Endoscopic Ultrasound Evaluation Research Articles

Pathology results of endoscopic ultrasound-guided tissue acquisition in retroperitoneal masses: a multicenter study.

Malignant etiologies are found in 70-80% of symptomatic retroperitoneal masses. Histology is required for diagnosis and treatment. Information about endoscopic ultrasound (EUS)-guided tissue acquisition (EUS-GTA) is scant for retroperitoneal masses. This study aimed to assess the pathology results of EUS-GTA for diagnosing retroperitoneal masses. This retrospective, multicenter study involved patients from 5 care centers. All patients with retroperitoneal masses who underwent EUS evaluation were enrolled. We recorded demographic and clinical characteristics, location and size of the mass, type of needle (FNA/FNB), and complications related to the procedure. A total of 43 patients were included. The median age was 50.5 (range: 23-83) years, and 22 (51.2%) were female. The initial symptom was abdominal pain in 23 (52.3%) cases and weight loss in 11 (25%). Initial imaging was by computed tomography in 33 (75%) patients. Diagnosis with EUS-GTA was reached in 67.5% (29/43) cases. The most frequent histological diagnosis was carcinoma, in 25.5% (11/43). A malignant etiology was found in 31 (72%): 20 were primary tumors from the retroperitoneum, and 11 were metastases. In patients with metastasis, surgery was avoided and medical treatment was indicated. No adverse events were reported. EUS and EUS-GTA can frequently provide accurate tissue diagnosis and significantly impact the subsequent management.

Endoscopic ultrasound evaluation of portal cavernoma cholangiopathy and endoscopic management of choledochal variceal rupture during ERCP.

Endoscopic ultrasound evaluation of portal cavernoma cholangiopathy and endoscopic management of choledochal variceal rupture during ERCP.

Hemostatic matrix for treating intracollection bleeding after endoscopic ultrasound-guided drainage and endoscopic necrosectomy of walled-off pancreatic necrosis in a patient with cirrhosis.

A 45-year-old man with alcoholic liver cirrhosis was referred to our institute for treatment of infected walled-off pancreatic necrosis (WOPN) 6 months after an episode of acute pancreatitis. Computed tomography confirmed cirrhotic liver disease with collateral vessels and a pancreatic fluid collection at the body-tail (9 × 3 cm). Laboratory tests showed low platelets (55 000/mm3) and international normalized ratio of 1.5. Endoscopic ultrasound (EUS) evaluation showed perigastric collateral circulation and a WOPN with necrotic material accounting for 90 % of the total volume ([Fig. 1]).

Preoperative EUS vs. PET-CT Evaluation of Response to Neoadjuvant Therapy for Esophagogastric Cancer and Its Correlation with Survival.

The objective of our study was to investigate whether Endoscopic Ultrasonography (EUS) and Positron Emission Tomography-Computed Tomography (PET-CT) restaging can predict survival in upper gastrointestinal tract adenocarcinomas and to assess their accuracy when compared to pathology. We conducted a retrospective study on all patients who underwent EUS for staging of gastric or esophago-gastric junction adenocarcinoma between 2010 and 2021. EUS and PET-CT were performed, and preoperative TNM restaging was conducted using both procedures within 21 days prior to surgery. Disease-free survival (DFS) and overall survival (OS) were evaluated. A total of 185 patients (74.7% male) were included in the study. The accuracy of EUS for distinguishing between T1-T2 and T3-T4 tumors after neoadjuvant therapy was 66.7% (95% CI: 50.3-77.8%), and for N staging, the accuracy was 70.8% (95% CI: 51.8-81.8%). Regarding PET-CT, the accuracy for N positivity was 60.4% (95% CI: 46.3-73%). Kaplan-Meier analysis revealed a significant correlation between positive lymph nodes on restaging EUS and PET-CT with DFS. Multivariate COX regression analysis identified N restaging with EUS and PET-CT, as well as the Charlson comorbidity index, as correlated factors with DFS. Positive lymph nodes on EUS and PET-CT were predictors of OS. In multivariate Cox regression analysis, the independent risk factors for OS were found to be the Charlson comorbidity index, T response by EUS, and male sex. Both EUS and PET-CT are valuable tools for determining the preoperative stage of esophago-gastric cancer. Both techniques can predict survival, with preoperative N staging and response to neoadjuvant therapy assessed by EUS being the main predictors.

Endoscopic Ultrasound View of Pneumatosis Cystoides Intestinalis

Pneumatosis cystoid intestinalis (PCI) is a rare condition, with a worldwide incidence of 0.3-1.2%. PCI is classified into primary (idiopathic) and secondary forms, with 15% and 85% of presentations, respectively. This pathology was associated with a wide variety of underlining etiologies to explain the abnormal accumulation of gas within the submucosa (69.9%), subserosa (25.5%), or both layers (4.6%). Many patients endure misdiagnosis, mistreatment, or even inadequate surgical exploration. In this case, a patient presented acute diverticulitis, after treatment, a control colonoscopy was performed that found multiple rounds and elevated lesions. To further study the subepithelial lesion (SEL), a colorectal endoscopic ultrasound (EUS) was performed with an overtube in the same procedure. For safe insertion of the curvilinear array EUS, an overtube with colonoscopy was positioned through the sigmoid as described by Cheng et al. The EUS evaluation evidenced air reverberation in the submucosal layer. The pathological analysis was consistent with PCI's diagnosis. The diagnosis of PCI is usually made by colonoscopy (51.9%), surgery (40.6%), and radiological findings (10.9%). Although the diagnosis can be made by radiological studies, a colorectal EUS and colonoscopy can be made in the same section without radiation and with high precision. As it is a rare disease, there are not enough studies to define the best approach, although colorectal EUS should be preferred for a reliable diagnosis.

S1714 Diagnosis and Management of Intraductal Papillary Neoplasm of the Bile Duct via Endoscopic Ultrasound Evaluation

Introduction: Intrampullary papillary neoplasm (IAPN) is a rare tumor seen in women in their 60s, with an incidence of 0.025 per 100,000. The 5-year survival rate is 33%. It is distinct from an ampullary adenoma, which arises from the duodenal mucosa overlying the ampulla. It is unlikely to be cured by ampullectomy. Case Description/Methods: A 63-year-old woman with prior cholecystectomy was found to have abnormal liver tests (AST 104, AST 233, alkaline phosphatase 290) and mild hyperbilirubinemia (total bilirubin 1.7). Abdominal ultrasound showed diffuse biliary dilatation without obvious stones or stricture. MRCP showed multiple filling defects in the distal common bile duct (CBD). ERCP revealed a prominent ampulla. Digital cholangioscopy done for further investigation showed an exophytic papillary tumor in the distal CBD (Figure) along with excess luminal mucous (Figure). The endoscopic and cholangioscopic findings of a papillary intraluminal mass and mucobilia was suggestive of intraductal papillary neoplasm of the bile duct (IPNB). A 69-year-old woman with a complicated biliary history was seen by her PCP for jaundice and R shoulder pain and was found to have cholelithiasis and choledocholithiasis. She underwent laparoscopic cholecystectomy after MRI showed CBD stones. An ampullary prominence of 1 cm was concerning for an invasive carcinoma. ERCP showed multifocal frond like papillary projections at the left hilum and distal CBD and copious thick mucin through the examined extrahepatic duct and hilum; concerning for IPNB with progression to cholangiocarcinoma. Both patients underwent surgical evaluation. Discussion: IAPN is a rare tumor with poor prognosis. It is unclear if it is a variant of IPNB that also includes the ampulla or if it primarily arises within the ampullary channel and spreads proximally into the bile duct and the pancreatic duct. Diagnosis is established by cholangioscopy with biopsies. Endoscopic ultrasound of the ampulla and pancreas is essential. Cholangioscopy should be undertaken for tumor mapping. Pancreaticoduodenectomy should be treatment of choice for IAPN or IAPN with adenocarcinoma without distant metastases in order to achieve tumor free margins, as seen via pathology tissue. IAPN should be suspected based on endoscopic ampullary features such as a prominent ampulla, prolapse of papillary fronds on sphincterotomy, lack of resolution of cholestasis despite duct clearance. Cholangioscopy should be undertaken establish an early diagnosis.Figure 1.: Photo 1 (top): exophytic papillary tumor in the distal common bile duct; Photo 2 (bottom): excess luminal mucous in common bile duct.

S2021 Dilemma of a Rectal Mass

Introduction: Mucosal prolapsing polyps of the colon are uncommon findings during colonoscopy that are often misdiagnosed as malignant lesions that many times lead to unnecessary endoscopic and surgical resection. At times rectal prolapse/ mucosal prolapse syndrome can present as rectal submucosal mass similar to one another. Herein we present a case of a 63-year-old male with rectal prolapse that mimicked Submucosal rectal mass. Case Description/Methods: A 63-year-old male with prior medical history of hypertension, hyperlipidemia, obesity, treated Heliobacter pylori, hemorrhoids presented to the gastroenterology clinic due to 3-month history of dizziness, abdominal pain and bright red blood per rectum. Initial vitals were stable except for tachycardia. Physical examination was unremarkable except for external rectal hemorrhoids that were appreciated. Labs were also unremarkable on admission except for Normocytic anemia. Patient was planned and taken for colonoscopy which had poor bowel preparation, revealed large rectal mass, 2 small polyps in ascending and transverse colon which were resected. Patient was planned for flexible sigmoidoscopy and lower endoscopic ultrasound evaluation of rectal mass which revealed a hypoechoic, submucosal lesion measuring 14mm by 7mm. Patient underwent endoscopic submucosal resection of the rectal mass and removal of lesion. Post op he had rectal pain along with hypotension, which led patient to be admitted for overnight observation. On follow up patient complained of recurrent dizziness and BRBPR, sigmoidoscopy was planned and revealed superficial mucosal ulceration which was treated with bipolar cautery. Pathology of the rectal mass revealed largely denuded benign appearing congested polyp with granulation tissue and cautery artifacts. Patient’s symptoms improved on subsequent follow ups (Figure). Discussion: Mucosal prolapse presents as a common underlying mechanism rectal prolapse, inflammatory polyps, solitary rectal ulcer syndrome that were previously proposed to be grouped under the umbrella term “mucosal prolapse syndrome”. Mucosal prolapse can manifest as ulcerated, flat erythematous, or polypoid lesions. At times they can even mimic adenocarcinomas, adenomas both endoscopically and histologically. Most of the time rectal prolapses polyps have been seen in patients with mucosal prolapse syndrome. Thus, it is vital to differentiate and diagnose rectal prolapse versus true rectal mass in order to exclude malignancies. This will help guide management and surveillance strategy.Figure 1.: Nodules from Colonoscopy.

S122 Endoscopic Ultrasound Evaluation of Primary Pancreatic Lymphoma Compared to Adenocarcinoma: A Case-Control Study

Introduction: Primary pancreatic lymphoma (PPL) is a rare extranodal lymphoma representing 0.5% of all pancreatic neoplasms. Prognosis and treatment strategies of PPL vastly differ from pancreatic ductal adenocarcinoma (PDAC), therefore making an accurate diagnosis is vital. Our aim is to describe the presentation, endoscopic ultrasound (EUS) features, and the role of fine needle aspiration (FNA) in the diagnosis of PPL compared with PDAC. Methods: Out of 1,946 patients who underwent EUS-FNA of solid pancreatic lesions, 11 were diagnosed with PPL. Patients who had peripancreatic lesions, lymph nodes, or bile duct masses were excluded. Age and gender- matched controls with a diagnosis of PDAC were identified in a 1:3 ratio. Presenting symptoms, demographics, and EUS characteristics were evaluated. Results: There were 11 patients with PPL and 33 age and gender-matched controls with PDAC. The median age was 65 years (60-76) and 63.6% were males. There was no difference between two groups in smoking, alcohol consumption, or history of a second malignancy. PPL patients were more likely to present with abdominal pain (81.8% vs 26.4%, p=0.01). Pancreatic head location was most common in both groups. Both PPL and PDAC tended to be hypoechoic and poorly defined on EUS, while PPL were more commonly described as heterogeneous (36.4% vs 6.1%, p=0.01). PPL were significantly larger on EUS (45.8 mm vs 31 mm, p< 0.01) and less likely associated with pancreatic duct dilation. A higher number of FNA passes was required for the diagnosis of PPL compared to PDAC (5 vs 3, p< 0.01). Conclusion: While PPL remains rare, making an accurate distinction with PDAC is critical as treatment and prognosis radically differ. On presentation, PPL is more likely to cause abdominal pain. Certain EUS features were found to be beneficial in differentiating PPL from PDAC in our study, as PPL tend to be larger, more likely heterogeneous, and are less likely associated with pancreatic duct dilation compared to PDAC. Tissue diagnosis is more challenging in PPL as reflected by a significantly higher number of passes obtained on EUS- FNA. Table 1. - Adenocarcinoma (n=33) Primary Pancreatic Lymphoma (n=11) P value Ethnicity, white n (%) 21 (63.6) 8 (72.7) 0.58 Smoking history ( >15 pack-years), n (%) 9 (27.3) 5 (45.5) 0.26 Alcohol history ( >1 drink/day), n (%) 7 (21.2) 2 (18.2) 0.83 History of cancer diagnosis, n (%) 10 (30.3) 3 (27.3) 0.85 Multiple pancreatic lesions, n (%) 1 (3) 0 0.56 Presenting symptoms Abdominal pain, n (%) 12 (36.4) 9 (81.8) 0.01 Jaundice, n (%) 11 (33.3) 6 (54.5) 0.21 Weight loss, n (%) 8 (24.2) 3 (27.3) 0.84 Incidental, n (%) 5 (15.2) 1 (9.1) 0.61 Located in the head of the pancreas, n (%) 23 (69.7) 9 (81.8) 0.43 Regional lymphadenopathy on imaging, n (%) 20 (60.6) 10 (90.9) 0.06 EUS features Hypoechoic, n (%) 31 (93.9) 9 (81.8) 0.23 Heterogeneous, n (%) 2 (6.1) 4 (36.4) 0.01 Poorly defined, n (%) 23 (69.7) 8 (72.7) 0.85 Common bile duct dilation, n (%) 14 (42.4) 5 (45.5) 0.86 Pancreatic duct dilation, n (%) 23 (69.7) 3 (27.3) 0.01 Number of passes on FNA, mean (IQR) 3 (1-3) 5 (2-7) 0.008 Largest diameter on EUS (mm), median (IQR) 31 (25-38.8) 45.8 (35.5-56) 0.001 Treatment Chemotherapy, n (%) 29 (87.9) 10 (90.9) 0.78 Radiation therapy, n (%) 17 (51.5) 2 (18.2) 0.053 Surgery, n (%) 7 (21.2) 1 (9.1) 0.37

Endoscopic ultrasound elastography for malignant pancreatic masses and associated lymph nodes: Critical evaluation of strain ratio cutoff value.

BACKGROUNDEndoscopic ultrasound (EUS) can detect small lesions throughout the digestive tract; however, it remains challenging to accurately identify malignancies with this approach. EUS elastography measures tissue hardness, by which malignant and nonmalignant pancreatic masses (PMs) and lymph nodes (LNs) can be differentiated. However, there is currently little information regarding the strain ratio (SR) cutoff in Hispanic populations.AIMTo determine the diagnostic accuracy of EUS elastography for PMs and LNs with an SR cutoff value in Hispanics.METHODSA retrospective study of patients who underwent EUS elastography for PMs between December 2013 and December 2014. A qualitative (analysis of color maps) and quantitative (SR) analysis of PMs and their associated LNs was performed. The accuracy of EUS elastography in identifying malignant PMs and LNs and cutoff value for SR were analyzed. A PM and/or its associated LNs were considered malignant based on histopathological findings from fine-needle aspiration biopsy samples.RESULTSA sample of 121 patients was included, 45.4% of whom were female. 69 (57.0%) PMs were histologically malignant, with a median SR of 50.4 vs 33.0 for malignant vs nonmalignant masses (P < 0.001). EUS evaluation identified associated LNs in 43/121 patients (35.5%), in whom 22/43 (51.2%) patients had histologically confirmed malignant diagnosis, with a median SR of 30 vs 40 for malignant vs nonmalignant LNs (P = 0.7182). In detecting malignancy in PMs, an SR cutoff value of > 21.5 yielded a sensitivity of 94.2%, while a cutoff value of > 121 yielded a specificity of 96.2.2%. There were significant differences in the Giovannini scores, a previously established elastic score system, between the patients grouped by their final histology results (P < 0.001). For LNs, SR cutoff values of > 14.0 and > 155 yielded a sensitivity of 90.9% and a specificity of 95.2%, respectively, in detecting malignancy.CONCLUSIONEUS elastography is a helpful technique for the diagnosis of solid PMs and their associated LNs. The proposed SR cutoff values have a high sensitivity and specificity for the detection of malignancy.

Cap-Assisted Endoscopic Mucosal Resection for Rectal Neuroendocrine Tumors: An Effective Option

Introduction: The incidence of rectal neuroendocrine tumors (r-NETs) is increasing, and most small r-NETs can be treated endoscopically. The optimal endoscopic approach is still debatable. Conventional endoscopic mucosal resection (EMR) leads to frequent incomplete resection. Endoscopic submucosal dissection (ESD) allows higher complete resection rates but is also associated with higher complication rates. According to some studies, cap-assisted EMR (EMR-C) is an effective and safe alternative for endoscopic resection of r-NETs. Aims: This study aimed to evaluate the efficacy and safety of EMR-C for r-NETs ≤10 mm without muscularis propria invasion or lymphovascular infiltration. Methods: Single-center prospective study including consecutive patients with r-NETs ≤10 mm without muscularis propria invasion or lymphovascular invasion confirmed by endoscopic ultrasound (EUS), submitted to EMR-C between January 2017 and September 2021. Demographic, endoscopic, histopathologic, and follow-up data were retrieved from medical records. Results: A total of 13 patients (male: 54%; n = 7) with a median age of 64 (interquartile range: 54–76) years were included. Most lesions were located at the lower rectum (69.2%, n = 9), and median lesion size was 6 (interquartile range: 4.5–7.5) mm. On EUS evaluation, 69.2% (n = 9) of tumors were limited to muscularis mucosa. EUS accuracy for the depth of invasion was 84.6%. We found a strong correlation between size measurements by histology and EUS (r = 0.83, p < 0.01). Overall, 15.4% (n = 2) were recurrent r-NETs and had been pretreated by conventional EMR. Resection was histologically complete in 92% (n = 12) of cases. Histologic analysis revealed grade 1 tumor in 76.9% (n = 10) of cases. Ki-67 index was inferior to 3% in 84.6% (n = 11) of cases. The median procedure time was 5 (interquartile range: 4–8) min. Only 1 case of intraprocedural bleeding was reported and was successfully controlled endoscopically. Follow-up was available in 92% (n = 12) of cases with a median follow-up of 6 (interquartile range: 12–24) months with no evidence of residual or recurrent lesion on endoscopic or EUS evaluation. Conclusion:EMR-C is fast, safe, and effective for resection of small r-NETs without high-risk features. EUS accurately assesses risk factors. Prospective comparative trials are needed to define the best endoscopic approach.

Clinical application of endoscopic ultrasonography in evaluation of colorectal and peri-colorectal lesions

Clinical application of endoscopic ultrasonography in evaluation of colorectal and peri-colorectal lesions

Exocrine Pancreatic Insufficiency is Undiagnosed in Some Patients with Diarrhea-Predominant Irritable Bowel Syndrome Using the Rome IV Criteria.

Irritable bowel syndrome (IBS) is one of the most frequent disorders in clinical practice, with a mean 7.6-10.8% worldwide prevalence. A study showed that 6.1% of patients with diarrhea-predominant IBS (IBS-D) had severe exocrine pancreatic insufficiency (EPI). We aimed to identify the prevalence of EPI based on fecal elastase stool testing (Fel-1) in IBS-D and the clinical characteristics that may predict the diagnosis of EPI. Patients aged > 18years presenting to tertiary hospital outpatient clinics with IBS-D completed validated questionnaires and gave a stool sample where Fel-1 concentration was measured. Patients with Fel-1 < 100µg/g represented EPI and > 100 to < 200µg/g underwent testing for pancreatic pathology with laboratory and endoscopic ultrasound (EUS) evaluation. One hundred forty patients (mean age 60years, females 75.7%) were studied. EPI was found in 5% (95% CI 2.2-10.4), and pancreatic steatosis was the main EUS finding (71%). Dyspepsia was an independent factor associated with EPI (OR 34.7; 95% CI 4.95-366.37, p = 0.0007). After pancreatic enzyme replacement therapy (PERT), patients showed a significant improvement in the Bristol stool scale (p < 0.0001), bowel movements per day (p < 0.005), distension score (0.0009), pain score (0.0277) and IBS severity (0.0034). EPI is present in 5% of patients who fulfill Rome IV criteria for D-IBS, and dyspepsia was an independent symptom strongly associated with EPI. Pancreatic steatosis was the main endoscopic ultrasound finding. After PERT therapy, patients had significantly improved stool frequency, stool consistency, abdominal pain, distension and IBS severity score.

Associated risk factor analysis and the prognostic impact of positive resection margins after endoscopic resection in early esophageal squamous cell carcinoma.

Endoscopic resection for early esophageal cancer has a risk of residual margins. The risk these residual margins pose have not been fully evaluated. The present study aimed to investigate the associated risk factors and prognosis of residual margins following the endoscopic resection of early esophageal squamous cell carcinoma. In total, 369 patients (381 lesions) with early esophageal squamous cell carcinoma treated in the Fourth Hospital of Hebei Medical University (Shijiazhuang, China) with endoscopic resection were retrospectively analyzed. Sex, age, location, tumor diameter, depth of tumor invasion, endoscopic treatment, endoscopic ultrasonography (EUS) before resection, work experience of endoscopists and the degree of tumor differentiation were all evaluated as potential risk factors. In addition, the prognosis of patients with positive margins were analyzed. A total of 73 patients (73/381, 19.2%) had positive margins after endoscopic resection. Amongst the 65 patients who were successfully followed up, five patients succumbed to cardiovascular and cerebrovascular diseases, one patient received radiotherapy, two patients received radiotherapy and chemotherapy whilst one patient received chemotherapy. By contrast, 12 patients received surgery and 20 patients received additional endoscopic mucosal resection or endoscopic submucosal dissection. The other 29 patients were followed up regularly and no recurrence could be found. Univariate analysis revealed that tumor diameter, endoscopic treatment, depth of invasion, EUS before resection, degree of tumor differentiation and direction of invasion were all associated with the positive margin. Multivariate logistic regression analysis then found that EUS before resection, degree of tumor differentiation and depth of tumor invasion are independent risk factors for positive margins after endoscopic resection. These results suggest that poorly differentiated lesions and deeper invasion depth can increase the risk of positive margin after endoscopic resection. As a result, EUS evaluation before resection may reduce the risk of invasion depth. In addition, for poorly differentiated lesions, more aggressive treatment regimens may be recommended for preventing recurrence.

Value of pancreatic cyst fluid SPINK1 and glucose in differentiating potentially malignant cysts from those of benign nature: A prospective cohort study.

Diagnosis of malignant pancreatic cystic lesions (PCLs) is challenging as there is no investigation that offers both high diagnostic sensitivity and specificity for a definite diagnosis. Accurate diagnosis of cyst type is vital in order to not miss opportunities for early treatment of potentially malignant lesions and to avoid unnecessary surgeries. Serine protease inhibitor Kazal type I (SPINK1) and glucose are promising cyst fluid markers for differentiation of mucinous from non-mucinous cysts. We aim to validate the value of SPINK1 and glucose in detecting potentially malignant PCLs. A prospective study was conducted on 80 patients presenting with PCLs. Endoscopic ultrasound (EUS) evaluation of detailed cyst morphology and EUS with fine needle aspiration (FNA) were done. Fluid analysis for carcinoembryonic antigen (CEA), glucose and SPINK1 and cytopathology were done. We compared these data with the final diagnosis based on cytopathological and postoperative histopathological examination. Cyst fluid SPINK1 was significantly higher in malignant or potentially malignant cysts compared to benign cysts (0.91 vs 0.47 ng/ml; P = 0.001). Also, glucose was significantly lower in malignant or potentially malignant cysts compared to benign cysts (21.5 vs 68.5 mg/dl; P = 0.0001). Glucose and SPINK1 had the best sensitivity and specificity for differentiating mucinous from non-mucinous cysts with 84.78% and 73.53% (AUC 0.76; 95% CI [0.65-0.88]; cutoff value = 42 mg/dl), and 70.59% and 65.22% (AUC 0.72; 95% CI [0.64-0.86]; cutoff value = 0.58 ug/L) respectively. CEA level >192 ng/ml, high SPINK1 level and lymph node enlargement were the independent predictors of malignant cysts. Cyst fluid SPINK1 and glucose are promising diagnostic markers for the diagnosis of potentially malignant PCLs.

S3464 Rare GI Malignancy: Case of Ampullary Carcinoma

Introduction: Ampullary Pancreatic Cancer is a rare malignant tumor that only counts for 0.2% of GI tract carcinomas. It often presents with non-specific symptoms requiring high clinical suspicion. Here we describe a case of ampullary carcinoma presenting as a 3 week history of abdominal pain. Case Description/Methods: This is a 64-year-old male with a medical history of HTN and Dyslipidemia, who presented with 3-week history of dull aching intermittent epigastric abdominal pain. Exam was significant for scleral icterus and positive Murphy’s sign. Labs were significant for elevated liver enzymes, alkaline phosphatase and total bilirubin. Abdominal US showed dilated CBD measuring 11 mm and biliary sludge in the gall bladder. MRCP confirmed CBD dilatation; however, it was negative for choledocholithiasis. Subsequently, the patient underwent EUS and ERCP that showed an ampullary mass (Figure 1). Pathology findings were consistent with tubulovillous adenoma with focal adenocarcinoma. The patient underwent an exploratory laporatomy and pancreaticoduodenectomy. Biopsy revealed final pathology consistent with invasive adenocarcinoma involving the ampulla and periampullary duodenum extending to the pancreas of > 0.5 cm (mixed intestinal and pancreatobiliary type) with uninvolved margins. The postoperative course was uneventful, and he was discharged with the intention to administer adjuvant chemotherapy in an outpatient setting. Discussion: Ampullary cancer accounts for about 6% of peri-ampullary malignancies. It usually presents earlier than other peri-ampullary malignancies due to its anatomic location that may cause early biliary obstruction with jaundice. Other clinical signs are abdominal pain, weight loss and lethargy, however not specific. Laboratory and radiological workup might reveal elevation in liver enzymes and biliary dilatation, which often prompt the need for endoscopic ultrasound evaluation. In our case, the pathology report revealed stage 2 ampullary adenocarcinoma with mixed intestinal and pancreatobiliary features without metastasis or lymph node involvement. Pancreaticoduodenectomy is the first-line therapy for such patients. Prognosis and utility of adjuvant chemotherapy depend on tumor subtype with intestinal variant appear to have better outcomes. Additional research is needed to evaluate the best regimen of adjuvant chemotherapy and its significance in affecting survival for such patients following surgery.Figure 1.: A and B: two views of a mass surrounding major papilla (arrow).

Use of artificial intelligence in endoscopic ultrasound evaluation of pancreatic pathologies

Use of artificial intelligence in endoscopic ultrasound evaluation of pancreatic pathologies

Use of artificial intelligence in endoscopic ultrasound evaluation of pancreatic pathologies

Use of artificial intelligence in endoscopic ultrasound evaluation of pancreatic pathologies

The New American Joint Committee on Cancer T staging system for stomach: increased complexity without clear improvement in predictive accuracy for endoscopic ultrasound

BackgroundThe efficacy of endoscopic ultrasound (EUS) for determining the T category of gastric cancer is variable. The aim of this study was to evaluate the superiority of EUS by using the 6th edition American Joint Committee on Cancer (AJCC) staging system for stomach cancer compared to the new 7th/8th edition.MethodsA retrospective analysis of clinical and EUS imaging features of 348 gastric carcinoma patients who underwent radical resection were retrospectively analyzed. Differences between the 6th and 7th/8th edition T staging systems for preoperative EUS evaluation were compared.ResultsThe accuracy of EUS T staging was 72.4% for the 7th/8th edition and 78.4% for the 6th edition. T3 stage accuracy was significantly worse when the T3 group status was changed. The tumor location, echoendoscope type, and histological type were associated with inaccuracy. We further analyzed the EUS image features for each tumor T stage and found that an indistinctly visible muscularis propria (MP) or with obvious thickening was considered an indicator of lesions involved in the MP with a sensitivity of 81.3%; an MP completely disappeared and accompanied with a serosal layer intact may be a marker that the lesion invaded to the subserosa. We also found that irregularities in the outer edge of the gastric wall were markers of gastric serosal layer penetration with a positive predictive value of 92.2%.ConclusionsThe increased complexity of the 7th/8th edition T staging system is accompanied by worsening of the predictive accuracy for EUS as compared to the 6th edition. Furthermore, the tumor location, echoendoscope type, histological type, and EUS image features for each tumor T stage should warrant attention.

ID: 3526872 DIAGNOSTIC YIELD OF ENDOSONOGRAPHIC CHARACTERIZATION OF ASYMPTOMATIC BILIARY DILATION: A SYSTEMATIC REVIEW & METANALYSIS

Common bile duct (CBD) dilation is a frequent indication for referral for endoscopic ultrasound (EUS). Among asymptomatic individuals, biliary dilation may not be clinically significant, however EUS is often relied upon for exclusion of benign and malignant pathology that might require further intervention. The yield of EUS evaluation for this indication is not well characterized, and has significant implications for health resource utilization, since asymptomatic biliary dilation is prevalent. Through this systematic review, we sought to appraise the yield of EUS evaluation of asymptomatic patients with radiologic evidence of CBD dilation without identifiable etiology.

Guidelines on Pancreatic Cystic Neoplasms: Major Inconsistencies With Available Evidence and Clinical Practice— Results From an International Survey

Guidelines on Pancreatic Cystic Neoplasms: Major Inconsistencies With Available Evidence and Clinical Practice— Results From an International Survey