Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours

BACKGROUND/AIM

Some endoscopic ultrasonographic (EUS) features have been reported to be suggestive of malignancy in gastrointestinal stromal cell tumours (SCTs). The aim of this study was to assess the predictive value of these features for malignancy.

METHODS

A total of 56 histologically proven cases of SCT studied by EUS between 1989 and 1996 were reviewed. There were 42 gastric tumours, 12 oesophageal tumours, and two rectal tumours. The tumours were divided into two groups: (a) benign SCT, comprising benign leiomyoma (n = 34); (b) malignant or borderline SCT (n = 22), comprising leiomyosarcoma (n = 9), leiomyoblastoma (n = 9), and leiomyoma of uncertain malignant potential (n = 4). The main EUS features recorded were tumour size, ulceration, echo pattern, cystic spaces, extraluminal margins, and lymph nodes with a malignant pattern. The two groups were compared by univariate and multivariate analysis.

RESULTS

Irregular extraluminal margins, cystic spaces, and lymph nodes with a malignant pattern were most predictive of malignant or borderline SCT. Pairwise combinations of the three features had a specificity and positive predictive value of 100% for malignant or borderline SCT, but a sensitivity of only 23%. The presence of at least one of these three criteria had 91% sensitivity, 88% specificity, and 83% predictive positive value. In multivariate analysis, cystic spaces and irregular margins were the only two features independently predictive of malignant potential. The features most predictive of benign SCTs were regular margins, tumour size < or = 30 mm, and a homogeneous echo pattern. When the three features were combined, histology confirmed a benign SCT in all cases.

CONCLUSIONS

The combined presence of two out of three EUS features (irregular extraluminal margins, cystic spaces, and lymph nodes with a malignant pattern) had a positive predictive value of 100% for malignant or borderline gastrointestinal SCT. Tumours less than 30 mm in diameter with regular margins and a homogeneous echo pattern are usually benign.

[Anorectal echo-endoscopy: applications in pediatrics]

PEDIATRIC INDICATIONS: Anorectal echoendoscopy is widely used in adults for the pretreatment work-up of rectal cancer and for the exploration of fecal incontinence. It can also be useful in the pediatric setting as recently described with rotative or linear heads. The exploration can be performed after an evacuating enema or if needed after giving a neuroleptanalgesic. The anorecal walls and neighboring areas-bladder, genital organs, perirectal spaces, vessels-can be explored. The ultrasonographic aspect of the walls is similar to that described in adults although less thick, particularly at the level of the anus sphincters. Signs of defects, abscesses and fistulizations are the same as in adults. BOWEL DISORDERS AND INCONTINENCE: Echoendoscopy can characterize rare subepithelial tumors of the rectum and vascular anomalies, but its main interest is for the exploration of bowel disorders and incontinence, particularly after surgical treatment for anorectal malformations. The quality of the muscular tissue and the quality of the surgical repair can be assessed before deciding on the need for a second operation. In this context, anorectal echoendoscopy can also disclose Hirschsprung's disease and other forms of idiopathic megarectum, including certain types with major thickening of the internal sphincter. It can also detect defects induced by prior disimpaction maneuvers. A NONINVASIVE EXAM: Anorectal echoendoscopy is a promising exploration technique in pediatric gastroenterology. Descriptions of the sphincters and anorectal anatomy are very precise and descriptions of functional disorders, whether primary or secondary to surgery, can be quite helpful for guiding subsequent management.

[Granular cell tumor of the common bile duct. Contribution of endoscopic ultrasonography in 2 cases]

We report two cases of granular cell tumors involving the common bile duct in patients presenting with obstructive jaundice. Pre-operative endoscopic ultrasonography showed short asymmetric stricture with small well delimited hypoechoic mass in the distal common bile duct wall and proximal dilatation. These tumors were misdiagnosed as a bile duct carcinoma in one case and biliary metastasis of a melanoma in the other. Histological examination of the resected specimen showed granular cell tumors. A review of the previously reported cases shows that preoperative diagnosis is uncommon. It should be considered when endoscopic ultrasonography performed for biliary obstruction in a young woman shows a small and well limited hypoechoic mass.

Imaging and staging of bilio-pancreatic tumours: role of endoscopic and intraductal ultrasonography and guided cytology

The promotion and development of endoscopic ultrasonography (EUS) should be pursued and accelerated in specialist centres involved in the management of bilio-pancreatic diseases. In trained hands, and for resectable patients, EUS is the gold standard of the imaging of tumours of the pancreas and extra-hepatic bile ducts, either for diagnostic purposes or loco-regional extension assessment. Thus, it complements ultrasonography, spiral CT or MRI but comes before ERCP which should be avoided as far as possible in resectable patients. The possibility of obtaining histology without risk of seeding with a diagnostic accuracy greater than 90% both for tumours and nodes, constitutes a significant advance in the management of pancreatic tumours.

Noninvasive imaging of insulinomas and gastrinomas with endoscopic ultrasonography and somatostatin receptor scintigraphy

BACKGROUND

Classic morphological techniques are of limited value for imaging endocrine duodenopancreatic tumors, and invasive procedures such as intraarterial stimulation are often used. Two noninvasive procedures, endoscopic ultrasonography (EUS) and somatostatin receptor scintigraphy (SRS), were recently described with promising results.

METHODS

In this study we correlated the results of preoperative EUS (n = 34) and SRS (n = 30) with operative findings in patients with histologically proven insulinoma (n = 20) or gastrinoma (n = 21).

RESULTS

The sensitivity and positive predictive value (PPV) of EUS were respectively 77% and 94% for pancreatic tumors (insulinomas and gastrinomas), 40% and 100% for duodenal gastrinomas, and 58% and 78% for metastatic lymph nodes. The sensitivity and PPV of SRS for insulinoma were 60% and 100%, respectively. In patients with gastrinoma, the sensitivity and PPV of SRS were respectively 25% and 100% for pancreatic gastrinomas, 72% and 100% for duodenal gastrinomas or periduodenal metastatic lymph nodes, and 67% and 80% for liver metastasis. In patients with multiple endocrine neoplasia, neither one of the two techniques detected all tumors. Overall sensitivity of combined EUS and SRS was 89% for insulinoma (n = 9) and 93% for gastrinoma (n = 14).

CONCLUSIONS

EUS and SRS for gastrinomas and insulinomas should be considered as the initial preoperative imaging procedures and may render invasive procedures unnecessary for most patients.

[Videolaparoscopic excision of insulinoma. A study of 5 cases]

STUDY AIM

Evaluation of the feasibility of the videolaparoscopic resection in pancreatic insulinomas, and reporting of five cases.

PATIENTS AND METHOD

From 1996 to 1998, a videolaparoscopic resection was attempted in five patients with sporadic, unique and benign insulinoma. The insulinoma was recognised and localised by preoperative ultrasonography in the pancreatic head (n = 1), body (n = 3) or tail (n = 1). For the videolaparoscopic procedure, three to five trocars were necessary. Cephalic and corporeal insulinomas were approached through an opening of the gastrocolic ligament and caudal insulinoma required mobilisation of the splenic flexure of the colon and dissection of the splenic pedicle. Peroperative ultrasonography was not used.

RESULTS

Four resections were exclusively performed with videolaparoscopy: three enucelations and one distal pancreatectomy with splenic preservation. The cephalic insulinoma could not be found by laparoscopic exploration and required a laparotomy to be recognised and enucleated; it was located further down than expected. There were no postoperative complications in four patients. One enucleation was complicated by a pancreatic fistula that required reoperation. All the patients were cured with a 6- to 16-month follow-up.

CONCLUSION

Selected insulinomas may be operated on with videolaparoscopy. Preoperative endoscopic ultrasonography is necessary for this selection. Videolaparoscopic approach is contraindicated in multiple insulinomas, in insulinomas located on the posterior wall or deeply located in the head of the pancreas, and in malignant tumors. Videolaparoscopic resection is mainly indicated in unique and benign insulinomas, superficially located on the anterior wall of the pancreas, to be resected by enucleation or distal pancreatectomy. Disadvantage of laparoscopic approach compared to conventional approach is the absence of palpation and difficulty to explore the whole pancreas; advantage is the lack of parietal incision and the good postoperative comfort.

[Intraductal papillary mucinous tumors of the pancreas: are there any preoperative clinical and laboratory factors predictive of degeneration. Results of a French-Belgium collective series]

Intraductal papillary and mucinous tumors are rare. We retrospectively analysed clinical, surgical and histological features and outcome of 41 operated patients (29 males, 12 females, mean age = 63 years). The commonest presenting manifestation was acute pancreatitis (41%). Tumor was located in only one pancreatic segment in 45% cases. Forty one per cent of patients had invasive carcinoma, 20% had tumor with severe dysplasia and 39% with minimal or moderate dysplasia. Only elevated age was significantly associated with invasive carcinoma. Eleven out of 17 patients with invasive carcinoma (65%) had a recurrence after surgery and 6 (35%) died. Among 24 patients with noninvasive tumor, 2 (8%) recurred without tumor-related death in the follow-up (48 months). This study underlines the need for early surgical resection in patients with intraductal papillary and mucinous tumor because of the high frequency of invasive carcinoma and the poor outcome of patients with invasive carcinoma.

[Pancreatic echo-endoscopy and preoperative localization of insulinomas]

Preoperative localization of insulinomas often fails because of the small size of these tumors. The aim of this study was to analyse the value of endoscopic ultrasonography of the pancreas in comparison with them to those of conventional localization procedures.

PATIENTS AND METHODS

From 1983 to 1997, 32 patients, operated with a preoperative diagnosis of insulinoma, underwent one or more localization procedures: ultrasonography (US) (n = 31), computed tomography (CT) (n = 31), magnetic resonance imaging (MRI) (n = 10), angiography (ANG) (n = 6), transhepatic portal venous samplings (THPVS) (n = 3), and/or endoscopic ultrasonography (EUS) (n = 25). More recently, 4 patients had scintigraphy with labelled octreotide. During surgery, intraoperative palpation and ultrasonography of the pancreas, performed in all but one cases (laparoscopy), allowed the localization of 29 solitary tumors and 2 multiple tumors (one of which in a case of a MEN II). A malignant tumor was found in 6 patients.

RESULTS

The sensitivity of the localization procedures was as follows: US = 19%, CT = 39%, IRM = 30%, ANG = 33%, THPVS = 0%, EUS = 96%. Labelled octreotide scintigraphy was positive in 3/4 cases. Surgical procedures included: 15 enucleations or partial resections, 14 left pancreatectomies (5 of which with splenectomy), 3 duodenopancreatectomies. In one case the tumor was resected laparoscopically (distal pancreatectomy).

CONCLUSION

EUS was the best preoperative localization procedure in this study. It may avoid the need for other imaging procedures. Combined with intraoperative ultrasonography, EUS could allow laparoscopic resections in selected cases.

Endoscopic ultrasonography in the evaluation of pediatric digestive diseases: preliminary results

BACKGROUND AND STUDY AIMS

Endoscopic ultrasonography (EUS) is rarely used in pediatrics. Its feasibility and potential indications have been assessed in this retrospective study.

PATIENTS AND METHODS

Twenty-three EUS examinations were carried out on 18 children (mean age 12 years, ranging from 4 to 16 years) using a mechanically rotating 7.5 and 12 MHz sector scan transducer. Upper digestive tract EUS (n = 17) was performed in children suffering from biliopancreatic diseases, angiomatosis or digestive tumors. They were performed under intravenous sedation. Anorectal EUS (n = 6), carried out after simple lavage in most cases, investigated tumors (adenomas and carcinoid tumor) or proctological diseases.

RESULTS

No technical failures or complications were encountered. EUS proved useful in the diagnosis of pancreatitis and portal hypertension. When included in pretherapeutic examinations, it provided useful information in cases of angiomatosis, biliary lithiasis and polyps. It was also useful in the follow-up of children after endoscopic excision or surgical treatment of adenomas or tumors (carcinoid tumor, neurofibroma).

CONCLUSION

EUS would therefore appear to be a promising technique in pediatric gastroenterology. More work is needed in order to better determine its indications and the need for equipment specific to children.

Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography

OBJECTIVE

The purpose of this study was to compare dual-phase helical CT and endosonography for the diagnosis and staging of pancreatic tumors.

SUBJECTS AND METHODS

Thirty patients with suspected pancreatic tumors underwent endosonography and dual-phase helical CT. A pathologic diagnosis was obtained in all cases with surgery (n = 23) or biopsy (n = 7), resulting in 27 neoplasms. Dual-phase helical CT and endosonographic findings were correlated with surgical and pathologic findings to determine diagnosis and resectability of pancreatic tumors.

RESULTS

Overall diagnostic sensitivity was 92% for dual-phase helical CT and 100% for endosonography (p = .45). Overall accuracy for staging of pancreatic tumors was 93% for both dual-phase helical CT and endosonography. Overall accuracy for predicting resectability was 90% for both dual-phase helical CT and endosonography. Accuracy of predicting unresectability was 100% for dual-phase helical CT and 86% for endosonography (p > .80). Differences were not considered statistically significant.

CONCLUSION

Dual-phase helical CT and endoscopic sonography do not differ significantly for diagnosis and assessment of resectability of pancreatic tumors.

[Severe hemorrhagic gastritis of radiation origin]

Severe gastric complications due to radiotherapy are uncommon, in particular hemorrhagic gastritis. A high total dose and, above all, high daily fraction appear to be the main risk factors in gastric injuries. A case of hemorrhagic gastritis induced by radiotherapy requesting a total gastrectomy is reported. The patient was treated for a primary gastric non-Hodgkin's lymphoma. Hemorrhagic gastritis occurred despite a low total dose (40 Gy) and 2 Gy daily fractions. Upper gastrointestinal endoscopy and repeated biopsies are usually insufficient to exclude a tumor recurrence. Endoscopic ultrasonography may argue for a recurrence or for radiation lesions. As the conservative treatment is usually ineffective, these gastrointestinal radiation injuries ought to be treated surgically. Besides it allows to ascertain the benign nature of radiation lesions.

Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series

BACKGROUND

Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery.

METHODS

Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed.

RESULTS

Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001).

CONCLUSIONS

This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy.

Endoscopic ultrasonography in rectal linitis plastica

BACKGROUND

Rectal linitis plastica (RLP) is a rare tumor with a poor prognosis. RLP can be a primary tumor, secondary to gastric linitis, or a metastatic form of breast or prostate carcinoma. Diagnosis is difficult because of nonspecific clinical and endoscopic findings and frequent negative biopsies (50%). The aim of this study was to evaluate the endosonographic appearance of RLP and to study the usefulness of endoscopic ultrasonography (EUS) in the follow-up of patients with RLP.

METHODS

Twenty-two video-recorded EUS examinations performed in 11 patients with histologically proven RLP were retrospectively studied. Response to conservative treatment was evaluated in three patients with secondary RLP.

RESULTS

In every case of RLP, EUS showed a circumferential thickening of the rectal wall (mean 13 mm); the thickening was mainly seen in the submucosa and the muscularis propria. In nine cases EUS showed signs of locoregional involvement (perirectal fat infiltration [n = 6], ascites [n = 5], lymph nodes [n = 3]) which was not seen by CT. In follow-up evaluations, EUS showed a lack of response to treatment in two patients with RLP secondary to gastric linitis. In the remaining patient with RLP secondary to breast carcinoma, EUS at first showed no response. The chemotherapy protocol was modified, and then improvement became evident at EUS.

CONCLUSIONS

RLP shows typical features of rectal EUS that may assist in the diagnosis of this rare disease. Moreover, EUS can be useful in evaluating the response of this disease to treatment.

Endosonographic features of esophageal granular cell tumors

BACKGROUND AND STUDY AIMS

Granular cell tumors of the esophagus are rare tumors. A definite diagnosis is achieved by endoscopic biopsies in only 50% of cases. Endoscopic ultrasonography (EUS) is the best procedure in the evaluation of upper gastrointestinal tract submucosal tumors. The aim of this study was to describe the endosonographic findings of esophageal granular cell tumors.

METHODS

From January 1989 to March 1994, 15 patients with 21 granular cell tumors which had negative biopsies were examined by EUS (Olympus GF UM3 or GF UM20,7,5 and 12 MHz). In five cases, the tumor was also studied with a 20 MHz Olympus miniprobe. The final histological diagnoses were obtained by subsequent endoscopic snare resection in 20 cases and surgically in one case.

RESULTS

The endosonographic features (with the GF UM3 or GF UM20) of esophageal granular cell tumors were: a) a tumor size of less than 2 cm in 95% of cases; b) an hypoechoic solid pattern in 100% of cases; c) a tumor arising in the inner layers in 95% (second echo-poor layer n=15; third echo-rich layer n=5). In one case, the endosonographic finding was transmural malignant infiltration of the esophageal wall (histologically confirmed).

CONCLUSION

When a granular cell tumor of the esophagus is suspected, EUS can show the inner layer location of the tumor and thus contribute to planning the endoscopic resection or follow up. When the tumor also invades the outer layers, EUS can contribute to planning the surgical resection.

Diagnostic strategies for extrahepatic cholestasis of indefinite origin: endoscopic ultrasonography or retrograde cholangiography? Results of a prospective study

BACKGROUND AND STUDY AIMS

Due to its lower morbidity, it has been suggested that endoscopic ultrasonography (EUS) might replace endoscopic retrograde cholangiography (ERC) in the management of extrahepatic cholestasis of unknown origin. The present study aimed to compare the diagnostic accuracy of EUS and ERC in the management of cholestasis of unknown origin, taking into account the patient's general status and the necessity of endoscopic therapy.

PATIENTS AND METHODS

Sixty-eight patients with cholestasis of unknown origin were studied prospectively. EUS followed by ERC was carried out on a blinded basis by two endoscopists; diagnostic and therapeutic suggestions were made after either examination. During the ERC procedure and before withdrawing the tube, the endoscopist provided the final conclusions and carried out appropriate endoscopic treatment.

RESULTS

A correct diagnosis was obtained with EUS and ERC in 94% and in 92% of cases, respectively (not significant). After EUS, diagnostic ERC was necessary for diagnosis and therapy in 24% and 58% of cases, respectively. After ERC, EUS was requested in 41% of cases. The higher the American Society of Anesthesiologists (ASA) grade, the less it was necessary to perform a complementary investigation. In ASA grade 1 patients, endoscopic therapy was suggested in 38% of cases after EUS and in 33% after ERC (not significant); in ASA grade 3 patients, it was suggested in 93% of cases.

CONCLUSIONS

The diagnostic sensitivities of EUS and ERC are similar for extrahepatic cholestasis. ERC is first indicated in poor candidates for surgery, since endoscopic therapy is frequently required. In good candidates for surgery, EUS should be carried out first in order to stage a tumor or identify choledocholithiasis.

[Benign tumors of the stomach]

The term "benign gastric tumours" comprises three distinct entities: submucosal tumours, polyps and carcinoid tumours. Submucosal tumours are rare and most often conjunctive (leiomyoma, schwannoma, lipoma, etc.), but may also be heterotopic or congenital. Because of their subepithelial location, samples taken during endoscopic examination are rarely contributory. Endoscopic ultrasonography is the examination of reference for characterisation of these tumours. Polyps of epithelial origin, are common, most often small and without degenerative potential. They can be histologically diagnosed during endoscopic ultrasonography. Carcinoid tumours, which are very rare, are discussed elsewhere in this issue.

[Contribution of endosonography to the diagnosis and follow-up of pediatric gastric neurofibroma revealing von Recklinghausen's disease]

BACKGROUND

Gastrointestinal involvement in von Recklinghausen's disease (RD) is rare during childhood; its symptoms are late and its prognosis is poor, related to local recurrence and risk of malignant transformation.

CASE REPORT

A 13 year-old boy was admitted for hematemesis revealing gastric ulcer. A second episode of hematemesis led to identify a sessile gastric tumor in this patient having numerous skin café-au-lait spots. Recurrent bleeding required laparotomy that showed diffuse infiltration into the anterior gastric wall: histological examination of the excised piece showed characteristic features of neurofibromatosis. The patient was not compliant to the endosonographic survey so that a symptomatic relapse led to total gastrectomy: histological examination did not show malignant transformation.

CONCLUSION

Endoscopy is a major tool for identifying gastrointestinal localization of RD but endosonography is necessary to precise the extent of the tumor.