AbstractBackgroundSurveillance of pancreatic cysts focuses on the detection of (mostly morphologic) features warranting surgery. European guidelines consider elevated CA19.9 as a relative indication for surgery. We aimed to evaluate the role of CA19.9 monitoring for early detection and management in a cyst surveillance population.MethodsThe PACYFIC‐registry is a prospective collaboration that investigates the yield of pancreatic cyst surveillance performed at the discretion of the treating physician. We included participants for whom at least one serum CA19.9 value was determined by a minimum follow‐up of 12 months.ResultsOf 1865 PACYFIC participants, 685 met the inclusion criteria for this study (mean age 67 years, SD 10; 61% female). During a median follow‐up of 25 months (IQR 24, 1966 visits), 29 participants developed high‐grade dysplasia (HGD) or pancreatic cancer. At baseline, CA19.9 ranged from 1 to 591 kU/L (median 10 kU/L [IQR 14]), and was elevated (≥37 kU/L) in 64 participants (9%). During 191 of 1966 visits (10%), an elevated CA19.9 was detected, and these visits more often led to an intensified follow‐up (42%) than those without an elevated CA19.9 (27%; p < 0.001). An elevated CA19.9 was the sole reason for surgery in five participants with benign disease (10%). The baseline CA19.9 value was (as continuous or dichotomous variable at the 37 kU/L threshold) not independently associated with HGD or pancreatic cancer development, whilst a CA19.9 of ≥ 133 kU/L was (HR 3.8, 95% CI 1.1–13, p = 0.03).ConclusionsIn this pancreatic cyst surveillance cohort, CA19.9 monitoring caused substantial harm by shortening surveillance intervals (and performance of unnecessary surgery). The current CA19.9 cutoff was not predictive of HGD and pancreatic cancer, whereas a higher cutoff may decrease false‐positive values. The role of CA19.9 monitoring should be critically appraised prior to implementation in surveillance programs and guidelines.

BACKGROUND:Endoscopic ultrasound (EUS)-guided tissue acquisition is extensively used, but the optimal sampling device is still a matter of debate. We performed meta-analyses on studies comparing fine-needle aspiration (FNA) with fine-needle biopsy (FNB) needles, and studies comparing different FNB needles. METHODS:Online databases were searched for randomized controlled trials (RCTs) of at least 50 cases with a suspected solid pancreatic or nonpancreatic lesion that compared FNA with FNB needles. Outcome measures included diagnostic accuracy, adequacy, number of passes, presence of tissue cores, and adverse events. We also performed meta-regression analysis on the effect of FNB design on diagnostic accuracy. Quality was assessed using the QUADAS-2 tool. RESULTS:18 RCTs comparing FNA with FNB needles were included. FNB provided a higher pooled diagnostic accuracy (87 % vs. 80 %; P = 0.02) and tissue core rate (80 % vs. 62 %; P = 0.002), and allowed diagnosis with fewer passes (P = 0.03), in both pancreatic and nonpancreatic lesions. A total of 93 studies were included comparing different FNB devices. Pooled diagnostic accuracy was higher for forward-facing bevel needles than for the reverse bevel needle. In this analysis, study quality was low and heterogeneity was high (I2  = 80 %). CONCLUSION:FNB outperformed FNA when sampling pancreatic and nonpancreatic lesions. Forward-facing bevel FNB needles seemed to outperform the reverse bevel FNB needle, but the low quality of evidence prevents us from making strong recommendations on the optimal FNB design.

BACKGROUND:In the absence of rapid on-side pathological evaluation, endoscopy staff generally "smears" endoscopic ultrasound guided fine needle aspiration (EUS-FNA) specimens on a glass slide. As this technique is vulnerable to preparation artifacts, we assessed if its quality could be improved through a smear-preparation-training for endoscopy staff.METHODS:In this prospective pilot study, 10 endosonographers and 12 endoscopy nurses from seven regional EUS-centers in the Netherlands were invited to participate in a EUS-FNA smear-preparation-training. Subsequently, post training slides derived from solid pancreatic lesions were compared to pre-training "control" slides. Primary outcome was to assess if the training positively affects smear quality and, consequently, diagnostic accuracy of EUS-FNA of solid pancreatic lesions.RESULTS:Participants collected and prepared 71 cases, mostly pancreatic head lesions (48%). Sixty-eight controls were selected from the pretraining period. The presence of artifacts was comparable for smears performed before and after training (76% vs 82%, P = .36). Likewise, smear cellularity (≥50% target cells) before and after training did not differ (44% (30/68) vs 49% (35/71), P = .48). Similar, no difference in diagnostic accuracy for malignancy was detected (P = .10).CONCLUSION:In this pilot EUS-FNA smear-preparation-training for endoscopy personnel, smear quality and diagnostic accuracy were not improved after the training. Based on these results, we plan to further study other training programs and possibilities.

Background and study aims The traditional “smear technique” for processing and assessing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is sensitive to artifacts. Processing and evaluation of specimens collected in a liquid medium, liquid-based cytology (LBC) may be a solution. We compared the diagnostic value of EUS-FNA smears to LBC in pancreatic solid lesions in the absence of rapid on-site evaluation (ROSE). Patients and methods Consecutive patients who required EUS-FNA of a solid pancreatic lesion were included in seven hospitals in the Netherlands and followed for at least 12 months. Specimens from the first pass were split into two smears and a vial for LBC (using ThinPrep and/or Cell block). Smear and LBC were compared in terms of diagnostic accuracy for malignancy, sample quality, and diagnostic agreement between three cytopathologists. Results Diagnostic accuracy for malignancy was higher for LBC (82 % (58/71)) than for smear (66 % (47/71), P = 0.04), but did not differ when smears were compared to ThinPrep (71 % (30/42), P = 0.56) or Cell block (62 % (39/63), P = 0.61) individually. Artifacts were less often present in ThinPrep (57 % (24/42), P = 0.02) or Cell block samples (40 % (25/63), P < 0.001) than smears (76 % (54/71)). Agreement on malignancy was equally good for smears and LBC (ĸ = 0.71 versus ĸ = 0.70, P = 0.98), but lower for ThinPrep (ĸ = 0.26, P = 0.01) than smears. Conclusion After a single pass, LBC provides higher diagnostic accuracy than the conventional smear technique for EUS-FNA of solid pancreatic lesions in the absence of ROSE. Therefore, LBC, may be an alternative to the conventional smear technique, especially in centers lacking ROSE.

BACKGROUND:Because most pancreatic intraductal papillary mucinous neoplasms (IPMNs) will never become malignant, currently advocated long-term surveillance is low-yield for most individuals.AIM:To develop a score chart identifying IPMNs at lowest risk of developing worrisome features or high-risk stigmata.METHODS:We combined prospectively maintained pancreatic cyst surveillance databases of three academic institutions. Patients were included if they had a presumed side-branch IPMN, without worrisome features or high-risk stigmata at baseline (as defined by the 2012 international Fukuoka guidelines), and were followed ≥ 12 months. The endpoint was development of one or more worrisome features or high-risk stigmata during follow-up. We created a multivariable prediction model using Cox-proportional logistic regression analysis and performed an internal-external validation.RESULTS:875 patients were included. After a mean follow-up of 50 months (range 12-157), 116 (13%) patients developed worrisome features or high-risk stigmata. The final model included cyst size (HR 1.12, 95% CI 1.09-1.15), cyst multifocality (HR 1.49, 95% CI 1.01-2.18), ever having smoked (HR 1.40, 95% CI 0.95-2.04), history of acute pancreatitis (HR 2.07, 95% CI 1.21-3.55), and history of extrapancreatic malignancy (HR 1.34, 95% CI 0.91-1.97). After validation, the model had good discriminative ability (C-statistic 0.72 in the Mayo cohort, 0.71 in the Columbia cohort, 0.64 in the Erasmus cohort).CONCLUSION:In presumed side branch IPMNs without worrisome features or high-risk stigmata at baseline, the Dutch-American Risk stratification Tool (DART-1) successfully identifies pancreatic lesions at low risk of developing worrisome features or high-risk stigmata.

BACKGROUND AND AIM:A recently carried out randomized controlled trial showed the benefit of a novel 20-G fine-needle biopsy (FNB) over a 25-G fine-needle aspiration (FNA) needle. The current study evaluated the reproducibility of these findings among expert academic and non-academic pathologists. METHODS:This study was a side-study of the ASPRO (ASpiration versus PROcore) study. Five centers retrieved 74 (59%) consecutive FNB and 51 (41%) FNA samples from the ASPRO study according to randomization; 64 (51%) pancreatic and 61 (49%) lymph node specimens. Samples were re-reviewed by five expert academic and five non-academic pathologists and rated in terms of sample quality and diagnosis. Ratings were compared between needles, expert academic and non-academic pathologists, target lesions, and cytology versus histological specimens. RESULTS:Besides a higher diagnostic accuracy, FNB also provided for a better agreement on diagnosing malignancy (ĸ = 0.59 vs ĸ = 0.76, P < 0.001) and classification according to Bethesda (ĸ = 0.45 vs ĸ = 0.61, P < 0.001). This equally applied for expert academic and non-academic pathologists and for pancreatic and lymph node specimens. Sample quality was also rated higher for FNB, but agreement ranged from poor (ĸ = 0.04) to fair (ĸ = 0.55). Histology provided better agreement than cytology, but only when a core specimen was obtained with FNB (P = 0.004 vs P = 0.432). CONCLUSION:This study shows that the 20-G FNB outperforms the 25-G FNA needle in terms of diagnostic agreement, independent of the background and experience of the pathologist. This endorses use of the 20-G FNB needle in both expert and lower volume EUS centers.

Background/Objectives: For the currently recommended pancreatic cyst surveillance to be feasible, participant adherence is a prerequisite. Our objective was to evaluate the psychological burden of pancreatic cyst surveillance from a participant's perspective. Methods: The present participant survey is part of an international cohort study (PACYFIC study, www.pacyfic.net), which prospectively records the outcome of surveillance of asymptomatic pancreatic cysts. Participants are invited to complete questionnaires before and during cyst surveillance. Results: 109 participants, 31 enrolled before and 78 during surveillance (median time since cyst diagnosis 16.5 (IQR 36) months), returned a total of 179 questionnaires. The majority indicated that surveillance reduces concerns of developing pancreatic cancer (82%), gives a sense of certainty (81%) and is a good method to detect cancer ( 91%). Participants already undergoing surveillance reported more negative aspects than those still to commence, like sleeping worse (30% vs 13%, P = 0.035), postponing plans (32% vs 13%, P = 0.031), and finding the follow-up burdensome (33% vs 13%, P = 0.044). Overall, the vast majority (94%) deemed advantages to outweigh disadvantages. Anxiety and depression scores were low (median Hospital Anxiety and Depression Scale 4 for anxiety (IQR 6), 2 for depression (IQR 5)). Conclusion: The psychological burden of pancreatic cyst surveillance is low. Therefore, participant adherence is expected to be high and annual surveillance seems feasible. (C) 2019 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Background Instead of choosing one endoscopic ultrasound (EUS) needle over the other, some advocate the use of fine-needle aspiration (FNA) and fine-needle biopsy (FNB) consecutively. We explored the yield of combined use of 20G FNB and 25G FNA needles in patients with a suspicious solid gastrointestinal lesion. Methods Patients from the ASPRO study who were sampled with both needles during the same procedure were included. The incremental yield of dual sampling compared with the yield of single needle use on the diagnostic accuracy for malignancy was assessed for both dual sampling approaches - FNA followed by FNB, and vice versa. Results 73 patients were included. There were 39 (53%) pancreatic lesions, 18 (25 %) submucosal masses, and 16 (22%) lymph nodes. FNA was used first in 24 patients (33%) and FNB was used first in 49 (67%). Generally, FNB was performed after FNA to collect tissue for ancillary testing (75%), whereas FNA was used after FNB to allow for on-site pathological assessment (76 %). Diagnostic accuracy for malignancy of single needle use increased from 78% to 92% with dual sampling (P = 0.002). FNA followed by FNB improved the diagnostic accuracy for malignancy (P = 0.03), whereas FNB followed by FNA did not (P = 0.13). Conclusion Dual sampling only improved diagnostic accuracy when 25G FNA was followed by 20G FNB and not vice versa. As the diagnostic benefit of the 20G FNB over the 25G FNA needle has recently been proven, sampling with the FNB needle seems a logical first choice.

Most studies comparing fine needle aspiration (FNA) to fine needle biopsy (FNB) were underpowered, limited to a single indication, or performed in a single center. Accuracy of diagnosis, but also, procurement of sufficient tissue quantity is becoming increasingly important in the era of personalized medicine. This global prospective randomized multicenter study compared the performance of a large-bore 20G FNB (ProCore) to a small-caliber 25G FNA (Echotip) needle (both Cook Medical). The study was conducted in 13 EUS-centers across the world. Consecutive patients with a solid pancreatic lesion, lymph node, or other solid lesion ≥1 cm in size were enrolled between February 2015 and September 2016. Patients were randomized 1:1 for ≥3 passes with FNA or FNB. Primarily, we compared diagnostic accuracy for malignancy and the diagnosis according to the Bethesda classification (non-diagnostic, benign, atypical, malignant). The final diagnosis was based on surgical resection specimens or, in non-operated patients on more than 9 months of follow-up. Secondly, we assessed needle safety, yield per pass, sample sufficiency, cellularity, and histological tissue core yield. Multivariable analysis was performed adjusting for indication, lesion size, number of passes, and presence of an on-site pathologist. Supplementary analysis was done to assess variation of diagnostic accuracy between centers. 608 consecutive patients were randomized to FNA (n=306) or FNB (n=302) biopsy of 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other solid lesions (25%). Diagnosis of malignancy was established in 463 (76%) cases. Sampling was technically feasible in all FNA, and all but four FNB (99%) cases (p=0.043), with no difference in adverse events (3 in FNA and 2 in FNB). Sample sufficiency was equally good for FNA and FNB (82% versus 87%, p=0.062), as was sample cellularity (62% vs 62%, p=0.733). FNB resulted in a higher histological yield (77% versus 44%, p<0.001) and showed a higher diagnostic accuracy for malignancy (87% vs 78%, p=0.002), and for the Bethesda classification (82% versus 72%, p=0.002, table 1). This difference in accuracy was independent of indication, lesion size, number of passes, and presence of an on-site pathologist (OR 3.53, 95% CI 1.51-8.26, p=0.004, table 2). Diagnostic accuracy differed between the centers, but this did not affect the difference in diagnostic accuracy between the needles (p=0.836). The 20G ProCore FNB needle out-performed the widely used 25G FNA needle, in terms of histological yield and diagnostic accuracy, in pancreatic as well as non-pancreatic lesions, independent of the number of passes or presence of an on-site pathologist. The observation that these findings were consistent amongst 13 centers from all over the world supportsthe general applicability of our findings.Tabled 1Table 1. Performance characteristics for final diagnosisDiagnostic outcome parametersFNBn=302FNAn=306p-valueAccuracy for malignancy1st pass72% (218/302)65% (200/306)0.0691-3 passes86% (261/302)76% (232/306)0.0014th and additional passes86% (24/28)77% (47/61)0.345Overall87% (263/302)78% (237/306)0.002Accuracy for Bethesda classification1st pass65% (197/302)60% (182/306)0.1431-3 passes81% (245/302)70% (215/306)0.0024th and additional passes79% (22/28)72% (44/61)0.519Overall82% (248/302)72% (219/306)0.002 Open table in a new tab Tabled 1Table 2. Multivariable analysis of factors influencing diagnostic accuracy for malignancy.VariablesCorrect diagnosis, % (n/n)Odds ratio (95% CI)P-valueNeedle typeFNB87 (263/302)3.53 (1.51-8.26)0.004FNA78 (233/306)IndicationPancreas86 (268/312)2.89 (1.47-5.67)0.002Lymph node82 (121/147)2.20 (1.02-4.75)0.044Submucosal and other solid lesions75 (111/149)*0.008Lesion size1-3 cm79 (237/299)1.47 (0.92-2.36)0.106≥3 cm85 (232/273)Needle passes1-382 (419/514)2.41 (1.05-5.57)0.039>389 (78/88)Presence of ROSEYes83 (83/100)0.92 (0.52-1.79)0.917No83 (415/502)*reference category Open table in a new tab

OBJECTIVES:Our aim was to identify baseline characteristics associated with disease progression and malignant transformation in low-risk suspected intraductal papillary mucinous neoplasms (IPMNs).METHODS:This is a retrospective cohort study of prospectively maintained databases of pancreatic cysts at 3 international, academic institutions. Five hundred fifty-nine adult patients with clinically suspected asymptomatic IPMN evaluated by radiologic studies or endoscopic ultrasound between 2003 and 2013 without worrisome features and under surveillance for 12 months or longer were included. We evaluated the relationship of baseline demographics and cyst features to disease progression (size increase, development of worrisome features, or high-grade dysplasia/cancer).RESULTS:After a median of 44 months follow-up, 269 (48%) patients experienced cyst size increase, 68 (12%) developed worrisome features, and 11 (2%) developed high-grade dysplasia/cancer. In multivariable Cox-regression analysis, no baseline characteristics were associated with size increase. An initial cyst size of 2 cm or greater, multifocality, history of prostate cancer, and smoking were the strongest predictors of development of new worrisome features. Univariable analysis found male sex, diabetes, and recent weight loss associated with development of high-grade dysplasia/cancer.CONCLUSIONS:Our study demonstrates that low-risk suspected IPMNs carry a small but clinically relevant risk of disease progression and provides data on baseline characteristics that may help in risk stratification.

Background and Aims: Several studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle. Methods: Consecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders. Results: A total of 608 patients were allocated to FNA (n=306) or FNB (n=302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (P=.043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, P<.001), accuracy for malignancy (87% vs 78%, P=.002) and Bethesda classification (82% vs 72%, P=.002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; P=.004), and did not differ among centers (P=.836). Conclusion: The 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.)

Background:The risk of malignancy increases up to 60% if the main pancreatic duct is involved in intraductal papillary mucinous neoplasm (IPMN).Therefore most international guidelines advice resection in surgically fit patients with main duct or mixed type(MD/MT)-IPMN.The goal of resection is to prevent malignancy or to increase life expectancy in invasive carcinoma.During the update of the European evidence-based guideline for pancreatic cystic neoplasms it became clear that data are lacking on surgical outcomes.We aimed to evaluate short-and long-term outcomes after pancreatectomy for MD/MT-IPMN.Methods: Patients who underwent partial or total pancreatectomy for MD/MT-IPMN in 4 Dutch pancreatic centers between January 2001 and December 2016 were analyzed retrospectively.Primary outcomes were disease related death and surgical morbidity and mortality.Secondary outcomes were recurrence, and functional outcomes.Results: In total, 123 patients were included, 72 male (58.5%), mean age 67.5 (SD 9.5), 109 (88.7%) underwent partial and 14 (11.4%)total pancreatectomy.MD-IPMN was present in 28 (22.8%) of the patients, 24 (86%) underwent partial and 4 total pancreatectomy.MT-IPMN was present in 95 (77.2%) of the patients, 85 (90%) underwent partial and 10 total pancreatectomy.Histopathological examination showed high-grade dysplasia (19.5%) or invasive carcinoma (20.3%) in only 39.8% of patients.The incidence of major complications (Clavien Dindo $3) was 30.1%.The incidence of clinically relevant ISGPS grade B/C pancreatic fistula was 14.6%.Thirty day mortality was 2.1%.During a median follow-up of 24 months (IQR 11.8 -39.3), 4 (21.1%)patients with high-grade dysplasia developed recurrence, whereas 13 patients with invasive IPMN developed recurrence.Median overall survival was 47 months (IQR 25.5-69.5);disease related mortality (i.e.malignant IPMN) was 14.2%.Follow-up was performed by CT or MRI.Conclusion: This large multicenter cohort of patients undergoing surgery for MD/MT-IPMN shows acceptable surgical major morbidity and mortality.More patients, 48% died during follow-up after surgery related to invasive IPMN itself, than from surgery 21%. Su1339

Background and Objectives: Endoscopic ultrasound (EUS) fine needle biopsy (FNB) needles were designed to improve histologic yield, while maintaining the flexibility to permit ease of use. However, the diagnostic benefit of EUS-FNB needles as compared to the conventional fine needle aspiration (FNA) needles remains unclear. This study aimed to identify the diagnostic accuracy of combined needle use of a new 20-gauge ProCore FNB needle and a 25-gauge FNA needle. Methods: For this study, cases were selected in which both the 20-gauge ProCore FNB needle and the 25-gauge FNA needle were used during a single EUS procedure for sampling of a solid pancreatic mass, lymph node, or submucosal mass. Tissue acquisition was performed in the course of the ASPRO trial, a multicenter randomized study comparing the diagnostic value of 20-gauge ProCore FNB and 25-gauge FNA needles (ClinicalTrials.gov: NCT02167074). The protocol allowed additional sampling with the nonassigned needle, at the discretion of an endosonographer. Results: Of all 615 patients who were randomized for the ASPRO study, 74 were sampled with both needle types. In these combined needle cases, FNA was used first in 24 and ProCore FNB in 50 cases. Target lesions encompassed 39 solid pancreatic lesions, 18 submucosal masses, and 17 lymph nodes. Most pancreatic lesions were located in the head (25/39), lymph nodes were mainly located in the abdomen (15/18), and submucosal lesions were located in the stomach (8/20), esophagus (4/20), small intestines (3/20), and rectum (3/20). The main reason to use ProCore in addition to FNA was to collect more tissue for ancillary testing (79%). FNA was generally used in addition to ProCore to allow for on-site pathological assessment (76%). The regimen of FNA followed by ProCore resulted in 100% accuracy, while for ProCore followed by FNA, 88% was reached (P = 0.086). The type of target lesion, either pancreatic or nonpancreatic, did not affect the diagnostic accuracy of the two sampling regimens (odds ratio 1.2, 95% confidence interval 0.22–6.61, P = 0.834). Conclusion: FNA followed by ProCore FNB provides for a 100% diagnostic accuracy and tends to outperform ProCore FNB followed by FNA. Accuracy rates were independent of the type of target lesion.

Background: The first report on the performance of a recently introduced flexible 20-gauge ProCore biopsy needle was promising, with a diagnostic yield of >85%. However, before implementation of this device, its reproducibility should be established not only in the hands of academic experts but also in nonacademic practice. Objectives: To evaluate the interobserver agreement among expert and nonacademic pathologists in grading the quality and diagnostic value of specimens obtained with the new flexible 20-gauge ProCore fine needle biopsy (FNB) needle (Cook Medical, Limerick, Ireland). Methods: Five international endoscopic ultrasound centers prospectively collected 74 samples (39 solid pancreatic masses and 35 lymph nodes) using a new needle. All samples were independently reviewed by five expert academic and five nonacademic pathologists for sufficiency of tissue quality, percentage of target cells present, presence of tissue cores, suitability for additional analysis (i.e., immunohistochemistry), and diagnostic classification (nondiagnostic, benign, neoplastic, or malignant). Agreement was calculated using the Fleiss’ kappa statistic and 95% confidence intervals (CIs). Results: Overall, 91% of cases were considered to be of sufficient quality, with moderate agreement among the ten reviewing pathologists [κ = 0.49, [Table 1]]. Agreement was higher within the group of expert academic pathologists (P = 0.02). Interobserver agreement on the diagnostic classification was good among both academic (κ = 0.62; 95% CI 0.57–0.67) and nonacademic pathologists (κ = 0.59; 95% CI 0.55–0.64). Regarding sample quantity, tissue cores were considered present in 70% of cases (κ = 0.37), with a higher level of agreement among expert pathologists (P < 0.001). As for cellularity of the sample, the presence of ≥50% of target cells was reported in 68% of cases (κ = 0.31). In addition, suitability for additional analyses was rated as positive in the majority of samples (76%), with higher agreement among expert academic pathologists (P < 0.001). When comparing pancreatic to lymph node samples, agreement on the diagnostic classification was higher for lymph nodes (κ = 0.64; 95% CI 0.61–0.67) than for pancreatic masses (κ = 0.54; 95% CI 0.51–0.58, P < 0.001). In addition, lymph node specimens provided higher agreement with regard to possibility for additional analysis (κ = 0.51; 95% CI 0.46–0.56 vs. κ = 0.38; 95% CI 0.33–0.43, P < 0.001). Agreement on specimen quality was higher for pancreatic samples (κ = 0.62; 95% CI 0.57–0.67 vs. κ = 0.43; 95% CI 0.38–0.48, P < 0.001). Conclusion: There was good interobserver agreement among both expert academic and nonacademic pathologists in the assessment of the quality and diagnostic value of specimens obtained with the new 20-gauge ProCore biopsy needle. Follow-up data are required to confirm the diagnostic accuracy of this agreement.

EUS Fine Needle Biopsy (FNB) needles were designed to improve histologic yield, while maintaining the flexibility to permit ease of use. However, the diagnostic benefit of EUS-FNB needles as compared to the conventional fine needle aspiration (FNA) needles remains unclear. This study aimed to identify the diagnostic accuracy of combined needle use of a new 20G ProCore FNB needle and the 25G FNA needle.

Background and study aims: Although Endoscopic Ultrasound (EUS)-guided tissue sampling is widely used, the optimal sampling strategy remains subject of debate. We evaluated practice patterns within the international endosonographic community.Patients and methods: An online questionnaire was sent to 400 endosonographers from the United States, Europe, and Asia.Results: A total of 186 (47 %) endosonographers participated: United States 54 (29 %), Europe 85 (46 %), and Asia 47 (25 %). European (75 %) and Asian (84 %) respondents routinely check coagulation status, whereas US respondents only check on indication (64 %, P=0.007). While propofol sedation is standard in the United States (83 %), conscious sedation is still widely used in Europe (52 %) and Asia (84 %, P<0.001). Overall, the 22-gauge needle is most commonly used (52 %). For fine-needle aspiration (FNA) of solid pancreatic lesions, 22-gauge (45 %) and 25-gauge (49 %) needles are used equally. For fine-needle biopsy (FNB) of solid masses, the 25-gauge device is less favored than the 22-gauge FNA device (49% versus 21%). The 19-gauge needle is generally used for FNB of submucosal masses (62 %). Rapid onsite pathological evaluation (ROSE) is utilized more often by US (98 %) than by European and Asian respondents (51 %, P<0.001). Cytolyt (52 %), formalin (15 %) and alcohol (15 %) are used for FNA specimen preservation in the United States and Europe, while saline (27 %) and alcohol (38 %) are widely used in Asia (P<0.001).Conclusions: EUS-guided tissue sampling practices vary substantially within the international endosonographic community and differ considerably from recommendations expressed in guidelines. Because the clinical relevance of these variations is largely unknown, the outcome of this survey suggests a need for further studies.

_Achtergrond en het waarom van de studie_ Pancreascysten komen voor bij 2,5% van de bevolking en worden vaak per toeval ontdekt. Het risico op maligne ontaarding van een pancreascyste is waarschijnlijk klein, maar exacte cijfers ontbreken. Uit voorzichtigheid adviseren de huidige richtlijnen intensieve surveillance. _Vraagstelling_ Wat is het nut van surveillance van patienten met een pancreascyste en wat zijn de risicofactoren voor maligne ontaarding hiervan?