield, EUS-FNA limitations include the inability to determine histologic architecture, and a small quantitative sample which may be inadequate for further immunohistochemical staining or molecular testing. EUS-FNB, with its larger core biopsy needle, was designed to overcome these potential limitations. It remains unclear if EUS-FNB has truly overcome these obstacles, and the optimal selection of FNA or FNB in different clinical contexts for different lesions is yet to be determined. We present a review on studies examining EUS-FNA vs EUS-FNB.

Conclusion: For solid pancreatic masses, there is no difference in diagnostic accuracy or tissue cores rates when accompanied by rapid on-site evaluation (ROSE). The diagnostic yield is higher in FNB compared to FNA in cases where ROSE is not accessible. In addition, one study indicated that the combined approach of EUS-FNA + FNB resulted in a higher diagnostic yield than EUS-FNA alone, accompanied by a reduced number of needle passes required.

In solid gastrointestinal lesions, FNB is associated with a relatively better diagnostic adequacy and tissue cores rates, with less number of needle passes.

Regarding lymph node biopsy, the availability of prospective trials is limited. Based on the current literature, we would like to propose EUS-FNB as the recommended approach for lymph nodes.

Introduction

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was first introduced in 1991. It is often used in conjunction with rapid onsite evaluation (ROSE) by a pathologist to improve diagnostic ability [1,2]. EUS-FNA is now standard of care for sampling pancreatic solid masses, subepithelial lesions, and lymph nodes. The European Society of Gastroenterology and American Society of Gastroenterology recommends EUS-FNA as the first line for diagnosing pancreatic lesions [3-5].

In pancreatic adenocarcinoma, cytology is sufficient for diagnosis; meanwhile, other diseases such as neuroendocrine tumors, lymphoma, autoimmune pancreatitis, tuberculosis and mass-forming chronic pancreatitis, require core tissue samples and immunohistochemistry staining [6].

In an attempt to overcome the limitations of EUS-FNA, endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) was first introduced in the early 2000s to obtain tissue specimens as opposed to aspiration-based cytology. EUS-FNB is another technique that may hypothetically be superior by obtaining a core tissue sample. However, previous studies using the first- and second-generation biopsy needles reported no superior outcomes of EUS-FNB compared with EUS-FNA using conventional FNA needles [7-9]. In recent years, tissue acquisition using the third-generation biopsy needles, e.g. forward-facing bevel needles (Procore; COOK Medical, Bloomington, Indiana, USA), fork-tip needles (SharkCore; Medtronic, Dublin, Ireland) and Franseen needles (Acquire; Boston Scientific, Marlborough, Massachusetts, USA), for solid pancreatic lesions have been widely performed. This newer generation biopsy needle can obtain larger core tissue specimens which may lead to better yield for definitive diagnosis [10,11].

Besides pancreatic solid masses, other common indications for performing endoscopic ultrasound-guided EUS-FNA or EUS-FNB include the identification and staging of subepithelial lesions in the gastrointestinal (GI) tract, and the evaluation of lymphadenopathy associated with GI and lung cancers [12].

Methods

A review was performed based on literature search utilizing PUBMED and Google Scholar for comparison of EUS-FNA vs EUS-FNB for pancreatic masses, gastrointestinal subepithelial lesions, and peri-hepatic or peri-pancreatic lymph nodes due to lymphadenopathy.

Results

Pancreatic masses

Timely and accurate pathological diagnosis is a crucial initial step in the management of solid pancreatic masses. Adequate tissue sampling is essential to facilitate accuracy of diagnosis and avoid potentially unnecessary surgical procedures in some particular conditions, such as autoimmune pancreatitis and lymphoma [6,17,18]. While EUS-FNA has been the standard of care, EUS-FNB has been designed to retrieve larger tissue samples, with preserved architecture for histological assessment.

Khan et al. [13] searched several databases from inception to 10 April 2016 to identify studies comparing diagnostic yield of second generation FNB needles with standard FNA needles. Fifteen studies with a total of 1024 patients were included in the analysis. They found no significant difference in the diagnostic yield between FNA and FNB, when FNA is accompanied by ROSE. However, in the absence of ROSE, FNB is associated with a relatively better diagnostic adequacy in solid pancreatic lesions. Also, FNB required fewer passes to establish the diagnosis.

Similar findings were also demonstrated by Ayres et al. [14] in 2018, Hassan et al. in 2022 [15] and Li et al. [16] in 2022. Li et al searched for randomized controlled studies that reported the comparison of FNA and FNB in pancreatic solid mass. Outcome measures included diagnostic accuracy, number of needle passes, diagnostic adequacy, presence of tissue cores, and adverse events. Eighteen randomized control trial studies with a total of 2,718 patients (1,141 patients with EUS-FNA, 1,108 with EUS-FNB, and remaining 469 patients were sampled with both needles alternatively) were included in the meta-analysis. For solid pancreatic mass only, there was no difference in diagnostic accuracy or tissue cores rates [24,33].

Furthermore, in 2021, Gonzalez et al. [19] introduced a fresh perspective. They performed a retrospective chart review of all patients who underwent endoscopic ultrasound (EUS) at the Cleveland Clinic between January 2014 and September 2019. They included all adult patients who underwent either EUS-FNA or EUS-FNA + FNB for solid pancreatic or peri-pancreatic masses for the first time. The study showed that a combined strategy of conducting EUS-FNA followed by FNB in these pancreatic lesions led to a higher diagnostic yield, less number of needle passes, and fewer needles required compared to EUS-FNA alone. In addition, in 2024, the new study found that 71.4% of FNB-obtained samples were deemed adequate for molecular testing comparing to the 32.1% adequacy observed with FNA [34].

In conclusion, conflicting data exist among prospective studies evaluating the superiority of different EUS-TA techniques. Taken together, both methods provide overall high, and comparable, diagnostic accuracy and specimen adequacy for diagnosis. Adverse events, including bleeding, are rare in both techniques, with pancreatitis being the most common adverse event. Multiple trials have demonstrated that fewer passes are required for EUS-FNB compared to EUS-FNA. In addition, EUS-FNB demonstrated superiority in obtaining samples adequate for molecular testing compared to EUS-FNA. A combination approach with EUS-FNA + FNB was also shown to be superior to EUS-FNA alone in solid pancreatic masses. Further prospective studies are needed to validate these findings and the cost-effectiveness of this strategy.

Gastrointestinal subepithelial lesions

Neoplasms of the GI tract originating from the muscularis mucosa, submucosa, or muscularis propria are collectively known as subepithelial lesions (SEL). Initial diagnosis of SELs relies on EUS, which is the most accurate imaging modality for such lesions and can depict the individual histologic layers [21]. While certain SELs such as lipomas may have characteristic ultrasonic appearances, EUS alone is typically insufficient for definitive diagnosis of most SELs. Therefore, tissue sampling via FNA or FNB is necessary.

EUS-FNA stands as the most prevalent approach for acquiring SEL tissue originating from the submucosal and muscularis propria layers [20]. Nevertheless, the diagnostic precision of EUS-FNA varies, spanning from 34% to 93% [21,22]. Furthermore, the amount of tissue obtained by EUS-FNA is often insufficient for immunohistochemical staining required to distinguish different types of SEL [23].

There are limited comparative studies specifically dedicated to examining EUS-FNA and EUS-FNB in SELs, although several larger prospective trials included cohorts with SEL. One of the initial RCTs focused solely on SELs was conducted by Kim et al. [24], in a limited sample of 22 patients, the majority of which were ultimately diagnosed with gastric SELs originating from the muscularis propria. The patients were randomized into two groups, receiving either EUS-FNA or EUS-FNB, with the unique endpoint being the number of passes required to obtain macroscopically optimal core samples as evaluated by the endoscopist. The median number of needle passes necessary to achieve macroscopically optimal core sampling via EUS-FNB was notably lower compared to that required by EUS-FNA (2 vs 4). On the whole, the rates of retrieving macroscopically and histologically optimal core samples with EUS-FNB were 92% and 75% respectively, which was superior to that of EUS-FNA (30% and 20% respectively).

In a subsequent study by Iwai et al. [23] in 2017 also concentrating on gastric SEL originating from the muscularis propria, 24 patients were randomized to either receive EUS-FNA first followed by EUS-FNB or vice versa. The rate of accurate diagnosis on immunohistochemical staining tended to be higher for EUS-FNB (91.3%) compared to EUS-FNA (73.9%, P= 0.120), however, the study was limited by sample size, underpowered, and ultimately failed to reach statistical significance.

In a more extensive randomized controlled trial with 70 patients conducted in 2018 by Hedenstrom et al. [25], a similar superiority of EUS-FNB over EUS-FNA for SEL was observed. The EUS-FNB group had a diagnostic accuracy of 83% which was significantly higher than that of the EUS-FNA group at 49% (P<0.001).

A meta-analysis by Li et al. [16] also found that in SEL, FNB is associated with a relatively better diagnostic accuracy, diagnostic adequacy and tissue cores rates, and less number of needle passes.

On the other hand, a cohort of 18 patients with SEL from a study by Nagula et al. [26] showed no significant difference in diagnostic yield between EUS-FNA and EUS-FNB (83.3% vs 75%, P=0.754).

In summary, the majority of current clinical studies showed that FNB has a better diagnostic accuracy and higher tissue core rates with less number of needle passes required.

Lymphoadenopathy (peri-hepatic, peri-pancreatic)

Lymphadenopathy may result from various causes, including benign inflammatory and infectious conditions or malignant etiologies. Determining the etiology and elucidating the malignant potential of lymphadenopathy with tissue sampling is crucial for clinical management.

The sensitivity of EUS-FNA in obtaining an adequate tissue specimen for cytological evaluation is suboptimal, with reported rates of 88%-96% [27]. This is typically attributed to damaged lymph node architecture with FNA. Core biopsy is thought to preserve lymph node architecture which becomes increasingly valuable for diagnostic purposes when the differential diagnosis includes lymphoma, metastasis, mycobacterial infection, and sarcoidosis [27-31].

Similar to SELs, there were few published prospective RCTs dedicated to comparing EUS-FNA and EUS-FNB solely for lymph node biopsy. However, in a subgroup of lymph node biopsies (n = 46) in the aforementioned RCT by Nagula et al. [26], there was no difference between EUS-FNA and EUS-FNB in diagnostic yield (92.9% vs 94.4%) or number of passes needed for diagnosis (median 2, P = 0.43).

In a prospective study conducted by De Moura et al. [32], a comparison was made between EUS-FNA and EUS-FNB specifically for lymph node diagnosis. The study revealed comparable diagnostic accuracy between EUS-FNA and EUS-FNB (78.8% vs. 83.2%, P = 0.423). Notably, the specificity of EUS-FNB showed a significant superiority (100% vs. 93.62%, P = 0.01). Upon further subgroup analysis based on lymph node location, it was shown that EUS-FNB exhibited significantly higher sensitivity, specificity, and overall diagnostic accuracy for peri-hepatic lesions (88.9% vs. 70.5%, P = 0.038).

Collectively, these studies provide a significant foundation for further direct comparison trials, and advocates for the preference of EUS-FNB over EUS-FNA in lymph node biopsy, particularly for peri-hepatic lesions.

Conclusion

Endoscopic ultrasound tissue acquisition is routinely utilized in the evaluation of pancreatic masses, gastrointestinal subepithelial lesions, and lymph node biopsies. Based on the literature reviewed, we conclude the following: EUS-FNA and EUS-FNB both provide high diagnostic accuracy, with low technical failure and adverse events, and thus either technique can be utilized for EUS-TA of pancreatic lesions, subepithelial lesions, and lymph nodes.

For solid pancreatic masses, there is no difference in diagnostic accuracy or tissue cores rates when using ROSE. The diagnostic yield is higher in FNB compared to FNA in cases where ROSE is not accessible. In addition, a study indicated that the combined approach of EUS-FNA + FNB resulted in a higher diagnostic yield than EUS-FNA alone in solid pancreatic masses. FNB compared to FNA showed a reduced number of needle passes and more adequate tissue for molecular test.

In solid gastrointestinal lesions, FNB is associated with a relatively better diagnostic adequacy, diagnostic adequacy and tissue cores rates, and less number of needle passes.

Concerning lymph node biopsy, there is a scarcity of prospective trials, emphasizing the need for more extensive prospective studies. Based on the existing literature, we would like recommend EUS-FNB for lymph nodes.

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