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Background Although on-site cytopathology services have a significant impact on efficiency and accuracy of EUS-guided FNA (EUS-FNA), the availability of this service is variable. Objective To evaluate the impact of an intensive 2-day training program to educate endosonographers in EUS-related cytopathology. Design Pilot study. Setting Tertiary care medical center. Subjects Six endosonographers (5 male, median age, 35 years) with minimal previous cytopathology exposure comprised the study cohort. Methods Pre- and posttraining testing was administered. Training commenced with a cytopathology tutorial focusing on 4 performance measures: specimen adequacy, sample interpretation, specimen processing, and preliminary diagnosis. Eight live EUS-FNA cases were then performed, and study participants independently completed 4 questions based on performance measures for each case. The ability to independently smear and stain slides and operate a microscope was additionally assessed after a hands-on tutorial. Main Outcome Measurements Comparison of pretraining and posttraining scores, improvement in performance measures for live cases, and ability to independently handle specimens and operate a microscope. Results Compared with pretraining, mean posttraining test scores improved by 63% from 48 to 78 out of 100. Mean live case performance score was 95%. Performances improved from 89% on day 1 to 100% on day 2. After training, all endosonographers could independently smear/stain slides and operate a microscope. Limitations Long-term impact is unclear. Conclusions An intensive 2-day program was effective in training endosonographers in the basics of EUS-related cytopathology. Incorporating basic cytopathology in EUS fellowship curriculum will likely improve diagnostic performance of tissue acquisition procedures.

Supplemental digital content is available in the text., Objectives Although a large gauge needle can procure more tissue at endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), its advantage over smaller needles is unclear. This study compared flexible 19G and 25G needles for EUS-FNA of solid pancreatic masses. Methods This was a randomized trial of patients undergoing EUS-FNA of pancreatic masses using flexible 19G or 25G needle. Main outcome measure was to compare median number of passes for on-site diagnosis. Secondary measures were to compare specimen bloodiness, complications, technical failures, and histological core tissue procurement. Results One hundred patients were randomized to EUS-FNA using flexible 19G or 25G needle. Median of 1 pass was required to achieve on-site diagnosis of 96% and 92% (P = 0.68) in 19G and 25G cohorts. There was no significant difference in technical failure (0% vs 2%, P = 0.99) or adverse events (2% vs 0%, P = 0.99) between 19G and 25G cohorts. Although histological core tissue procurement was significantly better with flexible 19G needle (88% vs 44%, P < 0.001), specimens were bloodier (severe bloodiness, 36% vs 4%; P < 0.001). Conclusions As there is no significant difference in the performance of flexible 19G and 25G needles, needle choice for sampling pancreatic masses should be based on endoscopist preference and need for histology.

Background When on-site cytopathology support is not available, EUS-guided fine needle aspiration (EUS-FNA) is performed for cell-block preparation to allow off-site interpretation. Objective To identify the number of passes required to obtain a diagnostic cell block by using a 25-gauge needle for sampling pancreatic masses. Design Randomized trial. Setting Tertiary care hospital. Patients Sixty-two patients with solid pancreatic mass lesions. Interventions EUS-FNA was performed by using a 25-gauge needle. After establishing a preliminary on-site diagnosis, patients were randomized to 2 or 4 FNA passes for a cell block. A cell block was evaluated by a pathologist blinded to on-site interpretation for the presence of a tissue pellet, histological core tissue size, and diagnostic accuracy. Main Outcome Measurements To determine the number of passes required to obtain a diagnostic cell block with a 25-gauge FNA needle. Results Sixty-two patients were randomized to undergo either 2 (n = 31) or 4 (n = 31) FNA passes for a cell block. Before randomization, an on-site diagnosis was established in all 62 patients (100%). The final diagnosis was adenocarcinoma in 45 (72.6%), neuroendocrine/other tumor in 7 (11.3%), and chronic pancreatitis in 10 (16.1%). There was no difference in the presence of a tissue pellet (93.5 vs 96.8%; P = .99), the median size of the histological core (0.006 vs 0.05 mm 2 ; P = .12), or the presence of a diagnostic cell block (80.6 vs 80.6%; P = .99) between patients randomized to 2 or 4 FNA passes, respectively. Limitations Only pancreatic masses were evaluated. Conclusions The 25-gauge FNA needle yielded a diagnostic cell block in only 81% of patients, irrespective of whether 2 or 4 FNA passes were performed. These findings have important implications for centers without on-site cytopathology services. (Clinical trial registration number NCT01809028.)

100 Multi-Center Randomized Trial Comparing the 19G and 25G Needles for EUS-Guided FNA of Large Solid Pancreatic Mass Lesions Muhammad Hasan, Jayapal Ramesh, Ji Young Bang, Bronte a. Holt, Shantel Hebert-Magee, Amy L. Logue, Robert Hawes, Shyam Varadarajulu* Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; Medicine, University of Alabama at Birmingham, Birmingham, AL Background: Retrospective studies suggest that given the increased necrosis in large solid pancreatic mass lesions, more passes are required at EUS-FNA for establishing onsite diagnostic adequacy. The hypothesis of this study is that a larger gauge needle will procure more tissue than a smaller gauge needle and therefore will establish the diagnosis with fewer FNA passes. Aim: To compare 19 and 25G needles for EUS-FNA of large solid pancreatic mass lesions. Methods: In this multi-center trial, patients with solid pancreatic mass lesions 35mm or greater in size were randomized to undergo EUS-FNA using 19 or 25G needle. FNA maneuvers were performed using the fanning technique and without the use of suction. A pathologist blinded to randomization sequence evaluated specimens onsite for diagnostic adequacy. Main outcome measures: Compare the median number of passes needed to establish onsite diagnostic adequacy, specimen quality (bloodiness graded as mild if!33%, moderate if 34-66%, severe if O67%) and complications between 19 and 25G needles. Sample size was estimated based on detecting a difference of one pass required to establish onsite diagnostic adequacy, using standard deviation of 1 for 19G and 1.9 for 25G needle (power 80%, aZ0.05). Results: Of 80 randomized patients (19GZ40; 25GZ40) there was no significant difference in patient or disease characteristics between the cohorts (Table). Except for specimen bloodiness that was significantly greater in the 19G cohort, there was no difference in the median number of passes required to establish onsite diagnostic adequacy, final diagnosis, technical failures (none) or complications (none) between the two cohorts. Conclusion: 19G needle has no advantage over a 25G needle for establishing onsite diagnostic adequacy when performing EUS-FNA of large solid pancreatic mass lesions.

years) with an EUS finding of pancreatic solid lesion were included in the study. Cytological final diagnosis was adenocarcinoma in 25/30 (83.3%) cases, neuroendocrine tumor 1/30 (3.3%), IPMN with high grade dysplasia 2/30 (6.7%), GIST in 1/30 (3.3%) and negative for malignant cells 1/30 (3.3%). The difference between the overall blood amount score per technique was not statistically significant (pZ0.61) as well as the cellularity score (pZ0.08). In 13/30 pts (43%) the two techniques reported concordant T/N ratio. In 6/30 pts (20%) final diagnosis was achieved only by capillary obtained smears. In 1/30 pt (3.3%) the diagnosis was done with aspiration. In the remnant, the ratio between the two techniques was similar. Adequacy was reached in 24/30 (80%) with aspiration and 29/30 (97%) with capillary technique (pZ 0.04). Conclusions: Aspiration and capillary sampling techniques provided similar results in cellularity and blood amount. However adequacy rate was significantly superior in capillary technique. Furthermore, in 20% of cases, final diagnosis was achieved only with capillary samples. Mo1412 The 25G FNA Needle: Good for Onsite but Poor for Offsite Evaluation? Results of a Randomized Trial Shyam Varadarajulu*, Bronte a. Holt, Muhammad Hasan, Ji Young Bang, Amy L. Logue, Robert Hawes, Shantel Hebert-Magee Center for Interventional Endoscopy, Florida Hospital, Orlando, FL Background: The diagnostic performance of EUS-FNA is related to the availability of a high quality onsite cytopathologist. When onsite cytopathology support is not available, FNA is performed for cell block preparation to allow offsite interpretation. Although a recent meta-analysis has proven the superiority of the 25G needle for sampling solid pancreatic masses, there is no data on the optimal number of passes required to obtain a diagnostic cell block. Aim: To identify the number of passes required to obtain a diagnostic cell block when using a 25G needle for sampling pancreatic mass lesions. Methods: Consecutive patients with solid pancreatic masses underwent EUS-FNA using a 25G needle. Once preliminary onsite diagnosis was established, patients were randomized to undergo either two or four FNA passes (fanning technique) using the same needle for cell block preparation. The same pathologist who rendered onsite diagnosis evaluated the cell block specimens at a later time but was blinded to information on patients, onsite diagnosis and randomization sequence. Cell block was evaluated for (a) presence of tissue pellet, (b) size of pellet and (c) diagnostic accuracy (tissue representative of final diagnosis). Final diagnosis was established by long-term patient follow-up or surgical histology. Based on prior literature, sample size was estimated at 62 patients. Results: 62 patients (Female 54.8%, median ageZ 71yrs) were randomized to undergo either two (nZ31) or four (nZ31) FNA passes for cell block. Prior to randomization, onsite diagnosis was established in all 62 patients with a diagnostic accuracy of 100%. The median number of passes required to establish onsite diagnosis was 1 (IQRZ1-2). The final diagnosis was adenocarcinoma in 45 (72.5%), neuroendocrine/other tumor in 7 (11.3%) and chronic pancreatitis in 10 (16.1%). There was no difference in patient or tumor characteristics between the randomized cohorts (Table). There was no difference in the presence of tissue pellet (93.5 vs. 96.8%; pZ0.99), median size of tissue pellet (0.006 vs.0.05mm; pZ0.11) or diagnostic accuracy (80.6% vs. 80.6%; pZ0.99) between patients randomized to two or four FNA passes, respectively. SUMMARY: Despite establishing a 100% onsite diagnosis, the same 25G needle when used in the same mass yielded a diagnostic cell block in only 80% of patients, irrespective of the number of FNA passes performed. Conclusions: While the aspirate obtained from a 25G needle is excellent for onsite evaluation, the cell block obtained from it is suboptimal for off-site interpretation. The role of larger gauge needles to obtain a better cell block needs investigation. These findings have important implications for centers and endosonographers that do not have access to onsite cytopathology services. www.giejournal.org Two FNA Passes (N[31) Four FNA Passes (N[31) p Median passes to onsite diagnosis, n (IQR) 1 (1-2) 1 (1-2) 0.68 Median tumor size, mm (IQR) 30 (19-40) 35 (22-40) 0.26 Vascular invasion, n (%) 18 (58.1) 20 (64.5) 0.60 Tumor in head/uncinate, n (%) Body/tail, n(%) 27 (87.1) 4 (12.9) 24 (77.4) 7 (22.6) 0.51 Diagnostic accuracy of cell block, n (%) 25 (80.6) 25 (80.6) 0.99 Mo1413 EUS-Guided Tissue Acquisition: Meta-Analysis Comparing the Procore and Standard FNA Needles Ji Young Bang*, Muhammad Hasan, Robert Hawes, Shyam Varadarajulu Center for Interventional Endoscopy, Florida Hospital, Orlando, FL Background: To overcome the limitations associated with cytology, a ProCore biopsy platform has been developed in 19, 22 and 25G sizes. However, individual studies Vol comparing the ProCore and FNA needles have yielded varying conclusions. Purpose of the Study: This meta-analysis was conducted to compare the performance of the ProCore and standard FNA needles when performing EUS-guided tissue acquisition. Methods: All published manuscripts and presented abstracts (International Scientific Meetings) that compared the ProCore and FNA needles were analyzed. Excluded were non-comparative and technical feasibility studies. Main outcome measures: Compare the rates of diagnostic adequacy, diagnostic accuracy, histological core tissue procurement and mean number of passes to diagnosis when sampling all solid organ lesions and solid pancreatic masses. Results: A total of 21 studies involving 1617 patients met inclusion criteria. There was significant heterogeneity in study design and end points. Study outcomes are shown in the Table. There was no significant difference in diagnostic adequacy/accuracy, histological core tissue procurement or mean number of passes to diagnosis between both cohorts. Subgroup analysis did not reveal any difference between the 19, 22/25G needles for any of the outcome measures. Conclusions: Current data does not demonstrate a significant difference in performance between the ProCore and standard FNA needles for establishing a diagnosis with fewer no. of passes, for yielding a better cytological aspirate or histological core tissue. Therefore, the choice of a needle should be based on endosonographer preference and needle costs.