This study aimed to evaluate the comparative effectiveness of conventional fine-needle aspiration (FNA), fine-needle biopsy (FNB), and combined cytology–histology sampling (FNAB) using Franseen needles, and to determine whether a dual-modality sampling strategy enhances diagnostic accuracy across diverse pathologies

Background: For EUS guided tissue acquisition in the diagnosis of gastrointestinal, pancreatobiliary, and mediastinal diseases, Franseen-tip needles have shown superior tissue architecture preservation and improved histology adequacy but evidence regarding their overall impact on diagnostic yield remains mixed. Furthermore, whether cytology and histology obtained concurrently using the same needle—an approach now increasingly adopted—improves diagnostic performance is not fully established. 

Methods: We conducted a retrospective review of all patients who underwent EUS-guided tissue sampling at a tertiary referral center in Surat, India.  Between January 2015 and March 2025, tissue acquisition predominantly involved FNA using 22G or 25G needles with slow-pull suction (Group A), and FNB using 22G ProCore needles when histology was required. From 2019 onward, Franseen needles were adopted as standard, and combined cytology and histology sampling (FNAB) without stylet or suction became routine (Group B). Variables analyzed included tissue adequacy, sensitivity, specificity, malignancy prediction, and disease-specific diagnostic yield. A propensity-matched analysis compared Groups A and B to control for confounders.

A total of 989 patients were included; 631 (63.8%) had malignant disease. The most common sampling sites were lymph nodes (n=381), pancreatic lesions (n=354), bile duct (n=81), periampullary region (n=45), gallbladder (n=39), luminal wall (n=42), and others. Franseen needles were used in 816 (82.5%) procedures, while FNB was performed in 748 (75.5%). Overall cytology adequacy was 92.5%, while histology adequacy was 87.0%. Cytology achieved a sensitivity of 92.4% and specificity of 95.3%. When combining cytology and histology with Franseen needles (FNAB), adequacy significantly improved (97.4% vs 91.9% with non-Franseen FNA; p=0.0012), as did specificity (94.8% vs 87.7%; p=0.042). Sensitivity and PPV were higher with FNAB, though differences were not statistically significant. In malignant lesions, FNAB provided the highest adequacy (98.9%) and sensitivity (96.4%), significantly outperforming both standalone FNA (adequacy 94.1%; p=0.0004) and FNB (91.6%; p<0.001). In benign lesions, FNAB also demonstrated superior adequacy (98.7% vs 87.4% with FNA; p=0.0048) and higher sensitivity (95.5% vs 88.8%; p=0.0374). Disease-specific analysis revealed the greatest advantage of FNAB in pancreatic carcinoma (adequacy 98.9% vs 89.4% with FNB; p=0.0003) and tuberculosis (adequacy 98.7% vs 91.0% with FNA; p=0.0048), particularly in lesions with fibrosis, necrosis, or firm tissue consistency. Propensity-matched comparison of Groups A and B showed no significant difference in overall diagnostic adequacy (92.3% vs 95.4%; p=0.36) or sensitivity (93.3% vs 92.9%; p=1.00). Discordance between cytology and histology was low (3.7%), with moderate agreement (κ=0.49), indicating complementary contributions rather than redundancy.

Discussion:Franseen needles, propensity-matched analysis showed that needle type alone does not determine diagnostic yield; rather, synergistic combination of cytology and histology enables optimal outcomes.

FNAB using Franseen needles offers the most robust diagnostic performance among all tissue acquisition approaches evaluated. The strategy provides higher adequacy and superior sensitivity in both malignant and benign diseases, with particular benefit in pancreatic cancer and tuberculosis. Incorporating both cytology and histology into routine