EUS-guided Trucut Biopsy Research Articles

The value of touch imprint cytology in EUS-guided Trucut biopsy

EUS-guided Trucut biopsy (TCB) enables the acquisition of tissue cores for histologic assessment. Touch imprint cytology (TIC) can be performed at the time of a biopsy to assess the adequacy of the sample; however, limited information is available on the diagnostic value of TIC of these specimens. To investigate the diagnostic accuracy of TIC compared with a TCB. Consecutive EUS-guided TCB and TIC (n = 109) were retrospectively and independently reviewed by a surgical pathologist (for the TCB) and a cytopathologist (for TIC) blinded to the final diagnoses. University of Iowa Hospitals and Clinics, Iowa. Diagnostic accuracy of a TCB, TIC, and combined TCB + TIC. The diagnostic accuracy of a TCB was 92.7% (95% CI, 83.1%-97.3%), TIC was 82.6% (95% CI, 74.3%-88.6%), and TCB + TIC was 95.4% (95% CI, of 89.4%-98.3%). The diagnostic accuracy of a TCB alone was superior to TIC alone (P = .038); a TCB was diagnostic in 14 cases that were nondiagnostic by TIC. The addition of TIC allowed for the identification of 3 malignancies (2.8%) that were not identified on TCB alone. In 22 cases, TIC was considered diagnostic, but a TCB provided additional specific diagnostic information. Retrospective study and relatively low numbers. TIC is a valuable tool for use in a EUS-guided TCB; TIC is independently diagnostically accurate, which allows for confidence in a rapid preliminary diagnosis, and it provides additional diagnostic value when combined with TCB.

Primary pancreatic lymphoma: endoscopic ultrasound-guided Trucut biopsy to the rescue!

A 64-year-old diabetic woman presented with a 1-week history of abdominal pain and cholestatic jaundice. Her laboratory tests showed: leukocyte count 7.2 × 109/L (normal range 3.5 – 10.5 × 109/L), total bilirubin 10.5 μg/dL (0.1 – 1.0 μg/dL), aspartate aminotransferase (AST) 337 U/L (12 – 31 U/L), alanine aminotransferase (ALT) 624 U/L (9 – 29 U/L), alkaline phosphatase 724 U/L (50 – 130 U/L), lipase 24 U/L (10 – 73 U/L), CA 19 – 9 28 units/mL (< 55 units/mL) and IgG4 137 mg/dL (8 – 140 mg/dl). Abdominal computed tomography revealed a pancreatic head mass that was encasing the portal vein and common hepatic artery but sparing the superior mesenteric artery, with evidence of peripancreatic and portal lymphadenopathy; there was no evidence of hepatic or splenic involvement ([Fig. 1]). Her chest radiograph was normal. Endoscopic ultrasound (EUS) revealed a 4.3-cm, echo-poor pancreatic head mass and a 1.4-cm (short axis) peripancreatic lymph node ([Fig. 2], [3]). EUS-guided fine-needle aspiration (EUS-FNA) of the pancreatic head and of the peripancreatic lymph node was performed.

Evaluation of endoscopic approaches for deep gastric-muscle–wall biopsies: what works?

A major barrier to furthering our understanding of the pathophysiology of neuromuscular GI diseases, including functional GI disorders, is the inability to obtain deep gastric-wall biopsy specimens that include both layers of the muscularis propria, which allows evaluation of specific cell types, including myenteric ganglia. The aims of this preclinical study were to (1) evaluate different endoscopic approaches for obtaining deep gastric-muscle-wall biopsy specimens and (2) determine if myenteric ganglia were present in the tissue samples. This was a preclinical acute study by using a pig model. Multiple samples were obtained from 4 pigs. The endoscopic techniques evaluated were (1) EUS-guided tru-cut biopsy of the gastric wall, (2) jumbo biopsy of the post-EMR site, (3) jumbo biopsy of the gastrotomy margin, (4) serosal-side biopsy through a gastrotomy, and (5) double-EMR resection. Resected tissue was submitted for histology to determine which wall layers were included in the resected specimen. Hematoxylin and eosin staining was used to determine which muscle layers were biopsied, and an antibody to protein gene product 9.5 was used to determine if myenteric ganglia were present in the sample. Seventy-two tissue samples were obtained: EUS-guided tru-cut biopsy (n=16), jumbo biopsy of the post-EMR site (n=16), jumbo biopsy of the gastrotomy (n=16), serosal-side biopsy (n=16), and double-EMR resection (n=8). Only the double-EMR resection tissues showed the presence of longitudinal muscle, indicating the presence of both muscle layers and the myenteric plexus. Immunofluorescence studies demonstrated the presence of myenteric ganglia only in the double-EMR tissues and in none of the other gastric samples. No adjacent organs were included in the resection. The double-EMR technique was the only studied technique that resulted in a deep gastric-wall sample and provided sufficient tissue to evaluate both muscle layers and the intermuscular layer that contain myenteric ganglia. Further studies are needed to verify the efficacy and to assess the safety of this approach.

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EUS with Trucut Biopsy for Diagnosis of Intra-Abdominal Tuberculosis

An 80-year Italian old male presented with left upper quadrant pain, excessive fatigue, weight loss and normocytic anemia. EGD revealed thickened and inflamed gastric mucosa and 2 submucosal gastric impressions. CT scan of the abdomen showed low attenuation lesions in the omentum adjacent to the stomach and low attenuation gastrohepatic ligament lymph nodes. The working diagnosis was lymphoma. Using linear EUS and fine needle aspiration, tissue was collected for cytology and microbiology. Cytology was initially non-diagnostic, so Trucut needle biopsy was performed. Perigastric lymph nodes cytology was positive for necrotic material with numerous lymphoid cells. AFB and fungal studies were negative. Trucut biopsy on pathology revealed necrotizing granuloma without acid-fast bacilli. 4 weeks later AFB culture grew M. Tuberculosis complex. Another patient who was a 44-year-old male with AIDS presented with fever, dysphagia, vomiting, weight loss and intermittent non-bloody diarrhea. On admission he was febrile and tachycardic. Physical exam revealed cachectic ill-appearing male. Abdominal examination was unremarkable. There was no palpable lymphadenopathy. Patient was anemic; CD4 cell count was 5. EGD revealed extrinsic compression of the stomach. CT scan of the abdomen showed a mass in the splenic hilum, indenting the posterior aspect of the stomach, and smaller masses in the paragastric region. EUS was performed with multiple fine needle aspirations of the lesions and but it did not provide definitive diagnosis, so EUS was repeated with Trucut biopsy. Histology revealed necrotic tissue mixed with lymphoid cells, histiocytes, caseating granuloma with presence of AFB, further identified as Mycobacteria tuberculosis. Patient was treated with four-drug regimen; his condition improved and he was discharged. Diagnosis of abdominal tuberculosis presents a challenge because it is uncommon, inaccessible, and yields few numbers of bacilli on FNA. It is important to realize, that TB seems to be resurging and abdominal TB needs to be considered in the differential in both immunocompromised and immunocompetent patients. In the above 2 cases we show that EUS with Trucut needle tissue acquisition can be an accurate and safe method of diagnosing lesions accessible through the gastrointestinal tract. EUS guided Trucut biopsy played crucial role in diagnosis of intra-abdominal tuberculosis in both the immunocompromized and immunocompetent patient.

Utility of EUS-Guided Trucut Biopsy To Distinguish Pancreatic Rests from Gastrointestinal Stromal Tumors (A Case Series)

Utility of EUS-Guided Trucut Biopsy To Distinguish Pancreatic Rests from Gastrointestinal Stromal Tumors (A Case Series)

EUS-guided tissue sampling: comparison of ”dual sampling” (Trucut biopsy plus FNA) with ”sequential sampling” (Trucut biopsy and then FNA as required)

Both endoscopic ultrasound- (EUS-) guided tissue sampling techniques, fine-needle aspiration (FNA) and Trucut biopsy, have advantages and limitations. The aim of this study was to develop a strategy of combining these two EUS-guided sampling techniques in order to maximize the diagnostic accuracy and minimize duplication. In this multicenter study we performed "dual sampling" (i. e. with both FNA and Trucut biopsy) in 95 patients during phase 1 of the study and "sequential sampling" (i. e. performing FNA only when Trucut biopsy tissue cores were macroscopically inadequate) in 72 patients during phase 2. During the study period, 167/401 patients referred for EUS-guided sampling were eligible for the study; only solid lesions were included. In 143/167 patients (86 %), sampling was performed via the transesophageal or transgastric routes. When the dual sampling strategy was used, an accurate diagnosis was achieved in 78/95 patients by FNA, compared with 85/95 by Trucut biopsy ( P = 0.21). The combined accuracy of the dual sampling strategy was higher than FNA alone (88/95 vs. 78/95, P = 0.048), but was not significantly higher than Trucut biopsy alone (88/95 vs. 85/95, P = 0.61). Using the sequential sampling strategy, an accurate diagnosis was achieved in 66/72 patients (92 %) compared with 88/95 (93 %) for dual sampling ( P = 1.0), and 8/72 patients (11 %) had to undergo FNA after Trucut biopsy failed to obtain an adequate sample. One patient with mediastinal tuberculosis developed a cold abscess following Trucut biopsy. A sequential sampling strategy, in which EUS-guided Trucut biopsy is attempted first, and FNA performed only when Trucut biopsy fails to obtain a macroscopically adequate sample, achieves a diagnostic accuracy of 92 %, with 11 % of patients requiring both sampling procedures.

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound for diagnosis of chronic pancreatitis

The diagnosis of chronic pancreatitis is based on altered pancreatic morphology and function. A spectrum of disease exists, and milder forms of disease may be missed by CT but demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS). The accuracy of ERCP and EUS for diagnosis of "minimal change" or "early" chronic pancreatitis is controversial, particularly when the results from these imaging procedures are discordant with each other or with tests of pancreatic function; in some cases ERCP and EUS should be considered indeterminate for diagnosis. This review discusses recent data concerning the accuracy of ERCP and EUS for diagnosis of chronic pancreatitis, the use of EUS fine-needle aspiration for differential diagnosis of pancreatic masses, and the use of EUS and EUS-guided TruCut biopsy for diagnosis of autoimmune pancreatitis.

Endoscopic ultrasound (EUS)-guided Trucut biopsy adds significant information to EUS-guided fine-needle aspiration in selected patients: A prospective study

Objective. Endoscopic ultrasound (EUS)-guided Trucut biopsy (EUS-TCB) has recently emerged as a method that seeks to overcome the limitations of EUS-guided fine needle aspiration (EUS-FNA) by providing a core-tissue specimen needed to increase the yield and accuracy of the diagnosis. The aim of our study was to evaluate whether EUS-TCB adds any information to EUS-FNA in selected patients and to assess the diagnostic yield, overall accuracy and complications of EUS-TCB as compared with EUS-FNA. Material and methods. The study prospectively included 30 patients who had undergone both procedures. Results. The yield of adequate tissue harvesting was similar for EUS-FNA and EUS-TCB (96.4% versus 89.3%, p=NS), with the same number of passes done. The diagnostic accuracy of EUS-FNA was also similar to that of EUS-TCB for the diagnosis of malignant mediastinal masses (73.7% versus 68.4%, p=NS). However, the accuracy for obtaining a specific diagnosis was significantly lower for EUS-FNA compared with EUS-TCB (5.3% and 68.4%, p<0.005). EUS-TCB did not appear to help as a rescue procedure in mediastinal tumours, after a false negative result of EUS-FNA. All cases of submucosal tumours were correctly classified by EUS-TCB as gastrointestinal stromal cell tumours (GISTs) or leiomyomas, while EUS-FNA raised only a suspicion of mesenchymal tumour. Conclusions. EUS-TCB was certainly useful when immunohistochemistry was needed, for example in submucosal tumours and lymphoma, as well as to confirm and characterize the primary or metastatic origin of mediastinal masses. The information provided by EUS-FNA and EUS-TCB is complementary, especially in selected cases where a complete histological diagnosis has an important impact on the clinical management.

EUS-guided trucut biopsy of hypoechoic intramural tumors of the stomach: a single-center experience in 17 cases

The aim of this prospective study was to assess the diagnostic yield and safety of EUS-guided trucut biopsy (TCB) in patients with hypoechoic intramural tumors (HITs) of the stomach.

Hypervascular pancreatic tumor diagnosed as a serous cystadenoma by EUS-guided Trucut biopsy

Hypervascular pancreatic tumor diagnosed as a serous cystadenoma by EUS-guided Trucut biopsy

Recurrent malignant thymoma diagnosed by EUS-guided Trucut biopsy

Recurrent malignant thymoma diagnosed by EUS-guided Trucut biopsy

Endoscopic Ultrasound Guided Trucut Biopsy of Pancreatic Cystic Lesions

Cystic pancreatic tumors are often associated with a distinctive clinical presentation, diverse pathological features, and usually indolent biological behavior. Clinical, imaging, laboratory, and pathology findings may permit early tumor detection, distinction from pseudocysts, and determination of the tumor type. The relatively limited accuracy of any one modality requires that we consider the combined results when making management decisions. Limitations of current techniques, including endoscopic ultrasound guided fine needle aspiration and cyst fluid analysis, have prompted efforts to develop improved diagnostic modalities, including endoscopic ultrasound guided trucut biopsy (EUS TCB). Although many centers have reported their experience with EUS TCB, there are no reports of the diagnostic utility and safety of EUS TCB. Our preliminary experience suggests that EUS TCB can safely be utilized in patients with cystic pancreatic tumors to provide a sufficient tissue sample to allow adequate histologic examination and diagnosis. The results may assist patient counseling and optimize clinical care and prognostic determination. The purpose of this chapter is to describe the potential role and technique of EUS TCB in patients with a cystic pancreatic lesion.

Endoscopic Ultrasound–Guided Trucut Biopsy of the Cyst Wall for Diagnosing Cystic Pancreatic Tumors

Nonoperative methods for diagnosis of pancreas cysts often lack sufficient accuracy. Accurate diagnosis is needed to determine prognosis and guide clinical management. The aim of this study was to determine whether the tissue obtained by endoscopic ultrasound-guided trucut biopsy (EUS TCB) is sufficient for histologic diagnosis of cystic pancreatic tumors (CPTs). EUS TCB was performed in patients with a suspected CPT. A dedicated gastrointestinal pathologist reviewed the core biopsies. The final diagnosis was based on clinical, laboratory, imaging, and biopsy findings, and resected specimens when available. EUS TCB was performed in 10 patients with a suspected CPT. Final diagnoses included serous cystadenoma (SCA, n=5), islet cell tumor (n=2), mixed seromucinous lesion (n=1), polycystic disease of the pancreas (n=1), and pseudocyst (n=1). EUS TCB was nondiagnostic in 3 of 10 patients. Among the other 7 patients, TCB diagnosed 4 SCAs, obviating the need for planned surgery in 3 patients. In the fourth patient with an SCA, the TCB result ruled out metastatic disease from locally recurrent lung cancer, allowing a narrowed radiation field. EUS TCB confirmed the need for surgery in 2 patients with an islet cell tumor. In 1 patient, EUS TCB findings were "partially" diagnostic, leading to previously unplanned surgery. This report establishes the capability and safety of EUS TCB to collect sufficient tissue for diagnosing CPTs. The results might help guide clinical management.

EUS-guided Trucut mural biopsies in the investigation of unexplained thickening of the esophagogastric wall

In patients with thickened esophagogastric wall on CT but without evidence of malignancy on endoscopic mucosal biopsies, obtaining adequate histology from the gut wall is difficult. We examined whether it is feasible to obtain diagnostic tissue core from the gut wall by using EUS-guided Trucut biopsy technique in this group of patients. Ten patients were included in this study. Under EUS guidance, mucosa was penetrated by using a 19-gauge Trucut needle, and a 18-mm tissue tray was advanced obliquely through the wall layers to avoid penetration of the serosa. Then, the cutting sheath was fired over the tray. Biopsies were performed without complications. Diagnoses of carcinoma were made in 5 patients. Four other patients had benign histology, and, during follow-up, all these diagnoses have been proven to be true negatives. One Trucut biopsy specimen was considered false negative. The EUS-guided Trucut mural biopsy technique could yield diagnostic tissue cores in patients with unexplained thickening of the esophagogastric wall.

EUS-guided Trucut biopsy of suspected nonfocal chronic pancreatitis

The diagnosis of early chronic pancreatitis (CP) is difficult, and the role of EUS-FNA cytology for this indication remains unclear. The aim of this study is to determine the utility and the safety profile of EUS-guided Trucut biopsy (EUS-TCB) for the histologic diagnosis of suspected nonfocal CP. After radial EUS, patients with suspected CP (> or =3 EUS criteria) underwent attempted transgastric EUS-TCB of the pancreas. Histopathologic specimens were examined by one pathologist and were classified as nondiagnostic, normal pancreas, and probable or definite CP. Within 1 week after EUS, ERCP was performed by an endoscopist blinded to the EUS results. The severity of CP by ERCP was stratified by the Cambridge classification. Agreement between tests for the diagnosis of CP was evaluated by a kappa statistic. Of 45 patients screened, 15 declined and 30 (12 men and 18 women, mean age 44 years) underwent diagnostic EUS. Of these, 18 (60%) had suspected CP and 16 underwent attempted biopsy. Calcific pancreatitis in two patients precluded EUS-TCB. EUS-TCB results were as follows: probable CP (1), normal pancreas (8), nondiagnostic (6), device malfunction (1). Complications after EUS-TCB occurred in two patients with normal pancreatic biopsies were the following: acute pancreatitis (1) and abdominal pain without pancreatitis (1), both of whom were hospitalized and discharged within 23 hours. Six patients refused ERCP and two (per protocol) did not undergo ERCP. For the remaining 22, agreement between diagnostic EUS and ERCP was moderate (kappa, 0.40). Agreement between EUS and ERCP with EUS-TCB were poor (kappa, 0) and fair (kappa, 0.25), respectively. Transgastric EUS-TCB of suspected nonfocal CP infrequently demonstrates histologic CP in clinically suspected disease. Because of potential complications and limited diagnostic yield, this technique is not currently recommended for evaluation of these patients.

Predictive Factors of Gastrointestinal Stromal Tumors in a Consecutive Series of Patients Evaluated by Endoscopic Ultrasound

Background: GISTs has been increasingly recognized since the development of immunohistochemical techniques allows for determination of CD117 or c-kit, an specific marker for GISTs. On the other hand, the diagnosis of GIST has important prognostic and therapeutic implications. Endosonographic predicting factors of GIST have never been investigated. Aim: To identify predictive factors of GIST in a consecutive series of patients with subepithelial tumors evaluated by EUS. Patients and Methods: We included all consecutive patients referred for EUS evaluation of a subepithelial tumor from September 1997 to December 2003 and who had histological or cytological definitive diagnosis. EUS was performed under conscious sedation with a radial echoendoscop (GF UM20 or GF UM160, Olympus). Variables analysed were: age, gender and US findings such as tumour size, location, echogenicity, echo pattern , margins, layer of origin, presence of calcifications, intratumoral nodules, cystic areas and lymph nodes. Gold standard used was histology of resected specimens (n = 58), endoscopic biopsies (n = 10), endoscopic resection (n = 5), EUS-guided trucut biopsy (n = 2) and EUS-guided FNA cytology (n = 5). Immunohistochemical determination of C-kit was positive in all cases. Results: Eighty six patients (44M/42F, mean age 59 + 16) with 88 lesions (44 GISTs/44no-GISTs) were evaluated. Final diagnosis was as follows: GISTs (n = 44), carcinoid tumour (n = 9), lipoma (n = 7), heterotopic pancreas (n = 7), leiomyoma (n = 4), esophageal cancer (n = 4), endometriosis (n = 2), granulous cell tumour (n = 2), metastases (n = 2), and miscellanea (n = 7). Malignancy was significantly higher in GISTs (18 vs 9, p = 0.04). Univariate analysis showed that GISTs were larger (46 ± 17 mm vs 30 ± 20 mm, p = 0.001), more heterogeneous (24 vs 11, p = 0.001), more often located in the stomach (39 vs 28, p = 0.006) originating in the muscularis propria (27 vs 11, p = 0.001) and with cystic areas (28 vs 6, p = 0.001) than non-GISTs tumors. The gastric location, origin in muscularis propria and the presence of cystic areas were the only variables that independently predicted GIST in the multivariate analysis. The ROC curve made with these three variables showed an AUC of 0.810. Conclusions: Localization in the stomach, origin in the muscularis propria and the presence of cystic areas are good predictors for GIST. This has important impact in terms of prognosis and therapeutic management. Background: GISTs has been increasingly recognized since the development of immunohistochemical techniques allows for determination of CD117 or c-kit, an specific marker for GISTs. On the other hand, the diagnosis of GIST has important prognostic and therapeutic implications. Endosonographic predicting factors of GIST have never been investigated. Aim: To identify predictive factors of GIST in a consecutive series of patients with subepithelial tumors evaluated by EUS. Patients and Methods: We included all consecutive patients referred for EUS evaluation of a subepithelial tumor from September 1997 to December 2003 and who had histological or cytological definitive diagnosis. EUS was performed under conscious sedation with a radial echoendoscop (GF UM20 or GF UM160, Olympus). Variables analysed were: age, gender and US findings such as tumour size, location, echogenicity, echo pattern , margins, layer of origin, presence of calcifications, intratumoral nodules, cystic areas and lymph nodes. Gold standard used was histology of resected specimens (n = 58), endoscopic biopsies (n = 10), endoscopic resection (n = 5), EUS-guided trucut biopsy (n = 2) and EUS-guided FNA cytology (n = 5). Immunohistochemical determination of C-kit was positive in all cases. Results: Eighty six patients (44M/42F, mean age 59 + 16) with 88 lesions (44 GISTs/44no-GISTs) were evaluated. Final diagnosis was as follows: GISTs (n = 44), carcinoid tumour (n = 9), lipoma (n = 7), heterotopic pancreas (n = 7), leiomyoma (n = 4), esophageal cancer (n = 4), endometriosis (n = 2), granulous cell tumour (n = 2), metastases (n = 2), and miscellanea (n = 7). Malignancy was significantly higher in GISTs (18 vs 9, p = 0.04). Univariate analysis showed that GISTs were larger (46 ± 17 mm vs 30 ± 20 mm, p = 0.001), more heterogeneous (24 vs 11, p = 0.001), more often located in the stomach (39 vs 28, p = 0.006) originating in the muscularis propria (27 vs 11, p = 0.001) and with cystic areas (28 vs 6, p = 0.001) than non-GISTs tumors. The gastric location, origin in muscularis propria and the presence of cystic areas were the only variables that independently predicted GIST in the multivariate analysis. The ROC curve made with these three variables showed an AUC of 0.810. Conclusions: Localization in the stomach, origin in the muscularis propria and the presence of cystic areas are good predictors for GIST. This has important impact in terms of prognosis and therapeutic management.

Endoscopic Ultrasound Guided Trucut Biopsy of the Cyst Wall in Establishing the Diagnosis of Cystic Pancreatic Tumors

Background: Non-operative methods for diagnosis of pancreas cysts (including EUS and cyst fluid analysis) often lack sufficient accuracy. Accurate diagnosis is needed to determine prognosis and guide clinical management. This is the first report of EUS TCB for preoperative diagnosis of cystic pancreatic tumors (CPTs). Aim: To determine if the tissue obtained by EUS TCB of the wall of a cyst is sufficient to determine the type of CPT. Methods: EUS TCB was performed in patients with a suspected CPT. A dedicated GI pathologist reviewed the core biopsies. The final diagnosis was based on clinical, laboratory, imaging and biopsy findings, and resected specimens when available. Charts were retrospectively reviewed to determine the feasibility of TCB. Results: EUS TCB was performed in 9 patients with a suspected CPT; mean age 67 years (range 43-84). The final diagnoses included serous cystadenoma (SCA, n=5), islet cell tumor (n=2), mixed seromucinous lesion (n=1), and pseudocyst (n=1). EUS TCB was non-diagnostic in 2 of 9 patients (one with a pseudocyst and one with a SCA). Among the other 7 patients, TCB diagnosed 4 SCAs, obviating the need for planned surgery in 3 of the 4 patients. In the fourth patient with a SCA, the TCB findings ruled-out metastatic disease from recurrent lung cancer allowing a more narrowed field of radiation. EUS TCB also confirmed the need for surgery in 2 patients with an islet cell tumor. In one patient, EUS TCB findings were “partially” diagnostic leading to previously unplanned surgery. Therefore, of the 9 patients undergoing EUS TCB, the findings of TCB altered the decision of whether to go to surgery in 4 patients, confirmed the need for surgery in 2 patients, and altered the field of radiation administered in 1 patient. No complications were identified after EUS TCB. Conclusions: This is the first report establishing the capability and safety of EUS TCB for diagnosing CPTs. The results help gastroenterologists and surgeons guide management and indicate or obviate the need for resection. Further study is needed to determine if the findings in this select population are widely applicable and to more clearly define the overall role of EUS TCB in patients with suspected CPTs.

The Safety of Endosonography-Guided FNA and/or Trucut Biopsy in Patients on Aspirin, NSAIDs or Prophylactic Low Molecular Weight Heparin

The Safety of Endosonography-Guided FNA and/or Trucut Biopsy in Patients on Aspirin, NSAIDs or Prophylactic Low Molecular Weight Heparin John Meenan, Laura Doig, Charles Vu Background: Endoscopic ultrasound (EUS)-FNA is classified as a high risk procedure for gastrointestinal bleeding under the American Society of Gastrointestinal Endoscopy guidelines. Limited data suggest that aspirin and other non-steroidal anti-inflammatory drug (NSAIDs) in standard doses do not increase the risk of significant bleeding after EGD or colonoscopy with biopsy, polypectomy or biliary sphincterotomy. Because of the paucity of data, the same recommendation is extrapolated to EUS-FNA. Aim: To compare the safety of EUS-guided FNA or trucut biopsy (TCB) in patients who are taking aspirin, NSAIDs or prophylactic low molecular weight heparin (LMWH) and those who are not. Methods: Consecutive patients undergoing EUS FNA or TCB were prospectively analyzed for all complications. We excluded patients on non-aspirin antiplatelet drugs from EUS-FNA or TCB because of their profound effect on platelets. Cystic aspirate cases were given routine antibiotic prophylaxis. All patients were assessed for evidence of immediate and late (by a phone call within 48hours for outpatient or by review as inpatient) complications after the procedure. Bleeding was considered significant if there was: hematemesis, melena, continuous intraluminal oozing requiring hemostatic procedures or EUS evidence of an expanding hypoechoic area extraluminally. Results: 224 patients underwent EUS-FNA or TCB on 243 sites (153 pancreatic, 55 intraabdominal, 34 mediastinal, 1 rectal), of which 194 were solid, 46 cystic and 3 ascites. One (3.6%) of 28 patients taking potentially risky drugs (23 aspirin/NSAIDs and 5 LMWH) developed extraluminal bleeding compared to 5 (2.6%) of the remaining 196 patients (p Z 0.263). None of these patients developed any clinically significant sequel. One patient from the low-risk group developed intraluminal bleeding requiring injection therapy and hemoclipping. Two patients (one from each group) reported self limiting mild hematemesis. One patient (0.65%) developed pancreatitis. There was no difference in the bleeding complications between the FNA and TCB group (p Z 0.246). Conclusion: EUS-FNA or TCB appears to be safe in patients taking aspirin, NSAIDs or prophylactic LMWH. W1256 Transrectal Ultrasound (TRUS) Helps Select Patients for Transanal Excision (TAE) of Early (T1) Rectal Cancers and Large Polyps Girish Mishra, Saulette Roberson, John Sweeney, Edward Levine, Russell Howerton, Greg Waters Background and Significance: TAE is an extremely effective and attractive surgical approach in patients with T1 rectal cancers and polyps that are not amenable to endoscopic removal. T2 rectal cancers have a higher local recurrence rate and may be selected for more invasive surgery with either a low anterior resection,or an abdomino perineal resection. Thus, accurate staging is critical in selecting patients for a TAE. TRUS is highly sensitive in T and N-staging for rectal cancer, but its diagnostic accuracy for distinguishing T1 and T2 rectal cancers has been challenged. Study Aims: To determine the accuracy of TRUS in determining resectability by TAE for T1 rectal cancers and polyps too large to be resected endoscopically. Methods: 183 TRUS were performed at our institution between August 2001 and October 2004. 21 TAE were performed for either T1 lesions by TRUS or for large polypoid masses localized to the mucosa by TRUS, but technically challenging to remove endoscopically. Results: The mean age of patients staged either T1 or T2 was 62 (33-80). 13 of 15 patients (87%) were accurately classified as having T1 disease. 2 lesions were understaged. 6 polypoid lesions (100%) that were either tubulovillous or villous adenomas were accurately classified as being localized to the mucosa. All patients (nZ11) staged T2 by TRUS were confirmed to be T2 at pathology. No difference was noted in the predictive value of TRUS for T1 vs T2 lesions (pZ.4923, exact test). Correlation between TRUS and pathology was kZ.85.Conclusions: TRUS is highly accurate in delineating depth of invasion for T1 rectal cancers and large, polypoid lesions unamenable to polypectomy. The ability to accurately delineate T1 vs T2 rectal cancer by TRUS allows for the appropriate selection of patients for TAE and thus, avoidance of more invasive surgery with higher morbidity and mortality.

Prospective Evaluation of EUS-Guided Tru-Cut Biopsy for Suspected Nonfocal Chronic Pancreatitis

Background: The diagnosis of early chronic pancreatitis (CP) is difficult and the role of EUS-FNA cytology remains debatable. Aims: 1) determine the utility and safety profile of EUS-guided tru-cut biopsy (EUS-TCB; Quick-Core, Wilson-Cook Medical, Inc.) for the diagnosis of suspected nonfocal CP; 2) Compare agreement of EUS and ERCP to each other and individually to EUS-TCB for suspected CP. Methods: Inclusion criteria: Patients between 18-60 yrs old with>3 months of upper abdominal pain and suspected CP.