Theodoros Topalidis

Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis

OBJECTIVE:The clinical value of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic lesions is uncertain in patients with normal parenchyma and chronic pancreatitis. The aim of this study was to analyze the diagnostic yield and influence of EUS-FNA on the clinical management of patients with pancreatic lesions, in the presence (CP) or absence (NP) of chronic pancreatitis.METHODS:A total of 207 consecutive patients with NP (n = 133) and CP (n = 74) were examined using linear array echo endoscopes for the procedure and 22-gauge needles.RESULTS:Adequate specimens were obtained from 200 lesions. A correct final diagnosis was established at histology (n = 108), bacteriology (n = 9), and clinical follow-up (n = 83). Cytology gave 17 false-negative EUS-FNA results (overall sensitivity: 85%). In patients with NP, 60 solid adenocarcinomas were detected, 32 other malignancies, and 38 benign lesions, with 11 false-negative results (sensitivity: 89%). In patients with CP, only seven of 13 malignancies (all solid adenocarcinomas) were identified using FNA (sensitivity: 54%). Overall, malignancy was identified in 116 patients, 32 of whom (27%) had lesions other than primary solid adenocarcinomas. Management was altered in 25 of these patients, which changed the surgical approach in 21%. EUS-FNA influenced the therapeutic approach in 44% of the total patient group.CONCLUSIONS:EUS-FNA was especially useful in patients with a focal pancreatic lesion with normal parenchyma. Its sensitivity in patients with CP was unacceptably low, and resection of the tumor using standard surgical techniques was still usually required to confirm the correct diagnosis. Diagnostic EUS-FNA influenced clinical management in nearly half of patients.

EUS-Guided Fine-Needle Aspiration of Suspected Hilar Cholangiocarcinoma in Potentially Operable Patients with Negative Brush Cytology

BACKGROUND:Despite improvements of diagnostic modalities differentiation between benign and malignant hilar strictures remains a challenge. Hilar neoplasia requires preoperative tissue diagnosis to avoid risk of inappropriate extensive surgery. This is commonly attempted using various techniques at ERCP, which have variable sensitivity and accuracy. We used endosonography-guided fine-needle aspiration (EUS-FNA) for the preoperative diagnosis of hilar cholangiocarcinoma (HC).METHODS:Prospective evaluation of 44 patients (31 male, mean age: 59 yr) with strictures at the liver hilum were diagnosed by CT and/or ERCP. All were suspicious of HC but had inconclusive tissue diagnosis. They underwent EUS-FNA with linear echo endoscope and 22 gauge needles.RESULTS:Adequate material was obtained in 43 of 44 patients. Cytology revealed HC in 26 and other malignancies in 5 patients; 12 had benign results: sclerosing cholangitis (n = 4), primary sclerosing cholangitis (n = 4), inflammation (n = 3), sarcoid-like lesion (n = 1). There were no significant differences in age, lesion size, or echo features among patients with adenocarcinomas, other malignancies, or benign lesions. Thirty-two patients underwent surgery, 2 had autopsy, 10 were followed up clinically. Four of the benign results were false negatives. No complications occurred. Accuracy, sensitivity, and specificity were 91%, 89%, and 100%, respectively. EUS and EUS-FNA changed preplanned surgical approach in 27 of 44 patients.CONCLUSION:These results suggest that EUS-FNA is of value as a new, less-invasive approach for tissue diagnosis of hilar strictures of unknown cause. It was technically feasible without significant risks, when other diagnostic tests were inconclusive and was able to change preplanned management in about half of the patients.

Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNA-based differential cytodiagnosis in 153 patients.

OBJECTIVE:Mediastinal lymphadenopathy (ML) is a cause for concern, especially in patients with previous malignancy. The investigation of choice is thoracic CT with a variable sensitivity and specificity requiring tissue diagnosis. We used endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of ML in patients with and without previous malignancy. The cause, distribution of lesions, and incidence of second cancers were investigated.METHODS:Linear echoendoscopes and 22-gauge needles for cytology were used for EUS-FNA. A cytological diagnosis of malignancy was accepted, and histology or consistent follow-up of at least 9 months confirmed benign results.RESULTS:One hundred fifty-three patients underwent EUS-FNA between November 1997 and November 1999 (mean age, 60 yr; range, 13–82 yr; 105 men). Cytology was adequate in 150 patients. Final diagnosis was malignancy in 84 and benign in 66 patients (sensitivity, specificity, and diagnostic accuracy: 92%, 100%, 95%, respectively). In 101 patients without previous cancer cytology identified 48 malignant (lung, 41; extrathoracic, 7) and 51 benign lesions (inflammation, 35; various, 9; sarcoidosis, 7) (sensitivity, specificity, accuracy: 88%, 100%, 94%). Fifty-two patients had prior malignancy, mostly in extrathoracic sites. Cytology revealed recurrences in 21 patients, second cancer in 9 and benign lesions in 21 patients (inflammatory, 11; sarcoidosis, 8; tuberculosis, 1; abscess, 1) (sensitivity, specificity, accuracy: 97%, 100%, 98%).CONCLUSIONS:In patients without previous cancer malignant ML originates from the lung >80%. In those with previous malignancy recurrence of extrathoracic sites is the major cause. Benign lesions and treatable second cancers occur in a significant frequency, emphasizing the need for tissue diagnosis. EUS-FNA is a safe and minimally invasive alternative for cytodiagnosis in the mediastinum.

Endosonography-guided, fine-needle aspiration cytology extending the indication for organ-preserving pancreatic surgery

Abstract OBJECTIVE: Organ preserving pancreatic resections are considered whenever malignant disease is ruled out. In tumors of low malignant potential such as cystadenomas and neuroendocrine tumors, the diagnosis is rarely established preoperatively. We studied the feasibility of cytodiagnosis using endosonography-guided fine-needle aspiration in determining the operative approach. METHODS: A total of 78 patients (16 female, 62 male; mean age 61.4 yr, range 31–82 yr) with focal pancreatic lesions underwent EUS-FNA. Final diagnosis was confirmed by histology, cytology, or clinical follow up (>9 months). Patients with tumors of low malignant potential were managed by customized pancreatic resections. RESULTS: Final diagnosis was malignant tumors in 36 patients, tumors of low malignant potential in nine (six, neuroendocrine, two, borderline mucinous cystadenomas, one, borderline adenocarcinoma), and benign in 31 (two inadequate smears). No complications occurred. With six false-negative and no false-positive results, the accuracy, sensitivity, specificity, and positive and negative predictive values were 92%, 84%, 100%, 100%, and 86%, respectively. Five patients with low malignant tumors underwent duodenum-preserving pancreatic head resection, three mid segment resection, and one pylorus-preserving pancreatoduodenectomy. CONCLUSIONS: EUS-FNA is useful in the preoperative cytodiagnosis of pancreatic tumors of low malignant potential. It extends the indication for organ-preserving pancreatic resections and avoids the unnecessary sacrifice of adjacent organs.

Endoscopic ultrasound–guided biopsy for the diagnosis of focal lesions of the spleen

OBJECTIVES:Needle biopsy of splenic lesions using computed tomography (CT) or ultrasound (US) is difficult if the size of the lesion is small. It may be dangerous if the lesion is adjacent to the splenic hilum or located peripherally. We used endoscopic ultrasound–guided fine needle aspiration (EUS-FNA) to elucidate the tissue diagnosis of splenic abnormalities.METHODS:EUS-FNA was performed in 12 patients when US- or CT-guided biopsy was inconclusive (n = 5), was not attempted because of small tumor size (0.9–1.4 cm; n = 4), or was considered dangerous (n = 3). A linear echo-endoscope and 22-gauge needles were used for cytology and bacteriology.RESULTS:The age of the patients was 19–68 yr (median 32 yr). Seven patients were male and five female. The size of the lesions was 0.8–4.2 cm (median 1.4 cm). Cytology was inadequate in one patient. Bacteriology was positive for Staphylococcus aureus and Serratia in one patient each, and cultures were positive for Mycobacterium tuberculosis in two patients. A positive diagnosis was made in 10 of 12 patients (83%). Final diagnoses were tuberculosis in two patients, Hodgkins disease in two, sarcoidosis in two, abscesses in two, metastatic colon cancer in one, and infarction in one. Suspected recurrence of non-Hodgkins lymphoma was not confirmed in one case. One patient experienced pain after puncture, but no hematoma was demonstrated on subsequent US examination.CONCLUSIONS:EUS-FNA cytodiagnosis in patients with unknown splenic lesions seems feasible, even in very small foci, when CT- or US-guided biopsy fails. Additional material for bacteriology may show benign treatable diseases such as abscesses or tuberculosis.

Prospective evaluation of malignant cell seeding after percutaneous endoscopic gastrostomy in patients with oropharyngeal/esophageal cancers

BACKGROUND AND STUDY AIMS Insertion of a percutaneous endoscopic gastrostomy (PEG) is standard care for many patients with oropharyngeal (ENT) and esophageal malignancies in order to ensure enteral feeding. The current pull-through insertion technique involves direct contact with the tumor and case reports have demonstrated the presence of metastases at insertion sites. The aim of the current study was to prospectively evaluate the risk of malignant cell seeding and the development of abdominal wall metastases after PEG placement. PATIENTS AND METHODS A total of 50 consecutive patients with ENT/esophageal tumors were included. After PEG placement (40 pull-through technique, 10 direct insertion), brush cytology was taken from the PEG tubing and the transcutaneous incision site. A second cytological assessment was performed after a follow-up period of 3 - 6 months. RESULTS In total, 26 patients with ENT cancer, 13 with esophageal cancer, and one with esophageal infiltration of lung cancer underwent pull-through PEG placement with no immediate complications. Cytology following brushing of tubing and incision sites demonstrated malignant cells in 9 /40 cases (22.5 %). Correlation analyses revealed a higher rate of malignant seeding in older patients and in those with higher tumor stages. At follow-up, cytology was undertaken in 32 /40 patients who had undergone pull-through PEG placement. Malignant cells were present in three on cytology, resulting in a metastatic seeding rate of 9.4 %. CONCLUSION This study showed that malignant cells were present in 22.5 % of patients immediately after pull-through PEG placement; local metastases were verified at follow-up in 9.4 %, all of which were from esophageal squamous cell carcinoma. This risk is particularly high in the older age group and in patients with higher tumor stages. Therefore, pull-through PEG placement should be avoided in these patients and direct access PEG favored instead.

22-gauge core vs 22-gauge aspiration needle for endoscopic ultrasound-guided sampling of abdominal masses

AIM To compare the aspiration needle (AN) and core biopsy needle (PC) in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of abdominal masses. METHODS Consecutive patients referred for EUS-FNA were included in this prospective single-center trial. Each patient underwent a puncture of the lesion with both standard 22-gauge (G) AN (Echo Tip Ultra; Cook Medical, Bloomington, Indiana, United States) and the novel 22G PC (EchoTip ProCore; Cook Medical, Bloomington, Indiana, United States) in a randomized fashion; histology was attempted in the PC group only. The main study endpoint was the overall diagnostic accuracy, including the contribution of histology to the final diagnosis. Secondary outcome measures included material adequacy, number of needle passes, and complications. RESULTS Fifty six consecutive patients (29 men; mean age 68 years) with pancreatic lesions (n = 38), lymphadenopathy (n = 13), submucosal tumors (n = 4), or others lesions (n = 1) underwent EUS-FNA using both of the needles in a randomized order. AN and PC reached similar overall results for diagnostic accuracy (AN: 88.9 vs PC: 96.1, P = 0.25), specimen adequacy (AN: 96.4% vs PC: 91.1%, P = 0.38), mean number of passes (AN: 1.5 vs PC: 1.7, P = 0.14), mean cellularity score (AN: 1.7 vs PC: 1.1, P = 0.058), and complications (none). A diagnosis on the basis of histology was achieved in the PC group in 36 (64.3%) patients, and in 2 of those as the sole modality. In patients with available histology the mean cellularity score was higher for AN (AN: 1.7 vs PC: 1.0, P = 0.034); no other differences were of statistical significance. CONCLUSION Both needles achieved high overall diagnostic yields and similar performance characteristics for cytological diagnosis; histological analysis was only possible in 2/3 of cases with the new needle.

4558 Preliminary results of eus guided fine-needle aspiration cytodiagnosis of hilar cholangiocarcinoma.

Background: In spite of improvement of diagnostic modalities tissue diagnosis of obstructions at the liver hilum remains a challenge. Extensive hepatic resections with intention to cure or modern palliative concepts require exact diagnosis, which is rarely achieved preoperatively. Attempts were made by brushings and biopsies during ERCP with variable sensitivity. This is the first report of endosonograpghy guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of hilar cholangiocarcinoma. Methods: 10 patients (7 male, 3 female, age: 47-78, mean age: 62.5) with strictures at the liver hilum, diagnosed by computed tomography and/or ERCP prospectively and consecutively underwent EUS-FNA with longitudinal echoendoscope and 22 gauge needles. Results: In 9 patients adequate material was achieved. Cytology revealed chloangiocarcinoma in 7 patients and hepatocellular carcinoma in one. 8 out of ten patients underwent surgery, in the other two lymph node and liver metastases were detected during pre-surgery examinations. In these EUS-FNA cytology revealed adenocarcinoma. One benign inflammatory lesion on cytology proved to be false negative in frozen section. No complication occurred. Accuracy, sensitivity, and positive predictive value were 89%, 89% and 100%, respectively. Conclusion: Primary cholangiocarcinoma of the hilum can be difficult to discern from other malignancies or benign lesions. These results suggest that EUS-FNA is a new less invasive approach for tissue diagnosis of Klatskin tumors, which for the first time proved to be technically feasible without significant risks.