Gross visual inspection by endosonographers during endoscopic ultrasound-guided fine needle aspiration Hirotoshi Ishiwatari a, * , Junya Sato a , Shinya Fujie a , Keiko Sasaki b , Junichi Kaneko a , Tatsunori Satoh a , Hiroyuki Matsubayashi a , Yoshihiro Kishida a , Masao Yoshida a , Sayo Ito a , Noboru Kawata a , Kenichiro Imai a , Naomi Kakushima a , Kohei Takizawa a , Kinichi Hotta a , Hiroyuki Ono a a Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan b Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan article info Article history: Received 25 June 2018 Received in revised form 30 November 2018 Accepted 1 December 2018 Available online xxx Keywords: Endoscopic ultrasound Fine needle aspiration Gross visual inspection Needle abstract Background/objectives: A clear criterion for terminating endoscopic ultrasound fine needle aspiration (EUS-FNA) without rapid on-site evaluation (ROSE) has not been established. However, a possible so- lution includes gross visual inspection (GVI) of the sample obtained with EUS-FNA. We performed a retrospective study to elucidate the efficacy of GVI for the diagnostic yield of EUS-FNA. Methods: Patients who underwent EUS-FNA of a pancreatic mass using a standard 22-G needle from January 2017 to December 2017 were included in the study. At least two punctures were performed for each patient, and GVI was performed for each pass by endoscopists. The correlation between GVI and pathological findings were investigated per needle pass for the first two passes. Regarding GVI, we evaluated the presence of a visible core (with or without) and the sample quantity (large or small). Results: We evaluated 126 EUS-FNA specimens and analyzed 252 needle passes. A final diagnosis of malignancy was made for 119 patients (94%). Accuracy rates were 92.5% with a visible core and 70.0% without a visible core (p < 0.01), and 85.2% for large sample quantities and 70.2% for small sample quantities (p < 0.01). Univariate analysis indicated that the presence of a visible core and large sample quantity were associated with accuracy. Multivariate analysis indicated that only the presence of a visible core was significant. Conclusions: GVI can predict the correct diagnosis when ROSE is unavailable. Evaluating the presence of a visible core is more sensitive than assessing the quantity of the sample obtained. © 2018 IAP and EPC. Published by Elsevier B.V. All rights reserved. Introduction Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has become a well-established procedure for determining di- agnoses of patients with suspected pancreatic masses because of its high diagnostic yield [1e4]. Routine EUS-FNA for pancreatic masses uses 22-gauge (G) and 25-G needles; however, a single pass with these needles is associated with suboptimal performance [3]. Consequently, multiple passes are necessary to achieve a satisfac- tory diagnostic yield [3]. Diagnosis by rapid on-site evaluation (ROSE) is highly reliable and reduces the number of passes [5e9]. However, ROSE is not implemented in many institutions, particularly in Europe and Asia, because of the limited pathology staffing, cost, and additional procedure time [3,10]. Without ROSE, there is no clear criterion for determining the number of FNA passes; therefore, unnecessary passes are performed. A possible solution for this problem is gross visual inspection (GVI) of samples obtained during EUS-FNA. Several researchers regard the presence of a visible core in the specimen as an indicator for terminating EUS-FNA; however, little is known about the in- fluence of GVI of samples obtained by standard 22-G needles on the diagnostic yield [3,11,12]. Therefore, in this study, we aimed to elucidate the clinical benefit of GVI of samples obtained with EUS- FNA. * Corresponding author. Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, Japan. E-mail address: ishihiro481019@gmail.com (H. Ishiwatari). Contents lists available at ScienceDirect Pancreatology journal homepage: www.elsevier.com/locate/pan https://doi.org/10.1016/j.pan.2018.12.001 1424-3903/© 2018 IAP and EPC. Published by Elsevier B.V. All rights reserved. Pancreatology xxx (xxxx) xxx Please cite this article as: Ishiwatari H et al., Gross visual inspection by endosonographers during endoscopic ultrasound-guided fine needle aspiration, Pancreatology, https://doi.org/10.1016/j.pan.2018.12.001