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Depth diagnosis of early gastric carcinoma using EUS
Abstracts
Conclusion: Pancreatic cyst size has considerable variation. Radiographic prediction of malignancy cannot be made on size alone. There is a significant difference in size of pseudocysts compared to either malignant cysts or serous cysts. However, cyst aspiration by EUS-FNA with fluid analysis is essential for distinguishing between malignant cysts and all other benign pancreatic cysts due to the poor correlation of size.
The value of liquid-based cytology in the EUS-FNA for pancreatic tumors Siyu Sun, Nan Ge, Sheng Wang, Xiang Liu, Qingjie Lu Aims of the Study: The aim of this study was to evaluate the role of liquid-based cytology with the ThinPrep (TP) (Cytyc; Cytyc, Co, Boxborough, MA, USA) technique, using endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for suspicious pancreatic lesions. Methods: Between January and December 2007, We performed EUS-guided FNA biopsy of focal pancreatic lesions in 32 adult patients, with 22-G FNA needle. Study subjects were all consecutive patients and potential candidates for surgery. The sample was examined by both conventional smears (CS) and TP techniques. TP smears of all FNA were prepared from needle rinsing obtained following preparation of CS. All cytological diagnoses were correlated with the CS and/or surgically histological diagnoses in order to evaluate the role of liquid-based cytology with the TP technique. Results: Using TP technique diagnosis was successfully established in 28 patients out of 32, whereas using CS cytology diagnosis was established in 20 patients (p ! 0.05). Inadequate material was observed in 2 cases (6.3%) with the TP technique and in 9 cases (28.1%) with the CS technique (p ! 0.05). TS was superior to CS regarding presence of red blood cells, tissue artifacts, quality of the smear background, and cell recognition (P ! 0.001). Conclusions: We believe that the TP technique has a good overall yield for the FNA of pancreatic lesions. Combining liquid-based cytology with convetional techniques to prepare material may improve EUS-FNA performance by decreasing the number of inadequate specimens and by increasing the possibility to obtain cell blocks allowing for ancillary techniques such as immunohistochemistry and molecular biology.
EUS-FNA is more advantageous than ERCP in tissue sampling for pathological diagnosis of pancreatic cancer Tsuneyoshi Ogawa, Hirofumi Kawamoto, Ryo Harada, Naoko Kurihara, Hironari Kato, Ken Hirao, Osamu Mizuno, Etsuji Ishida, Kazuhide Yamamoto Objectives: The pathological diagnosis is essential in the treatment of the patients with pancreatic cancer. It is reported that accuracy rates for EUSFNA of pancreatic cancer are higher than ERCP tissue sampling. This study was conducted to determine the efficacy of EUS-FNA in comparison with ERCP tissue sampling for pathological diagnosis of pancreatic cancer. Methods: Between January 2006 and October 2007, 73 consecutive patients (43 man and 30 women, mean age of 65 years) with pancreatic cancer on whom EUSFNA was performed were enrolled in this study. EUS-FNA was performed by using a 7.5 MHz linear-array echoendscope (GF-UM2000P; Olympus, Tokyo, Japan) and a 22-gauge needle (Echotip; Wilson-Cook). The final diagnosis was assessed by surgery or clinical course such as death or disease progression. As controls, 54 consecutive patients (31 man and 23 women, mean age of 64 years) with pancreatic cancer on whom ERCP tissue sampling was performed between January 2004 and December 2005 were reviewed. Tissue sampling at ERCP was performed transpapillary; collection of pure pancreatic and/or bile juice, brushing and/or biopsy of the pancreatic or bile duct stricture. Positive rates of cytology and histology were analyzed in each specimen. Results: A total of 73 pancreatic cancers were aspirated (Pancreas head 25, body-tail 48). Tissue acquisition rate was 98% (72/73) and the accuracy in EUS-FNA was 93% (67/72). ERCP tissue sampling was performed on 54 patients (head 27, body-tail 27; collection of pure pancreatic/bile juice 35/7, pancreatic/bile duct brushing 10/11, pancreatic/bile duct biopsy 16/12). The accuracy in ERCP tissue sampling was 61% (33/54). In the body-tail, EUS-FNA had greater accuracy than ERCP tissue sampling (96% vs. 44%, p ! 0.001), despite no significant difference between EUS-FNA and ERCP tissue sampling in the head (88% vs. 78%, p Z 0.34). No complications relating to EUS-FNA and ERCP were observed. Conclusion: EUS-FNA is more accurate than ERCP tissue sampling for the pathological diagnosis of pancreatic cancer, especially in the body-tail of the pancreas.
Depth diagnosis of early gastric carcinoma using EUS Takafumi Hyodo Background: Tumor depth diagnosis of early gastric carcinoma is necessary for appropriate choice of its treatment: Surgical operation or endoscopic resection. Endoscopic ultrasonography (EUS) is the most useful modality for this tumor depth diagnosis although narrow banding method (NBI) has enabled us precisely to determine the horizontal extension of the carcinoma. The aim of this study is to
S258 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
clarify the ultrasonographical and histological factors to contribute to differentiate mucosal carcinoma from submucosal carcinoma. Patients and Methods: Between 2005 and 2007, 168 patients agreed to undergo EUS before its treatment. Conventional echoendoscope (UM240, Olympus) and/or miniprobe (20MHz, Olympus) were used. Using EUS, we evaluated the ultrasonographical factors (the presence of submucosal changes, the disappearance of mucosal muscular layer [mm], mucosal thickness, submucosal focal expansion) and histological factors (fibrosis [F], lymphoid follicle [LF], dilated vessel [V], aberrant gland [AG], granulation feature [G]) in all these patients. The differential criteria between mucosal carcinoma and submucosal carcinoma included the presence of submucosal change and submucosal focal expansion. Results: The overall accuracy rate for depth diagnosis was 143/168 (85%). The ultrasonographical factor of submucosal focal expansion is the most reliable marker for the differentiation between mucosal and submucosal lesions. Two histological factors of V and AG in the submucosal layer significantly contributed to misjudgment of the depth diagnosis: The decrease of accuracy rates were respectively 125/141(89%) to 18/27(67%) and 135/156(87%) to 8/12(67%). Conclusion: To carry out the precise depth diagnosis for early gastric carcinoma, we first have to detect the presence of the submucosal change: cancer invasion or original histological structure (F, LF, V, and AG), and second evaluate submucosal focal expansion possibly caused by submucosal invasion of carcinoma.
Door knocking method: a useful new technique for obtaining adequate sample in EUS-FNA Tadayuki Takagi Background: Although EUS-FNA is less invasive means of obtaining cytological and histopathological specimens, several complications have been reported such as hemorrhage, infection, and tumor seeding in a few cases. Therefore, number of puncture is desirable as few as possible. The average puncture time was 2.51 times for 229 cases of pancreatic cancer in our hospital from 1997 to 2006. Overall rate of tissue sampling was 97.8%, and 4 complications (hematoma 2, hemorrhage 1, portal vein thrombosis 1). The aim of this study was to evaluate whether our new technique, so called ‘‘Door Knocking Method’’ may be useful for obtaining adequate samples with less number of puncture than usual or not. Patients and Methods: Ten patients who underwent EUS-FNA for pancreatic cancer were enrolled in 2007. EUS-FNA was performed using 22G needle by experienced endoscopist (TT, KH, NM, KY). The puncture for EUS-FNA was twice at random by conventional method and ‘‘Door Knocking Method’’ in each case. ‘‘Door Knocking Method’’ is the technique which makes the big knocking sound between the slider and the stopper when EUS-FNA is performed. That is, we advance the needle in the mass as fast as possible. The efficacy of this new technique to obtain enough specimens was evaluated in comparison with the conventional method. Results: Patient’s characteristics were as follows; location: 2 in pancreas head and 8 in body, tumor size: TS1 (less2cm) 1, TS2 6, and TS3 (above4cm) 3, puncture route: 5, 2, and 3 via stomach, bulb, and 2nd portion, respectively. The overall diagnostic accuracy (sensitivity) for malignancy was 100% and no complication occurred in ten cases. The accuracy rate of each puncture method were 70% and 90%, by conventional and new method, respectively. Odds ratio of puncture method was 3.9, respectively. Conclusion: Difference of 20% caused by puncture method was important in clinical practice. Because, ‘‘Door Knocking Method’’ may have a potential not only to improve a diagnostic ability, but also to reduce the number of puncture and complication of EUS-FNA, although further study will be needed.
Usefulness of endoscopic ultrasonography for preoperative staging of tumors of the ampulla of Vater Yukiko Takayama Background: It is difficult to evaluate local progression of tumors of the ampulla of Vater, because of the anatomical complexity and smallness of the ampulla. Although diagnosis of tumors of the ampulla by endoscopic ultrasonography (EUS) has been reported, local progression is difficult to diagnose, especially in patients with small tumors and without using an antispastic agent. We tried using the soft balloon cover of the transvaginal ultrasonography probe to perform EUS in such patients, because it deforms the ampulla less than the EUS balloon, and distend the duodenum adequately without an antispastic agent and with little water. Objective: To evaluate the usefulness of EUS for preoperative staging of tumors of the ampulla and the usefulness of EUS with a soft baloon for small tumors without an antispastic agent. Patients and Methods: 58 patients with a tumor of the ampulla were preoperatively examined by EUS over 20 years. 1) The preoperative diagnose of local progression by EUS, duodenal invasion (Du), and pancreatic invasion (Panc) in all patients, and UICC T classifications in the carcinoma patients were compared with the resected specimens. 2) The preoperative diagnose of Du and Panc and T classifications by EUS were compared with the histological findings in a group with tumors O 20 mm with an antispastic agent (GroupA), and a group with tumors ! 20 mm without an antispastic agent (Group B). 3) The preoperative diagnose of Du and Panc and T classifications by EUS with the soft baloon in Group A and Group B were compared with the histological findings.
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Conclusion: Pancreatic cyst size has considerable variation. Radiographic prediction of malignancy cannot be made on size alone. There is a significant difference in size of pseudocysts compared to either malignant cysts or serous cysts. However, cyst aspiration by EUS-FNA with fluid analysis is essential for distinguishing between malignant cysts and all other benign pancreatic cysts due to the poor correlation of size.
The value of liquid-based cytology in the EUS-FNA for pancreatic tumors Siyu Sun, Nan Ge, Sheng Wang, Xiang Liu, Qingjie Lu Aims of the Study: The aim of this study was to evaluate the role of liquid-based cytology with the ThinPrep (TP) (Cytyc; Cytyc, Co, Boxborough, MA, USA) technique, using endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for suspicious pancreatic lesions. Methods: Between January and December 2007, We performed EUS-guided FNA biopsy of focal pancreatic lesions in 32 adult patients, with 22-G FNA needle. Study subjects were all consecutive patients and potential candidates for surgery. The sample was examined by both conventional smears (CS) and TP techniques. TP smears of all FNA were prepared from needle rinsing obtained following preparation of CS. All cytological diagnoses were correlated with the CS and/or surgically histological diagnoses in order to evaluate the role of liquid-based cytology with the TP technique. Results: Using TP technique diagnosis was successfully established in 28 patients out of 32, whereas using CS cytology diagnosis was established in 20 patients (p ! 0.05). Inadequate material was observed in 2 cases (6.3%) with the TP technique and in 9 cases (28.1%) with the CS technique (p ! 0.05). TS was superior to CS regarding presence of red blood cells, tissue artifacts, quality of the smear background, and cell recognition (P ! 0.001). Conclusions: We believe that the TP technique has a good overall yield for the FNA of pancreatic lesions. Combining liquid-based cytology with convetional techniques to prepare material may improve EUS-FNA performance by decreasing the number of inadequate specimens and by increasing the possibility to obtain cell blocks allowing for ancillary techniques such as immunohistochemistry and molecular biology.
EUS-FNA is more advantageous than ERCP in tissue sampling for pathological diagnosis of pancreatic cancer Tsuneyoshi Ogawa, Hirofumi Kawamoto, Ryo Harada, Naoko Kurihara, Hironari Kato, Ken Hirao, Osamu Mizuno, Etsuji Ishida, Kazuhide Yamamoto Objectives: The pathological diagnosis is essential in the treatment of the patients with pancreatic cancer. It is reported that accuracy rates for EUSFNA of pancreatic cancer are higher than ERCP tissue sampling. This study was conducted to determine the efficacy of EUS-FNA in comparison with ERCP tissue sampling for pathological diagnosis of pancreatic cancer. Methods: Between January 2006 and October 2007, 73 consecutive patients (43 man and 30 women, mean age of 65 years) with pancreatic cancer on whom EUSFNA was performed were enrolled in this study. EUS-FNA was performed by using a 7.5 MHz linear-array echoendscope (GF-UM2000P; Olympus, Tokyo, Japan) and a 22-gauge needle (Echotip; Wilson-Cook). The final diagnosis was assessed by surgery or clinical course such as death or disease progression. As controls, 54 consecutive patients (31 man and 23 women, mean age of 64 years) with pancreatic cancer on whom ERCP tissue sampling was performed between January 2004 and December 2005 were reviewed. Tissue sampling at ERCP was performed transpapillary; collection of pure pancreatic and/or bile juice, brushing and/or biopsy of the pancreatic or bile duct stricture. Positive rates of cytology and histology were analyzed in each specimen. Results: A total of 73 pancreatic cancers were aspirated (Pancreas head 25, body-tail 48). Tissue acquisition rate was 98% (72/73) and the accuracy in EUS-FNA was 93% (67/72). ERCP tissue sampling was performed on 54 patients (head 27, body-tail 27; collection of pure pancreatic/bile juice 35/7, pancreatic/bile duct brushing 10/11, pancreatic/bile duct biopsy 16/12). The accuracy in ERCP tissue sampling was 61% (33/54). In the body-tail, EUS-FNA had greater accuracy than ERCP tissue sampling (96% vs. 44%, p ! 0.001), despite no significant difference between EUS-FNA and ERCP tissue sampling in the head (88% vs. 78%, p Z 0.34). No complications relating to EUS-FNA and ERCP were observed. Conclusion: EUS-FNA is more accurate than ERCP tissue sampling for the pathological diagnosis of pancreatic cancer, especially in the body-tail of the pancreas.
Depth diagnosis of early gastric carcinoma using EUS Takafumi Hyodo Background: Tumor depth diagnosis of early gastric carcinoma is necessary for appropriate choice of its treatment: Surgical operation or endoscopic resection. Endoscopic ultrasonography (EUS) is the most useful modality for this tumor depth diagnosis although narrow banding method (NBI) has enabled us precisely to determine the horizontal extension of the carcinoma. The aim of this study is to
S258 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
clarify the ultrasonographical and histological factors to contribute to differentiate mucosal carcinoma from submucosal carcinoma. Patients and Methods: Between 2005 and 2007, 168 patients agreed to undergo EUS before its treatment. Conventional echoendoscope (UM240, Olympus) and/or miniprobe (20MHz, Olympus) were used. Using EUS, we evaluated the ultrasonographical factors (the presence of submucosal changes, the disappearance of mucosal muscular layer [mm], mucosal thickness, submucosal focal expansion) and histological factors (fibrosis [F], lymphoid follicle [LF], dilated vessel [V], aberrant gland [AG], granulation feature [G]) in all these patients. The differential criteria between mucosal carcinoma and submucosal carcinoma included the presence of submucosal change and submucosal focal expansion. Results: The overall accuracy rate for depth diagnosis was 143/168 (85%). The ultrasonographical factor of submucosal focal expansion is the most reliable marker for the differentiation between mucosal and submucosal lesions. Two histological factors of V and AG in the submucosal layer significantly contributed to misjudgment of the depth diagnosis: The decrease of accuracy rates were respectively 125/141(89%) to 18/27(67%) and 135/156(87%) to 8/12(67%). Conclusion: To carry out the precise depth diagnosis for early gastric carcinoma, we first have to detect the presence of the submucosal change: cancer invasion or original histological structure (F, LF, V, and AG), and second evaluate submucosal focal expansion possibly caused by submucosal invasion of carcinoma.
Door knocking method: a useful new technique for obtaining adequate sample in EUS-FNA Tadayuki Takagi Background: Although EUS-FNA is less invasive means of obtaining cytological and histopathological specimens, several complications have been reported such as hemorrhage, infection, and tumor seeding in a few cases. Therefore, number of puncture is desirable as few as possible. The average puncture time was 2.51 times for 229 cases of pancreatic cancer in our hospital from 1997 to 2006. Overall rate of tissue sampling was 97.8%, and 4 complications (hematoma 2, hemorrhage 1, portal vein thrombosis 1). The aim of this study was to evaluate whether our new technique, so called ‘‘Door Knocking Method’’ may be useful for obtaining adequate samples with less number of puncture than usual or not. Patients and Methods: Ten patients who underwent EUS-FNA for pancreatic cancer were enrolled in 2007. EUS-FNA was performed using 22G needle by experienced endoscopist (TT, KH, NM, KY). The puncture for EUS-FNA was twice at random by conventional method and ‘‘Door Knocking Method’’ in each case. ‘‘Door Knocking Method’’ is the technique which makes the big knocking sound between the slider and the stopper when EUS-FNA is performed. That is, we advance the needle in the mass as fast as possible. The efficacy of this new technique to obtain enough specimens was evaluated in comparison with the conventional method. Results: Patient’s characteristics were as follows; location: 2 in pancreas head and 8 in body, tumor size: TS1 (less2cm) 1, TS2 6, and TS3 (above4cm) 3, puncture route: 5, 2, and 3 via stomach, bulb, and 2nd portion, respectively. The overall diagnostic accuracy (sensitivity) for malignancy was 100% and no complication occurred in ten cases. The accuracy rate of each puncture method were 70% and 90%, by conventional and new method, respectively. Odds ratio of puncture method was 3.9, respectively. Conclusion: Difference of 20% caused by puncture method was important in clinical practice. Because, ‘‘Door Knocking Method’’ may have a potential not only to improve a diagnostic ability, but also to reduce the number of puncture and complication of EUS-FNA, although further study will be needed.
Usefulness of endoscopic ultrasonography for preoperative staging of tumors of the ampulla of Vater Yukiko Takayama Background: It is difficult to evaluate local progression of tumors of the ampulla of Vater, because of the anatomical complexity and smallness of the ampulla. Although diagnosis of tumors of the ampulla by endoscopic ultrasonography (EUS) has been reported, local progression is difficult to diagnose, especially in patients with small tumors and without using an antispastic agent. We tried using the soft balloon cover of the transvaginal ultrasonography probe to perform EUS in such patients, because it deforms the ampulla less than the EUS balloon, and distend the duodenum adequately without an antispastic agent and with little water. Objective: To evaluate the usefulness of EUS for preoperative staging of tumors of the ampulla and the usefulness of EUS with a soft baloon for small tumors without an antispastic agent. Patients and Methods: 58 patients with a tumor of the ampulla were preoperatively examined by EUS over 20 years. 1) The preoperative diagnose of local progression by EUS, duodenal invasion (Du), and pancreatic invasion (Panc) in all patients, and UICC T classifications in the carcinoma patients were compared with the resected specimens. 2) The preoperative diagnose of Du and Panc and T classifications by EUS were compared with the histological findings in a group with tumors O 20 mm with an antispastic agent (GroupA), and a group with tumors ! 20 mm without an antispastic agent (Group B). 3) The preoperative diagnose of Du and Panc and T classifications by EUS with the soft baloon in Group A and Group B were compared with the histological findings.
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