Comparative analysis of different biopsy techniques for pancreatic lesions in diagnostic value, safety, and cost-effectiveness

Abstract

Background: Pancreatic cancer is highly lethal and often diagnosed at an advanced stage, highlighting the need for early and accurate diagnosis. Although imaging plays a crucial role, definitive pathological confirmation requires biopsy. Percutaneous ultrasound-guided core needle biopsy (US-CNB), computed tomography-guided core needle biopsy (CT-CNB), and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) are the three main biopsy techniques, each differing in diagnostic accuracy, safety, and cost-effectiveness. The aim of this study was to compare the diagnostic value, safety, and cost-effectiveness of these three biopsy techniques for suspiciously malignant pancreatic lesions.

Methods: We retrospectively evaluated patients with suspicious malignant pancreatic lesions who underwent US-CNB, CT-CNB, or EUS-FNA from January 2018 to January 2023. We compared technical success rates, sample adequacy, diagnostic accuracy, sensitivity, specificity, and complication rates of three groups. Additionally, we calculated the cost/effectiveness ratio (C/E) and incremental cost-effectiveness ratio (ICER) for each method.

Results: A total of 399 patients were enrolled (US-CNB, n=86; CT-CNB, n=55; EUS-FNA, n=258), achieving 100% technical success. Sample adequacy satisfaction rates were 97.70% for US-CNB, 90.90% for CT-CNB, and 74.03% for EUS-FNA, with EUS-FNA significantly lower compared to the other two methods (P<0.001). Diagnostic accuracy was significantly higher for US-CNB (97.70%) and CT-CNB (90.90%) compared to EUS-FNA (69.80%) (P<0.001). Complication rates were 15.12% for US-CNB, 16.36% for CT-CNB, and 10.47% for EUS-FNA, with no significant differences (P=0.319). Compared to EUS-FNA, ICER for US-CNB was -14,367.7 yuan and for CT-CNB was -8,279.22 yuan per correct diagnosis, both below the willingness-to-pay threshold.

Conclusions: US-CNB and CT-CNB demonstrate superior diagnostic accuracy and specimen adequacy compared to EUS-FNA for suspected malignant pancreatic lesions. There are no significant differences in postoperative complication rates among three biopsy methods. In terms of cost-effectiveness, US-CNB and CT-CNB have lower costs and higher effectiveness than EUS-FNA, indicating greater economic efficiency.

Keywords: Pancreatic cancer; core needle biopsy (CNB); cost-effectiveness analysis; fine needle aspiration (FNA); ultrasound-guided.

Figure 1

The flow chart of patient inclusion process. CT-CNB, computed tomography-guided core needle biopsy; EUS-FNA, endoscopic ultrasound-guided fine needle aspiration; US-CNB, ultrasound-guided core needle biopsy.

Figure 2

A 69-year-old male patient underwent US-CNB for pancreatic head lesion. (A) On gray-scale ultrasound, a hypoechoic lesion demonstrated unclear boundaries and an irregular shape, measuring 6.8 cm × 5.2 cm (arrow indicates the lesion). (B,C) Contrast-enhanced ultrasound revealed slight peripheral hyper-enhancement during the arterial phase (19 s) and hypo-enhancement within the lesion followed by overall hypo-enhancement during the venous phase (113 s) (arrow indicates the lesion). (D) A core needle biopsy of the pancreatic head was performed under percutaneous ultrasound guidance (arrow indicates the puncture needle). On the second day post-procedure, the abdominal drainage tube (initially placed due to massive ascites, which was drained before the ultrasound-guided biopsy) discharged bloody fluid, and the patient’s hemoglobin level dropped from 124 g/L pre-procedure to 115 g/L post-procedure. Hemostasis was achieved with sodium carbazochrome sulfonate and batroxobin. US-CNB, ultrasound-guided percutaneous core needle biopsy.

Figure 3

A 68-year-old male individual underwent CT-guided percutaneous core needle biopsy for pancreatic lesion. (A) On non-contrast CT, a low-density lesion shows in the pancreatic body and tail (arrow indicates the lesion). (B,C) The lesion exhibited unclear boundaries and an irregular shape. Post-contrast imaging revealed hypo-enhancement of the lesion (arrow indicates the lesion). (D) A core needle biopsy of the pancreatic lesion was performed under CT guidance (arrow indicates the puncture needle). (E) On the second day post-procedure, an abdominal CT scan revealed a mixed, slightly high-density mass measuring approximately 10.6 cm × 7.8 cm in the left upper abdomen, without enhancement, suggesting a possible hematoma (* indicates the bleeding site). Hemostasis was managed with carbazochrome sodium sulfonate and batroxobin. (F) A follow-up CT scan 4 weeks later showed a reduction in the size of the hematoma to approximately 2.4 cm × 1.8 cm (* indicates the bleeding site). CT, computed tomography.

Figure 4

A 49-year-old male patient underwent endoscopic ultrasound-guided fine needle aspiration. (A) A hypoechoic lesion with unclear boundaries was identified in the pancreatic head by endoscopic ultrasound (arrow indicates the lesion). (B) Doppler imaging showed no blood flow signals around or within the pancreatic lesion (arrow indicates the lesion). (C) Under endoscopic ultrasound guidance, fine needle aspiration of the pancreatic head lesion was performed (arrow indicates the puncture needle). The day after the procedure, the patient experienced intermittent hematemesis and black stools, accompanied by a drop of hemoglobin levels (from 118 g/L pre-procedure to 92 g/L post-procedure). In addition to pharmacological hemostasis, the patient received a transfusion of red blood cell suspension, which successfully resolved the bleeding.