Grace E. White

The level of carcinoembryonic antigen and the presence of mucin as predictors of cystic pancreatic mucinous neoplasia.

Objectives: Characterization of pancreatic cysts using endoscopic ultrasound-guided fine-needle aspiration includes cytological interpretation and chemical analysis. We prospectively analyzed the contribution of carcinoembryonic antigen (CEA) and cytological identification of extracellular mucin as predictors of mucinous neoplasia and malignancy. Methods: From January 2003 to October 2005, all patients referred to the University of Virginia with cystic lesions of the pancreas underwent endoscopic ultrasound-guided fine-needle aspiration with cytological evaluation and CEA level analysis. Data were collected prospectively and confirmed by resection or tissue biopsy. Univariate and multivariate analyses were performed on the following variables with regard to their ability to predict mucinous neoplasia: age (<55 or >55 years), sex, CEA level (<300 or >300 ng/mL), and cytological appreciation of extracellular mucin (positive or negative). P values less than 0.05 were considered significant. Results: A total of 43 patients were included in this study. There were 19 men and 24 women with a mean age of 63 ± 14 years. The only complication was pancreatitis secondary to cyst leak in one patient. Multivariate analysis confirmed CEA level greater than 300 ng/mL (P= 0.007) and the identification of mucin (P < 0.001) as significant predictors. Conclusions: With pancreatic cyst fluid analysis, the strongest predictor of mucinous neoplasia is the presence of identifiable mucin, followed by a CEA level greater than 300 ng/mL. The workup of cystic lesions of the pancreas should include chemical analysis for the CEA level and cytological examination with particular attention to extracellular mucin.

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.

Presence of Lymph Node Vasculature: A New EUS Criterion for Benign Nodes?

Objectives Lymph nodes normally have prominent centrally located blood vessels, which may become obliterated with tumor infiltration. The presence of intranodal vasculature has been noted to coincide with benign cytology. We sought to determine the test characteristics of the presence of intranodal mediastinal vasculature during endoscopic ultrasound (EUS). Methods 67 mediastinal lymph nodes evaluated by EUS in 66 patients over a 1-year period were evaluated for the presence of intranodal vasculature, which was considered benign when it traversed through the node without disruption. Results Of the 67 lymph nodes evaluated, 29 (43%) were found to be malignant on cytopathologic review. Benign vascular markings were present in 15/67 (22.4%) lymph nodes evaluated. All 15 (100%) of these nodes were found to have benign fine-needle aspiration (FNA) results. The presence of benign vasculature had a negative predictive value of 100%. Conclusions The presence of intranodal vasculature was universally associated with a benign diagnosis. The addition of this EUS finding improves the ability to characterize lymph nodes and predict the likelihood of malignant involvement.

Performance of Endoscopic Ultrasound in Staging Rectal Adenocarcinoma Appropriate for Primary Surgical Resection

BACKGROUND & AIMS Endoscopic ultrasound (EUS) often is used to stage rectal cancer and thereby guide treatment. Prior assessments of its accuracy have been limited by small sets of data collected from tumors of varying stages. We aimed to characterize the diagnostic performance of EUS analysis of rectal cancer, paying particular attention to determining whether patients should undergo primary surgical resection. METHODS We performed a retrospective observational study using procedural databases and electronic medical records from 4 academic tertiary-care hospitals, collecting data on EUS analyses from 2000 through 2012. Data were analyzed from 86 patients with rectal cancer initially staged as T2N0 by EUS. The negative predictive value (NPV) was calculated by comparing initial stages determined by EUS with those determined by pathology analysis of surgical samples. Logistic regression models were used to assess variation in diagnostic performance with case attributes. RESULTS EUS excluded advanced tumor depth with an NPV of 0.837 (95% confidence interval [CI], 0.742-0.908), nodal metastasis with an NPV of 0.872 (95% CI, 0.783-0.934), and both together with an NPV of 0.767 (95% CI, 0.664-0.852) compared with pathology analysis. Incorrect staging by EUS affected treatment decision making for 20 of 86 patients (23.3%). Patient age at time of the procedure correlated with the NPV for metastasis to lymph node, but no other patient features were associated significantly with diagnostic performance. CONCLUSIONS Based on a multicenter retrospective study, EUS staging of rectal cancer as T2N0 excludes advanced tumor depth and nodal metastasis, respectively, with an approximate NPV of 85%, similar to that of other modalities. EUS has an error rate of approximately 23% in identifying disease appropriate for surgical resection, which is lower than previously reported.