The Dilemma of Endoscopic Ultrasound–Guided Tissue Acquisition in Resource-Limited Settings: Precision or Access?

The diagnostic evaluation of solid pancreatic mass lesions remains one of the most challenging issues in gastroenterology practice.[1] Endoscopic ultrasound (EUS)–guided tissue acquisition has improved our ability to diagnose pancreatic mass lesions, and over the past decade, the development of fine-needle biopsy (FNB) needles has shifted practice patterns from cytology-based diagnosis toward histology-based diagnosis.[2] [3] However, whether this shift improves outcomes across all health care settings—particularly those with limited resources—remains an unresolved dilemma.

A prospective, randomized pilot study by Nayak et al in the current issue of the journal provides valuable insight by comparing EUS-guided fine-needle aspiration (FNA) and EUS-guided FNB for solid pancreatic lesions from a low-resource tertiary care center.[4] By assessing diagnostic performance, safety, sample adequacy, and cost simultaneously, the study addresses real-world feasibility. The authors reported that EUS-FNB had a marginally higher diagnostic accuracy compared with EUS-FNA (95.2 vs. 90%). Although this numerical difference favors FNB, it did not reach statistical significance, and the sensitivity for detecting malignancy was nearly identical between the two modalities. These findings reinforce that contemporary EUS-FNA, when performed by experienced operators, continues to provide good diagnostic performance for pancreatic adenocarcinoma. The slightly higher specificity observed with FNB reflects the advantage of preserving tissue architecture, which is especially helpful in reducing interpretive ambiguity in inflammatory conditions.[5] However, the limited number of benign lesions in this pilot study necessitates cautious interpretation of this finding.

A major advantage of FNB is its ability to procure core tissue suitable for histology, immunohistochemistry, and molecular testing.[6] While this is undeniably valuable in selected clinical contexts, the present study demonstrates that most samples in both arms achieved similar cellularity, and these results were achieved without routine rapid on-site evaluation, a resource that remains unavailable in many low-resource settings. The findings of the current study challenge the assumption that FNB is universally required to obtain diagnostically adequate tissue. In settings where cytopathology services are more readily available than advanced histopathology, EUS-FNA remains the primary diagnostic modality for the majority of patients with suspected pancreatic malignancy. In these situations, instead of routine replacement of FNA, selective use of FNB may represent a more pragmatic strategy.

A key finding of this study is its explicit evaluation of costs, with EUS-FNB being approximately INR 5,200 more expensive than FNA per procedure. This is an important cost difference, especially in resource-limited settings, where patients often bear health care expenses out of pocket. In high-resource health care systems, the added expense of FNB may be justified by benefits such as reduced repeat procedures and expanded molecular testing. In contrast, in resource-limited settings, the primary objective often is establishing a reliable diagnosis. The current study has demonstrated that EUS-FNA offers high sensitivity, acceptable accuracy, and excellent safety at a lower cost, and therefore, its role as a first-line diagnostic modality cannot be overlooked. Importantly, cost-effectiveness should not be misconstrued as a compromise in quality; rather, it reflects the alignment of diagnostic strategy with local health care realities.

The increasing adoption of EUS-FNB worldwide reflects genuine advances in EUS-guided tissue acquisition.[7] However, this study serves as a reminder that a diagnostic approach appropriate for centers in high-income countries may not be optimal or ideal in resource-limited health care systems. A tiered strategy may be more effective in centers with excellent endoscopic expertise but limited resources or a lack of advanced histopathology support, with EUS-FNA as the initial diagnostic modality and the selective use of FNB reserved for nondiagnostic cases, suspected lymphoma, or autoimmune pancreatitis, or situations in which preservation of histological architecture is crucial for diagnosis.

As a single-center pilot study with a limited sample size, these findings should be interpreted with caution. Larger, multicenter studies are needed to confirm these results. Additionally, long-term outcomes, repeat procedure rates, and downstream costs need to be incorporated into formal cost-effectiveness analyses. Also, as molecular diagnostics become more integrated into pancreatic cancer care, future research should reassess the role of cytology versus core biopsy across diverse health care settings.

In conclusion, this study provides a crucial counterbalance to the narrative that newer technologies should universally replace established practices across diverse health care settings. The optimal strategy is not an absolute choice between FNA and FNB, but judicious, context-sensitive use of both diagnostic tools.

Conflict of Interest

None declared.

• References

• 1 Rana A, Rana SS. Endoscopic ultrasound-guided tissue acquisition: techniques and challenges. J Cytol 2019; 36 (01) 1-7
• 2 Bush N, Rana SS. Endoscopic ultrasound biopsy needle. J Digest Endosc 2022; 13: 240-242
• 3 Wallace MB, Majumder S, Storz P, van Hooft JE. Emerging diagnostic indications for endoscopic ultrasound. Gastroenterology 2026; (e-pub ahead of print)
• 4 Endoscopic Ultrasound(EUS)-Guided Tissue Acquisition in Solid Pancreatic Lesions: FNA(Fine needle aspiration) or FNB(Fine needle biopsy)? A Randomized Pilot Study from a low-resource tertiary care centre. J Digest Endosc 2026
• 5 Termsinsuk P, Chuncharunee A, Charatcharoenwitthaya P, Pausawasdi N. Diagnostic performance of endoscopic ultrasound-guided fine needle biopsy with histological analysis versus combined cytohistological analysis in solid pancreatic lesions: a systematic review and meta-analysis. Dig Dis Sci 2025; 70 (10) 3563-3580
• 6 Bang JY, Jhala N, Seth A. et al. Standardisation of EUS-guided FNB technique for molecular profiling in pancreatic cancer: results of a randomised trial. Gut 2023; 72 (07) 1255-1257
• 7 Zhao Y, Xiong D, Aruna. et al. Fine needle biopsy versus fine needle aspiration in the diagnosis of immunohistochemistry-required lesions: a multicenter study with prospective evaluation. Endosc Ultrasound 2023; 12 (06) 456-464

Publication History

Article published online:
12 February 2026