Rapid Onsite Evaluation for Endoscopic Ultrasound–Guided Fine-Needle Biopsy: Are There Any Other Applicable Situations?

We read with great interest the recently published study by Crinò et al1Crinò S.F. et al.Gastroenterology. 2021; 161: 899-909.e5Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar comparing the diagnostic accuracy of endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) with or without rapid onsite evaluation (ROSE).1Crinò S.F. et al.Gastroenterology. 2021; 161: 899-909.e5Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The researchers concluded that in patients with solid pancreatic lesions, the diagnostic accuracy of EUS-FNB alone with 3 needle passes reached 97% and was noninferior compared to EUS-FNB plus ROSE, rendering ROSE not routinely recommended. However, we found some points that require further discussion. First, the diagnostic accuracy rate of a 22G needle was unexpected high in this study. In a meta-analysis with which we were involved,2Li D.F. et al.J Gastroenterol Hepatol. 2020; 35: 1264-1276Crossref PubMed Scopus (10) Google Scholar the diagnostic accuracy rate of a 22G needle was 92.17%, and a 22G needle was an independent factor associated with a higher diagnostic accuracy rate. In another meta-analysis conducted by van Riet et al3van Riet P.A. et al.Endoscopy. 2021; 53: 411-423Crossref PubMed Scopus (27) Google Scholar with 18 RCT studies included, the investigators concluded that FNB provided a pooled diagnostic accuracy of 87%. However, the diagnostic accuracy rate of the 22G FNB needle reached over 97% in this study by Crinò et al.1Crinò S.F. et al.Gastroenterology. 2021; 161: 899-909.e5Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar No more effort is needed to improve the diagnostic accuracy with such a high diagnostic accuracy rate. There is no room for diagnostic improvement with ROSE. The analysis of additional diagnostic value of ROSE perhaps lacks statistical significance. Second, all EUS procedures were performed by expert endosonographers in this study. However, the value of ROSE for endosonographers with less experience should not be ignored. To our knowledge, no study has explored the role of ROSE on EUS trainees performing EUS-FNB. However, it is certain that trainees have lower diagnostic accuracy rates than expert endosonographers. EUS-fine-needle aspiration (FNA) alone has a limited diagnostic accuracy rate compared to EUS-FNB, as Crinò et al1Crinò S.F. et al.Gastroenterology. 2021; 161: 899-909.e5Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar declared in the article. However, EUS-FNB has equal diagnostic yield compared to EUS-FNA plus ROSE.4Chen Y.I. et al.Endoscopy. 2022; 54: 4-12Crossref PubMed Scopus (8) Google Scholar Therefore, we hypothesize that the less-accurate trainees may benefit from ROSE. ROSE may not be as useless as Crinò et al declared in this study. Nevertheless, further studies are needed. Third, the factors associated with EUS-FNB outcomes are complicated. However, only the needle types were analyzed in this study. The lesion size and lesion site may affect EUS-FNB outcomes. A study by Takahashi et al5Takahashi K. et al.Diagnostics (Basel). 2020; : 11Google Scholar concluded that a lesion size of <10 mm predicted a less accurate histopathologic diagnosis (odds ratio, 6.97; 95% confidence interval, 1.02-47.67; P = 0.041). Based on our experience, the lesions located in the uncinate process may be difficult to target, and less core tissue can be obtained in these lesions. ROSE may be useful in lesions with small size or located in the uncinate process, for which the diagnostic accuracy rate may be suboptimal. The sampling techniques also greatly affected EUS-FNB outcomes. Two recent randomized controlled trials both concluded that wet suction resulted in significantly better quality of the specimens and more core tissue than dry suction.6Wang Y. et al.Endoscopy. 2020; 52: 995-1003Crossref PubMed Scopus (12) Google Scholar,7Tong T. et al.J Gastroenterol Hepatol. 2021; 36: 1663-1669Crossref PubMed Scopus (3) Google Scholar Actually, we are conducting a multicenter randomized clinical trial to compare the diagnostic efficacy of 3 suction techniques (wet suction, dry suction, and slow pull) for EUS-FNB.8Li S.Y. et al.Dig Liver Dis. 2020; 52: 734-739Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The primary outcome is that wet suction is not superior to dry suction and slow pull in obtaining core tissues. Therefore, the role of different sampling techniques is not established yet. The role of ROSE in sampling techniques is not established, either. In general, we deem that more subgroup analyses are needed to clarify whether ROSE is useful in some specific situations. In conclusion, this study may have a great impact on clinical practice because of the novelty and large sample size. Additional discussion about the high diagnostic accuracy of FNB and the impact of ROSE on trainees is warranted. Moreover, subgroup analyses could be conducted to address the concerns raised here. Endoscopic Ultrasound–guided Fine-needle Biopsy With or Without Rapid On-site Evaluation for Diagnosis of Solid Pancreatic Lesions: A Randomized Controlled Non-Inferiority TrialGastroenterologyVol. 161Issue 3PreviewThe benefit of rapid on-site evaluation (ROSE) on the diagnostic accuracy of endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) has never been evaluated in a randomized study. This trial aimed to test the hypothesis that in solid pancreatic lesions (SPLs), diagnostic accuracy of EUS-FNB without ROSE was not inferior to that of EUS-FNB with ROSE. Full-Text PDF ReplyGastroenterologyVol. 162Issue 2PreviewWe thank Sun et al1 and Li et al2 for their comments on our article, “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.”3 Full-Text PDF