To the Editor:We read with great interest the article by Cho et al,1

Cho IR, Jeong SH, Kang H, et al. Comparison of contrast-enhanced versus conventional EUS-guided fine-needle aspiration/biopsy in diagnosis of solid pancreatic lesions: a randomized controlled trial. Gastrointest Endosc. Epub 2021 Jan 23.

which compared the diagnostic sensitivity for pathologic diagnosis of solid pancreatic lesions (SPLs) between a contrast-enhanced harmonic EUS(CEH-EUS) group and a conventional EUS group. The authors recommended that CEH-EUS-guided fine-needle aspiration/biopsy (FNA/B) might be considered for small, indeterminate SPLs, consistent with the previous study.2Kitano M. Kudo M. Yamao K. et al.Characterization of small solid tumors in the pancreas: the value of contrast-enhanced harmonic endoscopic ultrasonography.Patients were randomly assigned to the CEH-EUS group (n = 120) and the conventional EUS group (n = 120). Actually, the randomized controlled design was the strength of this study. However, we believe that a crossover design might be a better choice.3Wang Y. Wang R.H. Ding Z. et al.Wet- versus dry-suction techniques for endoscopic ultrasound-guided fine-needle aspiration of solid lesions: a multicenter randomized controlled trial. In the CEH-EUS group, CEH-EUS–guided FNA/B was performed, followed by conventional EUS-guided FNA/B. In the conventional EUS group, conventional EUS was used first. This design method can not only balance the basic characteristics of patients and lesions but also enlarge the sample size in each group to 240 patients.

In addition, when the diagnostic values of the 2 groups were evaluated, the criterion standard was mainly based on the results of FNA/B instead of the surgical results. False positive or negative results might occur during FNA/B. We were puzzled that the authors used the results of EUS-FNA/B to evaluate the diagnostic value of EUS-guided FNA/B and each pass. In our opinion, the diagnostic value used in this article should be converted to the adequacy of the tissue sample.

Finally, the authors concluded that larger needle diameters might predict a higher diagnostic value. However, they put 19-gauge and 22-gauge needles into the same group to make a comparison with a 25-gauge needle. Although no significant differences in needle type and size between the 2 groups were noted, fewer FNB needles and more 25-gauge needles used in the conventional group underestimated the diagnostic value of conventional EUS.

In conclusion, it is an excellent study, providing us with a better understanding of CEH-EUS-guided FNA/B.

Disclosure

All authors disclosed no financial relationships.

References

Cho IR, Jeong SH, Kang H, et al. Comparison of contrast-enhanced versus conventional EUS-guided fine-needle aspiration/biopsy in diagnosis of solid pancreatic lesions: a randomized controlled trial. Gastrointest Endosc. Epub 2021 Jan 23.

Kitano M. Kudo M. Yamao K. et al.

Characterization of small solid tumors in the pancreas: the value of contrast-enhanced harmonic endoscopic ultrasonography.

Am J Gastroenterol. 107: 303-310Wang Y. Wang R.H. Ding Z. et al.

Wet- versus dry-suction techniques for endoscopic ultrasound-guided fine-needle aspiration of solid lesions: a multicenter randomized controlled trial.

Endoscopy. 52: 995-1003Article InfoIdentification

DOI: https://doi.org/10.1016/j.gie.2021.02.016

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© 2021 by the American Society for Gastrointestinal Endoscopy

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