Endoscopic ultrasound and fine needle aspiration for the diagnosis of hepatocellular carcinoma

Liver cancer is one of the most frequent solid cancers. The major risk factor associated with the development of hepatocellular carcinoma (HCC) is cirrhosis caused by hepatitis B, hepatitis C virus or chronic alcohol consumption. The overall prognosis of patients with HCC is very poor and this is mainly due to the advanced stages of cancer at presentation and also because of underlying cirrhosis. When HCC is diagnosed at early stages, prognosis is better with five-year disease free survival of around 50% with resection, or local ablative treatments such as radio-frequency ablation or percutaneous ethanol injection, and 70-80% with liver transplantation. Therefore, systematic screening of all the high-risk patients is the key to an early diagnosis of small HCC and the use of an appropriate treatment modality. The currently available tools for the screening, surveillance and diagnosis of HCC in the presence of cirrhosis remain sub-optimal. The advancements made in the past 10 years, however, have made HCC a potentially curable disease in a highly selected group of patients. This review will briefly discuss the current guidelines for surveillance and diagnosis of HCC in high-risk subjects and then review the potential role of endoscopic ultrasound and fine needle aspiration for the diagnosis of small HCC.

Widespread endoscopic mucosal resection of the esophagus with strategies for stricture prevention: a preclinical study

BACKGROUND AND STUDY AIMS

Circumferential endoscopic mucosal resection of the esophagus is complicated by stricture formation. Prophylactic measures for avoiding such strictures have not been well studied. The aim of this preclinical study was to assess strategies for prevention of esophageal strictures in a porcine model following widespread endoscopic mucosal resection (EMR).

METHODS

A total of 18 60-kg pigs were included in the study. The roles of strip width (group 1), prophylactic steroids (group 2), and prophylactic stents (group 3) in the prevention of post-mucosectomy strictures were studied. Six animals were included in each group. Esophageal mucosal resection was achieved using a novel widespread EMR technique previously described by our group. Animals in group 1 underwent partial (50% circumference) mucosal resection without prophylactic measures, while animals in the other two groups underwent circumferential mucosal resection. Animals in group 2 received 80 mg of triamcinolone injected directly into the exposed submucosal tissue (20 mg injection in four quadrants). Animals in group 3 received esophageal metal stents coated with small-intestine submucosa (SIS) that were deployed immediately post-resection. Animals were kept alive for 1 month.

RESULTS

Partial and circumferential widespread EMRs were achieved in all animals. There were no procedural complications. Repeat endoscopy at 1 month showed no strictures in group 1. Only four animals were studied in group 2, owing to the high complication rate (periesophageal abscess in all animals) with one early death. Three of the surviving animals developed mild to tight strictures. In group 3, all animals developed tight strictures; however, there was early stent migration in four animals and premature stent removal in two animals because of persistent vomiting.

CONCLUSIONS

Partial widespread EMR of the esophagus heals without stricture formation and does not require prophylactic intervention. The use of deep mural steroid injection following a circumferential resection does not appear to prevent strictures and may result in serious adverse events. Short-term use of esophageal stents is inadequate for stricture prevention. However, better results may be anticipated with longer term (at least 6 weeks) stent use.