RESUMO
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)â years underwent screening with a median of 3 (1-11) screening visits during a median follow-up of 28 (1-152)â 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 45â 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 50â years. Potentially relevant lesions (multifocal PanIN2 lesions, low/moderate-grade branch-duct IPMNs) occurred also significantly more often after the age of 50â 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 12â months (n=180) or IAR that decided to be screened at ≥24â months intervals (n=30). CONCLUSIONS: It appears safe to start screening for PDAC in IAR of non-CDKN2a FPC families at the age of 50â years. MRI-based screening supplemented by EUS at baseline and every 3rd year or when changes in MRI occur appears to be efficient.
Assuntos
Carcinoma , Detecção Precoce de Câncer/métodos , Pâncreas , Neoplasias Pancreáticas , Idade de Início , Carcinoma/diagnóstico , Carcinoma/epidemiologia , Carcinoma/patologia , Endossonografia/métodos , Feminino , Alemanha/epidemiologia , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Pâncreas/diagnóstico por imagem , Pâncreas/patologia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/epidemiologia , Neoplasias Pancreáticas/patologia , Fatores de TempoRESUMO
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.
Assuntos
Neoplasias das Glândulas Suprarrenais/patologia , Biópsia por Agulha Fina/normas , Neoplasias do Sistema Digestório/diagnóstico por imagem , Neoplasias do Sistema Digestório/patologia , Neoplasias do Mediastino/patologia , Ultrassonografia de Intervenção/normas , Neoplasias das Glândulas Suprarrenais/diagnóstico por imagem , Doenças do Esôfago/diagnóstico por imagem , Doenças do Esôfago/patologia , Reações Falso-Positivas , Humanos , Linfonodos/diagnóstico por imagem , Linfonodos/patologia , Neoplasias do Mediastino/diagnóstico por imagem , Cisto Pancreático/diagnóstico por imagem , Cisto Pancreático/patologia , Gastropatias/diagnóstico por imagem , Gastropatias/patologiaRESUMO
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.
Assuntos
Doenças do Sistema Digestório/diagnóstico por imagem , Doenças do Sistema Digestório/diagnóstico , Endossonografia , Adulto , Idoso , Análise de Variância , Colangiopancreatografia Retrógrada Endoscópica , Estudos de Coortes , Doenças do Sistema Digestório/terapia , Neoplasias do Sistema Digestório/diagnóstico , Neoplasias do Sistema Digestório/diagnóstico por imagem , Feminino , Neoplasias Gastrointestinais/diagnóstico por imagem , Trato Gastrointestinal/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores Socioeconômicos , Resultado do Tratamento , Adulto JovemRESUMO
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.
Assuntos
Dissecação/educação , Dissecação/métodos , Endoscopia do Sistema Digestório , Endoscopia/educação , Endoscopia/métodos , Neoplasias Gástricas/cirurgia , Animais , Modelos Animais , Estudos Prospectivos , SuínosRESUMO
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.
Assuntos
Glândulas Suprarrenais/patologia , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico , Neoplasias das Glândulas Suprarrenais/patologia , Idoso , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico/efeitos adversos , Feminino , Humanos , Masculino , Análise Multivariada , Estudos Retrospectivos , SegurançaAssuntos
Pólipos do Colo/diagnóstico , Pólipos do Colo/cirurgia , Colonoscopia/normas , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/prevenção & controle , Detecção Precoce de Câncer/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Adenoma/diagnóstico , Adenoma/cirurgia , Sedação Consciente/normas , Desinfecção/métodos , HumanosRESUMO
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.
Assuntos
Biópsia por Agulha Fina/métodos , Endossonografia , Pâncreas/diagnóstico por imagem , Cisto Pancreático/diagnóstico por imagem , Biomarcadores/análise , Cistadenoma Mucinoso/diagnóstico por imagem , Cistadenoma Mucinoso/patologia , Cistadenoma Seroso/diagnóstico por imagem , Cistadenoma Seroso/patologia , Diagnóstico Diferencial , Humanos , Pâncreas/patologia , Cisto Pancreático/patologia , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/patologia , Pseudocisto Pancreático/diagnóstico por imagem , Pseudocisto Pancreático/patologia , Sensibilidade e EspecificidadeRESUMO
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.
Assuntos
Biópsia por Agulha Fina/métodos , Endossonografia/métodos , Neoplasias Esofágicas/diagnóstico por imagem , Esôfago/diagnóstico por imagem , Estadiamento de Neoplasias/métodos , Algoritmos , Neoplasias Esofágicas/patologia , Esôfago/patologia , Humanos , Metástase LinfáticaAssuntos
Ar , Dióxido de Carbono , Colonoscopia/métodos , Hipnóticos e Sedativos , Insuflação/métodos , Propofol , Feminino , Humanos , MasculinoRESUMO
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.
Assuntos
Infecções por Helicobacter/complicações , Infecções por Helicobacter/tratamento farmacológico , Helicobacter pylori , Rosácea/complicações , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Rosácea/microbiologiaRESUMO
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.
Assuntos
Carcinoma Ductal Pancreático/genética , Neoplasias Pancreáticas/genética , Sistema de Registros , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Ductal Pancreático/patologia , Diagnóstico por Imagem/métodos , Detecção Precoce de Câncer , Feminino , Predisposição Genética para Doença , Testes Genéticos , Hereditariedade , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Fenótipo , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Espanha , Adulto JovemAssuntos
Carcinoma Ductal de Mama/diagnóstico por imagem , Ecocardiografia/métodos , Endossonografia/métodos , Neoplasias Pancreáticas/diagnóstico por imagem , Algoritmos , Animais , Biópsia por Agulha Fina , Carcinoma Ductal de Mama/patologia , Carcinoma Ductal de Mama/cirurgia , Modelos Animais de Doenças , Ecocardiografia Transesofagiana/métodos , Estudos de Viabilidade , Previsões , Humanos , Imageamento por Ressonância Magnética , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Localized low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma can regress after Helicobacter pylori eradication, but IgV(H) gene monoclonality may persist. We studied the long-term histological and molecular follow-up of 24 patients and the possible association of t(11;18) with the persistent monoclonality. PATIENTS AND METHODS: From January 1994, 24 untreated patients with stage I low-grade gastric MALT lymphoma associated with H. pylori were prospectively studied. They all received eradication treatment and were sequentially followed-up with endoscopies for histological and molecular studies. Rearrangement of the IgV(H) gene was studied by PCR analysis. MALT1 locus alterations were studied by FISH. RESULTS: Twenty-two of the 24 patients (91%) achieved disappearance of the lymphoma. Eighteen (82%) of the 22 histologically cured patients and 16 of the 19 (84%) with long follow-up had monoclonality. Three patterns of development of IgV(H) gene rearrangements were observed: four patients (21%) had polyclonal rearrangements; eight (58%) had maintained/intermittent monoclonality and four (21%) had occasional monoclonality, mostly after H. pylori reinfection. Only one patient (6%) with persistent monoclonality relapsed. The remaining 18 patients maintained the remission, despite the persistent monoclonality in 15, for a median of 66 months (range 20-113). t(11;18) was not found in any of the patients with persistent monoclonality. Time and the number of endoscopies performed were not related with the occurrence of monoclonality. CONCLUSIONS: In stage I low-grade gastric MALT lymphoma eradication of H. pylori achieves prolonged histological remission in 90% of patients, but molecular remission is not accomplished in most cases. Molecular disease persists for years, but is not associated with t(11;18).