Endoscopic ultrasound-guided fine-needle aspiration of celiac lymph nodes

The correlation between the margin of resection and prognosis in esophagogastric junction adenocarcinoma

Adenocarcinoma of the gastroesophageal junction (AEG) has become increasingly common in Western and Asian populations. Surgical resection is the mainstay of treatment for AEG; however, determining the distance from the upper edge of the tumor to the esophageal margin (PM) is essential for accurate prognosis. Despite the relevance of these studies, most have been retrospective and vary widely in their conclusions. The PM is now widely accepted to have an impact on patient outcomes but can be masked by TNM at later stages. Extended PM is associated with improved outcomes, but the optimal PM is uncertain. Academics continue to debate the surgical route, extent of lymphadenectomy, preoperative tumor size assessment, intraoperative cryosection, neoadjuvant therapy, and other aspects to further ensure a negative margin in patients with gastroesophageal adenocarcinoma. This review summarizes and evaluates the findings from these studies and suggests that the choice of approach for patients with adenocarcinoma of the esophagogastric junction should take into account the extent of esophagectomy and lymphadenectomy. Although several guidelines and reviews recommend the routine use of intraoperative cryosections to evaluate surgical margins, its generalizability is limited. Furthermore, neoadjuvant chemotherapy and radiotherapy are more likely to increase the R0 resection rate. In particular, intraoperative cryosections and neoadjuvant chemoradiotherapy were found to be more effective for achieving negative resection margins in signet ring cell carcinoma.

Comparison between transpapillary versus transmural endoscopic ultrasound-guided decompression for biliary obstruction: a meta-analysis

BACKGROUND

Recent advances have led to the development of transmural endoscopic ultrasound guided biliary drainage (EUS-BD) for cases where the duodenal papilla cannot be accessed.

OBJECTIVES

We performed a meta-analysis comparing efficacy and complications of both approaches for biliary drainage.

REVIEW METHODS

English articles were searched in PubMed. Primary outcomes included technical success and complications. Secondary outcomes were clinical success and subsequent stent malfunction. Patient demographics and etiology of obstruction were collected and relative risk ratios and 95% CIs were calculated. P-value <0.05 was considered as statistically significant.

RESULTS

Initial database search yielded 245 studies from which 7 were chosen based upon inclusion criteria for final analysis. There was no statistically different relative risk for technical success when comparing primary EUS-BD to endoscopic retrograde cholangiopancreatography (ERCP) (RR: 1.04) or overall procedural complication rate (RR 1.39). EUS-BD did have increased specific risk of cholangitis (RR: 3.01). Likewise, primary EUS-BD and ERCP had similar RR for clinical success (RR: 1.02) and overall stent malfunction (RR: 1.55), but stent migration was higher in the primary EUS-BD group (RR: 5.06).

CONCLUSIONS

Primary EUS-BD may be considered when the ampulla cannot be accessed, when there is gastric outlet obstruction, or presence of a duodenal stent.

Forward-view Endoscopic Ultrasound: A Systematic Review of Diagnostic and Therapeutic Applications

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and therapeutic procedures have been performed by a curved linear array (CLA) echoendoscope since the early 1990's. This particular echoendoscope, allowing real time visualization of aspiration needles and of other devices, has substantially remained unchanged since its introduction to the market. In a context of rapidly expanding indications for EUS-guided procedures, a dedicated forward view (FV) echoendoscope has been developed and tested under different clinical conditions. The FV echoendoscope is equipped with front endoscopic and EUS view, allowing deployment of needles and other devices through the working channel in straight direction. Several new diagnostic and therapeutic applications may thereby potentially be feasible with the FV echoendoscope and the established ones may prove easier to accomplish. The published literature with the FV echoendoscope has been systematically reviewed and the results are presented analytically and discussed in detail. EUS-FNA and therapeutic procedures, including pancreatic pseudocyst drainage, treatment of gastric fundal varices, celiac plexus neurolysis, and duct drainage were reported. The FV echoendoscope showed some unique advantages, opening new possibilities such as EUS-FNA in difficult gastrointestinal tracts and combined endoscopic/EUS treatment with frontal approach. However, no statistically significant evidence of superiority of the FV echoendoscope vs. the CLA echoendoscope was found in pancreatic pseudocyst drainage. No complications specifically attributable to the use of the FV echoendoscope were reported.

Distant lymph node metastases in gastroesophageal junction adenocarcinoma: impact of endoscopic ultrasound-guided fine-needle aspiration

OBJECTIVE

Endoscopic ultrasound (EUS) is established as the most accurate technique for pre-operative locoregional staging of gastroesophageal junction (GEJ) adenocarcinoma, the purpose of the present study was to evaluate the distant lymph nodes (LNs) EUS-fine-needle aspiration (FNA) impact in therapeutic decision for patients with GEJ adenocarcinoma.

MATERIALS AND METHODS

Retrospective study was made, with cross-sectional, non-probabilistic analysis from prospectively collected database for all GEJ adenocarcinoma staging patients referred between January 2009 and August 2012 in Paoli-Calmette Institute in Marseille-France.

RESULTS

A total of 154 patients with GEJ adenocarcinoma were managed in our institution, of whom 113 (73.3%) had non-distant metastatic disease at computed tomography (CT) scan and underwent EUS for initial tumor staging prior to a treatment decision. On A total of 113 patients undergoing EUS, 8 (7%) patients underwent endoscopic resection and 6 (5.3%) underwent direct surgical resection. Of the remaining 99 patients (87.6%), 24 (21.2%) distant LN EUS-FNA were made. Seventeen LN had EUS malignant features, including 9 (52.9%) that were confirmed as malignant and underwent palliative treatment with chemotherapy. Ninety (79.6%) patients were treated with pre-operative neoadjuvant therapy and were revaluated after. 4 (4.4%) had metastatic disease at CT scan (underwent palliative treatment) and 65 (72.2%) underwent EUS restaging to treatment decision revaluation. Of these, twelve (18.4%) distant LN EUS-FNA were performed. Seven had LN EUS malignancy features, including 4 (57.1%) that were confirmed as malignant and underwent palliative treatment. The remaining 61 patients underwent surgery. As stated above, 21 patients (23.3%) did not undergo EUS restaging, including 10 (47.6%) that did not go to surgery because patient's age, poor general status and comorbidities, 6 (28.5%) had a loss of follow-up, 1 (4.7%) underwent to surgery due to chemotherapy collateral effects, 3 (14.2%) were still on pre-operative chemotherapy and 1 (4.7%) died for sepsis after mediastinal EUS-FNA, this was the only complication event evidenced. EUS-FNA changed clinical management in 54.2% of patients who met the criteria inclusion (distant LN with malignancies EUS features), which corresponds to 11.5% of patients with GEJ adenocarcinoma.

CONCLUSION

EUS-FNA was able to provide a different tumor staging and these differences were associated with treatment received. EUS-FNA had a significant impact on treatment decision.

Distant lymph node metastases in gastroesophageal junction adenocarcinoma: impact of endoscopic ultrasound-guided fine-needle aspiration

OBJECTIVE

Endoscopic ultrasound (EUS) is established as the most accurate technique for pre-operative locoregional staging of gastroesophageal junction (GEJ) adenocarcinoma, the purpose of the present study was to evaluate the distant lymph nodes (LNs) EUS-fine-needle aspiration (FNA) impact in therapeutic decision for patients with GEJ adenocarcinoma.

MATERIALS AND METHODS

Retrospective study was made, with cross-sectional, non-probabilistic analysis from prospectively collected database for all GEJ adenocarcinoma staging patients referred between January 2009 and August 2012 in Paoli-Calmette Institute in Marseille-France.

RESULTS

A total of 154 patients with GEJ adenocarcinoma were managed in our institution, of whom 113 (73.3%) had non-distant metastatic disease at computed tomography (CT) scan and underwent EUS for initial tumor staging prior to a treatment decision. On A total of 113 patients undergoing EUS, 8 (7%) patients underwent endoscopic resection and 6 (5.3%) underwent direct surgical resection. Of the remaining 99 patients (87.6%), 24 (21.2%) distant LN EUS-FNA were made. Seventeen LN had EUS malignant features, including 9 (52.9%) that were confirmed as malignant and underwent palliative treatment with chemotherapy. Ninety (79.6%) patients were treated with pre-operative neoadjuvant therapy and were revaluated after. 4 (4.4%) had metastatic disease at CT scan (underwent palliative treatment) and 65 (72.2%) underwent EUS restaging to treatment decision revaluation. Of these, twelve (18.4%) distant LN EUS-FNA were performed. Seven had LN EUS malignancy features, including 4 (57.1%) that were confirmed as malignant and underwent palliative treatment. The remaining 61 patients underwent surgery. As stated above, 21 patients (23.3%) did not undergo EUS restaging, including 10 (47.6%) that did not go to surgery because patient's age, poor general status and comorbidities, 6 (28.5%) had a loss of follow-up, 1 (4.7%) underwent to surgery due to chemotherapy collateral effects, 3 (14.2%) were still on pre-operative chemotherapy and 1 (4.7%) died for sepsis after mediastinal EUS-FNA, this was the only complication event evidenced. EUS-FNA changed clinical management in 54.2% of patients who met the criteria inclusion (distant LN with malignancies EUS features), which corresponds to 11.5% of patients with GEJ adenocarcinoma.

CONCLUSION

EUS-FNA was able to provide a different tumor staging and these differences were associated with treatment received. EUS-FNA had a significant impact on treatment decision.

Initial evaluation of the forward-viewing echoendoscope prototype for performing fine-needle aspiration, Tru-cut biopsy, and celiac plexus neurolysis

BACKGROUND AND AIMS

A forward-viewing echoendoscope (FV-CLA) has been recently developed for performing interventional endoscopic ultrasound (EUS). The role of FV-CLA in performing standard EUS-guided fine-needle aspiration (FNA), Tru-cut biopsy (TCB), and celiac plexus neurolysis (CPN) is unknown. Our aims were to evaluate the feasibility of the FV-CLA for performing EUS-guided FNA/TCB and CPN.

METHODS

In this prospective study conducted over a 3-month period, 30 patients were evaluated with the FV-CLA. Procedures performed were FNA in 28 lesions, TCB in one, and CPN in five patients.

RESULTS

EUS-guided FNA was undertaken at the following sites: mediastinum (n=3), liver (n=2), retroperitoneal mass (n=2), pancreas head/uncinate (n=9), pancreas body (n=6), pancreas tail (n=4), and perigastric lymph node (n=2). The median size of the lesions was 37×34 mm. A median of two passes was performed (range: 1-7). Final cytopathology diagnosed malignancies in 21 patients, with adenocarcinoma suspected for one.TCB of a mediastinal lymph node revealed lymphoma. FNA was benign in six patients. The sensitivity, specificity, positive predictive value, and negative predictive value for a malignancy diagnosis was 96% (95% confidence interval [CI], 87-96%), 100% (95% CI, 70-100%), 100% (92-100), and 86% (60-86%), respectively. CPN was successful in all five patients. It was easier to deploy the needle from the echoendoscope at all locations, including the duodenum, and irrespective of the site of the lesion.

CONCLUSIONS

The initial evaluation and safety profile of the FV-CLA echoendoscope for performing standard FNA/TCB and CPN appear to be favorable. The narrow image does not preclude basic therapeutic maneuvers. A major advantage appears to be easy needle deployment at any site within reach of the echoendoscope.

Does the surgeon still have a role to play in the diagnosis and management of lymphomas?

BACKGROUND

Over the course of the past 40 years, there have been a significant number of changes in the way in which lymphomatous disease is diagnosed and managed. With the advent of computed tomography, there is little role for staging laparotomy and the surgeon's role may now more diagnostic than therapeutic.

AIMS

To review all cases of lymphoma diagnosed at a single institution in order determine the current role of the surgeon in the diagnosis and management of lymphoma.

PATIENTS AND METHODS

Computerized pathology records were reviewed for a five-year period 1996 to 2000 to determine all cases of lymph node biopsy (incisional or excisional) in which tissue was obtained as part of a planned procedure. Cases of incidental lymphadenopathy were thus excluded.

RESULTS

A total of 297 biopsies were performed of which 62 (21%) yielded lymphomas. There were 22 females and 40 males with a median age of 58 years (range: 19-84 years). The lymphomas were classified as 80% non-Hodgkin's lymphoma, 18% Hodgkin's lymphoma and 2% post-transplant lymphoproliferative disorder. Diagnosis was established by general surgeons (n = 48), ENT surgeons (n = 9), radiologists (n = 4) and ophthalmic surgeons (n = 1). The distribution of excised lymph nodes was: cervical (n = 23), inguinal (n = 15), axillary (n = 11), intra-abdominal (n = 6), submandibular (n = 2), supraclavicular (n = 2), periorbital (n = 1), parotid (n = 1) and mediastinal (n = 1). Fine needle aspiration cytology had been performed prior to biopsy in only 32 (52%) cases and had suggested: lymphoma (n = 10), reactive changes (n = 13), normal (n = 5), inadequate (n = 4). The majority (78%) of cervical lymph nodes were subjected to FNAC prior to biopsy whilst this was performed in only 36% of non-cervical lymphadenopathy.

CONCLUSION

The study has shown that lymphoma is a relatively common cause of surgical lymphadenopathy. Given the limitations of FNAC, all suspicious lymph nodes should be biopsied following FNAC even if the FNAC is reported normal or demonstrating reactive changes only. With the more widespread application of molecular techniques, and the development of improved minimally-invasive procedures, percutaneous and endoscopic techniques may come to dominate, however, at present; the surgeon still has an important role to play in the diagnosis if not treatment of lymphomas.

Endoscopic Ultrasonograpic Findings of Benign Mediastinal and Abdominal Lymphadenopathy Confirmed by EUS-guided Fine Needle Aspiration

BACKGROUND/AIMS

Distinguishing benign and malignant lymph nodes by the findings of endoscopic ultrasonography (EUS) is still controversial. We tried to evaluate EUS findings of benign mediastinal and abdominal lymphadenopathy (BLAP) confirmed by EUS-guided fine needle aspiration (FNA).

METHODS

A total of 37 patients with enlarged mediastinal or abdominal lymph nodes (diameter >/=1 cm) were enrolled and EUS-FNA was performed. Final diagnosis was based on FNA cytology and follow up imaging studies (CT scans or EUS).

RESULTS

Thirteen patients were confirmed to have BLAP by EUS-FNA. Causes of BLAP were as follows; (i) extrapulmonary tuberculosis in six cases including patients with postoperative states due to cervical cancer and advanced gastric cancer, (ii) Kikuchi disease in one case, (iii) hypereosinophilic syndrome in one case, (iv) reactive hyperplasia in five cases including patients with postoperative states due to thyroid cancer, lung cancer, and EGC with ESD. EUS findings of BLAP revealed that median lymph node size was 24.7 mm. Lymph nodes were oval or round shaped in 9 cases, sharp borders in 9 cases, hypoechoic echo pattern in 7 cases, heterogenous internal echo pattern in 7 cases. Other findings included internal septation, calcification, multiplicity, attachment to the gastrointestinal tract wall, and conglomeration.

CONCLUSIONS

EUS findings of BLAP were not different from those of malignant lymphadenopathy previously reported in other studies.

The impact of endoscopic ultrasound and computed tomography on the TNM staging of early cancer in Barrett's esophagus

INTRODUCTION

Computed tomography (CT) and endoscopic ultrasound (EUS) are part of the regular staging protocol in esophageal cancer. The value of the two methods was assessed in patients with early cancer in Barrett's esophagus.

METHODS

One hundred consecutive patients (median age 64 yr, interquartile range [IQR] 58-72) with suspected early cancer in Barrett's esophagus who were referred to our hospital for endoscopic therapy were prospectively included in a standardized staging program with upper gastrointestinal endoscopy, EUS (7.5 MHz in all cases plus 12.5 or 20 MHz for elevated and/or depressed lesions), CT of the chest and upper abdomen, and abdominal ultrasonography. The results were summarized in accordance with the TNM classification. On the basis of the lymph node findings on CT and/or EUS, the patients were assigned to three categories: C1, no suspicious lymph nodes; C2, paraesophageal lymph nodes < or =1 cm in size at the tumor level, lymph nodes > or =1 cm in size not at the tumor level in the mediastinum or celiac trunk; and C3, paraesophageal lymph nodes > 1 cm in size at the tumor level. The EUS and CT findings were checked every 6 months in patients who underwent endoscopic treatment. Surgical resection was scheduled in operable patients if staging showed a T category higher than T1 and/or the lymph node staging was assessed as C3. Patients with suspected submucosal infiltration underwent diagnostic endoscopic resection, and if submucosal involvement was confirmed were referred for surgery.

RESULTS

The median follow-up period was 25 months (IQR 19.5-30.0). The T category diagnosed with CT was < or = T1 in all patients. On EUS, the T category was classified as T1 in 92% of cases (N = 92) and as > T1 in 8% (N = 8, p < 0.05). Enlarged lymph nodes (C2 and C3) were detected in 45% of the patients. Significantly more C2 lymph nodes were diagnosed with EUS than CT (28 vs 19, p < 0.05). Lymph nodes at the level with the highest suspicion, C3, were detected using CT in only three of nine cases. Sensitivity of CT for N staging was not acceptable compared with EUS (38%vs 75%). No extranodal metastases were found on CT.

CONCLUSIONS

In suspected early cancer in Barrett's esophagus, EUS is superior to CT for T staging and N staging. As CT had no influence on the TNM classification in any of these patients, it may be possible to dispense with this method as a staging procedure in patients with cancer in Barrett's esophagus. By contrast, EUS is required in order to differentiate between patients with cancer in Barrett's esophagus in whom endoscopic therapy is suitable and those in whom surgical treatment is required.