Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis using 4-Fr pancreatic plastic stents placed with common-type guidewires: Results from a prospective multinational registry.

BACKGROUND AND AIM: Pancreatic plastic stents (PPS) can reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Prospective multicenter documentation of PEP rate after PPS placement is scarce. A new 4-Fr stent designed to be deployed over a 0.035-inch guidewire was used to assess the effectiveness of PEP prophylaxis. METHODS: High-PEP-risk patients received a 4-Fr PPS for primary or secondary prophylaxis at seven centers in four countries. Patients were followed until spontaneous PPS migration, endoscopic stent removal, or for 4 months, whichever came first. Main outcome was PEP rate. RESULTS: One hundred six (106) patients received PPS for PEP prophylaxis [61 (58%) primary, 45 (42%) secondary prophylaxis]. Median age was 54 years. Eighty-one (76%) PPS were placed using a 0.035-inch guidewire. By investigator choice 99 (93%) stents were single pigtail. Median stent length was 8 cm (range 3-12 cm). Technical success achieved in 100% of cases. Two patients in the primary prophylaxis group (3%, 95% CI 0.4-11%) experienced mild/moderate PEP. Seventy-eight PPS available for analysis underwent spontaneous migration after a median of 29 days. There were no reports of stent-induced ductal trauma. Post-hoc analysis of migration rate by PPS length showed no statistically significant trend. CONCLUSIONS: Among high-risk patients in the primary prophylaxis group, observed rates of PEP are low (3%, 95% CI 0.4-11%) with the use of prophylactic 4-Fr pancreatic duct stents compatible with a 0.035-inch guidewire. This low rate is not unequivocally due to the prophylactic stent.

The role of endoscopy in the management of pancreatic necrosis.

The management of acute pancreatitis has seen many advances over the past three decades. Attempts to improve care have led to new definitions, classification systems, and treatment strategies. Despite those efforts, considerable morbidity and mortality result from complications of severe acute pancreatitis. Much attention has been given to new ways to treat these complications, including inflammatory pancreatic fluid collections and associated infections. Endoscopy has become one of the established modalities for the treatment of these complications in many expert centers. This chapter will specifically address the role of endoscopy in the management of pancreatic necrosis.

Double balloon enteroscopy: effective and minimally invasive method for removal of retained video capsules.

BACKGROUND AND AIM: Prior case series document removal of retained video capsules predominantly via surgical intervention. Data on endoscopic removal of retained capsules are limited. Our aim was to describe an endoscopic method of retrieval using double balloon enteroscopy (DBE). METHODS: A retrospective case series examination found 10 patients who underwent DBE for retrieval of a retained video capsule at two large tertiary referral academic centers from May 2007 to June 2013. RESULTS: Mean age of patients was 64.9 ± 18.1 years (four females, six males). Five patients failed to pass the capsule as a result of an ileal or jejunal stricture (one patient with ulcerative colitis; four patients with Crohn's disease); two patients had a small bowel stricture as a result of non-steroidal anti-inflammatory drug enteropathy; one patient had intermittent partial small bowel obstruction without evidence of a stricture; one patient had an obstructing malignant jejunal mass and one patient had a small bowel stricture as a result of radiation enteritis. Endoscopic removal via DBE was successful in eight of 10 patients (80%). The remaining two patients underwent surgical removal of the retained capsule. The two failed cases of capsule retrieval were both patients with suspected ileal disease. CONCLUSIONS: The most common cause of capsule retention was underlying Crohn's disease. DBE is an effective and minimally invasive method of capsule retrieval, including those patients with ileal disease, which has not been previously described. DBE can prevent unnecessary surgery while providing endoscopic therapy of inflammatory strictures by dilation.

Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study.

OBJECTIVE: Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography (DBE-ERCP) is an effective method for interventions in the pancreaticobiliary system in the post-surgical patient. However, use of currently available endoscopic accessories during this procedure is limited due of the length of the conventional instrument (200 cm). The aim of this study was to explore the utility of the short DBE (152 cm) for the management of pancreaticobiliary disorders in patients with surgically altered anatomies. METHODS: Data were collected retrospectively on patients with various anatomic variations in whom ERCP was performed using the short DBE from April 2008 to November 2011. Basic demographic information, clinical presentation, preoperative imaging, and type of surgery, procedural technical success rate, and adverse events were evaluated. Descriptive analysis was used to document the demographic and clinical data of the patients. RESULTS: We identified 79 patients in whom DBE-ERCP was attempted (38 % male, mean age 58 years). Indications for the procedure were removal of a previously placed stent (n = 5), suspected sphincter of Oddi dysfunction type 1 (n = 3), surgical biliary leak (n = 3), pancreatic anastomotic stricture (n = 2), suspected biliary stones (n = 48), and biliary strictures visualized on imaging (n = 18). Overall, the success rate of DBE-ERCP in all patients was 81 % (64/79). The scope could not reach the papilla or surgical anastomosis in 8 cases and duct cannulation failed in 7 cases. The following interventions were performed: biliary sphincterotomy (n = 39), dilation of CBD stenosis with a balloon (n = 30), biliary stent insertion (n = 25), stone removal (n = 35), brushing cytology of biliary strictures (n = 3), and stent retrieval (n = 4). Three patients developed post-procedure pancreatitis. There was 1 episode of self-limited bleeding. CONCLUSIONS: The current study demonstrates that DBE assisted ERCP for pancreaticobiliary interventions using a short enteroscope are feasible in patients with surgically altered anatomy.

Should all endoscopically excised rectal polyps be tattooed? A plea for localization.

BACKGROUND: More than 5-8 % of endoscopically removed rectal polyps presumed to be benign contain invasive carcinoma. Tattooing has been advocated for follow-up localization of the resection site. Despite proven benefits, the authors propose that tattooing is not routinely performed when benign-appearing rectal polyps are endoscopically excised, thereby confounding management when invasive cancer is found. The secondary goal of the study was to determine the frequency of localization, polyp characteristics, and accuracy of predicting malignant potential at the authors' institution. METHODS: All patients with rectal neoplasia discovered during endoscopic polypectomy from 1 January 2003 to 1 August 2010 were retrospectively identified from Temple University Hospital's Tumor Registry. Demographic and clinical data were extracted from medical records including polyp size, gross appearance, pathology, resection margins, location based on preoperative colonoscopy, initial removal technique, tattoo performance, and ensuing procedures. RESULTS: During the study period, 49 patients had colonoscopic excision of presumed benign rectal polyps with ensuing diagnosis of neoplasia in the specimen. The malignant histology included adenocarcinoma (n = 5), carcinoma in situ (n = 21), carcinoid (n = 22), and composite carcinoid (n = 1). Only two polyps were tattooed at the initial polypectomy. Three polyps were "suspicious for malignancy." None of the suspicious polyps were tattooed. One of the suspicious lesions was an adenocarcinoma, and the remaining two were benign. The distance from the anal verge was noted in only seven patients. The predominant excision technique was hot snare polypectomy (n = 29). None of the incomplete polyp excisions for 15 patients were "suspicious for malignancy" or tattooed. Several strategies were used to manage incomplete resections including surveillance (40 %), repeat colonoscopic polypectomy (27 %), and surgery (33 %). CONCLUSIONS: Most malignant rectal polyps are neither diagnosed nor tattooed at initial colonoscopy. Moreover, the distance of the polyp from the anal verge is rarely measured, and gross characteristics are not well described. Tattooing of all endoscopically excised rectal polypectomy sites would avoid confounding of subsequent identification and management.

Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos).

BACKGROUND: The feasibility of single-operator cholangioscopy (SOC) for biliary diagnostic and therapeutic procedures was previously reported. OBJECTIVE: To confirm the utility of SOC in more widespread clinical use. DESIGN: Prospective clinical cohort study. SETTING: Fifteen endoscopy referral centers in the United States and Europe. PATIENTS: Two hundred ninety-seven patients requiring evaluation of bile duct disease or biliary stone therapy. INTERVENTIONS: SOC examination and, as indicated, SOC-directed stone therapy or forceps biopsy. MAIN OUTCOME MEASUREMENTS: Procedural success defined as ability to (1) visualize target lesions and, if indicated, collect biopsy specimens adequate for histological evaluation or (2) visualize biliary stones and initiate fragmentation and removal. RESULTS: The overall procedure success rate was 89% (95% CI, 84%-92%). Adequate tissue for histological examination was secured in 88% of 140 patients who underwent biopsy. Overall sensitivity in diagnosing malignancy was 78% for SOC visual impression and 49% for SOC-directed biopsy. Sensitivity was higher (84% and 66%, respectively) for intrinsic bile duct malignancies. Diagnostic SOC procedures altered clinical management in 64% of patients. Procedure success was achieved in 92% of 66 patients with stones and complete stone clearance during the study SOC session in 71%. The incidence of serious procedure-related adverse events was 7.5% for diagnostic SOC and 6.1% for SOC-directed stone therapy. LIMITATIONS: The study was observational in design with no control group. CONCLUSIONS: Evaluation of bile duct disease and biliary stone therapy can be safely performed with a high success rate by using the SOC system.

Small bowel cancers diagnosed by device-assisted enteroscopy at a U.S. referral center: a five-year experience.

BACKGROUND: Primary malignant neoplasms of the small bowel comprise only 1-3% of all gastrointestinal malignancies. Small bowel cancers pose a significant diagnostic challenge. The recent development of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE) have greatly facilitated evaluation of the small bowel. METHODS: We retrospectively reviewed all cases referred to a single U.S. center from September 2004 to July 2009 to determine the frequency and type of primary small bowel cancers found on DAE. RESULTS: The charts of 555 patients who underwent a total of 805 procedures (768 double-balloon and 37 rotational enteroscopies) were reviewed. A total of 20 patients with small bowel cancers were diagnosed. There was no gender predominance (ten men and ten women). The average age at presentation was 66 ± 11 years, essentially identical to our overall population. We identified eight neuroendocrine tumors, five adenocarcinomas, four GIST, two lymphomas, and one poorly differentiated carcinoma. CONCLUSIONS: Small bowel cancer is a rare but important finding on DAE. The per-patient incidence in our series was 3.6%. A recent multicenter Japanese series showing a higher incidence of small bowel tumors (14%) included polyposis syndrome patients and benign lesions, which were excluded from our study. The high frequency of neuroendocrine tumors in our series was also in contrast to the Japanese series, where lymphoma and GIST were more common. This may reflect a difference between our referral populations. Most of our patients underwent surgery as a consequence of these findings, underscoring the importance of identifying these tumors. DAE provides direct endoscopic access to the small bowel and is a valuable tool in the diagnosis of small bowel cancers.

Defining venous involvement in borderline resectable pancreatic cancer.

BACKGROUND: Pancreatic adenocarcinoma impinging the portal and/or superior mesenteric vein (PV-SMV) is classified as borderline resectable, and preoperative chemoradiation is recommended to increase the margin-negative resection rate. There is no consensus about what degree of venous impingement constitutes borderline resectability. METHODS: All patients undergoing potentially curative pancreatectomy for pancreatic adenocarcinoma were reviewed. Venous involvement was classified by preoperative computed tomography according to Ishikawa types: (I) normal, (II) smooth shift without narrowing, (III) unilateral narrowing, (IV) bilateral narrowing, (V) bilateral narrowing with collateral veins. RESULTS: From 1990-2009, 109 patients underwent resection of pancreatic adenocarcinoma involving the PV-SMV. Seventy-four patients received preoperative chemoradiation, whereas 35 did not. Patients who received preoperative therapy had a significantly longer median overall survival rate of 23 months compared with 15 months for patients without preoperative therapy (P = 0.001). Preoperative chemoradiation was associated with higher R0 resection rate and negative lymph nodes (both P < 0.0001) but did not affect the need for vein resection. When stratified by Ishikawa types, preoperative therapy was associated with improved overall survival among patients with types II and III but not types IV and V. Similarly, the correlation between preoperative therapy and R0 resection rate was observed only among patients with Ishikawa types II and III. CONCLUSIONS: Preoperative therapy for borderline resectable pancreatic adenocarcinoma is associated with higher margin-negative resection and survival rates in patients with Ishikawa type II and III tumors, defined as a smooth shift or unilateral narrowing of the PV-SMV. Patients with bilateral venous narrowing were less likely to benefit from preoperative treatment.

Double-balloon enteroscopy in the elderly: safety, findings, and diagnostic and therapeutic success.

BACKGROUND: Double-balloon enteroscopy (DBE) is an important tool in the evaluation and management of small-bowel disease. Limited data are available on the safety, findings, and outcomes of DBE in elderly patients. OBJECTIVE: To determine the safety and efficacy of DBE in elderly patients. DESIGN: Single-center, retrospective analysis of prospectively collected database. SETTING: Open-access, tertiary care referral center. PATIENTS: A total of 176 patients undergoing DBE (216 procedures) for evaluation of small-bowel disease between August 2007 and August 2008. INTERVENTIONS: Argon plasma coagulation of bleeding small-bowel lesions. MAIN OUTCOME MEASUREMENTS: DBE complication rate, diagnostic/therapeutic success of DBE. METHODS: An age cutoff of 75 years and older was used to designate patients as elderly. Data on complications, indications, findings, and diagnostic and therapeutic success of DBE were compared between age groups. RESULTS: The mean age of patients was 66 +/- 16.4 years (range 20-95 years). DBE was performed in 185 patients, including 60 patients age 75 years and older and 110 patients younger than age 75. An overall complication rate of 0.9% was seen for DBE in this study, with no significant difference between age groups. No major complications were observed in elderly patients. Elderly patients were more likely to have angioectasias (39% vs 23%; P = .01) and were more likely to require endoscopic therapy during DBE (46.8% vs 29.2%; P = .01). LIMITATIONS: Single-center, retrospective study. CONCLUSIONS: DBE is safe in elderly patients. Elderly patients are more likely to have angioectasias and to require endoscopic therapy during DBE.

Spiral enteroscopy: prospective U.S. multicenter study in patients with small-bowel disorders.

BACKGROUND: The performance characteristics of spiral enteroscopy have not been well-described. OBJECTIVE: To determine the technical performance, diagnostic and therapeutic yields, and safety of oral spiral enteroscopy in patients with suspected or established small-bowel pathology. DESIGN: Prospective, multicenter, cohort study, with centralized database. SETTING: Ten U.S. tertiary-care medical centers. PATIENTS: This study involved 148 participants, of whom 101 were referred for obscure bleeding. All participants referred for antegrade deep enteroscopy were considered eligible. INTERVENTION: Spiral enteroscopy. MAIN OUTCOME MEASUREMENTS: Examination duration, depth of insertion, spiral enteroscopy findings, mucosal assessment upon withdrawal, and patient symptom assessment (day 1 and day 7 after the procedure). RESULTS: Spiral enteroscopy was successful in 93% of patients, with a median depth of insertion beyond the angle of Treitz of 250 cm (range 10-600 cm). The mean (± standard deviation) total procedure time was 45.0 ± 16.2 minutes for all procedures, and 35.4 minutes for diagnostic procedures. The diagnostic yield was 65%, of which 48% revealed more than one abnormality. The most common findings were angiectasias (61.5%), inflammation (7.5%), and neoplasia (6.8%). Argon plasma coagulation ablation accounted for 64% of therapeutic interventions. LIMITATIONS: This was not a randomized, controlled trial of deep enteroscopy modalities. CONCLUSION: Spiral enteroscopy appears to be safe and effective for evaluation of the small bowel. The procedure duration, depth of insertion, and diagnostic and therapeutic yields compare favorably with previously published data on other deep enteroscopy techniques such as single-balloon and double-balloon enteroscopy. Comparative studies are warranted.

Complications associated with double balloon enteroscopy at nine US centers.

BACKGROUND & AIMS: Double balloon enteroscopy (DBE) was introduced into the US in 2004. Potential complications include perforation, pancreatitis, and gastrointestinal bleeding. Prevalence and risk factors for complications have not been described in a US population. METHODS: We conducted a retrospective study of DBE complications in 9 US centers. We obtained detailed information for each complication including patient history, maneuvers performed during the DBE, and presence of altered surgical anatomy. RESULTS: We collected data from 2478 DBE examinations performed from 2004 to 2008. The dataset included 1691 (68%) anterograde DBE, 722 (29%) retrograde DBE (including 5 per-stomal DBEs), and 65 (3%) DBE-facilitated endoscopic retrograde cholangiopancreatography ERCP cases. There were a total of 22 (0.9%) major complications including perforation in 11 (0.4%), pancreatitis in 6 (0.2%), and bleeding in 4 (0.2%) patients. One of 6 cases of pancreatitis occurred post retrograde DBE. Perforations occurred in 3/1691 (0.2%) anterograde examinations and 8/719 (1.1%) retrograde DBEs (P = .004). Eight (73%) perforations occurred during diagnostic DBE examinations. Four of 8 retrograde DBE perforations occurred in patients with prior ileoanal or ileocolonic anastomoses. In the subset of 219 examinations performed in patients with surgically altered anatomy, perforations occurred in 7 (3%), including 1/159 (0.6%) anterograde DBE examinations, 6/60 (10%) retrograde DBEs, and 1 of 5 (20%) peristomal DBE examinations (P < .005 compared with patients without surgically altered anatomy). CONCLUSIONS: DBE is associated with a higher complication rate compared with standard endoscopic procedures. The perforation rate was significantly elevated in patients with altered surgical anatomy undergoing diagnostic retrograde DBE examinations.

Endoscopic therapy of dysplasia and early-stage cancers of the esophagus.

Endoscopic treatments have become a viable alternative for some patients with early-stage esophageal neoplasia. Although esophagectomy remains the standard of care for high-grade dysplasia and superficial cancers, surgical morbidity and mortality may deter patients who are medically unfit or reluctant to undergo surgery. Photodynamic therapy (PDT) and endoscopic mucosal resection (EMR) are the best-studied nonsurgical approaches at present. PDT has been reported to eradicate high-grade dysplasia (HGD) and early Barrett's cancers at rates ranging from 75% to 100% and 17% to 100%, respectively, and a recent randomized controlled trial confirmed that PDT may prevent progression of HGD to cancer. Complete remission rates greater than 90% have also been reported with EMR and other mucosa-ablating interventions, although recurrence rates necessitate close endoscopic surveillance and retreatment in some patients. In addition to PDT and EMR, several emerging endoscopic treatment options for superficial esophageal neoplasia may provide attractive alternatives to surgery.

Correlation of molecular response as measured by 18-FDG positron emission tomography with outcome after chemoradiotherapy in patients with esophageal carcinoma.

PURPOSE: To determine whether 18-fluorodeoxyglucose positron emission tomography (PET) computed tomography scans predict the pathologic complete response and disease-free and overall survival in patients with esophageal carcinoma undergoing definitive or preoperative chemoradiotherapy. METHODS AND MATERIALS: The records of patients with esophageal carcinoma presenting for definitive or preoperative treatment and undergoing pre- and post-treatment 18-fluorodeoxyglucose PET-computed tomography scans were retrospectively reviewed. The histologic type, T stage, and nodal status were the variables investigated to determine a relationship with the baseline standardized uptake value (SUV) of the primary tumor at diagnosis. We also attempted to determine whether a relationship exists between the percent decrease in SUV and a pathologic complete response, overall and disease-free survival. RESULTS: A total of 81 patients, 14 women and 67 men, underwent 18-fluorodeoxyglucose PET-computed tomography scanning before treatment and 63 also had post-treatment scans. T stage and tumor location predicted in univariate, but not multivariate, analysis for the initial SUV. Of the patients with a postchemoradiotherapy SUV of <2.5, 66% had tumor in the surgical specimen and 64% of patients had positive lymph nodes at surgery that were not imaged on the postchemoradiotherapy PET scan. A trend existed for post-treatment SUV and the days from radiotherapy to surgery to predict for a pathologic complete response (p = 0.09 and p = 0.08, respectively). The post-treatment SUV predicted for disease-free survival in the definitive chemoradiotherapy group (p = 0.01). CONCLUSIONS: A correlation was found between the depth of tumor invasion and the baseline SUV. The post-treatment SUV predicted for disease-free survival in the definitive chemoradiotherapy group. Caution should be exercised in using post-treatment PET scans to determine the necessity for surgical resection.

EUS-guided biliary drainage or enteroscopy-assisted ERCP in patients with surgical anatomy and biliary obstruction: an international comparative study.

Background and study aims: How enteroscopy-assisted ERCP (e-ERCP) and endoscopic ultrasound-guided biliary drainage (EUS-BD) compare in patients with surgically altered upper gastrointestinal anatomy is currently unknown. The aims of this study were to compare efficacy and safety of both techniques and study predictors of these outcomes. Patients and methods: This was an international, multicenter comparative cohort study at 10 tertiary centers. Outcomes data included technical success (biliary access with cholangiography and stent placement [when indicated]), clinical success (resolution of biliary obstruction) and adverse events (AEs) (graded according to the ASGE lexicon). Results: A total of 98 patients underwent EUS-BD (n = 49) or e-ERCP (n = 49). Technical success was achieved in 48 (98 %) patients in the EUS-BD group as compared to 32 (65.3 %) patients in the e-ERCP group (OR 12.48, P = 0.001). Clinical success was attained in 88 % of patients in EUS-BD group as compared to 59.1 % in the e-ERCP group (OR 2.83, P = 0.03). Procedural time was significantly shorter in the EUS-BD group (55 min vs 95 min, P < 0.0001). AEs occurred more commonly in the EUS-BD group (20 % vs. 4 %, P = 0.01). However, the majority (90 %) of AEs were mild/moderate. Length of stay was significantly longer in the EUS-BD group (6.6 d vs. 2.4 d, P < 0.0001). Conclusions: EUS-BD can be performed with a higher degree of clinical efficacy and shorter procedure time than e-ERCP in patients with surgically-altered upper gastrointestinal anatomy. Whether or not this approach should be first-line therapy in this patient population is highly dependent on the indication for the procedure, the patient's anatomy, and local practice and expertise.

Initial experience with a novel EUS-guided core biopsy needle (SharkCore): results of a large North American multicenter study.

BACKGROUND AND AIMS: The ability to safely and effectively obtain sufficient tissue for pathologic evaluation by using endoscopic ultrasound (EUS) guidance remains a challenge. Novel designs in EUS needles may provide for improved ability to obtain such core biopsies. The aim of this study was to evaluate the diagnostic yield of core biopsy specimens obtained using a novel EUS needle specifically designed to obtain core biopsies. PATIENTS AND METHODS: Multicenter retrospective review of all EUS-guided fine-needle biopsies obtained using a novel biopsy needle (SharkCore FNB needle, Medtronic, Dublin, Ireland). Data regarding patient demographics, lesion type/location, technical parameters, and diagnostic yield was obtained. RESULTS: A total of 250 lesions were biopsied in 226 patients (Median age 66 years; 113 (50 %) male). Median size of all lesions (mm): 26 (2 - 150). Overall, a cytologic diagnosis was rendered in 81 % specimens with a median number of 3 passes. When rapid onsite cytologic evaluation (ROSE) was used, cytologic diagnostic yield was 126/149 (85 %) with a median number of 3 passes; without ROSE, cytologic diagnostic yield was 31/45 (69 %, P = 0.03) with a median number of 3 passes. Overall, a pathologic diagnosis was rendered in 130/147 (88 %) specimens with a median number of 2 passes. Pathologic diagnostic yield for specific lesion types: pancreas 70/81 (86 %), subepithelial lesion 13/15 (87 %), lymph node 26/28 (93 %). Ten patients (10/226, 4 %) experienced adverse events: 4 acute pancreatitis, 5 pain, 1 fever/cholangitis. CONCLUSIONS: Initial experience with a novel EUS core biopsy needle demonstrates excellent pathologic diagnostic yield with a minimum number of passes.

Palliative gastroenterology.

Continuous improvements in endoscopic imaging and accessories have opened up a field of interventional endoscopy. This highly technical offshoot of gastroenterology uses not just standard endoscopic techniques but also newer endoscopic ultrasound (EUS) imaging or fluoroscopic monitoring to facilitate procedures that were once performed either surgically or percutaneously, if at all. This review will update the role of these novel procedures that can be used to assist in the palliative care of patients whose malignancies involve the gastrointestinal tract. The emphasis will be on those palliative interventions that are used to overcome intestinal obstruction in the gastrointestinal tract and restore luminal patency. The role of EUS-guided celiac plexus neurolysis to assist in pain control, especially in patients with pancreatic malignancies, will also be detailed.

Can molecular imaging predict response to preoperative chemoradiation in patients with rectal cancer? A Fox Chase Cancer Center prospective experience.

This study was undertaken to correlate change in fluorine-18 fluorodeoxyglucose positron emission tomography ((18)FDG-PET) uptake with response to combined-modality neoadjuvant therapy in patients with locally advanced rectal cancer. Twenty patients (13 male; 7 female) underwent (18)FDG-PET scans before and 3 to 4 weeks after completion of chemoradiation before surgery. Staging by endoscopic ultrasound was T3/T4 (17/1); two patients were unable to undergo endorectal ultrasound. Fifteen patients had perirectal lymphadenopathy. Median radiation dose was 5,040 cGy (range, 4,500 to 5,500 cGy). All patients received continuous infusion 5-fluorouracil (or capecitabine) with radiation. Median pre- and post-chemoradiation standard uptake values were 9.4 (range, 3.6 to 37.0) and 3.05 (range, 0.5 to 8.2), respectively. Median percent standard uptake value decrease observed in the postchemoradiation PET scans was 71% (range, 7% to 95%). Six patients (30%) had pathologic complete response. Only two of six patients with postchemoradiation standard uptake values

The integration of 18-fluoro-deoxy-glucose positron emission tomography and endoscopic ultrasound in the treatment-planning process for esophageal carcinoma.

PURPOSE: Accurate delineation of the gross tumor volume (GTV) is important in radiation therapy treatment planning. We evaluated the impact of PET and endoscopic ultrasound (EUS) compared with CT simulation in the planning of radiation fields for patients with esophageal carcinoma. MATERIAL AND METHODS: Twenty-five patients presenting with esophageal carcinoma for radiation therapy underwent PET scans in the treatment position after conventional CT simulation. Patients underwent PET/CT scanning after being injected with 10 to 20 mCi of [F-18]-2-deoxy-2-fluro-D-glucose. The length of the abnormality seen on the CT portion of the PET/CT scan vs. the PET scan alone was determined independently by 2 separate investigators. The length of the GTV and detection of regional adenopathy by PET was also correlated with EUS in 18 patients. Of the 18 patients who had EUS, 2 had T2 tumors and 16 had T3 tumors. Eighteen patients had adenocarcinoma and 7 had squamous cell carcinoma. Nine tumors were located at the gastroesophageal junction, 8 at the lower esophagus, 7 in the middle esophagus, and 1 in the cervical esophagus. The PET scans were reviewed to determine the length of the abnormality by use of a standard uptake value (SUV) of 2.5 to delineate the tumor extent. RESULTS: The mean length of the cancer was 5.4 cm (95% CI 4.4-6.4 cm) as determined by PET scan, 6.77 cm (95% CI, 5.6-7.9 cm) as determined by CT scan, and 5.1 cm (95% CI, 4.0-6.1 cm) for the 22 patients who had endoscopy. The length of the tumors was significantly longer as measured by CT scans compared with PET scans (p = 0.0063). EUS detected significantly more patients with periesophageal and celiac lymphadenopathy compared to PET and CT. The SUV of the esophageal tumors was higher in patients with peri-esophageal lymphadenopathy identified on PET scans. CONCLUSION: Endoscopic ultrasound and PET scans can add additional information to aid the radiation oncologist's ability to precisely identify the GTV in patients with esophageal carcinoma.

Endoscopic oncology.

Endoscopy plays a critical role in the management of patients with malignancies involving the gastrointestinal tract. Endoscopic ultrasound has provided essential staging information, made more complete by the ability to perform fine needle aspiration of suspicious lymph nodes. Novel endoscopic resection and ablative techniques are expanding therapeutic choices in premalignant and malignant conditions. Obstruction, virtually anywhere along the length of the gastrointestinal tract, can be relieved with new stents. All of these advances have made the therapeutic gastroenterologist a key member of the team managing patients with tumors of the gastrointestinal tract.