Alfredo J. Hernandez

Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography.

BACKGROUND AND STUDY AIMS Endoscopic retrograde cholangiography (ERC) with stenting is the procedure of choice for biliary decompression in patients with obstructive jaundice. In cases where biliary access cannot be achieved, interventional endoscopic ultrasound-guided cholangiography (IEUC) has become an alternative to percutaneous transhepatic cholangiography (PTC). PATIENTS AND METHODS We report on 5 years of experience in patients who underwent IEUC after failed endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided access to the targeted biliary duct was attempted with one of two approaches: transgastric-transhepatic (intrahepatic) or transenteric-transcholedochal (extrahepatic). A stent was then advanced over the wire and into the biliary tree. RESULTS A total of 49 patients underwent IEUC: 35 had biliary obstruction due to malignancy and 14 had a benign etiology. The overall success rate of IEUC was 84% (41/49), with an overall complication rate of 16%. Of the 35 patients who underwent the intrahepatic approach, 23 had a stent placed across the major papilla, one had a stent placed intraductally in the common bile duct, and three patients underwent placement of a gastrohepatic stent. Resolution of obstruction was achieved in 29 patients, with a success rate of 83%. In all, 14 patients underwent an extrahepatic approach. In 8/14 (57%), stent placement across the major papilla was achieved. A transenteric stent was placed in four patients. Biliary decompression was achieved in 12/14 cases (86%). Based on intention-to-treat analysis, the intrahepatic approach achieved success in 29 of 40 cases (73%), and the extrahepatic approach was successful in seven of nine cases (78%). There were no procedure-related deaths. CONCLUSION IEUC offers a feasible alternative to PTC in patients with obstructive jaundice in whom ERC has failed.

Does FDG-PET Add Information to EUS and CT in the Initial Management of Esophageal Cancer? A Prospective Single Center Study

PURPOSE:There is no algorithm for the initial staging of esophageal cancer that is considered standard of care. This prospective blinded study analyzes the utility of FDG-PET as an adjunct to EUS and CT for the management of patients with esophageal cancer.METHODS:Between December 2003 and October 2006, patients diagnosed with esophageal carcinoma underwent EUS, CT, and FDG-PET at their initial evaluation. Two thoracic surgeons were given staging EUS results and CT scan reports. They were asked if the patient needed surgical resection, neoadjuvant chemotherapy followed by resection, or palliation. With each case, one surgeon was unblinded to the FDG-PET results. The treatment decisions of each surgeon were compared to determine if PET altered clinical management.RESULTS:A total of 50 patients (45 male, 5 female) were enrolled and data were prospectively collected. Forty-three (86%) had adenocarcinoma and 7 (14%) had squamous cell carcinoma. EUS was completed in 88% (44) of cases while 6 (12%) were incomplete secondary to tight stenosis. Nineteen were treated with surgery, 25 with neoadjuvant chemotherapy and surgery, and 6 with palliative chemoradiation. In 49 of 50 patients, the surgeons came to identical management decisions independent of PET results. In the one case that the treatment decision differed, the EUS was incomplete. The agreement on treatment strategy was 98% (κ= 0.97, 95% CI 0.93–0.99).CONCLUSION:This study shows that the addition of FDG-PET to EUS and CT offers little information to the initial treatment stratification of patients with esophageal cancer. However, in patients with incomplete EUS, FDG-PET may have some clinical utility.

EUS-FNA as the initial diagnostic modality in centrally located primary lung cancers.

Background and Aims The need to safely and accurately diagnose lung neoplasms is crucial as the only prospect for a cure is surgical resection. A small amount of data exists on the use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) as the initial diagnostic modality of primary lung cancer. Methods We performed a retrospective review of an established prospective database of all patients undergoing EUS-FNA of a primary lung neoplasm adjacent to the esophagus during January 2001 to August 2005 in one tertiary care center. The indications for the procedure, diagnostic accuracy, and complications were reviewed. Results A total of 17 cases (9 females, 8 males) were identified. The mean age was 66 (SD 10.6). There were 9 lesions within the hilum and 8 lesions within the upper lobes. The median size of the lung lesions was 5 (range 2 to 12)×4 (range 2 to 9) cm. The median and mean number of FNA passes was 3. All the procedures provided an accurate diagnosis of the primary lung lesion without need for further intervention. One patient with active hemoptysis was transiently hospitalized for aspiration pneumonia postprocedure. Conclusions EUS-FNA is a safe, relatively cost-effective, and accurate initial diagnostic modality for the diagnosis of lung lesions adjacent to the esophagus or invading the mediastinum. Although further randomized prospective trials are warranted, this modality should be considered as a first step in the diagnostic armamentarium in centrally located lung lesions.

Endoscopic Ultrasound-guided Fine Needle Aspiration of a Malignant Pleural Effusion to Diagnose and Stage Lung Cancer: When Should this Approach be Considered?

A 77-year-old asymptomatic man with a history of longterm tobacco use was referred for EUS of an enlarged subcarinal lymph node noted on a routine follow-up computerized tomography (CT) (Fig. 1). He had a history of stage IVB squamous cell carcinoma of the right nasal cavity for which he had undergone induction radiation therapy and craniofacial resection in June 2004, as well as a history of stage IA pulmonary adenocarcinoma for which he had undergone a left upper lobectomy in February 2004. The goal of EUS was to obtain diagnostic and staging information. Linear array EUS (GFUC-140P, Olympus America Inc., Melville, NY) failed to reveal an enlarged subcarinal lymph node that had been noted on CT. However, a right pleural effusion with adhesed solid pleuralbased lesions was noted (Fig. 2). Prophylactic intravenous antibiotics were administered, and a 22-gauge needle was used to make one pass into the pleural lesions/fluid. Cytologic smears were hypercellular and showed a uniform population of discohesive small cells (approximately two to three times the size of resting lymphocytes) that had scant cytoplasm (Fig. 3). Crush artifact and nuclear molding were present, and the neoplastic cells had granular chromatin devoid of nucleoli. Numerous mitotic figures and apoptotic bodies were present. Immunocytochemistry showed the neoplastic cells to react with antibodies to pankeratin and not with antibodies to CD45 (leukocyte common antigen). A diagnosis of small cell carcinoma was rendered.