Pramoda Koduru

Topical steroids in eosinophilic esophagitis: Systematic review and meta‐analysis of placebo‐controlled randomized clinical trials

Eosinophilic esophagitis (EoE) is a clinicopathologic condition characterized by symptoms of esophageal dysfunction in the presence of eosinophil‐predominant inflammation of esophageal mucosa. Topical steroids are recommended as first line pharmacologic therapy in EoE. We aimed to determine the efficacy of topical steroids in inducing histologic and clinical remission in children and adults with EoE.

Utility of confocal laser endomicroscopy in identifying high-grade dysplasia and adenocarcinoma in Barrett's esophagus: a systematic review and meta-analysis.

Confocal laser endomicroscopy (CLE) is a novel endoscopic technique that has emerged as an important tool in the in-vivo visualization and detailed assessment of the mucosal layer and subcellular structures in Barrett’s esophagus. Current guidelines recommend four-quadrant random biopsies for identification of high-grade dysplasia (HGD) in Barrett’s esophagus. However, random biopsies are associated with sampling error and inconsistent histopathologic interpretation. CLE, by providing targeted biopsies, could decrease the sampling error and increase the yield of detection of HGD/adenocarcinoma [esophageal adenocarcinoma (EAC)]. We carried out a meta-analysis to evaluate the diagnostic accuracy of the CLE-based targeted biopsies in detecting HGD/adenocarcinoma compared with four-quadrant random biopsies. A search using medical subject headings (MeSH) terms and keywords was performed in the MEDLINE and Cochrane review databases and relevant studies were identified. All the studies that compared the diagnostic yield from CLE-based targeted biopsies to detect HGD/adenocarcinoma with a gold standard of histopathology were included and a meta-analysis was carried out to estimate the pooled sensitivity, specificity, and positive and negative likelihood ratios using Meta-Disc software. There were a total of seven studies with 345 patients and 3080 lesions that were finally included in the meta-analysis. All the studies had reported per-lesion analyses; however, only four of the seven studies had data reported on per-patient analyses. ‘Per-lesion’ analysis for the diagnosis of HGD/adenocarcinoma yielded a pooled sensitivity and specificity of 68% [95% confidence interval (CI) of 64–73%] and 88% (95% CI of 87–89%), respectively. The pooled positive and negative likelihood ratios were 6.56 (95% CI of 3.61–11.90) and 0.24 (95% CI of 0.09–0.63), respectively. Similar numbers were calculated on the basis of ‘per-patient’ basis, which showed a pooled sensitivity and specificity of 86% (95% CI of 74–96%) and 83% (95% CI of 77–88%), respectively. The pooled positive and negative likelihood ratios were 5.61 (95% CI of 2.00–15.69) and 0.21 (95% CI of 0.08–0.59), respectively. CLE, by providing targeted biopsies, has a good diagnostic accuracy in identifying HGD/EAC; however, the overall prevalence of HGD/EAC in the studies included was much higher than what would be seen in clinical practice and these results should be interpreted with caution. Because of its relatively low sensitivity and negative predictive value, CLE may currently not replace standard biopsy techniques for the diagnosis of HGD/EAC in Barrett’s esophagus.

The role of endoscopic ultrasound in pancreatic cancer screening.

Pancreatic cancer (PC) is a highly lethal cancer. Despite a significant advancement in cancer treatment, the mortality rate of PC is nearly identical to the incidence rates. Early detection of tumor or its precursor lesions with dysplasia may be the most effective approach to improve survival. Screening strategies should include identification of the population at high risk of developing PC, and an intense application of screening tools with adequate sensitivity to detect PC at an early curable stage. Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) seem to be the most promising modalities for PC screening based on the data so far. EUS had an additional advantage over MRI by being able to obtain tissue sample during the same examination. Several questions remain unanswered at this time regarding the age to begin screening, frequency of screening, management of asymptomatic pancreatic lesions detected on screening, timing of resection, and extent of surgery and impact of screening on survival. Novel techniques such as needle-based confocal laser endomicroscopy (nCLE), along with biomarkers, may be helpful to identify pancreatic lesions with more aggressive malignant potential. Further studies will hopefully lead to the development of strategies combining EUS with other technological/biological advancements that will be cost-effective and have an impact on survival.

Diagnosis of cystic lymphangioma of the colon by endoscopic ultrasound: Biopsy is not needed!

Cystic lymphangioma of the colon (CLC) is a rare benign lesion that is usually asymptomatic and found incidentally during colonoscopy. Limitations in the conventional noninvasive diagnostic techniques have led to surgical resection of these lesions for diagnostic confirmation. Classic endoscopic ultrasound (EUS) findings of colonic cystic lymphangioma are submucosal anechoic cystic spaces with septations, intact muscularis propria, and no solid component. Patients who are asymptomatic with lesions having classic appearance as cystic lymphangioma with EUS can be observed without any intervention. We herein report a case of cystic lymphangioma of distal transverse colon in an asymptomatic patient diagnosed noninvasively using 20-MHz miniprobe EUS and managed conservatively without any surgical intervention.

Role of endoscopic ultrasound in diagnosis and management of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is an aggressive tumor and a leading cause of cancer-related deaths globally. The mortality rate remains high despite many advances in treatment. HCC is frequently diagnosed late in its course due to lack of classical symptoms at earlier stages. Endoscopic ultrasound (EUS) has emerged as an important diagnostic tool for the diagnostic evaluation, staging, and treatment of gastrointestinal tract disorders. EUS-guided fine needle aspiration has been a valuable addition to EUS by being able to obtain tissue under direct visualization. Here, we review the potential role of EUS in the diagnosis and management of HCC. EUS seems to be a safe and reliable alternative method for obtaining tissue for diagnosis of liver cancer, especially for lesions that are inaccessible by traditional methods. EUS could play an important role in the diagnosis and management of HCC.

Pancreatic neuroendocrine tumor masquerading as metastasis in a patient with esophageal cancer: Diagnosis by endoscopic ultrasound-guided fine-needle aspiration

The role of endoscopic ultrasound (EUS) and guided biopsies has been well established for the locoregional staging of esophageal cancers. However, their role in posttreatment surveillance is unclear. Here, we describe a case of a pancreatic mass diagnosed on the follow-up positron emission tomography scan, concerning for a metastatic lesion. EUS-guided fine-needle aspiration (FNA) helped in establishing the diagnosis of neuroendocrine tumor, which tends to have a similar sonographic appearance. Therefore, it is imperative to evaluate a suspicious mass seen on computed tomography/positron emission tomography scan. EUS and EUS-guided FNA can serve as useful modalities to confirm the diagnosis by cytopathology.

Multiple Space Occupying Lesions in the Spleen: A Diagnostic Dilemma

Pramoda Koduru1, Uma Kundu2 and Manoop S Bhutani1* 1Department of Gastroenterology, Hepatology and Nutrition, UT MD Anderson Cancer Center, Houston, Texas, USA 2Department of Pathology, UT MD Anderson Cancer Center, Houston, Texas, USA *Corresponding author: Manoop S Bhutani, Director of Endoscopic Research and Development, Department of Gastroenterology, Hepatology and Nutrition-Unit 1466, UT MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, Texas, USA, Tel: 713-794-5073; Fax: 713-563-4398; E-mail: manoop.bhutani@mdanderson.org

Sa1109 Clinical Impact of EUS Exam in the Evaluation of Subepithelial Lesions of the Lower Gastrointestinal Tract

among trainee endoscopists. Methods: Colorectal lesions of a range of proven histopathology were imaged with pEC (pEC;XEC-300) with 450-fold magnification before performing polypectomies. All pEC video sequences were stored and divided into a teaching set and a validation set. Each trainee participated in the teaching session whereby representative endocytoscopy video sequences and images of 10 different colorectal lesions were presented and endocytoscopy features characterizing neoplastic and benign lesions were explained. Following the teaching session, five trainee endoscopists who were blinded to histopathology and endoscopic findings, were asked to predict the histology based on pEC features for neoplasia of 47 unknown cases. Histological confirmation of neoplastic lesions was used as the gold standard. After scoring each video, the correct histopathology diagnosis was revealed to all investigators. Consecutive pEC cases were grouped into tertiles for analysis (i.e. tertile 1 included cases 1-15, tertile 2 16-30, tertile 3 31-47). Results: Forty six patients underwent screening and surveillance during which pEC videos of 47 colorectal lesions: 12 hyperplastic, 35 neoplastic, were obtained. Of the forty seven scored videos of the colorectal lesions the overall diagnosis accuracy rates for predicting neoplasia from tertile 1 to tertile 3 improved from 83 % to 87%. The overall sensitivity, specificity and accuracy for all tertiles combined were 86%, 77% and 81% respectively. Figure 1 illustrates calculated learning curve pattern. Table 1 demonstrates overall accuracy and kappa estimates for each endoscopist. Conclusion: We demonstrated an overall modest improvement trend among trainee endoscopists in learning interpretation of pEC images of colorectal lesions after reviewing at least 45 images. Although a distinct learning curve pattern of pCE in predicting neoplastic lesions could not be constructed, this novel technology requires further evaluation by endoscopists in order to establish a learning curve pattern. Table 1