EUS-guided tissue acquisition in the study of the adrenal glands: Results of a nationwide multicenter study.

BACKGROUND: There are limited data about the role of endoscopic ultrasound-guided tissue acquisition (EUS-TA), by fine needle aspiration (EUS-FNA) or biopsy (EUS-FNB), in the evaluation of the adrenal glands (AG). The primary aim was to assess the diagnostic yield and safety. The secondary aims were the malignancy predictors, and to create a predictive model of malignancy. METHODS: This was a retrospective nationwide study involving all Spanish hospitals experienced in EUS-TA of AGs. Inclusion period was from April-2003 to April-2016. Inclusion criteria: all consecutive cases that underwent EUS-TA of AGs. EUS and cytopathology findings were evaluated. Statistical analyses: diagnostic accuracy of echoendoscopist's suspicion using cytology by EUS-TA, as gold standard; multivariate logistic regression model to predict tumor malignancy. RESULTS: A total of 204 EUS-TA of AGs were evaluated. Primary tumor locations were lung70%, others19%, and unknown11%. AG samples were adequate for cytological diagnosis in 91%, and confirmed malignancy in 60%. Diagnostic accuracy of the endosonographer's suspicion was 68%. The most common technique was: a 22-G (65%) and cytological needle (75%) with suction-syringe (66%). No serious adverse events were described. The variables most associated with malignancy were size>30mm (OR2.27; 95%CI, 1.16-4.05), heterogeneous echo-pattern (OR2.11; 95%CI, 1.1-3.9), variegated AG shape (OR2.46; 95%CI, 1-6.24), and endosonographer suspicion (OR17.46; 95%CI, 6.2-58.5). The best variables for a predictive multivariate logistic model of malignancy were age, sex, echo-pattern, and AG-shape. CONCLUSIONS: EUS-TA of the AGs is a safe, minimally invasive procedure, allowing an excellent diagnostic yield. These results suggest the possibility of developing a pre-EUS procedure predictive malignancy model.

Refinement of screening for familial pancreatic cancer.

OBJECTIVE: Surveillance programmes are recommended for individuals at risk (IAR) of familial pancreatic cancer (FPC) to detect early pancreatic cancer (pancreatic ductal adenocarcinoma, PDAC). However, the age to begin screening and the optimal screening protocol remain to be determined. METHODS: IAR from non-CDKN2A FPC families underwent annual screening by MRI with endoscopic ultrasonography (EUS) in board-approved prospective screening programmes at three tertiary referral centres. The diagnostic yield according to age and different screening protocols was analysed. RESULTS: 253 IAR with a median age of 48 (25-81) years underwent screening with a median of 3 (1-11) screening visits during a median follow-up of 28 (1-152) months. 134 (53%) IAR revealed pancreatic lesions on imaging, mostly cystic (94%), on baseline or follow-up screening. Lesions were significantly more often identified in IAR above the age of 45 years (p<0.0001). In 21 IAR who underwent surgery, no significant lesions (PDAC, pancreatic intraepithelial neoplasia (PanIN) 3 lesions, high-grade intraductal papillary mucinous neoplasia (IPMN)) were detected before the age of 50 years. Potentially relevant lesions (multifocal PanIN2 lesions, low/moderate-grade branch-duct IPMNs) occurred also significantly more often after the age of 50 years (13 vs 2, p<0.0004). The diagnostic yield of potentially relevant lesions was not different between screening protocols using annual MRI with EUS (n=98) or annual MRI with EUS every 3rd year (n=198) and between IAR screened at intervals of 12 months (n=180) or IAR that decided to be screened at ≥24 months intervals (n=30). CONCLUSIONS: It appears safe to start screening for PDAC in IAR of non-CDKN2a FPC families at the age of 50 years. MRI-based screening supplemented by EUS at baseline and every 3rd year or when changes in MRI occur appears to be efficient.

PanGen-Fam: Spanish registry of hereditary pancreatic cancer.

PURPOSE: To describe the organisation of the registry and the preliminary results in terms of characteristics of high-risk pancreatic ductal adenocarcinoma (PDAC) families recruited to date and findings of the screening programme. To compare early onset sporadic cases (⩽50 years), sporadic cases (>50 years) and cases with family history of cancer, for PDAC possible risk factors. METHODS/PATIENTS: Families with hereditary cancer syndromes predisposing to PDAC were recruited from two main sources: Spanish hospitals participating in PanGenEU, a pan-European multicentre case-control study, and their genetic counseling unit. Individuals at high-risk of PDAC were enrolled into a screening programme, consisting of Endoscopic ultrasound, computerised tomography, magnetic resonance imaging. Genetic testing of candidate genes was offered according to each patient's risk. RESULTS: Among 577 consecutive PDAC cases, recruited via PanGenEU, 36 (6%) had ⩾2 first-degree relative with PDAC: Familial pancreatic cancer (FPC). So far PanGen-Fam has recruited 42 high-risk PDAC families; 25 (60%) had FPC. Five index cases with cancer were positive for BRCA2 and one for BRCA1 germline mutations. In the second year of prospective PDAC screening, one neuroendocrine tumour and a high-grade dysplasia lesion suspicious of carcinoma were diagnosed among 41 high-risk individuals. Furthermore EUS detected chronic-pancreatitis-like parenchymal changes in 15 patients. CONCLUDING STATEMENT: The identification and recruitment of PDAC high-risk families into the PanGen-Fam registry provides an opportunity to detect early onset cancer and precursor pancreatic cancer lesions at a potentially curative stage and to increase the knowledge of the natural history of the disease.

Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB), of submucosal tumors, diffuse esophageal/gastric wall thickening, pancreatic solid masses and cystic-appearing lesions, mediastinal lesions unrelated to lung or esophageal cancer, cancer of the esophagus, stomach, and rectum, lymph nodes of unknown origin, adrenal gland masses, and focal liver lesions. False-positive cytopathological results and needle tract seeding are also discussed. The present Clinical Guideline describes the results of EUS-guided sampling in the different clinical settings, considers the role of this technique in patient management, and makes recommendations on circumstances that warrant its use. A two-page executive summary of evidence statements and recommendations is provided. A separate Technical Guideline describes the general technique of EUS-guided sampling, particular techniques to maximize the diagnostic yield depending on the nature of the target lesion, and sample processing. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling.

Impact of endoscopic ultrasonography on the management of a prospective cohort of 700 consecutive patients referred for diagnostic endoscopic ultrasonography.

BACKGROUND: endoscopic ultrasonography (EUS) is a high accuracy technique for the study of many digestive diseases. The degree of knowledge about the impact of EUS on the management of these patients is inadequate. AIM: to determine the therapeutic impact of endoscopic ultrasonography (EUS) on a prospective cohort of patients. METHODS: all patients referred for EUS over a period of 2 years were prospectively evaluated in order to asses: 1. EUS provides new information not previously known; 2. theoretic impact of EUS on patient management; 3. real impact of EUS on final therapy; 4. changes in the aggressiveness of the therapeutic decision after EUS. RESULTS: 700 patients were included. Preoperative assessment of digestive tumors was the commonest indication. EUS provided "new information" in the 89% of the patients. With regard to endoscopist opinion, these findings should alter the management in 79% of patients ("theoretic impact"). However, EUS prompted a change in the management in 67% of patients ("real impact"). Final therapy post-EUS was less aggressive in 34% of patients. Changes in therapeutic decision were associated with EUS findings, alcohol intake and age ≥ 57 years old. CONCLUSIONS: 1) EUS findings, advanced age, and alcohol intake are associated with a change in the management in 2 out of every 3 patients referred for EUS. 2) Therapeutic decision (post-EUS) is less aggressive in a third of these patients, what should represent a significant economic saving.

Impacto de la ultrasonografía endoscópica en el manejo terapéutico de una cohorte prospectiva de 700 pacientes consecutivos referidos para USE diagnóstica / No disponible

Antecedentes: la ultrasonografía endoscópica (USE) es una técnica de gran precisión para el estudio de diferentes patologías digestivas. El grado de conocimiento sobre el impacto de la USE en el tratamiento de estos pacientes es escaso. Objetivo: determinar el impacto terapéutico de la USE en una cohorte prospectiva de pacientes. Material y métodos: estudio que evalúa de forma prospectiva a todos los pacientes remitidos para USE en un periodo de 2 años. Se analiza: a) si la USE aporta información no conocida previamente; b) el impacto teórico de la USE en el tratamiento; c) el impacto final/real de USE en el tratamiento; d) la variación en la decisión terapéutica tras realizar la USE. Resultados: se incluyeron 700 pacientes. La indicación más frecuente de USE era el estudio preoperatorio de tumores digestivos. La USE aportó “información nueva” en el 89% de los casos. En opinión del ecoendoscopista estos hallazgos deberían suponer un cambio terapéutico en el 79% de los pacientes (“impacto teórico”). Sin embargo, el tratamiento sólo se modificó en el 67% de los casos (“impacto real”). La estrategia terapéutica post-USE fue menos agresiva en el 34% de los casos. Los cambios en la actitud terapéutica se asociaban con los hallazgos de USE, ingesta de alcohol y edad > 57 años. Conclusiones: – Los hallazgos de la USE, la edad avanzada y el consumo de alcohol, se asocian con un cambio terapéutico en 2 de cada 3 pacientes remitidos a una unidad de USE. – La decisión terapéutica final (post-USE) es menos agresiva en un tercio de estos pacientes, lo que podría representar un ahorro económico significativo(AU)

Antecedents: endoscopic ultrasonography (EUS) is a high accuracy technique for the study of many digestive diseases. The degree of knowledge about the impact of EUS on the management of these patients is inadequate. Aim: to determine the therapeutic impact of endoscopic ultrasonography (EUS) on a prospective cohort of patients. Methods: all patients referred for EUS over a period of 2 years were prospectively evaluated in order to asses: 1. EUS provides new information not previously known; 2. theoretic impact of EUS on patient management; 3. real impact of EUS on final therapy; 4. changes in the aggressiveness of the therapeutic decision after EUS. Results: 700 patients were included. Preoperative assessment of digestive tumors was the commonest indication. EUS provided “new information” in the 89% of the patients. With regard to endoscopist opinion, these findings should alter the management in 79% of patients (“theoretic impact”). However, EUS prompted a change in the management in 67% of patients (“real impact”). Final therapy post-EUS was less aggressive in 34% of patients. Changes in therapeutic decision were associated with EUS findings, alcohol intake and age >= 57 years old. Conclusions: 1) EUS findings, advanced age, and alcohol intake are associated with a change in the management in 2 out of every 3 patients referred for EUS. 2) Therapeutic decision (post- EUS) is less aggressive in a third of these patients, what should represent a significant economic saving(AU)

Training model for teaching endoscopic submucosal dissection of gastric tumors.

INTRODUCTION: The elevated risk of complications and technical complexity of endoscopic submucosal dissection (ESD) has limited its implementation in our medical system. OBJECTIVE: To design and evaluate a training program for learning the ESD technique. METHODS: Four endoscopists with no experience with ESD underwent a 4-step training program: 1) review of the existing literature, didactic material, and theoretical aspects of ESD; 2) ESD training in an ex-vivo animal model; 3) ESD training in an in-vivo animal model (supervised by ESD expert); and 4) ESD performance in a patient. A standard gastroscope and an ESD knife (IT, Flex or Hook-knife Olympus) were employed. The classical ESD technique was performed: rising of the lesion, circumferential incision, and submucosal dissection. RESULTS: Ex-vivo animal model: 6 x swine stomach/esophagus -cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) and fundus/cardia (n = 1)-; size of resected specimen: 4-10 cm; ESD duration: 105-240 minutes; therapeutic success: 100%; complications: perforation (1/6: 16%) sealed with clips. In-vivo animal model: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size: 2-5 cm; duration: 40-165 minutes; success: 100%; complications: 0%. PATIENT: ESD of a gastric lesion located in the antrum/body; size: 3 cm; duration 210 minutes; a complete resection was achieved; no complications. CONCLUSIONS: The results of the present study support the usefulness of this model for learning ESD in our system.

Training model for teaching endoscopic submucosal dissection of gastric tumors

Introduction: the elevated risk of complications and technicalcomplexity of endoscopic submucosal dissection (ESD) has limitedits implementation in our medical system.Objective: to design and evaluate a training program forlearning the ESD technique.Methods: four endoscopists with no experience with ESD underwenta 4-step training program: 1) review of the existing literature,didactic material, and theoretical aspects of ESD; 2) ESDtraining in an ex-vivo animal model; 3) ESD training in an in-vivoanimal model (supervised by ESD expert); and 4) ESD performancein a patient. A standard gastroscope and an ESD knife (IT,Flex or Hook-knife Olympus®) were employed. The classical ESDtechnique was performed: rising of the lesion, circumferential incision,and submucosal dissection.Results: ex-vivo animal model: 6 x swine stomach/esophagus–cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) andfundus/cardia (n = 1)–; size of resected specimen: 4-10 cm; ESDduration: 105-240 minutes; therapeutic success: 100%; complications:perforation (1/6: 16%) sealed with clips. In-vivo animalmodel: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size:2-5 cm; duration: 40-165 minutes; success: 100%; complications:0%. Patient: ESD of a gastric lesion located in theantrum/body; size: 3 cm; duration 210 minutes; a complete resectionwas achieved; no complications.Conclusions: the results of the present study support the usefulnessof this model for learning ESD in our system(AU)

Linear EUS: the clinical impact of N staging in esophageal carcinoma.

This review article focuses on nodal staging of esophageal cancer. Transesophageal endoscopic ultrasound (EUS) is the most accurate technique for preoperative local-regional staging of esophageal carcinoma (TN staging), once the CT and/or the PET scan have excluded the presence of distant metastasis. EUS guided fine needle aspiration (EUS-FNA) helps improve diagnostic accuracy in esophageal cancer lymph node staging. In certain subgroup of patients who present with a number of EUS lymph node criteria, EUS FNA may be avoided without affecting diagnostic accuracy. In tumors of the distal esophagus detection and biopsy of celiac lymph nodes may be successfully performed by EUS and EUS FNA, and important therapeutic decissions may be derived from such a practice.

Endoscopic ultrasound and fine needle aspiration in inflammatory and cystic pancreatic pathology.

To achieve an accurate diagnosis on the nature of pancreatic cystic lesions may be difficult. This review article attempts to provide an overview of the potential role of endoscopic ultrasound (EUS) and EUS guided fine needle aspiration in the evaluation of cystic lesions of the pancreas.

Effect of Helicobacter pylori eradication therapy in rosacea patients.

OBJECTIVE: The causal relation between rosacea and Helicobacter pylori infection is discussed. We evaluated the clinical evolution of rosacea after infection eradication. PATIENTS AND METHODS: We have prospectively studied 44 patients diagnosed with rosacea. Helicobacter pylori infection was determined, and infected patients were treated with eradication therapy. The evolution of dermatological symptoms in a subgroup of 29 infected patients in whom eradication had been achieved was followed during 16.8 (+/- 17.8) months. Median age was 50.6 (+/- 14.1) years for 22 women (75.9%) and 7 men (24.1%). Clinical response according to gender and clinical subtype of rosacea was evaluated. RESULTS: Complete improvement was observed in 10 patients (34.5%; 95% CI: 18.6-54.3%), relevant improvement in 9 (31.1%; 95% CI: 16-51%), poor improvement in 5 (17.2%; 95% CI: 6.5-36.4%), and absence of improvement in 5 cases (17.2%; 95% CI: 6.5-36.4%). No significant differences in dermatological evolution according to sex were observed. Regarding subtype of rosacea there was a relevant improvement in 83.3% (95% CI: 64.1-93.8%) of cases with papulopustular type as opposed to 36.5% (95% CI: 20-56.1%) of cases with erythematous predominance, p = 0.02. CONCLUSIONS: Based on these results, the relation between Helicobacter pylori and rosacea is supported, and infection should be investigated in these patients because an appreciable percentage of patients diagnosed with rosacea and Helicobacter pylori infection can benefit from eradication therapy, mainly in the papulopustular subtype.