Role of Endoscopic Ultrasound in Staging and Vascular Assessment of Pancreatic Cancer

Introduction Computed tomography (CT) of the abdomen with contrast stands as the gold standard for assessing pancreatic cancer, encompassing both staging and vascular analysis. However, not all patients are suitable candidates for contrast-enhanced CT (CECT) scans due to factors such as contrast agent allergies, pregnancy, renal impairment, radiation risks, and limited tissue sampling capability in CECT scans of the abdomen. In light of these challenges, this study evaluated the diagnostic capabilities of endoscopic ultrasound (EUS) compared to CECT for staging and vascular assessment of pancreatic cancer. Methods Fifty patients diagnosed with pancreatic cancer underwent evaluations using both CECT scans and EUS, focusing on staging and vascular invasion assessment. Vascular evaluation was carried out using a categorization system based on EUS findings, classifying them into three types based on the tumor-vessel relationship: Type 1 indicating clear invasion or encasement of a vessel by a tumor or contact with a vessel wall exceeding 180 degrees, Type 2 representing abutment, wherein a tumor contacts a vessel wall but at an angle less than 180 degrees, and Type 3 implying clear non-invasion, where a discernible distance exists between a tumor and a vessel. In this categorization, Type 1 and Type 2 indicated signs of vascular invasion, while Type 3 indicated vascular non-invasion. These findings were subsequently compared to the results from CECT scans. The endoscopist performing EUS was blinded to the CT outcomes prior to the examination. Results Regarding pancreatic cancer staging, EUS exhibited remarkable sensitivity, specificity, and accuracy rates of 100% according to the T criterion.As for vascular invasion assessment, EUS demonstrated sensitivity, specificity, and accuracy of 100%, 95.93%, and 96%, respectively, for venous invasion. For arterial invasion, the figures were 95.65% sensitivity, 100% specificity, and an overall accuracy of 99.5%. Conclusion EUS is an effective modality for evaluating both staging and vascular invasion in pancreatic cancer, boasting exceptional sensitivity, specificity, and accuracy rates. The findings are robust enough to consider EUS a viable alternative to CT scans in evaluation, with the added advantage of EUS offering tissue sampling capability.

Endohepatology: The endoscopic armamentarium in the hand of the hepatologist

ABSTRACT

Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.

Insulinoma in Patient With Nonalcoholic Steatohepatitis

An insulinoma is a rare neuroendocrine tumor characterized by inappropriate secretion of insulin with resultant hypoglycemia and concomitant symptoms. Symptoms include diaphoresis, tremor, palpitations, tachycardia, visual disturbances, weakness, confusion, syncope, seizures, and even coma. Enteropancreatic neoplasms are rare in general but among them, insulinomas are among the more common neuroendocrine tumors though they still have a very low incidence. They can be benign or malignant, however, the latter is exceptionally rare. In the case of malignancy, such spread usually includes metastasis to the liver and surrounding nodes. They can also be sporadic or occur in association with other inherited conditions. Herein, we present a case of insulinoma in a 51-year-old female.

Cystic pancreatic neoplasms in a tertiary gastroenterologic referral center: Evaluation of the diagnostic accuracy of endoscopic ultrasound, progression rate and malignancy rate in a large unicentric cohort

INTRODUCTION

Cystic pancreatic neoplasms (CPN) are frequently diagnosed due to better diagnostic techniques and patients becoming older. However, diagnostic accuracy of endoscopic ultrasound (EUS) and value of follow-up are still unclear.

MATERIAL AND METHODS

The aim of our retrospective study was to investigate the frequency of different cystic pancreatic neoplasms (intraductal papillary mucinous neoplasm [IPMN], serous and mucinous cystadenoma, solid pseudopapillary neoplasia), diagnostic accuracy, size progression, and rate of malignancy using EUS in a tertiary reference center in Germany. Between January 1, 2012 and December 31, 2018, 455 patients were diagnosed with cystic pancreatic lesions (798 EUS examinations).

RESULTS

Endoscopic ultrasound diagnosed 223 patients with cystic pancreatic neoplasms, including 138 (61.9%) patients with branch duct IPMN, 16 (7.2%) with main duct IPMN, and five (2.2%) with mixed-type IPMN. In the largest subgroup of branch duct IPMN, cysts were size progressive in 20 patients (38.5%). Fine needle aspiration (FNA) was performed in 21 patients, and confirmed the suspected diagnosis in 12/21 patients. 28 surgical resections were performed, in 7/28 patients (25%), high-grade dysplasia or cancer was diagnosed. Endoscopic ultrasound diagnosis of serous and mucinous cystic pancreatic neoplasms was correct in 68.4%.

CONCLUSIONS

Endoscopic ultrasound differential diagnosis of CPNs is challenging. Even in a tertiary expert center, differentiation of serous and mucinous cystic neoplasia is not guaranteed. Relevant size progression of CPN, however, is rare, as is the rate of malignancy. The data of this study suggest that morphologic criteria to assess pancreatic cysts alone are not sufficient to allow a clear diagnosis. Hence, for the improved assessment of pancreatic cysts, EUS should be combined with additional tests and techniques such as MRT/MRCP, contrast-enhanced EUS, and/or FNA/fine needle biopsy including fluid analysis. The combination and correlation of imaging studies with EUS findings is mandatory.

Gastric Adenocarcinoma of the Remnant Stomach After Roux-en-Y Diagnosed by Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE)

It can be difficult to evaluate for pathology with traditional endoscopic modalities following a Roux-en-Y gastric bypass. This is due to the truncated gastrointestinal tract and excluded distal stomach formed during a Roux-en-Y procedure. In these circumstances, a modified endoscopic procedure, known as endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) is used. Although the Roux-en-Y procedure slightly increases the risk of gastric adenocarcinoma in the general population, the occurrence of gastric adenocarcinoma in the excluded stomach, specifically, is uncommon. Herein, we present a case of gastric adenocarcinoma of the excluded stomach, diagnosed 20 years after a Roux-en-Y procedure. This case is unique because after an extensive five-year workup for melena and iron deficiency anemia, the malignancy was ultimately diagnosed utilizing the innovative EDGE procedure.

Peculiar Presentation of Gastrointestinal Stromal Tumor in a Patient With Early Satiety

Gastrointestinal stromal tumors (GISTs) are one of the most common, potentially malignant, subepithelial lesions identified in the gastrointestinal tract. Hypothesized to derive from the interstitial cells of Cajal (ICC), GISTs commonly demonstrate gain of function mutations in proto-oncogenic receptor tyrosine kinase CD117 (KIT). Depending on mitotic activity and tumor size characteristics, GISTs may transform from benign to malignant neoplasms. Increasing evidence suggests that early identification of a GIST is paramount for optimal prognostic outcomes. We present a rare case of a GIST located in the uncinate pancreas identified via endoscopic ultrasound (EUS) and diagnosed with an EUS-guided fine needle aspiration (EUS-FNA) biopsy.

Correlation between endoscopic resection outcomes and endosonographic findings in gastric tumors with muscularis propria origin

Endoscopic resection is an effective treatment for subepithelial tumors arising from the muscularis propria layer of the stomach. However, the invasion pattern revealed by the pathological examination of tumor specimens is often not consistent with the findings of preprocedural endoscopic ultrasounds (EUS). We compared the real growing patterns of tumors, as evaluated on histopathological examination, with their EUS images, and analyzed the outcomes of endoscopic resections in relation to the EUS findings. From January 2006 to June 2015, 32 patients underwent endoscopic resection for gastric tumors originating from the muscularis propria at our hospital. We divided the patients into 3 groups according to the location of the tumor as diagnosed using pre procedural EUS: submucosa (group I, n = 5), muscularis propria (group II, n = 14), and tumors extending into the outer cavity (group III, n = 13). Histopathological examination revealed 15 patients with gastrointestinal stromal tumors (GISTs), 14 with leiomyomas, and 3 with schwannomas. Accuracy of EUS in evaluating tumor invasion was 56%. Some tumors in groups I and II was removed by endoscopic submucosal dissection only. Muscular dissection was needed in 10 patients (71%) in group II and 9 patients (69%) in group III. Four patients (31%) in group III were found to have subserosal tumors. The complete resection rate was 88% (23 patients) among patients who underwent endoscopic submucosal dissection and endoscopic muscular dissection, and 67% (4 patients) among patients who underwent endoscopic subserosal dissection (ESSD). The tumor was completely removed in 12 patients (86%) in group II and 10 patients (77%) in group III. EUS accurately predicts the layer of the subepithelial tumor in the stomach; however, the pattern of invasion of surrounding structures is difficult to evaluate using EUS.

Murine Typhus Presenting as Septic Acute Cholangitis in a Young Woman From South Texas

Murine (endemic) typhus is a zoonotic disease spread by fleas carrying Rickettsia typhi bacteria. Typically, murine typhus presents with mild and nonspecific flu-like symptoms. However, it can manifest with severe systemic complications potentially leading to delayed treatment or unnecessary interventions.

We present the case of a young woman from South Texas who presented to the emergency department after 10 days of fever, myalgia, headache, nausea, and right-sided abdominal pain. She was found to be febrile, severely hypotensive, suffering from acute liver injury with a predominantly cholestatic pattern, acute kidney injury, severe thrombocytopenia, and hyponatremia. She was initially managed with broad-spectrum antibiotics for undifferentiated septic shock, and doxycycline was added due to suspicion of a Rickettsial infection. Although radiographic findings showed some evidence of biliary involvement, they were not typical for common biliary diseases. However, due to her severe clinical presentation and findings suggesting possible acute cholangitis, she underwent an endoscopic ultrasound with endoscopic retrograde cholangiopancreatography, which revealed no evidence of acute obstructive biliary disease. Without strong evidence to explain her presentation, an extensive chronic liver disease workup was done, which was negative. The patient ultimately clinically improved with antibiotics alone.

This case demonstrates an atypical presentation of murine typhus, presenting with septic shock and masquerading as acute cholangitis. With the rising incidence of murine typhus in endemic areas of the United States, this case reinforces the importance of being cognizant of the typical and atypical presentations of murine typhus, which may allow for early appropriate treatment and potentially avoid unnecessary interventions. Additionally, in this study, we conducted a literature review of murine typhus cases associated with acute biliary dysfunction.

Lemmel's Syndrome Secondary to Common Bile Duct Compression by an Inflamed Duodenal Diverticulum

A 50-year-old female presented with acute epigastric abdominal pain, diarrhea, nausea, and vomiting for two days. Laboratory data showed hyperbilirubinemia and leukocytosis. Abdominal imagining was concerning for a pancreatic head/uncinate process lesion concerning a pancreatic neoplasm. Subsequent esophagogastroduodenoscopy with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography found the major papilla adjacent to an inflamed and infected duodenal diverticulum, which was extrinsically compressing the distal common bile duct, causing biliary obstruction and common bile duct dilation. These findings are consistent with a diagnosis of Lemmel’s syndrome. A biliary sphincterotomy was performed to relieve the obstruction and one temporary plastic biliary stent was placed into the common bile duct. The duodenal diverticulitis was treated with antibiotics for 10 days and the patient made a good recovery.

Neuroendocrine Tumor: A Rare, Aggressive Tumor of the Gallbladder

We report a case of rare and aggressive gallbladder neuroendocrine carcinoma (GB-NEC), diagnosed with the help of endoscopic ultrasound (EUS). A 65-year-old asymptomatic male, with a past medical history of hypertension, underwent abdominal ultrasound for the screening of an abdominal aortic aneurysm. He was found to have a mixed echogenicity area near the stomach, an incidental finding on abdominal ultrasound. The patient had an upper gastrointestinal (GI) endoscopy exam, which revealed an antral mass that was biopsied. The tissue specimen showed an epithelioid mesenchymal tumor of unclassified type and, eventually, the patient underwent partial gastrectomy. Surgical pathology reported a low-grade sub-serosal gastrointestinal stromal tumor (GIST) of the resected tissue specimen. He was later discharged and advised to follow up with abdominal computed tomography (CT) every year. Two years later, his abdominal CT revealed a new 3.7 cm x 2.0 cm mass in the posterior gallbladder fundus. Subsequently, the patient underwent laparoscopic cholecystectomy and the excisional biopsy reported a T3NXM1 neuroendocrine small cell carcinoma. Then, he received six cycles of systemic chemotherapy with carboplatin and etoposide, showing excellent response initially. However, a repeat CT abdomen/pelvis with contrast, on his eighth-month follow-up, demonstrated the interval development of an infiltrative mass in the pancreatic head. The gastroenterology team was then consulted, who performed sphincterotomy with temporary stent placement and celiac plexus neurolysis. Also, a transduodenal fine-needle aspiration (FNA) of the pancreatic mass was performed, which revealed metastatic small cell carcinoma. Based on these findings, the patient received an additional three cycles of carboplatin/etoposide chemotherapy, along with one cycle of immunotherapy. However, the patient had a poor response to chemotherapy, and he eventually chose hospice care.

Emergency Presentation of Gastric Ectopic Pancreas

Ectopic pancreas is a rare embryological abnormality apparently not in association with others. Stomach and duodenum are the most common organs involved. Symptoms are nonspecific. Patients may complain of dyspepsia, abdominal pain or intestinal obstruction. Malignant evolution of ectopic pancreatic cells has been reported. Diagnosis can be very challenging due to the rarity of the disease and the absence of specific symptoms and radiological findings. We report two cases of young-adult men admitted to the emergency department due to acute upper gastro-intestinal and pancreatic symptoms. In both cases, during upper gastrointestinal endoscopy no mucosal vegetations were found. Endoscopic ultrasonography revealed gastric lesions originating from the muscularis propria, with a pattern suspected but not conclusive for malignancy. Fine needle aspiration was inconclusive in both cases. The patients underwent abdominal computed tomography, that showed gastric masses originating from the antrum and the lesser curvature of the stomach, with enlarged locoregional lymph nodes. According to the patients’ symptoms, family history, radiological and cytological findings, the patients were scheduled for an explorative laparoscopy. In both cases, gastric ectopic pancreas was found. Clinical presentation of ectopic pancreas is heterogeneous and the diagnosis can be challenging, especially in an emergency setting. Endoscopic ultrasonography and fine needle aspiration can be useful for the diagnosis and clinical staging, but they can be unspecific. Diagnostic-therapeutic laparoscopy should be considered in symptomatic patients.

Endoscopic ultrasound (EUS) elastography and strain ratio, could it help in differentiating malignant from benign pancreatic lesions?

Evaluating the role of endoscopic ultrasound (EUS) elastography and strain ratio in differentiation between malignant and benign pancreatic lesions.Three hundred twenty-five patients with solid pancreatic lesions were enrolled in this prospective study from 2014 to 2017. EUS real-time elastography scoring and strain ratio were done to all patients and compared to the final diagnosis to assess its sensitivity, specificity, positive and negative predictive values (PPV and NPV) in differentiating malignant from benign lesions.A cut-off value of 4.2 we had sensitivity of 95%, specificity of 63%, PPV of 89%, NPV of 81%, and accuracy of 87%. Another cut-off value of 10.9 showed a sensitivity of 75%, specificity of 88%, PPV of 95%, NPV of 54%, and accuracy of 79%. Adding the elastography to the better cut-off value gave a sensitivity of 97%, specificity of 63%, PPV of 89%, NPV of 88%, and accuracy of 89%.Real-time elastography and strain ration are valuable in differentiating malignant from pancreatic lesions.

Foreign body embedded in the lower esophageal wall located by endoscopic ultrasonography: A case report

RATIONALE

Ingested esophageal foreign bodies are commonly seen in adult population. In very few instances, esophageal foreign body may pass through the mucosal surface, re-epithelialize or migrate into surrounding soft tissues.

PATIENT CONCERNS

A 55-year-old Chinese male was admitted to our hospital with a 10-day history chest and upper abdominal pain without dysphasia, cough or other symptoms.

DIAGNOSES

We initially suspected chronic gastritis, and thoracic computed tomography and endoscopy ultrasonography (EUS) were used to identify a fish bone completely embedded within the lower esophageal wall.

INTERVENTIONS

Under the EUS-guidance, we marked the foreign body using methylene blue with saline solution, which was followed by successful thoracoscopy and surgical removed of the foreign body.

OUTCOMES

The patient recovered well and was discharged 1 week postoperatively. One month postoperatively, the patient was symptom free and the chest wound was complete healed.

LESSONS

Our case showed that computed tomography is necessary to diagnose the esophageal foreign body, and EUS may help confirm the position of foreign body, especially those embedded in the esophageal submucosa. We advocate necessary surgery at the first accurate diagnosis in patient with esophageal foreign body when endoscopy is not possible.

Successful creation of pancreatic cancer organoids by means of EUS-guided fine-needle biopsy sampling for personalized cancer treatment

BACKGROUND AND AIMS

Pancreatic cancer organoids are tumor models of individualized human pancreatic ductal adenocarcinoma (PDA), created from surgical specimens and used for personalized treatment strategies. Unfortunately, most patients with PDA are not operative candidates. Creation of human PDA organoids at the time of initial tumor diagnosis is therefore critical. Our aim was to assess the feasibility of creating human PDA organoids by EUS fine-needle biopsy (EUS-FNB) sampling in patients with PDA.

METHODS

In this prospective clinical trial in patients referred to evaluate a pancreatic mass, EUS-FNA was performed for initial onsite diagnosis. Two additional needle passes were performed with a 22-gauge FNB needle for organoid creation. Primary outcome was successful isolation of organoids within 2 weeks of EUS-FNB sampling (P0, no passages), confirmed by organoid morphology and positive genotyping.

RESULTS

Thirty-seven patients with 38 PDA tumors were enrolled. Successful isolation of organoids (P0) was achieved in 33 of 38 tumors (87%). Establishment of PDA organoid lines for ≥5 passages of growth (P5, five passages) was reached in 25 of 38 tumors (66%). In the single patient with successful P5 FNB sampling-derived and P5 surgically derived organoids, there was identical matching of specimens. There were no serious adverse events. Two patients developed bleeding at the EUS-FNB puncture site requiring hemostasis clips.

CONCLUSIONS

Pancreatic cancer organoids can be successfully and rapidly created by means of EUS-FNB sampling using a 22-gauge needle at the time of initial diagnosis. Successful organoid generation is essential for precision medicine in patients with pancreatic cancer in whom most are not surgically resectable. (Clinical trial registration number: NCT03140592.).

Diagnosis of Chronic Pancreatitis Incorporating Endosonographic Features, Demographics, and Behavioral Risk

OBJECTIVES

Diagnosing chronic pancreatitis remains challenging. Endoscopic ultrasound (EUS) is utilized to evaluate pancreatic disease. Abnormal pancreas function test is considered the "nonhistologic" criterion standard for chronic pancreatitis. We derived a prediction model for abnormal endoscopic pancreatic function test (ePFT) by enriching EUS findings with patient demographic and pancreatitis behavioral risk characteristics.

METHODS

Demographics, behavioral risk characteristics, EUS findings, and peak bicarbonate results were collected from patients evaluated for pancreatic disease. Abnormal ePFT was defined as peak bicarbonate of less than 75 mEq/L. We fit a logistic regression model and converted it to a risk score system. The risk score was validated using 1000 bootstrap simulations.

RESULTS

A total of 176 patients were included; 61% were female with median age of 48 years (interquartile range, 38-57 years). Abnormal ePFT rate was 39.2% (69/176). Four variables formulated the risk score: alcohol or smoking status, number of parenchymal abnormalities, number of ductal abnormalities, and calcifications. Abnormal ePFT occurred in 10.7% with scores 4 or less versus 92.0% scoring 20 or greater. The model C-statistic was 0.78 (95% confidence interval, 0.71-0.85).

CONCLUSIONS

Number of EUS pancreatic duct and parenchymal abnormalities, presence of calcification, and smoking/alcohol status were predictive of abnormal ePFT. This simple model has good discrimination for ePFT results.

Comparison of two different size needles in endoscopic ultrasound-guided fine-needle aspiration for diagnosing solid pancreatic lesions: A meta-analysis of prospective controlled trials

BACKGROUND

This meta-analysis aimed to provide a pooled analysis of prospective controlled trials comparing the diagnostic accuracy of 22-G and 25-G needles on endoscopic ultrasonography (EUS-FNA) of the solid pancreatic mass.

METHODS

We established a rigorous study protocol according to Cochrane Collaboration recommendations. We systematically searched the PubMed and Embase databases to identify articles to include in the meta-analysis. Sensitivity, specificity, and corresponding 95% confidence intervals were calculated for 22-G and 25-G needles of individual studies from the contingency tables.

RESULTS

Eleven prospective controlled trials included a total of 837 patients (412 with 22-G vs 425 with 25-G). Our outcomes revealed that 25-G needles (92% [95% CI, 89%-95%]) have higher sensitivity than 22-G needles (88% [95% CI, 84%-91%]) on solid pancreatic mass EUS-FNA (P = 0.046). However, there were no significant differences between the 2 groups in overall diagnostic specificity (P = 0.842). The pooled positive and negative likelihood ratio of the 22-G needle were 12.61 (95% CI, 5.65-28.14) and 0.16 (95% CI, 0.12-0.21), respectively. The pooled positive likelihood ratio was 12.61 (95% CI, 5.65-28.14), and the negative likelihood ratio was 0.16 (95% CI, 0.12-0.21) for the 22-G needle. The pooled positive likelihood ratio was 8.44 (95% CI, 3.87-18.42), and the negative likelihood ratio was 0.13 (95% CI, 0.09-0.18) for the 25-G needle. The area under the summary receiver operating characteristic curve was 0.97 for the 22-G needle and 0.96 for the 25-G needle.

CONCLUSION

Compared to the study of 22-G EUS-FNA needles, our study showed that 25-G needles have superior sensitivity in the evaluation of solid pancreatic lesions by EUS-FNA.

A multicenter study on the utility and safety of EBUS-TBNA and EUS-B-FNA in children

BACKGROUND AND AIM

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound with an echobronchoscope-guided fine needle aspiration (EUS-B-FNA) are useful modalities in the evaluation of mediastinal lymphadenopathy in adults; however, there is sparse data in children. The aim of this multicenter study is to describe the efficacy and safety of EBUS-TBNA and EUS-B-FNA in children with mediastinal lymphadenopathy of undefined etiology.

METHODS

Retrospective analysis of consecutive pediatric (<18 years) subjects who underwent EBUS-TBNA or EUS-B-FNA for the evaluation of mediastinal lymphadenopathy. The demographic characteristics, indications, procedural details, pathological, cytological and microbiological diagnosis, diagnostic yield, and complications are presented.

RESULTS

Of the 3,424 EBUS/EUS-B-FNA procedures, 67 (1.9%) were performed in the pediatric (3-17 years) population. Of these, 19 (28.4%) were performed in children ≤12 years of age. Overall, EBUS-TBNA and EUS-B-FNA were performed in 53 and 12 subjects, respectively. In two subjects, no significant lymph node was seen on EBUS. The procedure was performed under moderate sedation in spontaneously breathing subjects in 54 (80.6%) instances. An adequate sample was obtained in 60 (92.3%) subjects while a diagnostic sample was obtained in 37 (56.9%) of the 65 subjects. The diagnostic yield was not significantly different (P = 0.59) between EBUS-TBNA (58.5%) and EUS-B-FNA (50%). The sensitivity of EBUS-TBNA/EUS-B-FNA was 79.1% and led to a change in diagnosis in 28 (41.8%) subjects. Complications, all minor were encountered in six (8.9%) subjects.

CONCLUSIONS

EBUS-TBNA and EUS-B-FNA are safe techniques with a good diagnostic yield in the evaluation of children with mediastinal lymphadenopathy. Pediatr Pulmonol. 2016;51:1031-1039. © 2016 Wiley Periodicals, Inc.

Yield of new versus reused endobronchial ultrasound-guided transbronchial needle aspiration needles: A retrospective analysis of 500 patients

Background:

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) requires a dedicated needle for aspiration of mediastinal lesions. There is no data on reuse of these needles.

Methods:

This is a retrospective study of patients who underwent EBUS-TBNA with either new or reused EBUS-TBNA needles. The needles were reused after thorough cleaning with filtered water and organic cleaning solution, disinfection with 2.4% glutaraldehyde solution followed by ethylene oxide sterilization. The yield of EBUS-TBNA was compared between the two groups.

Results:

A total of 500 EBUS-TBNA procedures (351 new, 149 reused needles) were performed. The baseline characteristics were different in the two groups with suspected granulomatous disorders (sarcoidosis or tuberculosis) being significantly more common in the new compared to the reused needle group. Similarly, the median, interquartile range number of lymph node stations sampled, and the total number of passes were significantly higher in the new versus the reused needle group. The diagnostic yield was significantly higher with new needle as compared to reused needle (65.2% vs. 53.7%, P = 0.02). On multivariate logistic regression analysis, clinical suspicion of granulomatous disorders (odds ratio 1.86 [95% confidence interval, 1.20-2.87], P = 0.005) was the only predictor of diagnostic yield, after adjusting for the type of needle (new or reused), total number of passes and the number of lymph node stations sampled. No case of mediastinitis was encountered in either group.

Conclusions:

The yield of EBUS-TBNA might be similar with single reuse of needles as compared to new needles. However, reuse of needle should be performed only when absolutely necessary.

EUS-guided portal pressure measurement using a digital pressure wire with real-time remote display: a novel, minimally invasive technique for direct measurement in an animal model

BACKGROUND AND AIMS

Hepatic venous pressure gradient (HVPG) currently serves as a surrogate for portal pressure measurement but has many limitations. We developed a novel technique for rapid and direct portal pressure measurements using a digital pressure wire delivered through an EUS-guided 22-gauge FNA needle. Our aims were to evaluate (1) the short-term safety and technical feasibility, (2) procedural duration and subjective workload assessment, and (3) accuracy compared with a transjugular criterion standard approach.

METHODS

The subjects were Yorkshire pigs, weighing 40 to 55 kg. The portal vein was identified by using a linear array echoendoscope and accessed with a commercially available 22-gauge FNA needle preloaded with a digital pressure wire. Access was confirmed by portal venography. Mean digital pressure measurements were recorded over 30 to 60 seconds, and the National Aeronautics and Space Administration Task Load Index was scored. The control measurements were conventional transjugular catheterization with a balloon occlusion catheter to obtain free and wedged hepatic pressures, with subsequent HVPG calculation.

RESULTS

The total time required for EUS identification and needle access of the portal vein, venography, and digital pressure measurement was less than 5 minutes in 5 of 5 pigs. The National Aeronautics and Space Administration Task Load Index scores revealed a low subjective workload. Baseline portal pressure measurements via EUS ranged from 5 mm Hg to 10 mm Hg (mean, 6.4 mm Hg). HVPG measurements were consistently ±1 mm Hg of portal pressure.

CONCLUSIONS

This study is the first report of direct EUS-guided portal pressure measurements by using a digital pressure wire. This method is routinely performed in minutes and provides real-time pressure tracings via wireless transmission. This novel approach for direct portal pressure measurement has the potential to replace traditional indirect HVPG measurements.

Sudden appearance of free fluid during endoscopic ultrasound-guided fine-needle aspiration

During endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of a pancreatic malignancy, a small quantity of free fluid, not seen before, suddenly appeared in the view, and time was spent ruling out ongoing hemorrhage. However, during follow-up, the patient gradually developed peritoneal signs and was referred for surgery. The images presented elucidate the diagnosis and raise the question of a theoretical change in diagnostic and therapeutic approach.

Poor 'real-life' negative predictive value of cross-sectional imaging in obstructive jaundice

BACKGROUND

Cross-sectional imaging remains the first-line test for obstructive jaundice despite high miss rates for pancreatobiliary tumours. Improvements in resolution and slice thickness of spiral computed tomography⁄magnetic resonance imaging⁄magnetic resonance cholangiopancreatography promised to increase accuracy.

OBJECTIVE

To assess whether the post-test probability of neoplasm is truly altered by the presence or absence of a mass on computed tomography⁄magnetic resonance imaging in obstructive jaundice.

METHODS

The institutional endoscopic ultrasound (EUS) database was retrospectively reviewed to stratify patients presenting to EUS over a two-year period for obstructive jaundice (suspicious for malignancy) according to their pre-EUS imaging results. The primary analysis involved the calculation of the positive predictive value and negative predictive value (NPV) of imaging with 95% binomial CIs. Test performance of EUS⁄fine-needle aspiration (FNA) was also calculated. Final diagnosis was determined by positive cytology⁄histology; negative EUS was supplemented by clinical follow-up.

RESULTS

The positive predictive value (n = 51) and NPV (n = 53) of pre-EUS imaging was 98% (95% CI 90% to 100%) and 9% (95% CI 3% to 21%), respectively (accuracy 53%), with post-test suspicion of malignancy similar between imaging-positive and -negative groups. EUS demonstrated a mass in 96% of imaging-positive cases versus 85% in imaging-negative cases (exact P = 0.09). Malignant or suspicious FNA cytology was obtained with EUS in 92% of the imaging-positive group, and 62% of the imaging-negative group (75% of subgroup with FNA) (P < 0.001).

CONCLUSION

Lack of a definite mass on pre-EUS imaging had low NPV, and was clearly not sufficiently accurate or reassuring in this clinical setting. In suspicious obstructive jaundice, EUS with FNA has a high diagnostic yield regardless of the findings of pre-EUS cross-sectional imaging and, as such, EUS may be a more reasonable first-line test in this high-suspicion setting.

Synthesis and magnetic properties of Gd doped EuS nanocrystals with enhanced Curie temperatures

EuS nanocrystals (NCs) were doped with Gd resulting in an enhancement of their magnetic properties. New EuS and GdS single source precursors (SSPs) were synthesized, characterized, and employed to synthesize Eu(1-x)Gd(x)S NCs by decomposition in oleylamine and trioctylphosphine at 290 °C. The doped NCs were characterized using X-ray diffraction, transmission electron microscopy, and scanning transmission electron microscopy, which support the uniform distribution of Gd dopants through electron energy loss spectroscopy (EELS) mapping. X-ray absorption spectroscopy (XAS) revealed the dopant ions in Eu(1-x)Gd(x)S NCs to be predominantly Gd(3+). NCs with a variety of doping ratios of Gd (0 ≤ x < 1) were systematically studied using vibrating sample magnetometry and the observed magnetic properties were correlated with the Gd doping levels (x) as quantified with ICP-AES. Enhancement of the Curie temperature (T(C)) was observed for samples with low Gd concentrations (x ≤ 10%) with a maximum T(C) of 29.4 K observed for NCs containing 5.3% Gd. Overall, the observed T(C), Weiss temperature (θ), and hysteretic behavior correspond directly to the doping level in Eu(1-x)Gd(x)S NCs and the trends qualitatively follow those previously reported for bulk and thin film samples.

Role of EUS-FNA-based cytology in the diagnosis of mucinous pancreatic cystic lesions: a systematic review and meta-analysis

BACKGROUND

Preoperative diagnosis of malignancy in pancreatic cystic lesions (PCLs) remains challenging. Most non-mucinous cystic lesions (NMCLs) are benign, but mucinous cystic lesions (MCLs) are more likely to be premalignant or malignant.

AIM

The aim of this study was to assess the sensitivity, specificity, and positive and negative likelihood ratios (LRs) of EUS-FNA-based cytology in differentiating MCLs from non-mucinous PCLs.

METHODS

We conducted a comprehensive search of MEDLINE, SCOPUS, Cochrane, and "CINAHL Plus" databases to identify studies, in which the results of EUS-FNA-based cytology of PCLs were compared with those of surgical biopsy or surgical excision histopathology. A DerSimonian-Laird random effect model was used to estimate the pooled sensitivity, specificity, and LRs, and a summary receiver-operating characteristic (SROC) curve was constructed.

RESULTS

We included 376 patients from 11 distinct studies who underwent EUS-FNA-based cytology and also had histopathological diagnosis. The pooled sensitivity and specificity in diagnosing MCLs were 0.63 (95% CI, 0.56-0.70) and 0.88 (95% CI, 0.83-0.93), respectively. The positive and negative LRs in diagnosing MCLs were 4.46 (95% CI, 1.21-16.43) and 0.46 (95% CI, 0.25-0.86), respectively. The area under the curve (AUC) was 0.89.

CONCLUSIONS

EUS-FNA-based cytology has overall low sensitivity but good specificity in differentiating MCLs from NMCLs. Further research is required to improve the overall sensitivity of EUS-FNA-based cytology to diagnose MCLs while evaluating PCL.

Bayesian Adaptation of the Summary ROC Curve Method for Meta-analysis of Diagnostic Test Performance

Meta-analytic methods for diagnostic test performance, Bayesian methods in particular, have not been well developed. The most commonly used method for meta-analysis of diagnostic test performance is the Summary Receiver Operator Characteristic (SROC) curve approach of Moses, Shapiro and Littenberg. In this paper, we provide a brief summary of the SROC method, then present a case study of a Bayesian adaptation of their SROC curve method that retains the simplicity of the original model while additionally incorporating uncertainty in the parameters, and can also easily be extended to incorporate the effect of covariates. We further derive a simple transformation which facilitates prior elicitation from clinicians. The method is applied to two datasets: an assessment of computed tomography for detecting metastases in non-small-cell lung cancer, and a novel dataset to assess the diagnostic performance of endoscopic ultrasound (EUS) in the detection of biliary obstructions relative to the current gold standard of endoscopic retrograde cholangiopancreatography (ERCP).

Through-the-scope balloon dilation for endoscopic ultrasound staging of stenosing esophageal cancer

Dilation of malignant esophageal strictures often is required to complete staging by endoscopic ultrasound (EUS). This study was designed to determine the successful dilation rate (ability to complete staging) and complication rate of through-the-scope (TTS) balloon dilation for malignant esophageal strictures during EUS. We retrospectively reviewed EUS reports for all cases of primary esophageal cancer staged at five centers between January 2002 and October 2004. All dilations were performed with TTS balloons. Among 272 endoscopic ultrasounds, dilation was required in 77 (28%) and was successful in 73 cases (95%). There was one esophageal perforation after dilation (1.3%; 95% confidence interval (CI), 0.2-7) and one esophageal perforation after EUS without dilation (0.5%; 95% CI, 0.1-2.8; P = 0.48 by two-sided Fisher exact test). There were no other major complications. TTS balloon dilation is highly successful in permitting complete staging of obstructing tumors. The rate of complications after dilation with a TTS balloon dilator is low and similar to the baseline rate of EUS in this setting.