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7234 Usefulness of three-dimensional expression by endoscopic ultrasonography in the diagnosis of gastric cancer invasion.
7233 GASTROINTESTINAL AUTONOMOUS NERVE TUMOR (GANT) OF THE STOMACH: REPORT OF A CASE WITH PREOPERATIVE EUS ASSESSMENT AND EUS GUIDED FINE NEEDLE ASPIRATION BIOPSY. Christian Oesterreicher, Arnulf Ferlitsch, Helene Wiener, Renate Kain, Fritz Laengle, Ewald Schober, Georg Oberhuber, Rainer Schoefl, Dept of Internal Medicine IV, Univ of Vienna, Vienna, Austria; Dept of Pathology, Univ of Vienna, Vienna, Austria; Dept of Surg, Univ of Vienna, Vienna, Austria; Dept of Radiology, Univ of Vienna, Vienna, Austria; Dept of Internal Medicine IV, Vienna, Austria. Background: Gastrointestinal autonomic nerve tumor is an uncommon stromal tumor of the intestinal tract and retroperitoneum originally described by Herrera et al. in 1984 under the name plexosarcoma. Since then, 69 cases have been reported with only 7 patients showing occurrence of multiple tumor locations. Biologic behavior seems to correlate with size and mitotic activity. Case report: A 22-yr-old female patient presented with fatigue and occasional upper abdominal pain. Laboratory data showed severe hypochromic anemia (hgb 5,4 mg/dl), physical examination did not show further pathology. EGD revealed a 2cm submucosal tumor in the posterior gastric wall with negative biopsy result. Abdominal sonography additionally showed an approx. 40 mm, partly echopoor, partly echofree lesion located between stomach and pancreas, without clear border to the pancreatic tail. CT scan revealed a 20 mm tumor of the gastric wall with strong contrast enhancement and a 45 mm hypodense tumor of uncertain origin. All other diagnostic procedures concerning anemia did not reveal any pathological results. Standard EUS with the Olympus GF UM 130 radial scanner showed on the site of the macroscopically polypoid lesion a 20 mm submucosal, echopoor- tumor of benign aspect (e.g. leiomyoma). The other, bigger lesion was located between the posterior stomach wall and the pancreatic tail, 40mm in diameter and of inhomogeneous echopoor structure, adjacent to the pancreas without clear border to the gastric wall. DD between a gastric or pancreatic lesion was demonstrated with an EUS guided fine needle aspiration (Pentax FG 32) showing strong evidence of a gastric mesenchymal tumor, compatible with leiomyoma or gastrointestinal stromal tumor (GIST). Preoperative MR confirmed the tumor findings, the bigger one probably originating from the gastric wall. Afterwards surgery was performed with an atypical stomach resection (R 0), revealing two GIST in the gastric wall (∅ 20 and 33 mm), immunohistochemically gastrointestinal autonomic nerve tumors (mitotic rate 7-12 per 50/HPF). Postoperative course was free of complications, and so far (6 month) with no recurrence of disease. Conclusion: To the authors knowledge, we present the 8th patient with multiple locations of this rare entity GANT, but the first case where EUS assessment is reported. The key examination was the endoscopic ultrasound guided fine needle aspriration biopsy, which was confirmed by surgery.
7234 USEFULNESS OF THREE-DIMENSIONAL EXPRESSION BY ENDOSCOPIC ULTRASONOGRAPHY IN THE DIAGNOSIS OF GASTRIC CANCER INVASION. Seisuke Okamura, Akemi Tsutsui, Naoki Muguruma, Soichi Itikawa, Koji Tsujigami, Yoshio Okita, Susumu Ito, Kazunori Umino, Sch of Medicine, Univ of Tokushima, Tokushima city, Japan; Med Design Co , Ltd, Yokohama city, Japan. Objective: Many studies have reported the usefulness of endoscopic ultrasonography (EUS) in the diagnosis of gastric cancer invasion. However, the diagnostic capacity of EUS should be further improved. In this study, we examined the usefulness of three-dimensional expression by EUS in the diagnosis of gastric cancer invasion. Subjects and Methods: In 54 gastric cancer lesions that were histologically diagnosed after April 1995 by EUS using an ultrasonic miniprobe in our department, the rate of accurately diagnosing invasion was compared between period A and period B. The period between April 1995 and October 1996, when examination of threedimensional expression was started at our department, was regarded as period A (35 lesions) , while the period from October 1996 to date was regarded as period B (19 lesions) . Furthermore, the usefulness of threedimensional expression was examined in l9 lesions during period B. In the three-dimensional expression, we pulled ultrasonic miniprobe out at defi-
VOLUME 51, NO. 4, PART 2, 2000
nite speed manually, and recorded the images on VTR. We connected VTR output to images processing equipment (Indigo2, Silicon Graphics), and compressed each tomographic image (30 frame/sec) by EUS by Motion JPEG method. We selected necessary frames from the images, and converted them into volume data by the three-dimensional image processing software (Medical Design Composer 1.0) which we developed. We determined arbitrary cross sections and the external form on volume data, and observed the lesions spatially. Result: The rate of accurate diagnosis of invasion by EUS was 77.8% (42/54) , overall. Percentages were 74.3% (26/35: T1-m 71.4%, T1-sm 83.3%, T2-pm 50%) during period A and 84.2% (6/19: T1-m 87.5%, T1-sm 66.7%) during period B. During period B, the whole lesion was scanned in each direction for three-dimensional expression. Furthermore, more detailed examination could be performed by expressing random cross sections from three-dimensional data, improving the diagnostic capacity of this procedure. In 8 of 19 patients, superficial expression was possible. In these lesions, the rate of accurately diagnosed invasion was 100% (8/8) . Although these patients were selected based on lesion size and the absence of the influence of heart beats, it was suggested that three-dimensional expression contributes to improving the diagnosis of invasion. Conclusion: Three-dimensional expression of EUS findings in patients with gastric cancer may improve the diagnosis of invasion.
7235 ENDOSCOPIC ULTRASONOGRAPHY IN GASTRIC MALT AND GASTRITIS. Bocus Paolo, De Bona Manuela, Bellumat Angelo, Barbazza Renzo, Zucca Emanuele, Roggero Enrico, De Boni Michele, Gastroenterology and Endoscopy Unit Hosp of Feltre, Feltre (BL), Italy; Gastroenterology and Endoscopy Unit Hosp of Feltre, Felte (BL), Italy; Service Oncologico Cantonale, Hosp San Giovanni, Bellinzona, Switzerland. A close association between gastric Helicobacter pyloriinfection and MALT lymphoma of the stomach has been described and H. pylorieradication can result in histological regression of the gastric lymphoma in most cases. Recent studies suggest that EUS may provide informations useful to predict the lymphoma response to antibiotic therapy: deeper the gastric wall infiltration lower the response rate. AIMS:to compare the gastric wall structure in early gastric MALT lymphoma and chronic H. pylori-associated gastritis. METHODS:10 pts. with low grade gastric MALT lymphoma occasionally diagnosed by biopsies taken in the presence of an endoscopic pattern of gastritis and 10 pts. with H. pylori-associated gastritis were evaluated. Both groups have negative endoscopic appearance (no severe lesions except erythema or aspect of mild atrophy). EUS was performed with a radial (Olympus GF-UM 20 7.5-12 MHz) echoendoscope with the water-filled technique. Thickness of the entire gastric wall and of the mucosa and submucosa layers was measured in antrum, corpus and fundus. RESULTS:structure of the wall with respect to echogenicity, layering and thickness is similar in the two groups (i.e. low-grade MALT lymphoma and gastritis). CONCLUSION:Patients with histological diagnosis of lowgrade gastric lymphoma but no evidence of any endoscopic lesions showed an EUS pattern with normal frequencies (7.5-12 MHz) superimposable to the one observed in H. pylori-associated gastritis. This subset of MALT lymphoma patients may have an early disease with the highest chances of prolonged remission with antibiotic therapy.
GASTROINTESTINAL ENDOSCOPY
AB301
7234 USEFULNESS OF THREE-DIMENSIONAL EXPRESSION BY ENDOSCOPIC ULTRASONOGRAPHY IN THE DIAGNOSIS OF GASTRIC CANCER INVASION. Seisuke Okamura, Akemi Tsutsui, Naoki Muguruma, Soichi Itikawa, Koji Tsujigami, Yoshio Okita, Susumu Ito, Kazunori Umino, Sch of Medicine, Univ of Tokushima, Tokushima city, Japan; Med Design Co , Ltd, Yokohama city, Japan. Objective: Many studies have reported the usefulness of endoscopic ultrasonography (EUS) in the diagnosis of gastric cancer invasion. However, the diagnostic capacity of EUS should be further improved. In this study, we examined the usefulness of three-dimensional expression by EUS in the diagnosis of gastric cancer invasion. Subjects and Methods: In 54 gastric cancer lesions that were histologically diagnosed after April 1995 by EUS using an ultrasonic miniprobe in our department, the rate of accurately diagnosing invasion was compared between period A and period B. The period between April 1995 and October 1996, when examination of threedimensional expression was started at our department, was regarded as period A (35 lesions) , while the period from October 1996 to date was regarded as period B (19 lesions) . Furthermore, the usefulness of threedimensional expression was examined in l9 lesions during period B. In the three-dimensional expression, we pulled ultrasonic miniprobe out at defi-
VOLUME 51, NO. 4, PART 2, 2000
nite speed manually, and recorded the images on VTR. We connected VTR output to images processing equipment (Indigo2, Silicon Graphics), and compressed each tomographic image (30 frame/sec) by EUS by Motion JPEG method. We selected necessary frames from the images, and converted them into volume data by the three-dimensional image processing software (Medical Design Composer 1.0) which we developed. We determined arbitrary cross sections and the external form on volume data, and observed the lesions spatially. Result: The rate of accurate diagnosis of invasion by EUS was 77.8% (42/54) , overall. Percentages were 74.3% (26/35: T1-m 71.4%, T1-sm 83.3%, T2-pm 50%) during period A and 84.2% (6/19: T1-m 87.5%, T1-sm 66.7%) during period B. During period B, the whole lesion was scanned in each direction for three-dimensional expression. Furthermore, more detailed examination could be performed by expressing random cross sections from three-dimensional data, improving the diagnostic capacity of this procedure. In 8 of 19 patients, superficial expression was possible. In these lesions, the rate of accurately diagnosed invasion was 100% (8/8) . Although these patients were selected based on lesion size and the absence of the influence of heart beats, it was suggested that three-dimensional expression contributes to improving the diagnosis of invasion. Conclusion: Three-dimensional expression of EUS findings in patients with gastric cancer may improve the diagnosis of invasion.
7235 ENDOSCOPIC ULTRASONOGRAPHY IN GASTRIC MALT AND GASTRITIS. Bocus Paolo, De Bona Manuela, Bellumat Angelo, Barbazza Renzo, Zucca Emanuele, Roggero Enrico, De Boni Michele, Gastroenterology and Endoscopy Unit Hosp of Feltre, Feltre (BL), Italy; Gastroenterology and Endoscopy Unit Hosp of Feltre, Felte (BL), Italy; Service Oncologico Cantonale, Hosp San Giovanni, Bellinzona, Switzerland. A close association between gastric Helicobacter pyloriinfection and MALT lymphoma of the stomach has been described and H. pylorieradication can result in histological regression of the gastric lymphoma in most cases. Recent studies suggest that EUS may provide informations useful to predict the lymphoma response to antibiotic therapy: deeper the gastric wall infiltration lower the response rate. AIMS:to compare the gastric wall structure in early gastric MALT lymphoma and chronic H. pylori-associated gastritis. METHODS:10 pts. with low grade gastric MALT lymphoma occasionally diagnosed by biopsies taken in the presence of an endoscopic pattern of gastritis and 10 pts. with H. pylori-associated gastritis were evaluated. Both groups have negative endoscopic appearance (no severe lesions except erythema or aspect of mild atrophy). EUS was performed with a radial (Olympus GF-UM 20 7.5-12 MHz) echoendoscope with the water-filled technique. Thickness of the entire gastric wall and of the mucosa and submucosa layers was measured in antrum, corpus and fundus. RESULTS:structure of the wall with respect to echogenicity, layering and thickness is similar in the two groups (i.e. low-grade MALT lymphoma and gastritis). CONCLUSION:Patients with histological diagnosis of lowgrade gastric lymphoma but no evidence of any endoscopic lesions showed an EUS pattern with normal frequencies (7.5-12 MHz) superimposable to the one observed in H. pylori-associated gastritis. This subset of MALT lymphoma patients may have an early disease with the highest chances of prolonged remission with antibiotic therapy.
GASTROINTESTINAL ENDOSCOPY
AB301