The learning curve for EUS-guided FNA of pancreatic cancer

BACKGROUND: EUS-guided FNA is an effective and safe method for tissue diagnosis of pancreatic cancer. However, EUS-guided FNA is technically challenging and requires special training. The number of cases required to become proficient and the technical steps required to achieve proficiency are unknown. METHODS: The first 57 EUS-guided FNAs of pancreatic masses by a trained endosonographer were analyzed retrospectively. For 50 masses, the histopathologic diagnosis ultimately was cancer. The sensitivity for the EUS-guided FNA diagnosis of adenocarcinoma was compared in quintiles of 10 procedures. RESULTS: Sensitivity for the diagnosis of pancreatic cancer from first to last quintile were, respectively, 50%, 40%, 70%, 90%, and 80%. There was a significant increase in sensitivity for the first 30 cases after improvement in specific technical skills: shortening of echoendoscope position, scrupulous maintenance of the US view of the needle tip at all times, swift jabbing punctures, sampling multiple areas of the mass in each pass, and performing more than 10 "jiggles" per needle pass. Sensitivity for the diagnosis of pancreatic cancer was greater than 80% for the last 20 of the 57 cases, a level that was maintained for cases 51 through 80. CONCLUSIONS: The current American Society for Gastrointestinal Endoscopy guideline of 25 supervised EUS-FNA procedures for the diagnosis of pancreatic adenocarcinoma is reasonable.