Post written by Antonio Facciorusso, MD, PhD, from the Gastroenterology Unit, University of Foggia, Foggia, Italy.

Endoscopic ultrasound (EUS) fine-needle aspiration (FNA) did not prove to outperform bite-on-bite biopsy in patients with subepithelial lesions (SELs) showing a pooled diagnostic yield as high as 60%. Based on this evidence, current guidelines recommend EUS-guided sampling only in specific subgroups of patients with SELs, particularly in poor surgical candidates with large lesions ≥2 cm or when there is a suspicion of carcinoma or metastasis to the GI wall. There is limited evidence on the diagnostic performance of fine-needle biopsy (FNB) in patients with SELs; the aim of this meta-analysis was to compare EUS-guided FNB performance to FNA in patients with gastrointestinal SELs. This is the first meta-analysis comparing EUS-FNB to EUS-FNA in patients with SELs.

With a meta-analysis of 10 studies directly comparing EUS-guided FNB and FNA in patients with SELs, we made several key observations. First, FNB clearly outperformed FNA in all of the diagnostic outcomes evaluated. In patients with SELs, FNB showed exciting rates of adequate samples (94.9%), optimal histological core procurement (89.7%), and diagnostic accuracy (87.9%). On the other hand, our meta-analysis confirmed the poor results achieved with FNA already reported in the literature (80.6% sample adequacy and 65% histological core procurement rate). Second, in line with the experience with pancreatic masses, the positive results based on FNA with the presence of ROSE may suggest this strategy is as competitive as FNB in terms of sample adequacy, although a non-significant favorable trend with the latter was observed. However, FNB showed clearly superior rates of histological procurement and diagnostic accuracy even when compared to FNA with the presence of ROSE; therefore, we might conclude that FNB allows to obviate the need of an on-site pathologist, thus enabling the achievement of a satisfactory diagnostic yield even in centers where resource constraints render ROSE not available. Third, as expected, the number of needle passes through the lesion needed to obtain adequate samples was significantly lower with EUS-FNB (mean difference: -0.75), although this finding should be interpreted with caution due to the high heterogeneity observed. Finally, both the EUS sampling techniques were safe with a very limited number of adverse events observed (mainly mild bleeding).

Figure 2. Meta-analysis comparing sample adequacy of fine-needle biopsy (FNB) sampling and FNA. FNB sampling clearly outperformed FNA in terms of sample adequacy (odds ratio, 2.54; 95% CI, 1.29-5.01; P = .007) with no evidence of heterogeneity (I² = 9%).

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