Paul S. Sepe

EUS-guided FNA for the diagnosis of GI stromal cell tumors: sensitivity and cytologic yield.

BACKGROUND EUS-guided FNA has been well documented to aid in the diagnosis of subepithelial lesions by providing cytologic material. Studies to date evaluating the sensitivity of EUS-FNA for the diagnosis of GI stromal cell tumors (GIST) have been small, and few have relied on surgical histologic diagnosis as the reference standard. OBJECTIVE Our purpose was to determine the diagnostic yield and sensitivity of EUS-FNA for the diagnosis of GIST and to identify EUS features of GIST that are predictive of the ability to obtain adequate tissue by EUS-FNA. DESIGN All patients with histologically confirmed, c-kit-positive GIST who underwent EUS-FNA from 1998 to 2006 were reviewed. EUS images were examined for mass size, shape, location, wall layer, heterogeneity, echogenicity, cystic spaces, lobulation, ulceration, and central umbilication. Needle gauge, number of needle passes, and presence of a cytologist during the EUS-FNA were recorded. RESULTS A total of 37 patients (29 with diagnostic FNA cytology; 8 with nondiagnostic cytology) met the inclusion criteria. The diagnostic yield and sensitivity of EUS-FNA cytology for the diagnosis of GIST was 78.4% (29/37). The sensitivity was 84.4% (27/32) for GISTs located in the stomach, but poor for lesions located in the duodenum because none of these tumors yielded diagnostic cytology (n = 3). An increase in size up to 10 cm, round/oval shape, and identification of the origin of GIST within a specific sonographic wall layer were statistically significant in their ability to predict adequate tissue yield. CONCLUSIONS The sensitivity of EUS-FNA cytology for the diagnosis of GIST is 78.4% and is influenced by size, location, shape, and layer of origin.

A guide for the diagnosis and management of gastrointestinal stromal cell tumors

Gastrointestinal stromal cell tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal tract and are frequently detected on routine endoscopy. Although only ∼10–30% of GISTs are clinically malignant, all may have some degree of malignant potential. Preoperative determination of malignancy risk can be estimated from tumor size and location, but reliable histopathologic criteria are not currently available. Given such biological uncertainty, accurate diagnosis is essential to differentiate these lesions from other truly benign, subepithelial tumors. Endoscopic ultrasound-guided fine-needle aspiration has emerged as an important procedure to secure a tissue diagnosis of a GIST. When encountering GISTs, gastroenterologists are faced with challenging management decisions, especially in the face of small, incidentally discovered lesions. The majority of localized GISTs are managed via surgical resection, although a select few may be observed using serial endoscopic ultrasound examinations. This Review provides a general overview of GISTs, with an emphasis on their endoscopic diagnosis, the management of localized disease, and the management of incidentally discovered GISTs.

A prospective evaluation of fatty pancreas by using EUS

BACKGROUND Fatty liver is associated with obesity, diabetes, hyperlipidemia, and the metabolic syndrome. The pathophysiology of fatty pancreas is poorly understood, but it may be closely related to fatty liver. OBJECTIVE The aim of our study was to determine the prevalence of fatty pancreas and risk factors associated with its development. DESIGN Prospective, single center study. SETTING Tertiary-care academic medical center. PATIENTS This study involved 250 consecutive patients referred for EUS examination. INTERVENTION All patients undergoing EUS at our institution were prospectively identified. Information regarding demographics, tobacco use, alcohol use, blood test results, and comorbidities were collected before EUS. Pancreatic echogenicity was graded in comparison to the spleen at the time of EUS by using an a priori specified grading scheme. MAIN OUTCOME MEASUREMENTS Prevalence of fatty pancreas and factors associated with its development. RESULTS During the study period, 250 consecutive patients were prospectively enrolled. The prevalence of fatty pancreas was 27.8% (95% CI, 22.1-34.1). Fatty liver was seen in 22.6% of patients. Factors associated with fatty pancreas on univariate analysis were increasing body mass index (BMI) (P=.004), fatty liver (P<.0001), hyperlipidemia (P=.04), and the metabolic syndrome (odds ratio [OR] 3.13, P=.004). The presence of any metabolic syndrome components, that is, BMI≥30, hyperlipidemia, diabetes, or hypertension, increased the prevalence of fatty pancreas by 37% (OR 1.37, P=.01). Factors independently associated with fatty pancreas on multivariate analysis were increasing BMI (OR 1.05, P=.03) and fatty liver (OR 3.61, P<.001). We found no association between fatty pancreas and chronic pancreatitis or adenocarcinoma of the pancreas. LIMITATIONS Single institution study. All patients were referred for EUS, which limits generalizability. Lack of histological confirmation of pancreatic fat. CONCLUSION We found a strong association between fatty pancreas and the metabolic syndrome.

Endoscopic Ultrasound–guided Pancreatic Fiducial Placement: How Important Is Ideal Fiducial Geometry?

Objective Image-guided radiation therapy allows precise tumor targeting using real-time tracking of radiopaque fiducial markers. To enable appropriate tracking, it is recommended to place fiducials with “ideal fiducial geometry” (IFG). Our objectives were to determine the proportion of patients in whom IFG can be achieved when fiducials are placed by endoscopic ultrasound (EUS) and surgery and to determine if attaining IFG is necessary for delivering radiation. Methods This single-center retrospective cohort study included 77 patients with biopsy-proven advanced pancreatic cancer who underwent either EUS-guided or laparotomy/laparoscopy-assisted fiducial placement between September 2005 and July 2009. Results Gold fiducials were implanted by EUS in 39 patients (51%) and by surgery in 38 patients (49%). The proportion of patients with IFG was significantly higher for surgical placement [18/38, 47%; 95% confidence interval (CI), 32%–63%] compared with EUS-guided placement (7/39, 18%; 95% CI, 8%–32%), P = 0.0011. However, fiducial tracking was successfully used for Cyberknife therapy in 35 (90%) of 39 (95% CI, 77%–97%) patients in the EUS group compared with 31 (82%) of 38 (95% CI, 67%–92%) patients in the surgery group. There were 5 procedure-related complications in the EUS group. Conclusions Achieving IFG appears unnecessary for successful tracking and delivery of radiation.

Revitalizing pathology laboratories in a gastrointestinal pathophysiology course using multimedia and team-based learning techniques

In 2008, we changed the gastrointestinal pathology laboratories in a gastrointestinal pathophysiology course to a more interactive format using modified team-based learning techniques and multimedia presentations. The results were remarkably positive and can be used as a model for pathology laboratory improvement in any organ system. Over a two-year period, engaging and interactive pathology laboratories were designed. The initial restructuring of the laboratories included new case material, Digital Atlas of Video Education Project videos, animations and overlays. Subsequent changes included USMLE board-style quizzes at the beginning of each laboratory, with individual readiness assessment testing and group readiness assessment testing, incorporation of a clinician as a co-teacher and role playing for the student groups. Student responses for pathology laboratory contribution to learning improved significantly compared to baseline. Increased voluntary attendance at pathology laboratories was observed. Spontaneous student comments noted the positive impact of the laboratories on their learning. Pathology laboratory innovations, including modified team-based learning techniques with individual and group self-assessment quizzes, multimedia presentations, and paired teaching by a pathologist and clinical gastroenterologist led to improvement in student perceptions of pathology laboratory contributions to their learning and better pathology faculty evaluations. These changes can be universally applied to other pathology laboratories to improve student satisfaction.

How to Create an Unfunded Teaching Fellowship During the Gastroenterology Fellowship That Positively Impacts Subsequent Teaching Activities and Career Path

The gastrointestinal (GI) pathophysiology course is a 2.5-week required preclinical course at the end of medical school’s second-year pathophysiology organ system blocks. In 1993, I was appointed co-course director of this course. teaching using the Case-Based Method. In October 2002, I went for the first of numerous times to Harvard Business School to observe and learn from Professor Garvin. Here the professors consistently use the Case Method with question, listen, and respond as the prime teaching strategy. In addition, each professor summarizes with high-yield, takehome points at the end of class. Learning these 3 key teaching strategies made all the difference in my individual ratings, overall course ratings, and how I taught the current teaching and academic fellows to teach.

The Use of Standard Gastrointestinal Endoscopic Ultrasound to Assess Cardiac Anatomy.

In this prospective observational study, conducted at an academic medical center, we evaluated the feasibility of performing a basic transesophageal echocardiography (TEE) examination using endoscopic ultrasound (EUS) technology to determine what cardiac structures could be assessed. This may be potentially beneficial during hemodynamic emergencies in the endoscopy suite resulting from hypovolemia, depressed ventricular function, aortic dissection, pericardial effusions, or aortic stenosis. Of the 20 patients enrolled, 18 underwent EUS with a linear echoendoscope for standard clinical indications followed by a cardiac assessment performed under the guidance of a TEE-certified cardiac anesthesiologist. Eight of the 20 standard views of cardiovascular structures per the 1999 American Society of Echocardiography/Society of Cardiovascular Anesthesiologists guidelines for TEE could be obtained using the linear echoendoscope. The following cardiac valvular structures were visualized: aortic valve (100%), mitral valve (100%), tricuspid valve (33%), and pulmonic valve (11%). Left ventricular and right ventricular systolic function could be assessed in 89% and 67% of patients, respectively. Other structures such as the ascending and descending aorta, pericardium, left atrial appendage, and interatrial septum were identified in 100% of patients. Doppler-dependent functions could not be assessed. Given that the EUS images were not directly compared with TEE in these patients, we cannot comment definitively on the quality of these assessments and further studies would need to be performed to make a formal comparison. Based on this study, EUS technology can consistently assess the mitral valve, aortic valve, aorta, pericardium, and left ventricular function. Given its limitations, EUS technology, although not a substitute for formal echocardiography, could be a helpful early diagnostic tool in an emergency setting.