Tissue acquisition for comprehensive genomic profiling of gallbladder cancer using a forward-viewing echoendoscope in a patient who underwent Roux-en-Y reconstruction

A 50-year-old man with a history of total gastrectomy, distal pancreatectomy, splenectomy, and Roux-en-Y reconstruction was admitted to our hospital with a gallbladder tumor that had infiltrated the liver and abdominal wall. Because malignant cells were not collected during the percutaneous biopsy, we planned to perform an endoscopic ultrasound-guided fine-needle biopsy with a 22-G Franseen needle using a forward-viewing echoendoscope. Using intermittent manual compression, the forward-viewing echoendoscope reached the duodenum under fluoroscopic guidance. Endoscopic ultrasound-guided fine-needle biopsy was performed using a 22-G needle and 20-mL syringe and yielded a sufficient specimen with a single puncture. Malignant cells were promptly identified during on-site evaluation. The composition of the specimen (> 20% cancer cells and tissue area exceeding 25 mm2) enabled comprehensive genomic profiling. Subsequently, high-tumor mutational burden was diagnosed based on comprehensive genomic profiling, and pembrolizumab was initiated as a second-line therapy. Even in cases involving Roux-en-Y reconstruction, endoscopic ultrasound-guided fine-needle biopsy using a forward-viewing echoendoscope can result in collection of a high-quality specimen.

Utility of Forward-View Echoendoscopy for Transcolonic Fine-Needle Aspiration of Extracolonic Lesions: An Institutional Experience

Background/Aims

Non-invasive tissue sampling from the lower intra-abdominal and pelvic cavity is challenging. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in this situation is not well-established because of the limitations of the curved linear-array echoendoscopy-EUS for colonic insertion. The aim of this study was to report our institutional experience of transcolonic EUS-FNA using forward-viewing therapeutic linear echoendoscopy-EUS (FV-EUS) in combination with fluoroscopic guidance.

Methods

Medical records of 13 patients who underwent transcolonic EUS-FNA of extracolonic lesions using FV-EUS in combination with fluoroscopic guidance at Aichi Cancer Center Hospital, Nagoya, Japan from June 2015 to November 2018 were retrospectively reviewed.

Results

Using FV-EUS under fluoroscopic guidance, the FNA procedure could be performed successfully in all patients (100% technical success), with a median procedure time of 31 minutes. The sensitivity, specificity, and accuracy of EUS-FNA for detecting malignant lesions in this study were 91%, 100%, and 92%, respectively. There were no adverse events associated with the EUS-FNA procedure.

Conclusions

FV-EUS in combination with fluoroscopic guidance is an easy, safe, and effective technique for FNA of extracolonic lesions in the lower abdomen.

Forward-viewing linear echoendoscope: a new option in the endoscopic ultrasound armamentarium (with video)

The forward-viewing linear echoendoscope (FV-EUS) has been developed with the aim of overcoming limitations of standard curved linear-array echoendoscopes (CLA-EUS) and to further expand interventional applications of EUS. The main characteristic of the FV-EUS is a shifting in the orientation of both endoscopic and ultrasound views from oblique to forward, with the exit of the working channel at the tip of the instrument. This allows exit of the devices parallel to the longitudinal axis of the endoscope, thus resulting in a more direct and stable access to the lesion while increasing the precision and force applied to the target. Accumulating evidence has shown that the FV-EUS can be used instead of the standard CLA-EUS scope for routine fine needle aspiration, with extremely good performance for subepithelial lesions and for difficult to reach locations. Several areas of use of this echoendoscope are yet to be better defined, such as its potential for therapeutic and interventional procedures, as well as for natural orifice transluminal endoscopic surgery. The current report provides an updated overview of the available evidence for both diagnostic and interventional uses of the FV-EUS.