Compliance with Fetal Fibronectin Testing at a Canadian Tertiary Care Perinatal Centre.

OBJECTIVE: The purpose of this study was to assess compliance with fetal fibronectin (fFN) testing recommendations at a single tertiary care perinatal centre. The secondary objective was to identify factors associated with compliance with these recommendations. METHODS: A retrospective cohort study was conducted from January 1, 2016 to December 31, 2016 of all patients who presented to the IWK Health Centre with suspected preterm labour. Inclusion criteria included symptoms of preterm labour prior to 370 weeks gestation, singleton or multiple pregnancy, and established fetal wellbeing. Exclusion criteria included severe fetal anomaly, contraindications to tocolysis, transfer from community hospital, or inadequate documentation. Provider compliance was evaluated to determine: 1) whether the test was performed for appropriate indications according to provincial fFN guidelines; 2) whether fFN results were appropriately being used to inform patient care. Logistic regression was used to determine factors associated with compliance. RESULTS: A total of 528 patients presented with symptoms of preterm labour. The overall compliance with testing recommendations was 76.1%. Compliance for patients who met criteria for fFN testing was 73%, and compliance for those not meeting criteria was 76.4%. Of patients with a negative fFN result, 85.3% were appropriately discharged home without intervention. Gestational age, time of day, and non-obstetrician provider type were found to be associated with compliance. CONCLUSION: Despite regional and national guidelines, this study demonstrates a compliance rate of 76% in our centre, indicating a gap in provider knowledge regarding proper use and interpretation of fFN. Non-obstetrician provider type was associated with decreased compliance.

Performance characteristics of EUS for locoregional evaluation of ampullary lesions.

BACKGROUND: The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. OBJECTIVES: To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions. DESIGN: Retrospective cohort study. SETTING: Tertiary-care referral center. PATIENTS: All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012. INTERVENTION: EUS. MAIN OUTCOME MEASUREMENTS: Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy. RESULTS: We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively. LIMITATION: Retrospective design. CONCLUSIONS: EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection.

Cystic pancreatic neuroendocrine tumors: outcomes of preoperative endosonography-guided fine needle aspiration, and recurrence during long-term follow-up.

BACKGROUND AND STUDY AIMS: The role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis and management of cystic pancreatic neuroendocrine tumors (PNETs) is unclear. We aimed to compare clinical/endosonographic characteristics of cystic with solid PNETs, determine diagnostic accuracy of preoperative EUS-FNA, and evaluate recurrence rates after resection. PATIENTS AND METHODS: All patients with cystic or solid PNET confirmed by EUS-FNA between 2000 and 2014 were identified. A matched case-control study compared 50 consecutive patients with cystic PNETs with 50 consecutive patients with solid PNETs, matched by gender and age at diagnosis of index cystic PNET. We compared clinical/endosonographic characteristics, assessed diagnostic accuracy of preoperative EUS-FNA for identifying malignancy, and analyzed tumor-free survival of patients with cystic and solid PNETs. RESULTS: Cystic PNETs tended to be larger than solid PNETs (mean 26.8 vs. 20.1 mm, P = 0.05), more frequently nonfunctional (96 % vs. 80 %, P = 0.03), and less frequently associated with multiple endocrine neoplasia type 1 (10 % vs. 28 %, P = 0.04). With surgical pathology as reference standard, EUS-FNA accuracies for malignancy of cystic and solid PNETs were 89.3 % and 90 %, respectively; cystic PNETs were less associated with metastatic adenopathy (22 % vs. 42 %, P = 0.03) and liver metastasis (0 % vs. 26 %, P < 0.001). Cystic fluid analysis (n = 13), showed benign cystic PNETs had low carcinoembryonic antigen (CEA), Ki-67 ≤ 2 %, and no loss of heterozygosity. Patients with cystic and solid PNETs had similar recurrence risk up to 5 years after complete resection. CONCLUSIONS: Cystic PNETs have distinct clinical and EUS characteristics, but were associated with less aggressive biological behavior compared with solid PNETs. EUS-FNA is accurate for determining malignant potential on preoperative evaluation. Despite complete resection, recurrence is observed up to 5 years following surgery.

Treatment of clinical T2N0M0 esophageal cancer.

BACKGROUND: Management of clinical T2N0M0 (cT2N0M0) esophageal cancer remains controversial. We reviewed our institutional experience over 21 years (1990-2011) to determine clinical staging accuracy, optimal treatment approaches, and factors predictive of survival in this patient population. METHODS: Patients with cT2N0M0 esophageal cancer determined by endoscopic ultrasound (EUS) were identified through a prospectively collected database. Demographics, perioperative data, and outcomes were examined. Cox regression model and Kaplan-Meier plots were used for statistical survival analysis. RESULTS: A total of 731 patients underwent esophagectomy, of whom 68 cT2N0M0 patients (9 %) were identified. Fifty-seven patients (84 %) had adenocarcinoma. Thirty-three patients (48.5 %) were treated with neoadjuvant chemoradiation followed by surgery, and 35 underwent surgical resection alone. All resections except one included a transthoracic approach with two-field lymph node dissection. Thirty-day operative mortality was 2.9 %. Only 3 patients (8.5 %) who underwent surgery alone had T2N0M0 disease identified by pathology: the disease of 15 (42.8 %) was found to be overstaged and 17 (48.5 %) understaged after surgery. Understaging was more common in poorly differentiated tumors (p = 0.03). Nine patients (27.2 %) had complete pathologic response after chemoradiotherapy. Absence of lymph node metastases (pN0) was significantly more frequent in the neoadjuvant group (29 of 33 vs. 21 of 35, p = 0.01). Median follow-up was 44.2 months. Overall 5-year survival was 50.8 %. On multivariate analysis, adenocarcinoma (p = 0.001) and pN0 after resection (p = 0.01) were significant predictors of survival. CONCLUSIONS: EUS was inaccurate in staging cT2N0M0 esophageal cancer in this study. Poorly differentiated tumors were more frequently understaged. Adenocarcinoma and absence of lymph node metastases (pN0) were independently predictive of long-term survival. pN0 status was significantly more common in patients undergoing neoadjuvant therapy, but long-term survival was not affected by neoadjuvant therapy. A strategy of neoadjuvant therapy followed by resection may be optimal in this group, especially in patients with disease likely to be understaged.

Performance characteristics of molecular (DNA) analysis for the diagnosis of mucinous pancreatic cysts.

BACKGROUND: Diagnosis of mucinous pancreatic cysts (MPCs) is challenging due to the poor sensitivity of cytology provided by EUS-guided-FNA (EUS-FNA). OBJECTIVE: To quantify the test characteristics of molecular (DNA) analysis in suspected low-risk MPCs. DESIGN: A prospective cohort study performed in between 2008 and 2011. SETTING: Academic referral center. PATIENTS: Consecutive patients who underwent EUS-FNA of suspected MPCs. INTERVENTION: EUS-FNA and molecular (DNA) analysis of cyst fluid. MAIN OUTCOME MEASUREMENTS: The sensitivity and specificity of molecular analysis in the diagnosis of MPCs using the criterion standard of surgical pathology in resected cysts. RESULTS: Patients with suspected MPCs underwent EUS-FNA and cyst fluid DNA analysis. Surgical resection was performed in 48 patients (17%), confirming a mucinous pathology in 38 (79%). In this group, molecular analysis had a sensitivity of 50% and a specificity of 80% in identifying MPCs (accuracy of 56.3%). The combination of molecular analysis with cyst fluid carcinoembryonic antigen (CEA) and cytology resulted in higher MPC diagnostic performance than either one of its individual components, with a sensitivity, specificity, and accuracy of 73.7%, 70%, and 72.9%, respectively. There was no significant difference in accuracy between molecular analysis and CEA/cytology in this group. LIMITATIONS: Single-center experience. CONCLUSION: Molecular analysis aids in the diagnosis of MPCs when cytology is nondiagnostic or cyst fluid is insufficient for CEA or its level is indeterminate. Our results do not support the routine use of molecular analysis, which should be used selectively after review of imaging findings and cyst fluid studies. Further studies are needed to assess DNA's performance in malignant cysts.

Alterations in cyst fluid genetics following endoscopic ultrasound-guided pancreatic cyst ablation with ethanol and paclitaxel.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound (EUS)-guided ethanol lavage with paclitaxel injection has been shown to be effective for the treatment of pancreatic cystic neoplasms; however, the evidence for effectiveness is based primarily on cyst resolution on imaging. The aim of this study was to evaluate changes in pancreatic cyst fluid DNA following EUS-guided pancreatic cyst ablation (PCA) with ethanol and paclitaxel. PATIENTS AND METHODS: In a single-center, prospective study, patients with suspected benign pancreatic cysts (15 - 50 mm in diameter; ≤ 5 compartments) underwent EUS-PCA with ethanol and paclitaxel followed 3 months later by repeat EUS-FNA, cyst aspiration for repeat DNA analysis, and possible repeat EUS-PCA. Abdominal imaging was repeated 3 - 4 months and 12 months after the second EUS. Changes in baseline pancreatic cyst fluid DNA, procedural complications, and radiographic changes in cyst volume were evaluated. RESULTS: A total of 22 patients (median age 67 years; 15 women) with cysts in the head or uncinate (n = 10), body or neck (n = 8), and tail (n = 4), measuring a median diameter of 25 mm (range 15 - 43 mm), underwent one (n = 22) or two (n = 9) EUS-PCA procedures. Baseline cyst DNA included mutations in 11 patients (50 %). Postablation cyst fluid (n = 19) showed elimination of all baseline mutations in eight patients, new mutations in three, and no changes in eight without a baseline mutation. The largest per-protocol postablation image-defined volume change (n = 20) from either of the follow-up abdominal imaging studies (n = 20) demonstrated complete response ( < 5 % original volume) in 10 patients (50 %), partial response (5 % - 25 % original volume) in 5 (25 %), and a persistent cyst (> 25 % original volume) in 5 (25 %). During a median follow-up of 27 months (range 17 - 42 months), adverse events from all EUS-PCAs (n = 31) included abdominal pain alone in four patients (13 %), pancreatitis in three (10 %), peritonitis in one (3 %), and gastric wall cyst in one (3 %). The adverse events were classified as moderately severe in four patients (three with pancreatitis, one with peritonitis). CONCLUSION: EUS-PCA with ethanol and paclitaxel may possibly eliminate mutant DNA in neoplastic pancreatic cysts. This technique leads to complete or partial image-defined resolution in 75 % of cysts but may lead to rare adverse events. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01643460).

Impact of preoperative endoscopic ultrasound-guided fine needle aspiration on postoperative recurrence and survival in cholangiocarcinoma patients.

BACKGROUND AND STUDY AIM: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is frequently performed for suspected biliary tumors for diagnosis and staging but carries a theoretical risk of needle-track seeding. We aimed to evaluate the impact of preoperative EUS-FNA on long-term outcomes for patients with cholangiocarcinoma (CCA). PATIENTS AND METHODS: In a retrospective single-center study of consecutive patients with CCA with preoperative EUS-FNA, main outcome measures were overall survival and progression-free survival. RESULTS: In 150 patients with confirmed CCA, 61 underwent preoperative FNA. Median overall survival was 18.5 months (95% confidence limits [CL] 15.4, 25.7): 111 patients died and 39 survived. Of the 150 patients, 119 underwent curative-intent surgical resection, with median progression-free survival of 17.8 months (95% CL 14.5, 22.8); 89/119 patients had tumor recurrence or died, and 30/119 remained alive and disease-free. On multivariable analysis, overall survival was associated with: undergoing curative-intent surgery (hazard ratio [HR] 5.79, P = 0.001), lack of lymph node involvement (HR 1.89, P = 0.011), younger age (HR 1.51 for every 10 years, P < 0.0015), and small tumor size (HR 1.11 for every 1 cm, P = 0.029). For patients undergoing curative-intent surgery, on multivariable analysis, improved progression-free survival was associated with: lack of lymph node involvement (HR 1.88, P = 0.010), smaller tumor size (HR 1.16 for every 1 cm smaller, P = 0.003), and younger age (HR 1.53 for every 10 years, P < 0.001). Number of needle passes showed no statistically significant impact on overall survival. CONCLUSION: Preoperative EUS-FNA in patients with CCA does not appear to adversely affect overall or progression-free survival.

Utility of EUS-guided biopsy of extramural pelvic masses.

BACKGROUND: The diagnostic utility of EUS-guided FNA (EUS-FNA) and EUS-guided Trucut biopsy (EUS-TCB) of pelvic masses has not been well described. OBJECTIVE: To evaluate the utility of EUS in the diagnosis of pelvic masses. DESIGN: Retrospective cohort study. SETTING: Single tertiary referral hospital in Indianapolis, Indiana. PATIENTS: Consecutive patients referred for EUS evaluation of pelvic mass from January 2002 to July 2009. Patients with newly diagnosed rectal cancer or a known/suspected intramural mass were excluded. INTERVENTIONS: EUS-FNA and/or EUS-TCB. MAIN OUTCOME MEASUREMENTS: Endosonographic features and cytological and pathological findings were evaluated. The final diagnosis was confirmed by surgical pathology or cytology and clinical follow-up. The sensitivities and specificities of EUS-TCB were calculated in a subset of patients with available surgical pathology. RESULTS: A total of 69 patients were identified, and 40 with intramural lesions (n = 36) or incomplete follow-up (n = 4) were excluded. The remaining 29 patients (15 men, mean age 58.5 ± 10.8 years) with pelvic masses (mean size 40.8 ± 20.1 mm) were evaluated. EUS-FNA or EUS-TCB helped to make the diagnosis in 25 of 29 patients (86%). Compared with surgical pathology (available in 17 patients), EUS-FNA had a sensitivity of 88% (95% CI, 53%-98%) and specificity of 100% (95% CI, 65%-100%) for malignancy. EUS-TCB alone had a sensitivity of 67% (95% CI, 21%-94%) and specificity of 100% (95% CI, 34%-100%) for malignancy, but the combination of EUS-FNA and EUS-TCB had a sensitivity of 100% (95% CI, 68%-100%) and a specificity of 100% (95% CI, 68%-100%). Complications after EUS-FNA included a pelvic abscess in 2 patients (7%) with a cystic pelvic mass. LIMITATION: Single-center study. CONCLUSION: EUS-FNA and EUS-TCB are sensitive for the diagnosis of malignancy in pelvic masses. Sampling of cystic masses in this region is discouraged.

A prospective, randomized study of EUS-guided celiac plexus neurolysis for pancreatic cancer: one injection or two?

BACKGROUND: The technique of alcohol injection during EUS-guided celiac plexus neurolysis (CPN) in patients with pancreatic cancer-related pain has not been standardized. OBJECTIVE: To compare pain relief and safety of alcohol given as 1 versus 2 injections during EUS-guided CPN (EUS-CPN). Secondary outcomes examined were characteristics that predict response and survival. DESIGN: Single-blinded, prospective, randomized, parallel-group study. SETTING: Tertiary-care center. PATIENTS: This study involved patients with pancreatic cancer-related pain. INTERVENTION: EUS-CPN done by injecting 20 mL of 0.75% bupivacaine and 10 mL 98% alcohol into 1 or 2 sites at the celiac trunk. Participants were interviewed by telephone at 24 hours and weekly thereafter. MAIN OUTCOME MEASUREMENTS: Time until onset of pain relief, duration of pain relief, complications. RESULTS: Fifty patients (mean age 63 years; 24 men) were enrolled and randomized (29 in 1-injection, 21 in 2-injections groups). Pain relief was observed in 37 (74%) patients: 20 (69%) in the 1-injection group and 17 (81%) in the 2-injection group (chi-square P = .340). Median onset of pain relief was 1 day for both 1-injection (range 1-28 days) and 2-injection (range 1-21 days) groups (Mann-Whitney P = .943). Median duration of pain relief in the 1-injection and 2-injection groups was 11 weeks and 14 weeks, respectively (log-rank P = .612). Complete pain relief was observed in 4 (8%) patients total, 2 in each group. There were no long-term complications. LIMITATIONS: Single-blinded study. CONCLUSION: There were no differences in onset or duration of pain relief when either 1 or 2 injections were used. There was no difference in safety or survival between the 2 groups.

Role of EUS for preoperative evaluation of cholangiocarcinoma: a large single-center experience.

BACKGROUND: Accurate preoperative diagnosis and staging of cholangiocarcinoma (CCA) remain difficult. OBJECTIVE: To evaluate the utility of EUS in the diagnosis and preoperative evaluation of CCA. DESIGN: Observational study of prospectively collected data. SETTING: Single tertiary referral hospital in Indianapolis, Indiana. PATIENTS: Consecutive patients with CCA from January 2003 through October 2009. INTERVENTIONS: EUS and EUS-guided FNA (EUS-FNA). MAIN OUTCOME MEASUREMENTS: Sensitivity of EUS for the detection of a tumor and prediction of unresectability compared with CT and magnetic resonance imaging (MRI); sensitivity of EUS-FNA to provide tissue diagnosis, by using surgical pathology as a reference standard. RESULTS: A total of 228 patients with biliary strictures undergoing EUS were identified. Of these, 81 (mean age 70 years, 45 men) had CCA. Fifty-one patients (63%) had distal and 30 (37%) had proximal CCA. For those with available imaging, tumor detection was superior with EUS compared with triphasic CT (76 of 81 [94%] vs 23 of 75 [30%], respectively; P < .001). MRI identified the tumor in 11 of 26 patients (42%; P = .07 vs EUS). EUS identified CCA in all 51 (100%) distal and 25 (83%) of 30 proximal tumors (P < .01). EUS-FNA (median, 5 passes; range, 1-12 passes) was performed in 74 patients (91%). The overall sensitivity of EUS-FNA for the diagnosis of CCA was 73% (95% confidence interval, 62%-82%) and was significantly higher in distal compared with proximal CCA (81% vs 59%, respectively; P = .04). Fifteen tumors were definitely unresectable. EUS correctly identified unresectability in 8 of 15 and correctly identified the 38 of 39 patients with resectable tumors (53% sensitivity and 97% specificity for unresectability). CT and/or MRI failed to detect unresectability in 6 of these 8 patients. LIMITATION: Single-center study. CONCLUSION: EUS and EUS-FNA are sensitive for the diagnosis of CCA and very specific in predicting unresectability. The sensitivity of EUS-FNA is significantly higher in distal than in proximal CCA.

Endoscopic ultrasound-guided Trucut biopsy of gastrointestinal mesenchymal tumor.

BACKGROUND: Data on the utility of endoscopic ultrasound-guided Trucut biopsy (EUS-TCB) for suspected gastrointestinal mesenchymal tumor (GIMT) are limited. This study aimed to determine the diagnostic yield and complications from EUS-TCB for GIMT. METHODS: Consecutive patients with suspected upper gastrointestinal or rectal GIMT from the muscularis propria with a maximal diameter of 20 mm or more were enrolled in a prospective, single-center cohort. An EUS-TCB was performed when on-site fine-needle aspiration (FNA) cytology review of the lesion was deemed suboptimal. Gastrointestinal stromal tumor (GIST) and leiomyoma were defined by the presence or absence of positive immunochemistry (IC) for c-kit, respectively. All GIMTs with a nondiagnostic IC were considered as unspecified. The outcomes assessed included diagnostic pathologic and IC yield (when tested) and procedural complications. RESULTS: In this study, 38 patients (24 women; median age, 62 years) with suspected GIMT (median maximal diameter, 42 mm; range, 20-120 mm) in the esophagus (n=6), stomach (n=28), duodenum (n=3), or rectum (n=1) underwent EUS-TCB without complications. Final diagnoses included GIST for 20 patients, leiomyoma for 13 patients, unspecified GIMT for 3 patients, and unknown disorder for 2 patients. An EUS-FNA was performed for 33 (87%) of the 38 patients, a diagnostic final cytology for 25 (76%) of 33 patients, and an FNA-IC for 12 (50%) of 24 patients. The EUS-TCB (median, 3 passes; range, 1-8 passes) obtained a visible tissue specimen in 37 (97%) of the 38 patients, with a median overall maximal fragment length of 3.5 mm (range, 0-15 mm). The diagnostic final TCB histology and TCB-IC were obtained, respectively, in 79 and 97% of the samples tested. CONCLUSIONS: In this cohort, EUS-TCB provided diagnostic histology and IC for 79 and 97% of the patients, respectively. For the initial biopsy of GIMT, EUS-TCB may be considered an acceptable alternative to EUS-FNA.

Survival in patients with pancreatic cancer after the diagnosis of malignant ascites or liver metastases by EUS-FNA.

BACKGROUND: The expected survival after the EUS-FNA diagnosis of malignant ascites or liver metastases from pancreatic cancer is not known. OBJECTIVE: To report overall and 1-year survival in these patients. DESIGN: Retrospective cohort series. SETTING: Tertiary referral hospital. PATIENTS: Consecutive subjects with newly diagnosed pancreatic cancer from June 1998 and March 2008 in whom EUS-FNA of the liver or ascitic fluid confirmed hepatic metastases or malignant ascites. INTERVENTIONS: Calculation of survival after diagnosis by using the Social Security Death Index. MAIN OUTCOME MEASUREMENTS: Survival after EUS-FNA diagnosis of stage IV pancreatic cancer. RESULTS: EUS-FNA identified liver metastases and malignant ascites from primary pancreatic cancer in 75 and 13 patients, respectively, and all 88 died during follow-up. For all 88 patients, the 1-year survival rate and median survival were 3.4% (95% CI, 1.1%-10.4%) and 82 days (range 2-754 days), respectively. The 1-year survival rates for those with liver metastases (4.0% [95% CI, 1.3%-12.1%]) and for those with malignant ascites (0% [95% CI, 0-24.7%]) were similar (P = 1.0). The median survival for patients with liver metastases of 83 days (range 2-754 days) was similar to that for those with malignant ascites (64 days; range 2-153 days) (P = .13). No clinical variable considered predicted survival of more than, less than, or 3 months. LIMITATIONS: Retrospective series with variable treatment for malignancy. CONCLUSIONS: In patients with pancreatic cancer, identification of malignant ascites or liver metastases by EUS-FNA is associated with a very poor prognosis.

EUS-guided FNA of local recurrence of pancreatic cancer after surgical resection.

BACKGROUND: EUS-guided FNA (EUS-FNA) is a sensitive test for the preoperative diagnosis of pancreatic cancer. Its use for diagnosing local tumor recurrence after surgical resection has not been described. OBJECTIVE: To determine the sensitivity of EUS-FNA for this indication. DESIGN: Retrospective cohort study. SETTING: Tertiary referral hospital in the United States. PATIENTS: Consecutive patients referred for EUS with clinical and/or radiographic suspicion of pancreatic cancer recurrence. INTERVENTIONS: EUS ± FNA of retroperitoneal mass. MAIN OUTCOME MEASUREMENT: Sensitivity of EUS-FNA. RESULTS: Seventeen patients (9 male, median age 71 years) underwent EUS at a median of 17 months (range 7-46 months) after a classic Whipple procedure (n = 7), pylorus-sparing Whipple procedure (n = 7), or distal pancreatectomy (n = 3) for suspected local recurrence of pancreatic cancer. The primary tumor (median size 2.5 cm, range 1.5-7.9 cm) was located in the head in 14 patients, the body in 1, and the tail in 2. Final surgical margins at any site were positive in only 1 of 17 patients (+ retroperitoneal margin). At the time of suspected recurrence, 4 patients (24%) were asymptomatic. EUS disclosed a mass (median size 21 mm, range 12-30 mm) in 16 of 17 patients (94%). Transgastric EUS-FNA (n = 16, median 4.5 passes, range 2-10) disclosed recurrent malignancy in 13 of 16 (79%), atypical cells in 1 of 16 (7%), and benign cytology in 2 of 16 (14%). Subsequent radiographic evidence of increasing tumor burden was seen in 1 of 2 patients with benign cytology; however, follow-up for the 2 other patients with benign biopsy specimens was not available. Depending on the status of the 2 patients without available follow-up, the sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of recurrent cancer ranged from 81% to 93%, was 100%, and ranged from 81% to 93%, respectively. LIMITATIONS: Small, single-center retrospective cohort. CONCLUSIONS: EUS-FNA is sensitive for the diagnosis of retroperitoneal recurrence of pancreatic cancer after surgical resection.

EUS for pancreatic neuroendocrine tumors: a single-center, 11-year experience.

BACKGROUND: Pancreatic neuroendocrine tumors (PNTs) are rare tumors with malignant potential. EUS and EUS-guided FNA (EUS-FNA) have been shown to be superior to other imaging methods in the preoperative localization and diagnosis of PNTs. OBJECTIVES: To evaluate the clinical presentation, EUS morphology, and sensitivity of EUS-FNA cytology in a large consecutive cohort with histologically and/or cytologically confirmed PNTs. DESIGN: Retrospective study of all consecutive patients from July 1995 to November 2006 who underwent EUS for a known or suspected PNT and had a subsequently histologically confirmed PNT. SETTING: Tertiary referral center. PATIENTS: Ninety-two patients with suspected PNT. INTERVENTIONS: EUS evaluation with or without EUS-FNA of PNTs. MAIN OUTCOME MEASUREMENTS: Clinical and EUS features of PNTs and sensitivity of EUS-FNA for the diagnosis of PNTs. RESULTS: Ninety-two patients underwent EUS; 76 patients had confirmed histopathology, of whom 69 (91%) were symptomatic. Patients with functional PNTs presented with diarrhea, peptic ulcer disease, and hypoglycemia. Tumor locations and echogenic features were similar except that nonfunctional PNTs tended to be larger and have cystic features. Patients with malignant PNTs were older (P = .03), presented with abdominal pain, and had larger tumors (P = .0006) with irregular margins. Eighty-nine percent of patients underwent EUS-FNA. Sensitivity of EUS-FNA for the diagnosis of a PNT was 87%. Sensitivity of EUS-FNA was similar in functional and nonfunctional PNTs. The sensitivity of EUS-FNA was higher for malignant PNTs (P = .008). LIMITATIONS: Retrospective single tertiary center. CONCLUSIONS: EUS and EUS-FNA are sensitive tools, especially in cases of suspected symptomatic PNTs in which other imaging modalities have failed.

Role of endoscopic ultrasound for evaluating gastrointestinal tract disorders in pediatrics: a tertiary care center experience.

BACKGROUND: Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) has a well-established role in the evaluation of various gastrointestinal (GI) tract disorders in adults. The clinical impact of EUS on the management of the pediatric population remains less clear. This study evaluates the feasibility, safety, and applications of EUS ± FNA in pediatric GI tract disorders. PATIENTS AND METHODS: Using a prospectively maintained EUS database, all patients 18 years of age or younger referred for EUS at our institution were identified. Retrospective chart review was conducted to document procedure indications, type of anesthesia used, EUS findings, final FNA cytology results, and clinical impact of EUS ± FNA on the subsequent management of pediatric patients. RESULTS: Fifty-eight EUS procedures were performed in 56 patients (35 girls). Median age was 16 years (range 4-18 years). The main indications for EUS were acute or recurrent pancreatitis, abdominal pain of suspected pancreatobiliary origin, suspected biliary obstruction, upper GI mucosal/submucosal lesions, and evaluation of pancreatic abnormalities seen on prior imaging. Sedation used included nurse-administered propofol sedation in 38 (73%), general anesthesia in 9 (17%), and fentanyl with meperidine in 3 (6%). Five therapeutic procedures performed included celiac plexus blocks in 4 and 1 EUS-guided pancreatogram. In 44 (86%) patients, EUS provided a new diagnosis. The procedure was successfully completed in all patients with no reported complications. CONCLUSIONS: EUS ± FNA is feasible and safe and makes a significant impact on most pediatric patients. Nurse-administered propofol sedation appears to be safe and well tolerated in this group.

Soil and foliar application of rock dust as natural control agent for two-spotted spider mites on tomato plants.

Mineral-based products represent a valid alternative to synthetic pesticides in integrated pest management. We investigated the effects of a novel granite dust product as an agent for controlling two-spotted spider mites, Tetranychus urticae Koch (Acari: Tetranychidae), on tomato plants (Solanum lycopersicum L.). Two-choice tests for repellency and repulsiveness, and no-choice bioassays with different type of applications (soil, foliar, and soil-foliar) were used in order to evaluate performance and action of the product. Evaluation of epidermal micromorphology and mesophyll structure of treated plants and elemental analyses of leaves were performed. In repulsiveness experiments, almost all dust treatments significantly inhibited mites from migrating to and/or settling on the treated leaf. In repellency experiments, foliar and soil dust treatments were not significantly different from control. Significant mortality was observed for all dust treatments in two-choice and in no-choice bioassays, suggesting mites are susceptible to rock dust by contact, and by indirect interaction through the feeding on plants subjected to soil application of rock dust. Leaf epidermal micromorphology and mesophyll structure of treated plants showed structural variation due to mineral accumulation, which was also confirmed by elemental analyses of leaves. These results demonstrate for the first time that granite rock dust interacts with two-spotted spider mites by modifying pest behavior and via acaricidal action, providing more insights in understanding the mechanism of this novel natural product as pest management tool.

A prospective randomized trial of 1 versus 2 injections during EUS-guided celiac plexus block for chronic pancreatitis pain.

BACKGROUND: The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-CPB) in patients with chronic pancreatitis is not known. OBJECTIVE: To compare the clinical effectiveness and safety of EUS-CPB by using 1 versus 2 injections in patients with chronic pancreatitis and pain. The secondary aim is to identify factors that predict responsiveness. DESIGN: A prospective randomized study. INTERVENTIONS: EUS-CPB was performed by using bupivacaine and triamcinolone injected into 1 or 2 sites at the level of the celiac trunk during a single EUS-CPB procedure. MAIN OUTCOME MEASUREMENTS: Duration of pain relief, onset of pain relief, and complications. RESULTS: Fifty [corrected] subjects were enrolled (23 received 1 injection, 27 [corrected] received 2 injections). The median duration of pain relief in the 31 responders was 28 days (range 1-673 days). [corrected] Fifteen [corrected] of 23 (65%) [corrected] subjects who received 1 injection [corrected] had relief from pain compared with 16 of 27 (59%) [corrected] subjects who received 2 injections [corrected] (P = .67). [corrected] The median times to onset in the 1-injection and 2-injections groups were 21 and 14 days, respectively (P = .99). No correlation existed between duration of pain relief and time to onset of pain relief or onset within 24 hours. Age, sex, race, prior EUS-CPB, and smoking or alcohol history did not predict duration of pain relief. LIMITATION: Telephone interviewers were not blinded. CONCLUSIONS: There was no difference in duration of pain relief or onset of pain relief in subjects with chronic pancreatitis and pain when the same total amount of medication was delivered in 1 or 2 injections during a single EUS-CPB procedure. Both methods were safe.

Initial experience with EUS-guided Tru-cut biopsy of benign liver disease.

BACKGROUND: Histologic biopsy of the liver is often essential for diagnosing hepatic parenchymal disease. Tissue acquisition is traditionally obtained by a surgical, transvascular, or percutaneous route. OBJECTIVE: To describe our initial experience with EUS-guided Tru-cut biopsy (EUS-TCB) of benign liver disease. DESIGN: A prospective case series. SETTING: A tertiary-referral hospital in Indianapolis, Indiana. PATIENTS: Consecutive subjects undergoing EUS with suspected hepatic parenchymal disease. INTERVENTIONS: EUS-TCB of the liver. MAIN OUTCOME MEASUREMENTS: Liver biopsy specimen yield, diagnosis, and procedural complications. Specimens were routinely stained with hematoxylin and eosin and with special stains for reticulin, iron, and trichome. Each case was reviewed by a single experienced pathologist for the number of portal spaces, total specimen length, and final diagnosis. An adequate specimen was defined as 6 or more complete portal tracts. RESULTS: Between February 2007 and March 2008, 21 consecutive patients (mean age 45 years; 13 women) were evaluated. The most common indications for liver biopsy were suspected nonalcoholic steatohepatitis (n = 9), intrahepatic cholestasis (n = 4), and suspected cirrhosis (n = 3). Transgastric biopsy (median 3 passes, range 1-4) into the left lobe (n = 18) or both the left and caudate lobe (n = 3) yielded a median total specimen length of 9 mm (range 1-23 mm). The median total number of portal tracts in the specimen was 2 complete (range 0-10) plus 3 partial (range 0-8) tracts. Six or more complete portal tracts were present in 6 of 21 (29%). A histologic diagnosis was obtained in 19 of 21 (90%). There were no complications. LIMITATIONS: The small sample size and low-risk population. CONCLUSIONS: In our initial experience, transgastric EUS-TCB of suspected benign liver disease by using a 19-gauge needle appears safe and feasible. Samples obtained are usually smaller than those traditionally considered adequate for histologic assessment. Further refinement of this technique appears indicated.

Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study.

BACKGROUND: The role of pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts remains unclear. OBJECTIVE: Our purpose was to evaluate the utility of a detailed DNA analysis of pancreatic cyst fluid to diagnose mucinous and malignant cysts. DESIGN: Prospective, multicenter study. PATIENTS: Patients with pancreatic cysts presenting for EUS evaluation. INTERVENTION: EUS-guided pancreatic cyst aspirates cytology evaluation, carcinoembryonic antigen (CEA) level determination, and a detailed DNA analysis; incorporating DNA quantification, k-ras mutation and multiple allelic loss analysis, mutational amplitude, and sequence determination. MAIN OUTCOME MEASUREMENTS: Cyst fluid analysis compared with surgical pathologic or malignant cytologic examination. RESULTS: The study cohort consisted of 113 patients with 40 malignant, 48 premalignant, and 25 benign cysts. Cyst fluid k-ras mutation was helpful in the diagnosis of mucinous cysts (odds ratio 20.9, specificity 96%), whereas receiver-operator characteristic curve analysis indicated optimal cutoff points for allelic loss amplitude (area under the curve [AUC] 0.79; optimal value > 65%) and CEA (AUC 0.74; optimal value >148 ng/mL). Components of DNA analysis detecting malignant cysts included allelic loss amplitude over 82% (AUC 0.9) and high DNA amount (optical density ratio >10, AUC 0.79). The criteria of a high amplitude k-ras mutation followed by allelic loss showed maximum specificity (96%) for malignancy. All malignant cysts with negative cytologic evaluation (10/40) could be diagnosed as malignant by using DNA analysis. LIMITATIONS: Limited follow-up, selection bias. CONCLUSIONS: Elevated amounts of pancreatic cyst fluid DNA, high-amplitude mutations, and specific mutation acquisition sequences are indicators of malignancy. The presence of a k-ras mutation is also indicative of a mucinous cyst. DNA analysis should be considered when cyst cytologic examination is negative for malignancy.

EUS-guided FNA aspiration of kidney masses: a multicenter U.S. experience.

BACKGROUND: Tissue sampling of renal lesions is traditionally performed with percutaneous US or CT guidance. To date, only 3 known cases of EUS-guided FNA (EUS-FNA) of a renal mass have been reported. OBJECTIVE: To describe a multicenter experience with the indications, yield, and complications from attempted EUS-FNA of a kidney mass. DESIGN: Retrospective case series. SETTING: Six tertiary referral hospitals in the United States. PATIENTS: Consecutive subjects undergoing attempted EUS-FNA of a kidney mass. Endosonographers at 15 other teaching hospitals were contacted regarding EUS findings and follow-up of any EUS-guided renal biopsies previously attempted or considered at that institution. INTERVENTIONS: EUS-FNA of a kidney mass. MAIN OUTCOME MEASUREMENTS: Biopsy indications, yield, diagnosis, and complications. RESULTS: Fifteen procedures in 15 patients (9 men; median age 67 years) were performed at 6 (37%) of 16 hospitals (Indiana University plus 15 other hospitals). Kidney masses (median diameter 32 mm; range 11-60 mm) were located in the upper (n = 12) and lower (n = 3) poles of the left (n = 10) and right (n = 5) kidneys, respectively. Initial mass detection was by previous imaging in 13 (87%) patients or by EUS in 2 (13%) patients. Results of EUS-FNA (median 3 passes; range 2-4 passes) in 13 (87%) procedures were diagnostic of (n = 7) or highly suspicious for (n = 1) renal cell carcinoma (RCC), atypical cells (n = 2), oncocytoma (n = 1), benign cyst (n = 1), and nondiagnostic (n = 1). No complications were encountered. Surgical resection confirmed RCC in 7 patients in whom preoperative EUS-FNA demonstrated RCC (n = 5) or oncocytoma (n = 1) or was not performed (n = 1). LIMITATIONS: Retrospective series, small number of patients. CONCLUSIONS: EUS-FNA of renal masses is rarely performed at the U.S. teaching hospitals surveyed. This technique appears safe and feasible and should be considered when results would affect patient management.