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Su1582 Endoscopic Ultrasound-Guided Fine Needle Biopsy (EUS-FNB) for the Histopathologic Diagnosis of Solid Liver Masses
Abstracts
drainage drastically improves symptoms of peripancreatic abscess due to pancreatic leak. EUS-guided drainage of the pancreatic duct temporally improves clinical symptoms of obstructive pancreatitis, which can be attempted before conducting reoperative surgery.
Su1581 Role of Endoscopic Ultrasound (EUS) Evaluating Patients With Adrenal Gland Enlargement or Mass Melissa Martinez Mateo*, Julia K. Leblanc, Mohammad a. AL-Haddad, Stuart Sherman, John Dewitt Gastroenterology, Indiana University School of Medicine, indianapolis, IN Introduction: Studies evaluating the role of EUS-FNA(fine needle aspiration) in adrenal lesions are limited to patients with lung cancer or other malignancy and, generally lack long-term follow-up of benign lesions, surgical correlation, and description of its clinical impact. This study aims to report the utility and clinical impact of EUS-FNA of adrenal masses at our institution over a 15 year period. Methods: In a retrospective single-center case series, we identified consecutive patients from 10/97 to 12/11 who had EUS-FNA of either adrenal gland. The following were retrieved from medical records: EUS indications, findings, pathology, complications and follow-up abdominal imaging (CT or MRI) or surgery. Benign EUS-FNA adrenal cytology (anything without definitive malignancy) was considered correct if follow-up imaging at ⬎ 4months showed the lesion increased ⱕ 1cm of the original size. Results: 94 patients (52% male, median age 66 years, range: 32-86), had EUS-FNA (median 3 passes; range 1-7) of the left (n⫽90) and/or right (n⫽5) adrenal without complications. The median maximal adrenal diameter was 2.4 cm (range 0.7-8). Procedure indications: cancer staging (n⫽26) or, suspected recurrence (n⫽5), pancreatic (n⫽20), mediastinal (n⫽10), adrenal (n⫽7), lung (n⫽7) mass or other (n⫽19). Previous CT showed adrenal gland enlargement or mass in 59%. Twenty-five (26%) biopsies were malignant: metastatic lung (n⫽ 10), esophageal (n⫽5), colon (n⫽2), pancreatic (n⫽2), or other cancers (n⫽6). Nine (10%) biopsies were non-diagnostic and follow up in these CT showed a stable lesion in 5 but, was unavailable in 4. Sixty (64%) were benign: aldosteronoma (n⫽1), pheochromocytoma (n⫽1), paraganglioma (n⫽1) and adenomas/benign adrenal tissue (n⫽57). Available follow-up in 36/60 (60%) benign lesions showed: stable size by imaging in 27, confirmation as benign in 5 by repeat EUS-FNA (n⫽1) or adrenalectomy (n⫽4), or cancer in 4 by later CT-guided adrenal biopsy (metastatic NSCLC in one, neuroendocrine cancer in one), enlargement of previous and new contralateral adrenal mass on repeat CT (NSCLC in one), or adrenalectomy (adrenocortical carcinoma in one). Follow-up was unavailable in 24/60 (40%) benign biopsies. EUS-FNA of either adrenal made initial the diagnosis of stage IV cancer in 17, cancer recurrence in 7, and ruled out metastasis in 10 patients with underlying malignancy and available follow-up. For patients with malignant or benign cytology and available follow-up (n⫽61), the sensitivity, specificity, PPV and NPV of adrenal EUS-FNA for malignancy was 86% (CI 68-95%), 97% (CI 83-100%), 96% (CI 79-100%) and 89% (CI 74-96%) respectively. Conclusion: Adrenal gland EUS-FNA is a safe, minimally invasive and sensitive technique with significant impact in the management of patients with adrenal gland mass or enlargement.
Su1582 Endoscopic Ultrasound-Guided Fine Needle Biopsy (EUS-FNB) for the Histopathologic Diagnosis of Solid Liver Masses Hyun Jong Choi*1, Jong Ho Moon1, Hee Kyung Kim2, Dong Choon Kim1, Yun Nah Lee1, Tae Hoon Lee1, Sang-Woo Cha1, Young Deok Cho1, Sang-Heum Park1, Sun-Joo Kim1 1 Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Republic of Korea; 2Department of Pathology, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Republic of Korea Background and Aims: Percutaneous liver biopsy remains the gold standard for histopathological evaluation of solid liver masses. However, percutaneous approach may be limited in some conditions. Obtaining histologic samples of liver masses is essential for the accurate pathologic evaluation and immunohistochemical studies. A recently developed EUS biopsy needle is expected to offer effective tissue core sampling. The aim of this study was to evaluate the clinical impact of EUS-guided fine needle biopsy (EUS-FNB) for solid liver masses. Patients and Methods: Total 21 patients (7 uncharacterized liver masses, 6 metastatic liver masses, 5 intrahepatic cholangiocarcinomas, and 3 hepatocellular carcinomas) were enrolled in this study. Inclusion criteria were solid liver masses that were poorly accessible by percutaneous approach, nondiagnostic after percutaneous biopsy, or combined with pancreatic or biliary maligancies. The EUS-FNB needle used in this study was 22G EchoTip ProCore (Cook Endoscopy, Bloomington, IN). Obtained specimen was divided into three segments for the on-site examination, cytologic examination, and histologic examination. Results: In all patients, on-site cytopathologic examination revealed adequate cellularity of specimen. The mean number of needle pass for adequate cellularity was 1.1 (range 1 to 4). Histologic examination with immunochemical stain and histopathological confirmation were possible in 90.5% (19/21). By EUS-
www.giejournal.org
FNB, five uncharacterized liver masses were diagnosed as 2 intrahepatic cholangiocarcinomma, 2 neuroendoscrine carcinoma, and one metastatic adenocarcinoma. The results of EUS-FNB in two patients were nondiagnostic. No procedure-related complications were occurred. Conclusions: EUS-FNB of liver masses provided cytologic and histologic evaluation and was safe and reliable modality for histopathological diagnosis. EUS-FNB may be considered as alternative to percutaneous liver biopsy, especially when percutaneous approach is difficult. Keywords: Endoscopic ultrasonography, fine needle aspiration biopsy, liver mass
Su1583 Endoscopic Ultrasound-Guided Liver Biopsy: a Multicenter Experience David L. Diehl*1, Amitpal S. Johal1, Frederick K. Shieh1, Jayapal Ramesh7, Shyam Varadarajulu9, Aman Ali8, Mohammad a. AL-Haddad2, Timothy B. Gardner4, Stuart R. Gordon4, Isaac Raijman6, Harshit S. Khara5, Rakhee Mangla5, Jonh J. Pineda-Bonilla1, Harry R. Aslanian3 1 Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA; 2Gastroenterology, Indiana University, Indianapolis, IN; 3 Gastroenterology, Yale University, New Haven, CT; 4Gastroenterology, Dartmouth Medical Center, Hanover, CT; 5Gastroenterology, Norwalk Hospital, Norwalk, CT; 6Gastroenterology, Digestive Associates of Houston, Houston, TX; 7Gastroenterology, University of Alabama, Birmingham, AL; 8Gastroenterology, Southern Illinois University, Springfield, IL; 9Gastroenterology, Florida Hospital, Orlando, FL Introduction: Endoscopic ultrasound-guided liver biopsy (EUS-LB) is a newer method of liver biopsy which offers several advantages over existing techniques including real-time visualization of the liver and its vascular structures, increased patient comfort, and ability to sample both lobes. In patients already undergoing EGD/EUS, EUS-LB can spare the patient from having to undergo an additional procedure. However, there is limited data in the literature regarding the safety and efficacy of EUS-LB. Our goal is further characterize the diagnostic yield and safety profile of EUS-LB on a larger scale. Methods: Patients undergoing EGD/EUS with an indication for LB were included in this prospective, non-randomized, multi-center study. Elevated LFTs was the indication for LB in all patients. Patient demographics, procedure information, diagnostic yield, specimen adequacy, and complications rates were recorded. Patients were called 30 days post-procedure to check for procedurerelated complications. LB was done with 19 g EUS-FNA needle (19g Expect or Expect Flexible, Boston Scientific, Marlborough, MA). 1 or 2 passes were made in the left lobe depending on endoscopist’s preference or assessment of tissue yield after the first pass. Right lobe FNA was done as per endoscopist’s preference. Tissue was formalin-fixed and stained with H&E and trichrome. Using a microscope micrometer, specimen length was measured and number of complete portal triads (CPTs) counted. Results: 38 patients underwent EUS-LB. The indication was abnormal LFTs in all cases. Half of the patients were male, with mean age of 52.4yr (31-79). LB specimens sufficient for pathological diagnosis were obtained in 37 of 38 patients (97.4%). 36 of needle passes were performed under suction, while 2 were performed without suction, with respective success rates of 36 of 36 (100%), and 1 of 2 (50%). 28 of 38 (74%) patients had bilateral lobar biopsies; 10 had only the left lobe sampled. Left-lobar biopsies had a mean aggregate length of 26 mm (1-75), and mean of 8.9 CPTs (0-30). Right-sided biopsies tended to be somewhat smaller (mean aggregate length of 18 mm (3-44), 6.5 CPTs, range 0-29). 8 or more total CPTs were obtained in 82% of patients. One complication occurred (1/38, 2.6%). Bleeding in a thrombocytopenic and coagulopathic (platelets 64K, INR 1.4) inpatient being evaluated for elevated LFTs was encountered. CT showed a pericapsular hematoma and angioembolization was required for hemostasis. No other patient had postprocedural bleeding, abdominal pain, or procedure-related issues at the 30 day telephone follow-up. Conclusion: EUS-LB can be performed successfully and safely in patients who are undergoing EGD or EUS and who are also going to undergo liver biopsy by other means. Tissue yields are acceptable for pathologic diagnosis in almost all biopsies.
Su1584 Azygos Vein Blood Flow by Color Doppler Endoscopic Ultrasound (CD-EUS) Correlates to the Hepatic Venous Pressure Gradient.in Cirrhotic Patients Priscila P. Flores1, Ubiratan C. Santos1, Denise Matos1, Guilherme Rezende1, MôNica Soldan*2 1 Liver Unit, Hospital Universitário Clementino Fraga Filho - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; 2Gastroenterology Unit - Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Introduction: The azygos vein is one of the blood outflow routes in portal hypertension and its diameter and flow increase in portal hypertension. HVPG
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB375
drainage drastically improves symptoms of peripancreatic abscess due to pancreatic leak. EUS-guided drainage of the pancreatic duct temporally improves clinical symptoms of obstructive pancreatitis, which can be attempted before conducting reoperative surgery.
Su1581 Role of Endoscopic Ultrasound (EUS) Evaluating Patients With Adrenal Gland Enlargement or Mass Melissa Martinez Mateo*, Julia K. Leblanc, Mohammad a. AL-Haddad, Stuart Sherman, John Dewitt Gastroenterology, Indiana University School of Medicine, indianapolis, IN Introduction: Studies evaluating the role of EUS-FNA(fine needle aspiration) in adrenal lesions are limited to patients with lung cancer or other malignancy and, generally lack long-term follow-up of benign lesions, surgical correlation, and description of its clinical impact. This study aims to report the utility and clinical impact of EUS-FNA of adrenal masses at our institution over a 15 year period. Methods: In a retrospective single-center case series, we identified consecutive patients from 10/97 to 12/11 who had EUS-FNA of either adrenal gland. The following were retrieved from medical records: EUS indications, findings, pathology, complications and follow-up abdominal imaging (CT or MRI) or surgery. Benign EUS-FNA adrenal cytology (anything without definitive malignancy) was considered correct if follow-up imaging at ⬎ 4months showed the lesion increased ⱕ 1cm of the original size. Results: 94 patients (52% male, median age 66 years, range: 32-86), had EUS-FNA (median 3 passes; range 1-7) of the left (n⫽90) and/or right (n⫽5) adrenal without complications. The median maximal adrenal diameter was 2.4 cm (range 0.7-8). Procedure indications: cancer staging (n⫽26) or, suspected recurrence (n⫽5), pancreatic (n⫽20), mediastinal (n⫽10), adrenal (n⫽7), lung (n⫽7) mass or other (n⫽19). Previous CT showed adrenal gland enlargement or mass in 59%. Twenty-five (26%) biopsies were malignant: metastatic lung (n⫽ 10), esophageal (n⫽5), colon (n⫽2), pancreatic (n⫽2), or other cancers (n⫽6). Nine (10%) biopsies were non-diagnostic and follow up in these CT showed a stable lesion in 5 but, was unavailable in 4. Sixty (64%) were benign: aldosteronoma (n⫽1), pheochromocytoma (n⫽1), paraganglioma (n⫽1) and adenomas/benign adrenal tissue (n⫽57). Available follow-up in 36/60 (60%) benign lesions showed: stable size by imaging in 27, confirmation as benign in 5 by repeat EUS-FNA (n⫽1) or adrenalectomy (n⫽4), or cancer in 4 by later CT-guided adrenal biopsy (metastatic NSCLC in one, neuroendocrine cancer in one), enlargement of previous and new contralateral adrenal mass on repeat CT (NSCLC in one), or adrenalectomy (adrenocortical carcinoma in one). Follow-up was unavailable in 24/60 (40%) benign biopsies. EUS-FNA of either adrenal made initial the diagnosis of stage IV cancer in 17, cancer recurrence in 7, and ruled out metastasis in 10 patients with underlying malignancy and available follow-up. For patients with malignant or benign cytology and available follow-up (n⫽61), the sensitivity, specificity, PPV and NPV of adrenal EUS-FNA for malignancy was 86% (CI 68-95%), 97% (CI 83-100%), 96% (CI 79-100%) and 89% (CI 74-96%) respectively. Conclusion: Adrenal gland EUS-FNA is a safe, minimally invasive and sensitive technique with significant impact in the management of patients with adrenal gland mass or enlargement.
Su1582 Endoscopic Ultrasound-Guided Fine Needle Biopsy (EUS-FNB) for the Histopathologic Diagnosis of Solid Liver Masses Hyun Jong Choi*1, Jong Ho Moon1, Hee Kyung Kim2, Dong Choon Kim1, Yun Nah Lee1, Tae Hoon Lee1, Sang-Woo Cha1, Young Deok Cho1, Sang-Heum Park1, Sun-Joo Kim1 1 Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Republic of Korea; 2Department of Pathology, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Republic of Korea Background and Aims: Percutaneous liver biopsy remains the gold standard for histopathological evaluation of solid liver masses. However, percutaneous approach may be limited in some conditions. Obtaining histologic samples of liver masses is essential for the accurate pathologic evaluation and immunohistochemical studies. A recently developed EUS biopsy needle is expected to offer effective tissue core sampling. The aim of this study was to evaluate the clinical impact of EUS-guided fine needle biopsy (EUS-FNB) for solid liver masses. Patients and Methods: Total 21 patients (7 uncharacterized liver masses, 6 metastatic liver masses, 5 intrahepatic cholangiocarcinomas, and 3 hepatocellular carcinomas) were enrolled in this study. Inclusion criteria were solid liver masses that were poorly accessible by percutaneous approach, nondiagnostic after percutaneous biopsy, or combined with pancreatic or biliary maligancies. The EUS-FNB needle used in this study was 22G EchoTip ProCore (Cook Endoscopy, Bloomington, IN). Obtained specimen was divided into three segments for the on-site examination, cytologic examination, and histologic examination. Results: In all patients, on-site cytopathologic examination revealed adequate cellularity of specimen. The mean number of needle pass for adequate cellularity was 1.1 (range 1 to 4). Histologic examination with immunochemical stain and histopathological confirmation were possible in 90.5% (19/21). By EUS-
www.giejournal.org
FNB, five uncharacterized liver masses were diagnosed as 2 intrahepatic cholangiocarcinomma, 2 neuroendoscrine carcinoma, and one metastatic adenocarcinoma. The results of EUS-FNB in two patients were nondiagnostic. No procedure-related complications were occurred. Conclusions: EUS-FNB of liver masses provided cytologic and histologic evaluation and was safe and reliable modality for histopathological diagnosis. EUS-FNB may be considered as alternative to percutaneous liver biopsy, especially when percutaneous approach is difficult. Keywords: Endoscopic ultrasonography, fine needle aspiration biopsy, liver mass
Su1583 Endoscopic Ultrasound-Guided Liver Biopsy: a Multicenter Experience David L. Diehl*1, Amitpal S. Johal1, Frederick K. Shieh1, Jayapal Ramesh7, Shyam Varadarajulu9, Aman Ali8, Mohammad a. AL-Haddad2, Timothy B. Gardner4, Stuart R. Gordon4, Isaac Raijman6, Harshit S. Khara5, Rakhee Mangla5, Jonh J. Pineda-Bonilla1, Harry R. Aslanian3 1 Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA; 2Gastroenterology, Indiana University, Indianapolis, IN; 3 Gastroenterology, Yale University, New Haven, CT; 4Gastroenterology, Dartmouth Medical Center, Hanover, CT; 5Gastroenterology, Norwalk Hospital, Norwalk, CT; 6Gastroenterology, Digestive Associates of Houston, Houston, TX; 7Gastroenterology, University of Alabama, Birmingham, AL; 8Gastroenterology, Southern Illinois University, Springfield, IL; 9Gastroenterology, Florida Hospital, Orlando, FL Introduction: Endoscopic ultrasound-guided liver biopsy (EUS-LB) is a newer method of liver biopsy which offers several advantages over existing techniques including real-time visualization of the liver and its vascular structures, increased patient comfort, and ability to sample both lobes. In patients already undergoing EGD/EUS, EUS-LB can spare the patient from having to undergo an additional procedure. However, there is limited data in the literature regarding the safety and efficacy of EUS-LB. Our goal is further characterize the diagnostic yield and safety profile of EUS-LB on a larger scale. Methods: Patients undergoing EGD/EUS with an indication for LB were included in this prospective, non-randomized, multi-center study. Elevated LFTs was the indication for LB in all patients. Patient demographics, procedure information, diagnostic yield, specimen adequacy, and complications rates were recorded. Patients were called 30 days post-procedure to check for procedurerelated complications. LB was done with 19 g EUS-FNA needle (19g Expect or Expect Flexible, Boston Scientific, Marlborough, MA). 1 or 2 passes were made in the left lobe depending on endoscopist’s preference or assessment of tissue yield after the first pass. Right lobe FNA was done as per endoscopist’s preference. Tissue was formalin-fixed and stained with H&E and trichrome. Using a microscope micrometer, specimen length was measured and number of complete portal triads (CPTs) counted. Results: 38 patients underwent EUS-LB. The indication was abnormal LFTs in all cases. Half of the patients were male, with mean age of 52.4yr (31-79). LB specimens sufficient for pathological diagnosis were obtained in 37 of 38 patients (97.4%). 36 of needle passes were performed under suction, while 2 were performed without suction, with respective success rates of 36 of 36 (100%), and 1 of 2 (50%). 28 of 38 (74%) patients had bilateral lobar biopsies; 10 had only the left lobe sampled. Left-lobar biopsies had a mean aggregate length of 26 mm (1-75), and mean of 8.9 CPTs (0-30). Right-sided biopsies tended to be somewhat smaller (mean aggregate length of 18 mm (3-44), 6.5 CPTs, range 0-29). 8 or more total CPTs were obtained in 82% of patients. One complication occurred (1/38, 2.6%). Bleeding in a thrombocytopenic and coagulopathic (platelets 64K, INR 1.4) inpatient being evaluated for elevated LFTs was encountered. CT showed a pericapsular hematoma and angioembolization was required for hemostasis. No other patient had postprocedural bleeding, abdominal pain, or procedure-related issues at the 30 day telephone follow-up. Conclusion: EUS-LB can be performed successfully and safely in patients who are undergoing EGD or EUS and who are also going to undergo liver biopsy by other means. Tissue yields are acceptable for pathologic diagnosis in almost all biopsies.
Su1584 Azygos Vein Blood Flow by Color Doppler Endoscopic Ultrasound (CD-EUS) Correlates to the Hepatic Venous Pressure Gradient.in Cirrhotic Patients Priscila P. Flores1, Ubiratan C. Santos1, Denise Matos1, Guilherme Rezende1, MôNica Soldan*2 1 Liver Unit, Hospital Universitário Clementino Fraga Filho - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; 2Gastroenterology Unit - Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Introduction: The azygos vein is one of the blood outflow routes in portal hypertension and its diameter and flow increase in portal hypertension. HVPG
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB375