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⁎4542 Endoscopic ultrasonography value in the diagnosis and follow up of the malt gastric lymphoma after helicobacter pylori treatment.
*4541 CLINICAL SIGNIFICANCE OF GASTRITIS CYSTICA POLYPOSA AND ROLE OF ENDOSCOPIC ULTRASONOGRAPHY. Il K. Chung, Eun J. Kim, Dae J. Kim, Hong S. Kim, Sang H. Park, Moon S. Lee, Moon H. Lee, Sun J. Kim, Soon Chung Hyang Coll of Medicine, Chonan, ChoongN, South Korea; Soonchunhyang Univ Chunan Hosp, Chonan, ChoongN, South Korea; Soon Chung Hyang Coll of Medicine, Chonan, South Korea. Background:Gastritis cystica polyposa(GCP) is one of multiple cystic lesion in mucosa(superficialis) and/or submucosal layer(profunda) of stomach. This lesion has been regarded as a benign lesion. However, some authors have reported that gastric cancer and adenoma is arising from GCP, and gastric cancer associated with gastric cystic lesion has also been described. Endoscopic ultrasonography(EUS) is the best diagnostic tool to evaluate small gastric cystic lesion, and it can give exclusive information for gastric tumor lesions associated with gastric submucosal cystic lesion at preoperative state. The aim of this study was to evaluated the typical EUS findings of GCP, the efficacy of EUS as diagnostic tool in GCP and its related tumor lesions. Patient and method:From Jan 1995 to November 1999, we have tried 1350 cases of endoscopy and EUS to differentiate gastric protruding or elevated lesion, 9 cases of GCP was confirmed by endoscopic resection or operation. We analysis clinical features and diagnosis in gastrofiberoscopy and EUS, compare to histologic diagnosis. Results: Clinical symptoms of GCP are abdominal discomfort or indigestion in all GCP patients. Operative history of subtotal gastrectomy was noted in only 3 cases of GCP. Initial endoscopic diagnosis to GCP was incomplete in all cases. Endoscopic findings of GCP are various; 3 gastric polyp, 2 SMT, 2 flat elevated lesion, 1 hypertrophic gastritis, and 1 small polyp coexist with gastric cancer. We could diagnosed GCP in 8 patients through EUS(sensitivity 88.9%, positive predictable rate is 100%). EUS findings is characterized by 14.1mm(9-26) of mean size, multiple variable sized anechoic lesion with intervening hyperechoic structure(8 cases), irregular margin(7), musoca and submucosal thickening(6), and submucosal invasion(5 GCP profunda). In histologic findings, 6 GCP were associated with underlying gastritis only, but two gastric tubular adenomas were located in mucosa above cystic dilatation of gastric gland. One small GCP lesion was noted in other site of upper body in patient with early gatric cancer. Conclusions:EUS is an effective diagnostic tool to evaluate and differentiate GCP from the protruding and elevated gastric lesion, and an important role to decide method of management of GCP. EUS is monopolistic diagnostic procedure to evaluate GCP associated with gastric tumor lesions before resection, and more clinical usefulness of EUS is expected to lighten pathogenetic relationship in these two disease entities in future. *4542 ENDOSCOPIC ULTRASONOGRAPHY VALUE IN THE DIAGNOSIS AND FOLLOW UP OF THE MALT GASTRIC LYMPHOMA AFTER HELICOBACTER PYLORI TREATMENT. Luis Sabbagh, Oscar Gutierrez, Benedicto Velasco, Albis Hani, Claudia Sanmiguel, Claudia Jaramillo, Gabriel Gomez, Alvaro Caro, Clin REINA SOFIA, Bogota, Colombia; Univ NACIONAL, Bogota, Colombia; Univ JAVERIANA, Bogota, Colombia. Introduction. Gastric lymphomas represent the 3 to 10% of the gastric neoplasms. Endoscopic Ultrasonography (EUS) is today the gold standard to evaluate the gastric wall, allowing the reliable measurement of the wall thickness, tumor extension and peri gastric node involvement. These characteristics make this tool the first choice to follow up the response of patients with gastric lymphoma under treatment. The main objective of this study was to prospectively evaluate the utility of EUS in the follow up of patients with superficial involvement of low grade MALT gastric lymphoma (mucosa associated lymphoid tissue) under treatement for Helicobacter pylori. Methods.The study was conducted at the Clinica Reina Sofía a tertiary care center. The inclusion criteria were patients with histology and immuno histochemistry diagnosis of low grade MALT gastric lymphoma with superficial involvement (no deeper than submucosa layer and without node involvement). EUS was performed before and on the 3rd, 6th, 9th, 12th, and 18th month after antibiotic treatment with claritromicin, amoxacilin and lansoprazol for Helicobacter pylori eradication. The main outcome variable was defined as the measurement of the tumor involvement of the gastric wall (in millimeters, normal value of 3 mm) by EUS on the specified times. At the same time, biopsy samples were taken. Results.The study period of time was 18 months; during this time, 14 patients were included in the study. The median of the gastric mucosa before treatment was 7 mm (range 3 - 9 mm). Two patients did not respond to the treatment and remained with the same gastric mucosa thickness and positive biopsy for the neoplasm. There was a significant reduction of the gastric mucosa thickness after the sixth month of treatment in 12 patients (85.7%), with a median of 4 mm. The tumor was not evident at the biopsy specimen in this group of patients and the eradication of the Helicobacter pylori was demonstrated. There was a good correlation
VOLUME 51, NO. 4, PART 2, 2000
between the EUS evaluation and the histological findings for tumor evidence and for Helicobacter pylori infection. Conclusions: The results of the present study showed that EUS is a useful tool for the diagnosis and follow up of patients with low grade MALT gastric lymphoma with superficial involvement. There was a good correlation between H pylori eradication, gastric mucosa thickness reduction by EUS and histopathological findings. *4543 ENDOSCOPIC ULTRASOUND GUIDED FINE NEEDLE ASPIRATION FOR THE DIAGNOSIS OF THE GASTROINTESTINAL SUBMUCOSAL TUMORS. Kenji Yamao, Kazuhiko Ohashi, Tuneya Nakamura, Takashi Suzuki, Suguru Koshikawa, Aichi Cancer Ctr Hosp, Nagoya, Japan. Objectives: Careful observation of EUS findings can be of assistance in predicting the histopathological nature of SMTs. However, an exact differentiation between benign and malignant SMTs by EUS alone is impossible. The aim of this study was to evaluate the efficacy of EUS and EUS FNA for the differential diagnosis of SMTs. Materials and Methods: From December 1994 to September 1999, EUS and EUS FNA using the Olympus curved linear array echoendoscope (XGF-UC3 and GF-UC4) were performed for 25 cases (10-200mm in size) resected for suspected malignant myogenic tumors by EUS or EUS FNA. The patients with suspected benign myogenic tumors by EUS and EUS FNA were followed up without operation. Final diagnosis of resected cases were leiomyosarcomas in 15 (high grade 6 and low grade 16), endocrine cell carcinoma, metastatic carcinoma and Glomus tumor each in one. Criteria for assessing myogenic tumor by EUS were as follows: a suspected malignancy ≥4cm or smaller < 4cm with cyst spaces; a suspected benign mass with regular borders, echo-homogeneity and measuring < 3cm. Results: The accuracy rate for EUS and EUS-guided FNA were 40% and 92%, respectively. EUS-FNA could also provide definitive diagnosis of 3 non-myogenic tumors. EUS Malignant Benign Indeterninate Malignant 15 4 5 Benign 0 0 1 Total 15 4 6 EUS FNA Malignant Benign Indeterminate Malignant 22# 0 1* Benign 1 1## 0 Total 23 1 1 *insufficient material #Carcinoid & metastatic carcinoma each in 1 ## Glomus tumor 1 Conclusion: EUS FNA is an effective modality to enhance the specificity of EUS diagnosis for suspected myogenic tumor. *4544 PROSPECTIVE COMPARISON OF 22 GAUGE VERSUS 19 GAUGE NEEDLE FOR ENDOSCOPIC ULTRASOUND DIRECTED FINE NEEDLE ASPIRATION OF PANCREATIC MASSES: DOES SIZE MATTER? Drew B. Schembre, Geoffrey C. Jiranek, Stephen F. Hogan, Virginia Mason Med Ctr, Seattle, WA. Background: EUS guided FNA allows for accurate diagnosis of pancreatic neoplasms. Yield is hampered by the small amount of tissue obtained with a standard 22 gauge needle. Larger needles may improve diagnosis but may also increase risks. Methods: We prospectively analyzed all patients referred with pancreatic masses over six months. After staging with radial EUS (Olympus GF-UM20), real-time FNA was attempted using curved linear array EUS (Olympus GF-UC30P) with a 22 gauge needle (Wilson Cook EchoTip®) and a 19 gauge needle, (Mediglobe). The order of use was alternated. Smears and cell blocks of aspirates were made immediately and sent for interpretation. Diagnosis was confirmed at surgery, by additional core biopsies or by clinical course. Cytologic diagnosis, needle characteristics and complications were recorded and aspirates blindly reviewed for relative quantity and quality of cellular material. Results: Over six months, 22 patients were referred for EUS of a pancreatic mass. Of these, 20 underwent FNA, 6 with 22 g alone, 1 with 19 g alone and 14 with both, (attempt failed with the stiffer 19g needle in 2 additional cases). 14 of these cases eventually were proven to be cancers. Other diagnoses included one CIS, 2 chronic pancreatitis, 3 cysts or pseudocysts. Average total needle passes per case was 2.7, divided equally between types. 22 g detected 10 of 13 cancers, (77% sens.) with 100% specificity. 19 g detected 8 of 9 cancers (89% sens.) with 100% specificity, when tissue was obtained. Overall sensitivity was 82%. Accuracy with 22 g needle was 79% and 93% with 19 g needle, for an overall accuracy of 85%. Of eight cancers sampled with both needles, three 19 g aspirates were felt to be of better quality, due to increased tissue sampling, preservation of architecture and greater cellularity. Three 22 g. aspirates were felt to be superior due to less blood and better cellularity. Two samples were identical. In several cases, cell blocks of spun aspirates from both needles increased yield. One case of minor bleeding was linked to use of a 19 g needle. In no case was cancer detected with one needle and not the other. Conclusion: 1). Both 19 g and 22 g needles are useful for EUS guided FNA of pancreatic masses. 2). Needle size does not clearly correlate with specimen size or quality. 3). 19 gauge needles were more difficult to place, especially from the duodenum and may be associated with a higher risk of bleeding. 4). Cell blocks of aspirates probably increase diagnostic yield.
GASTROINTESTINAL ENDOSCOPY
AB163
VOLUME 51, NO. 4, PART 2, 2000
between the EUS evaluation and the histological findings for tumor evidence and for Helicobacter pylori infection. Conclusions: The results of the present study showed that EUS is a useful tool for the diagnosis and follow up of patients with low grade MALT gastric lymphoma with superficial involvement. There was a good correlation between H pylori eradication, gastric mucosa thickness reduction by EUS and histopathological findings. *4543 ENDOSCOPIC ULTRASOUND GUIDED FINE NEEDLE ASPIRATION FOR THE DIAGNOSIS OF THE GASTROINTESTINAL SUBMUCOSAL TUMORS. Kenji Yamao, Kazuhiko Ohashi, Tuneya Nakamura, Takashi Suzuki, Suguru Koshikawa, Aichi Cancer Ctr Hosp, Nagoya, Japan. Objectives: Careful observation of EUS findings can be of assistance in predicting the histopathological nature of SMTs. However, an exact differentiation between benign and malignant SMTs by EUS alone is impossible. The aim of this study was to evaluate the efficacy of EUS and EUS FNA for the differential diagnosis of SMTs. Materials and Methods: From December 1994 to September 1999, EUS and EUS FNA using the Olympus curved linear array echoendoscope (XGF-UC3 and GF-UC4) were performed for 25 cases (10-200mm in size) resected for suspected malignant myogenic tumors by EUS or EUS FNA. The patients with suspected benign myogenic tumors by EUS and EUS FNA were followed up without operation. Final diagnosis of resected cases were leiomyosarcomas in 15 (high grade 6 and low grade 16), endocrine cell carcinoma, metastatic carcinoma and Glomus tumor each in one. Criteria for assessing myogenic tumor by EUS were as follows: a suspected malignancy ≥4cm or smaller < 4cm with cyst spaces; a suspected benign mass with regular borders, echo-homogeneity and measuring < 3cm. Results: The accuracy rate for EUS and EUS-guided FNA were 40% and 92%, respectively. EUS-FNA could also provide definitive diagnosis of 3 non-myogenic tumors. EUS Malignant Benign Indeterninate Malignant 15 4 5 Benign 0 0 1 Total 15 4 6 EUS FNA Malignant Benign Indeterminate Malignant 22# 0 1* Benign 1 1## 0 Total 23 1 1 *insufficient material #Carcinoid & metastatic carcinoma each in 1 ## Glomus tumor 1 Conclusion: EUS FNA is an effective modality to enhance the specificity of EUS diagnosis for suspected myogenic tumor. *4544 PROSPECTIVE COMPARISON OF 22 GAUGE VERSUS 19 GAUGE NEEDLE FOR ENDOSCOPIC ULTRASOUND DIRECTED FINE NEEDLE ASPIRATION OF PANCREATIC MASSES: DOES SIZE MATTER? Drew B. Schembre, Geoffrey C. Jiranek, Stephen F. Hogan, Virginia Mason Med Ctr, Seattle, WA. Background: EUS guided FNA allows for accurate diagnosis of pancreatic neoplasms. Yield is hampered by the small amount of tissue obtained with a standard 22 gauge needle. Larger needles may improve diagnosis but may also increase risks. Methods: We prospectively analyzed all patients referred with pancreatic masses over six months. After staging with radial EUS (Olympus GF-UM20), real-time FNA was attempted using curved linear array EUS (Olympus GF-UC30P) with a 22 gauge needle (Wilson Cook EchoTip®) and a 19 gauge needle, (Mediglobe). The order of use was alternated. Smears and cell blocks of aspirates were made immediately and sent for interpretation. Diagnosis was confirmed at surgery, by additional core biopsies or by clinical course. Cytologic diagnosis, needle characteristics and complications were recorded and aspirates blindly reviewed for relative quantity and quality of cellular material. Results: Over six months, 22 patients were referred for EUS of a pancreatic mass. Of these, 20 underwent FNA, 6 with 22 g alone, 1 with 19 g alone and 14 with both, (attempt failed with the stiffer 19g needle in 2 additional cases). 14 of these cases eventually were proven to be cancers. Other diagnoses included one CIS, 2 chronic pancreatitis, 3 cysts or pseudocysts. Average total needle passes per case was 2.7, divided equally between types. 22 g detected 10 of 13 cancers, (77% sens.) with 100% specificity. 19 g detected 8 of 9 cancers (89% sens.) with 100% specificity, when tissue was obtained. Overall sensitivity was 82%. Accuracy with 22 g needle was 79% and 93% with 19 g needle, for an overall accuracy of 85%. Of eight cancers sampled with both needles, three 19 g aspirates were felt to be of better quality, due to increased tissue sampling, preservation of architecture and greater cellularity. Three 22 g. aspirates were felt to be superior due to less blood and better cellularity. Two samples were identical. In several cases, cell blocks of spun aspirates from both needles increased yield. One case of minor bleeding was linked to use of a 19 g needle. In no case was cancer detected with one needle and not the other. Conclusion: 1). Both 19 g and 22 g needles are useful for EUS guided FNA of pancreatic masses. 2). Needle size does not clearly correlate with specimen size or quality. 3). 19 gauge needles were more difficult to place, especially from the duodenum and may be associated with a higher risk of bleeding. 4). Cell blocks of aspirates probably increase diagnostic yield.
GASTROINTESTINAL ENDOSCOPY
AB163