1. Comparison of Franseen and fork-tip needles for EUS-guided fine-needle biopsy of solid mass lesions: A systematic review and meta-analysis.

Mohan BP, et al. Endosc Ultrasound. 2019 Nov-Dec;8(6):382-391. doi: 10.4103/eus.eus_27_19.

KEY POINTS

  • The aim of this study was to compare the rates of diagnostic-yield between Franseen and fork-tip needles for EUS-guided fine-needle biopsy (FNB).
  • Systematic review and meta-analysis; 23 studies included, 1632 patients underwent FNB for solid organ of the GI tract (740 patients underwent Fork-tip needle FNB; 942 patients underwent Franseen-tip needle FNB).
  • The overall rate of FNB diagnostic yield was 92.8% and there was no difference in the diagnostic-yield rate for Fork-tip and Franseen-tip needles (92.8% vs. 92.7%, P = 0.98). 
  • There was no difference in the diagnostic yield with ≤2 needle‐passes as compared to >2 needle-passes (89.8% vs. 93.2%, P = 0.50) and with ROSE as compared to without ROSE (93.7% vs 95.9%, P = 0.25). 
  • The overall rate of adverse events was 4.2% (3.7% with Franseen-tip needle vs. 6.2% with Fork-tip needle, P = 0.31). 
  • Both Franseen-tip and Fork-tip needles show similar diagnostic yield, with comparable adverse events; they provide an adequate sample with ≤ 2 needle-passes and obviate the need for ROSE.

ABSTRACT

Franseen-tip and Fork-tip needles have been widely used in EUS guided fine-needle biopsy (FNB) of solid organs. There is conflicting data on the performance of these needles and unanswered questions on the ideal number of needle-passes and the requirement of an onsite cytopathologist (ROSE). We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through July 2018) to identify studies that reported on the use of Forktip and Franseen-tip needles in EUS-FNB of solid organs. The primary outcome was to estimate and compare the pooled rates of diagnostic-yield. A subgroup analysis compared the outcomes based on the number of needle-passes and the availability of ROSE. A total of 23 study-arms were available for analysis. The pooled rate of diagnostic yield with Fork-tip needle was 92.8% (95% CI 85.3 – 96.6, I2 = 73.1) and the pooled rate of diagnostic yield with Franseen-tip needle was 92.7% (95% CI 86.4 – 96.2, I2 = 88.4).

 

2. Impact of metal and plastic stents on endoscopic ultrasound-guided aspiration cytology and core histology of head of pancreas masses

Bekkali NLH, et al. Endoscopy. 2019 Nov;51(11):1044-1050. doi: 10.1055/a-0824-6982. 

KEY POINTS

  • The aim of this study was to assess whether stents impair fine-needle aspiration (FNA) or fine-needle biopsy (FNB).
  • 631 patients with a solid mass in the head of the pancreas who underwent EUS-guided tissue sampling were included; 141 had SEMS, 149 had plastic stents, and 341 had no stent.
  • SEMS were associated with an increased occurrence of incorrect diagnosis of EUS tissue sampling (OR 1.96).
  • Increasing tumor size (OR 0.72), increasing number of passes (OR 0.84), and fork-tip biopsy needle (OR 0.52) were independently associated with a decrease in incorrect diagnosis. 
  • SEMS use had a negative impact on tissue diagnosis in pancreatic head masses.

ABSTRACT

Background Stents are frequently placed in patients with biliary obstruction due to a mass in the head of the pancreas. The impact of plastic or self-expandable metal stents (SEMSs) on endoscopic ultrasound (EUS)-guided tissue sampling is unclear. This study aimed to assess, using strict pathological criteria, whether stents impair fine-needle aspiration (FNA) or fine-needle biopsy (FNB).

Methods All patients with a solid mass in the head of the pancreas who underwent EUS-guided tissue sampling between 2010 and 2016 at our unit were included. Factors with possible impact on diagnostic performance were analyzed using logistic regression. Analysis was performed using both strict (malignant only) and less strict (suspicious for malignancy) cutoffs.

Results Of 631 individuals undergoing 698 procedures, 535 (84.8 %) had a final diagnosis of malignancy, 141 had SEMS, 149 had plastic stents, and 341 had no stent. Using strict criteria, SEMS were associated with an increased occurrence of incorrect diagnosis of EUS tissue sampling, with an odds ratio (OR) of 1.96 (95 % confidence interval [CI] 1.24 – 3.10). Increasing tumor size (OR 0.72, 95 %CI 0.59 – 0.87), increasing number of passes (OR 0.84, 95 %CI 0.72 – 0.99), and fork-tip biopsy needle (OR 0.52, 95 %CI 0.31 – 0.86) were independently associated with a decrease in incorrect diagnosis. Repeat tissue sampling was more common with SEMSs (10.2 %) than with plastic stents (2.9 %) or no stents (4.5 %) (P < 0.02).

Conclusion SEMS use had a negative impact on tissue diagnosis in pancreatic head masses, whereas use of a fork-tip biopsy needle and increasing number of passes were independently associated with improved accuracy.

 

3. Main duct and mixed type intraductal papillary mucinous neoplasms without enhancing mural nodules: Duct diameter of less than 10 mm and segmental dilatation of main pancreatic duct are findings support surveillance rather than immediate surgery

Kim TH, et al. Pancreatology. 2019 Dec;19(8):1054-1060. doi: 10.1016/j.pan.2019.09.010. 

KEY POINTS

  • The aim of this study was to identify the rates of high-grade dysplasia (HGD) and invasive carcinoma according to the morphological features of the main pancreatic duct (MPD) in patients with MD and mixed IPMN.
  • Retrospective study; 259 patients with histologically proven MD and mixed-type IPMNs who underwent surgery.
  • MPD diameter of ≥10 mm (OR 2.5; P = 0.02], diffuse MPD dilatation (OR 3.2; P = 0.02), and presence of enhancing MNs (11% vs 70%; OR 9.6; P < 0.0001) were significant predictors of HGD and invasive carcinoma.
  • Patients without enhancing MN and having both segmental MPD dilatation and MPD diameter of <10 mm show a low rates of HGD and invasive carcinoma (3.8%) and watchful follow-up instead of immediate surgical resection might be possible in these patients.

ABSTRACT

Objective The guidelines for pancreatic intraductal papillary mucinous neoplasms (IPMNs) recommend surgical resection of all main-duct (MD) and mixed-type IPMNs in surgically fit patients. We conducted this study to identify the rates of high-grade dysplasia (HGD) and invasive carcinoma according to the morphological features of the main pancreatic duct (MPD) in patients with MD and mixed IPMN.

Methods We performed a retrospective study of 259 patients with histologically proven MD and mixed-type IPMNs who underwent surgery at six academic institutions.

Results The rate of HGD and invasive carcinoma was 11.1% (24/216) in patients without enhancing mural nodules (MNs) and 69.8% (30/43) in patients with MNs. Multivariate analysis showed that MPD diameter of ≥10 mm [odds ratio (OR), 2.5; 95% confidence interval (CI), 1.155–5.505; P = 0.02], diffuse MPD dilatation (OR, 3.2; 95% CI, 1.152–8.998; P = 0.02), and presence of enhancing MNs in MPD (OR, 9.6; 95% CI, 3.928–23.833, P < 0.0001) were significant predictors of HGD and invasive carcinoma. Of the 216 patients without enhancing MNs, 79 patients (36.6%) having both segmental MPD dilatation and MPD diameter of <10 mm showed significantly lower rates of HGD and invasive carcinoma (3/79, 3.8%) than patients having both diffuse MPD dilatation and MPD diameter ≥10 mm (9/36, 25%, P = 0.001).

Conclusions MD and mixed-type IPMNs having segmental MPD dilatation with MPD dilation <10 mm and no enhancing MNs on imaging showed a significantly lower rate of HGD and invasive carcinoma, and watchful follow-up instead of immediate surgical resection might be possible in these patients.

 

4. What is the outcome of patients affected by Intraductal Papillary Mucinous Neoplasms without high-risk stigmata? A single-center retrospective study

Ricci C, et al. Pancreas. 2019 Oct;48(9):1167-1174. doi: 10.1097/MPA.0000000000001388.

KEY POINTS

  • The aim of this study was to define the natural history of IPMN without high-risk stigmata (HRS).
  • Retrospective study; 356 patients affected by IPMNs without HRS.
  • 53 patients (14.9%) died: 6 patients from pancreatic cancer (1.7%) and 47 from reasons not related to the disease (13.2%).
  • The years of life lost with respect to the general population were 2 years and 3 months (15 years and 3 months vs 17 years and 6 months). 
  • Younger age (<65 years), follow-up more than 3 years, and surgery significantly increased the years of life lost.
  • The patients affected by IPMNs without HRS rarely died from the disease. 

ABSTRACT

Objectives The objectives of the study were to define the natural history of intraductal papillary mucinous neoplasms (IPMNs) without high-risk stigmata (HRS) and to identify factors capable of influencing outcome and management.

Methods This is a retrospective study of patients affected by IPMNs without HRS. Survival analyses included overall survival, disease-specific survival, and years of life lost. Uni- and multivariate analyses were carried out to identify factors capable of predicting years of life lost.

Results Three hundred fifty-six patients were analyzed. Fifty-three patients (14.9%) died: no postoperative mortality, 6 (1.7%) patients from pancreatic cancer and 47 (13.2%) from reasons not related to the disease. Mean overall survival and disease-specific survival were 199.4 (SD, 16.6) and 281 months (SD, 6.9), respectively. The years of life lost of the sample observed with respect to the general population were 2 years and 3 months (15 years and 3 months vs 17 years and 6 months). Younger age, length of follow-up more than 3 years, and surgery significantly increased the years of life lost.

Conclusions The patients affected by IPMNs without HRS rarely died from the disease. Young age (<65 years) and follow-up more than 3 years seemed to be the only factors capable of influencing the outcome and management.