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Sanchez-Avila M, Amin K, Chauhan A, Geng Z, Mallery S, Snover DC. In Search of Nodular Gastric Antral Vascular Ectasia: A Distinct Entity or Simply Hyperplastic Polyps Arising in Gastric Antral Vascular Ectasia? Arch Pathol Lab Med 2024; 148:55-60. [PMID: 37014971 DOI: 10.5858/arpa.2022-0230-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 04/06/2023]
Abstract
CONTEXT.— Nodular gastric antral vascular ectasia (GAVE) is a reported phenotype of GAVE that has histologic features overlapping with gastric hyperplastic polyps (GHPs), with additional features often seen in flat mucosa of GAVE. OBJECTIVE.— To determine if nodular GAVE and GHPs are distinct lesions by evaluating the prevalence of features reported in nodular GAVE in GHPs with or without associated GAVE. DESIGN.— A review of all lesions diagnosed as GHPs between 2014 and 2017 was performed. Slides were analyzed for a number of features including established histologic features of GAVE without knowledge of clinical or endoscopic features. RESULTS.— A total of 90 polyps were analyzed including 18 from patients with GAVE (20%). GAVE polyps were larger than non-GAVE polyps (average size, 1.3 cm versus 0.68 cm; P < .001), with more common extensive ulceration and associated granulation tissue (61.11% [n = 11] versus 4.17% [n = 3]; P = .004), fibrin thrombi (50% [n = 9] versus 15% [n = 11]; P = .003), moderate to marked vascular ectasia (83% [n = 15] versus 35% [n = 11]; P = .001), and fibrohyalinosis (72% [n = 13] versus 28% [n = 20]; P = .001). All polyps showed foveolar hyperplasia and smooth muscle proliferation. There were no features that were exclusively found in GAVE or non-GAVE cases. CONCLUSIONS.— Nodular GAVE appears to represent GHPs arising in a background of GAVE, with superimposed features found in flat mucosa of GAVE stomachs. The presence of fibrin thrombi, marked vascular ectasia, fibrohyalinosis, and/or ulceration in a GHP is suggestive but not diagnostic of GAVE, and the absence of these features does not rule out GAVE.
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Affiliation(s)
- Monica Sanchez-Avila
- From the Departments of Laboratory Medicine and Pathology (Sanchez-Avila, Chauhan, Amin, Snover)
| | - Khalid Amin
- From the Departments of Laboratory Medicine and Pathology (Sanchez-Avila, Chauhan, Amin, Snover)
| | - Aastha Chauhan
- From the Departments of Laboratory Medicine and Pathology (Sanchez-Avila, Chauhan, Amin, Snover)
| | - Zhuo Geng
- Gastroenterology (Geng, Mallery), University of Minnesota, Minneapolis
| | - Shawn Mallery
- Gastroenterology (Geng, Mallery), University of Minnesota, Minneapolis
| | - Dale C Snover
- From the Departments of Laboratory Medicine and Pathology (Sanchez-Avila, Chauhan, Amin, Snover)
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Wilson N, Issak A, Amin K, Tuttle TM, Trikudanathan G, Mallery S. Primary Pancreatic Liposarcoma: An Unexpected Cause of a Pancreatic Mass. ACG Case Rep J 2023; 10:e01242. [PMID: 38107608 PMCID: PMC10723886 DOI: 10.14309/crj.0000000000001242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/18/2023] [Indexed: 12/19/2023] Open
Abstract
Liposarcoma is the most common type of soft-tissue sarcoma and typically occurs in the extremities or retroperitoneum. Primary liposarcoma of the pancreas is exceedingly rare, with only 10 cases reported since 1979. We present a patient who was incidentally discovered to have a pancreatic mass on imaging, which was ultimately diagnosed as dedifferentiated pancreatic liposarcoma. We review the clinical and histologic features of pancreatic liposarcoma in this case and in the 10 previously reported cases to increase awareness and knowledge of this rare disease.
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Affiliation(s)
- Natalie Wilson
- Department of Internal Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Abdulfatah Issak
- Department of Internal Medicine, University of Minnesota Medical Center, Minneapolis, MN
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, MN
| | - Khalid Amin
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, MN
| | - Todd M. Tuttle
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN
| | - Guru Trikudanathan
- Department of Internal Medicine, University of Minnesota Medical Center, Minneapolis, MN
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, MN
| | - Shawn Mallery
- Department of Internal Medicine, University of Minnesota Medical Center, Minneapolis, MN
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, MN
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Trikudanathan G, Dirweesh A, Faizi N, Schat R, Suryavwanshi G, Lunos S, Jonason D, Azeem N, Amateau SK, Mallery S, Chauhan A, Freeman ML. Predicting need for intervention in acute necrotizing pancreatitis following discharge- A single center experience in 525 patients. Pancreatology 2022; 22:1063-1070. [PMID: 36371404 DOI: 10.1016/j.pan.2022.09.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/30/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND AIMS The clinical course of necrotizing pancreatitis (NP) is variable and unpredictable, with some patients managed conservatively, but a significant proportion become symptomatic and needing intervention for drainage and/or necrosectomy. The aim of this study was to identify patients based on baseline clinical and imaging metrics who will likely need intervention and therefore closer follow-up. METHODS All NP patients managed in our institution between 2010 and 2019 were identified from a prospective database and those who did not undergo intervention during initial hospitalization were followed longitudinally post discharge until clinical and imaging resolution of necrosis. Patients were categorized into a conservative arm or intervention arm (endoscopic/percutaneous/surgical drainage and/or necrosectomy) for criteria defined according to IAP/APA guidelines. Clinical and imaging characteristics during initial presentation were analyzed between the two groups to identify independent predictors for eventual intervention using multivariable logistic regression. A nomogram was designed based on factors that were significant as defined by P value < 0.05. RESULTS Among 525 patients, 340 who did not meet criteria for intervention during initial admission were included for study and followed for an average 7.4 ± 11.3 months. 140 were managed conservatively and 200 needed intervention (168 within 6 months and 32 after 6 months). Independent predictors of need for eventual intervention were white race [OR 3.43 (1.11-10.62)], transferred status [OR 3.37 (1.81-6.27)], and need for TPN [OR 6.86 (1.63-28.9)], necrotic collection greater than 6 cm [OR 8.66 (4.10-18.32)] and necrotic collection with greater than 75% encapsulation [OR 41.3 (8.29-205.5)]. A prediction model incorporating these factors demonstrated an area under the curve of 0.88. CONCLUSIONS Majority of NP patients do not need intervention during initial admission but may require drainage/necrosectomy mostly in the first 6 months following discharge. Need for subsequent intervention can be accurately predicted by a combination of clinical and imaging features on index admission.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, USA.
| | - Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, USA
| | - Nauroze Faizi
- Department of Radiology, University of Minnesota, USA
| | - Robben Schat
- Department of Radiology, University of Minnesota, USA
| | - Gaurav Suryavwanshi
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, USA
| | - Scott Lunos
- Clinical and Translational Science Institute, Biostatistical Design and Analysis Center, University of Minnesota, USA
| | - David Jonason
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, USA
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, USA
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, USA
| | - Anil Chauhan
- Department of Radiology, University of Minnesota, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, USA
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Abdallah M, Vantanasiri K, Young S, Azeem N, Amateau SK, Mallery S, Freeman ML, Trikudanathan G. Visceral artery pseudoaneurysms in necrotizing pancreatitis: risk of early bleeding with lumen-apposing metal stents. Gastrointest Endosc 2022; 95:1150-1157. [PMID: 34871553 DOI: 10.1016/j.gie.2021.11.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/13/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Visceral artery pseudoaneurysm (PSA) in necrotizing pancreatitis (NP) is associated with significant morbidity and mortality. This study aimed to evaluate the incidence, clinical presentation, management, and outcomes of PSA in NP. METHODS All NP patients managed at our institution between 2010 and 2020 were retrospectively reviewed from a prospectively maintained database for PSA. Demographics, clinical presentation, method of diagnosis, management, and outcomes were collected. RESULTS Thirty-nine of 607 patients (6.4%) with NP had a confirmed diagnosis of PSA. Demographics, presence of infected necrosis, development of organ failure(s), and severity of disease were similar between PSA and no PSA. Endoscopic and percutaneous drainages for walled-off necrosis (WON) were more common in the PSA group. Seven patients developed PSA without requiring any intervention for WON, and 17 patients (43.6%) had lumen-apposing metal stents (LAMSs) placed before PSA diagnosis. The time from NP diagnosis to PSA diagnosis was shorter in these patients (n = 17) compared with the remaining patients (n=22; 47 days [interquartile range {IQR}: 17-85] vs 109 days [IQR: 61-180.5, P=0.009]). In addition, 7 of 11 patients (63.6%) with early PSA (defined by <3 weeks from index cystgastrostomy/cystduodenostomy) had an indwelling LAMS at the time of the PSA diagnosis. Seventy-seven percent of patients presented with anemia, 74.3% with GI bleeding, and 30% with hemorrhagic shock. CT was diagnostic for PSA in 83.9% with a false-negative rate of 16.1%. Splenic (50%) and gastroduodenal (28%) arteries were the most common arteries involved by PSA. Angiography and embolization for PSA were successful in 33 of 35 patients. In-hospital mortality was observed in 9 patients (23.1%). CONCLUSIONS Although visceral artery PSA affects a small percentage of NP patients, it is associated with significant morbidity and mortality. In addition, bleeding from PSA induced by erosion of LAMSs may occur in the first 2 weeks, prompting individualization of removal intervals.
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Affiliation(s)
- Mohamed Abdallah
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kornpong Vantanasiri
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shamar Young
- Department of Interventional Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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Mettler T, Stuart J, Racila E, Mallery S, Amin K. Mediastinal ganglioneuroma diagnosed by transesophageal endoscopic ultrasound guided fine needle aspiration (EUS-FNA). Diagn Cytopathol 2020; 48:769-772. [PMID: 32396276 DOI: 10.1002/dc.24445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/24/2020] [Accepted: 03/27/2020] [Indexed: 11/09/2022]
Abstract
Ganglioneuromas are rare benign tumors that arise from the sympathetic nerve fibers and represent the final maturation stage of neuroblast tumors. The most common sites of involvement in the body include posterior mediastinum, followed by retroperitoneum, adrenal gland, and soft tissues of the head and neck. In the mediastinum, this tumor is most frequently located in posterior compartment, together with other neurogenic tumors. The reports of mediastinal ganglioneuroma diagnosed by fine needle aspiration (FNA), especially endoscopic ultrasound-guided FNA (EUS-FNA) are very sparse. We describe the clinical, radiologic, cytologic, gross and histologic features of mediastinal ganglioneuroma diagnosed by transesophageal endoscopic ultrasound-guided fine needle aspiration.
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Affiliation(s)
- Tetyana Mettler
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jimmie Stuart
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emilian Racila
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Khalid Amin
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
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Trikudanathan G, Hashmi H, Dirweesh A, Amateau S, Azeem N, Mallery S, Freeman ML. Rendezvous transgastric and percutaneous sinus tract endoscopy (STE) for debridement of necrotic collections with deep retroperitoneal extension: a case series (with video): Meeting presentations: Digestive Disease Week 2018. Endosc Int Open 2020; 8:E668-E672. [PMID: 32355886 PMCID: PMC7165004 DOI: 10.1055/a-1134-4786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 01/06/2019] [Indexed: 11/12/2022] Open
Abstract
Background and study aims Infected necrotic collections extending deep into the retroperitoneum may not be amenable solely to endoscopic necrosectomy. Rendezvous transgastric and percutaneous sinus tract endoscopic necrosectomy was conceived to maximize debridement and obviate the need for open necrosectomy or video-assisted retroperitoneal debridement. Patients and methods Patients who underwent simultaneous rendezvous transgastric and sinus tract endoscopic transluminal necrosectomy at the same session were identified from a prospectively maintained database. Demographic data, clinical outcomes, immediate and late complications were evaluated. Results Among 415 patients with necrotizing pancreatitis, four patients (three males, median age 47 years) underwent this intervention after a median 29.5 days following placement of percutaneous drain. Intra-procedural bleeding following dilation of percutaneous tract required placement of esophageal stent for tamponade. No patients required rescue open necrosectomy or video assisted retroperitoneal debridement. Complete removal of percutaneous drains was accomplished in all patients after a median of 78.5 days. Conclusions Our novel approach is safe and effective and can expand the available armamentarium for management of large necrotic collection with deep retroperitoneal extension.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Hiba Hashmi
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Stuart Amateau
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Martin L. Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
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Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156:1994-2007.e3. [PMID: 30776347 DOI: 10.1053/j.gastro.2019.01.269] [Citation(s) in RCA: 172] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | | | - Hjalmar C van Santvoort
- Department of Surgery, the University Medical Center Utrecht and the St. Antonius Hospital Nieuwegein, the Netherlands
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
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Adler DG, Mallery S, Amateau S, Nieto J, Taylor LJ, Siddiqui A. A pilot study of a 20-mm lumen-apposing metal stent to treat pancreatic fluid collections: First reported multicenter use of a new device. Endosc Ultrasound 2019; 8:136-138. [PMID: 31006708 PMCID: PMC6482603 DOI: 10.4103/eus.eus_58_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Douglas G Adler
- Division of Gastroenterology, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Shawn Mallery
- Division of Gastroenterology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Stuart Amateau
- Division of Gastroenterology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jose Nieto
- Division of Gastroenterology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Linda Jo Taylor
- Division of Gastroenterology, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Ali Siddiqui
- Division of Gastroenterology, School of Medicine, Jefferson University, Philadelphia, PA, USA
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Siddiqui A, Kunda R, Tyberg A, Arain MA, Noor A, Mumtaz T, Iqbal U, Loren DE, Kowalski TE, Adler DG, Saumoy M, Gaidhane M, Mallery S, Christiansen EM, Nieto J, Kahaleh M. Three-way comparative study of endoscopic ultrasound-guided transmural gallbladder drainage using lumen-apposing metal stents versus endoscopic transpapillary drainage versus percutaneous cholecystostomy for gallbladder drainage in high-risk surgical patients with acute cholecystitis: clinical outcomes and success in an International, Multicenter Study. Surg Endosc 2018; 33:1260-1270. [DOI: 10.1007/s00464-018-6406-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 08/24/2018] [Indexed: 02/06/2023]
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Moisini I, Amin K, Mallery S, Stewart J, Mettler T. Efficacy of endoscopic-guided fine-needle aspiration in the diagnosis of gastrointestinal spindle cell tumors. Diagn Cytopathol 2018; 46:663-669. [DOI: 10.1002/dc.23976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/28/2018] [Accepted: 05/01/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Ioana Moisini
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center; Rochester New York
| | - Khalid Amin
- Department of Pathology and Laboratory Medicine, University of Minnesota Medical Center; Minneapolis Minnesota
| | - Shawn Mallery
- Department of Pathology and Laboratory Medicine, University of Minnesota Medical Center; Minneapolis Minnesota
| | - Jimmie Stewart
- Department of Pathology and Laboratory Medicine, University of Minnesota Medical Center; Minneapolis Minnesota
| | - Tetyana Mettler
- Department of Pathology and Laboratory Medicine, University of Minnesota Medical Center; Minneapolis Minnesota
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Nemoto Y, Attam R, Arain MA, Trikudanathan G, Mallery S, Beilman GJ, Freeman ML. Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients. Pancreatology 2017; 17:663-668. [PMID: 28803859 DOI: 10.1016/j.pan.2017.07.195] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 07/05/2017] [Accepted: 07/30/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. METHODS Consecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. RESULTS Of 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. CONCLUSIONS An algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series.
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Affiliation(s)
- Yukako Nemoto
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Japan; Department of Gastroenterology, Kohsei Chuo General Hospital, Japan
| | - Rajeev Attam
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States; Advanced Endoscopy, Southern California Permanente Medical Group, Kaiser Permanente Downey, United States
| | - Mustafa A Arain
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | | | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States.
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12
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Sekulic M, Amin K, Mettler T, Miller LK, Mallery S, Stewart J. Pancreatic involvement by metastasizing neoplasms as determined by endoscopic ultrasound-guided fine needle aspiration: A clinicopathologic characterization. Diagn Cytopathol 2017; 45:418-425. [PMID: 28205397 DOI: 10.1002/dc.23688] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pancreatic tumors often represent primary neoplasms, however organ involvement with metastatic disease can occur. The use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to determine the underlying pathology provides guidance of clinical management. METHODS 25 cases were identified in a retrospective review of our institution's records from 2006 to 2016. Clinical parameters and prognosis are described. RESULTS Metastatic lesions to the pancreas diagnosed by EUS-FNA accounted for 4.2% of all pancreatic neoplastic diagnoses, each lesion had a median greatest dimension of 1.5 cm, were most often located in the head of the pancreas, and by EUS were typically hypoechoic masses with variably defined borders. Patients were of a median age of 64 years old at diagnosis of the metastatic lesion(s) and the mean interval from primary diagnosis to the diagnosis of metastasis to the pancreas was 58.7 months (95% confidence interval, CI, 35.4 to 82.0 months). The rates of 24-month overall survival after diagnoses of metastatic renal cell carcinoma or all other neoplasms to the pancreas were 90% and 7% respectively. The origin of the neoplasms included the kidney (n = 10), colon (n = 4), ovary (n = 3), lung (n = 2), et al. Smear-based cytomorphology, and a combination of histomorphology and immunohistochemical studies from cell block preparations showed features consistent with the neoplasm of derivation. CONCLUSION Metastases to the pancreas can be diagnosed via EUS-FNA, with enough specimen to conduct immunohistochemical studies if necessary to delineate origin. The determination of metastatic disease to the pancreas alters management and prognosis of the patient. Diagn. Cytopathol. 2017;45:418-425. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Miroslav Sekulic
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Khalid Amin
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Tetyana Mettler
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Lizette K Miller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Shawn Mallery
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Jimmie Stewart
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
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Trikudanathan G, Munigala S, Barlass U, Malli A, Han Y, Sekulic M, Bellin M, Chinnakotla S, Dunn T, Pruett T, Beilman G, Peralta JV, Arain M, Amateau S, Mallery S, Freeman ML, Attam R. Evaluation of Rosemont criteria for non-calcific chronic pancreatitis (NCCP) based on histopathology - A retrospective study. Pancreatology 2016; 17:63-69. [PMID: 27836330 DOI: 10.1016/j.pan.2016.10.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 10/12/2016] [Accepted: 10/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rosemont classification for chronic pancreatitis has not been evaluated specifically in non-calcific chronic pancreatitis (NCCP) patients and to this date, it has not been correlated with the gold standard namely histopathology. OBJECTIVE To assess the correlation of EUS Rosemont criteria for NCCP with histopathology from surgical specimens and evaluate the impact of age, sex, BMI, smoking and alcohol on Rosemont classification. METHODS Adult patients undergoing TPIAT for NCCP between July 2009 and January 2013 were identified from our institutional database. The presence or absence of standard and Rosemont (major and minor) criteria were determined by expert endosonographers using linear endosonography. Patients were categorized into normal, indeterminate and suggestive with CP based on Rosemont classification. Histology was obtained at time of TPIAT from the resected pancreas by wedge biopsy of head, body and tail. All histopathology were re-reviewed by a GI pathologist blinded to endosonographic features and clinical outcomes. Available pancreatic tissue was graded for severity of intralobular and perilobular pancreatic fibrosis by the Ammann classification system. RESULTS 50 patients with NCCP (42 females, mean age± SD = 37.9 ± 10.8) underwent TPIAT with preoperative EUS during the study period. Univariate analysis of features such as age, sex, BMI, smoking and alcohol history showed no significant difference between patients identified as normal and those identified as indeterminate/suggestive (p > 0.05). Rosemont "Normal" was poor in excluding CP as 5/9 patients (55.5%) had CP on histopathology. 25/26 patients (96.2%) with features "suggestive" of CP had evidence of CP on histopathology. 12/15 patients (80.0%) with "indeterminate" features had CP on histopathology. CONCLUSIONS Rosemont classification can be used independent of patient characteristics (age, sex and BMI) and environmental factors (smoking and alcohol exposure). In our cohort, Rosemont classification was strongly predictive of CP in patients with features "suggestive" of CP. However, "normal" Rosemont classification had poor correlation in this study. This is maybe due to lack of true comparator "normal" pancreas which cannot be obtained reasonably. The strength of agreement for diagnosis of CP was substantial between the standard and Rosemont criteria.
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Affiliation(s)
| | - Satish Munigala
- Division of Gastroenterology, St Louis University School of Medicine, USA
| | - Usman Barlass
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Ahmad Malli
- Department of Internal Medicine, University of Minnesota, Minneapolis, USA
| | - Yusheng Han
- Department of Pathology, University of Minnesota, Minneapolis, USA
| | - Miroslav Sekulic
- Department of Pathology, University of Minnesota, Minneapolis, USA
| | - Melena Bellin
- The Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA
| | | | - Ty Dunn
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Timothy Pruett
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Gregory Beilman
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Jose-Vega Peralta
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Mustafa Arain
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Stuart Amateau
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Shawn Mallery
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Martin L Freeman
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Rajeev Attam
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA.
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Abstract
Inflammation in ectopic pancreatic tissue can clinically present with pain or obstructive symptoms, depending on the location of the ectopic tissue. We present a rare case of gastric outlet obstruction secondary to pancreatitis of ectopic pancreatic tissue in the pylorus.
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Affiliation(s)
- Saleh Elwir
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN, USA
| | - Brooke Glessing
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN, USA
| | - Khalid Amin
- Department of Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Eric Jensen
- Department of Surgical Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Shawn Mallery
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN, USA
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15
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Attam R, Trikudanathan G, Arain M, Nemoto Y, Glessing B, Mallery S, Freeman ML. Endoscopic transluminal drainage and necrosectomy by using a novel, through-the-scope, fully covered, large-bore esophageal metal stent: preliminary experience in 10 patients. Gastrointest Endosc 2014; 80:312-8. [PMID: 24721519 DOI: 10.1016/j.gie.2014.02.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 02/10/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Interventions for necrotizing pancreatitis have undergone a recent paradigm shift toward minimally invasive techniques, including endoscopic transluminal necrosectomy (ETN). The optimal stent for endoscopic transmural drainage remains unsettled. OBJECTIVE To evaluate a novel large-bore, fully covered metal through-the-scope (TTS) esophageal stent for cystenterostomy in large walled-off necrosis (WON). DESIGN Retrospective case series. SETTING Single tertiary care academic center. PATIENTS Ten patients with large (>10 cm) WON collections who underwent endoscopic transmural drainage and ETN. INTERVENTION Initial cystenterostomy was performed by using EUS, and in the same session, a TTS (18 × 60 mm), fully covered esophageal stent was placed to create a wide-bore fistula into the cavity. In 1 or more later sessions, the stent was removed, and ETN was performed as needed. MAIN OUTCOME MEASUREMENTS Technical and clinical success rates and adverse events. RESULTS The TTS stent was successfully deployed at the initial cystogastrostomy in all 10 patients. All patients had large WON (median size 17 cm, range 11-30 cm) and underwent intervention at a median of 30 days (range 12-117 days) after onset of acute pancreatitis. Resolution of WON was achieved in 9 of the 10 patients (90%) after a median of 3 endoscopic sessions. There were no early adverse events. Late adverse events occurred in 3 patients (30%); worsening of infection from stent migration and occlusion of cystogastrostomy (2 patients), and fatal pseudoaneurysmal bleeding from erosion of infected necrosis into a major artery distant from the stent (1 patient). The stent was easily removed in all the cases after resolution or improvement of the necrotic cavity. LIMITATIONS Retrospective, single-center evaluation of a small number of cases. No comparative arm to determine the relative efficacy or cost-effectiveness of these stents compared with conventional plastic stents. CONCLUSIONS Endoscopic therapy using a large-bore TTS, fully covered esophageal stent is feasible for use in the treatment of large WON. Further studies are needed to validate these findings.
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Affiliation(s)
- Rajeev Attam
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Guru Trikudanathan
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Mustafa Arain
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Yukako Nemoto
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Brooke Glessing
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Shawn Mallery
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Martin L Freeman
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
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Mainville G, Allen C, Ayers L, Hagen J, Tong M, Kellough D, Mallery S. Sustained Overexpression of Insulin-Like Growth Factor II mRNA–Binding Protein 3 in Oral Epithelial Dysplasia: A Potential Prognostic Biomarker Of Impending Invasion. Oral Surg Oral Med Oral Pathol Oral Radiol 2013. [DOI: 10.1016/j.oooo.2013.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Berzosa M, Davies SF, Gupta K, Debol SM, Li R, Miranda D, Mallery S. Diagnostic bedside EUS in the intensive care unit: a single-center experience. Gastrointest Endosc 2013; 77:200-8. [PMID: 23218946 DOI: 10.1016/j.gie.2012.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/05/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND The knowledge of bedside diagnostic EUS in critically ill patients is limited. OBJECTIVE To investigate the indications, feasibility, safety, and clinical utility of diagnostic EUS in the intensive care unit (ICU). DESIGN Retrospective. SETTING Tertiary-care referral teaching hospital. PATIENTS All consecutive patients who had EUS done in the ICU within a 6-year period. INTERVENTION Bedside EUS and EUS-guided FNA. MAIN OUTCOME MEASUREMENTS EUS indications, complications, and impact on management. RESULTS A total of 64 EUS procedures were performed in 63 patients (38 men, 25 women; age range 27-78 years); 1 patient underwent 2 separate EUS procedures. EUS was performed while the patients were mechanically ventilated in 70% (45/64) of cases. Indications for EUS included jaundice (n = 24), mass of unknown etiology (n = 25), unexplained pancreatitis (n = 7), and staging of known cancer (n = 3). In 5 cases, EUS was used as an alternative to other imaging modalities because of morbid obesity (n = 3) or contraindication to intravenous contrast material (n = 2). Complications included reversible oxygen desaturation (n = 4), nonsustained ventricular tachycardia (n = 1), and transient hypotension (n = 1). Overall, EUS influenced management in 97% (62/64) of cases. LIMITATIONS Retrospective, single-center study. CONCLUSION ICU-based EUS can be performed with few intraprocedural complications and can be a valuable diagnostic modality in the ICU setting. It appears to be particularly useful for determining the etiology of jaundice, masses of unknown etiology, and pancreatitis. It may have particular value as a diagnostic technique on selected patients with unstaged cancer and when morbid obesity or the inability to use intravenous contrast material precludes the use of other imaging modalities in the critically ill patient.
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Affiliation(s)
- Manuel Berzosa
- Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA
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18
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Kennedy P, Tee B, Kennedy K, Mallery S, Fields H, Sun Z. Poster 76: Enhanced Mandibular Distraction Osteogenesis Using A Tissue Engineering Approach. J Oral Maxillofac Surg 2012. [DOI: 10.1016/j.joms.2012.06.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Zhong N, Zhang L, Takahashi N, Shalmiyev V, Canto MI, Clain JE, Deutsch JC, DeWitt J, Eloubeidi MA, Gleeson FC, Levy MJ, Mallery S, Raimondo M, Rajan E, Stevens T, Topazian M. Histologic and imaging features of mural nodules in mucinous pancreatic cysts. Clin Gastroenterol Hepatol 2012; 10:192-8, 198.e1-2. [PMID: 21982970 DOI: 10.1016/j.cgh.2011.09.029] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 09/17/2011] [Accepted: 09/24/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Mural nodules predict malignancy within pancreatic cysts, but it is not clear whether endoscopic ultrasound (EUS) and computed tomography (CT) accurately identify nodules. We assessed images and the histology of mural nodules in branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) and mucinous cystic neoplasms (MCNs) and identified criteria to distinguish mural nodules from mucus. METHODS We reviewed pathology specimens and EUS and CT images from consecutive patients with resected BD-IPMNs or MCNs. A blinded interobserver study of the EUS images was then conducted to identify features that distinguished nodules from mucus. After education about these features, the raters interpreted the EUS images again. RESULTS On the basis of histologic analysis, 22 of 57 cases had epithelial nodules. Cancer or high-grade dysplasia was found in 23% of cysts with nodules versus 3% without nodules (P = .02). On the basis of reports, EUS detected epithelial nodules with 75% sensitivity and 83% specificity, whereas these values were 24% and 100%, respectively, for CT. Mucus accounted for 65% of intracystic lesions detected by EUS and was often diagnosed by using change in body position and fine-needle aspiration. Interobserver analysis identified 3 features that were detected by EUS (echogenicity, edge, and rim) that distinguished mucus from epithelial nodules. The diagnostic accuracy of the raters improved from a mean of 57% to 79% after education about these features (P = .004); accuracy was 90% when all 3 features of mucus were present. CONCLUSIONS Malignancy is associated with epithelial nodules in BD-IPMNs and MCNs, but most echogenic lesions detected in cysts by EUS are mucus. Knowledge of features that discriminate mucus from mural nodules improves the diagnostic accuracy of EUS.
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Affiliation(s)
- Ning Zhong
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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20
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Kim YS, Gupta K, Mallery S, Li R, Kinney T, Freeman ML. Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series. Endoscopy 2010. [PMID: 20419625 DOI: 10.1007/s-0029-1244082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66 +/- 18.2 years; malignant = 10, benign = 5). Mean diameter of measured bile ducts was 14.3 +/- 5.17 mm (range 4-23 mm). The reasons for initial ERCP failure were tumor infiltration or edema (n = 9), intradiverticular papilla (n = 2), pre-existing duodenal stent (n = 1), and anatomic anomalies (n = 3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100 %), with drainage being successful in 12 / 15 (80 %). Failures occurred in three patients due to inability to traverse the biliary stricture (n = 2) or dissection of a choledochocele with the guide wire (n = 1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.
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Affiliation(s)
- Y S Kim
- Internal Medicine, Gacheon Gil Medical Center of Gacheon Medical School, Incheon, Korea
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21
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Kim YS, Gupta K, Mallery S, Li R, Kinney T, Freeman ML. Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series. Endoscopy 2010; 42:496-502. [PMID: 20419625 DOI: 10.1055/s-0029-1244082] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66 +/- 18.2 years; malignant = 10, benign = 5). Mean diameter of measured bile ducts was 14.3 +/- 5.17 mm (range 4-23 mm). The reasons for initial ERCP failure were tumor infiltration or edema (n = 9), intradiverticular papilla (n = 2), pre-existing duodenal stent (n = 1), and anatomic anomalies (n = 3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100 %), with drainage being successful in 12 / 15 (80 %). Failures occurred in three patients due to inability to traverse the biliary stricture (n = 2) or dissection of a choledochocele with the guide wire (n = 1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.
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Affiliation(s)
- Y S Kim
- Internal Medicine, Gacheon Gil Medical Center of Gacheon Medical School, Incheon, Korea
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22
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Kim YS, Gupta K, Mallery S, Li R, Kinney T, Freeman ML. Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series. Endoscopy 2010. [PMID: 20419625 DOI: 10.1055/s-0029-124408217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66 +/- 18.2 years; malignant = 10, benign = 5). Mean diameter of measured bile ducts was 14.3 +/- 5.17 mm (range 4-23 mm). The reasons for initial ERCP failure were tumor infiltration or edema (n = 9), intradiverticular papilla (n = 2), pre-existing duodenal stent (n = 1), and anatomic anomalies (n = 3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100 %), with drainage being successful in 12 / 15 (80 %). Failures occurred in three patients due to inability to traverse the biliary stricture (n = 2) or dissection of a choledochocele with the guide wire (n = 1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.
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Affiliation(s)
- Y S Kim
- Internal Medicine, Gacheon Gil Medical Center of Gacheon Medical School, Incheon, Korea
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23
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Berzosa M, Tsukayama DT, Davies SF, Debol SM, Cen YY, Li R, Mallery S. Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of extra-pulmonary tuberculosis. Int J Tuberc Lung Dis 2010; 14:578-584. [PMID: 20392350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
SETTING The incidence of extra-pulmonary tuberculosis (EPTB) is surprisingly high among certain subgroups of patients in industrialized countries. Diagnosis is often difficult and can require costly invasive workup. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe, minimally invasive, accurate, out-patient diagnostic modality for assessing mediastinal and abdominal lymphadenopathy and masses. OBJECTIVE To evaluate the usefulness of EUS-FNA for diagnosing EPTB. DESIGN Retrospective 6-year review, including all patients who had evidence of lymphadenopathy or mass on computed tomography scan accessible by EUS and consideration of tuberculosis (TB) in the differential diagnosis. RESULTS Of 81 potential patients, a total of 20 cases with EPTB diagnosed by EUS-FNA were identified. Necrotizing granulomas had a 58% likelihood of TB vs. 14% for other cytologic findings (P < 0.0001); necrosis was also predictive, with a 44% likelihood of TB vs. 19% (P < 0.0225). EUS-FNA cytology was diagnostic for TB when an African-born patient had necrotizing granulomas (P < 0.0001), and was highly suggestive with necrosis alone (P < 0.0514). Non-necrotizing granulomas were not predictive of TB and an alternative diagnosis was more likely, including sarcoidosis and cancer. CONCLUSION EUS-FNA is a useful diagnostic modality that should be used early in the diagnostic workup of suspected EPTB.
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Affiliation(s)
- M Berzosa
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
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24
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Kinney TP, Li R, Gupta K, Mallery S, Hunter D, Jensen E, Vickers S, Freeman ML. Therapeutic pancreatic endoscopy after Whipple resection requires rendezvous access. Endoscopy 2009; 41:898-901. [PMID: 19750454 DOI: 10.1055/s-0029-1215081] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- T P Kinney
- Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, Minnesota 55419, United States of America.
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Virtue MA, Mallery S, Li R, Sielaff TD. Clinical utility of endoscopic ultrasound in solid pancreatic mass lesions deemed resectable by computer tomography. JOP 2008; 9:167-171. [PMID: 18326924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
CONTEXT Appropriate surgical exploration and resection of pancreatic carcinoma depends on accurate preoperative evaluation. OBJECTIVE Determine the accuracy of endoscopic ultrasound in predicting the need for surgical exploration in patients with solid pancreatic masses deemed by computer tomography to be resectable without venous grafting (absence of distant metastatic disease or major vascular involvement). PATIENTS All patients between March 2000 and November 2003 with focal pancreatic mass lesions deemed to be surgically resectable by computer tomography. Forty-nine patients participated (29 males, 20 females; age range: 40-86 years). INTERVENTION Preoperative linear-array endoscopic ultrasound. MAIN OUTCOME MEASURE Surgical pathology compared to computer tomography and endoscopic ultrasound results. RESULTS Out of the 49 patients, 33 (67.3%) had pancreatic neoplasms and 16 (32.7%) had chronic pancreatitis. Endoscopic ultrasound correctly diagnosed all 16 patients with chronic pancreatitis. Endoscopic ultrasound correctly identified 18 (54.5%) of those with neoplasms as having unresectable disease while 6 (18.2%) patients were appropriately identified as resectable by endoscopic ultrasound. The remaining 9 patients (27.3%) were deemed resectable by endoscopic ultrasound, but were unresectable at the time of surgery. None of the patients were falsely designated as unresectable by endoscopic ultrasound. CONCLUSION Endoscopic ultrasound is an important compliment to computed tomography in predicting resectability and in avoiding nontherapeutic laparotomy of solid pancreatic neoplasms. Moreover, endoscopic ultrasound classification did not discourage surgery of resectable pancreatic masses.
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Affiliation(s)
- Mark A Virtue
- Department of Medicine, Division of Gastroenterology, University of Minnesota. Minneapolis, MN, USA.
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Stelow EB, Murad FM, Debol SM, Stanley MW, Bardales RH, Lai R, Mallery S. A limited immunocytochemical panel for the distinction of subepithelial gastrointestinal mesenchymal neoplasms sampled by endoscopic ultrasound-guided fine-needle aspiration. Am J Clin Pathol 2008; 129:219-25. [PMID: 18208801 DOI: 10.1309/nl2wyad8euh3xfrf] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We studied the use of immunocytochemical analysis with material procured by endoscopic ultrasound-guided fine-needle aspiration (EUS-guided FNA) for the diagnosis of subepithelial intramural gastrointestinal (GI) mesenchymal neoplasms (SIGIMNs). We identified all EUS-guided FNA specimens of SIGIMNs that had undergone immunocytochemical analysis. Results were compared with follow-up histologic diagnoses. There were 95 aspirates that were diagnosed as GI mesenchymal tumors (GI stromal tumors [GISTs], n = 46), leiomyomas (n = 38), peripheral nerve sheath tumors (n = 5), and other neoplasms by cytologic examination. Immunoreactivity with antibodies to CD117 always predicted GIST at follow-up; 15 of 16 cases immunoreactive with antibodies to CD34 were found to be GISTs at follow-up. Strong immunoreactivity with antibodies to smooth muscle actin or desmin usually predicted a leiomyoma at follow-up aside from a single glomus tumor and a case with apparent nonneoplastic smooth muscle contaminant. When sufficient material is present, immunocytochemical analysis used with material obtained by EUS-guided FNA is highly predictive of final pathologic diagnosis.
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27
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Stelow EB, Shami VM, Abbott TE, Kahaleh M, Adams RB, Bauer TW, Debol SM, Abraham JM, Mallery S, Policarpio-Nicolas ML. The use of fine needle aspiration cytology for the distinction of pancreatic mucinous neoplasia. Am J Clin Pathol 2008; 129:67-74. [PMID: 18089490 DOI: 10.1309/y16qcxe3ygmxx19q] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Cytology frequently has some role in preoperatively distinguishing pancreatic mucus-producing neoplasia (intraductal papillary mucinous neoplasms [IPMNs] and mucinous cystic neoplasms [MCNs]) from other pancreatic cysts. We evaluated all cytologic specimens at our institutions from resected pancreatic cystic lesions for lesional extracellular and cellular material. Lesional extracellular material was identified in 32 of 38 of the cytologic samples from cystic pancreatic mucus-producing neoplasms (28 of 31 IPMNs and 4 of 7 MCNs). Lesional cellular material was seen in 22 of 38 cases (17 of 31 IPMNs and 5 of 7 MCNs). Lesional material was more commonly identified in higher grade and invasive lesions. Lesional extracellular material was seen in 3 of 14 samples of other pancreatic cysts, and lesional cellular material was seen in 6 of 14 cases.
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Keenan J, Mallery S, Freeman ML. EUS rendezvous for pancreatic stent placement during endoscopic snare ampullectomy. Gastrointest Endosc 2007; 66:850-3. [PMID: 17719045 DOI: 10.1016/j.gie.2007.01.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Accepted: 01/04/2007] [Indexed: 12/17/2022]
Affiliation(s)
- Joseph Keenan
- Division of Gastroenterology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN 55415, USA
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Gupta K, Mallery S. Small-caliber endobronchial ultrasonic videoscope: successful transesophageal and transgastric FNA after failed passage of a standard ultrasonic endoscope. Gastrointest Endosc 2007; 66:574-7. [PMID: 17725948 DOI: 10.1016/j.gie.2007.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 02/05/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS-guided tissue acquisition is a valuable technique. Obstructing lesions of the oropharynx or esophagus may preclude passage of a standard echoendoscope. In the past this has prevented EUS-guided tissue sampling. The recently introduced small-caliber ultrasonic bronchovideoscope (developed for endobronchial ultrasound) may allow EUS-guided FNA in this setting. OBJECTIVE Our purpose was to assess the possible use of the ultrasonic bronchovideoscope to perform upper GI EUS in patients where passage of standard EUS scope was unsuccessful. DESIGN A descriptive case series. SETTING A tertiary referral center. RESULTS Two patients were evaluated after failure of passage of a standard echoendoscope (1 with congenital narrowing of the esophageal inlet, 1 with postoperative deformity). In both cases, sonographic visualization of the lesion of concern was achieved and FNA was performed successfully. CONCLUSIONS The ultrasonic bronchovideoscope may be a valuable tool to perform FNA of mediastinal and GI lesions in situations when a standard ultrasonic endoscope cannot be passed because of luminal narrowing.
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Affiliation(s)
- Kapil Gupta
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, Minnesota 55415, USA
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Policarpio-Nicolas ML, Shami VM, Kahaleh M, Adams RB, Mallery S, Stanley MW, Bardales RH, Stelow EB. Fine-needle aspiration cytology of pancreatic lymphoepithelial cysts. Cancer 2007; 108:501-6. [PMID: 17063496 DOI: 10.1002/cncr.22289] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Lymphoepithelial cysts (LECs) of the pancreas are extremely rare, benign, nonneoplastic cysts that can mimic pseudocysts or cystic neoplasms clinically and radiographically. The cytologic features of LECs have been described only in a handful of case reports and may overlap with both benign and malignant pancreatic tumors. METHODS The authors conducted a 5-year, retrospective, computerized review of the cytopathology files of 2 institutions for all diagnoses of pancreatic LECs. Clinical, radiographic, cytologic, and chemical findings were reviewed. RESULTS Four patients were identified. The study group consisted of 3 men and 1 woman who ranged in age from 33 years to 63 years. The masses were located throughout the pancreas. Tumor sizes ranged from 1.8 cm to 5.7 cm in greatest dimension. Smears from all patients revealed numerous anucleated squamous cells, rare benign nucleated cells, amorphous debris, and an absence of lymphocytes. Mildly atypical mucinous glandular and parakeratotic epithelium were identified in 2 patients, leading to diagnoses of atypical and suspicious for malignancy. Subsequent surgical follow-up of 3 patients revealed pancreatic LECs. CONCLUSIONS Pancreatic LECs are extremely rare, and certain cytologic pitfalls may hinder a correct prospective diagnosis. Familiarity with the lesion's clinical and cytologic features may help clinicians arrive at the appropriate prospective diagnosis and, thus, permit conservative management. Cancer
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Gupta K, Mallery S, Hunter D, Freeman ML. Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERCP. Rev Gastroenterol Disord 2007; 7:22-37. [PMID: 17392627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Although the success rates of endoscopic retrograde cholangiopancreatography (ERCP) in accessing the bile and pancreatic ducts are quite high, failure to achieve duct access still occurs. Options in these cases have traditionally included percutaneous access or open surgical intervention. A combination percutaneous and endoscopic approach (ie, rendezvous procedure) is often used in cases of failed biliary cannulation by ERCP and occasionally for pancreatic duct access. However, this technique often results in complications and is hampered by the difficulty in coordinating schedules between interventional radiologists and endoscopists and the lack of predictability of failed ERCP access. Several groups have described the use of endoscopic ultrasonography (EUS) in accessing the ducts in cases of failed ERCP. This technique has the potential to substantially reduce the need for a percutaneous or surgical approach in many cases. This article reviews the nonsurgical methods for accessing the biliary and pancreatic ducts after failure of ERCP as well as the current status and possible future applications of EUS-assisted drainage techniques.
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Affiliation(s)
- Kapil Gupta
- Division of Gastroenterology, Hepatology and Nutrition, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
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Abstract
This review, based on the Hennepin County Medical Center experience and review of the literature, vastly covers the up-to-date role of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (FNA) in evaluating tumorous lesions of the gastrointestinal tract and adjacent organs. Emphasis is given to the tumoral and nodal staging of esophageal, pulmonary, and pancreatic cancer. This review also discusses technical, pathological, and gastroenterologic aspects and the role of the pathologist and endosonographer in the evaluation of these lesions, as well as the corresponding FNA cytology and differential diagnosis.
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Affiliation(s)
- Ricardo H Bardales
- Department of Pathology, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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Varghese LR, Stanley MW, Lucido ML, Mallery S, Lai R, Bardales RH. Esophageal carcinoma with a rhabdoid phenotype: a case report of diagnosis by endoscopic ultrasound-guided fine-needle aspiration. Diagn Cytopathol 2006; 33:407-11. [PMID: 16299741 DOI: 10.1002/dc.20362] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Malignant extra renal tumors with rhabdoid phenotype are aggressive neoplasms associated with a poor prognosis. These tumors have been reported in soft tissue and various organs including the gastrointestinal tract. We report one of such tumors arising in the esophagus and discuss the cytopathologic, immunohistochemical, and ultrastructural features. Endoscopic ultrasound-guided fine-needle aspiration (FNA) cytology revealed a highly cellular tumor, consisting of polygonal poorly cohesive cells with prominent eosinophilic paranuclear cytoplasmic inclusions. Immunohistochemical staining showed strong cytoplasmic positivity for vimentin and cytokeratin. Electron microscopy revealed presence of numerous intermediate filaments. To the best of our knowledge, this is the first example of carcinoma with rhabdoid phenotype of the esophagus diagnosed by FNA cytology.
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Affiliation(s)
- Linda R Varghese
- Department of Pathology, Division of Gastroenerology, Hennepin County Medical Center, Minneapolis, Minnesota, USA.
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Abstract
Acinar cell carcinoma (ACC) of the pancreas is extremely uncommon and its cytologic features have rarely been described. We describe the cytologic features of cases we have seen, review the literature regarding its cytologic features and discuss the pitfalls that may be encountered and the use of immunohistochemistry for its diagnosis. We searched our databases for all cases of histologically confirmed pancreatic ACC which had undergone prior fine needle aspiration (FNA) of the primary pancreatic lesion. The clinical histories, radiographic and sonographic findings, cytologic features, original cytologic diagnoses, and final histologic diagnoses were reviewed. Four cases of pancreatic ACC were found that had undergone FNA prior to histologic confirmation of the diagnoses. They were from 2 men and 2 women aged 50-75 yr. All masses were in the head of the pancreas, 2 had apparent peri-pancreatic adenopathy and 1 had an apparent liver metastasis. On review, all 4 had had diagnostic material on cytology samples. Original cytologic diagnoses included "acinar cell carcinoma," "pancreatic endocrine tumor," "favor neuroendocrine tumor, low-grade" and "non-diagnostic specimen." The cytologic features included small to moderate-sized loose groups with numerous single cells, prominent acinar formation, little anisonucleosis and prominent nucleoli. The cytologic features showed significant overlap with those of pancreatic endocrine tumors.
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Affiliation(s)
- Edward B Stelow
- Department of Pathology, University of Virginia, Charlottesville, Virginia 22908, USA.
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Stelow EB, Woon C, Pambuccian SE, Thrall M, Stanley MW, Lai R, Mallery S, Gulbahce HE. Fine-needle aspiration cytology of pancreatic somatostatinoma: the importance of immunohistochemistry for the cytologic diagnosis of pancreatic endocrine neoplasms. Diagn Cytopathol 2005; 33:100-5. [PMID: 16007666 DOI: 10.1002/dc.20305] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Edward B Stelow
- Department of Pathology, University of Virginia, Charlottesville, 22908, USA.
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Abstract
Chronic pancreatitis (CP) refers to a spectrum of changes generally seen after repeated injury that ranges histologically from mild fibrosis to extensive fibroinflammatory replacement of acinar tissue with accumulation of calcific debris. Because CP can share clinical and radiological features with malignancy, it often is sampled by fine-needle aspiration (FNA). The cytology files at Hennepin County Medical Center (HCMC) were searched for 20 consecutive cases of CP sampled by FNA. Clinical data and cytological findings were recorded. A spectrum of cytological findings typifies aspirates of CP. In most cases, mixed inflammation with debris and calcific material is present. Often, ductal cells are present and at most show mild atypia but generally appear organized. Often, fibrotic acinar tissue also is present while definitive islets are identified only rarely. Although these cytological findings were consistent with CP, 3 of 17 patients with follow-up were found to have pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Edward B Stelow
- Department of Pathology and Laboratory Medicine, University of Virginia, Charlottesville, Virginia 22908, USA.
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Mesa H, Stelow EB, Stanley MW, Mallery S, Lai R, Bardales RH. Diagnosis of nonprimary pancreatic neoplasms by endoscopic ultrasound-guided fine-needle aspiration. Diagn Cytopathol 2005; 31:313-8. [PMID: 15468134 DOI: 10.1002/dc.20142] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a proven modality for the diagnosis of primary pancreatic neoplasms. We describe our experience in diagnosing nonprimary pancreatic tumors by EUS-FNA. Cytology files were searched for all EUS-FNA of the pancreas for the period 2000-2002. All cases diagnosed as neoplasms were selected and those diagnosed as nonprimary pancreatic tumors were reviewed and analyzed. One hundred ninety-one of 468 cases were diagnosed as neoplasms. Eleven of these cases were diagnosed as nonprimary pancreatic tumors (2.4% of all diagnoses and 5.7% of all neoplasms). The diagnoses were supported by clinical history (n = 7), cytological findings (n = 11), cell block histology (n = 11), cell block immunohistochemistry (n = 6), and flow cytometry (n = 1). EUS-FNA is a safe and minimally invasive method for the diagnosis of nonprimary pancreatic neoplasms. Evaluation of clinical history, cytomorphology, and ancillary techniques, especially those applied to cell block material, are essential for accurate diagnoses.
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Affiliation(s)
- Hector Mesa
- Department of Pathology, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Sobel JM, Lai R, Mallery S, Levy MJ, Wiersema MJ, Greenwald BD, Gunaratnam NT. The utility of EUS-guided FNA in the diagnosis of metastatic breast cancer to the esophagus and the mediastinum. Gastrointest Endosc 2005; 61:416-20. [PMID: 15758913 DOI: 10.1016/s0016-5107(04)02759-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Breast cancer can metastasize to the esophagus and the mediastinum. EUS-guided FNA (EUS-FNA) is being used increasingly as a less invasive alternative to mediastinoscopy for procuring a tissue diagnosis of mediastinal disease and may be useful for the diagnosis of breast cancer metastatic to the esophagus and the mediastinum. METHODS Twelve women (age range 54-82 years) with a history of breast cancer presented with dysphagia or other symptoms between 1 and 15 years after initial diagnosis and treatment. CT and endoscopy with biopsies suggested a mediastinal mass or lymphadenopathy with extrinsic esophageal compression but failed to provide a tissue diagnosis. EUS-FNA was performed for diagnosis. RESULTS Cytologic evaluation of specimens obtained by EUS-FNA confirmed breast cancer metastases in 11 of 12 patients (91%). Recurrent disease was found in intramural masses and periesophageal lymph nodes. No complication resulted from any EUS-FNA procedure. CONCLUSIONS EUS-FNA is safe and effective for the diagnosis of breast cancer metastases to the esophagus and the mediastinum. EUS-FNA may be useful as a first-line method of evaluation when breast cancer metastasis to the esophagus and the mediastinum is suspected.
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Affiliation(s)
- Jason M Sobel
- Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI 48106, USA
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Stelow EB, Debol SM, Stanley MW, Mallery S, Lai R, Bardales RH. Sampling of the adrenal glands by endoscopic ultrasound-guided fine-needle aspiration. Diagn Cytopathol 2005; 33:26-30. [PMID: 15945088 DOI: 10.1002/dc.20273] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Edward B Stelow
- Department of Pathology and Laboratory Medicine, University of Virginia, Charlottesville, Virginia, USA.
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Varghese LR, Stanley MW, Wakely PE, Lucido ML, Mallery S, Bardales RH. A case report of anthracosilicotic spindle-cell pseudotumor of mediastinal lymph node: Cytologic diagnosis by endoscopic ultrasound-guided fine-needle aspiration. Diagn Cytopathol 2005; 33:268-72. [PMID: 16138379 DOI: 10.1002/dc.20356] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Pigmented spindle-cell tumors of the lymph nodes have a broad differential diagnosis, including both benign and malignant neoplasms. Here, we report a case of a pigmented spindle-cell lesion in a mediastinal lymph node mimicking a spindle-cell melanoma on fine-needle aspiration cytology. Smears showed atypical polygonal and spindle cells with bland nuclear features and abundant cytoplasmic anthracotic pigment. Immunohistochemistry was negative for melanoma markers, but showed positivity for histiocyte markers. Polarization microscopy revealed minute birefringent intracellular crystals consistent with silica. Electron microscopy was confirmatory and a diagnosis of anthracosilicotic spindle-cell pseudotumor was made. To the best of our knowledge, fine-needle aspiration cytology findings of this lesion have not been reported.
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Affiliation(s)
- Linda R Varghese
- Department of Pathology, Hennepin County Medical Center, Minneapolis, Minnesota, USA.
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Abstract
BACKGROUND AND STUDY AIMS During linear-array endoscopic ultrasonography (EUS), the main pancreatic duct can be followed continuously from the major papilla into the pancreatic body in most patients. Often, the duct can also be seen crossing a sonographic border between the ventral and dorsal pancreatic anlagen. It was hypothesized that the presence of either feature excludes pancreas divisum, whereas the absence of these features suggests complete pancreas divisum. PATIENTS AND METHODS Pancreas divisum was sought during all linear-array EUS examinations conducted between July 1999 and June 2003. Charts were reviewed retrospectively, and patients who underwent endoscopic retrograde pancreatography after, but not before, EUS were included in the study. RESULTS A total of 162 patients had EUS before ERCP. Adequate evaluation of the pancreatic duct was possible in 78 % of the patients. The prevalence of pancreas divisum was 13.6 %. In patients with adequate duct visualization, the sensitivity, specificity, and positive and negative predictive values for EUS were 95 %, 97 %, 86 %, and 99 %, respectively. The overall accuracy of EUS for identifying pancreas divisum was 97 % in this subgroup. CONCLUSION Adequate EUS evaluation of pancreas divisum was possible in most cases. Linear-array EUS is a promising diagnostic test for pancreas divisum.
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Affiliation(s)
- R Lai
- Dept. of Internal Medicine, Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota, USA
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Stelow EB, Pambuccian SE, Bardales RH, Debol SM, Mallery S, Lai R, Stanley MW. The cytology of pancreatic foamy gland adenocarcinoma. Am J Clin Pathol 2004; 121:893-7. [PMID: 15198363 DOI: 10.1309/cj9e-f3xf-xwq3-w82t] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
All cell block specimens from pancreatic fine-needle aspirations (FNAs) obtained between January 1, 2002, and June 30, 2003, were reviewed for foamy gland adenocarcinoma (FGA). All smears from these cases were reviewed for cytologic features, including those previously noted in conventional pancreatic adenocarcinoma. Fifty-two cell block specimens showed adenocarcinoma. Of these, 12 (23%) showed histologic features of FGA. This pattern predominated in 6 cases and was present focally in 6 cases. Although there were relatively low nuclear/cytoplasmic (N/C) ratios, other features of adenocarcinoma were present universally, including loss of cohesiveness, nuclear overlap or loss of "honeycomb" architecture, anisonucleosis (> 4 to 1), irregular nuclear contours, prominent nucleoli, and atypical chromatin. Background necrosis was present in 8 cases. Distinct cell borders were present in 9 cases, and foamy cytoplasm was present in all cases. Pancreatic FGA is a recently described histologic pattern of pancreatic adenocarcinoma. It is not uncommon, and we identified the pattern, at least focally, in 23% of our FNA cell blocks. Although cytologic samples show low N/C ratios, most cytologic features of conventional pancreatic adenocarcinoma are present, and the diagnosis presents little additional difficulty.
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Affiliation(s)
- Edward B Stelow
- Department of Pathology, Hennepin County Medical Center, Minneapolis, MN 55415, USA
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Stelow EB, Pambuccian SE, Bardales RH, Debol SM, Mallery S, Lai R, Stanley MW. The Cytology of Pancreatic Foamy Gland Adenocarcinoma. Am J Clin Pathol 2004. [DOI: 10.1309/cj9ef3xfxwq3w82t] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Affiliation(s)
- Edward B Stelow
- Department of Pathology and Laboratory Medicine, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA
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Stelow EB, Lai R, Bardales RH, Linzie BM, Mallery S, Stanley MW. Endoscopic ultrasound-guided fine-needle aspiration cytology of peripheral nerve-sheath tumors. Diagn Cytopathol 2004; 30:172-7. [PMID: 14986297 DOI: 10.1002/dc.10274] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endoscopic ultrasound (EUS) has allowed for the fine-needle aspiration and diagnosis of many different gastrointestinal neoplasms, including mesenchymal tumors. Although most mesenchymal tumors of the gastrointestinal tract are gastrointestinal stromal tumors (GISTs), other mesenchymal tumors, including neural tumors, do occur. Proper diagnosis and differentiation of these tumors from GISTs are important because of their different prognoses and treatment regimens. We encountered three peripheral nerve-sheath tumors of the gastrointestinal tract aspirated by EUS (two schwannomas and a granular-cell tumor). We report on the endoscopic ultrasound, cytologic, histologic, and immunohistochemical findings of these cases.
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Affiliation(s)
- Edward B Stelow
- Department of Pathology and Laboratory Medicine, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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Abstract
BACKGROUND Only a few cases have been reported of EUS-guided drainage of obstructed pancreatic or bile ducts. An initial experience with EUS-guided rendezvous drainage after unsuccessful ERCP is reported. METHODS EUS-guided transgastric or transduodenal needle puncture and guidewire placement through obstructed pancreatic (n=4) or bile (n=2) ducts was attempted in 6 patients. Efforts were made to advance the guidewire antegrade across the papilla or surgical anastomosis. If guidewire passage was successful, rendezvous ERCP with stent placement was performed immediately afterward. RESULTS EUS-guided duct access and intraductal guidewire placement was accomplished in 5 of 6 cases, with successful traversal of the obstruction, and rendezvous ERCP, with stent placement in 3 of 6 cases (two biliary, one pancreatic). The procedure was clinically effective in all successful cases (two patients with malignant obstructive jaundice, one with relapsing pancreatitis after pancreaticoduodenectomy). There was one minor complication (transient fever) but no pancreatitis or duct leak after successful or unsuccessful procedures. CONCLUSIONS EUS is a feasible technique for allowing rendezvous drainage of obstructed biliary or pancreatic ducts through native papillae or anastomoses after initially unsuccessful ERCP.
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Affiliation(s)
- Shawn Mallery
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota 55415, USA
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Stelow EB, Lai R, Bardales RH, Mallery S, Linzie BM, Crary G, Stanley MW. Endoscopic ultrasound-guided fine-needle aspiration of lymph nodes: The Hennepin County Medical Center experience. Diagn Cytopathol 2004; 30:301-6. [PMID: 15108226 DOI: 10.1002/dc.10405] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) allows for the sampling and diagnosis of lesions of the gastrointestinal system and adjacent tissues. It has also proved helpful with the sampling of lymphadenopathy both for the staging of malignancy and for the diagnosis of lymphadenopathy of other causes. We review our experience with EUS-guided FNA of lymph nodes. The cytology files were searched at Hennepin County Medical Center (HCMC) for all cases of lymph nodes sampled by EUS. Clinical history, biopsy site, diagnosis, and follow-up information (including ancillary testing) were reviewed. Between January 1, 2000 and December 5, 2002, 217 lymph nodes from 185 different patients were sampled by EUS at HCMC. Biopsy sites included 62 mediastinal, 9 paraesophageal, and 146 intra-abdominal lymph nodes. Diagnoses were as follows: metastatic non-small cell carcinoma (n = 69); benign, reactive lymph node (n = 76); granulomatous lymphadenopathy (n = 18); malignant lymphoma (n = 7); atypical-suspicious for malignancy (n = 5); metastatic small cell carcinoma (n = 2); necrotic debris (n = 4), and foreign material (n = 1); 35 cases were nondiagnostic (16.1%) in 22 of 185 patients (11.9%). Ancillary tests including flow cytometry, cytogenetics, and cultures were performed. EUS-guided FNA of mediastinal and intra-abdominal lymph nodes provides diagnostic material from which ancillary testing may be performed.
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Affiliation(s)
- Edward B Stelow
- Department of Pathology and Laboratory Medicine, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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Mallery S. EUS for the evaluation of subepithelial tumors and thickened gastric folds. Rev Gastroenterol Mex 2003; 68 Suppl 3:68-73. [PMID: 15146804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Endoscopic ultrasound examination is extremely useful in clarifying potential etiologies of previously enigmatic subepithelial lesions and thick-fold gastropathies. In cases in which the endosonographic appearance is not diagnostic, EUS may aid in obtaining a definitive tissue diagnosis via EUS-guided needle biopsy or by establishing suitability for endoscopic mucosal resection. The evaluation of subepithelial tumors and thickened folds represents an ideal starting point for the novice endosonographer as adequate interpretation is not dependent upon a firm understanding of extraintestinal anatomy.
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Affiliation(s)
- Shawn Mallery
- Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, Minnesota, USA
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Mallery S. EUS in the evaluation of Barrett's esophagus. Is it necessary? Rev Gastroenterol Mex 2003; 68 Suppl 3:44-7. [PMID: 15146793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Shawn Mallery
- Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, Minnesota, USA
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Stelow EB, Stanley MW, Bardales RH, Mallery S, Lai R, Linzie BM, Pambuccian SE. Intraductal papillary-mucinous neoplasm of the pancreas. The findings and limitations of cytologic samples obtained by endoscopic ultrasound-guided fine-needle aspiration. Am J Clin Pathol 2003; 120:398-404. [PMID: 14502804 DOI: 10.1309/cepk-542w-3885-2lp8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
All clinically and ultrasonographically suspected examples of intraductal papillary-mucinous neoplasm (IPMN) aspirated during a 17-month period were reviewed and analyzed for follow-up. We identified 18 cases of suspected IPMN in patients 52 to 87 years old. All patients had dilated pancreatic ducts, with 3 showing sonographically apparent intraductal papillary lesions; 5 had adjacent cystic or solid pancreatic masses. Cytologic preparations showed thick, glistening, viscid, abnormal mucus in all cases. Aspirates from 13 lesions (72%) were acellular or sparsely cellular, but entrapped single or loosely cohesive neoplastic cells were identified in 16 cases (89%). Goblet cell morphologic features were common (6/18 [33%]), but papillary clusters and dysplastic changes were infrequent (3 [17%] each). In keeping with current therapeutic thinking, confirmatory histologic follow-up was available for only 4 patients (22%), as most people with lesions clinically, sonographically, and cytologically consistent with IPMN are elderly and often have comorbid conditions. Although endoscopic ultrasound-guided fine-needle aspiration has important limitations, gross and cytologic findings can aid in confirming the suspected diagnosis, and integration of complete clinical, sonographic, and cytologic information may be the best way to reach the most accurate diagnosis possible.
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Affiliation(s)
- Edward B Stelow
- Departments of Pathology and Laboratory Medicine, University of Minnesota, Minneapolis, USA
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