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Role of endoscopic Ultrasound in the management of submucosal tumors of the upper gastrointestinal tract: Results of a comprehensive questionnaire
ENDOSCOPIC ULTRASOUND ~561
563
CORRELATION OF MAGNETIC RESONANCE IMAGING AND ENDOSCOPIC ULTRASOUND IN THE DIAGNOSIS OF CHRONIC PANCREATITIS. S Tenner. EC Noordhoek, PA Banks, G Sica, D Lichtenstein, D Can'-Locke, J Van Dam. Center for Pancreatic Disease, Brigham and Women's Hospital. Harvard Medical School, Boston, MA, 02115.
EUS IN DIAGNOSING SMALL PANCREATIC INSULINOMAS UNDETECTABLE WITH OTHER IMAGING TECHNIQUES: A MULTICENTRIC STUDY T.L. Tio. N. Haddad, S. Lo, E. Ipp. Divisions of Gastroenterology, Georgetown University Wash. D.C., Yale University, New Haven, CT., Harbor UCLA, Los Angeles Introduction:The diagnosis of insulinoma in the pancreas remains a challenge particularly in pts. with negative imaging study.EUS has been reported to be the most accurate diagnostic method in localizing and assessing insulinoma.The purpose of the study was to assess the results of EUS in assessing insulinoma of the pancreas collected by different centers. Materials and Methods: Between 1988 and 1995 EUS was performed in 5 pts. with clinical symptoms suspicious of insulinoma. US,CT, angiegraphy and somatestinoma scan were performed in all patients.Only small tumors with a diameter less than 2cm were included.Surgery was performed and the results of preoperative imaging techniques were compared with that of the histology of resected specimen.There were 3 men and 2 women with an age range between 47 and 65 yrs. Results: In patient 1 the size of the tumor was correctly predicted by EUS with a diameter of 10ram. Angiography found abnormality, where as US and CT suggested the presence of abnormality but failed te define the size ef the tumor.The histology ascertained the diagnosis of insulinoma. In patient 2,3, and 4 enly EUS could imaged and correctly predict the size ef the tumor.Follew-up ranging from l0 months to 4 yrs. No recurrent tamer was fuund.In patient #5 EUS imaged a ellipsoid tumor ef 20ram, which, was net seen by ether imaging techniques.The histology of resected specimen confirmed the EUS finding. Conclusions: The study shows that EUS diagnosed small insulinomas in patients with clinical symptems of hypoglycemia and negative imaging studies.This is clinically important particularly fur the surgeon in assisting to localize the tumor and to design the strategy of treatment such as tumeranucleation vs extended Whipple resection. In the era of laparscopic surgery EUS my be helpful in selecting the appropriate patient fur minimally invasive therapy.This is of course essential particularly in patients with negative test ef currently available imaging techniques.With the availability ef EUS guided fain needle aspiration cytology EUS will beceme an important tissue diagnosis before surgery.
We have previously shown that endoscopic ultrasound (EUS) is superior to computed tomography (CT) and safer than endoscopic retrograde cholangiopancreatography (ERCP) in ascertaining the diagnosis of chronic pancreatitis (Am J Gastroenterology 1995,90:249). Magnetic resonance imaging (MRI) is thought to be superior to other forms of transabdominal imaging for the evaluation of diseases of the pancreas. The aim of this study was to compare MRI and EUS in the diagnosis of chronic pancreatitis. Eleven patients with chronic pancreatitis, defined by characteristic symptoms and an abnormal ERCP, underwent MRI and EUS. A single radiologist reviewed all MRI scans and a single gastroenterologist performed the endosonography. Endoscopic ultrasound was performed using an Olympus EUM-20 echoendoscope. MRI was performed on a 1.5 GE Signa with gadolinium. The radiologist and endosonographer were unaware of the results of the other study until the completion of reports. EUS and MRI examinations were performed within 10 weeks. Changes in the pancreatic parenchyma and/or pancreatic ducts consistent with chronic pancreatitis were appreciated in 10/11 patients undergoing MRI and 8/11 patients undergoing EUS. Correlation between EUS and MRI was high, kappa p = 0.82. We conclude that the correlation between EUS and MRI is high when the ERCP is abnormal. Although MRI and EUS may have equal sensitivity, the recent addition of fine-needle aspiration to EUS may lead to increased specificity, and increased accuracy when compared to MRI.
562
~564
ENDOSCOPIC ULTRASONOGRAPHY [EUS) IN STAGING OF EARLY ESOPHAGEAL CANCER {EEC| IN LINXJAN. CHflMA: PRELIMINARY
ROLE OF ENDOSCOPIC ULTRASOUND IN THE MANAGEMENT OF SUBMUCOSAL TUMORS OF THE UPPER GASTROINTESTINAL TRACT: RESULTS OF A COMPREHENSIVE QUESTIONNAIRE. ~J Van Dam, I Raijman; JE Geenen, MF Catalano,. Harvard Medical School, Boston, MA.; Univ. of Wisconsin, Milwaukee, WI.; Univ. of Texas, Houston TX. There are no universally accepted guidelines for the management of submucosal tumors (SMT) of the upper GI tract. The introduction of endoscopic ultrasound (EUS) has provided unprecedented information regarding the etiology of submucosal tumors. The purpose of this study was to query practicing gastroenterologists (GI MDs) regarding the role of endoscopic ultrasound in their current management of SMTs. METHODS: A detailed and comprehensive questionnaire was presented to GI MDs attending postgraduate GI courses during 1995. Respondents were asked to identify their type of practice, number of SMTs encountered per year, the role of endoscopic ultrasound in the evaluation of patients with SMTs, and the ultimate management of their patients. Questionnaires were completed anonymously. RESULTS: The 246 GI MDs who responded to the questionnaire identified themselves as private practitioners (n=159), university-based (n=39), university-affiliated (n=36), VAMCbased (n=9) or HMO-based (n=3). Many GI MDs (n=87) see more than 10 SMTs per year. Most (n=150) routinely refer their patients for EUS although most (n=159) do not have access to EUS in their primary institution. Almost all respondents (n=219) perform EGD with biopsy but do not perform endoscopic resection (n=234). Many (n=186) refer their patients for surgical consultation. Endoscopic surveillance is practiced by almost half of GI MDs (n=141) for leiomyomas, but only one third (n=60) for lipomas as identified by EUS. Of the GI MDs who have access to EUS in their own institution, most (76/84) have found it helpful in managing their patients with SMTs. Most (62/84) acknowledge that EUS has changed their management of SMTs and most (74/86) believe EUS is cost effective for managing patients with SMTs. CONCLUSIONS: Physician attitudes towards EUS in general practice are extremely positive. Most physicians (completing our questionnaire) who do not have access to EUS, routinely refer patients for EUS when SMTs are discovered on EGD. GI MDs acknowledge that EUS has changed their management of patients with SMTs and believe that EUS is cost effective.
RESULTS..TL Tie, SM DawSey, GQ Wang, DE Fleischer, MJ Roth, YX Xie, JA Kidwetl. H Wang. Georgetown University Medical Center. Washington, DC: National Cancer Institute, Bet;hes~la. MD; Cancer Hospital, CAMS, Bailing, China. Background: ELlS is the most accurate preoperative technique for staging the depth of invasion of advanced (T2-T4) esophageal cancer. EUS experience with staging EEC (T1L however, is limited. The p~posa of this study was to assess the accuracy end limitations of conventional EUS in staging EEC in the high-risk population of linxiao, China. Me4Jltocls: EndoscoPY, ctvomoendoscopy (using Lugel's iedineL and EUS were carried out on 40 consciously sedated patients with biopsy-prevan severe squamous dysplssia or squamous EC. using an Olympus UM20 echoendoscope with switchable 7.SMHz and 12MHz ultrasound ~equencies, The celiac: nodes. psrieardial nodes, and the entire esophagus were sYstemal:ically examined and videotaped, and step-frame photographs were taken every 1 em from the EGJ to the UES. 10 of the 40 pal:ients underwent surgical resactJcm 1-8 weeks a~er EUS. The res~.=ctad sgecimens were Cut in 2,0• blocks and totally embedded. ReSlJts:
EUS Histology
m
sn~
mp
Tis
1
1
Tlm
1
a
3
1
Tlsrn
I
1
T2
I
investve, a( acertt to the rap. CmteJuslons: In this preliminar~ study, co~nventional EUS. using 7.SMIHz and 12MHz ultrasound frequencies, showed limited accuracy for estimating the depth of invasion of EEC. Higher frequency EU$ insUum=ents and tt~e use of catheter echoprebes during endoscopy may be ~equir~ for accurate staging ef those ~arly lesions.
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY
431
563
CORRELATION OF MAGNETIC RESONANCE IMAGING AND ENDOSCOPIC ULTRASOUND IN THE DIAGNOSIS OF CHRONIC PANCREATITIS. S Tenner. EC Noordhoek, PA Banks, G Sica, D Lichtenstein, D Can'-Locke, J Van Dam. Center for Pancreatic Disease, Brigham and Women's Hospital. Harvard Medical School, Boston, MA, 02115.
EUS IN DIAGNOSING SMALL PANCREATIC INSULINOMAS UNDETECTABLE WITH OTHER IMAGING TECHNIQUES: A MULTICENTRIC STUDY T.L. Tio. N. Haddad, S. Lo, E. Ipp. Divisions of Gastroenterology, Georgetown University Wash. D.C., Yale University, New Haven, CT., Harbor UCLA, Los Angeles Introduction:The diagnosis of insulinoma in the pancreas remains a challenge particularly in pts. with negative imaging study.EUS has been reported to be the most accurate diagnostic method in localizing and assessing insulinoma.The purpose of the study was to assess the results of EUS in assessing insulinoma of the pancreas collected by different centers. Materials and Methods: Between 1988 and 1995 EUS was performed in 5 pts. with clinical symptoms suspicious of insulinoma. US,CT, angiegraphy and somatestinoma scan were performed in all patients.Only small tumors with a diameter less than 2cm were included.Surgery was performed and the results of preoperative imaging techniques were compared with that of the histology of resected specimen.There were 3 men and 2 women with an age range between 47 and 65 yrs. Results: In patient 1 the size of the tumor was correctly predicted by EUS with a diameter of 10ram. Angiography found abnormality, where as US and CT suggested the presence of abnormality but failed te define the size ef the tumor.The histology ascertained the diagnosis of insulinoma. In patient 2,3, and 4 enly EUS could imaged and correctly predict the size ef the tumor.Follew-up ranging from l0 months to 4 yrs. No recurrent tamer was fuund.In patient #5 EUS imaged a ellipsoid tumor ef 20ram, which, was net seen by ether imaging techniques.The histology of resected specimen confirmed the EUS finding. Conclusions: The study shows that EUS diagnosed small insulinomas in patients with clinical symptems of hypoglycemia and negative imaging studies.This is clinically important particularly fur the surgeon in assisting to localize the tumor and to design the strategy of treatment such as tumeranucleation vs extended Whipple resection. In the era of laparscopic surgery EUS my be helpful in selecting the appropriate patient fur minimally invasive therapy.This is of course essential particularly in patients with negative test ef currently available imaging techniques.With the availability ef EUS guided fain needle aspiration cytology EUS will beceme an important tissue diagnosis before surgery.
We have previously shown that endoscopic ultrasound (EUS) is superior to computed tomography (CT) and safer than endoscopic retrograde cholangiopancreatography (ERCP) in ascertaining the diagnosis of chronic pancreatitis (Am J Gastroenterology 1995,90:249). Magnetic resonance imaging (MRI) is thought to be superior to other forms of transabdominal imaging for the evaluation of diseases of the pancreas. The aim of this study was to compare MRI and EUS in the diagnosis of chronic pancreatitis. Eleven patients with chronic pancreatitis, defined by characteristic symptoms and an abnormal ERCP, underwent MRI and EUS. A single radiologist reviewed all MRI scans and a single gastroenterologist performed the endosonography. Endoscopic ultrasound was performed using an Olympus EUM-20 echoendoscope. MRI was performed on a 1.5 GE Signa with gadolinium. The radiologist and endosonographer were unaware of the results of the other study until the completion of reports. EUS and MRI examinations were performed within 10 weeks. Changes in the pancreatic parenchyma and/or pancreatic ducts consistent with chronic pancreatitis were appreciated in 10/11 patients undergoing MRI and 8/11 patients undergoing EUS. Correlation between EUS and MRI was high, kappa p = 0.82. We conclude that the correlation between EUS and MRI is high when the ERCP is abnormal. Although MRI and EUS may have equal sensitivity, the recent addition of fine-needle aspiration to EUS may lead to increased specificity, and increased accuracy when compared to MRI.
562
~564
ENDOSCOPIC ULTRASONOGRAPHY [EUS) IN STAGING OF EARLY ESOPHAGEAL CANCER {EEC| IN LINXJAN. CHflMA: PRELIMINARY
ROLE OF ENDOSCOPIC ULTRASOUND IN THE MANAGEMENT OF SUBMUCOSAL TUMORS OF THE UPPER GASTROINTESTINAL TRACT: RESULTS OF A COMPREHENSIVE QUESTIONNAIRE. ~J Van Dam, I Raijman; JE Geenen, MF Catalano,. Harvard Medical School, Boston, MA.; Univ. of Wisconsin, Milwaukee, WI.; Univ. of Texas, Houston TX. There are no universally accepted guidelines for the management of submucosal tumors (SMT) of the upper GI tract. The introduction of endoscopic ultrasound (EUS) has provided unprecedented information regarding the etiology of submucosal tumors. The purpose of this study was to query practicing gastroenterologists (GI MDs) regarding the role of endoscopic ultrasound in their current management of SMTs. METHODS: A detailed and comprehensive questionnaire was presented to GI MDs attending postgraduate GI courses during 1995. Respondents were asked to identify their type of practice, number of SMTs encountered per year, the role of endoscopic ultrasound in the evaluation of patients with SMTs, and the ultimate management of their patients. Questionnaires were completed anonymously. RESULTS: The 246 GI MDs who responded to the questionnaire identified themselves as private practitioners (n=159), university-based (n=39), university-affiliated (n=36), VAMCbased (n=9) or HMO-based (n=3). Many GI MDs (n=87) see more than 10 SMTs per year. Most (n=150) routinely refer their patients for EUS although most (n=159) do not have access to EUS in their primary institution. Almost all respondents (n=219) perform EGD with biopsy but do not perform endoscopic resection (n=234). Many (n=186) refer their patients for surgical consultation. Endoscopic surveillance is practiced by almost half of GI MDs (n=141) for leiomyomas, but only one third (n=60) for lipomas as identified by EUS. Of the GI MDs who have access to EUS in their own institution, most (76/84) have found it helpful in managing their patients with SMTs. Most (62/84) acknowledge that EUS has changed their management of SMTs and most (74/86) believe EUS is cost effective for managing patients with SMTs. CONCLUSIONS: Physician attitudes towards EUS in general practice are extremely positive. Most physicians (completing our questionnaire) who do not have access to EUS, routinely refer patients for EUS when SMTs are discovered on EGD. GI MDs acknowledge that EUS has changed their management of patients with SMTs and believe that EUS is cost effective.
RESULTS..TL Tie, SM DawSey, GQ Wang, DE Fleischer, MJ Roth, YX Xie, JA Kidwetl. H Wang. Georgetown University Medical Center. Washington, DC: National Cancer Institute, Bet;hes~la. MD; Cancer Hospital, CAMS, Bailing, China. Background: ELlS is the most accurate preoperative technique for staging the depth of invasion of advanced (T2-T4) esophageal cancer. EUS experience with staging EEC (T1L however, is limited. The p~posa of this study was to assess the accuracy end limitations of conventional EUS in staging EEC in the high-risk population of linxiao, China. Me4Jltocls: EndoscoPY, ctvomoendoscopy (using Lugel's iedineL and EUS were carried out on 40 consciously sedated patients with biopsy-prevan severe squamous dysplssia or squamous EC. using an Olympus UM20 echoendoscope with switchable 7.SMHz and 12MHz ultrasound ~equencies, The celiac: nodes. psrieardial nodes, and the entire esophagus were sYstemal:ically examined and videotaped, and step-frame photographs were taken every 1 em from the EGJ to the UES. 10 of the 40 pal:ients underwent surgical resactJcm 1-8 weeks a~er EUS. The res~.=ctad sgecimens were Cut in 2,0• blocks and totally embedded. ReSlJts:
EUS Histology
m
sn~
mp
Tis
1
1
Tlm
1
a
3
1
Tlsrn
I
1
T2
I
investve, a( acertt to the rap. CmteJuslons: In this preliminar~ study, co~nventional EUS. using 7.SMIHz and 12MHz ultrasound frequencies, showed limited accuracy for estimating the depth of invasion of EEC. Higher frequency EU$ insUum=ents and tt~e use of catheter echoprebes during endoscopy may be ~equir~ for accurate staging ef those ~arly lesions.
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY
431