Yield of Endoscopic Ultrasound Guided Fine Needle Aspiration (EUS-FNA) With and Without the Use of a Stylet in the Biopsy Needle

Research Method: All patients referred for EUS who are also likely to require FNA will be screened for study eligibility by way of the inclusion and exclusion criteria. After informed consent has been obtained patients will be randomized to 2 different groups by random number generation 1. Stylet in FNA first, Stylet out FNA second 2. Stylet out FNA first, Stylet in FNA second As each method of tissue sampling will be used for all patients they will effectively act as their own controls. In patients randomized to the first group the stylet in is left in place within the needle for the first three passes of the needle into the area to be sampled. A new 22 gauge EUS FNA is then used to obtain the FNA with the stylet out. In patients randomized to the second group a 22 gauge EUS FNA needle with the stylet out is used for the first three passes. A new needle with the stylet in is subsequently used for further sampling. Three passes will be done for each FNA biopsy. For each patient the sample adequacy, the number of bloody passes and the number of passes required to obtain an adequate sample will be recorded by the cytopathology technician. Each tissue sample will be prepared and analysed by experienced on-site cytopathology staff, who will be blinded to the group allocation of the respective patients. A positive or negative diagnosis will be recorded when the final cytology result is available. At the end of the study period a comparison between the two groups will be made in relation to the parameters outlined above. Statistical Analysis: Endpoints: The primary endpoint of our study will be the number of samples with a positive diagnosis in each group. Secondary end-points will be the number of bloody passes, the sample adequacy and the number of passes needed to obtain an adequate sample. Sample size calculation: The outcome will be represented as a proportion of FNA samples that have a positive diagnosis. The effect size between the stylet in FNA and stylet out FNA is expected to be 30%. This is at a significance level of p= 0.05 and 80% power. The number of patients in each arm is therefore 36. Description of methodology All patients who are referred for a pancreatic EUS and are likely to require an FNA will be identified and screened for eligibility for entry into the study according to the inclusion and exclusion criteria. Those patients who are seen in the office prior to an EUS appointment will be invited to enter the study by a research nurse or research assistant not involved with the procedure. They will be provided with written and verbal information on the study prior to making their decision. For patients who are referred directly for an EUS-FNA from another physician and who are not seen in the office beforehand a written invitation to enter the study will be sent in advance. This will provide detailed information on the research proposal as well as a helpline number which patients can use to contact one of the study co-ordinators for further advice. A follow up phone call to patients will be made by a study co-ordinator before they attend for the EUS; the initial contact letter will outline when this call will be made, and by whom. If patients elect to enter into the study informed consent will be obtained prior to randomization. Summary of procedures In patients randomized to the first group, under intravenous sedation, a linear endoscopic ultrasound examination is performed. The pancreatic mass is identified by endoscopic ultrasound and using a 22 gauge EUS FNA needle with the stylet in is used for the first pass. The stylet is then withdrawn and 10cc of suction is applied to the FNA needle. A sample is obtained by moving the needle in and out of the lesion for a minimum of 15 times. The sample is then collected for cytopathology. The stylet is replaced in the needle and another pass is performed by the same technique. Three passes will be done for each FNA biopsy. A new 22 gauge EUS FNA is then used to obtain the FNA with the stylet out by the same technique as outlined above. In patients randomized to the second group, under intravenous sedation a linear endoscopic ultrasound examination is performed. The pancreatic mass is identified by endoscopic ultrasound and using a 22 gauge EUS FNA needle with the stylet out is used for the first pass. The stylet is then withdrawn and 10cc of suction is applied to the FNA needle. A sample is obtained by moving the needle in and out of the lesion for a minimum of 15 times. The sample is then collected for cytopathology. The stylet is replaced in the needle and once loaded into position, the stylet is removed prior to starting another pass performed by the same technique. Three passes will be done for each FNA biopsy. Adverse events that can potentially occur include oversedation (1:500), pancreatitis (1:1000), perforation (1:5000), and bleeding (extremely rare with only one reported case in press) For each patient the sample adequacy, the number of bloody passes and the number of passes required to obtain an adequate sample will be recorded by the cytopathology technician. Each tissue sample will be prepared and analysed by experienced on-site cytopathology staff, who will be blinded to the group allocation of the respective patients. A positive or negative diagnosis will be recorded when the final cytology result is available. At the end of the study period a comparison between the two groups will be made in relation to the parameters outlined above. Follow-up: Within one day, all patients will be contacted to determine if any adverse events have occurred.