Comparative accuracy of needle sizes and designs for EUS tissue sampling of solid pancreatic masses: a network meta-analysis

      Background and Aims

      Variable diagnostic performance of sampling techniques during EUS-guided tissue acquisition of solid pancreatic masses based on needle type (FNA versus fine-needle biopsy [FNB]) and gauge (19-gauge vs 22-gauge vs 25-gauge) has been reported. We performed a systematic review with network meta-analysis to compare the diagnostic accuracy of EUS-guided techniques for sampling solid pancreatic masses.

      Methods

      Through a systematic literature review to November 2018, we identified 27 randomized controlled trials (2711 patients) involving adults undergoing EUS-guided sampling of solid pancreatic masses that evaluated the diagnostic performance of FNA and FNB needles based on needle gauge. The primary outcome was diagnostic accuracy. Secondary outcomes were sample adequacy, histologic core procurement rate, and number of needle passes. We performed pairwise and network meta-analyses and appraised the quality of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.

      Results

      In the network meta-analysis, no specific EUS-guided tissue sampling technique was superior, based on needle type (FNA vs FNB) or gauge (19-gauge vs 22-gauge vs 25-gauge) (low-quality evidence). Specifically, there was no difference between 25-gauge FNA versus 22-gauge FNA (relative risk [RR], 1.03; 95% confidence interval [CI], 0.91-1.17) and 22-gauge FNB versus 22-gauge FNA (RR, 1.03; 95% CI, 0.89-1.18) needles for diagnostic accuracy, sample adequacy, and histologic core procurement. Findings were confirmed in sensitivity analysis restricted to studies with no rapid on-site cytologic evaluation and no use of the fanning technique.

      Conclusion

      In a network meta-analysis, no specific EUS-guided tissue sampling technique was superior with regard to diagnostic accuracy, sample adequacy, or histologic procurement rate for solid pancreatic masses, with low confidence in estimates.

      Abbreviations:

      CI (confidence interval), EUS-TA (endoscopic ultrasound-guided tissue acquisition), FNB (fine-needle biopsy), GRADE (Grading of Recommendations Assessment, Development and Evaluation), RCT (randomized controlled trial), ROSE (rapid on-site cytopathology evaluation), RR (relative risk)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Wani S.
        • Muthusamy V.R.
        • McGrath C.M.
        • et al.
        AGA white paper: optimizing endoscopic ultrasound-guided tissue acquisition and future directions.
        Clin Gastroenterol Hepatol. 2018; 16: 318-327
        • Matsubayashi H.
        • Matsui T.
        • Yabuuchi Y.
        • et al.
        Endoscopic ultrasonography guided-fine needle aspiration for the diagnosis of solid pancreaticobiliary lesions: clinical aspects to improve the diagnosis.
        World J Gastroenterol. 2016; 22: 628-640
        • Wani S.
        • Mullady D.
        • Early D.S.
        • et al.
        The clinical impact of immediate on-site cytopathology evaluation during endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: a prospective multicenter randomized controlled trial.
        Am J Gastroenterol. 2015; 110: 1429-1439
        • Lai A.
        • Davis-Yadley A.
        • Lipka S.
        • et al.
        The use of a stylet in endoscopic ultrasound with fine-needle aspiration: a systematic review and meta-analysis.
        J Clin Gastroenterol. 2019; 53: 1-8
        • Bang J.Y.
        • Magee S.H.
        • 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
        • 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
        • James T.W.
        • Baron T.H.
        A comprehensive review of endoscopic ultrasound core biopsy needles.
        Expert Rev Med Devices. 2018; 15: 127-135
        • Khan M.A.
        • Grimm I.S.
        • Ali B.
        • et al.
        A meta-analysis of endoscopic ultrasound-fine-needle aspiration compared to endoscopic ultrasound-fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment.
        Endosc Int Open. 2017; 5: E363-E375
        • Machicado J.D.
        • Thosani N.
        • Wani S.
        Will abandoning fine-needle aspiration increase diagnostic yield from tissues collected during endoscopic ultrasound?.
        Clin Gastroenterol Hepatol. 2018; 16: 1203-1206
        • Cipriani A.
        • Higgins J.P.
        • Geddes J.R.
        • et al.
        Conceptual and technical challenges in network meta-analysis.
        Ann Intern Med. 2013; 159: 130-137
        • Nikolakopoulou A.
        • Mavridis D.
        • Furukawa T.A.
        • et al.
        Living network meta-analysis compared with pairwise meta-analysis in comparative effectiveness research: empirical study.
        BMJ. 2018; 360: k585
        • Reboussin D.M.
        • Allen N.B.
        • Griswold M.E.
        • et al.
        Systematic review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        Circulation. 2018; 138: e595-e616
        • Rouse B.
        • Cipriani A.
        • Shi Q.
        • et al.
        Network meta-analysis for clinical practice guidelines: a case study on first-line medical therapies for primary open-angle glaucoma.
        Ann Intern Med. 2016; 164: 674-682
        • Regueiro M.
        • Velayos F.
        • Greer J.B.
        • et al.
        American Gastroenterological Association Institute technical review on the management of Crohn's disease after surgical resection.
        Gastroenterology. 2017; 152: 277-295
        • Leucht S.
        • Chaimani A.
        • Cipriani A.S.
        • et al.
        Network meta-analyses should be the highest level of evidence in treatment guidelines.
        Eur Arch Psychiatry Clin Neurosci. 2016; 266: 477-480
        • Puhan M.A.
        • Schünemann H.J.
        • Murad M.H.
        • et al.
        A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis.
        BMJ. 2014; 349: g5630
        • Jansen J.P.
        • Fleurence R.
        • Devine B.
        • et al.
        Interpreting indirect treatment comparisons and network meta-analysis for health-care decision making: report of the ISPOR Task Force on Indirect Treatment Comparisons Good Research Practices: part 1.
        Value Health. 2011; 14: 417-428
        • Higgins J.P.
        • Altman D.G.
        • Gøtzsche P.C.
        • et al.
        Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • White I.R.
        • Barrett J.K.
        • Jackson D.
        • et al.
        Consistency and inconsistency in network meta-analysis: model estimation using multivariate meta-regression.
        Res Synth Methods. 2012; 3: 111-125
        • Bang J.Y.
        • Navaneethan U.
        • Hasan M.K.
        • et al.
        Endoscopic ultrasound-guided specimen collection and evaluation techniques affect diagnostic accuracy.
        Clin Gastroenterol Hepatol. 2018; 16: 1820-1828
        • Carrara S.
        • Anderloni A.
        • Jovani M.
        • et al.
        A prospective randomized study comparing 25-G and 22-G needles of a new platform for endoscopic ultrasound-guided fine needle aspiration of solid masses.
        Dig Liver Dis. 2016; 48: 49-54
        • Camellini L.
        • Carlinfante G.
        • Azzolini F.
        • et al.
        A randomized clinical trial comparing 22G and 25G needles in endoscopic ultrasound-guided fine-needle aspiration of solid lesions.
        Endoscopy. 2011; 43: 709-715
        • Fabbri C.
        • Polifemo A.M.
        • Luigiano C.
        • et al.
        Endoscopic ultrasound-guided fine needle aspiration with 22- and 25- gauge needles in solid pancreatic masses: a prospective comparative study with randomisation of needle sequence.
        Dig Liver Dis. 2011; 43: 647-652
        • Gimeno-Garcıa A.Z.
        • Elwassief A.
        • Paquin S.C.
        • et al.
        Randomized controlled trial comparing stylet-free endoscopic ultrasound-guided fine-needle aspiration with 22-G and 25-G needles.
        Dig Endosc. 2014; 26: 467-473
        • Lee J.K.
        • Lee K.T.
        • Choi E.R.
        • et al.
        A prospective, randomized trial comparing 25-gauge and 22-gauge needles for endoscopic ultrasound-guided fine needle aspiration of pancreatic masses.
        Scand J Gastroenterol. 2013; 48: 752-757
        • Siddiqui U.D.
        • Rossi F.
        • Rosenthal L.S.
        • et al.
        EUS-guided FNA of solid pancreatic masses: a prospective, randomized trial comparing 22-gauge and 25-gauge needles.
        Gastrointest Endosc. 2009; 70: 1093-1097
        • Vilmann P.
        • Saftoiu A.
        • Hollerbach S.
        • et al.
        Multicenter randomized controlled trial comparing the performance of 22 gauge versus 25 gauge EUS-FNA needles in solid masses.
        Scand J Gastroenterol. 2013; 48: 877-883
        • 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
        • Bang J.Y.
        • Hebert-Magee S.
        • Trevino J.
        • et al.
        Randomized trial comparing the 22-gauge aspiration and 22-gauge biopsy needles for EUS-guided sampling of solid pancreatic mass lesions.
        Gastrointest Endosc. 2012; 76: 321-327
        • Bang J.Y.
        • Hebert-Magee S.
        • Navaneethan U.
        • et al.
        EUS-guided fine needle biopsy of pancreatic masses can yield true histology: results of a randomised trial.
        Gut. 2018; 67: 2081-2084
        • Cheng B.
        • Zhang Y.
        • Chen Q.
        • et al.
        Analysis of fine-needle biopsy vs fine-needle aspiration in diagnosis of pancreatic and abdominal masses: a prospective, multicenter, randomized controlled trial.
        Clin Gastroenterol Hepatol. 2018; 16: 1314-1321
        • Ganc R.
        • Colaiacovo R.
        • Carbonari A.
        • et al.
        Endoscopic ultrasonography-fine-needle aspiration of solid pancreatic lesions: a prospective, randomized, single-blinded, comparative study using the 22 Gauge EchoTip® ProCoreTM HD (A) and the 22 Gauge EchoTip® Ultra HD (B) endoscopic ultrasound needles.
        Endosc Ultrasound. 2014; 3: S11
        • Hucl T.
        • Wee E.
        • Anuradha S.
        • et al.
        Feasibility and efficiency of a new 22G core needle: a prospective comparison study.
        Endoscopy. 2013; 45: 792-798
        • Lee B.S.
        • Cho C.M.
        • Jung M.K.
        • et al.
        Comparison of histologic core portions acquired from a core biopsy needle and a conventional needle in solid mass lesions: a prospective randomized trial.
        Gut Liver. 2017; 11: 559-566
        • Noh D.H.
        • Choi K.
        • Gu S.
        • et al.
        Comparison of 22-gauge standard fine needle versus core biopsy needle for endoscopic ultrasound-guided sampling of suspected pancreatic cancer: a randomized crossover trial.
        Scand J Gastroenterol. 2018; 53: 94-99
        • Othman M.O.
        • Abdelfatah M.M.
        • Padilla O.
        • et al.
        The cellularity yield of three different 22-gauge endoscopic ultrasound fine needle aspiration needles.
        Diagn Cytopathol. 2017; 45: 426-432
        • Sterlacci W.
        • Sioulas A.D.
        • Veits L.
        • et al.
        22-gauge core vs 22-gauge aspiration needle for endoscopic ultrasound-guided sampling of abdominal masses.
        World J Gastroenterol. 2016; 22: 8820-8830
        • Vanbiervliet G.
        • Napoléon B.
        • Saint Paul M.C.
        • et al.
        Core needle versus standard needle for endoscopic ultrasound-guided biopsy of solid pancreatic masses: a randomized crossover study.
        Endoscopy. 2014; 46: 1063-1070
        • Laquière A.
        • Lefort C.
        • Maire F.
        • et al.
        19 G nitinol needle versus 22 G needle for transduodenal endoscopic ultrasound-guided sampling of pancreatic solid masses: a randomized study.
        Endoscopy. 2019; 51: 436-438
        • Song T.J.
        • Kim J.H.
        • Lee S.S.
        • et al.
        The prospective randomized, controlled trial of endoscopic ultrasound-guided fine-needle aspiration using 22G and 19G aspiration needles for solid pancreatic or peripancreatic masses.
        Am J Gastroenterol. 2010; 105: 1739-1745
        • Mavrogenis G.
        • Weynand B.
        • Sibille A.
        • et al.
        25-gauge histology needle versus 22-gauge cytology needle in endoscopic ultrasonography-guided sampling of pancreatic lesions and lymphadenopathy.
        Endosc Int Open. 2015; 3: E63-E68
        • Kamata K.
        • Kitano M.
        • Yasukawa S.
        • et al.
        Histologic diagnosis of pancreatic masses using 25-gauge endoscopic ultrasound needles with and without a core trap: a multicenter randomized trial.
        Endoscopy. 2016; 48: 632-638
        • Park S.W.
        • Chung M.J.
        • Lee S.H.
        • et al.
        Prospective study for comparison of endoscopic ultrasound-guided tissue acquisition using 25- and 22-gauge core biopsy needles in solid pancreatic masses.
        PLoS One. 2016; 11: e0154401
        • Woo Y.S.
        • Lee K.H.
        • Noh D.H.
        • et al.
        22G versus 25G biopsy needles for EUS-guided tissue sampling of solid pancreatic masses: a randomized controlled study.
        Scand J Gastroenterol. 2017; 52: 1435-1441
        • Bang J.Y.
        • 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
        • Kandel P.
        • Nassar A.
        • Graddy C.
        • et al.
        Whole exome sequencing and genomic profiling of pancreas tumor tissue obtained with a novel fork-tipped EUS guided fine needle core biopsy: a randomized controlled trial [abstract].
        Gastrointest Endosc. 2018; 87 (full primary data provided by principal investigator, MBW): AB455-A456
        • Madhani K.
        • Farrell J.J.
        Management of autoimmune pancreatitis.
        Gastrointest Endosc Clin N Am. 2018; 28: 493-519
        • Kandel P.
        • Wallace M.B.
        Recent advancement in EUS-guided fine needle sampling.
        J Gastroenterol. 2019; 54: 377-387
        • Bang J.Y.
        • Kirtane S.
        • Krall K.
        • et al.
        In memoriam: fine needle aspiration, birth: fine needle biopsy: the changing trend in endoscopic ultrasound-guided tissue acquisition.
        Dig Endosc. 2019; 31: 197-202
        • Kong F.
        • Zhu J.
        • Kong X.
        • et al.
        Rapid on-site evaluation does not improve endoscopic ultrasound-guided fine needle aspiration adequacy in pancreatic masses: a meta-analysis and systematic review.
        PLoS One. 2016; 11: e0163056