Scandinavian Journal of Gastroenterology. 2014; 49: 347–354
ORIGINAL ARTICLE
Comparison of 22-gauge aspiration needle with 22-gauge biopsy needle in endoscopic ultrasonography-guided subepithelial tumor sampling
GWANG HA KIM1, YU KYUNG CHO2, EUN YOUNG KIM3, HYUNG KIL KIM4, JIN WOONG CHO5, TAE HEE LEE6, JEONG SEOP MOON7 & THE KOREAN EUS STUDY GROUP 1
Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea, 2Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea, 3Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea, 4Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea, 5Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea, 6Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea, and 7Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
Abstract Objective. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (EUS-FNA) may facilitate tissue sampling for histopathological diagnosis of subepithelial tumors (SETs) in the gastrointestinal (GI) tract. However, immunohistochemistry is not always feasible using EUS-FNA samples due to the low quality of specimens often obtained by aspiration. This study aimed to compare the use of 22-gauge (G) EUS-guided fine-needle biopsy (EUS-FNB) with 22G EUS-FNA for core sampling used for histopathological examination, including immunohistochemistry, in patients with GI SETs. Methods. Twenty-eight patients with GI SETs ‡2 cm in size were prospectively enrolled at five university hospitals in Korea between January and June 2013. They were randomized to undergo either EUS-FNB or EUS-FNA. Results. A total of 22 patients was finally analyzed in this study: 10 and 12 patients underwent EUS-FNA and EUS-FNB, respectively. Compared to the EUS-FNA group, the EUS-FNB group had a significantly lower median number of needle passes to obtain macroscopically optimal core samples (4 vs. 2, p = 0.025); higher yield rates of macroscopically and histologically optimal core samples with three needle passes (30% vs. 92%, p = 0.006; 20% vs. 75%, p = 0.010, respectively); and a higher diagnostic sufficiency rate (20% vs. 75%, p = 0.010). No technical difficulties were encountered in either group. Conclusions. This study shows that EUS-FNB has a better ability to obtain histological core samples and a higher diagnostic sufficiency rate than EUS-FNA and that EUS-FNB is a feasible, safe, and preferable modality for adequate core sampling for histopathological diagnosis of GI SETs.
Key Words: biopsy, endoscopic ultrasonography, subepithelial tumor
Introduction The exact incidence of subepithelial tumors (SETs) in the gastrointestinal (GI) tract is unknown, but the prevalence of gastric SETs detected during routine esophagogastroduodenoscopy is 0.36% [1]. GI SETs may include leiomyoma, GI stromal tumor (GIST),
schwannoma, lipoma, cyst, or ectopic pancreas. Surgical resection is the principal diagnostic and therapeutic method for SETs, especially for large and symptomatic ones. Preoperative pathological diagnosis of SETs may facilitate clinical decision making, but conventional endoscopic forceps biopsy does not yield adequate amounts of subepithelial tissue for definitive diagnosis.
Correspondence: Eun Young Kim, MD, Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 705-718, Korea. Tel: +82 53 650 4092. Fax: +82 53 624 3281. E-mail: [email protected]
(Received 4 October 2013; revised 12 November 2013; accepted 14 November 2013) ISSN 0036-5521 print/ISSN 1502-7708 online 2014 Informa Healthcare DOI: 10.3109/00365521.2013.867361
348
G. H. Kim et al.
Although endoscopic ultrasonography (EUS) is the best imaging modality for the evaluation of SETs, it cannot substitute histopathological diagnosis [2–5]. EUS-guided fine-needle aspiration (EUS-FNA) may provide adequate amounts of tissue for the diagnosis of SETs, but it does not always afford adequate samples for immunohistochemical analysis because of the often small number of cells obtained by aspiration [6]. Since some SETs, especially GI mesenchymal tumors such as GIST or schwannoma, have varied morphologic appearances, and diagnosis using a small biopsy is not straightforward, immunohistochemical analysis is strongly advisable, if not essential. EUS-guided Trucut biopsy (EUS-TNB) may overcome the limitations of EUS-FNA in procuring sufficient core tissue specimens [7,8]. Although EUS-TNB is more accurate than EUS-FNA for diagnosing GI mesenchymal tumors, the rigidity of its 19-gauge (G) caliber and the mechanical friction of the firing mechanism produced by the torqued echoendoscope limit its use for SETs located in the gastric antrum and duodenum [9,10]. Therefore, a needle facilitating adequate histological core sampling with easy maneuverability needs to be established. A 19G EUS-guided fine-needle biopsy (EUS-FNB) device with ProCore reverse-bevel technology was recently introduced. A multicenter study revealed that histological samples could be successfully obtained using this needle in most patients having GI SETs, with a diagnostic accuracy of >80% [11]. However, because of technical difficulties with this needle in transduodenal passes, the same FNB device was developed in a 22G platform. This prospective, randomized study aimed to compare the utility of the 22G EUS-FNB with the 22G EUS-FNA for collecting adequate histological core samples in patients with GI SETs. Methods Patients Patients with newly diagnosed GI SETs were prospectively enrolled at five university hospitals in Korea between January and June 2013, if they met the following criteria: having a hypoechoic mass in the submucosal and/or proper muscle layers on the basis of EUS and tumor ‡2 cm in size. Exclusion criteria were: SETs were not located in the submucosal and/ or proper muscle layers on EUS; EUS revealed the characteristic findings of lipoma, cyst, vessel or extraluminal lesions; the platelet count was
ORIGINAL ARTICLE
Comparison of 22-gauge aspiration needle with 22-gauge biopsy needle in endoscopic ultrasonography-guided subepithelial tumor sampling
GWANG HA KIM1, YU KYUNG CHO2, EUN YOUNG KIM3, HYUNG KIL KIM4, JIN WOONG CHO5, TAE HEE LEE6, JEONG SEOP MOON7 & THE KOREAN EUS STUDY GROUP 1
Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea, 2Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea, 3Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea, 4Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea, 5Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea, 6Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea, and 7Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
Abstract Objective. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (EUS-FNA) may facilitate tissue sampling for histopathological diagnosis of subepithelial tumors (SETs) in the gastrointestinal (GI) tract. However, immunohistochemistry is not always feasible using EUS-FNA samples due to the low quality of specimens often obtained by aspiration. This study aimed to compare the use of 22-gauge (G) EUS-guided fine-needle biopsy (EUS-FNB) with 22G EUS-FNA for core sampling used for histopathological examination, including immunohistochemistry, in patients with GI SETs. Methods. Twenty-eight patients with GI SETs ‡2 cm in size were prospectively enrolled at five university hospitals in Korea between January and June 2013. They were randomized to undergo either EUS-FNB or EUS-FNA. Results. A total of 22 patients was finally analyzed in this study: 10 and 12 patients underwent EUS-FNA and EUS-FNB, respectively. Compared to the EUS-FNA group, the EUS-FNB group had a significantly lower median number of needle passes to obtain macroscopically optimal core samples (4 vs. 2, p = 0.025); higher yield rates of macroscopically and histologically optimal core samples with three needle passes (30% vs. 92%, p = 0.006; 20% vs. 75%, p = 0.010, respectively); and a higher diagnostic sufficiency rate (20% vs. 75%, p = 0.010). No technical difficulties were encountered in either group. Conclusions. This study shows that EUS-FNB has a better ability to obtain histological core samples and a higher diagnostic sufficiency rate than EUS-FNA and that EUS-FNB is a feasible, safe, and preferable modality for adequate core sampling for histopathological diagnosis of GI SETs.
Key Words: biopsy, endoscopic ultrasonography, subepithelial tumor
Introduction The exact incidence of subepithelial tumors (SETs) in the gastrointestinal (GI) tract is unknown, but the prevalence of gastric SETs detected during routine esophagogastroduodenoscopy is 0.36% [1]. GI SETs may include leiomyoma, GI stromal tumor (GIST),
schwannoma, lipoma, cyst, or ectopic pancreas. Surgical resection is the principal diagnostic and therapeutic method for SETs, especially for large and symptomatic ones. Preoperative pathological diagnosis of SETs may facilitate clinical decision making, but conventional endoscopic forceps biopsy does not yield adequate amounts of subepithelial tissue for definitive diagnosis.
Correspondence: Eun Young Kim, MD, Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 705-718, Korea. Tel: +82 53 650 4092. Fax: +82 53 624 3281. E-mail: [email protected]
(Received 4 October 2013; revised 12 November 2013; accepted 14 November 2013) ISSN 0036-5521 print/ISSN 1502-7708 online 2014 Informa Healthcare DOI: 10.3109/00365521.2013.867361
348
G. H. Kim et al.
Although endoscopic ultrasonography (EUS) is the best imaging modality for the evaluation of SETs, it cannot substitute histopathological diagnosis [2–5]. EUS-guided fine-needle aspiration (EUS-FNA) may provide adequate amounts of tissue for the diagnosis of SETs, but it does not always afford adequate samples for immunohistochemical analysis because of the often small number of cells obtained by aspiration [6]. Since some SETs, especially GI mesenchymal tumors such as GIST or schwannoma, have varied morphologic appearances, and diagnosis using a small biopsy is not straightforward, immunohistochemical analysis is strongly advisable, if not essential. EUS-guided Trucut biopsy (EUS-TNB) may overcome the limitations of EUS-FNA in procuring sufficient core tissue specimens [7,8]. Although EUS-TNB is more accurate than EUS-FNA for diagnosing GI mesenchymal tumors, the rigidity of its 19-gauge (G) caliber and the mechanical friction of the firing mechanism produced by the torqued echoendoscope limit its use for SETs located in the gastric antrum and duodenum [9,10]. Therefore, a needle facilitating adequate histological core sampling with easy maneuverability needs to be established. A 19G EUS-guided fine-needle biopsy (EUS-FNB) device with ProCore reverse-bevel technology was recently introduced. A multicenter study revealed that histological samples could be successfully obtained using this needle in most patients having GI SETs, with a diagnostic accuracy of >80% [11]. However, because of technical difficulties with this needle in transduodenal passes, the same FNB device was developed in a 22G platform. This prospective, randomized study aimed to compare the utility of the 22G EUS-FNB with the 22G EUS-FNA for collecting adequate histological core samples in patients with GI SETs. Methods Patients Patients with newly diagnosed GI SETs were prospectively enrolled at five university hospitals in Korea between January and June 2013, if they met the following criteria: having a hypoechoic mass in the submucosal and/or proper muscle layers on the basis of EUS and tumor ‡2 cm in size. Exclusion criteria were: SETs were not located in the submucosal and/ or proper muscle layers on EUS; EUS revealed the characteristic findings of lipoma, cyst, vessel or extraluminal lesions; the platelet count was
