We conducted a retrospective cohort single-centre study, including patients with solid pancreatic mass who underwent EUS-TA between January 2017 and October 2020. Specifically, all procedures were performed at the Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, the only university hospital in Southern Thailand. The inclusion criteria were as follows: (1) evidence of the solid pancreatic mass confirmed by computed tomography (CT) scan or magnetic resonance imaging (MRI), (2) age at least 18 years, (3) technical success of EUS-FNA or EUS-FNB without ROSE and (4) no prior EUS-TA done. Patients who were scheduled to undergo EUS-TA but with uncorrectable coagulopathy or any other reasons which caused EUS-TA to be inoperable were, therefore, excluded. We identified eligible patients according to the inclusion and exclusion criteria from our registration database, and using the hospital’s medical electronic database, the patients’ and procedural data were collected.

The study protocol was approved by the Faculty of Medicine Institutional Review Board. The informed consent for the study was waived as this is retrospective in nature. However, all patients provided informed consent for EUS-TA before the procedures started.

Identification of solid pancreatic mass and the decision to perform EUS-TA

The identification of solid pancreatic mass on CT or MRI was certified by experienced radiologists. In our centre, the routine practice for patients with solid pancreatic mass depends on attending physicians. Usually, authorized physicians (gastroenterologists, oncologists or hepatobiliary surgeons) referred patients to advance endoscopists for tissue diagnosis before initiating systemic chemotherapy in unresectable patients or in patients with questionable diagnoses. However, the small solid pancreatic mass within resectable criteria may proceed to surgical resection without EUS-TA for tissue diagnosis.

EUS-FNA or EUS-FNB and cyto/histopathological evaluation

In this study, EUS was performed using a linear array echoendoscope (GF-UCT/P-180 series; Olympus Medical System, CORP., Tokyo, Japan) and ultrasound machine (Aloka; model SSD alpha 10, Tokyo, Japan) under conscious sedation by four experienced endosonographers (TP, NN, JS and BO). All patients with their first-time experiences of FNA or FNB for tissue acquisition in solid pancreatic mass were included.

The general protocol for EUS-TA was as follows: before the procedure, the cross-sectional abdominal imaging was reviewed; the solid pancreatic mass was then identified and confirmed by EUS. The decision to perform tissue acquisition technique (FNA or FNB) was at the discretion of the attending physicians: either needle type, the standard suction technique (20 mL, negative pressure) or the stylet slow pull technique, with or without fanning method. There were many factors for the decision such as the small tumour size and some endoscopist preferred biopsy needle but aspiration needle was preferred in limited budget patients. The location for TA, transgastric or transduodenal approach, was based on the location of the mass and endoscopists’ decisions. The FNA needle was a 22-gauge EZ-Shot (model number NA-200H-8022; Olympus Medical system, CORP., Japan), whereas the FNB needle was a 22-gauge Franseen needle (Acquire; Boston Scientific, USA). The needle was moved backward and forward within the lesion for at least 15 strokes. ROSE was unavailable for this procedure for an entire period of the study.

The tissue samples were expelled from the needle in a standardized manner. The stylet was firstly introduced at the tip of the needle to expel the tissue samples on the glass slide, followed by flushing the needle with air or normal saline to expel the retained tissue, which called the “touch and smear technique” [18].

The gross tissue specimen was initially evaluated by an endoscopist for adequate tissue sample (white or yellowish tissue at least 2 mm). This procedure is defined as macroscopic onsite evaluation (MOSE). The core tissues were collected in 10% neutral buffered formalin, and the smear glass slide was fixed in 95% alcohol solution for cytology.

The procedure-related data (total procedure time, needle type, location of tissue acquisition, number of needle passes, number of strokes per pass and immediate complication) were recorded into the Endo Smart programme. Finally, glass slides and core tissue samples were sent to the hospital’s Anatomical Pathology Center, where they were reviewed by an experienced cytopathologist.

All tissue samples of eligible patients were reviewed by a single experienced pathologist who was blinded to the procedural detail. The pathological results of ‘positive for adenocarcinoma or adenocarcinoma or carcinoma’ were considered adenocarcinoma. The pathological results of ‘suspicious for malignancy’ were then reviewed by two pathologists for final decision making whether they should be categorized as malignancy or not. The results of a specific diagnosis, such as lymphoma, tuberculosis or neuroendocrine tumour, were also reviewed. However, the definite diagnosis of mass-forming chronic pancreatitis was difficult to attain; it required not only a pathological result indicating fibrosis or chronic inflammation without malignant cell suspicion, but also cross-sectional imaging compatible with chronic pancreatitis and a stable clinical condition without evidence of malignancy on interval cross-sectional imaging after 6 months of follow-up. Meanwhile, the pathological results of unremarkable pancreatic tissue, nonpancreatic elements, atypical pancreatitis or acute pancreatitis were identified as non-diagnostic.

In patients with pancreatic cancer, the disease staging and surgical resectability criteria were applied by The American Joint Committee on Cancer (AJCC) cancer staging manual 8th edition and TNM staging [19].

Data collection

After eligible patients were identified from the endoscopic centre’s database, we collected the following demographic and clinical characteristics: age; sex; tumour location; CT or MRI results; initial laboratory data; ECOG status; procedural data (EUS findings, needle type, EUS-TA procedure time, technical details and complications following the procedure); pathological report, final diagnosis and disease stage by (AJCC) 8th edition if pancreatic cancer was diagnosed; and diagnosis yield using the hospital’s medical electronic database.

Statistical analysis

The patients were categorized into EUS-FNA and EUS-FNB groups. The comparisons of continuous variables between the two groups were analysed using Wilcoxon for non-normally distributed data and Student’s t-test for normally distributed data, whereas the categorical data were compared using the chi-square test or Fisher’s exact test. A p-value of < 0.05 was considered statistically significant. All statistical analyses were performed using the R programme (R foundation for statistical computing, Vienna, Austria).

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