Metastatic Squamous Cell Carcinoma of the Lung Disclosed From Constipation Workup.

A palpable rectal mass associated with gastrointestinal (GI) symptoms immediately raises concern for colorectal cancer, but rarely can represent distant metastatic disease. The incidence of symptomatic colorectal metastasis from a primary lung cancer without any pulmonary symptom is extremely rare. We report a rare case of constipation as the presenting symptom in a patient ultimately found to have metastatic squamous cell carcinoma of the lung. A rectal mass was readily palpable on examination, illustrating the importance of digital rectal examination. In addition, GI clinicians should maintain a high index of suspicion when evaluating patients at risk of non-GI malignancies.

Intramural Esophageal Hematoma With Associated Hemothorax.

Intramural esophageal hematoma (IEH) is a rare manifestation of esophageal wall injury with nonspecific symptoms. It may be caused by trauma or occur spontaneously. IEH is often discovered on computed tomography or esophagogastroduodenoscopy and is typically managed conservatively with supportive care to allow healing. It is frequently an isolated finding in the esophagus and seldom involves any other organ. We report a rare case of a patient discovered to have an obstructing IEH with associated hemothorax after an unrelated surgical admission.

Comparison of Endoscopic Ultrasound-Fine-Needle Aspiration and Endoscopic Ultrasound-Fine-Needle Biopsy for Solid Lesions in a Multicenter, Randomized Trial.

BACKGROUND & AIMS: Endoscopic ultrasound with fine-needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the gastrointestinal tract. Fine-needle biopsy (FNB) may provide higher diagnostic yield with fewer needle passes. The aim of this study was to assess the difference in diagnostic yield between FNA and FNB. METHODS: This is a multicenter, prospective randomized clinical trial from 6 large tertiary care centers. Patients referred for tissue sampling of solid lesions were randomized to either FNA or FNB of the target lesion. Demographics, size, location, number of needle passes, and final diagnosis were recorded. RESULTS: After enrollment, 135 patients were randomized to FNA (49.3%), and 139 patients were randomized to FNB (50.7%).The following lesions were sampled: mass (n = 210, 76.6%), lymph nodes (n = 46, 16.8%), and submucosal tumors (n = 18, 6.6%). Final diagnosis was malignancy (n = 192, 70.1%), reactive lymphadenopathy (n = 30, 11.0%), and spindle cell tumors (n = 24, 8.8%). FNA had a diagnostic yield of 91.1% compared with 88.5% for FNB (P = .48). There was no difference between FNA and FNB when stratified by the presence of on-site cytopathology or by type of lesion sampled. A median of 1 needle pass was needed to obtain a diagnostic sample for both needles. CONCLUSIONS: FNA and FNB obtained a similar diagnostic yield with a comparable number of needle passes. On the basis of these results, there is no significant difference in the performance of FNA compared with FNB in the cytologic diagnosis of solid lesions adjacent to the gastrointestinal tract. ClinicalTrials.gov identifier: NCT01698190.

Practice patterns in FNA technique: A survey analysis.

AIM: To ascertain fine needle aspiration (FNA) techniques by endosonographers with varying levels of experience and environments. METHODS: A survey study was performed on United States based endosonographers. The subjects completed an anonymous online electronic survey. The main outcome measurements were differences in needle choice, FNA technique, and clinical decision making among endosonographers and how this relates to years in practice, volume of EUS-FNA procedures, and practice environment. RESULTS: A total of 210 (30.8%) endosonographers completed the survey. Just over half (51.4%) identified themselves as academic/university-based practitioners. The vast majority of respondents (77.1%) identified themselves as high-volume endoscopic ultrasound (EUS) (> 150 EUS/year) and high-volume FNA (> 75 FNA/year) performers (73.3). If final cytology is non-diagnostic, high-volume EUS physicians were more likely than low volume physicians to repeat FNA with a core needle (60.5% vs 31.2%; P = 0.0004), and low volume physicians were more likely to refer patients for either surgical or percutaneous biopsy, (33.4% vs 4.9%, P < 0.0001). Academic physicians were more likely to repeat FNA with a core needle (66.7%) compared to community physicians (40.2%, P < 0.001). CONCLUSION: There is significant variation in EUS-FNA practices among United States endosonographers. Differences appear to be related to EUS volume and practice environment.

Small-bowel endoscopy core curriculum.

This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.

Diagnostic yield and safety of jumbo biopsy forceps in patients with subepithelial lesions of the upper and lower GI tract.

BACKGROUND: EUS-FNA often fails to make a definitive diagnosis in the evaluation of subepithelial lesions. The addition of jumbo biopsy forceps has the potential to improve diagnostic yield, but published series are limited. OBJECTIVE: To assess the likelihood of definitive diagnosis for subepithelial lesions by using jumbo biopsy forceps during EUS examination. DESIGN: Pooled retrospective analysis. SETTING: 6 tertiary referral centers. PATIENTS: All patients having undergone EUS examination for a subepithelial lesion in which jumbo biopsy forceps were used for tissue acquisition. MAIN OUTCOME MEASUREMENTS: Diagnostic yield of jumbo biopsy forceps use, complication rates, and comparison of diagnostic yield with that of EUS-FNA. RESULTS: A total of 129 patients underwent EUS with jumbo biopsy forceps; 31 patients (24%) had simultaneous EUS-FNA. The lesion locations were stomach (n = 98), esophagus (n = 14), duodenum (n = 11), colon (n = 5), and jejunum (n = 1). The average lesion size was 14.9 mm ± 9.3 mm. Overall, definitive diagnosis was obtained in 87 of 129 patients (67.4%) by using either method. A definitive diagnosis was provided by jumbo biopsy forceps use in 76 of 129 patients (58.9%) and by FNA in 14 of 31 patients (45.1%) (P = .175). The results in third-layer lesions were definitive with jumbo biopsy forceps in 56 of 86 lesions (65.1%) and with FNA in 6 of 16 lesions (37.5%) (P = .047). For fourth-layer lesions, the results with jumbo biopsy forceps were definitive in 10 of 25 (40.0%) and with FNA in 8 of 14 (57.1%) (P = .330). Forty-five of 129 patients (34.9%) experienced significant bleeding after biopsy with jumbo forceps and required some form of endoscopic hemostasis. LIMITATIONS: Retrospective study. CONCLUSIONS: Jumbo forceps are a useful tool for the definitive diagnosis of subepithelial lesions. The greatest benefit appears to be with third-layer (submucosal) lesions. The risk of bleeding is significant.

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.

Use of endoscopic ultrasound.

Endoscopic ultrasound (EUS) should be performed when it has the potential to affect the patient's management, as when establishing a diagnosis, performing locoregional tumor staging, or providing therapeutic intervention. Luminal malignancies, extraluminal malignancies, and other common indications for performing EUS are discussed in this article.

Endoscopic ultrasound-guided fine needle aspiration and cyst fluid analysis for pancreatic cysts.

CONTEXT: Endoscopic ultrasound (EUS) with EUS-guided fine needle aspiration (EUS-FNA) has been increasingly utilized to differentiate malignant/pre-malignant pancreatic cysts from those that are benign or have low malignant potential. OBJECTIVE: To determine the utility of EUS morphology, EUS-FNA cytology and cyst fluid analysis to distinguish mucinous cystic neoplasms from non-mucinous cystic neoplasms based on histopathology following surgical resection. DESIGN: A retrospective, single center case series. PARTICIPANTS: Patients who underwent EUS and EUS-FNA of known or suspected pancreatic cysts followed by surgical resection. The final diagnosis was based on histopathology. SETTING: Patients were divided in two groups: mucinous cystic neoplasms and non-mucinous cystic neoplasms. Patients with intraductal papillary mucinous tumors were excluded. MAIN OUTCOME MEASURES: Clinical profiles and EUS findings. RESULTS: Forty-eight patients (mean age: 52 years; 29 females, 19 males) were identified: 16 mucinous cystic neoplasms and 32 non-mucinous cystic neoplasms. There were more women in the mucinous cystic neoplasm group compared to the non-mucinous cystic neoplasm group (88% vs. 47%; P=0.011) but the two groups were otherwise similar. The sensitivity, specificity and frequency of cases correctly identified of EUS-FNA cytology for the diagnosis of mucinous cystic neoplasms were 12.5% (95% CI: 2.2-37.2%), 90.6% (95% CI: 75.0-97.5%) and 64.6% (95% CI: 50.4-77.0%), respectively. Median cyst fluid CEA for the mucinous cystic neoplasm group (277 ng/mL; n=14) was significantly higher (P=0.002) than the non-mucinous cystic neoplasm group (1.5 ng/mL; n=21). Cyst fluid CEA greater than 800 ng/mL had a sensitivity of 42.9% (95% CI: 21.3-67.4%) and specificity of 95.2% (95% CI: 75.6-99.9%) for the diagnosis of mucinous cystic neoplasm. On the other hand, a cyst fluid CEA greater than a best cut-off ranging from 3.5 to 8.5 ng/mL had a sensitivity of 92.9% (95% CI: 66.5-100%), a specificity of 66.7% (14/21; 95% CI: 45.2-83.0%), and an accuracy of 81.1% with a frequency of cases correctly identified of 77.1% (95% CI: 60.7-88.2%). CONCLUSIONS: EUS-FNA cytology and cyst fluid CEA greater than 800 ng/mL are insensitive but highly specific for differentiating mucinous cystic neoplasms from non-mucinous cystic neoplasms. EUS morphology alone cannot distinguish between the two groups.

Role of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms: correlation with surgical histopathology.

BACKGROUND & AIMS: Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors characterized by dilation of the main pancreatic duct, its side branches, or both. The purpose of this study was to evaluate the role of endoscopic ultrasound (EUS) in differentiating benign and malignant IPMNs. METHODS: We identified all patients between July 1996-November 2005 who underwent preoperative EUS for IPMNs. Malignancy was defined as the presence of invasive carcinoma; all other neoplasms were considered benign. The results of EUS and EUS-guided fine-needle aspiration (EUS-FNA) were compared with corresponding histopathology. RESULTS: Seventy-four patients (38 male; mean age, 65 years) with 21 (28%) malignant and 53 (72%) benign IPMNs were identified. Sixty-five (88%) underwent EUS-FNA. Compared with benign tumors, patients with malignant IPMNs were more likely to be older (P = .011), present with jaundice (P = .03) or weight loss (P = .03), and have EUS features of a dilated main pancreatic duct (P = .0001), solid lesion (P = .0001), pancreatic ductal filling defects (P = .03), or thickened septa within any cyst (P = .02). The sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of malignancy were 75% (95% confidence interval [CI], 53%-89%), 91% (95% CI, 79%-97%), and 86% (95% CI, 76%-93%), respectively. Cyst or pancreatic duct fluid carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 did not differ between groups. CONCLUSIONS: Older age, jaundice and weight loss, and EUS features of a solid lesion, dilated main pancreatic duct, ductal filling defects, and thickened septa are predictive of malignancy in patients with IPMNs. EUS-FNA cytology is helpful, but cyst fluid CEA and CA 19-9 are of limited value to differentiate malignant from benign IPMNs.