Carmen Popescu

Combined contrast-enhanced power Doppler and real-time sonoelastography performed during EUS, used in the differential diagnosis of focal pancreatic masses (with videos).

BACKGROUND Contrast-enhanced power Doppler (CEPD) and real-time sonoelastography (RTSE) performed during EUS were previously described to be useful for the differential diagnosis between chronic pseudotumoral pancreatitis and pancreatic cancer. OBJECTIVE To prospectively assess the accuracy of the combination of CEPD and RTSE to differentiate pancreatic focal masses. DESIGN Cross-sectional feasibility study. SETTING A tertiary-care academic referral center. PATIENTS The study group included 54 patients with chronic pancreatitis (n = 21) and pancreatic adenocarcinoma (n = 33). INTERVENTIONS Both imaging methods (CEPD and RTSE) were performed sequentially during the same EUS examination. Power Doppler mode examination was performed after intravenous injection of a second-generation contrast agent (2.4 mL of SonoVue), and the data were digitally recorded, comprising both the early arterial phase and venous/late phase. Three 10-second sonoelastographic videos were also digitally recorded that included the focal mass and the surrounding pancreatic parenchyma. Postprocessing analyses based on specially designed software were used to analyze the CEPD and RTSE videos. A power Doppler vascularity index was used to characterize CEPD videos, the values being averaged during a 10-second video in the venous phase. Hue histogram analysis was used to characterize RTSE videos, with the mean hue histogram values being also averaged during a 10-second video. MAIN OUTCOME MEASUREMENTS To differentiate chronic pancreatitis and pancreatic cancer. RESULTS The sensitivity, specificity, and accuracy of combined information provided by CEPD and RTSE to differentiate hypovascular hard masses suggestive of pancreatic carcinoma were 75.8%, 95.2%, and 83.3%, respectively, with a positive predictive value and negative predictive value of 96.2% and 71.4%, respectively. LIMITATION A single-center, average size of study population. CONCLUSIONS A combination of CEPD and RTSE performed during EUS seems to be a promising method that allows characterization and differentiation of focal pancreatic masses.

Power Doppler endoscopic ultrasonography for the differential diagnosis between pancreatic cancer and pseudotumoral chronic pancreatitis.

Objective. The accuracy of endoscopic ultrasonography (EUS) and EUS‐guided fine‐needle aspiration for the differential diagnosis of pancreatic masses is variable in the literature, being as low as 75% in some studies. The aim of the study was to assess the accuracy of power Doppler EUS for the differential diagnosis between pancreatic cancer and pseudotumoral chronic pancreatitis. Methods. We included 42 consecutive patients with pancreatic tumor masses (27 men and 15 women) examined by EUS between January 2002 and August 2004. Endoscopic ultrasonographic procedures included power Doppler EUS as well as EUS‐guided fine‐needle aspiration in all patients. Final diagnosis of pancreatic cancer was confirmed in 29 patients on the basis of a combination of information provided by imaging tests, follow‐up of at least 6 months, and laparotomy in 18 patients for diagnostic or palliative reasons. Results. Sensitivity and specificity of the absence of power Doppler signals inside the suggestive pancreatic mass were 93% and 77%, respectively, with accuracy of 88%. Moreover, the addition of the information provided by the presence of peripancreatic collaterals improved the sensitivity and specificity to 97% and 92%, with accuracy of 95%. Conclusions. Power Doppler EUS provides useful information for the differential diagnosis of pancreatic masses. The results were in concordance with previous studies that showed a hypovascular pattern of pancreatic carcinoma, as well as the formation of collaterals in advanced cases due to the invasion of the splenic or portal veins. Further studies of dynamic EUS with contrast agents are necessary to better characterize pancreatic masses.

Multicenter randomized controlled trial comparing the performance of 22 gauge versus 25 gauge EUS–FNA needles in solid masses

Abstract Background and aims. Few randomized studies have assessed the clinical performance of 25-gauge (25G) needles compared with 22-gauge (22G) needles during endoscopic ultrasound-guided fine needle aspiration (EUS–FNA) biopsy of intra-abdominal lesions. We aimed to compare the diagnostic yield, as well as performance characteristics of 22G versus 25G EUS biopsy needles by determining their diagnostic capabilities, the number of needle passes as well as cellularity of aspirated tissue specimen. Methods. The study is a prospective, randomized, multicenter study. Patients were referred between January 2009 and January 2010 for diagnostic EUS including EUS-guided FNA of different lesions adjacent to the upper GI tract. All patients were randomized to EUS–FNA performed with either a 22G or 25G aspiration needle. Results. EUS–FNA was performed in 135 patients (62 patients with a 22G needle). Sensitivity and specificity of the 22G needle was 94.1% and 95.8%, respectively, and for the 25G needle 94.1% and 100%, respectively. Investigators reported better visualization and performance for the 22G needle compared to the 25G (p < 0.0001). The number of tissue slides obtained was higher for the 22G needle during the second and third needle passes (p < 0.05). We did not observe significant differences between the number and preservation status of obtained cells (p > 0.05). Conclusions. A significant difference was found between the two types of needles in terms of reduced visualization of the 25G needle and suboptimal performance rating. However, this did not impact on overall results since both needles were equally successful in terms of a high diagnostic yield and overall accuracy.

Confocal laser endomicroscopy and immunoendoscopy for real-time assessment of vascularization in gastrointestinal malignancies

Gastrointestinal cancers represent a major cause of morbidity and mortality, with incomplete response to chemotherapy in the advanced stages and poor prognosis. Angiogenesis plays a crucial part in tumor growth and metastasis, with most gastrointestinal cancers depending strictly on the development of a new and devoted capillary network. Confocal laser endomicroscopy is a new technology which allows in vivo microscopic analysis of the gastrointestinal mucosa and its microvascularization during ongoing endoscopy by using topically or systemically administered contrast agents. Targeting markers of angiogenesis in association with confocal laser endomicroscopic examination (immunoendoscopy), as a future challenge, will add functional analysis to the morphological aspect of the neoplastic process. This review describes previous experience in endomicroscopic examination of the upper and lower digestive tract with emphasis on vascularization, resulting in a broad spectrum of potential clinical applications, and also preclinical research that could be translated to human studies.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy: a pilot study for use in focal pancreatic masses.

Copyright emerged in recent years as a novel method that enables in vivo microscopic analysis during ongoing endoscopy. Recently, CLE has gone beyond the superficial luminal indications with the development of a newmicroprobe (nCLE) (Cellvizio;Mauna Kea Technology, Paris, France). The aim of the present case series was to study the feasibility of EUS-guided nCLE and to correlate the findings with microscopy.

Clinical impact of EUS elastography followed by contrast-enhanced EUS in patients with focal pancreatic masses and negative EUS-guided FNA.

AIMS It is well known that endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has a high sensitivity (over 85%) and specificity (100%) for diagnosis of pancreatic cancer. The aim of the study was to establish a EUS based clinical diagnostic algorithm in patients with pancreatic masses and negative cytopathology after EUS-FNA, based on previously published results and cut-offs of real-time elastographic (RTE) EUS and contrast-enhanced harmonic (CEH) EUS. MATERIAL AND METHODS We included in the study a subgroup of 50 consecutive patients with focal pancreatic masses which underwent EUS examinations with negative EUS-FNA. RTE-EUS and CEH-EUS were performed sequentially in all patients. The sensitivity, specificity and accuracy of these methods were calculated separately. A clinical decision algorithm based on elastography followed by CEH was established. RESULTS For the diagnosis of possible malignancy, the sensitivity, specificity and accuracy of RTE-EUS were: 97.7%, 77.4%, and 84% respectively. CEH-EUS had similar results: 89.5%, 80.7%, and 84%, respectively. In 25 patients with soft/mixed appearance during elastography,sequential assessment using contrast-enhanced EUSwas performed. The specificity of CEH-EUS for detection of chronic pancreatitis in this sub-set of patients was excellent (100%). In other 25 patients with hard appearance in elastography (low strain) CEH-EUS had an excellent specificity (100%) and accuracy (93%) in the detection of pancreatic cancer. CONCLUSIONS The proposed algorithm with sequential use of elastography followed by CEH could be a good clinical tool in the set of patients with negative EUS-FNA results for the differentiation between benign and malignant focal pancreatic masses.

Power Doppler endoscopic ultrasound for the assessment of pancreatic neuroendocrine tumors.

Objective: Pancreatic neuroendocrine tumors (PNET) represent rare, heterogeneous tumors with clinical, imaging and treatment particularities. The aim of this study was to assess the role of power Doppler endoscopic ultrasound (EUS) in the diagnosis and characterization of PNET. Methods: All consecutive patients with PNET assessed by power Doppler EUS in the Research Centre of Gastroenterology and Hepatology Craiova, Romania, in the past 51 months were included in the study. All EUS examinations were performed initially in gray-scale mode, followed by power Doppler mode examinations, before and after contrast-enhancement. Each recorded EUS movie was further subjected to post-processing using a computer-enhanced dynamic analysis using a special plug-in which permitted assessment of vascularity index (EUS-VI). Results: Based on the analysis of all consecutive malignant focal pancreatic masses diagnosed in the study period, a total number of 131 consecutive patients were included: 14 patients with pancreatic neuroendocrine tumors and 117 patients with pancreatic adenocarcinoma. The sensitivity of the pre-contrast EUS-VI for the diagnosis of PNET was 71.43%, similar to EUS-FNA. After contrast enhancement, the EUS-VI is also higher in PNET (27.07%) as compared to pancreatic adenocarcinoma where it was significantly lower 9.82% (P < 0.001). However, the sensitivity of EUS-VI after contrast enhancement for the diagnosis of PNET was 100%, higher than pre-contrast EUS-VI, with an acceptable specificity (79.49%) and better accuracy (81.68%). Conclusion: Power Doppler EUS represents a useful method in the initial assessment of PNET. Using evaluation of vascularity through EUS-VI, the differentiation between PNET and pancreatic cancer could be possible, especially in the subgroup of patients where EUS-guided fine needle aspiration is falsely negative.