David H. Robbins

Diagnostic yield and safety of jumbo biopsy forceps in patients with subepithelial lesions of the upper and lower GI tract

BACKGROUNDnEUS-FNA often fails to make a definitive diagnosis in the evaluation of subepithelial lesions. The addition of jumbo biopsy forceps has the potential to improve diagnostic yield, but published series are limited.nnnOBJECTIVEnTo assess the likelihood of definitive diagnosis for subepithelial lesions by using jumbo biopsy forceps during EUS examination.nnnDESIGNnPooled retrospective analysis.nnnSETTINGn6 tertiary referral centers.nnnPATIENTSnAll patients having undergone EUS examination for a subepithelial lesion in which jumbo biopsy forceps were used for tissue acquisition.nnnMAIN OUTCOME MEASUREMENTSnDiagnostic yield of jumbo biopsy forceps use, complication rates, and comparison of diagnostic yield with that of EUS-FNA.nnnRESULTSnA total of 129 patients underwent EUS with jumbo biopsy forceps; 31 patients (24%) had simultaneous EUS-FNA. The lesion locations were stomach (n = 98), esophagus (n = 14), duodenum (n = 11), colon (n = 5), and jejunum (n = 1). The average lesion size was 14.9 mm ± 9.3 mm. Overall, definitive diagnosis was obtained in 87 of 129 patients (67.4%) by using either method. A definitive diagnosis was provided by jumbo biopsy forceps use in 76 of 129 patients (58.9%) and by FNA in 14 of 31 patients (45.1%) (P = .175). The results in third-layer lesions were definitive with jumbo biopsy forceps in 56 of 86 lesions (65.1%) and with FNA in 6 of 16 lesions (37.5%) (P = .047). For fourth-layer lesions, the results with jumbo biopsy forceps were definitive in 10 of 25 (40.0%) and with FNA in 8 of 14 (57.1%) (P = .330). Forty-five of 129 patients (34.9%) experienced significant bleeding after biopsy with jumbo forceps and required some form of endoscopic hemostasis.nnnLIMITATIONSnRetrospective study.nnnCONCLUSIONSnJumbo forceps are a useful tool for the definitive diagnosis of subepithelial lesions. The greatest benefit appears to be with third-layer (submucosal) lesions. The risk of bleeding is significant.

Comparing EUS-Fine Needle Aspiration and EUS-Fine Needle Biopsy for Solid Lesions: A Multicenter, Randomized Trial

BACKGROUND & AIMS Endoscopic ultrasound with fine‐needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the gastrointestinal tract. Fine‐needle biopsy (FNB) may provide higher diagnostic yield with fewer needle passes. The aim of this study was to assess the difference in diagnostic yield between FNA and FNB. METHODS This is a multicenter, prospective randomized clinical trial from 6 large tertiary care centers. Patients referred for tissue sampling of solid lesions were randomized to either FNA or FNB of the target lesion. Demographics, size, location, number of needle passes, and final diagnosis were recorded. RESULTS After enrollment, 135 patients were randomized to FNA (49.3%), and 139 patients were randomized to FNB (50.7%).The following lesions were sampled: mass (n = 210, 76.6%), lymph nodes (n = 46, 16.8%), and submucosal tumors (n = 18, 6.6%). Final diagnosis was malignancy (n = 192, 70.1%), reactive lymphadenopathy (n = 30, 11.0%), and spindle cell tumors (n = 24, 8.8%). FNA had a diagnostic yield of 91.1% compared with 88.5% for FNB (P = .48). There was no difference between FNA and FNB when stratified by the presence of on‐site cytopathology or by type of lesion sampled. A median of 1 needle pass was needed to obtain a diagnostic sample for both needles. CONCLUSIONS FNA and FNB obtained a similar diagnostic yield with a comparable number of needle passes. On the basis of these results, there is no significant difference in the performance of FNA compared with FNB in the cytologic diagnosis of solid lesions adjacent to the gastrointestinal tract. ClinicalTrials.gov identifier: NCT01698190.

Comparison of Endoscopic Ultrasound–Fine-needle Aspiration and Endoscopic Ultrasound–Fine-needle Biopsy for Solid Lesions in a Multicenter, Randomized Trial

BACKGROUND & AIMS Endoscopic ultrasound with fine‐needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the gastrointestinal tract. Fine‐needle biopsy (FNB) may provide higher diagnostic yield with fewer needle passes. The aim of this study was to assess the difference in diagnostic yield between FNA and FNB. METHODS This is a multicenter, prospective randomized clinical trial from 6 large tertiary care centers. Patients referred for tissue sampling of solid lesions were randomized to either FNA or FNB of the target lesion. Demographics, size, location, number of needle passes, and final diagnosis were recorded. RESULTS After enrollment, 135 patients were randomized to FNA (49.3%), and 139 patients were randomized to FNB (50.7%).The following lesions were sampled: mass (n = 210, 76.6%), lymph nodes (n = 46, 16.8%), and submucosal tumors (n = 18, 6.6%). Final diagnosis was malignancy (n = 192, 70.1%), reactive lymphadenopathy (n = 30, 11.0%), and spindle cell tumors (n = 24, 8.8%). FNA had a diagnostic yield of 91.1% compared with 88.5% for FNB (P = .48). There was no difference between FNA and FNB when stratified by the presence of on‐site cytopathology or by type of lesion sampled. A median of 1 needle pass was needed to obtain a diagnostic sample for both needles. CONCLUSIONS FNA and FNB obtained a similar diagnostic yield with a comparable number of needle passes. On the basis of these results, there is no significant difference in the performance of FNA compared with FNB in the cytologic diagnosis of solid lesions adjacent to the gastrointestinal tract. ClinicalTrials.gov identifier: NCT01698190.

Comparing Endoscopic Ultrasound–Fine-needle Aspiration and Endoscopic Ultrasound–Fine-needle Biopsy for Solid Lesions: A Multicenter, Randomized Trial—The New York Endoscopic Research Outcomes Group (NYERO)

BACKGROUND & AIMS Endoscopic ultrasound with fine‐needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the gastrointestinal tract. Fine‐needle biopsy (FNB) may provide higher diagnostic yield with fewer needle passes. The aim of this study was to assess the difference in diagnostic yield between FNA and FNB. METHODS This is a multicenter, prospective randomized clinical trial from 6 large tertiary care centers. Patients referred for tissue sampling of solid lesions were randomized to either FNA or FNB of the target lesion. Demographics, size, location, number of needle passes, and final diagnosis were recorded. RESULTS After enrollment, 135 patients were randomized to FNA (49.3%), and 139 patients were randomized to FNB (50.7%).The following lesions were sampled: mass (n = 210, 76.6%), lymph nodes (n = 46, 16.8%), and submucosal tumors (n = 18, 6.6%). Final diagnosis was malignancy (n = 192, 70.1%), reactive lymphadenopathy (n = 30, 11.0%), and spindle cell tumors (n = 24, 8.8%). FNA had a diagnostic yield of 91.1% compared with 88.5% for FNB (P = .48). There was no difference between FNA and FNB when stratified by the presence of on‐site cytopathology or by type of lesion sampled. A median of 1 needle pass was needed to obtain a diagnostic sample for both needles. CONCLUSIONS FNA and FNB obtained a similar diagnostic yield with a comparable number of needle passes. On the basis of these results, there is no significant difference in the performance of FNA compared with FNB in the cytologic diagnosis of solid lesions adjacent to the gastrointestinal tract. ClinicalTrials.gov identifier: NCT01698190.

Role of EUS in Mediastinal Nodes, Masses, Cysts, and Lung Cancer

Full minimally invasive evaluation of all lymph node stations (with the exception of station 6) is now possible with the advent of endobronchial and trans-esophageal endoscopic ultrasound. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) allows sampling of mediastinal lymph nodes relevant to lung cancer staging, particularly in the subcarinal area (station 7), lower para-esophageal lymph nodes (station 8), inferior pulmonary ligament lymph nodes (station 9), and celiac lymph nodes. EUS-FNA is an extremely powerful nonsurgical option for sampling metastatic nodes, sarcoidosis, and lymphoma. Both adrenal glands can be sampled by EUS-FNA through the trans-gastric approach or the trans-duodenal approach. EUS-FNA is also able to sample central primary lung masses abutting the esophagus, particularly when other techniques fail. EBUS-FNA has the distinct advantage to reach areas that have proven inaccessible to EUS. These stations include the right and left upper and lower para-tracheal areas (4R and 4L; 2R and 2L), right and left hilar areas (station 10) and the right and left interlobar stations (station 11). It is best to work in a multidisciplinary fashion with colleagues in thoracic surgery, pulmonary, radiology, and oncology to individualize the best staging approach for the patient.