EUS-guided FNA of solid pancreatic masses: A learning curve with 300 consecutive procedures
ABSTRACT The objective of our study was to assess a single operator's learning curve with regard to the number of passes, the diagnostic accuracy, and the complications associated with EUS-guided FNA (EUS-FNA) of solid pancreatic masses.
The number of passes, the diagnostic accuracy, and the complication rate were prospectively evaluated in 300 consecutive EUS-FNA of solid pancreatic masses performed by a single endosonographer over a 3-year period. The procedures were placed into 3 groups, which contained 100 procedures each. The endosonographer had undergone a third-tier EUS fellowship and had performed 45 supervised pancreatic EUS-FNA during his training.
Of the 300 EUS-FNA performed (median age 63 years, 64% men), no statistically significant differences among the 3 groups with regard to age, gender, race, location, or size of the mass were found. Diagnostic accuracy of the EUS-FNA procedure was similar over time (Group 1, 92%; Group 2, 92%; Group 3, 95%). Median number of passes showed a decreasing trend over the 3-year study period, despite an increasing trend of the number of procedures performed (r = -0.14, p = 0.42). The median number of passes was lower for Group 2 (median, 3; p = 0.02) and Group 3 (median, 3; p = 0.003) compared with Group 1 (median, 4). Group 3 (7/100, 7%) was less likely to encounter complications compared with Group 1 (13/100, 13%; p = 0.24) and Group 2 (18/100, 18%; p = 0.03). Frequency of serious complications was similar across the 3 groups (1%-3%).
With adequate third-tier training, a newly developed EUS program can achieve safe and accurate results of EUS-FNA of the pancreas. The learning curve, however, needs to continue after the fellowship, because more procedures are needed for one to gain proficiency and efficiency with EUS-FNA.
- SourceAvailable from: Erika Madrigal
Pancreatic Cancer - Clinical Management, 03/2012; , ISBN: 978-953-51-0394-3
- "Summarizing the results of 23 studies including 1,096 patients over a 21-year period, the sensitivity of EUS for the detection of a pancreatic mass was in the range of 85-100%. (Al-Haddad & Eloubeidi, 2010; Yasuda et al, 1988; DeWitt et al, 2004; Chhieng et al, 2002; Eloubeidi & Tamhane, 2005) The operating characteristics of EUS-FNA of solid pancreatic masses in 547 patients were: sensitivity 95%, specificity 92%, positive predictive value 98% and negative predictive value 80%, with and overall accuracy of 94.1%. (Eloubeidi et al, 2007) Such accuracy numbers allow for preoperative counseling of patients, minimizing surgeon's operative time in cases of unresectable disease, and avoiding surgical biopsies in those with inoperable disease, also allowing for conservative management of patients with benign pathology results. "
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- "Mertz and Gautam demonstrated a consistent improvement in the sensitivity of EUS-FNA of pancreatic lesions through 30–40 FNA cases for a single endoscopist who did not undergo dedicated training in EUS . Eloubeidi and Tamhane tracked the diagnostic accuracy and safety of FNA in a single endoscopist who had performed >300 EUS during a dedicated fourth year training program . During the first 300 FNAs performed after training, the diagnostic accuracy did not improve over time, but fewer passes per lesion were required, suggesting continued learning after a high volume training experience. "
ABSTRACT: Background. The optimal time to initiate hands-on training in endoscopic ultrasound fine needle aspiration (EUS-FNA) is unclear. We studied the feasibility of initiating EUS-FNA training concurrent with EUS training. Methods. Three supervised trainees were instructed on EUS-FNA technique and allowed hands-on exposure from the onset of training. The trainee and attending each performed passes in no particular order. During trainee FNA, the attending provided verbal instruction as needed but no hands-on assistance. A blinded cytopathologist assessed the adequacy (cellularity) and diagnostic yield of individual passes. Primary outcomes compared cellularity and diagnostic yield of attending versus fellow FNA passes. Results. We analyzed 305 FNA sites, including pancreas (51.2%), mediastinal/upper abdominal lymph node (LN) (28.5%) and others (20.3%). The average proportion of fellow passes with AC was similar to attending FNA-pancreas: 70.3 versus 68.8%; LN: 79.0 versus 81.7%; others 65.5 versus 68.7%; P > 0.05); these did not change significantly during the training period. Among cases with confirmed malignancy (n = 179), the sensitivity of EUS-FNA was 78.8% (68.4% fellow-only versus 69.6% attending only). There were no EUS-FNA complications. Conclusions. When initiated at the onset of EUS training, attending-supervised, trainee-directed FNA is safe and has comparable performance characteristics to attending FNA.Diagnostic and Therapeutic Endoscopy 11/2011; 2011:378540. DOI:10.1155/2011/378540
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ABSTRACT: This chapter highlights key fundamentals relevant to post-procurement tissue handling of materials obtains by aspiration and/or biopsy and details the subtle techniques that can significantly impact patient management and practice patterns. A basic knowledge of tissue handling and processing is imperative for endosonographers who attempt to achieve a greater than 95% diagnostic accuracy with their tissue-acquisition procedures.01/2014; 3(1):28-34. DOI:10.4103/2303-9027.123010