The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma

Diagnosis of pancreatic cancer

The ability to diagnose pancreatic carcinoma has been rapidly improving with the recent advances in diagnostic techniques such as contrast-enhanced Doppler ultrasound (US), helical computed tomography (CT), enhanced magnetic resonance imaging (MRI), and endoscopic US (EUS). Each technique has advantages and limitations, making the selection of the proper diagnostic technique, in terms of purpose and characteristics, especially important. Abdominal US is the modality often used first to identify a cause of abdominal pain or jaundice, while the accuracy of conventional US for diagnosing pancreatic tumors is only 50-70%. CT is the most widely used imaging examination for the detection and staging of pancreatic carcinoma. Pancreatic adenocarcinoma is generally depicted as a hypoattenuating area on contrast-enhanced CT. The reported sensitivity of helical CT in revealing pancreatic carcinoma is high, ranging between 89% and 97%. Multi-detector-row (MD) CT may offer an improvement in the early detection and accurate staging of pancreatic carcinoma. It should be taken into consideration that some pancreatic adenocarcinomas are depicted as isoattenuating and that pancreatitis accompanied by pancreatic adenocarcinoma might occasionally result in the overestimation of staging. T1-weighted spin-echo images with fat suppression and dynamic gradient-echo MR images enhanced with gadolinium have been reported to be superior to helical CT for detecting small lesions. However, chronic pancreatitis and pancreatic carcinoma are not distinguished on the basis of degree and time of enhancement on dynamic gadolinium-enhanced MRI. EUS is superior to spiral CT and MRI in the detection of small tumors, and can also localize lymph node metastases or vascular tumor infiltration with high sensitivity. EUS-guided fine-needle aspiration biopsy is a safe and highly accurate method for tissue diagnosis of patients with suspected pancreatic carcinoma. (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) has been suggested as a promising modality for noninvasive differentiation between benign and malignant lesions. Previous studies reported the sensitivity and specificity of FDG-PET for detecting malignant pancreatic tumors as being 71-100% and 64-90%, respectively. FDG-PET does not replace, but is complementary to morphologic imaging, and therefore, in doubtful cases, the method must be combined with other imaging modalities.

Nonoperative imaging techniques in suspected biliary tract obstruction

Evaluation of suspected biliary tract obstruction is a common clinical problem. Clinical data such as history, physical examination, and laboratory tests can accurately identify up to 90% of patients whose jaundice is caused by extrahepatic obstruction. However, complete assessment of extrahepatic obstruction often requires the use of various imaging modalities to confirm the presence, level, and cause of obstruction, and to aid in treatment plan. In the present summary, the literature on competing technologies including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiopancreatography (PTC), endoscopic ultrasound (EUS), intraductal ultrasonography (IDUS), magnetic resonance cholangiopancreatography (MRCP), helical CT (hCT) and helical CT cholangiography (hCTC) with regards to diagnostic performance characteristics, technical success, safety, and cost-effectiveness is reviewed. Patients with obstructive jaundice secondary to choledocholithiasis or pancreaticobiliary malignancies are the primary focus of this review. Algorithms for the management of suspected obstructive jaundice are put forward based on current evidence. Published data suggest an increasing role for EUS and other noninvasive imaging techniques such as MRCP, and hCT following an initial transabdominal ultrasound in the assessment of patients with suspected biliary obstruction to select candidates for surgery or therapeutic ERCP. The management of patients with a suspected pancreaticobiliary condition ultimately is dependent on local expertise, availability, cost, and the multidisciplinary collaboration between radiologists, surgeons, and gastroenterologists.

Cytologic diagnosis of pancreatic endocrine tumors by endoscopic ultrasound-guided fine-needle aspiration: A review

Precise localization and diagnosis of pancreatic endocrine tumors (PETs) is important, because pancreatic PETs have different clinical and biological behavior and treatment modalities than do exocrine pancreatic tumors. In contrast to the much more common exocrine adenocarcinomas, cytologic studies of PET are relatively rare and many cytopathologists lack experience with the cytomorphologic features of these tumors.During the last 10 yr, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has matured into an accurate, highly sensitive, and cost-effective modality for the preoperative localization of pancreatic PETs. This has resulted in an increased number of PETs first sampled as cytology specimens. This manuscript focuses on the cytomorphologic features most suggestive of pancreatic PETs, differential diagnosis, and diagnostic pitfalls of PETs. The technical development of EUS-guided FNA and the ancillary studies for pancreatic PETs are also reviewed. The data summarized in this review indicate that EUS-FNA is a valuable method in the recognition of pancreatic PETs and in most cases cytopathologists could reach a correct diagnosis of these tumors, including their hormone producing capability on aspirated cytologic material.

Negative predictive value of endoscopic ultrasound in a large series of patients with a clinical suspicion of pancreatic cancer

OBJECTIVES

Endoscopic ultrasound (EUS) has been shown to be very accurate in the diagnosis and staging of pancreatic cancer. The accuracy of EUS in predicting the absence of pancreatic cancer in a large series of patients with a clinical suspicion of pancreatic cancer is not well documented. Our aim was to determine the negative predictive value (NPV) of EUS in patients with a suspicion of pancreatic cancer.

METHODS

We retrospectively reviewed, from our EUS database (between January 1999 and March 2003), 693 patients who were suspected of having pancreatic cancer and had EUS examinations. A total of 155 patients were found by EUS to have a completely normal pancreas. Indications for EUS in these patients included: weight loss/abdominal pain; and/or pancreatic enlargement/fullness on computed tomography (CT); and/or bile duct/pancreatic duct narrowing on endoscopic retrograde cholangiopancreatography; and/or an elevated CA 19-9. Follow-up information was obtained in 135/155 (87%) patients from patient phone calls and/or physician visits and/or CT scan. The mean follow-up period was 25 months (range 8-48 months).

RESULTS

No patients developed pancreatic cancer during the follow-up period. Following the EUS examination, no work-up was required in 119/135 (88%) of patients. CT scan was performed in 16 patients at 6 months post-procedure, none of which showed a pancreatic mass. The NPV of EUS in excluding pancreatic cancer in those patients with follow-up was 100%.

CONCLUSION

EUS is highly specific in the diagnosis of pancreatic cancer with a NPV of 100% and obviates the need for further diagnostic testing. In patients with a clinical suspicion of pancreatic cancer, EUS should be considered as the initial diagnostic modality.

Gastrointestinal, Pancreatic, and Hepatic Cancer During Pregnancy

Pregnancy affects the clinical presentation, evaluation, treatment, and prognosis of patients with gastrointestinal cancer. Pregnant patients may present with advanced gastrointestinal cancer as a result of delayed diagnosis, in part because of difficulty differentiating signs and symptoms of cancer from signs and symptoms of normal pregnancy. The approach to cancer surgery and chemotherapy must be modified in pregnant patients to minimize fetal and maternal risks. Because of these factors, women who develop gastrointestinal cancers during pregnancy seem to have a poor prognosis. This article focuses on cancers of the colon, stomach, pancreas, and liver that occur during pregnancy.

[Aspiration biopsy, puncture and neurolysis of coeliac plexus with guided linear endoscopic ultrasonography--personal experience]

Endoscopic ultrasonography, as relatively new diagnostic procedure, has made a significant progress in detection and presentation of small lesions of digestive tract, as well as in other organs. By introducing linear ultrasonography in clinical practice, the possibilities of this procedure became even more apparent, anabling even more precise diagnosis and various therapeutic procedures. With endoscopic ultrasound (EUS) guided aspiration biopsy it is possible to obtain samples in specific, well defined layer of gastrointestinal tract wall, and also from different parts of other organs and formations, which finaly enables establishing definite patohystologic diagnosis. First linear EUS procedure in this part of south-east Europe, was performed in University Clinical Center "Bezanijska Kosa" (N. Milinic, M. Petrovic) in 1999, and first EUS guided aspiration biopsy was performed on July 4th 2000 (N. Milinic--biopsy of pancreas). Using "Pentax" FG-36UX linear echo-endoscope, until now, 40 pancreas biopsies, 34 stomach biopsies, 9 biopsies of mediastinal lymph nodes, cysts and tumors, 22 biopsies of masses in retroperitoneal region, 7 biopsies of papilla Vateri, 4 biopsies of left suprarenal gland, 2 punctures of renal cysts, 14 biopsies of focal liver lesions, 2 punctures of liver cysts, and 5 neurolyses of coeliac plexus was performed. From 134 EUS guided biopsy samples, 114 was, according to pathologist, adequate for patohystologic evaluation, and in 96 cases obtained samples was essential for obtaining definite diagnosis. The major problem in this issue was a lack of well trained and expirienced cytologist, as also is the current problem in Western countires with more expirience and practice in this field. EUS guided aspiration biopsy, as the procedure itself, was successful in all cases. There were no major complications during the procedures, mainly because of using Colour-Doppler technique in defferentiating vascular from other structures. Results so far are showing that linear endoscopic ultrasonography is extremely precise diagnostic method, and should be used in establishing definite diagnosis in many well defined indications, and also is showing the consecutive need for specialy trained and expirienced citologists.

Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis

BACKGROUND

Evaluation of a focal pancreatic mass in the setting of chronic pancreatitis (CP) is a diagnostic challenge. The objectives of the study were to compare the diagnostic yield and accuracy of EUS-guided FNA (EUS-FNA) in the evaluation of pancreatic-mass lesions in the presence or the absence of CP and to identify predictors of CP before EUS-FNA of pancreatic-mass lesions.

METHODS

The study design was analysis of data collected prospectively on all patients with solid pancreatic-mass lesions who underwent EUS-FNA at a tertiary referral center. A total of 282 consecutive patients underwent 300 EUS-FNA procedures of pancreatic-mass lesions over a 3-year period. The diagnostic yield and the accuracy of EUS-FNA was compared between patients with and without CP. CP was defined by the presence of more than 4 EUS criteria.

RESULTS

Final diagnosis was adenocarcinoma in 210 (70%), benign disease in 64 (21%), other pathology in 19 (6%), and indeterminate in 4 (2%); 3 patients (1%) were lost to follow-up. CP was noted in 75/300 (25%) patients. A lower sensitivity for EUS-FNA was observed in patients with CP than in those without CP (73.9% vs. 91.3%; p = 0.02). While patients with CP had a higher negative predictive value (88.9% vs. 45.5%; p < 0.001), no significant differences were observed for specificity (100% vs. 93.8%), positive predictive value (100% vs. 99.5%), and accuracy (91.5% vs. 91.4%) between those with and without CP. False-negative cytology was encountered in 24 cases: 6/71 (8%) with CP vs. 18/222 (8%) without CP. Patients with CP required more EUS-FNA passes to establish a diagnosis vs. those without CP (median, 5 vs. 2; p < 0.001). On multivariable analysis, age < 50 years (p < 0.001), male gender (p < 0.001), black race (p = 0.001), and the absence of jaundice (p = 0.005) were significantly associated with CP. The impact of EUS-FNA on long-term clinical management was not analyzed. The impact of individual EUS features of CP on sensitivity of EUS-FNA was not evaluated. By protocol, mass lesions that were benign required more passes to definitively exclude malignancy.

CONCLUSIONS

EUS-FNA has a low sensitivity for pancreatic-mass lesions in the setting of CP. This decreased sensitivity can be overcome by performing more numbers of passes at FNA, which improves diagnostic accuracy. Demographic features and clinical presentation are predictive of underlying CP in patients with pancreatic-mass lesions.

Fine-needle aspiration cytology of pancreatic somatostatinoma: the importance of immunohistochemistry for the cytologic diagnosis of pancreatic endocrine neoplasms

Pancreatic somatostatinoma is a rare pancreatic endocrine neoplasm representing as little as 1% of pancreatic endocrine neoplasms (PENs). The histologic features of this tumor are like those of other PENs, except that it commonly forms acinar structures and often has cells with abundant, granular cytoplasm. We have recently encountered two of these neoplasms sampled by endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). We discuss the cytologic and immunohistochemical findings of these two cases and the cytologic similarities these neoplasms share with pancreatic acinar-cell carcinoma (PACC). We review the cytologic features of PEN and PACC and discuss the importance of cell block immunohistochemistry in the diagnosis of pancreatic neoplasia sampled by EUS-guided FNA.

Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue

BACKGROUND

EUS-guided FNA (EUS-FNA) is an accurate technique for sampling extraintestinal masses and lymph nodes. The use of a Trucut needle to perform EUS-guided biopsy (EUS-TCB) may improve the results or simplify the procedure. To date, few studies have prospectively assessed the performance and the safety of EUS-TCB.

METHODS

Patients with a known or a suspected malignancy referred for a diagnostic and/or staging EUS examination were enrolled in a prospective study. EUS-guided biopsy was performed first with a 19-gauge Trucut needle. If the Trucut failed to obtain an adequate sample or when the "in room" touch preparation was benign, EUS-FNA was performed with a standard 22-gauge FNA needle. The objective of the study was to assess the yield of detection of malignancy and the safety of EUS-TCB in patients with known or suspected malignancies and to investigate if EUS-FNA has a role for rescue in cases of Trucut failure.

OBSERVATIONS

Thirty-nine lesions underwent EUS-TCB in 30 patients. Sufficient follow-up was available for all patients. By using EUS-TCB, we were able to obtain a sample for diagnosis in all but 3 patients (one pancreatic mass and two lymph nodes) in which technical problems arose. In these patients, the diagnosis was obtained in two cases by EUS-FNA and in the other one by EUS-TCB from the primary pancreatic tumor. The yield of detection of malignancy for EUS-TCB was 84%. No complications were recorded in any patients at 1 and 7 days of follow-up. The sample size is limited to generalize conclusions.

CONCLUSIONS

EUS-TCB is a safe and an accurate procedure to obtain a histologic diagnosis in patients with known or suspected malignancies. EUS-FNA can serve as a rescue technique in cases of Trucut failure.

Endoscopic ultrasound-guided fine-needle aspiration cytology for diagnosis above and below the diaphragm

Endosonography ultrasound (EUS) is a minimally invasive technology using a high-frequency ultrasound transducer that is incorporated into the tip of a conventional endoscope. This technique permits high-resolution imaging of the gastrointestinal wall and structures in its vicinity, as well as real-time endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). This is a review of the literature on EUS-guided FNA of the mediastinal and abdominal lymph nodes, the pancreas, intramural gastrointestinal masses, and other miscellaneous organs and body cavities. EUS-guided FNA is a recently developed procedure that has established itself as a safe, highly accurate, and clinically useful modality.

Usefulness of endoscopic ultrasound-guided fine-needle aspiration biopsy for the diagnosis of pancreatic cancer

BACKGROUND

Endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNAB) has come into widespread use, mainly in Western countries, as an efficient and safe method for the cytologic or histologic diagnosis of pancreatic cancer. However, it still has received relatively little attention in Japan. To evaluate the clinical status of EUS-FNAB in Japan, we retrospectively analyzed the results with regard to the ability of EUS-FNAB to diagnose pancreatic cancer, as well as its safety.

METHODS

A total of 52 patients (37 male, 15 female; mean age, 62.5 years; range, 33-85 years) with focal pancreatic lesions underwent EUS-FNAB at our group of hospitals in one region of Japan. Final diagnosis was confirmed by histologic examination of surgical specimens or clinical follow-up.

RESULTS

The final diagnoses were malignant tumors in 32 patients and benign ones in 20. Insertion of the needle into the lesion was successful in 50 of the 52 patients (96.2%). Adequate specimens were obtained by EUS-FNAB from 47 of the 50 pancreatic lesions (94.0%). With five false-negative and no false-positive results, the accuracy, sensitivity, specificity, and positive and negative predictive values were 89.4%, 82.1%, 100%, 100%, and 79.2%, respectively. No complications occurred.

CONCLUSIONS

EUS-FNAB is an efficient and safe method for the histologic diagnosis of pancreatic cancer. It should be considered as one of the indispensable modalities for the histological diagnosis of pancreatic cancer in Japan, as it is in Western countries.

Early diagnosis of pancreatobiliary duct malignancies by brush cytology and biopsy

Two hundred and five preoperative intraductal samplings (brushing and biopsy) were evaluated from 113 patients with biliary or Wirsung duct strictures. One hundred and three strictures could be specified by histology of the operative specimens, autopsy, or by the patients' clinical course. Preoperative diagnostic efficacy depended on the tumor location (it was the best for ampullary and para-papillary tumors), but the average quantitative indices for sensitivity, absolute sensitivity, specificity, positive and negative predictive values, diagnostic accuracy of cytology were 53%, 20%, 100%, 100%, 25%, 59%, respectively. The same values for biopsy were 43%, 34%, 100%, 100%, 36% and 56%. These figures improved after simultaneous cytology and biopsy. Close cooperation with the endoscopist was necessary in cases of negative, inconclusive and dysplastic (27%) samples. Repetition of sampling improved the results by 8%. Among the 26 preoperative false negative cases, sampling-, technical- and interpretative errors occurred in 84%, 4% and 12%, respectively. Revision of samples revealed 4 malignant cases among the false negative cytologic brushings. Reclassification of specimens considering the latest criteria - primary and secondary malignant features, pancreatic intraepithelial neoplasia (PanINs), etc. - resulted in improvement of the diagnostic efficiency.

[Endoscopic ultrasonography (EUS) in preoperative localization of neuroendocrine tumors (NET) of the pancreas]

BACKGROUND

Preoperative localization of pancreatic neuroendocrine tumours (NET) is usually very difficult. Noninvasive, imaging tests, such as abdominal ultrasound, CT or MRI are not sensitive enough as well as selective angiography. The aim of the study was to clarify the usefulness of the EUS in preoperative localization of the pancreatic NET.

METHODS

From September 1998 March 2005, EUS was performed in 1600 patients. Among them, in 10 (0.7%), this examination was carried out due to previous biochemical tests, which diagnosed the pancreatic NET. We studied the location, the size and echo-pattern of the neoplasm. The results were compared with operation and histology or EUS- FNA guided pancreatic biopsy in 9/10 patients. All EUS examinations were performed using Olympus GIF-130 videoecho-endoscope with 7,5 /12MHz switchable radial probe.

RESULTS

EUS correctly localized the pancreatic NET in 7/8 cases, (sensitivity:87.5%). In 2 patients, EUS accurately exclouded pancreatic NET. There were no false positive findings (specificity 100%). Six tumours were benign (75%), and two were malign (25%). We localized 6 insulinomas and single pancreatic carcinoid tumour. The median tumour size detected by EUS was 21mm.

CONCLUSION

EUS is highly accurate in preoperative localization of the pancreatic NET-s and We confirmed it in our study. EUS presents the method of choice for preoperative localization of the pancreatic NET.

An evidence-based approach to the diagnosis and staging of pancreatic cancer

Technology has revolutionized the diagnosis and staging of pancreatic malignancy. Previously, staging of disease was accomplished by exploratory laparotomy. Now, however, tumor size, lymph node and vascular involvement and the presence of metastases can be reliably assessed prior to operation using a widely available series of diagnostic tests, facilitating a preoperative assessment of tumor resectability. Appropriate use of these tests often spares patients with unresectable disease the need for operative intervention. As part of our staging algorithm we routinely employ a combination of clinical suspicion, a high-resolution helical CT scan and a serum CA 19-9 level. Endoscopic ultrasonography is useful in the patient in whom CT findings are equivocal, or in whom a tissue diagnosis is desired. Laparoscopy is reserved for patients with suspected advanced disease despite imaging findings to the contrary. Using this strategy, pancreatic malignancy may be diagnosed as expeditiously and as cost-effectively as is possible given current technology.

Impact of EUS in the evaluation of pancreaticobiliary disorders in children

BACKGROUND

While the role of EUS in the evaluation of pancreaticobiliary (PB) disorders in adults is well established, its utility in children remains unproven. This prospective study evaluates the feasibility, the safety, and the impact of EUS in the evaluation of PB disorders in children.

METHODS

All children (<18 years) referred for ERCP for evaluation of suspected PB disorders who underwent EUS before scheduled ERCP. The main outcome measure was to evaluate the impact of EUS in the evaluation of PB disorders in children. EUS was considered to have a significant impact if a new diagnosis was established or if the findings altered subsequent management.

RESULTS

Fourteen patients (mean age 13 years; range 5-17 years) underwent 15 EUS procedures over a 3-year period. Main indications were the following: acute or recurrent pancreatitis (6 patients), suspected biliary obstruction (5), and abdominal pain suggestive of PB origin (3). EUS diagnosed chronic pancreatitis (3 patients), idiopathic fibrosing pancreatitis (2), carcinoid tumor (1), pancreatic pseudocyst (1), pancreas divisum (1), choledocholithiasis (1), duodenal duplication cyst (1), and normal (4). Diagnosis of idiopathic fibrosing pancreatitis and carcinoid tumor was established by EUS-guided FNA. The procedure was successful in all patients, and no complications were encountered. EUS had an impact on patient management in 93% of cases: established new diagnosis (10), precluded need for ERCP (9), and provided additional information that facilitated focused endotherapy (4). A limitation was the small number of enrolled patients and absence of long-term clinical follow-up.

CONCLUSIONS

EUS and EUS-guided FNA are feasible, safe, and have significant impact that alters subsequent management in the majority of children with PB disorders. Further studies and dissemination of information is required to facilitate its increased application in children.

Pancreatitis associated with pancreatic carcinoma. Preoperative diagnosis: role of CT imaging in detection and evaluation

The combined occurrence of pancreatic carcinoma with acute or chronic pancreatitis is seldom seen in medical practice, but when present it is a challenging dilemma, plagued by confusing overlapping clinical findings and pitfalls in diagnostic imaging tests. This article reviews the presumptive pathophysiological aspects of this relationship, the perplexing clinical presentations and the advantages and limitations of the noninvasive imaging examinations. The role of state-of-the-art CT imaging in screening patients with acute and chronic pancreatitis is emphasized and the impute of additional more invasive tests in detecting pancreatic tumors in this cohort of patients is reviewed. The habitual use of CT imaging, followed when needed by complementary examinations, can improve on previously reported low detection rates and hopefully decrease the number of exploratory laparatomies and unnecessary major pancreatic surgical resections.

Emerging endoscopic techniques in oncology

New techniques have expanded the role of endoscopy in the diagnosis, staging, therapy, and palliation of malignancies. Three major areas of emerging technologies--endoscopic ultrasound (EUS), luminal stent technology, and photodynamic therapy (PDT)--are discussed in this article. Although EUS and PDT have been used for more than two decades, they have only recently emerged as established integral methods in the armamentarium of the gastrointestinal endoscopist.

The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer

Accurate staging of pancreatico-biliary cancer is essential for surgical planning and for identification of locally advanced and metastatic disease that is incurable by surgery. The complex regional anatomy of the pancreatico-biliary system makes histologic diagnosis of malignancy at this region difficult. The ability to position the endoscopic ultrasound transducer at endoscopy in direct proximity to the pancreas and the bile duct, combined with the use of fine-needle aspiration, enables accurate preoperative staging of cancer, especially cancer too small to be characterized by CT or MRI. Endoscopic ultrasonography (EUS) identifies patients unlikely to be cured by surgery due to vascular invasion or regional nodal metastasis, thereby limiting procedure-related morbidity and mortality. This article focuses on the utility and recent advances of EUS in the evaluation of pancreatico-biliary cancer.

Pancreatic FNA in 1000 cases: a comparison of imaging modalities

BACKGROUND

Image-guided FNA is a popular method for evaluating pancreatic lesions, but few large studies on pancreatic FNA exist.

METHODS

Cytologic material, imaging reports, and clinical follow-up information were reviewed from pancreatic FNA cases performed over a 5-year period.

RESULTS

A total of 1050 pancreatic FNAs were obtained by EUS (n = 843), US (n = 140), and CT (n = 67). On-site assessment was performed in 89.2% (n = 937) of cases. Findings were as follows: positive for neoplasm 48.9% (n = 503), negative 29.1% (n = 306), descriptive 10% (n = 105), suspicious 5.9% (n = 62), atypical/inconclusive 4.6% (n = 48), and nondiagnostic/inadequate 1.5% (n = 26). Follow-up in the form of histology or at least 6 months of clinical observation was available for 61.2% (n = 643). There was an overall false-positive rate of 0.3% and a false-negative rate of 14.3%. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were as follows: 79.4, 99.0, 99.4, 67.9, 84.5 for the total series, respectively; 79.9, 98.8, 99.2, 72.5, 86.5 for EUS, respectively; 77.9, 100, 100, 48.6, 81.7 for US, respectively; and 78.6, 100, 100, 47.1, 82.0 for CT, respectively. In general, accuracy was not influenced by lesion size or site, number of FNA passes, or number of procedures per patient. After controlling for lesion size, EUS resulted in greater accuracy than US or CT when evaluating lesions <3 cm ( p = 0.015).

CONCLUSIONS

All imaging modalities showed moderate to high sensitivity, specificity, and accuracy. Logistic regression analysis showed that for lesions <3 cm, the EUS method had higher accuracy than US or CT. No statistically significant difference was seen for larger lesions or for the number of FNA passes.

Malignant mediastinal lymphadenopathy detected by staging EUS in patients with pancreaticobiliary cancer

BACKGROUND

In patients with pancreatic cancer, the presence of malignant mediastinal lymphadenopathy (MML) would preclude definitive resection. A recent study suggested routine evaluation for mediastinal lymph-node metastases in all patients being evaluated for pancreaticobiliary masses. In our practice, we routinely assess for mediastinal lymph-node metastases in all patients undergoing EUS for pancreaticobiliary cancer.

METHODS

We retrospectively evaluated the presence of MML by EUS-guided FNA (EUS-FNA) in 160 consecutive patients with a definite diagnosis of pancreaticobiliary cancer (pancreatic and periampullary cancers) who underwent EUS-FNA by a single operator from 2000 to 2004. Lymph nodes that were round and hypoechoic with sharp margins were considered suspicious and were sampled by FNA.

RESULTS

Of the 160 patients included in this study, 78 had peripancreatic lymph nodes (49%: 95% CI[41%, 58%]), 25 had celiac lymph nodes (16%: 95% CI[10%, 22%]), and 14 patients had mediastinal lymph nodes (9%: 95% CI[4%, 13%]) that were suspicious for malignancy by morphologic criteria. In 8 of 14 patients with suspicious mediastinal lymph nodes, FNA documented MML in 5%: 95% CI[2%, 8%]. Only one of these 8 patients with MML had other sites of documented distant metastases by CT and/or positron emission tomography scans. However, 7 of 8 patients had locally advanced cancers.

CONCLUSIONS

MML is detected by staging EUS-FNA in 5% of patients with pancreaticobiliary cancer. Because of its important implications, endosonographers should routinely assess for MML in patients who undergo staging EUS for pancreaticobiliary malignancy.

EUS-guided FNA of solid pancreatic masses: a learning curve with 300 consecutive procedures

BACKGROUND

The objective of our study was to assess a single operator's learning curve with regard to the number of passes, the diagnostic accuracy, and the complications associated with EUS-guided FNA (EUS-FNA) of solid pancreatic masses.

METHODS

The number of passes, the diagnostic accuracy, and the complication rate were prospectively evaluated in 300 consecutive EUS-FNA of solid pancreatic masses performed by a single endosonographer over a 3-year period. The procedures were placed into 3 groups, which contained 100 procedures each. The endosonographer had undergone a third-tier EUS fellowship and had performed 45 supervised pancreatic EUS-FNA during his training.

RESULTS

Of the 300 EUS-FNA performed (median age 63 years, 64% men), no statistically significant differences among the 3 groups with regard to age, gender, race, location, or size of the mass were found. Diagnostic accuracy of the EUS-FNA procedure was similar over time (Group 1, 92%; Group 2, 92%; Group 3, 95%). Median number of passes showed a decreasing trend over the 3-year study period, despite an increasing trend of the number of procedures performed (r = -0.14, p = 0.42). The median number of passes was lower for Group 2 (median, 3; p = 0.02) and Group 3 (median, 3; p = 0.003) compared with Group 1 (median, 4). Group 3 (7/100, 7%) was less likely to encounter complications compared with Group 1 (13/100, 13%; p = 0.24) and Group 2 (18/100, 18%; p = 0.03). Frequency of serious complications was similar across the 3 groups (1%-3%).

CONCLUSIONS

With adequate third-tier training, a newly developed EUS program can achieve safe and accurate results of EUS-FNA of the pancreas. The learning curve, however, needs to continue after the fellowship, because more procedures are needed for one to gain proficiency and efficiency with EUS-FNA.

Assessment of the impact of an educational course on knowledge of appropriate EUS indications

BACKGROUND

The knowledge level of EUS among gastroenterologists likely influences the appropriateness of requested indications for EUS. It remains unknown what the impact is of a short EUS course, involving didactic teaching, on knowledge levels of EUS indications for EUS. The aim of this study was to assess the impact of a 3-day educational course on knowledge levels of attending gastroenterologists regarding the appropriateness of indications for EUS.

METHODS

A questionnaire was designed that tested knowledge of indications for EUS in 4 anatomic sites: esophagus, gastroduodenum, hepatopancreatobiliary system, and colorectum. This questionnaire was distributed to all attendees of a 3-day EUS educational course. All attendees completed the survey before and immediately after the course.

RESULTS

A total of 24 gastroenterologists completed the pre- and post-course survey. Before the course, respondents scored highest in questions on EUS applications in the gastroduodenum (94%) and the hepatopancreatobiliary system (88%) compared with the esophagus (72%) and the colorectum (74%). Statistically significant improvements in knowledge were recorded in all organ categories: gastroduodenum (100%, p = 0.002 vs. pretest score), hepatopancreatobiliary system (99%, p < 0.0001), esophagus (92%, p < 0.0001), and colorectum (93%, p = 0.0004). The biggest improvement was observed in knowledge levels for the esophagus (20%) and the colorectum (18%).

CONCLUSIONS

There was a consistent improvement in the gastroenterologists' knowledge levels of EUS indications among all organ categories after an educational course. Our findings suggest that education enhances gastroenterologists' understanding of EUS. Future studies should seek to assess the impact of these improved knowledge levels on the appropriateness of EUS referral patterns.

Pitfalls in endoscopic ultrasound-guided fine-needle aspiration and how to avoid them

Although a broad range of pancreatic, gastrointestinal, thoracic, and abdominal pathology may be sampled by endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA), certain difficulties tend to recur because of the frequency of certain sample types and because of the nature of their individual cytomorphologic profiles. With this in mind, we review certain pitfalls that may befall cytopathologists with EUS-guided FNA. We discuss the diagnosis of pancreatic ductal adenocarcinoma and of other pancreatic epithelioid tumors including pancreatic endocrine neoplasms, solid pseudopapillary tumors, and acinar cell carcinomas. We also discuss the diagnosis of pancreatic cystic neoplasia including intraductal papillary mucinous neoplasms and mucinous cystic neoplasms and the diagnosis of gastrointestinal mesenchymal neoplasia with particular attention to gastrointestinal stromal tumors. Finally, we discuss the interpretation of lymph node aspirates.

[Indications for pancreatic biopsy. Uncommon, but increasingly more important]

Pancreatic biopsy is an invasive diagnostic method that is only performed when all other diagnostic measures for establishing the diagnosis of a tumorous lesion of the pancreas have failed. Because of the advances in modern imaging techniques, fine needle biopsy of the pancreas guided by ultrasonography, computer tomography or endosonography has become a reliable method that allows the diagnosis of ductal adenocarcinoma or any of the other, rarer pancreatic tumors with high sensitivity and specificity. Complications are rare, particularly with the endosonographically guided biopsy. A new biopsy indication is the demonstration of certain markers or gene mutations that are needed for the initiation of special treatments, e.g. EGFR-Cetuximab.

EUS-guided transhepatic cholangiography: report of 6 cases

BACKGROUND

This report describes a novel application of EUS-guided cholangiography in which a transhepatic approach was used to alleviate perihilar and distal biliary obstructions when this could not be accomplished at ERCP.

METHODS

EUS-guided transhepatic cholangiography was used to alleviate symptoms of biliary obstruction in 6 patients. In 4 cases, after transgastric puncture of an intrahepatic branch of the obstructed bile duct with a 19- or a 22-gauge EUS needle, a guidewire was advanced antegrade across both the biliary stricture and the papilla. Subsequently, a rendezvous procedure was performed, allowing ERCP and stent placement.

OBSERVATIONS

EUS-guided transhepatic cholangiography was performed in 6 patients, with successful rendezvous ERCP and stent placement in 4, and transduodenal stent placement in another patient. Stent placement was unsuccessful in one patient, because of the inability to advance a guidewire into the common hepatic duct. There was no immediate complication of the procedures.

CONCLUSIONS

EUS-guided transhepatic cholangiography can be used to access and to drain bile ducts that are obstructed by proximal, as well as distal lesions when ERCP is unsuccessful.

Pancreatic neoplasms

Patients who present with signs and symptoms suggesting a pancreatic neoplasm typically undergo initial imaging with transabdominal ultrasound or CT. When a pancreatic mass or fullness is identified, it may represent an inflammatory mass, benign process, or malignancy. Endoscopic ultrasound (EUS) is performed commonly to further characterize the lesion, obtain a tissue diagnosis, and for staging. This article reviews the role of EUS for the diagnosis and staging of pancreatic tumors.

Differential diagnosis of pancreatic cancer and focal pancreatitis by using EUS-guided FNA

BACKGROUND

Despite advances in diagnostic imaging techniques, the differentiation between pancreatic cancer and focal pancreatitis remains difficult. This study evaluated the effectiveness of EUS-guided FNA in the differential diagnosis between pancreatic cancer and focal pancreatitis, with particular reference to detection of the K-ras point mutation.

METHODS

The study included 62 consecutive patients with pancreatic ductal cancer and 15 patients with focal pancreatitis demonstrated as a pancreatic mass lesion by EUS.

RESULTS

Sensitivity, specificity, overall accuracy, positive predictive value, and negative predictive value of cytopathologic diagnosis were 82%, 100%, 86%, 100%, and 58%, respectively. Sensitivity, specificity, overall accuracy, positive predictive value, and negative predictive value of histopathologic diagnosis were 44%, 100%, 55%, 100%, and 32%, respectively. The K-ras point mutation was found in 74% of pancreatic cancers and 0% of focal pancreatitis lesions. No complication of EUS-guided FNA was observed.

CONCLUSIONS

EUS-guided FNA is useful for the differential diagnosis of pancreatic mass lesions caused by pancreatic cancer and focal pancreatitis. Analysis for the K-ras point mutation in specimens obtained by EUS-guided FNA may enhance diagnostic accuracy in indeterminate cases.

ASGE guideline: complications of EUS

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

Sampling of the adrenal glands by endoscopic ultrasound-guided fine-needle aspiration

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has proven to be a valuable modality for the primary diagnosis and staging of gastrointestinal, and perigastrointestinal malignancy. Aside from assessing thoracic and abdominal lymph nodes and the liver for metastases, EUS can assess and sample the adrenal glands, which are frequently involved by metastatic disease, but can also harbor benign primary neoplasms. The cytology files at our institution were reviewed for all cases of EUS-guided FNA of the adrenal glands. Clinical histories, sonographic findings, and cytologic findings of all cases were reviewed. Results were compared with overall EUS-guided FNA performance and the performance of non-EUS-guided FNA of the adrenal. The utility of cell block immunohistochemistry (IHC) in these cases was reviewed. Between 1/1/00 and 5/15/04 there were 24 cases of EUS-guided FNA of the adrenal gland from 22 different patients (13 men; 9 women) at our institution. This represented 1.4% of overall EUS-guided FNA and 77% of adrenal gland FNA. Patient ages ranged from 37 to 86 yr (mean 69 +/- 11 yr). Most patients had other cancers or mass lesions and were being staged at the time of the procedure (19 of 22). Almost all FNAs were of the left adrenal gland (23 of 24). Lesion size ranged from 0.9 to 7.9 cm (mean 2.5 +/- 1.6 cm). Diagnostic material was present in all cases when compared with an overall EUS-guided FNA diagnostic rate of 88%. Material for cell block was present in 21 cases, and IHC was used in 3 cases. Final diagnoses were as follows: cortical tissue consistent with cortical adenoma (19), metastatic adenocarcinoma (3), pheochromocytoma (1), and adrenal cortical carcinoma (1). EUS-guided FNA of the adrenal gland is primarily used in the staging of other malignancies when lesions of the left adrenal are recognized sonographically. Diagnostic tissue is easily obtained, including material for cell block IHC, which allows definitive diagnosis in cases that present difficult differential diagnoses.

EUS findings in patients with autoimmune pancreatitis

BACKGROUND

Autoimmune pancreatitis is an increasingly recognized benign condition with a presentation similar to pancreatic neoplasia but responds to corticosteroid therapy. Clinical features, ERCP, and CT findings have been described. This study assessed the EUS and EUS-guided FNA features of proven autoimmune pancreatitis.

METHODS

The diagnosis of autoimmune pancreatitis was based on examination of surgical resection specimens or typical clinical findings (elevated immunoglobulin G level, no evidence of malignancy, characteristic non-EUS imaging studies, and clinical improvement, especially in response to treatment with a corticosteroid).

RESULTS

Presenting manifestations in 14 patients included obstructive jaundice, abdominal pain, and weight loss. Ten patients underwent surgery (including exploratory surgery). Six were successfully treated with corticosteroid. EUS revealed diffuse hypoechoic pancreatic enlargement (8/14) or a focal irregular hypoechoic mass (6/14). Features of chronic pancreatitis were not noted. EUS-guided FNA of the pancreas was suggestive of chronic inflammatory pancreatitis in 9 of 12 patients. Celiac and peripancreatic lymphadenopathy (up to 3 cm in diameter) was present in 6 patients. EUS-guided FNA of lymph nodes (3/4) did not reveal evidence of malignancy. Vascular involvement was noted in 3 patients.

CONCLUSIONS

The EUS features of autoimmune pancreatitis are easily mistaken for malignancy. However, a diffusely hypoechoic, enlarged pancreas, together with chronic inflammatory cells in aspirated cytologic specimens, is supportive of the diagnosis of autoimmune pancreatitis. When combined with clinical data, EUS and EUS-guided FNA may support a diagnosis of autoimmune pancreatitis, may warrant a trial of corticosteroid, and thereby may prevent unnecessary surgery.

Choriocarcinoma involving the pancreas as first manifestation of a metastatic regressing mixed testicular germ cell tumor

We describe an unusual case of metastatic choriocarcinoma of the pancreas arising from a regressing testicular mixed germ cell tumor that clinically mimicked a primary pancreatic tumor. A 54-year-old male presented with a 2-month history of progressive upper abdominal pain, weight loss, and jaundice. He also had a history of recurrent epididymitis associated with the presence of a right testicular mass shown to be cystic by ultrasound and stable for at least 10 years. A computed tomography scan showed an isolated 6 cm mass in the head of the pancreas. A pancreaticoduodenectomy was performed. Upon histological examination, the pancreatic tumor showed extensive hemorrhage and necrosis. In the viable area, the tumor was composed of an intimate mixture of mononuclear cytotrophoblast cells and multinucleated syncytiotrophoblasts with vascular invasion. These characteristic features led to the correct diagnosis on frozen section. The cytology of the tumor was nonspecific and suggested undifferentiated carcinoma of the pancreas. The trophoblastic origin of the tumor cells was confirmed by immunohistochemistry staining. The testicular mass showed a regressed mixed germ cell tumor of predominantly seminoma with focal teratoma but without a choriocarcinoma component. In conclusion, we present a rare and unusual case of a regressing testicular mixed germ cell tumor that presented as a primary pancreatic tumor. Cytological features of the pancreatic mass were not specific and raised the possibility of a primary undifferentiated carcinoma of the pancreas. Characteristic histological features of choriocarcinoma led to the correct diagnosis on frozen section. Subsequent resection of the testicular mass confirmed the presence of a cystic and scarring (regressing) mixed germ cell tumor but without evidence of choriocarcinoma.

Clinical impact of endoscopic ultrasonography on the management of malignancies

BACKGROUND & AIMS

There are limited data evaluating the clinical impact of endoscopic ultrasonography (EUS). We assessed the impact of EUS on management of known or suspected malignancies.

METHODS

Physicians requesting EUS were contacted before the examination and asked: "How would you manage this patient if EUS were not available?" Pre-EUS responses were recorded on standardized forms, and compared with management recommendations as determined by the same requesting physician after EUS. Endosonographers performing the study were blinded to the pre-EUS responses.

RESULTS

Responses were obtained from requesting physicians before and after EUS in 90 patients. Requesting physicians were composed of surgeons (33%), non-EUS-performing gastroenterologists (58%), oncologists (3%), internists (4%), and a pulmonologist (1%). After EUS, referring clinicians altered management plans in 46 of 90 patients (51%). By anatomic site, management changes occurred in 12 of 22 patients (56%) undergoing esophageal EUS, 9 of 15 (60%) undergoing gastric EUS, 21 of 43 (49%) undergoing pancreatic EUS, and 4 of 10 (40%) undergoing rectal EUS. There were no significant differences in the frequency of post-EUS management changes with respect to examination site (P = .76). EUS fine-needle aspiration (FNA) altered management in 9 of 20 (45%) patients. Management changes involved less complex or decreased risk-associated approaches in the majority (70%), and included 14 of 50 (28%) patients in whom surgical procedures were no longer planned.

CONCLUSIONS

Based on EUS examination findings, clinicians requesting EUS alter patient management in one half of cases, and more often pursue a less-complicated approach. EUS substantially impacts clinical care, and should be used in appropriate settings to guide patient management.

A cost-minimization analysis of alternative strategies in diagnosing pancreatic cancer

BACKGROUND

Several modalities currently exist for tissue confirmation of suspected pancreatic cancer prior to therapy. Since there is a paucity of cost-minimization studies comparing these different biopsy modalities, we analyzed costs and examined effectiveness of four alternative strategies for diagnosing pancreatic cancer.

METHODS

A decision analysis model of patients with suspected pancreatic cancer was constructed. We analyzed costs, failure rate, testing characteristics, and complication rates of four commonly employed diagnostic modalities: 1) computerized tomography or ultrasound-guided fine-needle aspiration (CT/US-FNA), 2) endoscopic retrograde cholangiopancreatography with brushings (ERCP-B), 3) Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA), and 4) laparoscopic surgical biopsy. If the first attempt with a particular modality failed, a different modality was employed to identify the most preferable secondary biopsy strategy.

RESULTS

This analysis identifies EUS-FNA as the preferred initial modality for the diagnosis of pancreatic cancer. Resultant expected costs and strategies in decreasing optimality include: 1) EUS-FNA (1,405 dollars), 2) ERCP-B (1,432 dollars), 3) CT/US-FNA (3,682 dollars), and 4) surgery (17,711 dollars). If a patient presents with obstructive jaundice, decision analysis modeling resulted in a total expected costs of 1,970 dollars if ERCP-B is successful at the time of biliary stent placement. Additional analyses to identify the preferred follow-up modality after a failed alternative method showed that EUS-FNA is the preferred secondary modality if any of the other three modalities failed first, in both the setting of and absence of obstructive jaundice. One- and two-way sensitivity analysis of the variables shows unchanged results over an acceptable range.

CONCLUSIONS

This cost-minimization study illustrates that EUS-FNA is the best initial and the preferred secondary alternative method for the diagnosis of suspected pancreatic cancer. In addition to local expertise and availability, costs and diagnostic yield should be considered when choosing an optimal diagnostic strategy.

Current standards of surgery for pancreatic cancer

Background

Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.

Methods

An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.

Results

Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.

Conclusion

The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.

Knowledge of indications for EUS among gastroenterologists and non-gastroenterologists

BACKGROUND

The level of awareness among non-gastroenterologists of the indications for EUS is unknown. This study assessed knowledge of the indications and the utility of EUS among gastroenterologists and non-gastroenterologists in a large multispecialty academic practice.

METHODS

A questionnaire was designed that tested knowledge of the indications for EUS with respect to 4 organ systems: esophagus, gastroduodenum, hepatopancreatobiliary system and colorectum. The questionnaire was distributed by electronic mail to gastroenterologists, general internists, non-gastroenterologist subspecialists, and surgeons in a large multispecialty practice.

RESULTS

The survey was distributed to 659 attending physicians of whom 227 (34%) replied: gastroenterologists (53%), internists (30%), non-gastroenterologist specialists (33%), and surgeons (28%). Knowledge of appropriate indications was highest among gastroenterologists (84.3%) compared with internists (68.9%), non-gastroenterologist specialists (65.4%), and surgeons (65.3%) (p < 0.0001). Among all non-gastroenterologists, knowledge of indications for hepatopancreatobiliary (mean 66.3% correct responses) and colorectal applications (64.0%) was inferior to knowledge of esophageal (71.5%) and gastroduodenal (83.5%) applications.

CONCLUSIONS

Internists, non-gastroenterologist specialists, and surgeons in a large multispeciality practice have moderate knowledge of the indications and the utility of EUS. Knowledge was at the lowest level for hepatopancreatobiliary and colorectal applications of EUS for all 3 groups of non-gastroenterologists. Future studies should focus on the education of non-gastroenterologists regarding the role of EUS and assess the impact of such education on the appropriateness of EUS referral patterns.

Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States

BACKGROUND

The aim of this study was to determine the frequency and the severity of pancreatitis after EUS-guided FNA of solid pancreatic masses. A survey of centers that offer training in EUS in the United States was conducted.

METHODS

A list of centers in which training in EUS is offered was obtained from the Web site of the American Society for Gastrointestinal Endoscopy. Designated program directors were contacted via e-mail. The information requested included the number of EUS-guided FNA procedures performed for solid pancreatic masses, the number of cases of post-procedure pancreatitis, and the method for tracking complications. For each episode of pancreatitis, technical details were obtained about the procedure, including the location of the mass, the type of fine needle used, the number of needle passes, and the nature of the lesion.

RESULTS

Nineteen of the 27 programs contacted returned the questionnaire (70%). In total, 4909 EUS-guided FNAs of solid pancreatic masses were performed in these 19 centers over a mean of 4 years (range 11 months to 9 years). Pancreatitis occurred after 14 (0.29%): 95% CI[0.16, 0.48] procedures. At two centers in which data on complications were prospectively collected, the frequency of acute pancreatitis was 0.64%, suggesting that the frequency of pancreatitis in the retrospective cohort (0.26%) was under-reported (p=0.22). The odds that cases of pancreatitis would be reported were 2.45 greater for the prospective compared with the retrospective cohort (95% CI[0.55, 10.98]). The median duration of hospitalization for treatment of pancreatitis was 3 days (range 1-21 days). The pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in one; one death (proximate cause, pulmonary embolism) occurred after the development of pancreatitis in a patient with multiple comorbid conditions.

CONCLUSIONS

EUS-guided FNA of solid pancreatic masses is infrequently associated with acute pancreatitis. The procedure appears to be safe when performed by experienced endosonographers. The frequency of post EUS-guided FNA pancreatitis may be underestimated by retrospective analysis.

Diagnosis of gastrointestinal tract lesions by endoscopic ultrasound-guided fine-needle aspiration biopsy

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) allows detailed imaging of both intramural and extramural structures of the gastrointestinal (GI) tract and also allows tissue samples to be obtained from masses and lesions in the GI tract. The objective of the current study was to determine the diagnostic utility of EUS-FNA in evaluating intramural and extramural GI tract lesions.

METHODS

The authors evaluated all EUS-FNA specimens of GI tract lesions obtained over a 30-month period (from August 2000 to February 2003). Samples of pancreatic and intrabdominal/mediastinal lymph nodes were excluded from the study. A single endosonographer performed all procedures. An attending cytopathologist also was present on site to assess specimen adequacy. Cytologic diagnoses were analyzed for correlations with final diagnoses, which were based on histologic examination of biopsied/resected pathology materials and/or clinical follow-up findings.

RESULTS

Sixty-two EUS-FNA specimens of intramural and extramural GI tract lesions were obtained from a total of 60 patients. The mean patient age was 58.8 years (standard deviation, 15.3 years). Thirty-six patients (60%) were male, and 24 (40%) were female. Twenty-eight patients had surgical pathologic evaluation of the corresponding lesions. The remaining 32 patients were followed clinically for a mean duration of 9.5 months (standard deviation, 7.7 months). The anatomic sites of the lesions were as follows: esophagus in 23 patients (37%), stomach in 13 patients (21%), duodenum in 15 patients (24%), and rectum/sigmoid in 11 patients (18%). It is noteworthy that 29 patients (43%) previously had experienced unsuccessful attempts at tissue diagnosis by endoscopic forceps biopsy. Of the 62 EUS-FNA specimens, 43, 4, and 15 were reported as being positive for a neoplasm, suspicious, and benign, respectively. Neoplastic lesions included carcinoma (n = 24), gastrointestinal stromal tumor (GIST; n = 18), neuroendocrine neoplasm (n = 2), and lymphoma (n = 1). There were two cases of endometriosis, three foregut duplication cysts, and one case of diverticulosis. There were two lesions that yielded false-negative findings (one gastric lymphoma and one GIST) secondary to sampling or interpretive error. There also were three cases that yielded false-positive findings (one case of endometriosis, one case of duodenal diverticula with smooth muscle hyperplasia, and one case of normal pancreas, which presented as a periduodenal mass). The sensitivity, specificity, and diagnostic accuracy of EUS-FNA in diagnosing GI tract neoplastic lesions were 89%, 88%, and 89%, respectively.

CONCLUSIONS

EUS-FNA provides accurate tissue diagnosis in a wide variety of extraintestinal mass lesions and intramural GI tumors, particularly in patients for whom previous endoscopic forceps biopsy was unsuccessful in establishing a diagnosis.

Interventional EUS cholangiography: A report of five cases

BACKGROUND

ERCP may be unsuccessful because of the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic cholangiography is a classic technique for accessing the bile duct and remains the primary alternative when biliary ERCP is unsuccessful. With the evolution of interventional EUS, additional options are available for management of biliary obstruction.

METHODS

EUS cholangiography was performed, after which the puncture was enlarged to form an enterocholedochal fistula that was used for interventions that resulted in biliary decompression in 5 patients with obstructive jaundice.

OBSERVATIONS

Cholangiography was readily performed in all 5 patients. In one patient, a guidewire could not be manipulated across the papilla via the enterocholedochal fistula, necessitating percutaneous intervention. Biliary decompression was achieved in the other 4 patients, in the last two, as a single procedure.

CONCLUSIONS

Interventional EUS cholangiography is a new technique that allows drainage of a dilated biliary system when the bile duct is inaccessible by conventional ERCP.

Optimal number of EUS-guided fine needle passes needed to obtain a correct diagnosis

BACKGROUND

The immediate assistance of a cytologist during EUS-guided FNA is not universal. The optimal number of fine needle passes during EUS-guided FNA has not been determined in a prospective study. The aim of this study was to determine the optimal number of passes required to obtain a correct diagnosis.

METHODS

Seven or more passes were made with a fine needle into a variety of lesions during EUS-guided FNA. Adequacy of the aspirate, diagnosis, and a "certainty score" were recorded after each pass and interpreted sequentially by a cytopathologist. Surgical histopathology and 1-year clinical follow-up were used as reference standards. The percentage of correctly diagnosed cases was calculated and stratified according to organ, disease group, and EUS characteristics of the lesion.

RESULTS

Lesions from 95 patients were categorized into the following locations: pancreas, lymph node, and miscellaneous. The sensitivity and specificity for 7 passes from the pancreas and miscellaneous lesion groups were, respectively, 83% and 100%. The sensitivity and specificity for 5 passes from the lymph node group were, respectively, 77% and 100%.

CONCLUSIONS

During EUS-guided FNA, at least 7 passes with a fine needle into pancreatic and miscellaneous lesions, and 5 passes into lymph nodes are needed to ensure a high degree of certainty for making a correct diagnosis.

Comparison of linear array endoscopic ultrasound and helical computed tomography for the staging of periampullary malignancies

BACKGROUND

The purpose of this study was to compare linear array endoscopic ultrasound (EUS) and helical computed tomography (CT) scan in the preoperative local staging evaluation of patients with periampullary tumors.

METHODS

Patients evaluated with EUS and CT for suspected periampullary malignancies from 1996 to 2000 were analyzed. Surgical/pathology staging results were the reference standard.

RESULTS

Forty-eight patients (28 men and 20 women; mean age, 62 +/- 4.9 years; range, 18-90 years) were identified. Malignancy was histologically confirmed in 44 patients. Parameters evaluated included tumor size, lymph node metastases, and major vascular invasion. EUS was significantly more sensitive (100%), specific (75%), and accurate (98%) than helical CT (68%, 50%, and 67%, respectively) for evaluation of the periampullary mass (P <.05). In addition, EUS detected regional lymph node metastases in more patients than helical CT. Sensitivity, specificity, and accuracy of EUS were 61%, 100%, and 84%, in comparison to 33%, 92%, and 68%, respectively, with CT. Major vascular involvement was noted in 9 of 44 patients. EUS correctly identified vascular involvement in 100% compared with 45% with CT (P <.05).

CONCLUSIONS

Linear array EUS was consistently superior to helical CT in the preoperative local staging of periampullary malignancies.

EUS-guided trucut needle biopsies in patients with solid pancreatic masses: a prospective study

BACKGROUND

A trucut needle biopsy device that can be used to obtain specimens from the pancreas and other perigastric organs under EUS guidance has been developed and successfully tested in animals. Moreover, EUS-guided trucut needle biopsy has been used safely in humans and appears to provide more accurate results than EUS-guided FNA. This study prospectively assessed the clinical utility of this new device in patients with solid pancreatic masses.

METHODS

Twenty-three consecutive patients with radiologically detected solid pancreatic masses underwent EUS-guided trucut needle biopsy. Pancreatic malignancy detected by EUS-guided trucut needle biopsy was considered a definitive diagnosis. Further diagnostic procedures and clinical course were used to establish or exclude the presence of malignancy in all other patients.

RESULTS

Pancreatic tissue was obtained in 17 of the 23 patients (74%), including all patients in whom the transgastric approach was used. No acute or long-term complication was observed. Histopathologic evaluation revealed pancreatic cancer in 12 patients. CT-guided biopsy specimens were obtained in 4 of the 5 patients with a negative EUS-guided trucut needle biopsy result; two were positive for adenocarcinoma. Overall diagnostic accuracy was 61%. Subgroup analysis of the 16 patients in whom EUS-guided trucut needle biopsy was successful and who were available for follow-up revealed a diagnostic accuracy of 87.5%.

CONCLUSIONS

This prospective study demonstrates that EUS-guided trucut needle biopsy, when performed transgastrically, is safe and accurate in the evaluation of patients with solid pancreatic masses.