Frank G. Gress

Endoscopic ultrasound–guided fine-needle aspiration biopsy using linear array and radial scanning endosonography

BACKGROUND Endoscopic ultrasound (EUS) accurately stages gastrointestinal malignancies but is less able to differentiate between neoplastic and inflammatory processes. EUS-guided fine-needle aspiration (EUS FNA) has been reported useful for obtaining a diagnosis in suspected gastrointestinal lesions. We report our entire experience with EUS FNA using both radial and linear array endosonography, including our diagnostic accuracy and complication rate. METHODS Two hundred eight consecutive patients (119 men, 89 women) referred for EUS evaluation of suspected gastrointestinal or mediastinal masses underwent EUS-guided FNA. We performed EUS FNA using radial scanning or linear array endosonography and a 23 gauge, 4 cm needle or a 22 gauge, 12 cm needle. Data collected included lesion types, number of passes, complications, and diagnostic accuracy. RESULTS Two hundred eight lesions were targeted, with a total of 705 FNA passes (mean 3.39 passes/patient). Overall diagnostic accuracy for our study population was 87% with a 89% sensitivity and 100% specificity. The diagnostic accuracy for each subgroup was 95% for mediastinal lymph node, 85% for intra-abdominal lymph node, 85% for pancreatic, 84% for submucosal, and 100% for perirectal masses. EUS FNA provided an adequate specimen in 90% of patients. The FNA results were similar for both types of endosonography. We observed immediate complications in 2% (4 of 208) of patients. All complications occurred with EUS FNA of pancreatic lesions and consisted of bleeding and pancreatitis in 2 patients each. For EUS FNA of pancreatic masses there was a 1.2% (2 of 121) risk of pancreatitis, 1% (1/121) risk of severe bleeding, and risk of death in less than 1%. CONCLUSIONS EUS-guided FNA appears to be technically feasible, safe, and accurate for obtaining diagnostic tissue of suspicious gastrointestinal and mediastinal lesions and provides important preoperative information.

Endoscopic Ultrasonography, Fine-Needle Aspiration Biopsy Guided by Endoscopic Ultrasonography, and Computed Tomography in the Preoperative Staging of Non-Small-Cell Lung Cancer: A Comparison Study

Accurate staging of non-small-cell lung cancer plays a crucial role in determining the treatment options available to patients with this disease. The preoperative documentation of metastasis to the mediastinal lymph nodes has therapeutic implications that have traditionally focused on palliation but more recently have included neoadjuvant strategies [1, 2]. Metastasis to the mediastinal lymph nodes occurs in nearly half of all patients with non-small-cell lung cancer. The development of mediastinal metastasis is probably the most frequent deterrent to cure, even when the presentation is localized. If metastasis involves contralateral or large, bulky (>1.5 to 2.0 cm) subcarinal lymph nodes, surgery alone may not be curative [3-9]. As a result of recent revisions to the staging systems for lung cancer, ipsilateral mediastinal and subcarinal lymph node involvement is now classified as potentially resectable, N2 disease; contralateral mediastinal lymph node involvement (N3 disease) precludes resection [10-12]. Computed tomography of the chest is the current method by which mediastinal lymphadenopathy is detected in non-small-cell lung cancer. However, its sensitivity for detection of metastasis to the lymph nodes varies; accuracy in previous studies has ranged from 52% to 88% [13-23]. This inconsistency has been attributed to the variable correlation of lymph node size with the presence of malignancy. When enlarged contralateral or ipsilateral mediastinal lymph nodes are seen on computed tomography of the chest, standard practice is to determine more accurate staging by performing aspiration biopsy of the lymph node with computed tomographic guidance; bronchoscopy; or, less commonly, a transthoracic approach. If these procedures are unsuccessful, open biopsy is performed by using mediastinoscopy or limited thoracotomy [24-26]. If contralateral lymph nodes are positive for malignancy, surgical resection of the primary tumor is contraindicated. The development of endoscopic ultrasonography has now made it possible to visualize, with high resolution, not only the gastrointestinal tract but also surrounding structures. Endoscopic ultrasonography has been shown to be superior to computed tomography in evaluating lymph nodes for metastases in esophageal, gastric, and pancreatic cancer [27-29]. Promising results for detecting posterior mediastinal lymph nodes in patients with lung cancer suggest a possible role for endoscopic ultrasonography in staging lymph nodes in patients with non-small-cell lung cancer [30-36]. Fine-needle aspiration biopsy guided by endoscopic ultrasonography was recently reported to further improve the accuracy of endoscopic ultrasonography in predicting malignancy of gastrointestinal masses, with rates as high as 87% to 91% [37-42]. We previously reported the results of endoscopic ultrasonography in 17 patients with lung cancer. This method was very accurate for detecting mediastinal lymphadenopathy; the overall accuracy was 71% compared with 41% for computed tomography (P = 0.032) [43]. During the initial study, however, fine-needle aspiration biopsy guided by endoscopic ultrasonography was not available. The goal of the present study was to prospectively evaluate the accuracy of endoscopic ultrasonography alone, endoscopic ultrasonography-guided fine-needle aspiration biopsy, and computed tomography of the chest in detecting mediastinal lymph node metastasis in patients with non-small-cell lung cancer. Methods Patient Selection The study sample consisted of all patients presenting to the Indiana University Thoracic Oncology Program between July 1993 and June 1995 with a diagnosis of non-small-cell lung cancer. The study was approved by the institutional review board, and all enrolled patients gave informed consent. Patients were excluded if they had documented unresectable disease (that is, distant metastasis or locally advanced staged disease [stage III b]) as shown on computed tomography of the chest or if they had a serious medical illness and a life expectancy of less than 1 year. All patients underwent initial preoperative intravenous contrast-enhanced computed tomography of the chest; the axial technique was used in 60% of patients, and the spiral technique was used in 40%. Computed tomography was done at the referring hospital or Indiana University Medical Center; the scans were read at Indiana University Medical Center by a senior attending radiologist who has recognized expertise in this area and used currently accepted radiographic techniques to stage the tumor. The radiologists determination of the benign or malignant nature of each lymph node was recorded on a preoperative computed tomography lymph node map; the American Thoracic Society mediastinal staging map (Figure 1) was used to describe the location of each node [12]. Any patient who had a questionably enlarged mediastinal lymph node (>1 cm in diameter) and was considered a surgical candidate was then scheduled for endoscopic ultrasonography. Figure 1. American Thoracic Society scheme for mapping mediastinal lymphadenopathy by anatomic location, as seen from behind with endoscopic ultrasonography. Endoscopic Ultrasonography Endoscopic ultrasonography was performed in an outpatient setting on all patients by one of three experienced endosonographers; the radial scanning echoendoscope (GFUM-20, Olympus America, Melville, New York) or the linear-array scanning echoendoscope (FG32UA, Pentax, Orangeburg, New York) was used for all procedures. When done by an experienced operator, endoscopic ultrasonography is similar to standard upper endoscopy both in technique and duration of the procedure. When fine-needle aspiration biopsy is performed, the procedure is slightly prolonged. Patients were sedated with meperidine and midazolam, the doses of which were titrated to achieve adequate conscious sedation. The instrument was advanced into the stomach, and the celiac axis was imaged. The probe was then withdrawn to the gastroesophageal junction and slowly withdrawn at 1-cm intervals. Images were obtained with 7.5- and 12-MHz frequencies at each interval. All imaged mediastinal lymph nodes were mapped by location according to the American Thoracic Society classification scheme [12]. From these data, an objective assessment was made as to whether the mediastinal lymphadenopathy detected by endoscopic ultrasonography was benign or possibly malignant according to the following previously reported criteria for malignancy: round shape; sharp, distinct borders; hypoechoic texture; and a short-axis diameter greater than 5 mm [36-39]. Malignancy was suspected if all of these criteria were present. All patients who were studied before the availability of endoscopic ultrasonography-guided fine-needle aspiration biopsy underwent surgical resection, and endoscopic ultrasonographic findings were correlated to surgical pathologic findings. Patients who were studied after the advent of fine-needle aspiration biopsy and were found to have no suspicious lymph nodes by endoscopic ultrasonography were directly referred for surgery because there was no indication for aspiration biopsy. Endoscopic Ultrasonography-Guided Fine-Needle Aspiration Biopsy Endoscopic ultrasonography-guided aspiration biopsy became available after the first 17 patients were enrolled in our pilot study. All posterior mediastinal lymph nodes that were suspicious for malignant involvement according to the endoscopic ultrasonographic criteria were noted; selected nodes underwent biopsy during the same procedure. Many of the patients had more than one suspicious lymph node. We performed biopsy only on the most suspicious lymph node, which would have the greatest effect on clinical staging (that is, determination of whether the metastasis was contralateral or subcarinal). This technique for ultrasonography-guided aspiration biopsy was initially developed for use with the linear-array instrument (Figure 2) and is described elsewhere [40-42]. We recently reported a similar technique that uses a radial scanning echoendoscope (Figure 3) [37]. Ultrasonography-guided aspiration biopsy involves the insertion of an aspiration catheter needle device through the accessory channel port of the echoendoscope; the needle is then deployed into the lymph node to be sampled under endoscopic ultrasonographic guidance. Aspiration biopsy is done by introducing a specially designed fine-needle aspiration catheter system that consists of a 4-cm long, 23-gauge needle attached to a 180-cm long, 5-French aspiration catheter (Wilson-Cook, Winston-Salem, North Carolina); in and out movements of the catheter are used while the operator firmly grasps the catheter at the point at which it enters the accessory port. Figure 2. A mediastinal lymph node as imaged with the linear-array endoscopic ultrasonography system. arrow Figure 3. Endoscopic ultrasonographic image obtained from the radial scanning instrument showing a large hypoechoic, oval subcarinal lymph node (LN) suspicious for metastatic involvement. Preliminary cytologic findings were obtained during fine-needle aspiration biopsy by a cytopathologist who was present during the procedure. Before the sample was reviewed, Diff-Quik stain (Harleco, Gibbstown, New Jersey) was applied to the slide that contained the deposited specimen. Additional passes were made until a positive cytologic result or a negative result on an adequate tissue sample was obtained [37]. Patients who were considered eligible for surgical resection after staging by computed tomography and endoscopic ultrasonography (that is, patients with a negative result on aspiration biopsy of contralateral or bulky subcarinal lymph nodes or those with nodes that seemed to be benign according to endoscopic ultrasonographic criteria) underwent thoracotomy for pulmonary resection with ipsilateral mediastinal and subcarinal lymph node dissection. During mediastinal dissection, each lymph node was placed in th

A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain

A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain

Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience.

Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience

Circumferential ablation of Barrett's esophagus that contains high-grade dysplasia: a U.S. multicenter registry

BACKGROUND The management strategies for Barretts esophagus (BE) that contains high-grade dysplasia (HGD) include intensive endoscopic surveillance, photodynamic therapy, thermal ablation, EMR, and esophagectomy. OBJECTIVE To assess the safety and effectiveness of endoscopic circumferential balloon-based ablation by using radiofrequency energy for treating BE HGD. DESIGN Multicenter U.S. registry. SETTING Sixteen academic and community centers; treatment period from September 2004 to March 2007. PATIENTS Patients with histologic evidence of intestinal metaplasia (IM) that contained HGD confirmed by at least 2 expert pathologists. A prior EMR was permitted, provided that residual HGD remained in the BE region for ablation. INTERVENTION Endoscopic circumferential ablation with follow-up esophageal biopsies to assess the histologic response to treatment. OUTCOMES Histologic complete response (CR) end points: (1) all biopsy specimen fragments obtained at the last biopsy session were negative for HGD (CR-HGD), (2) all biopsy specimens were negative for any dysplasia (CR-D), and (3) all biopsy specimens were negative for IM (CR-IM). RESULTS A total of 142 patients (median age 66 years, interquartile range [IQR] 59-75 years) who had BE HGD (median length 6 cm, IQR 3-8 cm) underwent circumferential ablation (median 1 session, IQR 1-2). No serious adverse events were reported. There was 1 asymptomatic stricture and no buried glands. Ninety-two patients had at least 1 follow-up biopsy session (median follow-up 12 months, IQR 8-15 months). A CR-HGD was achieved in 90.2% of patients, CR-D in 80.4%, and CR-IM in 54.3%. LIMITATIONS A nonrandomized study design, without a control arm, a lack of centralized pathology review, ablation and biopsy technique not standardized, and a relatively short-term follow-up. CONCLUSIONS Endoscopic circumferential ablation is a promising modality for the treatment of BE that contains HGD. In this multicenter registry, the intervention safely achieved a CR for HGD in 90.2% of patients at a median of 12 months of follow-up.

Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer.

Background/Goals Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) and celiac plexus neurolysis (CPN) have become important interventions in the management of pain due to chronic pancreatitis and pancreatic cancer. However, only a few well-structured studies have been performed to evaluate their efficacy. Given limited data, their use remains controversial. Herein, we evaluate the efficacy of EUS-guided CPB and CPN in alleviating chronic abdominal pain due to chronic pancreatitis and pancreatic cancer respectively. Study Methods Using Medline, Pubmed, and Embase databases from January 1966 through December 2007, a thorough search of the English literature for studies evaluating the efficacy of EUS-guided CPB and CPN for the management of chronic abdominal pain due to chronic pancreatitis and pancreatic cancer was conducted, along with a hand search of reference lists. Studies that involved less than 10 patients were excluded. Data on pain relief was extracted, pooled, and analyzed. Results A total of 9 studies were included in the final analysis. For chronic pancreatitis, 6 relevant studies were identified, comprising a total of 221 patients. EUS-guided CPB was effective in alleviating abdominal pain in 51.46% of patients. For pancreatic cancer, 5 relevant studies were identified with a total of 119 patients. EUS-guided CPN was effective in alleviating abdominal pain in 72.54% of patients. Conclusions EUS-guided CPB was 51.46% effective in managing chronic abdominal pain in patients with chronic pancreatitis, but warrants improvement in patient selection and refinement of technique, whereas EUS-guided CPN was 72.54% effective in managing pain due to pancreatic cancer and is a reasonable option for patients with tolerance to narcotic analgesics.

Principles of training in gastrointestinal endoscopy

1997-1998 James L. Achord, M.D., Chairman H. Worth Boyce, M.D. Steve Goodman, M.D. Frank Gress, M.D. Glenn W. W. Gross, M.D. Neil A. Jacobson, M.D. Stephen P. Martin, M.D. Paul Petersen, M.D. (TRAINEE) Francisco C. Ramirez, M.D. Choichi Sugawa, M.D. The American Society for Gastrointestinal Endoscopy publishes guidelines for training in gastrointestinal endoscopy to ensure optimal procedural training standards. The last guideline (1991)1 established threshold numbers at which competence could be subjectively assessed in various procedures. These numbers were intended to indicate numbers of procedures performed below which no trainee could reasonably expect to be competent, and most trainees require more than these minimal numbers. Unfortunately, the numbers have been widely used as goals to indicate competence. Research in objective evaluation of procedural skills makes revision of the guidelines at this time highly appropriate. Although developed with particular reference to gastroenterology fellowship programs, the following statement has broader applicability in other settings in which endoscopic training occurs.

Endoscopic ultrasound characteristics of mucinous cystic neoplasms of the pancreas

Abstract OBJECTIVE: Mucinous cystic neoplasms of the pancreas have a more favorable prognosis than ductal adenocarcinoma. Management of a subgroup, intraductal papillary-mucinous neoplasms, is controversial. Endoscopic ultrasound (EUS) with fine-needle aspiration biopsy may emerge as the imaging modality of choice. There are few studies describing the EUS features of these tumors. METHODS: A total of 35 consecutive cases of cystic tumors of the pancreas with an established pathological diagnosis were analyzed for characteristic EUS features. RESULTS: Mucinous cystadenocarcinomas (n = 14) were more likely to be characterized by hypoechoic cystic/solid mass or complex cyst and were frequently associated with a dilated main pancreatic duct. Benign mucinous duct ectasia (n = 6) were characterized by a dilated main pancreatic duct in conjunction with hyperechoic thickening of the duct wall. The two cases of intraductal mucinous hyperplasia additionally showed a hypoechoic mass. Intraductal papillary carcinoma (n = 11) had features in common with mucinous cystadenocarcinoma but also had echogenic foci in the mass and intraductal hyperechoic lesions. The two cases of microcystic cystadenoma showed either a mixed hypoechoic solid/cystic mass or a complex cyst without the additional features seen in mucinous cystadenocarcinoma. CONCLUSIONS: EUS features seem to exist that may help to differentiate cystic neoplasms from adenocarcinoma of the pancreas and, thus, to establish the preoperative diagnosis of cystic tumors of the pancreas.

Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States

BACKGROUND The aim of this study was to determine the frequency and the severity of pancreatitis after EUS-guided FNA of solid pancreatic masses. A survey of centers that offer training in EUS in the United States was conducted. METHODS A list of centers in which training in EUS is offered was obtained from the Web site of the American Society for Gastrointestinal Endoscopy. Designated program directors were contacted via e-mail. The information requested included the number of EUS-guided FNA procedures performed for solid pancreatic masses, the number of cases of post-procedure pancreatitis, and the method for tracking complications. For each episode of pancreatitis, technical details were obtained about the procedure, including the location of the mass, the type of fine needle used, the number of needle passes, and the nature of the lesion. RESULTS Nineteen of the 27 programs contacted returned the questionnaire (70%). In total, 4909 EUS-guided FNAs of solid pancreatic masses were performed in these 19 centers over a mean of 4 years (range 11 months to 9 years). Pancreatitis occurred after 14 (0.29%): 95% CI[0.16, 0.48] procedures. At two centers in which data on complications were prospectively collected, the frequency of acute pancreatitis was 0.64%, suggesting that the frequency of pancreatitis in the retrospective cohort (0.26%) was under-reported (p=0.22). The odds that cases of pancreatitis would be reported were 2.45 greater for the prospective compared with the retrospective cohort (95% CI[0.55, 10.98]). The median duration of hospitalization for treatment of pancreatitis was 3 days (range 1-21 days). The pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in one; one death (proximate cause, pulmonary embolism) occurred after the development of pancreatitis in a patient with multiple comorbid conditions. CONCLUSIONS EUS-guided FNA of solid pancreatic masses is infrequently associated with acute pancreatitis. The procedure appears to be safe when performed by experienced endosonographers. The frequency of post EUS-guided FNA pancreatitis may be underestimated by retrospective analysis.

EUS-guided fine-needle aspiration of the pancreas: evaluation of pancreatitis as a complication.

BACKGROUND EUS-guided fine-needle aspiration is rapidly becoming the procedure of choice for the diagnostic evaluation of pancreatic masses. Acute pancreatitis has been reported after EUS-guided fine-needle aspiration of the pancreas. This study evaluated the effect of EUS-guided fine-needle aspiration on the pancreas by serial measurement of amylase and lipase levels and determining the frequency of acute pancreatitis after EUS-guided fine-needle aspiration of pancreatic masses. METHODS In 100 consecutive patients referred for EUS-guided fine-needle aspiration of a pancreatic mass, amylase and lipase levels were determined immediately before and within 2 hours after the procedure. Additionally, patients were questioned as to the occurrence of symptoms of acute pancreatitis within 48 hours after EUS-guided fine-needle aspiration. RESULTS For 2 of 100 patients (2%) there was clinical and biochemical evidence of acute pancreatitis after EUS-guided fine-needle aspiration. Both patients had a history of recent pancreatitis. In addition, there was a significant increase in postprocedure lipase levels (p = 0.40) compared with amylase levels in this patient subset. CONCLUSION The frequency of acute pancreatitis after EUS-guided fine-needle aspiration of the pancreas was 2% in this study. A history of recent pancreatitis appears to be a potential risk factor. Amylase and lipase levels can be elevated after EUS-guided fine-needle aspiration and in most cases have no clinical significance.