Endoscopic ultrasound.guided fine-needle tissue acquisition – A review and update of literature

Ever since the first endoscopic ultrasound-guided fine needle aspiration (FNA) was done in 1992, the procedure has evolved to become an indispensable tool for tissue acquisition in patients with gastrointestinal tumors and periluminal lesions. With the growing evidence of neoadjuvant therapy and research into intratumoral therapy, the need to obtain tissue diagnosis for tumors is quite apparent. This review provides an overall perspective to the endosonographer on various issues that are a key for best practices in FNA, in addition to being an update for practicing experienced endosonographers.

Training endosonographers in cytopathology: improving the results of EUS-guided FNA

BACKGROUND

Although on-site cytopathology services have a significant impact on efficiency and accuracy of EUS-guided FNA (EUS-FNA), the availability of this service is variable.

OBJECTIVE

To evaluate the impact of an intensive 2-day training program to educate endosonographers in EUS-related cytopathology.

DESIGN

Pilot study.

SETTING

Tertiary care medical center.

SUBJECTS

Six endosonographers (5 male, median age, 35 years) with minimal previous cytopathology exposure comprised the study cohort.

METHODS

Pre- and posttraining testing was administered. Training commenced with a cytopathology tutorial focusing on 4 performance measures: specimen adequacy, sample interpretation, specimen processing, and preliminary diagnosis. Eight live EUS-FNA cases were then performed, and study participants independently completed 4 questions based on performance measures for each case. The ability to independently smear and stain slides and operate a microscope was additionally assessed after a hands-on tutorial.

MAIN OUTCOME MEASUREMENTS

Comparison of pretraining and posttraining scores, improvement in performance measures for live cases, and ability to independently handle specimens and operate a microscope.

RESULTS

Compared with pretraining, mean posttraining test scores improved by 63% from 48 to 78 out of 100. Mean live case performance score was 95%. Performances improved from 89% on day 1 to 100% on day 2. After training, all endosonographers could independently smear/stain slides and operate a microscope.

LIMITATIONS

Long-term impact is unclear.

CONCLUSIONS

An intensive 2-day program was effective in training endosonographers in the basics of EUS-related cytopathology. Incorporating basic cytopathology in EUS fellowship curriculum will likely improve diagnostic performance of tissue acquisition procedures.

Outcomes after implementing a tailored endoscopic step-up approach to walled-off necrosis in acute pancreatitis

BACKGROUND

The aim of the study was to compare the outcomes of patients with pancreatic or peripancreatic walled-off necrosis by endoscopy using the conventional approach versus an algorithmic approach based on the collection size, location and stepwise response to intervention.

METHODS

This was an observational before-after study of consecutive patients managed over two time intervals. In the initial period (2004-2009) symptomatic patients with walled-off necrosis underwent conventional single transmural drainage with placement of two stents and a nasocystic catheter, followed by direct endoscopic necrosectomy, if required. In the later period (2010-2013) an algorithmic approach was adopted based on size and extent of the walled-off necrosis and stepwise response to intervention. The main outcome was treatment success, defined as a reduction in walled-off necrosis size to 2 cm or less on CT after 8 weeks.

RESULTS

Forty-seven patients were treated in the first interval and 53 in the second. There was no difference in patient demographics, clinical or walled-off necrosis characteristics and laboratory parameters between the groups, apart from a higher proportion of women and Caucasians in the later period. The treatment success rate was higher for the algorithmic approach compared with conventional treatment (91 versus 60 per cent respectively; P < 0·001). On multivariable logistic regression, management based on the algorithm was the only predictor of treatment success (odds ratio 6·51, 95 per cent c.i. 2·19 to 19·37; P = 0·001).

CONCLUSION

An algorithmic approach to pancreatic and peripancreatic walled-off necrosis, based on the collection size, location and stepwise response to intervention, resulted in an improved rate of treatment success compared with conventional endoscopic management.

International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video)

BACKGROUND

The over-the-scope clip (OTSC) provides more durable and full-thickness closure as compared with standard clips. Only case reports and small case series have reported on outcomes of OTSC closure of GI defects.

OBJECTIVE

To describe a large, multicenter experience with OTSCs for the management of GI defects. Secondary goals were to determine success rate by type of defect and type of therapy and to determine predictors of treatment outcomes.

DESIGN

Multicenter, retrospective study.

SETTING

Multiple, international, academic centers.

PATIENTS

Consecutive patients who underwent attempted OTSC placement for GI defects, either as a primary or as a rescue therapy.

INTERVENTIONS

OTSC placement to attempt closure of GI defects.

MAIN OUTCOME MEASUREMENTS

Long-term success of the procedure.

RESULTS

A total of 188 patients (108 fistulae, 48 perforations, 32 leaks) were included. Long-term success was achieved in 60.2% of patients during a median follow-up of 146 days. Rate of successful closure of perforations (90%) and leaks (73.3%) was significantly higher than that of fistulae (42.9%) (P < .05). Long-term success was significantly higher when OTSCs were applied as primary therapy (primary 69.1% vs rescue 46.9%; P = .004). On multivariate analysis, patients who had OTSC placement for perforations and leaks had significantly higher long-term success compared with those who had fistulae (OR 51.4 and 8.36, respectively).

LIMITATIONS

Retrospective design and multiple operators with variable expertise with the OTSC device.

CONCLUSION

OTSC is safe and effective therapy for closure of GI defects. Clinical success is best achieved in patients undergoing closure of perforations or leaks when OTSC is used for primary or rescue therapy. Type of defect is the best predictor of successful long-term closure.

Can endoscopic ultrasound distinguish between mediastinal benign lymph nodes and those involved by sarcoidosis, lymphoma, or metastasis?

BACKGROUND

Lymph nodes (LNs) echofeatures on endoscopic ultrasound (EUS) and concurrent fine needle aspiration (FNA) are alternatives to highly invasive approaches for etiologic diagnosis of mediastinal lymphadenopathy (MLAD).

AIMS

To evaluate the efficacy of LNs echofeatures and FNA via EUS to distinguish benign LNs from LNs involved by sarcoidosis, lymphoma, and metastasis in non-lung cancer patients.

METHODS

A retrospective review of patients who underwent EUS-FNA for MLAD was performed. Echofeatures of LNs including echogenicity, margins, shape, and LN size were recorded. Final diagnosis was made based on surgical sampling or clinical diagnosis with long-term follow-up. Only patients diagnosed as benign MLAD, sarcoidosis, lymphoma, and metastasis included. Diagnostic value of echofeatures and FNA was evaluated.

RESULTS

Included were 162 patients with final diagnosis of benign (68), sarcoidosis (33), lymphoma (20), and metastasis (41). The median LN along axis in the benign group [20.5 mm (6-76)] was significantly shorter than in the metastasis [28 mm (9-82)] and sarcoidosis [27 mm (17-50)] groups (p < 0.05). The median LN short axis in the benign group [11 mm (2-50)] was significantly shorter than in the metastasis [17 mm (5-44)] and lymphoma [16 mm (7-47)] groups (p < 0.05). No other echofeatures showed a discriminant value among the groups. When performing FNA, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 73.7, 100, 100, 72.2, and 84.4 %, respectively.

CONCLUSION

Although benign MLAD tend to be smaller than other etiologies, echofeatures of LNs are not reliable etiologic diagnostic approach to MLAD. Therefore, FNA is suggested when feasible. However, due to relatively low sensitivity, LNs with benign FNA results should be subjected to further work-up if they are clinically suspicious.

Endoscopic ultrasound-guided tissue acquisition

Endoscopic ultrasound (EUS) is an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. While fine-needle aspiration (FNA) has been routinely carried out for establishing tissue diagnosis, the emerging concept of tailoring chemotherapeutic agents based on molecular markers has increased the demand for core tissue procurement by means of EUS-guided fine-needle biopsy (EUS-FNB). In addition, FNB may offset the limitations of FNA wherein the diagnostic sensitivity is incumbent on the availability of an onsite cytopathologist. Given the increasing number of procedures being done, developing a unit-specific algorithmic approach for needle selection is important to improve the procedural efficiency and utilization of resources. Finally, the best outcomes can be attained only by practicing evidence-based techniques, procuring adequate quantity of sample for ancillary studies and processing the specimens appropriately.

Primary pancreatic Ewing's sarcoma with portal vein tumor thrombosis

BACKGROUND

Extraosseous Ewing's sarcoma (EES) is a mesenchyme-derived small blue cell tumor, which is distinguished by its rarity, aggressiveness, dismal prognosis, and distinct pathogenesis. Occurring almost exclusively among children and young adults, EES can arise from a variety of organs and portends a rapid clinical deterioration and high likelihood of recurrence.

DISCUSSION

We present the first reported case of a primary pancreatic Ewing's sarcoma in a patient with concomitant portal vein thrombosis. The atypical presentation of this extraordinarily rare tumor underscores the imperative to maintain EES in the differential diagnosis of suspicious, indistinct pancreatic lesions in young patients. In addition, we review the available literature describing additional cases of primary pancreatic Ewing's sarcoma.

Characterization of some representative soils from the Ganges floodplain of Bangladesh

DOI: http://dx.doi.org/10.3329/dujbs.v21i2.11519Dhaka Univ. J. Biol. Sci. 21(2): 201-205, 2012 (July)

Endoscopic ultrasound-guided fine needle aspiration in cystic pancreatic lesions

Incidental pancreatic cysts are being increasingly recognized recently with incremented concern about health and frequent health check-up. Endoscopic ultrasound (EUS) has emerged as the principal modality for imaging pancreas for various pancreatic diseases including pancreatic cyst. But imaging alone cannot accurately identify the exact nature of the pancreatic cyst. EUS-guided fine needle aspiration is a useful adjunctive procedure to differentiate pancreatic cystic lesions. Cystic fluid analysis with cytologic evaluation is important to diagnose etiology of pancreatic cystic lesions, helping the clinician to more accurately assess the presence or potential for malignancy.

EUS-guided FNA of solid pancreas tumors

Although endoscopic ultrasonography (EUS) is considered superior to MRI and CT in detecting pancreatic masses, it is the ability to target and place a needle into suspicious lesions that has made EUS indispensible in the evaluation of patients with solid pancreatic tumors. Endoscopic ultrasound-guided-fine-needle aspiration (EUS-FNA) is an accurate and safe technique to confirm the diagnosis of pancreatic cancer. EUS-FNA is now the principal technique applied to obtain the diagnosis of malignancy. We have designed this article to address a number of the key technical aspects of EUS-FNA of solid pancreatic masses.

Aspects of infection in intensive care unit--prevention and control

Nosocomial infections are the main source of infection in a hospitalized patient. Source of contaminant may be multiple. In a cardiac ICU the vulnerable open heart surgery patients are with multiple invasive lines and monitors. Pediatrics and neonates are more vulnerable because of their poor immunity and nutritional debility. Frequent indwelling line access makes a patient more prone to systemic infection with variable organisms. Our aim is to minimize the chances of hospital acquired infection as far as possible by the use of systemic approach to the patients as guided by the international standard hospital protocol.

Lung cancer staging by combined endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS): The gastroenterologist's perspective

This review deals with the combined approach of endoscopic ultrasound and endobronchial ultrasound for lung cancer staging. The review provides an overview for the gastroenterologist who performs endosonography with regard to the current evidence supporting the use of endoscopic ultrasound and endobronchial ultrasound in clinical practice.

Salmonella-a new threat to neonates

Hospital admitted 582 neonates with suspected septicaemia were studied in Microbiology Department of Dhaka Medical College, Dhaka, Bangladesh. Samples being taken from neonatal unit of Dhaka Medical College Hospital and a Neonatal Private Hospital in one year (January to December 2004). Blood culture was done by Lytic-centrifugation method. The isolated organisms were identified using standard laboratory procedures. Among 582 sick neonates 59(10.14%) were culture positive and the predominant organisms were Gram Negative Bacteria (89.83%). Among the isolates Klebsiella spp. was the prime organism (33.90%). Salmonella was observed as the 2nd most common cause (22.03%) for sepsis of neonates. Of these isolated Salmonella strains 46.15% were Salmonella typhi and 53.85% were Salmonella spp. Next to Imipenem, Ciprofloxacin was observed as the drug of choice for treatment of Sepsis neonatorum.

Severe Cholestatic Jaundice in Hyperthyroidism after Treatment with 131-Iodine

A 39-year-old white man was referred to our hospital for evaluation of his jaundice and pruritus. The patient was treated with I for diffuse toxic goiter prior to his referral to our hospital. Clinical examination and laboratory investigations excluded viral hepatitis, autoimmune hepatitis, granulomatous disease, primary biliary disease, extrahepatic biliary obstruction, and heart failure. Liver biopsy showed severe intrahepatic and canalicular cholestasis with minimal inflammatory changes. The patient's jaundice promptly resolved with therapy for hyperthyroidism and thyroid storm as bilirubin levels decreased from 35 mg/dL (normal: 0.5-1.2 mg/dL) to 0.4 mg/dL. Thyrotoxicosis can be an uncommon cause of profound cholestasis. Our case differs from all other reports in the literature because of the severity of the cholestasis and its prompt resolution with treatment for thyrotoxicosis.

Granulocytic sarcoma presenting with malignant anasarca in a patient with secondary acute myeloid leukemia

Granulocytic sarcomas (GS) are rare extramedullary tumor masses composed of immature cells derived from the hematopoietic myeloid series. GS occur in 3% to 7% of cases of acute myeloid leukemia (AML) and can present before, during, or even after the diagnosis of AML. GS can involve different organs, individually or simultaneously, including the skin, lymph nodes, bone, breast, central nervous system, and lung among others. GS involving peritoneal and pleural fluids is a rare presentation. We present an unusual case of a patient with myelodysplastic syndrome whose disease progressed into a secondary AML and developed GS in the ascitic and pleural effusions as the predominant manifestation of disease progression.

Effects of extremely low frequency magnetic field on fertility of adult male and female rats

To investigate the effects of an extremely low-frequency (ELF) magnetic field on their fertility, adult male and female Sprague-Dawley rats were exposed to a 50 Hz sinusoidal magnetic field of approximately 25 microT (rms) for 90 days before they were mated with unexposed counterparts. Exposure to a 50 Hz field reduced male rat fertility. The number of pregnant females was reduced when mated with exposed males, and the number of resorptions increased. The effects of magnetic field on male fertility were shown to be partly reversible, when the same exposed group of males were remated 45 and 90 days after being removed from the fields. Exposure of adult female rats to 50 Hz magnetic fields for 90 days before mating significantly reduced their fertility. The mean numbers of implantations and living fetuses per litter were statistically significantly decreased in the 50 Hz group. These results suggest that low frequency magnetic fields have some adverse effects on fertility of male and female rats.

Investigation of the nonlinearity in the heart rate dynamics

This paper presents the application of a neural network to predict human heart rate. Electrocardiograms were measured from 5 healthy adult human subjects and 5 data sets were constructed calculating instantaneous heart rate from the measured signal. The nonlinear radial basis function neural network was applied to have a one step ahead prediction of the 1000 point heart rate. The results of the prediction are compared to that obtained by a linear autoregressive model. The results show that the neural network performs better than the autoregressive model in predicting heart rate for 2 data sets while for the other 3 data sets the performance of the two models is statistically similar. This indicates that the heart rate may be controlled nonlinearly by the autonomic nervous system.

Efficient gene transfer to airway epithelium using recombinant Sendai virus

Clinical studies of gene therapy for cystic fibrosis (CF) suggest that the key problem is the efficiency of gene transfer to the airway epithelium. The availability of relevant vector receptors, the transient contact time between vector and epithelium, and the barrier function of airway mucus contribute significantly to this problem. We have recently developed recombinant Sendai virus (SeV) as a new gene transfer agent. Here we show that SeV produces efficient transfection throughout the respiratory tract of both mice and ferrets in vivo, as well as in freshly obtained human nasal epithelial cells in vitro. Gene transfer efficiency was several log orders greater than with cationic liposomes or adenovirus. Even very brief contact time was sufficient to produce this effect, and levels of expression were not significantly reduced by airway mucus. Our investigations suggest that SeV may provide a useful new vector for airway gene transfer.

Versatility of the accessory C proteins of Sendai virus: contribution to virus assembly as an additional role

The P/C mRNA of Sendai virus (SeV) encodes a nested set of accessory proteins, C', C, Y1, and Y2, referred to collectively as C proteins, using the +1 frame relative to the open reading frame of phospho (P) protein and initiation codons at different positions. The C proteins appear to be basically nonstructural proteins as they are found abundantly in infected cells but greatly underrepresented in the virions. We previously created a 4C(-) SeV, which expresses none of the four C proteins, and concluded that the C proteins are categorically nonessential gene products but greatly contribute to viral full replication and infectivity (A. Kurotani et al., Genes Cells 3:111-124, 1998). Here, we further characterized the 4C(-) virus multiplication in cultured cells. The viral protein and mRNA synthesis was enhanced with the mutant virus relative to the parental wild-type (WT) SeV. However, the viral yields were greatly reduced. In addition, the 4C(-) virions appeared to be highly anomalous in size, shape, and sedimentation profile in a sucrose gradient and exhibited the ratios of infectivity to hemagglutination units significantly lower than those of the WT. In the WT infected cells, C proteins appeared to colocalize almost perfectly with the matrix (M) proteins, pretty well with an external envelope glycoprotein (hemagglutinin-neuraminidase [HN]), and very poorly with the internal P protein. In the absence of C proteins, there was a significant delay of the incorporation of M protein and both of the envelope proteins, HN and fusion (F) proteins, into progeny virions. These results strongly suggest that the accessory and basically nonstructural C proteins are critically required in the SeV assembly process. This role of C proteins was further found to be independent of their recently discovered function to counteract the antiviral action of interferon-alpha/beta. SeV C proteins thus appear to be quite versatile.