Wet-suction versus slow-pull technique for endoscopic ultrasound-guided fine-needle biopsy: a multicenter, randomized, crossover trial

Abstract

Background It is unknown whether there is an advantage to using the wet-suction or slow-pull technique during endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) with new-generation needles. We aimed to compare the performance of each technique in EUS-FNB.

Methods This was a multicenter, randomized, single-blind, crossover trial including patients with solid lesions of ≥ 1 cm. Four needle passes with 22 G fork-tip or Franseen-type needles were performed, alternating the wet-suction and slow-pull techniques in a randomized order. The primary outcome was the histological yield (samples containing an intact piece of tissue of at least 550 μm). Secondary end points were sample quality (tissue integrity and blood contamination), diagnostic accuracy, and adequate tumor fraction.

Results Overall, 210 patients with 146 pancreatic and 64 nonpancreatic lesions were analyzed. A tissue core was retrieved in 150 (71.4 %) and 129 (61.4 %) cases using the wet-suction and the slow-pull techniques, respectively (P = 0.03). The mean tissue integrity score was higher using wet suction (P = 0.02), as was the blood contamination of samples (P < 0.001). In the two subgroups of pancreatic and nonpancreatic lesions, tissue core rate and tissue integrity score were not statistically different using the two techniques, but blood contamination was higher with wet suction. Diagnostic accuracy and tumor fraction did not differ between the two techniques.

Conclusion Overall, the wet-suction technique in EUS-FNB resulted in a higher tissue core procurement rate compared with the slow-pull method. Diagnostic accuracy and the rate of samples with adequate tumor fraction were similar between the two techniques.

Publication History

Received: 10 April 2022

Accepted after revision: 01 August 2022

Accepted Manuscript online:
01 August 2022

Article published online:
27 September 2022

• References

• 1 Dumonceau JM, Polkowski M, Larghi A. et al. European Society of Gastrointestinal Endoscopy. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. . Endoscopy 2011; 43: 897-912
• 2 Hikichi T, Irisawa A, Bhutani MS. et al. Endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic masses with rapid on-site cytological evaluation by endosonographers without attendance of cytopathologists. J Gastroenterol 2009; 44: 322-328
• 3 Polkowski M, Jenssen C, Kaye P. et al. Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline – March 2017. Endoscopy 2017; 49: 989-1006
• 4 Bang JY, Navaneethan U, Hasan MK. et al. Endoscopic ultrasound-guided specimen collection and evaluation techniques affect diagnostic accuracy. Clin Gastroenterol Hepatol 2018; 16: 1820-1828
• 5 Erickson RA, Sayage-Rabie L, Beissner RS. Factors predicting the number of EUS-guided fine-needle passes for diagnosis of pancreatic malignancies. Gastrointest Endosc 2000; 51: 184-190
• 6 Wani S. Basic techniques in endoscopic ultrasound-guided fine needle aspiration: role of a stylet and suction. Endosc Ultrasound 2014; 3: 17-21
• 7 Crinò SF, Bernardoni L, Manfrin E. et al. Endoscopic ultrasound features of pancreatic schwannoma. Endosc Ultrasound 2016; 5: 396-398
• 8 Gkolfakis P, Crinò SF, Tziatzios G. et al. Comparative diagnostic performance of end-cutting fine-needle biopsy needles for endoscopic ultrasound tissue sampling of solid pancreatic masses: a network meta-analysis. Gastrointest Endosc 2022; DOI: 10.1016/j.gie.2022.01.019.
• 9 Bang JY, Hebert-Magee S, Navaneethan U. et al. EUS-guided fine needle biopsy of pancreatic masses can yield true histology. Gut 2018; 67: 2081-2084
• 10 Crinò SF, Le Grazie M, Manfrin E. et al. Randomized trial comparing fork-tip and side-fenestrated needles for EUS-guided fine-needle biopsy of solid pancreatic lesions. Gastrointest Endosc 2020; 92: 648-658
• 11 Bang JY, Hebert-Magee S, Navaneethan U. et al. Randomized trial comparing the Franseen and Fork-tip needles for EUS-guided fine-needle biopsy sampling of solid pancreatic mass lesions. Gastrointest Endosc 2018; 87: 1432-1438
• 12 Ashat M, Klair JS, Rooney SL. et al. Randomized controlled trial comparing the Franseen needle with the Fork-tip needle for EUS-guided fine-needle biopsy. Gastrointest Endosc 2021; 93: 140-150
• 13 Facciorusso A, Del Prete V, Buccino VR. et al. Diagnostic yield of Franseen and Fork-Tip biopsy needles for endoscopic ultrasound-guided tissue acquisition: a meta-analysis. Endosc Int Open 2019; 7: E1221-E1230
• 14 Mohan BP, Shakhatreh M, Garg R. et al. Comparison of Franseen and fork-tip needles for EUS-guided fine-needle biopsy of solid mass lesions: a systematic review and meta-analysis. Endosc Ultrasound 2019; 8: 382-391
• 15 Dreyer SB, Jamieson NB, Evers L. et al. Feasibility and clinical utility of endoscopic ultrasound guided biopsy of pancreatic cancer for next-generation molecular profiling. Chin Clin Oncol 2019; 8: 16
• 16 Gleeson FC, Kerr SE, Kipp BR. et al. Targeted next generation sequencing of endoscopic ultrasound acquired cytology from ampullary and pancreatic adenocarcinoma has the potential to aid patient stratification for optimal therapy selection. Oncotarget 2016; 7: 54526-54536
• 17 Gleeson FC, Voss JS, Kipp BR. et al. Assessment of pancreatic neuroendocrine tumor cytologic genotype diversity to guide personalized medicine using a custom gastroenteropancreatic next-generation sequencing panel. Oncotarget 2017; 8: 93464-93475
• 18 Rimbaş M, Crino SF, Gasbarrini A. et al. EUS-guided fine-needle tissue acquisition for solid pancreatic lesions: finally moving from fine-needle aspiration to fine-needle biopsy?. Endosc Ultrasound 2018; 7: 137-140
• 19 Chen JY, Ding QY, Lv Y. et al. Slow-pull and different conventional suction techniques in endoscopic ultrasound-guided fine-needle aspiration of pancreatic solid lesions using 22-gauge needles. World J Gastroenterol 2016; 22: 8790-8797
• 20 Bor R, Vasas B, Fábián A. et al. Prospective comparison of slow-pull and standard suction techniques of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of solid pancreatic cancer. BMC Gastroenterol 2019; 19: 6
• 21 Attam R, Arain MA, Bloechl SJ. et al. “Wet suction technique (WEST)”: a novel way to enhance the quality of EUS-FNA aspirate. Results of a prospective, single-blind, randomized, controlled trial using a 22-gauge needle for EUS-FNA of solid lesions.. Gastrointest Endosc 2015; 81: 1401-1407
• 22 Capurso G, Archibugi L, Petrone MC. et al. Slow-pull compared to suction tech-nique for EUS-guided sampling of pancreatic solid lesions: a meta-analysis of randomized controlled trials. Endosc Int Open 2020; 8: E636-E643
• 23 Wang Y, Wang RH, Ding Z. et al. Wet- versus dry-suction techniques for endoscopic ultrasound-guided fine-needle aspiration of solid lesions: a multicenter randomized controlled trial. Endoscopy 2020; 52: 995-1003
• 24 Mendoza Ladd A, Casner N, Cherukuri SV. et al. Fine needle biopsies of solid pancreatic lesions: tissue acquisition technique and needle design do not impact specimen adequacy. Dig Dis Sci 2021; DOI: 10.1007/s10620-021-07316-4.
• 25 Bang JY, Magee SH, Ramesh J. et al. Randomized trial comparing fanning with standard technique for endoscopic ultrasound‐guided fine‐needle aspiration of solid pancreatic mass lesions. Endoscopy 2013; 45: 445-450
• 26 Di Leo M, Crinò SF, Bernardoni L. et al. EUS-guided core biopsies of pancreatic solid masses using a new fork-tip needle: a multicenter prospective study. Dig Liver Dis 2019; 51: 1275-1280
• 27 Fabbri C, Luigiano C, Maimone A. et al. Endoscopic ultrasound-guided fine-needle biopsy of small solid pancreatic lesions using a 22-gauge needle with side fenestration. Surg Endosc 2015; 29: 1586-1590
• 28 Armellini E, Manfrin E, Trisolini E. et al. Histologic retrieval rate of a newly designed side-bevelled 20G needle for EUS-guided tissue acquisition of solid pancreatic lesions. United European Gastroenterol J 2019; 7: 96-104
• 29 Crinò SF, Di Mitri R, Nguyen NQ. et al. Endoscopic ultrasound-guided fine-needle biopsy with or without rapid on-site evaluation for diagnosis of solid pancreatic lesions: a randomized controlled non-inferiority trial. Gastroenterology 2021; 161: 899-909
• 30 Crinò SF, Larghi A, Bernardoni L. et al. Touch imprint cytology on endoscopic ultrasound fine-needle biopsy provides comparable sample quality and diagnostic yield to standard endoscopic ultrasound fine-needle aspiration specimens in the evaluation of solid pancreatic lesions. Cytopathology 2019; 30: 179-186
• 31 Alatawi A, Beuvon F, Grabar S. et al. Comparison of 22G reverse-beveled versus standard needle for endoscopic ultrasound-guided sampling of solid pancreatic lesions. United European Gastroenterol J 2015; 3: 343-352
• 32 Wani S, Muthusamy VR, McGrath CM. et al. AGA White Paper: Optimizing endoscopic ultrasound-guided tissue acquisition and future directions. Clin Gastroenterol Hepatol 2018; 16: 318-327
• 33 Pitman MB, Layfield L. The Papanicolaou Society of Cytopathology system for reporting pancreaticobiliary cytology. Switzerland: Springer International Publishing; 2015: 6
• 34 Facciorusso A, Bajwa HS, Menon K. et al. Comparison between 22G aspiration and 22G biopsy needles for EUS-guided sampling of pancreatic lesions: a meta-analysis. Endosc Ultrasound 2020; 9: 167-174
• 35 Facciorusso A, Sunny SP, Del Prete V. et al. Comparison between fine-needle biopsy and fine-needle aspiration for EUS-guided sampling of subepithelial lesions: a meta-analysis. Gastrointest Endosc 2020; 91: 14-22
• 36 Machin D, Campbell MJ, Fayers P, Pinol A. Sample size tables for clinical studies (2nd edn.). Oxford: Blackwell Science; 1997
• 37 Kahan BC. Accounting for centre-effects in multicentre trials with a binary outcome – when, why, and how?. BMC Med Res Methodol 2014; 14: 20
• 38 Schulz KF, Altman DG, Moher D. for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. Open Med 2010; 4: 60-68
• 39 Bang JY, Krall K, Jhala N. et al. Comparing needles and methods of endoscopic ultrasound-guided fine-needle biopsy to optimize specimen quality and diagnostic accuracy for patients with pancreatic masses in a randomized trial. Clin Gastroenterol Hepatol 2021; 19: 825-835
• 40 Crinò SF, Conti Bellocchi MC, Bernardoni L. et al. Diagnostic yield of EUS-FNA of small (≤15 mm) solid pancreatic lesions using a 25-gauge needle. Hepatobiliary Pancreat Dis Int 2018; 17: 70-74