Endoscopic Ultrasound Fine Needle Aspiration Research Articles

Endoscopic ultrasound fine-needle aspiration with an echobronchoscope (EUS-B-FNA) from a difficult-to-access paraspinal lesion.

Endoscopic ultrasound fine-needle aspiration with an echobronchoscope (EUS-B-FNA) from a difficult-to-access paraspinal lesion.

Randomized Controlled Trial Comparing the Usefulness of Endoscopic Ultrasound Processor

Although endoscopic ultrasonography (EUS) is a useful tool for diagnosing pancreatobiliary diseases, not many facilities perform this technique as it is difficult to master. Currently, two new EUS systems exist: EU-ME2/GF-UCT260, manufactured by Olympus, and SU-1/EG-580UT, manufactured by Fujifilm. Some reports have compared new EUS models to older versions, but the operability and image quality of these two latest systems have not been compared. Our study aimed to compare the usefulness of these two types of EUS. Forty consecutive patients were recruited and randomized in a two-arm clinical trial; Arm 1: EU-ME2/GF-UCT260 was used only for observation and SU-1/EG-580UT for EUS-fine needle aspiration (FNA); Arm 2: SU-1/EG-580UT was used only for observation and EU-ME2/GF-UCT260 for EUS-FNA. Using a crossover design, we evaluated image findings, ease of scope insertion, and visibility of the gastrointestinal (GI) tract. Each procedure was scored using a 5-point scale (Clinical Trial ID: UMIN000031373). SU-1/EG-580UT was significantly better in terms of lesion-delineating capacity: lesion border (P < 0.001), internal echo (P < 0.001). Significantly easier scope insertion was observed with SU-1/EG-580UT with respect to any insertion into the piriform recess (P = 0.018), the pylorus ring (P < 0.001), and the superior duodenal angle (P < 0.001). Visibility during gastrointestinal observation was also significantly better with the SU-1/EG-580UT (P < 0.001) than with the EU-ME2/GF-UCT260. SU-1/EG-580UT EUS demonstrated superior performance during ultrasonic endoscopic GI observation, operability, and ultrasonic image quality. The result of the superior ultrasound imaging quality of SU-1/EG-580UT EUS will aid in the identification of small pancreatic malignancies with unclear borders and prove useful in evaluating mural nodules of IPMN in detail. These findings could result in an increased use of EUS and improve identification and prognosis of patients with pancreatobiliary diseases.

Diagnostic yield and safety of EUS-FNA biopsy in sub-aortic and para-aortic lymph node stations with the trans-aortic approach: a case series and literature review

ABSTRACTBackground: Sub-aortic (station 5) and para-aortic (station 6) lymph nodes are not easily accessible due to the interposition of the aorta and the left pulmonary artery. Taking a biopsy from those stations could be of value when there are no other mediastinal lymph node stations or when biopsy in other sites failed to reach a diagnosis. Surgery is the gold standard technique in the evaluation of those stations; endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been proposed as a minimally invasive technique through the trans-aortic approach, with an acceptable diagnostic yield and safety profile.Objective: To evaluate diagnostic accuracy and safety of the trans-aortic EUS-FNA in lymph node stations 5 and 6.Methods: We reviewed all patients who underwent trans-aortic EUS-FNA from 2010 to 2017, for mediastinal lymph node enlargement or positron emission tomography/computed tomography (PET/CT) positivity (integrated 2-deoxy-2-fluoro-d-glucose). Demographic characteristics, lesion site and size, needle, final diagnosis, and complications were collected.Results: A total of 11 patients were included, 5 males, mean age 59 years. Samples were inadequate in two cases, a diagnosis of lung cancer was reached in four patients (two adenocarcinoma and two squamous cell carcinoma) and five cases were negative for malignancy (one confirmed by surgery, two were found to be cancer at percutaneous lung biopsy and transbronchial biopsy, one patient received a diagnosis of Langerhans cell histiocytosis by transbronchial lung cryobiopsy, and one patient was lost at follow-up). The sensitivity for malignancy was 57%, and the overall diagnostic accuracy was 45%. No complications occurred.Conclusions: Trans-aortic EUS-FNA could be proposed as a valuable and safe approach for taking biopsy from mediastinal lymph node stations 5 and 6.

Transhepatic forceps biopsy combined with biliary drainage in obstructive jaundice: safety and accuracy.

This study was conducted in order to investigate the safety and accuracy of percutaneous transluminal forceps biopsy (PTFB) during percutaneous biliary drainage (PTBD) in patients with a suspicion of malignant biliary stricture. Fifty consecutive patients with obstructive jaundice underwent PTFB during PTBD. Biopsy specimens were obtained using 5.2-F flexible biopsy forceps and these specimens were independently analysed by two pathologists. Consensus was obtained in case of discrepancy. Biopsy was considered as a true positive when tumour cells were retrieved. In the absence of tumour cells, comparison with available surgical findings and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) and/or percutaneous liver biopsy and/or imaging or clinical follow-up was made to distinguish true and false negatives. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were calculated. Influence of tumour location and pre-operative imaging findings was evaluated. Adverse events were reported. Biliary drainage and tissue sampling were achieved in 100% of patients. Sensitivity and specificity were 70 and 100%, respectively, while overall accuracy was 72%. After excluding the first 25 patients, accuracy and sensitivity for tissue sampling reached 80 and 78%, respectively. Sensitivity was better (87%) if stenosis was located at the upper part of the biliary tree, compared to the lower part (55%). In case of cholangiocarcinoma or intraductal invasion suspected on imaging, biopsy was contributive in 84 and 81% of patients, respectively. Four complications occurred consisting of one bile leak, two haemobilia and one pneumoperitoneum. PTFB combined with PTBD is a safe and effective technique for both histopathological diagnosis and biliary decompression of biliary strictures. Implications for patient care: • Percutaneous transbiliary forceps biopsy is technically feasible (100% of tissue sampling in our study) and is a safe technique. • Radiological management combining PTFB plus PTBD may allow diagnosis and treatment of the biliary stricture at the same time. • Sensitivity and accuracy for PTFB reached 78 and 80%, respectively, with a 100% specificity.

Gross visual inspection by endosonographers during endoscopic ultrasound-guided fine needle aspiration

Background/objectivesA clear criterion for terminating endoscopic ultrasound fine needle aspiration (EUS-FNA) without rapid on-site evaluation (ROSE) has not been established. However, a possible solution includes gross visual inspection (GVI) of the sample obtained with EUS-FNA. We performed a retrospective study to elucidate the efficacy of GVI for the diagnostic yield of EUS-FNA. MethodsPatients who underwent EUS-FNA of a pancreatic mass using a standard 22-G needle from January 2017 to December 2017 were included in the study. At least two punctures were performed for each patient, and GVI was performed for each pass by endoscopists. The correlation between GVI and pathological findings were investigated per needle pass for the first two passes. Regarding GVI, we evaluated the presence of a visible core (with or without) and the sample quantity (large or small). ResultsWe evaluated 126 EUS-FNA specimens and analyzed 252 needle passes. A final diagnosis of malignancy was made for 119 patients (94%). Accuracy rates were 92.5% with a visible core and 70.0% without a visible core (p < 0.01), and 85.2% for large sample quantities and 70.2% for small sample quantities (p < 0.01). Univariate analysis indicated that the presence of a visible core and large sample quantity were associated with accuracy. Multivariate analysis indicated that only the presence of a visible core was significant. ConclusionsGVI can predict the correct diagnosis when ROSE is unavailable. Evaluating the presence of a visible core is more sensitive than assessing the quantity of the sample obtained.

Uncommon Finding of a Gastrointestinal Stromal Tumor in a Patient with Hyperechoic Liver Lesions - Case Report

Abstract Introduction: Hyperechoic liver lesions identified by conventional ultrasonography are diverse in underlying pathology and most of the time require further investigations. Gastrointestinal stromal tumors (GIST) are rare neoplasms of the gastrointestinal tract which are uncommonly found in metastatic stages at first presentation. Case report: We present the case of a 51 years old woman with nonspecific symptoms in which conventional ultrasonography showed hyperechoic lesions in the right lobe of the liver with a diameter up to 40 mm. Esophagogastroduodenoscopy revealed a submucosal tumor on the small curvature of the stomach, on the anterior wall, with central ulceration, with normal narrow band imaging (NBI) mucosal pattern and negative gastric biopsy. Contrast enhanced ultrasonography was performed, describing multiple lesions with inhomogeneous enhancement in the arterial phase and rapid washout at the end of arterial phase. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) biopsy examination was definitive for the final diagnosis of epithelioid gastric gastrointestinal stromal tumor. The patient was diagnosed with T2N0M1 epithelioid gastric GIST, stage IV, and is currently under treatment with tyrosine kinase inhibitors. Conclusions: GIST represent a diagnostic challenge in medical practice because of its size, unusual location in the submucosal layer and lack of symptoms. The role of EUS-FNA is of paramount importance in increasing the accuracy of diagnosis in the case of GIST. The particularity in our case consists of the unusual presentation with the lack of specific symptoms and signs associated with the presence of metastatic lesions at the moment of the diagnosis of GIST.

Hypervascular lesions of the pancreas: Think before you act

BackgroundThe “classic” CT appearance of pancreatic neuroendocrine tumors (PNETs) is a solid, hypervascular lesion; however, non-PNET diagnoses may appear similar. In addition, some PNETs have a “non-classic” appearance. MethodsDemographic, imaging, endoscopic ultrasound-fine needle aspiration (EUS/FNA) results, and pathology data were analyzed for patients who underwent pancreatectomy for suspected or confirmed diagnosis of PNET from our institutional database. ResultsForty-three patients with a hypervascular lesion on CT had pancreatectomy for a pre-operative diagnosis of PNET. Final pathology revealed PNET in 30 (70%) and non-PNET diagnoses in 13 (30%). EUS/FNA had a sensitivity of 82% for the pre-operative diagnosis of PNET in patients with “classic” CT. Of 13 non-PNET diagnoses, 7 were benign. Among a total of 41 patients with a final diagnosis of PNET, 11 (27%) had “non-classic” CT (5 hypodense solid lesions, 3 isodense solid lesions, and 3 cystic lesions). Among these patients, EUS/FNA had a sensitivity of 100% in diagnosing PNET. ConclusionsConsideration of non-PNET diagnoses is important for patients with hypervascular lesions on CT. Appropriate pre-operative evaluation will optimize treatment plans.

A multicenter randomized trial comparing a 25-gauge EUS fine-needle aspiration device with a 20-gauge EUS fine-needle biopsy device

Several studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle. Consecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders. A total of 608 patients were allocated to FNA (n= 306) or FNB (n= 302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (P= .043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, P< .001), accuracy for malignancy (87% vs 78%, P= .002) and Bethesda classification (82% vs 72%, P= .002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; P= .004), and did not differ among centers (P= .836). The 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.).

A Unique Diagnosis of Metastatic Prostate Adenocarcinoma

Prostate adenocarcinoma is the most common non-skin cancer that affects men in the United States. Although its prevalence is high with 1/6 men being diagnosed with prostate cancer in their lives, the prognosis is often promising with only 1/36 men dying from prostate cancer. The prognosis of this cancer, like many, is based on the presence or absence of metastases. Gastroenterologists rarely encounter this malignancy as the primary is located in a genitourinary organ and the most common sites of metastasis are bone and lung, as well as local lymph nodes. However, there are rare cases when new or recurrent diagnoses of metastatic prostate cancer can be established via fine needle aspiration (FNA) of abnormal mediastinal lymph nodes under endoscopic ultrasound (EUS). An 80 year old man had a previous history of prostate adenocarcinoma that had been treated with radiation and adjuvant androgen deprivation therapy. About 18 months after completing treatment, steadily uptrending prostate serum antigen values prompted a PET scan. This showed increased uptake in multiple retroperitoneal lymph nodes, prompting a concern for metastasis. In addition, there were multiple mediastinal lymph nodes with increased uptake. Given the rare occurrence of mediastinal lymph node metastases in prostate malignancy, there was significant concern for a second malignancy. The patient underwent EUS to further evaluate (see image 1) and an FNA showed pathology consistent with prostate adenocarcinoma (see images 2 and 3). EUS FNA is a commonly used modality for concerning lymph nodes or masses noted on PET scans or other types of imaging. Similarly, prostate cancer is a common diagnosis, especially in elderly men. However, EUS FNA is very rarely used to confirm a diagnosis of metastatic prostate cancer. This case is unique because it highlights the potential for prostate adenocarcinoma to metastasize outside of its common sites of bone, lung, liver and retroperitoneal lymph nodes. It also illustrates the associated utility of EUS FNA. Case reports have described this method of diagnosis in only a select few cases. It is far more common for lymph node involvement above the diaphragm to be associated with lung, esophageal or head/neck cancers. Recognizing and sampling concerning mediastinal lymph nodes is vital to ensure that the correct primary malignancy is identified and appropriate chemotherapy or radiation regiments can be determined.2140_A Figure 1. EUS image showing an enlarged mediastinal lymph node (circled in red) prior to FNA.2140_B Figure 2. Papanicolaou stain showing a cohesive cluster of pleomorphic malignant cells (x200)2140_C Figure 3. Prostate specific antigen (PSA) immunohistochemical stain showing positive staining in the malignant cells, consistent with metastatic prostate adenocarcinoma (x200).

Sarcomatoid Carcinoma of the Pancreas: An Unusual Cause of Abdominal Pain

Introduction: Sarcomatoid carcinoma of the pancreas (SCP) is a rare and highly malignant variant of pancreas carcinoma that usually has a very poor prognosis. Epithelial-mesenchymal transition (EMT), a transition between different phenotypes, is regarded as an essential process in tumor progression. When EMT occurs, epithelial tumor cells lose their restricted phenotypes, concomitant with the loss of epithelial characteristics and the acquisition of motile behavior. These changes, which contribute to the transition from an epithelial morphology towards a more mesenchymal fibroblastic phenotype, have been reported to occur in some special tumors, such as cholangiocarcinomas; this change is also defined as sarcomatous change. Case Report: A 37-year-old-female with a history of hypertension presented to the hospital with the chief complaint of epigastric abdominal pain. Her abdominal pain progressively worsened and she came back to the hospital 3 weeks later. She also complained of pale, foul-smelling, floating stools that began 3 days prior to presentation with a decrease in her appetite. Routine laboratory showed: hemoglobin, 12.8 g/dL; WBC, 5,100 cells/uL; platelet, 244,000/mm3; with elevation in AST, ALT, alkaline phosphatase; total bilirubin, 4.0 mg/dL; direct bilirubin, 3.1 mg/dL; and LDH 306 u/L and negative viral markers. Tumor marker assays showed elevated CA19-9. Results: CT abdominal scan showed a hypoechoic mass in the uncinate process of the pancreas (Figure 1) with intrahepatic biliary ductal dilatation and dilation of the proximal common bile duct (CBD). The patient underwent an esophagogastroduodenoscopy with brush biopsies of the CBD with stent placement, as well as, an endoscopic ultrasound fine needle aspiration of the pancreatic mass. The patient underwent a pancreaticoduodenectomy to help diagnosis and remove the tumor. The histopathological diagnosis was as follows: ductal adenocarcinoma with sarcomatoid features with the invasion of the tumor in the extra-pancreatic common bile duct, stage IIB (Figure 2A & 2 B).1372_A.tif Figure 1: CT abdomen with contrast showing the hypoechoic mass in the head of the pancreas with intrahepatic biliary ductal dilatation.1372_B.tif Figure 2: Pathology specimen showing adenosquamous carcinomaDiscussion: Adenosquamous carcinoma of the pancreas is associated with high rates of recurrence and metastasis and carries a poor prognosis, much worse than even that of pancreatic adenocarcinoma, which has a reported median overall survival of no more than 5 months. SCP is a rarely appreciated subset of pancreatic malignancy that does not necessarily portend to a uniformly dismal prognosis.1372_C.tif Figure 3: Sarcomatous changes.

Endoscopic Ultrasound Fine Needle Aspiration and Biopsy Provide High Yields for Lymphoma Subclassification

Endoscopic Ultrasound Fine Needle Aspiration and Biopsy Provide High Yields for Lymphoma Subclassification

Esophagogastroduodenoscopy With Every Endoscopic Ultrasound Study - Is It Necessary? A Single Center Experience

Introduction: Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (EUS-FNA) have been used increasingly as a safe, accurate and diagnostic as well as therapeutic tool for a variety of gastrointestinal (GI) as well as non-GI conditions. In 2015, the ASGE and ACG released standard quality indicators for GI endoscopic procedures including EUS. Performing an EUS for an “appropriate” indication and having adequate photo documentation of structuresof interest were among the key indicators with different grades for the clarity of benefit. However, there was no mention for the utility of preprocedure esophagogastroduodenoscopy (EGD). Purpose: To see if an EGD prior to EUS in asymptomatic patients changes management or patient outcomes. Methods: A retrospective chart review of asymptomatic patients who underwent EGD prior to EUS over the last 4 years was conducted. Patients with symptoms that warranted an EGD were excluded. We estimated a sample size of 150 for 80% power and significance level of 0.05. Chi-Square analysis was used. Results: 1100 charts were reviewed, and 158 patients were included. Mean age was 60.5 years. 63 patients were males. It was noted that 23.4% and 35.4% were using alcohol or tobacco respectively, while 30% were on antiplatelet therapy. Most patients underwent EUS due to a pancreatic indication followed by a biliary indication (figure 1). Among all EGDs, only 33 were completely normal. 125 were associated with benign mucosal findings; 11 cases of Barrett’s esophagus and 4 cases of GI malignancy were detected as well. These findings lead to changes in patient management (figure 2). Overall, 67% of patients had some changes in their managment. There was a statistically significant association between male gender and detection of malignant lesions (P 0.013). Alcohol use was associated with findings on EGD as well as a need for an intervention, as a medication modification (P 0.05), tissue sampling (P 0.034) and schedule a follow procedure (P 0.046) (figure 3). Finally, EGD prior to EUS was safe and not associated with increased complications compared to EUS alone. Conclusion: Our study showed that performing an EGD prior to EUS in the absence of luminal or mucosal symptoms is safe and changed management in 67% of asymptomatic individuals.479_A Figure 1. Pie graph showing the percentages of EUS indications (Pancreatic and biliary indications represent the majority of cases)479_B Figure 2. Different intervention and change in management done as a result of the EGD findings479_C Figure 3. Alcohol’s association with change in management

CHRONIC PARENCHYMAL INFILTRATION FROM MALT LYMPHOMA: DIAGNOSIS BY ENDOBRONCHIAL ULTRASOUND

SESSION TITLE: Lung Pathology 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Mucosa-associated lymphoid tissue (MALT) lymphoma is a rare cause of pulmonary infiltrate. The lung accounts for only 4% of all extra-nodal marginal zone MALT lymphomas [1] and presents mostly as an incidental finding or with non-specific symptoms. CASE PRESENTATION: A previously healthy 59-year-old man presented with chest pain in 2013. A chest radiograph noted bilateral infrahiliar masses. Computed tomography (CT) of the chest showed bilateral lung consolidations (Figure 1). He was treated with antibiotics and lost to follow up. Five years later the patient presented with transient stroke-like symptoms and a chest x-ray showed a persistent infiltrate. CT chest noted large bibasilar consolidations with air bronchograms and dilated bronchi (Figure 2). These infiltrates were hypermetabolic on positron emission tomography (PET) with a maximum standardized uptake value (SUV) of 6.4. The patient underwent bronchoscopy with endobronchial ultrasound guided transbronchial 19 gauge needle aspiration (EBUS-TBNA) of the consolidative lesions. Immunohistochemistry and flow cytometry confirmed a diagnosis of MALT lymphoma. He was referred to oncology and initiated on rituximab and bendamustine. DISCUSSION: MALT lymphoma of the lung is a relatively rare disease that has been associated with chronic antigen stimulation in the context of infection, autoimmune disease and toxic exposure. The clinical presentation and radiographic findings are varied and can be mistaken for more common entities. Lesions are usually bilateral and often have associated air bronchograms and bronchiectasis [2]. The disease usually has an indolent course with a favorable prognosis. In most reported cases, diagnosis was achieved with open lung or CT-guided biopsy. The role of EBUS-TBNA for pulmonary MALT lymphoma has been previously described in mediastinal lymphadenopathy and was found to be useful [3]. To our knowledge, this is the first case of EBUS-TBNA of lung infiltrates to diagnose this condition. CONCLUSIONS: MALT lymphoma is a rare lung malignancy that should be considered in the differential diagnosis of non-resolving pulmonary lesions. Minimally invasive approaches such as bronchoscopy and EBUS-TBNA can retrieve sufficient tissue for diagnosis. Reference #1: Schreuder MI, Van den Brand M, Hebeda K, et al. Novel developments in the pathogenesis and diagnosis of extranodal marginal zone lymphoma. J Hemathopatol. 2017; 10: 91-107. Reference #2: Wislez M, Cadranel J, Antoine M, et al. Lymphoma of pulmonary mucosa-associated lymphoid tissue: CT scan findings and pathological correlations. Eur Respir J. 1999; 14: 423-429. Reference #3: Nunez AL, Jhala NC, Carroll AJ, et al. Endoscopic ultrasound and endobronchial ultrasound-guided fine-needle aspiration of deep-seated lymphadenopathy: Analysis of 1338 cases. Cytojournal. 2012;9:14. DISCLOSURES: Consultant relationship with Boston Scientific Please note: $1-$1000 Added 03/02/2018 by Alex Chee, source=Web Response, value=Consulting fee No relevant relationships by Isabel Londono Marulanda, source=Web Response Consultant relationship with Boston Scientific Please note: $5001 - $20000 Added 03/04/2018 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with Olympus Please note: $5001 - $20000 Added 03/04/2018 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Mihir Parikh, source=Web Response No relevant relationships by Andrew Schissler, source=Web Response

Updates in Therapeutic Endoscopic Ultrasonography.

The last decade has seen a dramatic rise in the possibilities of therapeutic endoscopic ultrasound (EUS). From EUS fine needle aspiration of cancerous lesion to pseudocyst drainage, it has now not only replaced some of the percutaneous techniques but has permitted to bypass all together laparoscopic approach for patient with altered anatomy or malignant gastric outlet obstruction. This review will emphasize the novel therapeutic EUS procedures added to our arsenal.

Characterization of subepithelial lesions of the stomach and esophagus by contrast-enhanced EUS: A retrospective study.

Background and Objectives:Subepithelial lesions (SELs) of the upper part of the digestive tract are rare, and it can be difficult to characterize them. Recently, contrast-enhanced endosonography (EUS) and elastometry have been reported as useful adjuncts to EUS and EUS-guided fine needle aspiration (EUS-FNA) in cases of pancreatic mass and lymph node involvement. The aim of this retrospective analysis was to evaluate whether contrast-enhanced EUS can discriminate benign submucosal lesions from malignant ones. We describe our retrospective experience using the contrast agent SonoVue® (Bracco Imaging, Milan, Italy) in an attempt to increase the diagnostic yield.Patients and Methods:Between May 2011 and September 2014, 14 patients (5 men, 9 women; median age 64 years, range 31–80 years) with SELs of the stomach or esophagus underwent EUS with SonoVue® (low mechanical index). There were 3 esophageal lesions and 11 gastric lesions. Mean size of the lesions was 30 mm (range 11–50 mm). They were discovered after anemia (n = 5), dysphagia (n = 1), and pain (n = 4) and during follow-up for resected gastrointestinal stromal tumors (GISTs) (n = 1) and a standard upper gastrointestinal endoscopy (n = 3). On endoscopic sonograms, 10 of these lesions were hypoechoic and located in the fourth layer (muscularis), and 4 were in the second or third layer (mucosa and submucosa). Contrast enhancement was assessed in the early phase (after several seconds) and late phase (>30 seconds); a final diagnosis was made based on the findings of EUS-FNA using a 19-gauge ProCore (Cook Medical, Bloomington, IN) (n = 9) or 22-gauge FNA system (Cook Medical) (n = 1), the resected specimen (n = 3), or deep biopsy (n = 1). Different immunostaining was used in the pathologic studies (RNA was analyzed later using the C-kit, CD-117, CD-34, desmin, DOG-1, α-smooth actin, caldesmon, PS-100, and Ki-67 antibodies).Results:Final diagnoses were leiomyoma (n = 4), GIST (n = 5), schwannoma (n = 1), inflammatory tumor of Helvig (n = 1), pancreas rest (n = 2), and fibrosis (n = 1). No complications occurred. All 5 GISTs showed enhancement in the early and late phases, whereas the 8 remaining lesions did not show any enhancement. Only 1 leiomyoma showed heterogeneous enhancement.Limitations:The monocentric and retrospective study design and small number of patients.Conclusions:In cases of SELs of the stomach or esophagus, SonoVue® could be a complementary tool to endosonography to differentiate GISTs (early and clear enhancement) from other SELs (few or no enhancement), such as leiomyomas or pancreatic rest. These results are similar to those of the few, small studies published on this topic, but more studies with a larger number of patients are needed to confirm these findings.

Comparison between groove carcinoma and groove pancreatitis

Background/objectivesThe pancreatoduodenal groove (anatomical groove) is a potential space bordered by the head of the pancreas, duodenum, and common bile duct. Discerning between groove carcinoma (GC) and groove pancreatitis (GP) is often difficult, but clinically important. We retrospectively analyzed and compared the findings of computed tomography (CT), laboratory tests, and endoscopic ultrasound-fine needle aspiration (EUS-FNA) for GC and GP. MethodsGC (n = 36) and GP (n = 44) patients at Asan Medical Center from January 1, 2000, to May 31, 2017 were retrospectively reviewed. MDCT findings, baseline characteristics, laboratory test results, and EUS and EUS-FNA findings of GC and GP patients were compared. ResultsCT showed no significant difference in groove enhancement between the groups. Mass-like lesions, cystic groove lesions, and calcification were observed in 86.1% and 15.9%, 38.9% and 75%, and 2.8% and 29.5% of GC and GP patients, respectively. Patients were tested for total bilirubin (GC: 2.0 vs. GP: 0.6 mg/dL), cancer antigen 19-9 (CA19-9) (GC: 76 vs. GP: 12.5 U/mL), and carcinoembryonic antigen (GC: 2.4 vs. GP: 2 ng/mL). Three GP patients died, and one GP patient was diagnosed with GC. However, among 30 GC patients with at least 1-year follow-up, 20 died. In multivariate logistic regression, CA19-9, and mass-like lesion on multidetector CT (MDCT) were discriminating factors between GC and GP. Among 23 (10 GC, 13 GP) patients who underwent EUS-FNA, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy of EUS-FNA were 90%, 100%, 100%, 92.86%, and 95.65%, respectively. ConclusionsSeveral MDCT and laboratory findings favor GC over GP. EUS-FNA should be considered in patients with elevated CA19-9 levels and mass-like lesions on MDCT.

Tissue acquisition in pancreatic cystic lesions

Despite the progress achieved by scientific research in recent years, pancreatic cystic lesions (PCLs) remain a challenging clinical problem. A significant percentage of benign PCLs are still wrongly sent to surgery, with all the related risks of a high number of surgery-related complications and mortality. Diagnosis of the type of PCL, and risk stratification for malignancy are essential for a correct management of these lesions. Several guidelines have identified some clinical and morphological aspects suggesting the need for more accurate exams. Endoscopic ultrasound fine needle aspiration (EUS-FNA) of cystic fluid for cytology is the advised method of tissue acquisition in several guidelines, and the most used technique around the world. However sensitivity and adequacy of this technique are limited by the low amount of cells dispersed in cystic fluid. Alternative techniques have been tested to target the cystic walls in an attempt to obtain microhistologic specimens in order to augment the probability of obtaining an adequate diagnostic sample.The aim of this review is to offer a critical overview of the existing literature on tissue acquisition in PCLs, and emphasize advantages and disadvantages of each technique, and unclear areas that need to be investigated with future research.

Ultrasonography of the Mediastinum: Techniques, Current Practice, and Future Directions.

In the everyday practice of respiratory physicians, ultrasound techniques play a key role by enabling several diagnostic and interventional procedures. The application of ultrasound to endoscopic procedures allows both a visualization and a guided sampling of mediastinal and hilar lymph nodes. Endobronchial ultrasound can be combined with transbronchial needle aspiration, and, similarly, endoscopic ultrasound can be combined with fine-needle aspiration to sample virtually all mediastinal nodal stations from the airways and the esophagus. Endobronchial ultrasound-transbronchial needle aspiration and endoscopic ultrasound-fine needle aspiration showed a complementary diagnostic yield, and, recently, endoscopic ultrasound with bronchoscope was introduced in clinical practice to perform a transesophageal needle aspiration by using an ultrasound bronchoscope. This technique allows a single operator to perform both transbronchial and transesophageal needle sampling with the same instrument during a single bronchoscopic procedure. Mediastinal staging impacts the management of patients affected by lung cancer, and the most recent guidelines clearly state that endobronchial ultrasound and endoscopic ultrasound should be the initial tissue sampling procedure over surgical staging. In addition, endoscopic ultrasound techniques demonstrated an excellent yield in diagnosing lymphoma and benign diseases, for example, sarcoidosis. The aim of this review was to discuss the current role and future perspectives of endosonography techniques available for the evaluation of the mediastinum. Special emphasis was placed on equipment and technical aspects, the diagnostic role, and future directions of development.

Follow-up of patients with pseudotumoral chronic pancreatitis: outcome and surveillance

Aim: to follow up patients with pseudotumoral chronic pancreatitis (PCP) to assess their outcome and identify an optimal surveillance interval.&#x0D; Methods: data obtained prospectively were analyzed in a retrospective manner. Patients with clinical evidence of chronic pancreatitis (abdominal pain in the epigastrium, steatorrhea, and diabetes mellitus), endoscopic ultrasound (EUS) criteria &gt; 4, and EUS-fine needle aspiration (FNA) were included. A pseudotumor was defined as a non-neoplastic space-occupying lesion, a cause of chronic pancreatitis that may mimic changes typical of pancreatic cancer on CT or endoscopic ultrasound but without histological evidence. A real tumor was defined as a neoplastic space-occupying lesion because of pancreatic cancer confirmed by histology.&#x0D; Results: thirty-five patients with chronic pancreatitis were included, 26 (74.2%) of whom were men. Nine (25.7%) patients were diagnosed with PCP and two (2/35; 5.7%) patients with PCP were diagnosed with pancreatic cancer on follow-up. The time between the diagnosis of PCP and pancreatic adenocarcinoma was 35 and 30 days in the two patients. Definitive diagnosis of pancreatic adenocarcinoma was made by surgery. In the remaining six patients with PCP, the median of follow-up was 11 months (range 1–22 months) and they showed no evidence of malignancy on surveillance. In the follow-up of patients without PCP but with chronic pancreatitis, none were diagnosed with pancreatic cancer. According to our data, older patients with chronic pancreatitis are at risk of PCP.&#x0D; Conclusion: according to characteristics of patient, detection of PCP should lead a surveillance program for pancreatic cancer with EUS-FNA in &lt; 1 month or directly to surgical resection.&#x0D; Core tip: actually, there are no clear recommendations for follow-up of patients with chronic pancreatitis and solid pancreatic mass lesions. We followed-up patients with chronic pancreatitis and solid pancreatic mass lesions and we assessed the final outcome and identified an optimal surveillance interval. We found that almost one-third of patients with chronic pancreatitis had PCP, and 22.2% had unresectable pancreatic adenocarcinoma less than 2 mo after the initial diagnosis. Endoscopic ultrasound fine needle aspiration can miss malignancy in nearly 25% of patients with PCP.

Expression of the obestatin/G-protein coupled receptor 39 (GPR39) system in healthy and diseased human pancreas

A clear criterion for terminating endoscopic ultrasound fine needle aspiration (EUS-FNA) without rapid on-site evaluation (ROSE) has not been established. However, a possible solution includes gross visual inspection (GVI) of the sample obtained with EUS-FNA. We performed a retrospective study to elucidate the efficacy of GVI for the diagnostic yield of EUS-FNA.Patients who underwent EUS-FNA of a pancreatic mass using a standard 22-G needle from January 2017 to December 2017 were included in the study. At least two punctures were performed for each patient, and GVI was performed for each pass by endoscopists. The correlation between GVI and pathological findings were investigated per needle pass for the first two passes. Regarding GVI, we evaluated the presence of a visible core (with or without) and the sample quantity (large or small).We evaluated 126 EUS-FNA specimens and analyzed 252 needle passes. A final diagnosis of malignancy was made for 119 patients (94%). Accuracy rates were 92.5% with a visible core and 70.0% without a visible core (p < 0.01), and 85.2% for large sample quantities and 70.2% for small sample quantities (p < 0.01). Univariate analysis indicated that the presence of a visible core and large sample quantity were associated with accuracy. Multivariate analysis indicated that only the presence of a visible core was significant.GVI can predict the correct diagnosis when ROSE is unavailable. Evaluating the presence of a visible core is more sensitive than assessing the quantity of the sample obtained.