The utility of esophagogastroduodenoscopy before endoscopic ultrasonography in patients undergoing endoscopic ultrasonography for pancreatico-biliary and mediastinal indications.

BACKGROUND: Oblique-viewing echoendoscopes may miss luminal lesions. There is no consensus on whether to routinely perform esophagogastroduodenoscopy (EGD) before endoscopic ultrasonography (EUS). Currently, practice patterns are variable and prospective data are needed. AIM: : To determine the proportion of clinically meaningful lesions detected when EGD is performed routinely before EUS. STUDY: This was a multicenter prospective cohort study conducted at tertiary referral center and large community practice. Patients undergoing EUS for pancreatico-biliary and mediastinal indications were enrolled. MAIN OUTCOMES: The primary outcome was the proportion of patients with a clinically meaningful lesion found on EGD. This was a combined outcome defined as any lesion that would alter medical management, or impact the subsequent EUS examination. RESULTS: Two hundred four patients were included in the final analysis. Clinically meaningful lesions were found on EGD in 45 patients [22.1%; 95% confidence interval (CI), 16.4-27.8]. Lesions that altered medical management were found in 32 patients (15.7%; 95% CI, 10.7-20.7). Lesions impacting the subsequent EUS examination were found in 20 patients (9.8%; 95% CI, 5.7-13.9). Clinically meaningful lesions found were (number of patients): esophagitis (14), ulcer (9), ring/stricture (7), large hiatal hernia (6), hyperplastic gastric polyp (5), Barrett esophagus (3), surgically altered anatomy (2), neoplastic lesion (2), subepithelial mass/GIST (1), stenosis (1), diverticulum (1), and fistula (1). CONCLUSIONS: EGD before EUS may detect enough clinically meaningful lesions to support the routine performance of EGD before EUS.

Dilation of both pancreatic duct and the common bile duct on computed tomography and magnetic resonance imaging scans in patients with or without obstructive jaundice.

OBJECTIVES: "Double-duct sign" (strictures in both common bile duct [CBD] and pancreatic duct [PD] with proximal dilation) on endoscopic retrograde cholangiopancreatography is considered suggestive of pancreatic malignancy. Dilation of CBD and PD is frequently noted on computed tomography/magnetic resonance imaging scans, sometimes found incidentally in patients without jaundice. The prevalence of malignancy in these patients is not established. METHODS: In this retrospective analysis, consecutive patients who underwent endoscopic ultrasound (EUS) at a tertiary care hospital from 2002 to 2006 for suspected pancreatic malignancy and had double-duct sign on imaging were included. We evaluated (1) prevalence of malignancy in patients with or without obstructive jaundice and (2) performance characteristics of EUS-fine-needle aspiration (FNA) in diagnosing malignancy in this setting. RESULTS: A final diagnosis of pancreatic malignancy was made in 142 (85.5%) of 166 patients with and 4 (5.9%) of 68 without obstructive jaundice (P < 0.005). The accuracy of EUS-FNA for diagnosing malignancy in patients with or without obstructive jaundice was 92.8% versus 98.5%. CONCLUSIONS: Dilation of both PD and CBD on computed tomography/magnetic resonance imaging scans is suggestive of pancreatic malignancy. The prevalence of malignancy, however, is markedly lower in patients without obstructive jaundice but is clinically significant and merits further diagnostic evaluation. Endoscopic ultrasound-FNA is highly accurate for diagnosing malignancy in this setting.

EUS/EUS-FNA for suspected pancreatic cancer: influence of chronic pancreatitis and clinical presentation with or without obstructive jaundice on performance characteristics.

BACKGROUND: The clinical utility of EUS-FNA is debated in patients with obstructive jaundice (ObJ) because of a very high pretest probability of pancreatobiliary malignancy (PBM) and biliary stent-induced inflammation that can potentially confound EUS-FNA diagnosis. EUS-FNA also has lower accuracy in patients with underlying chronic pancreatitis (CP). OBJECTIVE: Our purpose was to determine the clinical value of EUS-FNA for PBM diagnosis based on clinical presentation and presence of CP. DESIGN: Retrospective analysis of prospective database. SETTING: University hospital. PATIENTS: Patients who underwent EUS-FNA from 2002 to 2006 for suspected PBM based on (1) ObJ with biliary stricture or a mass lesion or (2) abnormal pancreatic imaging by CT/MRI: a focal pancreatic "mass" lesion; dilated pancreatic duct +/- common bile duct; or an enlarged head of pancreas. INTERVENTIONS: EUS was performed with a radial echoendoscope followed by a linear echoendoscope if a focal pancreatic lesion was identified. Fine-needle aspirates were assessed immediately by an attending cytopathologist. MAIN OUTCOME MEASUREMENTS: (1) Prevalence of cancer and (2) performance characteristics of EUS-FNA. RESULTS: PBM was diagnosed in 73.9% of patients with ObJ and biliary stricture or pancreatic mass, in 49.6% of patients with pancreatic mass, and in 7.0% of patients with an enlarged head of pancreas or dilated pancreatic duct +/- common bile duct. The prevalence of PBM was lower in all 3 presentations with associated CP. Both CP and presentation with ObJ lowered performance characteristics of EUS-FNA, but CP did so only in the subset of patients with ObJ. All except 1 false-negative diagnoses were due to cytologic misinterpretation. LIMITATION: Retrospective design. CONCLUSION: Among patients with suspected PBM, the accuracy of EUS-FNA is significantly lower only in a subset of patients with ObJ with underlying CP, largely as a result of difficulty in cytologic interpretation.

Impact of staging transesophageal EUS on treatment and survival in patients with non-small-cell lung cancer.

BACKGROUND: Transesophageal EUS-guided FNA (EUS-FNA) is safe, accurate, and cost effective in staging patients with non-small-cell lung cancer (NSCLC). However, the impact of EUS-FNA on patient survival has not been demonstrated. OBJECTIVE: To determine the impact of metastatic disease in mediastinal lymph nodes as determined by EUS staging on treatment choice and survival in patients with NSCLC. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary university-based referral center. PATIENTS: Patients with biopsy-proven NSCLC who underwent staging EUS-FNA. The relationship between the EUS nodal status and patient survival was evaluated. Cox proportional hazards models were used to determine the significance of EUS nodal status and patient characteristics on patient survival. MAIN OUTCOMES MEASUREMENTS: Impact of EUS-FNA on therapy and survival in patients with NSCLC. RESULTS: Of 125 patients with NSCLC, EUS-FNA confirmed metastatic disease in 46% of the patients. Patients who were node positive were more likely to receive chemotherapy and/or radiation therapy and were less likely to undergo surgery compared with patients who were node negative (P< .0001). Patients with N2 or N3 disease by EUS-FNA had a shorter survival time than patients who were node negative (P= .004). Adjusting for age, race, and sex, EUS-FNA was the most important predictor of survival of patients with NSCLC in this cohort of patients (hazard ratio 2.34, 95% CI 1.31-4.21). LIMITATIONS: Lack of surgical reference standard in all patients and referral to a tertiary center. CONCLUSIONS: Patients with node-positive NSCLC as detected by EUS-FNA have a shorter survival time compared with patients who were node negative. They are more likely to receive neoadjuvant therapy and less likely to receive surgery. Preoperative EUS-FNA is a minimally invasive technique that provides important prognostic information in patients with NSCLC.

Endoscopic diagnosis and staging of mucosa-associated lymphoid tissue lymphoma.

PURPOSE OF REVIEW: The role of endoscopy, including endoscopic ultrasound, in the diagnosis and management of mucosa-associated lymphoid tissue lymphomas of the stomach has evolved steadily in the last two decades. The present review summarizes recent findings and puts them in context with studies on the diagnosis and management of mucosa-associated lymphoid tissue lymphoma published earlier. RECENT FINDINGS: Several recent studies have emphasized the crucial role of endoscopic ultrasound in treatment planning in patients with gastric mucosa-associated lymphoid tissue lymphoma. This is important as early-stage gastric mucosa-associated lymphoid tissue lymphomas can be managed just by the eradication of Helicobacter pylori by appropriate antibiotic regimens. However, the more advanced lesions are treated with much more invasive treatment regimens involving radical gastrectomy, chemotherapy or radiation, or all. SUMMARY: Endoscopic ultrasound staging is highly accurate in predicting response to Helicobacter pylori eradication in patients with gastric mucosa-associated lymphoid tissue lymphoma. Normalization of gastric wall thickness and architecture can be used to monitor tumor regression following treatment. Endoscopic ultrasound findings can also be used to identify treatment failures and relapses and can help identify patients who need more aggressive therapy.

A prospective evaluation of an algorithm incorporating routine preoperative endoscopic ultrasound-guided fine needle aspiration in suspected pancreatic cancer.

BACKGROUND: Whether tissue diagnosis is required in the preoperative evaluation of patients with suspected pancreatic cancer remains controversial. We prospectively evaluated the accuracy, safety, and potential impact on surgical intervention of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the preoperative evaluation of suspected pancreatic cancer. METHODS: All patients who underwent EUS-FNA at our institution (n = 547) over a 4.5-year period were enrolled. Patients underwent surgical exploration and resection based on their comorbidity status, evidence of resectability based on spiral computed tomography (CT) and EUS imaging reviewed in a multidisciplinary approach. RESULTS: Of 547 patients enrolled (median age 64 years, 60% male), 49% presented with obstructive jaundice. The operating characteristics of EUS-FNA of solid pancreatic masses were: sensitivity 95% (95% CI: 93.2-95.4), specificity 92% (95% CI: 86.6-95.7), positive predictive value 98% (95% CI: 97-99), negative predictive value 80% (95% CI: 74.9-82.7). The overall accuracy of EUS-FNA was 94.1% (95% CI: 92.0-94). Of the 414 true positive patients by EUS-FNA, 138 (33%) were explored. Of patients deemed operable by combined imaging, 42% had surgical resection. Eighty-two percent of true positive patients were ultimately found inoperable and received palliative therapy or chemotherapy. Of the 94 patients with true negative cytology based on extended follow-up, only 7 (7%) underwent surgical resection. Of those with false negative diagnoses (n = 24), 5 patients underwent exploration/resection based on detection of mass lesions by EUS. The remaining patients had unresectable disease. Mild self-limiting pancreatitis occurred in (0.91%). CONCLUSIONS: EUS-FNA is a safe and highly accurate method for tissue diagnosis in suspected pancreatic cancer. This approach allows for preoperative counseling of patients, minimizing surgeon's operative time in cases of unresectable disease, and avoids surgical biopsies in the majority of patients with inoperable disease. In addition, it allows for conservative management of patients with benign biopsies. We still, however, recommend exploration of patients with clinical scenario suspicious for pancreatic cancer, a mass found on EUS or CT, but inconclusive or negative cytology.

EUS-guided FNA combined with flow cytometry in the diagnoses of suspected or recurrent intrathoracic or retroperitoneal lymphoma.

BACKGROUND: Limited data exist on the combined use of EUS-guided FNA (EUS-FNA) and flow cytometry (FC) in the diagnosis of lymphoma. The aim of this study was to evaluate the accuracy of EUS-FNA combined with FC in the diagnosis of primary or recurrent lymphoma. METHODS: This study was a retrospective analysis of a prospective collection of data over a 3-year period. Over 3 years, 29 patients with lesions (n=31) suspicious for lymphoma underwent EUS-FNA and FC. RESULTS: Of the 29 patients, 10 patients had lymphoma and 17 patients had nonlymphoma lesions; for two patients, final diagnosis was indeterminate because of insufficient material for FC. The lymphoma cases included non-Hodgkin's lymphoma (n=6, including 3 recurrences), mucosa-associated lymphoid tissue (MALT) lymphoma (n=2), a non-GI lymphoma with mediastinal lymphadenopathy (n=1), and an uncharacterized lymphoma (n=1). Of the 31 lesions, 8 were true positive, 18 were true negative, and 3 were false negative; for two lesions, we could not determine the final diagnosis. No false-positive results were encountered. The sensitivity, the specificity, and the accuracy of EUS-FNA combined with FC for diagnosing lymphoma were 72.7%: 95% CI [43.3%, 90.3%], 100%: 95% CI [82.4%, 100.0%], and 89.7%: 95% CI [73.6%, 96.4%], respectively. Limitations to this study include a short duration of follow-up and a lack of a surgical criterion standard. CONCLUSIONS: EUS-FNA in combination with FC allows the diagnosis of primary suspected or recurrent lymphoma. It also is an adjunct in staging MALT lymphoma and could direct clinicians toward further investigative procedures.