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Is Hood-Assisted Colonoscopy More Effective Than Narrow Band Imaging for Colorectal Adenoma Detection?
Abstracts
associated with infiltration of lymphocytes and plasma cells were observed in the all 26 cases, but no atypical cells were recognized in any cases. These histopathological findings were compatible with AIP, and IgG4 positive plasma cells were also observed in 20 of 26 cases with IgG4 immunostaining. Conclusion: EUS-FNA with a 19-gauge needle and histopathological examination of the obtained material were useful to confirm the diagnosis of AIP.
925 EUS FNA of Distant Extra-Vascular Migratory Metastasis (EVMM) and Tumor Thrombosis Michael J. Levy, Ferga C. Gleeson, Jonathan E. Clain, Amy C. Clayton, Michael Henry, Michael L. Kendrick, Michael B. Farnell, Randall K. Pearson, Bret T. Petersen, Elizabeth Rajan, Santhi Swaroop Vege, Naoki Takahashi, Mark D. Topazian, Kenneth K. Wang, Maurits J. Wiersema, Suresh T. Chari Background: Vascular invasion impacts cancer staging, prognosis, and therapy. Malignant infiltration usually results from direct and gross extension from a primary tumor and is readily identified by CT. Cancers may also migrate to remote sites along vascular channels, a process termed angiotropism or EVMM. Sometimes this pattern of spread can be seen with CT. Surgical and autopsy studies also demonstrate microscopic or diminutive (1-3 mm thick) spread not seen with CT. Additionally, a tumor thrombus may only be recognized at surgery or autopsy. We report the EUS FNA diagnosis of malignant perivascular cuffing and tumor thrombosis occurring distant from a primary tumor, including microinvasion with negative helical CT. Aims: To examine the capability and safety of EUS FNA for diagnosing distant perivascular tumor infiltration and tumor thrombus in CT positive and negative (i.e. microinvasion) patients. Methods: Using a prospectively maintained EUS database, we identified all examinations from 09/04 to 11/08 in which FNA was performed of a vascular wall or intravascular thrombus. We abstracted and analyzed date regarding demographic, radiology and EUS features, cytology results, and follow up data. Results: EUS FNA was performed from 31 vascular sites [vascular wall (nZ27), intravascular thrombus (nZ4)] during 29 exams in 27 patients [15 male, age 5511 years]. Cancer was diagnosed in 24/27 (89%) patients of whom 20 had pancreatic cancer. For diagnosis of vascular involvement remote from cancer (EVMM), a median of 3 FNAs (range 2-9) was obtained from wall of the celiac artery (nZ12), SMA (nZ6), hepatic artery (nZ5), splenic artery (nZ2), SMV (nZ1), aorta (nZ1); and intravascular FNA of portal vein (nZ4). FNA cytology was positive (nZ17) or suspicious (nZ2) among cancer patients. EUS FNA detected and confirmed microinvasion in 3 patients with negative helical CT. CT and EUS identified indeterminate peri- and intravascular findings in 3 patients ultimately diagnosed with benign disorders after a median follow-up of 3 (0.4-7) months. EUS FNA was negative in each of these patients. Conclusion: CT and EUS can identify peri- and intravascular tumor extension remote from the primary tumor and not resulting from gross infiltration. EUS can detect microinvasion (1-3mm) not seen on helical CT. Further study is needed to determine the prevalence, to establish the safety and accuracy of EUS FNA, and impact on prognosis, clinical care, and outcomes.
926 Ratio of Pancreatic Duct Caliber to Width of Pancreatic Gland By Endosonography Is Predictive of Pancreatic Cancer Mohamad A. Eloubeidi, Ashutosh Tamhane, Mahboob A. Khan, Leticia P. Luz, C. Mel Wilcox Background: While dilation of the pancreatic duct could be an important sign of pancreatic disease, its presence along with pancreatic gland atrophy might be a better indicator of the presence of pancreatic cancer. We hypothesized that the ratio of pancreatic duct (PD) diameter/to pancreatic gland (PG) (R0.4) as measured by EUS is predictive of pancreatic cancer. Methods: All patients presenting for EUS for a pancreatico-biliary indication were prospectively enrolled in this IRB-approved investigation. The pancreas evaluation was performed by single experienced endosonographer with either state of the art mechanical radial echoendoscope or electronic radial echoendoscope. The pancreas was examined for the presence of well published and validated features of chronic pancreatitis. The pancreatic duct (PD) diameter and the pancreatic gland (PG) diameter were measured at the level of the splenic/portal vein confluence (conventionally known as stage one) in all patients. When a solid pancreatic mass was identified, EUS-guided FNA was performed with a curvilinear echoendoscope in the presence of a cytologist. Patients were classified into four categories 1) Normal 2) Non-calcific chronic pancreatitis (NCCP) (O 4 features) 3) Calcific pancreatitis (CP) 4) Cancer. Results: Ninety one patients (mean age 60 years, 59% female, 69% Caucasian) were enrolled over 4 months. Final classification of patients was as follows: Pancreatic cancer (nZ10), Calcific pancreatitis (nZ7), 3) Normal/NCCP (nZ74). The median pancreatic duct diameter (7.6, 5.0. and 2.0 mm respectively; p!0.001) and the median pancreatic parenchyma diameter were significantly different between the three groups, (14, 22, and 16.5 mm respectively; PZ0.008). Similarly, the median ratio of PD/PG was different among the three groups (0.55, 0.25, and 0.12 respectively; P!0.001). Patients with pancreatic cancer were more
AB130 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
likely to have a PD/PG ratio of R0.4 compared to patients with CP, and Normal/ NCCP groups (80%, 14%, 0% respectively P!0.001). When subjects were classified as Cancer vs. No Cancer, the positive predictive value of ratio of PD/PG R0.4 was 89% (95% CI: 63 - 98), negative predictive value was 98% (95% CI: 95 - 99%) with a kappa of 82% (95% CI: 55 - 92) and overall accuracy of 97% (95% CI: 92- 99%). Conclusions: Ratio of pancreatic duct caliber to width of pancreatic gland by endosonography is predictive of pancreatic cancer. This sign should be used routinely by endosonographers as an aid to improve EUS diagnostic capability of pancreatic cancer when evaluating patients with suspected pancreatic disorders.
927 Is Hood-Assisted Colonoscopy More Effective Than Narrow Band Imaging for Colorectal Adenoma Detection? Akira Horiuchi, Yoshiko Nakayama Background and Aims: We previously reported that colonoscopy with a transparent retractable extension (TRE) device improved the adenoma detection rate without affecting intubation and withdrawal times (Am J Gastroenterol 103: 341-345, 2008). Other studies of non-retractable hood-assisted colonoscopy also reported improved yield of colorectal polyp detection. We compared the effects of TRE device and narrow band imaging (NBI) on colorectal adenoma detection. Methods: One hundred and seven patients with colonic adenomas found at the colonoscopy without using TRE or NBI were randomized to a second colonoscopy using either TRE or NBI. Adenoma removal was performed at the second colonoscopy. The principal outcome parameters were the number, size, shape and location of adenomas detected. Results: 107 patients (TRE group; NZ54, or NBI group, NZ53) were included in the study. The patients’ demographic characteristics, the indications for colonoscopy, the intubation time, and intubation rate of the terminal ileum were similar between the two techniques. There was a significant difference with regard to the mean procedure time between those receiving colonoscopy using with TRE or NBI (25 min vs. 21 min, PZ0.04) largely because more adenomas in the TRE group were found and were removed compared with NBI group. There was a 31% increase in adenomas detection with TRE compared to the initial procedure (P!0.0001). There was a slight (5%) but not significant increase using NBI. Additional adenomas were primarily found in the in ascending colon and rectum. Of interest, using NBI 3 adenomas seen at the first colonoscopy without TRE or NBI were missed. No complications occurred. Conclusions: Colonoscopy with TRE significantly improved the adenoma detection rate compared to repeat colonoscopy with NBI.
928 In Vivo Molecular Imaging of VEGF in Gastrointestinal Cancer Using Confocal Laser Endomicroscopy Sebastian Foersch, Ralf Kiesslich, Maximilian Waldner, Peter R. Galle, Markus F. Neurath, Martin Goetz Introduction: Vascular endothelial growth factor (VEGF) is a promising therapeutic target in colorectal cancer (CRC). However, in vivo visualization of VEGF in patients with CRC could not be achieved so far using standard endoscopic techniques. Confocal laser endomicroscopy (CLE) is a novel imaging technique for GI endoscopy in humans (EC 3830FK; Pentax, Japan) and animal research (FIVE1; Optiscan, Australia) providing in vivo microscopy at subcellular resolution during ongoing examination. Aim of the current study was to evaluate CLE for in vivo molecular imaging of VEGF in different rodent models of human CRC. Methods: Tumors were visualized in APCmin mice (nZ18) and nude mouse xenograft models after inguinal injection of human CRC cell lines (nZ6). VEGF-A was targeted with alexa fluor 488-labeled antibodies injected 24h before CLE. In vivo CLE was performed on 5-7 tumor sites with the rigid confocal system (FIVE1) that provides a high resolution of 0.7 mm and an adjustable imaging depth of 0-250 mm. 50-400 images were digitally recorded per mouse. In vivo tumor morphology was established with topical acriflavine staining. Biopsies were targeted to the areas examined by CLE to obtain histology, immunohistochemistry, and fluorescence microscopy. Healthy intestinal mucosa of the same mice served as negative controls. Results: Specific fluorescent VEGF staining was observed in 93% of tumors in both models, but not in healthy tissue. In APCmin tumors, decreased signal intensity was visualized in healthy mucosa in close proximity to the tumor whereas distant areas were VEGF-negative. This correlated well with histological signs of increasing malignant transformation. Even the distribution of VEGF on the tumor cells could be visualized due to the subcellular resolution of the confocal system. The correlation of CLE images and ex vivo microscopy was substantial. Conclusion: In vivo molecular imaging with specific targeting of VEGF is possible in murine tumors and human xenografts using CLE. Increased VEGF staining around intestinal neoplasia indicated tumor induced neoangiogenesis, which was present even in macroscopically normal mucosa. CLE can be performed with similar optics and scanners in human colonoscopy. Thus, in vivo molecular imaging may be easily transferable to molecular stratification of patients with CRC during ongoing colonoscopy.
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associated with infiltration of lymphocytes and plasma cells were observed in the all 26 cases, but no atypical cells were recognized in any cases. These histopathological findings were compatible with AIP, and IgG4 positive plasma cells were also observed in 20 of 26 cases with IgG4 immunostaining. Conclusion: EUS-FNA with a 19-gauge needle and histopathological examination of the obtained material were useful to confirm the diagnosis of AIP.
925 EUS FNA of Distant Extra-Vascular Migratory Metastasis (EVMM) and Tumor Thrombosis Michael J. Levy, Ferga C. Gleeson, Jonathan E. Clain, Amy C. Clayton, Michael Henry, Michael L. Kendrick, Michael B. Farnell, Randall K. Pearson, Bret T. Petersen, Elizabeth Rajan, Santhi Swaroop Vege, Naoki Takahashi, Mark D. Topazian, Kenneth K. Wang, Maurits J. Wiersema, Suresh T. Chari Background: Vascular invasion impacts cancer staging, prognosis, and therapy. Malignant infiltration usually results from direct and gross extension from a primary tumor and is readily identified by CT. Cancers may also migrate to remote sites along vascular channels, a process termed angiotropism or EVMM. Sometimes this pattern of spread can be seen with CT. Surgical and autopsy studies also demonstrate microscopic or diminutive (1-3 mm thick) spread not seen with CT. Additionally, a tumor thrombus may only be recognized at surgery or autopsy. We report the EUS FNA diagnosis of malignant perivascular cuffing and tumor thrombosis occurring distant from a primary tumor, including microinvasion with negative helical CT. Aims: To examine the capability and safety of EUS FNA for diagnosing distant perivascular tumor infiltration and tumor thrombus in CT positive and negative (i.e. microinvasion) patients. Methods: Using a prospectively maintained EUS database, we identified all examinations from 09/04 to 11/08 in which FNA was performed of a vascular wall or intravascular thrombus. We abstracted and analyzed date regarding demographic, radiology and EUS features, cytology results, and follow up data. Results: EUS FNA was performed from 31 vascular sites [vascular wall (nZ27), intravascular thrombus (nZ4)] during 29 exams in 27 patients [15 male, age 5511 years]. Cancer was diagnosed in 24/27 (89%) patients of whom 20 had pancreatic cancer. For diagnosis of vascular involvement remote from cancer (EVMM), a median of 3 FNAs (range 2-9) was obtained from wall of the celiac artery (nZ12), SMA (nZ6), hepatic artery (nZ5), splenic artery (nZ2), SMV (nZ1), aorta (nZ1); and intravascular FNA of portal vein (nZ4). FNA cytology was positive (nZ17) or suspicious (nZ2) among cancer patients. EUS FNA detected and confirmed microinvasion in 3 patients with negative helical CT. CT and EUS identified indeterminate peri- and intravascular findings in 3 patients ultimately diagnosed with benign disorders after a median follow-up of 3 (0.4-7) months. EUS FNA was negative in each of these patients. Conclusion: CT and EUS can identify peri- and intravascular tumor extension remote from the primary tumor and not resulting from gross infiltration. EUS can detect microinvasion (1-3mm) not seen on helical CT. Further study is needed to determine the prevalence, to establish the safety and accuracy of EUS FNA, and impact on prognosis, clinical care, and outcomes.
926 Ratio of Pancreatic Duct Caliber to Width of Pancreatic Gland By Endosonography Is Predictive of Pancreatic Cancer Mohamad A. Eloubeidi, Ashutosh Tamhane, Mahboob A. Khan, Leticia P. Luz, C. Mel Wilcox Background: While dilation of the pancreatic duct could be an important sign of pancreatic disease, its presence along with pancreatic gland atrophy might be a better indicator of the presence of pancreatic cancer. We hypothesized that the ratio of pancreatic duct (PD) diameter/to pancreatic gland (PG) (R0.4) as measured by EUS is predictive of pancreatic cancer. Methods: All patients presenting for EUS for a pancreatico-biliary indication were prospectively enrolled in this IRB-approved investigation. The pancreas evaluation was performed by single experienced endosonographer with either state of the art mechanical radial echoendoscope or electronic radial echoendoscope. The pancreas was examined for the presence of well published and validated features of chronic pancreatitis. The pancreatic duct (PD) diameter and the pancreatic gland (PG) diameter were measured at the level of the splenic/portal vein confluence (conventionally known as stage one) in all patients. When a solid pancreatic mass was identified, EUS-guided FNA was performed with a curvilinear echoendoscope in the presence of a cytologist. Patients were classified into four categories 1) Normal 2) Non-calcific chronic pancreatitis (NCCP) (O 4 features) 3) Calcific pancreatitis (CP) 4) Cancer. Results: Ninety one patients (mean age 60 years, 59% female, 69% Caucasian) were enrolled over 4 months. Final classification of patients was as follows: Pancreatic cancer (nZ10), Calcific pancreatitis (nZ7), 3) Normal/NCCP (nZ74). The median pancreatic duct diameter (7.6, 5.0. and 2.0 mm respectively; p!0.001) and the median pancreatic parenchyma diameter were significantly different between the three groups, (14, 22, and 16.5 mm respectively; PZ0.008). Similarly, the median ratio of PD/PG was different among the three groups (0.55, 0.25, and 0.12 respectively; P!0.001). Patients with pancreatic cancer were more
AB130 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
likely to have a PD/PG ratio of R0.4 compared to patients with CP, and Normal/ NCCP groups (80%, 14%, 0% respectively P!0.001). When subjects were classified as Cancer vs. No Cancer, the positive predictive value of ratio of PD/PG R0.4 was 89% (95% CI: 63 - 98), negative predictive value was 98% (95% CI: 95 - 99%) with a kappa of 82% (95% CI: 55 - 92) and overall accuracy of 97% (95% CI: 92- 99%). Conclusions: Ratio of pancreatic duct caliber to width of pancreatic gland by endosonography is predictive of pancreatic cancer. This sign should be used routinely by endosonographers as an aid to improve EUS diagnostic capability of pancreatic cancer when evaluating patients with suspected pancreatic disorders.
927 Is Hood-Assisted Colonoscopy More Effective Than Narrow Band Imaging for Colorectal Adenoma Detection? Akira Horiuchi, Yoshiko Nakayama Background and Aims: We previously reported that colonoscopy with a transparent retractable extension (TRE) device improved the adenoma detection rate without affecting intubation and withdrawal times (Am J Gastroenterol 103: 341-345, 2008). Other studies of non-retractable hood-assisted colonoscopy also reported improved yield of colorectal polyp detection. We compared the effects of TRE device and narrow band imaging (NBI) on colorectal adenoma detection. Methods: One hundred and seven patients with colonic adenomas found at the colonoscopy without using TRE or NBI were randomized to a second colonoscopy using either TRE or NBI. Adenoma removal was performed at the second colonoscopy. The principal outcome parameters were the number, size, shape and location of adenomas detected. Results: 107 patients (TRE group; NZ54, or NBI group, NZ53) were included in the study. The patients’ demographic characteristics, the indications for colonoscopy, the intubation time, and intubation rate of the terminal ileum were similar between the two techniques. There was a significant difference with regard to the mean procedure time between those receiving colonoscopy using with TRE or NBI (25 min vs. 21 min, PZ0.04) largely because more adenomas in the TRE group were found and were removed compared with NBI group. There was a 31% increase in adenomas detection with TRE compared to the initial procedure (P!0.0001). There was a slight (5%) but not significant increase using NBI. Additional adenomas were primarily found in the in ascending colon and rectum. Of interest, using NBI 3 adenomas seen at the first colonoscopy without TRE or NBI were missed. No complications occurred. Conclusions: Colonoscopy with TRE significantly improved the adenoma detection rate compared to repeat colonoscopy with NBI.
928 In Vivo Molecular Imaging of VEGF in Gastrointestinal Cancer Using Confocal Laser Endomicroscopy Sebastian Foersch, Ralf Kiesslich, Maximilian Waldner, Peter R. Galle, Markus F. Neurath, Martin Goetz Introduction: Vascular endothelial growth factor (VEGF) is a promising therapeutic target in colorectal cancer (CRC). However, in vivo visualization of VEGF in patients with CRC could not be achieved so far using standard endoscopic techniques. Confocal laser endomicroscopy (CLE) is a novel imaging technique for GI endoscopy in humans (EC 3830FK; Pentax, Japan) and animal research (FIVE1; Optiscan, Australia) providing in vivo microscopy at subcellular resolution during ongoing examination. Aim of the current study was to evaluate CLE for in vivo molecular imaging of VEGF in different rodent models of human CRC. Methods: Tumors were visualized in APCmin mice (nZ18) and nude mouse xenograft models after inguinal injection of human CRC cell lines (nZ6). VEGF-A was targeted with alexa fluor 488-labeled antibodies injected 24h before CLE. In vivo CLE was performed on 5-7 tumor sites with the rigid confocal system (FIVE1) that provides a high resolution of 0.7 mm and an adjustable imaging depth of 0-250 mm. 50-400 images were digitally recorded per mouse. In vivo tumor morphology was established with topical acriflavine staining. Biopsies were targeted to the areas examined by CLE to obtain histology, immunohistochemistry, and fluorescence microscopy. Healthy intestinal mucosa of the same mice served as negative controls. Results: Specific fluorescent VEGF staining was observed in 93% of tumors in both models, but not in healthy tissue. In APCmin tumors, decreased signal intensity was visualized in healthy mucosa in close proximity to the tumor whereas distant areas were VEGF-negative. This correlated well with histological signs of increasing malignant transformation. Even the distribution of VEGF on the tumor cells could be visualized due to the subcellular resolution of the confocal system. The correlation of CLE images and ex vivo microscopy was substantial. Conclusion: In vivo molecular imaging with specific targeting of VEGF is possible in murine tumors and human xenografts using CLE. Increased VEGF staining around intestinal neoplasia indicated tumor induced neoangiogenesis, which was present even in macroscopically normal mucosa. CLE can be performed with similar optics and scanners in human colonoscopy. Thus, in vivo molecular imaging may be easily transferable to molecular stratification of patients with CRC during ongoing colonoscopy.
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