Sofiya Reicher

Fluorescence in situ hybridization and K-ras analyses improve diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic masses.

Objectives: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is the main diagnostic modality for pancreatic mass lesions. However, cytology is often indeterminate, leading to repeat FNAs and delay in care. Here, we evaluate whether combining routine cytology with fluorescence in situ hybridization (FISH) and K-ras/p53 analyses improves diagnostic yield of pancreatic EUS-FNA. Methods: Fifty EUS-FNAs of pancreatic masses in 46 patients were retrospectively analyzed. Mean follow-up was 68 months. Thirteen initial cytologic samples (26%) were benign, 23 malignant (46%), and 14 atypical (28%). We performed FISH for p16, p53, LPL, c-Myc, MALT1, topoisomerase 2/human epidermal growth factor receptor 2, and EGFR, as well as K-ras/p53 mutational analyses. Results: On final diagnosis, 11 (79%) of atypical FNAs were malignant, and 3 benign (21%). Fluorescence in situ hybridization was negative in all benign and all atypical samples with final benign diagnosis. Fluorescence in situ hybridization plus K-ras analysis correctly identified 60% of atypical FNAs with final malignant diagnosis. Combination of routine cytology with positive FISH and K-ras analyses yielded 87.9% sensitivity, 93.8% specificity, 96.7% positive predictive value, 78.9% negative predictive value, and 89.8% accuracy. Conclusions: Combining routine cytology with FISH and K-ras analyses improves diagnostic yield of EUS-FNA of solid pancreatic masses. We propose to include these ancillary tests in the workup of atypical cytology from pancreatic EUS-FNA.Abbreviations: EUS - endoscopic ultrasound, FNA - fine-needle aspiration, FISH - fluorescence in situ hybridization, EGFR - epidermal growth factor receptor, HER2 - human epidermal growth factor receptor 2, TOP2 - topoisomerase 2

Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks

AIM To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks. METHODS We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n = 12) and bile leaks (n = 5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL(®) (Conmed, Utica, New York, United States) stents and three had Wallflex(®) (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall bladder fossa. Rate of complications such as migration, and in-stent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement. RESULTS All 17 patients underwent successful FCSEMS placement and removal. Etiologies of BBS included: cholecystectomies (n = 8), cholelithiasis (n = 2), hepatic artery compression (n = 1), pancreatitis (n = 2), and Whipple procedure (n = 1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n = 7), common hepatic duct (n = 1), hepaticojejunal anastomosis (n = 2), right intrahepatic duct (n = 1), and choledochoduodenal anastomatic junction (n = 1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n = 2), stent clogging (n = 1), cholangitis (n = 1), and sepsis with hepatic abscess (n = 1). CONCLUSION Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.

Hepatic Artery Compression of the Common Hepatic Duct: Direct Visualization by Single-Operator Peroral Cholangioscopy

p f A man presented with right upper-quadrant abdominal pain, jaundice, and pruritis. His initial total bilrubin level was 5.8 mg/dL, aspartate aminotransferase level was 86 U/L, alanine aminotransferase level was 409 U/L, alkaline hosphatase level was 402 U/L, and carbohydrate antigen 19-9 evel was 74 U/mL. Endoscopic retrograde cholangiopancretography (ERCP) performed at an outside facility revealed mall stones, sludge, and a proximal biliary stricture. A plastic iliary stent was placed to facilitate biliary drainage. Subseuently, liver function tests and carbohydrate antigen 19-9 evels normalized. The patient was then referred to our facility or further work-up of the biliary stricture. ERCP showed a 1to -cm smooth stricture in the common hepatic duct below ifurcation with mild intrahepatic duct dilation (Figure A, rrow). There was no obvious hilar mass on endoscopic ultraound. Biopsies of the stricture showed normal bile duct epihelium. Single-operator direct peroral cholangioscopy was hen performed with the SpyGlass system (Boston Scientific orp, Natick, MA). Mild extrinsic pulsatile compression of the ommon hepatic duct was observed at the stricture level, with ntact bile duct epithelium (Figure B, arrow; Supplementary ideo); the duct above and below the stricture was of normal ize. Intraductal ultrasound then was performed with a 20-MHz ndoscopic ultrasound miniprobe. The hepatic artery was ound wrapped around the bile duct at the level of the stricture Figure C, arrow). There was adequate biliary drainage during RCP, and the stent was removed. The patient remained asympomatic with normal total bilirubin and alkaline phosphatase evels 3 months after stent removal. Anatomically, the right hepatic artery runs posteriorly in lose proximity to the common hepatic duct, which might redispose to proximal bile duct compression. Band-like imingement of the common hepatic duct by right hepatic artery requently is recognized as an incidental finding on imaging.1 However, clinically significant impingement syndrome is quite rare and might indicate an aneurysm or aberrant hepatic artery anatomy.2 Definitive surgical treatment with hepaticojejunostomy is reserved for patients with true biliary obstruction. The SpyGlass single-operator peroral cholangioscopy system has increasingly been used for evaluation of indeterminate biliary strictures.3 It allows for direct visualization of the stricture and for targeted biopsies. We here report cholangioscopic visualization of pulsatile compression of the bile duct by the hepatic artery. Direct peroral cholangioscopy in conjunction with intraductal ultrasound was instrumental in making this diagnosis.

Time-of-day effect and the yield of endoscopic ultrasound fine needle aspiration.

Background and Objectives: The timing of the endoscopic procedures has been recently proposed to be a factor in the quality of colonoscopic polyp detection. We aimed to investigate whether the time-of-day has an effect on the diagnostic yield and specimen adequacy of endoscopic ultrasound fine needle aspiration (EUS-FNA). Materials and Methods: The retrospective study was set in a safety net community hospital. The 212 EUS-FNAs performed at our institution between July 2011 and January 2014 were retrospectively analyzed. Pancreatic masses, pancreatic cysts, and lymphadenopathy were most common indications for EUS-FNAs. Data were collected with regard to the timing of the procedure, presence of on-site cytopathologic evaluation, the number of needle passes, diagnosis, and specimen adequacy for cytopathologic evaluation. Statistical analysis was performed using unpaired two-tailed Students t-test. Results: There was no difference in the diagnostic yield for malignancy across all indications between the AM and PM groups. In the morning group 31/87 (36%) procedures and in the afternoon group 50/125 (40%) procedures were diagnostic for malignancy (P = 0.522). There was no difference in the specimen adequacy for cytopathologic evaluation across all indications between the AM and PM groups. In the morning group, 58/87 (67%) procedures and in the afternoon group 90/125 (72%) procedures were adequate for cytopathologic evaluation (P = 0.408). On-site cytopathologist was more available for AM than PM procedures; however, the lack of AM vs. PM difference in the yield and specimen adequacy persisted regardless of on-site cytopathologist presence. Conclusions: Time-of-day of the procedure (morning vs. afternoon) does not affect EUS-FNA diagnostic yield for malignancy or specimen adequacy for cytopathologic evaluation.