Endoscopic Ultrasound Features Research Articles

Use of Artificial Intelligence in the Prediction of Malignant Potential of Gastric Gastrointestinal Stromal Tumors.

This study aimed to investigate whether AI via a deep learning algorithm using endoscopic ultrasonography (EUS) images could predict the malignant potential of gastric gastrointestinal stromal tumors (GISTs). A series of patients who underwent EUS before surgical resection for gastric GISTs were included. A total of 685 images of GISTs from 55 retrospectively included patients were used as the training data set for the AI system. Convolutional neural networks were constructed to build a deep learning model. After applying the synthetic minority oversampling technique, 70% of the generated images were used for AI training and 30% were used to test AI diagnoses. Next, validation was performed using 153 EUS images of 15 patients with GISTs. In addition, conventional EUS features of 55 patients in the training cohort were evaluated to predict the malignant potential of GISTs and mitotic index. The overall sensitivity, specificity, and accuracy of the AI system for predicting malignancy risk were 83%, 94%, and 82% in the training dataset, and 75%, 73%, and 66% in the validation cohort, respectively. When patients were divided into low-risk and high-risk groups, sensitivity, specificity, and accuracy increased to 99% in the training dataset and 99.7%, 99.7%, and 99.6%, respectively, in the validation cohort. No conventional EUS features were found to be associated with either malignant potential or mitotic index (P > 0.05). AI via a deep learning algorithm using EUS images could predict the malignant potential of gastric GISTs with high accuracy.

CLINICAL, BIOLOGICAL AND ENDOSCOPIC ULTRASOUND CHARACTERISTICS OF PANCREATIC CANCER IN CHO RAY HOSPITAL

Background: Pancreatic cancer is a common disease of digestive cancers. The tumor progresses rapidly and malignantly, showed a low 5-year survival rate. However, when diagnosed and treated early, the 5-year survival rate of pancreatic cancer improves significantly. Endoscopic ultrasound (EUS) has the advantage that probe can optimal access to the pancreas and surrounding organs, therefore, diagnose pancreatic tumors can be made even when the tumor is small (< 2 cm). Furthermore, Endoscopic Ultrasound- Guided Fine needle aspiration (EUS-FNA) can determine the exact histology of the tumor. Objectives: 1. Investigate some clinical, biological and endoscopic ultrasound characteristics in patients with pancreatic cancer. 2. Evaluate the relationship between endoscopic ultrasound images with clinical and biological characteristics and compare the results between endoscopic ultrasound with computer tomography. Materials and methods: Descriptive cross-sectional studies in 58 patients with pancreatic cancer had endoscopic ultrasound. Results: In 58 patients with pancreatic cancer, we recorded that patients with a history of smoking accounted for 32.8%, and drinking alcohol 31%. Abdominal pain was 89.7%, 44.8% of patients show anorexia, 37.9% have weight loss. 69% of patients had CA 19-9 > 37 UI/ml. EUS found a patient with pancreatic tumor < 2 cm, but CT scan could not detect. Tumors in pancreatic head accounted for 60.3%; in the body 24.1%, 96.6% of pancreatic cancer have a hypoechoic structure, heterogeneous ultrasound. There was a significant relation between pancreatic head tumor and other part with jaundice (p = 0.013). Compatibility in diagnosis of vascular invasion between EUS and CT scan was average (K = 0.483). Conclusion: Smoking and alcohol consumption accounted for the highest proportion, abdominal pain was the most common clinical symptom. Endoscopic ultrasound can diagnose small pancreatic tumors that CT scan can not detect. Key words: Pancreatic cancer, endoscopic ultrasound, clinical characteristics, bio-marker

Rectal mucosal prolapse with an emphasis on endoscopic ultrasound appearance

AimThe diagnosis of mucosal prolapse syndrome (MPS) continues to be a challenge. Endoscopic ultrasound (EUS) is of clinical value in anorectal diseases. This study seeks to investigate the use of EUS in the diagnosis of MPS. MethodsA total of 39 patients diagnosed with MPS between June 2015 to December 2019 were included in this study. Their clinical histories, endoscopic images, EUS images, and pathological data were retrospectively collected, and the EUS images were reviewed to summarize the characteristics of MPS. ResultsIn total, 39 MPS patients were enrolled. The main presenting symptoms were bleeding (61.5%) and constipation (53.8%). Gross appearance of the rectal lesions was mainly classified into three types: 51.3% of the lesions were polypoidal/nodular, 33.3% were ulcerative and 15.4% were flat with erythematous mucosa only. A total of 10 patients underwent EUS operation. With regard to the EUS appearance of MPS, four patients with polypoidal/nodular lesions showed thickening of the mucosa on EUS. The diffuse thickening of the mucosa-submucosa layer and disappearance of the architectural structure was observed in four patients with ulcerative lesions. Finally, the thickening of the muscularis propria was observed in two flat lesions. The serosal layers were intact in all the MPS patients. Neither blood flow signals nor regional lymph nodes were observed on EUS. ConclusionThe EUS characteristics for MPS corresponding to different gross appearance can be classified into three types. These findings suggest that EUS is useful in the diagnosis of MPS.

A Pancreatic Cystic Neoplasms Drama. Accuracy of Diagnostic Presumption and Surgical Indication on a Ten-year Experience

Purpose: Pancreatic cystic neoplasms (PCN) represent a challenging diagnosis despite imaging improvement and guidelines updates. Endoscopic Ultra Sound (EUS) is able to add valuable diagnostic information such as fine needle aspiration (FNA) but the accuracy of this procedure alone is extremely variable and not surely superior to classic MRI and CT-scan. The main aim of this study is to assess the importance of EUS and main cystic features in PCN preoperative work-up in terms of diagnostic accuracy, analyzing at the same those patients with any kind of PCN who could have performed, in retrospect, a close surveillance instead of surgical resection. Method: Patients with a preoperative or pathological diagnosis of PCN were retrospectively reviewed from a prospective database. Data included cases operated from 2010 to 2019 directly or under the supervision of an experienced pancreatic surgery team in three different institutions with a radiologic-oriented diagnostic approach or mixed (radiologic and endoscopic). Preoperative diagnosis was matched with final histology to confirm the diagnostic accuracy of the PCN. Patients with a benign histological who did not show absolute indication on preoperative evaluation, as defined by current guidelines, were categorized as “unrequested surgery”. Results: 587 patients were retrospectively analyzed and in 109/587 cases (18.6%) final histology did not confirm preoperative diagnosis. When performing EUS a significantly lower incidence of diagnostic fallacy was observed (p= 0.024) but risk of overtreatment was similar regardless instrumental diagnostic path (p= 0.356). MPD dilatation and cytologic sampling were the only variables independently related to a correct diagnosis (p <0.001 and p= 0.036). Based on final histology, pancreatic resection could be avoided in 145/461 patients (31.5%). The rate of “unrequested surgery” changed significantly over the years (p= 0.033) and was related with age (p <0.001) , an elevated Ca 19-9 (p= 0.012), cyst dimension (p= 0.023) and type of operation (p <0.001). Conclusions: EUS is an effective procedure in the diagnostic management of PCN, influencing in this series the diagnostic accuracy. Nevertheless, it does not seem to be able to reduce surgical overtreatment. Risk of “unrequested surgery” reduced over the years and it seems correlated with the type of pancreatic resection, being higher for distal pancreatectomies.Tabled 1RadiologicDiagnosis n/tot (%)Radiologic + Endoscopic diagnosis n/tot (%)pDiagnostic accuracyAll cohort148/194 (76.3)330/393 (84)0.024IPMN83/90 (92.2)265/274 (96.7)0.071SCA18/32 (56.3)18/30 (60)0.765MCN29/39 (74.4)25/39 (64.1)0.326Other18/33 (54.5)22/50 (44)0.377Unrequested SurgeryAll cohort46/133 (34.6)99/328 (30.2)0.356IPMN26/90 (28.9)73/274 (26.6)0.678SCA13/32 (40.6)5/30 (16.7)0.038Other7/11 (63.6)21/24 (87.5)0.101 Open table in a new tab Rate of diagnostic accuracy and “unrequested surgery”

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study.

BACKGROUNDEndoscopic drainage of walled-off necrosis (WON) is still a challenge due to stent-associated problems. We explored endoscopic gastric fenestration (EGF) as an innovative alternative intervention.AIMTo assess the feasibility, efficacy and safety of EGF for WON.METHODSBetween March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound (EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy.RESULTSEGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min (EUS assessment, 32.3 min; initial fenestration, 28.8 min; expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent (LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients.CONCLUSIONEGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

Endosonographic features in patients with non-alcoholic early chronic pancreatitis improved with treatment at one year follow up.

Since the prevention of early chronic pancreatitis (ECP) into chronic pancreatitis might be critical for the reduction of pancreatic cancer, we tried to clarify the pathophysiology of ECP patients, focusing on ECP patients without alcoholic chronic pancreatitis. 27 ECP patients without alcoholic chronic pancreatitis and 33 patients with functional dyspepsia with pancreatic enzyme abnormalities (FD-P) were enrolled in this study. Diagnosis of ECP was made when imaging findings showed the presence of more than 2 out of 7 endoscopic ultrasound features. Duodenal degranulated eosinophils and glucagon-like peptide 1 producing cells were estimated by immunostaining. There were no significant differences in characteristics and psychogenic factors between ECP and FD-P patients. Interestingly, endoscopic ultrasound score in ECP patients significantly improved, albeit clinical symptoms in ECP patients showed no improvement at one year follow up. The extent of migration of duodenal degranulated eosinophils in FD-P patients was significantly higher compared to that in ECP patients. The levels of elastase-1 and trypsin in ECP patients with improved endoscopic ultrasound features were significantly reduced by the treatment. Further studies will be needed to clarify whether clinical symptoms and endoscopic ultrasound features in ECP patients without alcoholic chronic pancreatitis were improved in longer follow up study.

EUS in the diagnosis of pathologically undiagnosed esophageal tuberculosis

BackgroundEsophageal tuberculosis (ET) is relatively rare, and the diagnosis is challenging. The aim of this study was to evaluate the clinical features of ET and highlight the role of endoscopic ultrasonography (EUS) in the diagnosis of pathologically undiagnosed ET.MethodsWe retrospectively analysed the clinical features, radiological performances, conventional endoscopic appearances, EUS features, treatment and outcomes of pathologically undiagnosed ET between January 2011 and December 2018. All 9 patients failed to be diagnosed by at least two repeated biopsies (such as routine biopsy, multipoint or deep biopsy, and even or EUS-guided fine-needle aspiration (EUS-FNA)).ResultsNine patients (66.7% female) with a mean age of 45 years (range 29–59) complained of retrosternal pain or discomfort, or (and) dysphagia. Esophagoscopy demonstrated protruding lesions in the mucosa with central ulcers or erosion in five patients, submucosal bulges with smooth surfaces in one patient, submucosal bulges with diverticula in one patient, ulcers with suspicious fistula formation in one patient, and multiple ulcers in one patient. None of the patients received confirmed histopathological or bacteriological diagnoses by repeated biopsies. However, they were first suspected to have ET based on EUS examination. Because EUS found some characteristic ultrasonographic changes, which were very helpful for the diagnosis of ET when combined with clinical manifestations, the patients subsequently received diagnostic antituberculosis therapy. Finally, the patients recovered or improved with follow-up times ranging from 3 to 10 months.ConclusionsEUS could help in the diagnosis of ET on basis of EUS features like poorly defined esophageal wall structure, enlarged paraesophageal or mediastinal lymph nodes, hypoechoic lesions of esophageal wall that are linked to the enlarged paraesophageal lymph nodes. However all attempts should be made to obtain histological or microbiological diagnosis.

An Esophageal Leiomyoma Mistaken as an Esophageal Duplication Cyst

Esophageal leiomyoma is a benign tumor that accounts for two-thirds of esophageal benign tumors. In general, patients with esophageal leiomyoma are asymptomatic; however, as the tumor grows in size, symptoms such as dysphagia, chest discomfort, obstruction, or bleeding can appear. A 65-year-old man visited our clinic to receive treatment for a subepithelial tumor in the lower esophagus, which was incidentally found during endoscopy for work-up of chest discomfort and indigestion. On endoscopic ultrasonography (EUS), the tumor was 2.6×1.9 cm in size, with a cystic lesion located in the submucosal and proper muscle layers and thick cystic wall. Therefore, it was highly likely to be a duplication cyst. As the patient had symptoms such as chest discomfort, surgical resection was performed. The tumor was finally diagnosed as a leiomyoma with cystic degeneration. Leiomyoma with cystic change that has similar EUS features to duplication cyst is rare. Thus, we report the case with a literature review.

Peroral endoscopic tumor resection (POET) with preserved mucosa technique for management of upper gastrointestinal tract subepithelial tumors.

Third space endoscopy technique facilitates therapeutic endoscopy in subepithelial space. This study aimed to investigate peroral endoscopic tumor resection (POET) with preserved mucosa technique for upper gastrointestinal tract subepithelial tumors (UGI-SETs) removal. Between February 2011 and December 2019, consecutive patients with SETs of esophagus and stomach who underwent POET for enlarging size during follow-up, malignant endoscopic ultrasound features or by patient's request were enrolled. Demographic, endoscopic and pathological data were analyzed retrospectively. Totally 18 esophageal (mean ± SD age, 55.23 ± 4.15year-old, 38.89% female) and 30 gastric (52.65 ± 2.43year-old, 53.33% female) SETs in 47 patients (one with both esophageal and gastric lesions) were resected. The mean (± SD) endoscopic/pathological tumor size, procedure time, en-bloc/complete resection rate, and hospital stays of esophageal and gastric SET patients were 12.36 (± 7.89)/11.86 (± 5.67) and 12.57 (± 6.25)/12.35 (± 5.73) mm, 14.86 (± 6.15) and 38.21 (± 15.29) minutes, 88.89%/94.44% and 86.77%/93.30%, and 4.14 (± 0.21) and 4.17 (± 0.20) days, respectively. The overall complication rate was 18.75%, including 6 self-limited fever and 3 pneumoperitoneum relieved by needle puncture. There was no mortality or recurrence reported with mean follow-up period of 23.74 (± 4.12) months. POET is a safe and efficient third space endoscopic resection technique for removal of UGI-SETs less than 20mm. Long term data are warranted to validate these results.

Defining the endoscopic ultrasound features of chronic pancreatitis in Asians: a multicenter validation study.

Background Although endoscopic ultrasound (EUS) features and criteria have been described in chronic pancreatitis, challenges remain with interoperator variability and ease of adoption. The aim of this study was to define and validate the EUS features of chronic pancreatitis in a multicenter prospective study in Asia. Method The study was divided into two parts: the first part was conducted to derive the EUS features of chronic pancreatitis with adequate interoperator agreement; the second was to prospectively evaluate these features in a multicenter cross-sectional study and determine the optimal combination of features for the diagnosis of chronic pancreatitis. Prospectively enrolled cases had standard internationally validated radiologic or histologic features of chronic pancreatitis, and controls were patients without chronic pancreatitis who underwent EUS examination. Results The top six EUS features that had good interobserver agreement (mean kappa 0.73, range 0.60 – 0.90) were selected to be further evaluated in part II of the study. These included: hyperechoic foci with shadowing, lobularity with honeycombing, cysts, dilated main pancreatic duct, dilated side branches, and calculi in the main pancreatic duct. A total of 284 subjects (132 cases, 152 controls) were enrolled from 12 centers in Asia. All six features had high accuracy ranging from 63.3 % to 89.1 %. Two or more of these six EUS features accurately defined chronic pancreatitis (sensitivity 94.7 %, specificity 98.0 %), with an area under the receiver operating curve of 0.986. Conclusion This multicenter Asian study characterized and defined the EUS features of chronic pancreatitis. This provides a useful tool in clinical practice and further research in pancreatic cancer surveillance.

Clinical course of suspected small gastrointestinal stromal tumors in the stomach.

Gastric subepithelial lesions are frequently encountered during endoscopic examinations, and the majority of them are small and asymptomatic. Among these lesions, gastrointestinal stromal tumors (GISTs) are the major concern for patients and clinicians owing to their malignant potentials. Although previous guidelines suggested periodic surveillance for such small (≤ 20 mm) lesions, several patients and clinicians have still requested or prescribed repeated examinations or radical resection, posing extra medical burdens and risks. To describe the clinical course of suspected small gastric GISTs and provide further evidence for surveillance strategy for tumor therapy. This single-center, retrospective study was conducted at West China Hospital, Sichuan University. Consecutive patients with suspected small gastric GISTs were reviewed from November 2004 to November 2018. GIST was suspected according to endoscopic ultrasonography features: hypoechoic lesions from muscularis propria or muscularis mucosa. Eligible patients with suspected small (≤ 20 mm) GISTs were included for analysis. Patients' demographic data, lesions' characteristics, and follow-up medical records were collected. A total of 383 patients (male/female, 121/262; mean age, 54 years) with 410 suspected small gastric GISTs (1 lesion in 362 patients, 2 lesions in 16, 3 lesions in 4, and 4 lesions in 1) were included for analysis. The most common location was gastric fundus (56.6%), followed by body (29.0%), cardia (12.2%), and antrum (2.2%). After a median follow-up of 28 mo (interquartile range, 16-48; range, 3-156), 402 lesions (98.0%) showed no changes in size, and size of 8 lesions (2.0%) was increased (mean increment, 10 mm). Of the 8 lesions with size increment, endoscopic or surgical resection was performed in 6 patients (5 GISTs and 1 leiomyoma). For other 2 remaining patients, unroofing biopsy or endoscopic ultrasound-guided fine-needle aspiration was carried out (2 GISTs), while no further change in size was noted over a period of 62-64 mo. The majority of suspected small (≤ 20 mm) gastric GISTs had no size increment during follow-up. Regular endoscopic follow-up without pathological diagnosis may be highly helpful for such small gastric subepithelial lesions.

Endoscopic Ultrasound Features of Autoimmune Pancreatitis: A Unique Chronic Pancreatitis Pattern

Background: Autoimmune pancreatitis (AIP) is a special form of chronic pancreatitis (CP) with dramatic response to corticosteroid therapy. This study focused on the endoscopic ultrasound (EUS) features of newly diagnosed AIP. Methods: This retrospective single-center study included 286 patients of newly diagnosed AIP following the HISORt criteria, and all EUS was accomplished before corticosteroid therapy. The Rosemont criteria was applied to all the AIP patients not only for descriptions of CP features but also for diagnosis of CP. We also compared the EUS findings and the diagnosis of CP between the diffuse and focal types of AIP cases. Findings: For parenchymal changes of CP, hyperechoic foci, cystic lesion, parenchymal calcification, lobularity with/without honeycombing were all comparable between both groups, while hyperechoic striation was significantly more in the focal group (P = 0·02); for main pancreatic duct (MPD) changes of CP, MPD stones, diffuse irregularity and hyperechoic ductal margin were comparable in both groups, while MPD dilation was significantly more in the focal group (P = 0·03). A unique EUS characteristic of AIP parenchymal changes was noticed that we coined as the snowflake sign which was seen in a large number of AIP case (88·1%). The diagnosis of CP according to the Rosemont criteria was also comparable in both groups (P = 0·54). Interpretation: This study demonstrated that the newly diagnosed AIP patients showed unique CP EUS features with the snowflake sign seen in a large number of AIP cases; the diagnosis of CP according to the Rosemont criteria in the diffuse type and focal type AIP cases was comparable. Funding Statement: The authors stated: None. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study was approved by the Ethics Committee of our institution, and written consent was obtained in all patients.

The Role of Endoscopic Ultrasound and Endoscopic Resection for Gastric Glomus: A Case Series and Literature Review.

Background and ObjectivesPreoperative diagnosis of gastric glomus tumor is very difficult, and there are few reports regarding the endoscopic treatment of glomus tumor of the stomach. Our aim is to provide a retrospective assessment of the imaging features of endoscopic ultrasound (EUS) and treatment of choice of gastric glomus tumor.MethodsA database of all patients with gastric glomus tumor who was treated at Shengjing Hospital of China Medical University between March 2011 and March 2017 was retrospectively analyzed. The EUS characteristics and patients’ clinical data as well as their treatment were reviewed. At the same time, we compared EUS characteristics of gastric glomus tumor with that of gastrointestinal stromal tumor (GISTs), leiomyomas, schwannomas, and ectopic pancreas.ResultsEleven patients (3 male and 8 female patients) were included in the present study. The patients’ age ranged from 37 to 62 years (mean age, 50.1 years). Ten patients received EUS examination. Eight lesions were presented with mild-hyperechoic round or oval mass; one lesion was mild-hyperechoic oval mass with hypoechoic spots; one lesion was hypoechoic oval mass. One patient received endoscopic full-thickness resection; 3 patients were treated by endoscopic submucosal dissection; and laparoscopic resection was performed for 7 patients.ConclusionsGastric glomus has typical EUS features to differentiate from other submucosal tumors. Compared with surgery, endoscopic resection is also a safe and effective treatment of choice for gastric glomus tumor.

Evaluation of Upper Endoscopic and Endoscopic Ultrasound Features in the Differential Diagnosis of Gastrointestinal Stromal Tumors and Leiomyomas in the Upper Gastrointestinal Tract

Background: Differentiation between benign and malignant subepithelial lesions (SELs) in the upper gastrointestinal tract (UGT) leads to far-reaching clinical consequences. An accurate diagnosis can be challenging because of the insufficient diagnostic yield of upper endoscopy, endoscopic ultrasound (EUS), and different types of biopsy. Aim: Our aim was to reveal the efficacy of upper endoscopic and EUS features for the differential diagnosis of hypoechogenic SELs (gastrointestinal stromal tumors [GISTs] and leiomyomas) in the UGT. Materials and Methods: The research covers a case series study of 27 hypoechogenic SELs in the UGT between 2012 and 2015 at Vilnius University Hospital Santaros Klinikos. Upper endoscopic and EUS features of SELs were recorded. In order to standardize the diagnostic approach to GISTs and leiomyomas, we assigned scores for seven upper endoscopic and EUS features. Results: The mean total scores in the GIST group were significantly higher than those in the leiomyoma group: 3.25 ± 1.71 and 0.53 ± 0.83 (p < 0.0001), respectively. Increment by one score increased the odds ratio for GIST 5.87 times (95% CI 1.63–21.11; p = 0.007). The total score demonstrated very good discriminatory features of GISTs against leiomyomas (area under the receiver operating characteristic curve 0.94 [0.86–1]). The cutoff value of 1.5 total score indicated 83.3% sensitivity and 93.3% specificity in diagnosing GISTs. Conclusions: Upper endoscopy and EUS are useful methods in making a definite diagnosis of SELs. Their diagnostic accuracy for the differential diagnosis of GISTs and leiomyomas is sufficient.

Utility of Elastography with Endoscopic Ultrasonography Shear-Wave Measurement for Diagnosing Chronic Pancreatitis.

Background/AimsRosemont classification (RC) with endoscopic ultrasonography (EUS) is important for diagnosing chronic pancreatitis (CP) but is based only on subjective judgement. EUS shear wave measurement (EUS-SWM) is a precise modality based on objective judgment, but its usefulness has not been extensively studied yet. This study evaluated the utility of EUS-SWM for diagnosing CP and estimating CP severity by determining the presence of endocrine dysfunction along with diabetes mellitus (DM).MethodsBetween June 2018 and December 2018, 52 patients who underwent EUS and EUS-SWM were classified into two groups according to RC non-CP (indeterminate CP and normal) and CP (consistent and suggestive of CP). The EUS-SWM value by shear wave velocity was evaluated with a median value. The EUS-SWM value was compared with RC and the number of EUS features. The diagnostic accuracy and cutoff value of EUS-SWM for CP and DM and its sensitivity and specificity were calculated.ResultsThe EUS-SWM value significantly positively correlated with the RC and the number of EUS features. The EUS-SWM values that were consistent and suggestive of CP were significantly higher than that of normal. The area under the receiver operating characteristic (AUROC) curve for the diagnostic accuracy of EUS-SWM for CP was 0.97. The cutoff value of 2.19 had 100% sensitivity and 94% specificity. For endocrine dysfunction in CP, the AUROC was 0.75. The cutoff value of 2.78 had 70% sensitivity and 56% specificity.ConclusionsEUS-SWM provides an objective assessment and can be an alternative diagnostic tool for diagnosing CP. EUS-SWM may also be useful for predicting the presence of endocrine dysfunction.

Endoscopic Ultrasound Features Associated with Malignancy andAggressiveness of Nonhypovascular Solid Pancreatic Lesions: Resultsfrom a Prospective Observational Study.

On contrast-enhanced imaging studies, nonhypovascular (i. e., isovascular and hypervascular) patterns can be observed in solid pancreatic lesions (SPLs) of different nature, prognosis, and management. We aimed to identify endoscopic ultrasound (EUS) features of nonhypovascular SPLs associated with malignancy/aggressiveness. The secondary aims were EUS tissue acquisition (EUS-TA) outcome and safety in this setting of patients. This prospective observational study included patients with nonhypovascular SPLs detected on cross-sectional imaging and referred for EUS-TA. Lesion features (size, site, margins, echotexture, vascular pattern, and upstream dilation of the main pancreatic duct) were recorded. Malignancy/aggressiveness was determined by evidence of carcinoma at biopsy/surgical pathology, signs of aggressiveness (perineural invasion, lymphovascular invasion, and/or microscopic tumor extension/infiltration or evidence of metastatic lymph nodes) in the surgical specimen, radiologic detection of lymph nodes or distant metastases, and/or tumor growth > 5 mm/6 months. Uni- and multivariate analyses were performed to assess the primary aim. A total of 154 patients with 161 SPLs were enrolled. 40 (24.8 %) lesions were defined as malignant/aggressive. Irregular margins and size > 20 mm were independent factors associated with malignancy/aggressiveness (p < 0.001, OR = 5.2 and p = 0.003, OR = 2.1, respectively). However, size > 20 mm was not significant in the subgroup of other-than-neuroendocrine tumor (NET) lesions. The EUS-TA accuracy was 92 %, and the rate of adverse events was 4 %. Irregular margins on EUS are associated with malignancy/aggressiveness of nonhypovascular SPLs. Size > 20 mm should be considered a malignancy-related feature only in NET patients. EUS-TA is safe and highly accurate for differential diagnosis in this group of patients.

1265 Endoscopic Ultrasound an Excellent Tool for Diagnosis of Early Stages of Cholangiocarcinoma

INTRODUCTION: Cholangiocarcinoma (CC) is a biliary tract malignancy with a poor prognosis and 3-year survival rate of 95%.1 Due to late onset of symptoms, patients often present with metastatic disease. Data suggest that endoscopic ultrasound (EUS) is an excellent tool to diagnose cholangiocarcinoma with a sensitivity varying from 60 to 89%.2–5 CASE DESCRIPTION/METHODS: Case 1 An 80-year-old man with a 3-week history of weight loss, jaundice, and generalized pruritus underwent both ultrasound and abdominopelvic CT scan which demonstrated dilatation of the intra and extrahepatic ducts and no masses. MR with MRCP revealed a common bile duct (CBD) measuring 18 mm and a biliary stricture at the head of the pancreas; masses were not noted in the pancreas or bile duct. He subsequently underwent EUS-guided fine needle aspiration (FNA) that revealed a 9 × 6 mm hypoechoic distal CBD lesion and normal pancreatic head; FNA cytology revealed adenocarcinoma consistent with biliary origin. Based on the EUS impression and cytology, the patient was diagnosed with T1N0M0 extrahepatic cholangiocarcinoma. Case 2 A 69-year-old male with history of weight loss, jaundice, and acholic stools was found to have several pancreatic cysts clustered together, 18 mm in conglomerate with a dilated CBD to 11 mm and no masses on MR of the abdomen. A subsequent EUS showed a normal pancreas, a 1 × 1.2 cm distal CBD lesion without evidence of invasion into the pancreatic head and a 1.2 cm peripancreatic lymph node with equivocal EUS features for malignancy. FNA cytology of lymph nodes was negative for malignancy. ERCP showed a distal CBD stricture of 2 cm suspicious for malignancy; brushings showed adenocarcinoma. EUS findings were consistent with T1N0M0 extrahepatic cholangiocarcinoma. DISCUSSION: EUS-FNA is an established, minimally invasive diagnostic modality for pancreatico-biliary tumors with high sensitivity to diagnose tumors less than 3 cm.6 EUS has demonstrated benefit in the diagnosis and staging of extrahepatic cholangiocarcinoma, as compared to other modalities such as MRI.7 While ERCP is primarily a therapeutic modality, it can also be used for diagnosis of CC via ERCP guided forceps biopsy, brush cytology or cholangioscopic biopsy.7 Our cases highlights the utility of EUS in diagnosing early stage cholangiocarcinoma, while other imaging modalities are indeterminate. The second case also illustrates how ERCP guided brush cytology complements EUS imaging in the diagnosis of T1 extrahepatic cholangiocarcinoma.

Upper gastrointestinal submucosal lesions: Endoscopic ultrasonographic features and endoscopic curative effects

Upper gastrointestinal submucosal lesions: Endoscopic ultrasonographic features and endoscopic curative effects

Tu1383 HIGHER PREVALENCE OF PANCREATIC CYSTS AMONGST HIGH-RISK PANCREATIC DUCTAL ADENOCARCINOMA INDIVIDUALS UNDERGOING ENDOSCOPIC ULTRASOUND

Pancreatic ductal adenocarcinoma (PDAC) screening with endoscopic ultrasound (EUS) is recommended in high-risk individuals (HRIs) with predisposing germline genetic mutations or significant family history (FH) of PDAC. In this subset of patients, the presence and clinical significance of EUS features associated with chronic pancreatitis (CP) are unclear. The aim of this study is to define the prevalence and distribution of parenchymal and ductal changes observed during EUS of high-risk patients for PDAC.

Endoscopic ultrasound findings and pathological features of pancreatic carcinoma in situ.

Abstract Background and study aims Few studies have evaluated detection of pancreatic carcinoma in situ (PCIS). We evaluated findings of endoscopic ultrasound (EUS) and pathological features of PCIS. Patients and methods We histopathologically studied 16 patients with PCIS following EUS. Diagnostic features evaluated retrospectively included stricture of the main pancreatic duct (MPD) on EUS, presence or absence of hypoechoic areas surrounding the MPD stricture on EUS, the noncancerous part (pancreas of background) on EUS and histopathology, and histological findings adjacent to the area of PCIS. Results On EUS, stricture of the MPD was found in 15 patients (93.8 %). Hypoechoic areas surrounding the MPD stricture were observed in 9 patients (56.3 %), including three (18.8 %) with a 10- to 11-mm hypoechoic mass. EUS findings of the noncancerous part indicated chronic pancreatitis in six patients (37.5 %), pancreatic fatty infiltration in seven (43.8 %), early chronic pancreatitis in two (12.5 %), and normal pancreas in one (6.3 %). Histological findings of the noncancerous part (proximal to the MPD stricture) indicated chronic pancreatitis in 13 patients (81.3 %) and pancreatic fatty infiltration in five patients (31.3 %). Histopathologically, subepithelial inflammatory cell infiltration and fibrosis were present in all 16 patients with PCIS. Conclusions PCIS frequently causes localized changes in inflammation and fibrosis around the pancreatic duct. PCIS often accompanies chronic pancreatitis and pancreatic fatty infiltration in the background of the pancreas. EUS offers sufficient resolution to demonstrate pancreatic changes of PCIS.