EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis

BACKGROUND

Gastric varices (GVs) are conventionally managed with endoscopic cyanoacrylate (E-CYA) glue injection. Endoscopic ultrasound (EUS)-guided therapy using combination of coils and CYA glue (EUS-CG) is a relatively recent modality. There is limited data comparing the two techniques.

METHODOLOGY

This international multicentre study included patients with GV undergoing endotherapy from two Indian and two Italian tertiary care centres. Patients undergoing EUS-CG were compared with propensity-matched E-CYA cases from a cohort of 218 patients. Procedural details such as amount of glue, number of coils used, number of sessions required for obliteration, bleeding after index procedure rates and need for re-intervention were noted.

RESULTS

Of 276 patients, 58 (male 42, 72.4%; mean age-44.3 ± 12.1 years) underwent EUS-CG and were compared with 118 propensity-matched cases of E-CYA. In the EUS-CG arm, complete obliteration at 4 weeks was noted in 54 (93.1%) cases. Compared to the E-CYA cohort, EUS-CG arm showed significantly lower number of session (1.0 vs. 1.5; p < 0.0001) requirement, lower subsequent-bleeding episodes (13.8% vs. 39.1%; p < 0.0001) and lower re-intervention (12.1% vs. 50.4%; p < 0.001) rates. On multivariable regression analysis, size of the varix (aOR-1.17; CI 1.08-1.26) and technique of therapy (aOR-14.71; CI 4.32-50.0) were significant predictors of re-bleeding. A maximum GV size >17.5 mm had a 69% predictive accuracy for need for re-intervention.

CONCLUSION

Endoscopic ultrasound-guided therapy of GV using coil and CYA glue is a safe technique with better efficacy and lower re-bleeding rates on follow-up compared to the conventional endoscopic CYA therapy.

Endoscopic Ultrasound-Guided Therapies in Patients with Pancreatic Neuroendocrine Tumors

Pancreatic neuroendocrine neoplasms (PNETs) are rare but can be associated with significant morbidity and mortality. PNETs can be difficult to diagnose and have a propensity for metastasis before their diagnosis is established. To this end, many PNETs do not become apparent until late in their clinical course. Endoscopic ultrasound (EUS) has become the modality of choice for detecting these lesions due to its high tumor detection rate. Additionally, therapeutic techniques have arisen from EUS which allow for the treatment of PNETs. Overall, EUS has become a powerful diagnostic and therapeutic modality for addressing pancreatic lesions such as PNETs. In this perspective article, we provide an overview of the therapeutic potentials of EUS in the management of PNETs.

Bcl-10, trypsin and synaptophysin helps recognize acinar cell and mixed acinar neuroendocrine cell carcinoma of the pancreas on both preoperative cytological samples and needle biopsy specimens

OBJECTIVE

Acinar cell carcinoma (ACC) of the pancreas are known to be rare and difficult to be recognize because they mimic other unrelated tumors (neuroendocrine, solid pseudopapillary) with different clinical behavior. Especially in the setting of inoperable patients, fine needle aspiration cytology (FNAC), core needle biopsy (FNAB) and immunocyto/histochemistry (ICC/IHC) play a crucial role in the differential diagnosis. The biological material available for ICC tests obtained by minimal invasive procedures is usually limited. Aim of the current study was to evaluate diagnostic panel based on a limited number of ICC markers for typing preoperatively ACC of the pancreas.

METHODS

Of 1820 needle sampling procedures performed and related to pancreatic lesions, 21 cases were extracted with a confirmed diagnosis of ACC on histology. Of them,12 were pure ACC and 9 mixed acinar-neuroendocrine carcinoma (MANEC). Smears of ACC, MANEC and a control group composed of 34neuroendocrine, 7solid pseudopapillary, 50ductal and 4 adenosquamous carcinoma were assessed with an ICC panel made up of BCL10, trypsin, synaptophysin, chromograninA, β-catenin.

RESULTS

On cytology, BCL10 sensitivity and specificity for ACC was 100%. Trypsin correctly recognized 90% of the cases. Synaptophysin was helpful to correctly identify all the cases with a mixed neuroendocrine component. No significant cross-reaction was observed between BCL10 and trypsin in any of the control group case.

CONCLUSIONS

BCL10 is a determinant marker for the diagnosis of acinar cell carcinoma and mixed acinar neuroendocrine cell carcinoma of the pancreas in a pre-operative citologic/histologic setting.

Endoscopic Ultrasound Guided Gallbladder Interventions: a Review of the Current Literature

Interventional endoscopic ultrasound (EUS) is a rapidly expanding field with a wide variety of indications, including different drainage procedures and delivery of locoregional treatment mainly for pancreatic solid tumors. Transgastric or transduodenal gallbladder drainage in high-risk patients with acute cholecystitis or biliary decompression in patients with unresectable distal biliary malignant obstruction who failed endoscopic retrograde colangiography is one of the newest areas of EUS-guided intervention. The large-caliber lumen apposing metal stents placed during these procedures allow direct endoscopic gallbladder access and the possibility of performing gallstone treatment or resection of mucosal polyps. The current review presents the indications of endoscopic gallbladder interventions and discusses the results of available studies, foreseeing future potential applications.

EUS-guided radiofrequency ablation as an alternative to surgery for pancreatic neuroendocrine neoplasms: Who should we treat?

Pancreatic neuroendocrine neoplasms (PanNENs) are rare tumors, but their incidental diagnosis has significantly increased due to the widespread use of imaging studies. Therefore, most PanNENs are now diagnosed when completely asymptomatic and in early stages. PanNENs are classified according to their grade (Ki-67 index) and can be functional (F-) or nonfunctional (NF-) depending on the presence or absence of a clinical, hormonal hypersecretion syndrome. The mainstay treatment of PanNENs is a surgery that is mostly curative but also associated with significant short- and long-term adverse events. Therefore, less invasive alternative locoregional treatment modalities are warranted. Recently, few case reports and two case series have described EUS-guided radiofrequency ablation (EUS-RFA) for the treatment of patients with both F-PanNENs and NF-PanNENs. If for F-PanNENs EUS-RFA can very easily become the standard of care, for NF-PanNENEs it is still controversial how to select patients for EUS-RFA. A balance between overtreatment (i.e., RFA/surgery in patients who will not progress) and undertreatment (locoregional treatments in patients with undetected metastases) needs to be found based on solid data. The decision should also take into account patients’ comorbidity and risk of postoperative death, life expectancy, tumor location, risk of postoperative fistula and postoperative morbidity, and risk of long-term exocrine and/or endocrine insufficiency. To answer the important question on which a patient should be treated with EUS-RFA, properly designed studies to evaluate the efficacy of this treatment in large cohorts of patients with NF-PanNENs and to establish prognostic factors associated with treatment response are urgently needed.

Endoscopic ultrasound-guided fine-needle aspiration cytology in pancreaticobiliary carcinomas: diagnostic efficacy of cell-block immunocytochemistry

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration cytology was demonstrated to be a useful tool for the diagnosis and staging of pancreaticobiliary neoplastic lesions. Nonetheless, the diagnostic value of this procedure may be limited by low cellularity of the specimen, contamination of intestinal cells and unfeasibility of ancillary immunocytochemical procedures. The present study was to evaluate its usefulness in the diagnosis of neoplastic lesions.

METHODS

A series of 46 pancreaticobiliary carcinomas with available cell block preparations was submitted to immunocytochemistry against cytokeratins, carcinoembryonic antigen, E-cadherin, CD10 and p53. The sensitivity, specificity, positive and negative predictive values of the cytological smear in the discrimination of malignant lesions were calculated and compared with those of cell block preparation with the immunocytochemical stains against p53 and CD10.

RESULTS

According to our findings, the use of cell block preparations together with immunostains against p53 and CD10 allowed to discriminate malignant versus benign specimens with higher sensitivity than the only cytological examination. In detail, CD10 immunostaining was of significant help for the discrimination between cytological contaminants, such as benign gastrointestinal cells, and the neoplastic elements of pancreaticobiliary well differentiated adenocarcinomas. Also, intense nuclear immunoreactivity for p53 was encountered in about 2/3 of the cases and identified pancreatic malignancy with high sensitivity.

CONCLUSIONS

We suggest that immunocytochemistry against both CD10 and p53 could be applied case by case, mainly to differentiate gastrointestinal and pancreatic benign cellular contaminants showing hyperplasia or reactive changes from differentiated pancreaticobiliary adenocarcinomas.