Enrique Vazquez-Sequeiros

Utility of EUS in the evaluation of cystic pancreatic lesions.

BACKGROUND Preoperative differentiation of benign and malignant/potentially malignant pancreatic cystic lesions is problematic. Data to support the role of EUS and EUS-guided fine-needle aspiration (EUS-FNA) are limited. This study assessed the sensitivity, specificity, and accuracy of EUS, cytopathology, and analysis of cyst fluid for pancreatic cystic lesions. METHODS Retrospectively, 111 consecutive patients were identified (54 men, 57 women; mean age 59 years, range 18-79 years) who underwent EUS from July 1997 to September 2000 because of known or suspected pancreatic cystic lesions based on CT or transabdominal US. Thirty-four patients (16 men, 18 women; mean age 55 years, 25-79 years) who underwent surgery formed the basis for this analysis. EUS diagnosis was compared with surgical pathology. Selected patients underwent EUS-FNA to obtain specimens for cytopathologic analysis and for determination of carcinoembryonic antigen levels. Based on surgical pathology, cysts were classified as benign (simple cyst, pseudocyst, serous cystadenoma) or malignant/potentially malignant (mucinous cystadenoma, intraductal papillary mucinous tumor, cystic islet cell tumor, cystic adenocarcinoma). RESULTS EUS-FNA with cytopathologic assessment of cyst fluid was performed for 18 of the 34 patients; carcinoembryonic antigen level was determined in 11 cases. For EUS, cytopathology, and carcinoembryonic antigen, sensitivity was, respectively, 91%, (p = 0.01 vs. cytology), 27%, and 28%; specificity was, respectively, 60%, 100%, and 25%; and, accuracy was, respectively, 82%, 55%, and 27%. The sensitivity of EUS in all 13 patients with cystic islet cell tumor, intraductal papillary mucinous tumor, or cystic adenocarcinoma was 100%. Combining EUS, cytopathology, and carcinoembryonic antigen results did not improve accuracy. There were no complications related to the EUS or EUS-FNA. CONCLUSIONS EUS alone is sensitive and accurate in identifying malignant/potentially malignant pancreatic cystic lesions. EUS-FNA to obtain specimens for cytopathologic analysis and determination of carcinoembryonic antigen levels, although safe, does not enhance diagnostic yield.

Comparison of positron emission tomography, computed tomography, and endoscopic ultrasound in the initial staging of patients with esophageal cancer

IntroductionImprovement in esophageal cancer staging is needed. Positron emission tomography (PET), computed tomography (CT), and endoscopic ultrasound (EUS) in the staging of esophageal carcinoma were compared.MethodsPET, CT, and EUS were performed and interpreted prospectively in 75 patients with newly diagnosed esophageal cancer. Either tissue confirmation or fine needle aspiration (FNA) was used as the gold standard of disease. Sensitivity and specificity for tumor, nodal, and metastatic (TNM) disease for each test were determined. TNM categorizations from each test were used to assign patients to subgroups corresponding to the three treatment plans that patients could theoretically receive, and these were then compared.ResultsLocal tumor staging (T) was done correctly by CT and PET in 42% and by EUS in 71% of patients (P value > 0.14). The sensitivity and specificity for nodal involvement (N) by modality were 84% and 67% for CT, 86% and 67% for EUS, and 82% and 60% for PET (P value > 0.38). The sensitivity and specificity for distant metastasis were 81% and 82% for CT, 73% and 86% for EUS, and 81% and 91% for PET (P value > 0.25). Treatment assignment was done correctly by CT in 65%, by EUS in 75%, and by PET in 70% of patients (P value > 0.34).ConclusionsEUS had superior T staging ability over PET and CT in our study group. The tests showed similar performance in nodal staging and there was a trend toward improved distant disease staging with CT or PET over EUS. Assignment to treatment groups in relation to TNM staging tended to be better by EUS. Each test contributed unique patient staging information on an individual basis.

Initial experience with EUS-guided trucut needle biopsies of perigastric organs

BACKGROUND The aims of this study were to determine the feasibility, safety, and yield of a 19-gauge EUS-guided-trucut needle for obtaining biopsy specimens of perigastric organs. METHODS The study was performed in swine under general anesthesia. EUS-guided trucut needle biopsy specimens were obtained from the spleen, liver, pancreas body, and left kidney. Biopsy specimens were assessed for size, fragmentation, and representation of the target organ. OBSERVATIONS Twenty-eight biopsy specimens were obtained from the 4 target organs with two needles. Median biopsy length was 6 mm (spleen), 4 mm (liver), 6 mm (left kidney), and 2 mm (pancreas body). Of all the specimens, 75% to 100% had tissue representative of the target organ. EUS visualization of the needle was excellent and no complications were identified. CONCLUSIONS Use of the trucut needle under EUS guidance to obtain biopsy specimens of perigastric organs appears safe and yields specimens that are representative of the target organ sampled. Further study of the utility and safety of this needle in humans is warranted.

Age-related changes in the pancreas identified by EUS: a prospective evaluation.

BACKGROUND EUS is an important modality for the diagnosis of pancreatic disease. An understanding of normal pancreatic ductal and parenchymal variation in asymptomatic individuals is essential to improve EUS accuracy. The primary aim of this study was to determine age-related pancreatic parenchymal and ductular changes identifiable on EUS in individuals with no history or symptoms of pancreaticobiliary disease. Secondary aims were to define demographic and clinical factors associated with identifiable pancreatic parenchymal and ductular changes, and to determine the main pancreatic-duct diameter and pancreatic-gland width according to age. METHODS Patients referred for either upper endoscopy or EUS for an indication unrelated to pancreaticobiliary disease were prospectively enrolled. Patients were stratified by age (<40, 40-60, >60 years). Each patient was assessed for the presence of EUS findings for chronic pancreatitis. Logistic regression was used to identify factors associated with an abnormality. RESULTS A total of 120 patients (63 men, 57 women; median age, 52 years, interquartile range [IQR] 40-61 years) were prospectively evaluated. At least one parenchymal and/or ductular abnormality was identified in 28% of the patients, with a trend of increasing abnormality with age: <40 years (23%), 40 to 60 years (25%), and >60 years (39%); p = 0.13. No patient had more than 3 abnormal EUS features. Hyperechoic stranding (n = 22) was the most common finding in all age groups. The odds for any abnormality in men (relative to women) was significantly higher (OR 2.9: 95% CI[1.2, 6.8], p = 0.01), with 38% of men and 18% of women having an abnormality. Smoking, low alcohol intake, body mass index, and endoscopic finding were not significantly associated with an abnormal EUS. The overall median pancreatic-gland width and main pancreatic duct diameter were 15 mm (IQR 6-25 mm) and 1.7 mm (IQR 0.9-4.3 mm), respectively. CONCLUSIONS The frequency of EUS abnormalities in patients without clinical evidence of chronic pancreatitis increases with age, particularly after 60 years of age. The threshold number of EUS criteria for the diagnosis of chronic pancreatitis is variable. However, the typically used standard of 3 or more criteria appears appropriate. A higher number of threshold criteria may be needed in males and to a lesser extent in patients over 40 years of age, which should be related to clinical history and other structural or functional studies. Ductal or parenchymal calculi, ductal narrowing, ductal dilatation, or more than 3 abnormalities appear to be more specific features for the EUS diagnosis of chronic pancreatitis at any age.

Evaluation of indeterminate bile duct strictures by intraductal US

BACKGROUND Cholangiography and tissue sampling (brush cytology, biopsy) are the standard nonsurgical techniques for determining whether a bile duct stricture is benign or malignant. The aim of this study was to determine whether intraductal US is of assistance in distinguishing benign from malignant biliary strictures. METHODS A retrospective review was undertaken of 30 patients with indeterminate bile duct strictures who underwent ERCP and tissue sampling from September 1999 to November 2000. A 20 MHz over-the-guidewire intraductal US catheter probe was used during ERCP for further examination of the strictures. Final diagnoses of malignant strictures (18 patients) were confirmed histopathologically; confirmation of benign stricture (12 patients) was based on negative tissue sampling plus extended clinical follow-up. RESULTS Based on retrospective blinded review, the diagnosis by ERCP was correct in 67% of patients, by tissue sampling in 68%, by combined ERCP/tissue sampling in 67%, and by intraductal US in 90% (p = 0.04 vs. ERCP/tissue sampling) of cases. No complication of intraductal US or ERCP was recorded. CONCLUSIONS Intraductal US is safe and can improve on the ability at ERCP to distinguish benign from malignant biliary strictures.

Prospective comparison of helical CT (HCT), endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) for preoperative esophageal cancer (EC) staging

Prospective comparison of helical CT (HCT), endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) for preoperative esophageal cancer (EC) staging

Evaluation of indeterminate bile duct (BD) stenosis with a new over the wire intraductal ultrasound probe (IDUS)

Evaluation of indeterminate bile duct (BD) stenosis with a new over the wire intraductal ultrasound probe (IDUS)