- Email: [email protected]
Depth of gastric cancer invasion determined by endoscopic ultrasonography
ENDOSCOPIC ULTRASOUND t565
t'567
ENDOSONOGRAPHY GUIDED CELIAC PLEXUS NEUROLYSIS (EUS CPN) IN PATIENTS WITH PAIN DUE TO INTRA-ABDOMINAL MALIGNANCY (IAM). M Wiersema., L Wiersema. St. Vincent Hospitals and Health Care Center, Indianapolis, IN. Methods: 45 patients (mean age 66 yrs, 40-86) with abdominal pain and confirmed IAM (1~ tumor: pancreas 33, bile duct 3, stomach 2, other 7) underwent 48 EUS CPN procedures. 37 procedures were performed at the same setting as the EUS staging exam with fine needle aspiration biopsy (cytologically confirming IAM), 9 procedures were performed for EUS CPN alone (3 repeat) and 2 were performed at the time of ERCP with biliary stent placement. EUS CPN was performed via a transgastric approach with the linear array echoendoscope (Pentax) and a 4 cm 23 gauge needle (Wilson-Cook). Bupivacalne .25% (3 cc) followed by absolute ETOH (10 cc) was injected on both sides of the aorta at the level of the celiac trunk (total volume 26 cc). Pain was assessed pre- and post EUS CPN by a visual analog scale (range:0-10). Follow up evaluation occurred at 2, 7, 14 and 28 days and then monthly thereafter. Paired pre- and post EUS CPN pain scores were compared using the Wilcoxon signed rank test with a decrease in the pain score of > 3 required for a positive response (i.e.//o:#=3). Results: With a median follow-up of 92 days (range: 2-372), the mean pain score improved from a baseline of 6.7+_2.0 (range 2-10,median 7) to 1.7+_1.9 at 2 weeks, 2.0_+2.0 at 4 weeks, 2.0+_2.6 at .8 weeks, 1.3+_1.9 at 12 weeks and 1.3+_1.7 at 16 weeks (for all intervals p < .002). In those patients with _> 12 weeks of follow-up (n =20), the mean duration of the neurolysis was 133 days (median 112 days, range 2-336 days). At the last available follow-up interval, 52% of patients were using the same and 30% less pain medication than preprocedure and 16 of 48 had a pain score of 0 with the same (n=8) or less pain medication usage (n=8) when compared with baseline. Complications comprised self limited diarrhea (13%) and transient increase in pain (1 of 48). No patients were hospitalized for the procedure. Conclusions: EUS CPN is a safe, effective and long lasting method for improving pain control and reducing pain medication requirements in patients with IAM.
VISUALIZATION OF CELIAC AXIS (CE) AND SUPERIOR MESENTERIC ARTERY (SMA) BY ENDOSCOPIC ULTRASOUND (EUS). D.K.Yao. P.Nguyen, K.J.Cliang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, and I~VA Medical Center, Long Beach, CA. The CE and SMA are important vascular landmarks for EUS of the abdomen. Identifying these structures is critical for nodal/vascular staging and as a prelude to EUS-guided fine needle aspiration (FNA) and EUSguided celiac nerve block. The frequency of visualizing these structures is uncertain. Methods: A prospective evaluation of 111 consecutive patients presenting for their first upper EUS exam was conducted over a one year period (11/4/94-11/3/95). Indications for EUS included 107 patients with suspected or known malignancy (45 pancreatic, 29 esophageal, 24 gastric, and 9 others) and 4 for evaluation of CBD stones. EUS was performed using the Olympus GF-UM3 or GF-UM20 echoendoscope. EUS-guided FNA was performed using the Pentax FG32UA echoendoscope and the GIP-Mediglobe needle. The CE was detected by identifying the aorta at the proximal stomach and advancing the scope until the first branch-point was seen. Alternatively, the splenic artery at the body of the pancreas was followed medially into the celiac trunk. When celiac nodes were visualized, EUS-guided FNA was performed. The SMA was detected either through the proximal stomach or with the antral "pull-back" technique. The SMA was measured bidimensionally from the proximal stomach. Results: In 111 exams, the CE was specifically searched for in 107 and the SMA in 90. The SMA was measured in 73 of 82 exams.
t566
t568
PROSPECTIVE MULTICENTER EVALUATION OF EUS GUIDED FINE NEEDLE ASPIRATION BIOPSY (FNA): DIAGNOSTIC ACCURACY AND COMPLICATION ASSESSMENT. M. Wiersema P. Vilmann, M. Giovannini, K. Chang. Indianapolis, IN; Copenhagen, Denmark; Marseille, France; Orange, CA. Methods: 457 patients underwent EUS FNA of 554 lesions within and adjacent to the gastrointestinal tract. Surgical, autopsy and/or sufficient follow-up to ascertain the final diagnosis were available in 409 patients with 475 lesions. Biopsy sites included: 1.) mass lesions within the esophageal, gastric, duodenal and rectal walls, 2.) periesophageal, perigastric, periduodenal and perirectal lymph nodes/masses, and 3.) pancreas and liver masses. Results: The overall sensitivity for malignant disease is 83%, specificity for benign disease 91%, accuracy for all diagnoses 85%, PPV for malignancy 100% and NPV for benign disease 67%. The sensitivity for malignancy is greater in extraluminal than intraluminal lesions (90% versus 58%, p < .001). The diagnostic accuracy of EUS FNA in evaluating lymph nodes adjacent to the upper gastrointestinal tract and rectum is 94% (95% CI: 90-98%). Technical factors which demonstrate a trend or enhance the yield of EUS FNA include needle size greater than 25 gauge, presence of attendant cytopathology interpretation at the time of the exam, and employment of a needle with a stylet. Five complications occurred in 457 patient exams with three directly attributable to the FNA component (all related to puncture of cystic lesions). In patients with solid lesions the complication rate is .5% (95% CI: .1-.8%)versus 14% (95% CI: 621%) in cystic lesions (p < .001). Conclusions: EUS FNA is a sensitive and safe technique for diagnosing malignancy in patients with solid extraluminal lesions. The test is accurate in distinguishing benign from malignant lymph nodes. Aspiration of cystic lesions should be avoided due to the high risk of infectious complications.
DEPTH OF GASTRIC CANCER INVASION DETERMINED BY ENDOSCOPIC ULTRASONOGRAPHY J. YOSHIKAWA J. MATSUMOTO A. SAISHO T. ARIMA 2nd.Dept.of Int.Med.Kagoshima Univ.Kagoshima 890,Japan. Ability of endoscopic ultrasonography (EUS) for diagnosis of the depth of gastric cancer invasion was evaluated. In 166 patients with gastric cancer consisting of 105 early cancers and 61 advanced cancers, the EUS images obtained before operation or endoscopic mucosal resection were confirmed by the histology of resected specimens. In 119 (71.6%) out of 166 cases the EUS diagnosis corresponded with the histological findings. Overestimation and underestimation in EUS determination was disclosed in 36 and 11 cases respectively. In 30 cases the overestimation seems to be caused by fibrosis in accompanying ulceration as the area of interruptions of the submucosal layer(SM-layer) in EUS seems to be corresponding to the histological fibrosis. The fibrosis due to the ulceration frequently showed tapering or smooth shape at the tip of the interrupted SM-layer in EUS, while cancerous invasion showed an irregular figure at the tip of interrupted SM-layer without fusion toward the mucosal layer. Therefore the shape of the tip is considered to be an important finding in distinguishing cancerous invasion from fibrosis. Thickening of the "proper muscular layer(PM-layer) without interruption in EUS was found in 42 out of the total cases. In 13 of these 42 cases thickening of SM-layer without interruption was observed by EUS and they were histologically determined to have advanced cancers including scirrhus type. In the other 29 cases showing the interrupted SM-layer in addition to the thickening of PM-laYer, varic~us degrees of vertical cancerous invasion were detected. Among these 29 cases, 5 cases showing profound thickening of PM-layer of had advanced cancer. Whereas, findings of mild homogeneous thickening of PM-layer were recognized in 5 cases with early cancers. The findings of mild but unhomogeneous thickening of PM-layer were detected in 19 cases with various degrees of vertical cancerous invasions.In conclusion,the shape of the tip of interrupted SM-layer and the thickening of PM-layer observed by EUS are important determinants for the more exact diagnosis of the depth of gastric cancer invasion.
432
GASTROINTESTINAL ENDOSCOPY
Celiac Axis SMA SMA Short Axis SMA Long Axis
Visualized 106/107 (99%) 82/90 (91%) Ave. length (cm) + SD 0.6-2 + 0.12 0.74+0.14
Not Visualized 1/107 (1%) 8/90 (9%) Range 0.4-0.9 0.4-1.2
95% CI 0.59-0.65 0.71-0.77
EUS-guided FNA of celiac nodes was performed in 5/107 exams (4.7%). In 4/5 (80%), a diagnosis of malignancy was made by EUS-FNA and surgery was avoided. Conclusions: 1) The Celiac Axis was visualized in almost all patients and the SMA in 91%. 2) When detected, EUSguided FNA of celiac nodes was pivotal in avoiding surgery. 3) Routine visualization of these vascular structures should be included in staging relevant cancers.
VOLUME 43, NO. 4, 1996
t'567
ENDOSONOGRAPHY GUIDED CELIAC PLEXUS NEUROLYSIS (EUS CPN) IN PATIENTS WITH PAIN DUE TO INTRA-ABDOMINAL MALIGNANCY (IAM). M Wiersema., L Wiersema. St. Vincent Hospitals and Health Care Center, Indianapolis, IN. Methods: 45 patients (mean age 66 yrs, 40-86) with abdominal pain and confirmed IAM (1~ tumor: pancreas 33, bile duct 3, stomach 2, other 7) underwent 48 EUS CPN procedures. 37 procedures were performed at the same setting as the EUS staging exam with fine needle aspiration biopsy (cytologically confirming IAM), 9 procedures were performed for EUS CPN alone (3 repeat) and 2 were performed at the time of ERCP with biliary stent placement. EUS CPN was performed via a transgastric approach with the linear array echoendoscope (Pentax) and a 4 cm 23 gauge needle (Wilson-Cook). Bupivacalne .25% (3 cc) followed by absolute ETOH (10 cc) was injected on both sides of the aorta at the level of the celiac trunk (total volume 26 cc). Pain was assessed pre- and post EUS CPN by a visual analog scale (range:0-10). Follow up evaluation occurred at 2, 7, 14 and 28 days and then monthly thereafter. Paired pre- and post EUS CPN pain scores were compared using the Wilcoxon signed rank test with a decrease in the pain score of > 3 required for a positive response (i.e.//o:#=3). Results: With a median follow-up of 92 days (range: 2-372), the mean pain score improved from a baseline of 6.7+_2.0 (range 2-10,median 7) to 1.7+_1.9 at 2 weeks, 2.0_+2.0 at 4 weeks, 2.0+_2.6 at .8 weeks, 1.3+_1.9 at 12 weeks and 1.3+_1.7 at 16 weeks (for all intervals p < .002). In those patients with _> 12 weeks of follow-up (n =20), the mean duration of the neurolysis was 133 days (median 112 days, range 2-336 days). At the last available follow-up interval, 52% of patients were using the same and 30% less pain medication than preprocedure and 16 of 48 had a pain score of 0 with the same (n=8) or less pain medication usage (n=8) when compared with baseline. Complications comprised self limited diarrhea (13%) and transient increase in pain (1 of 48). No patients were hospitalized for the procedure. Conclusions: EUS CPN is a safe, effective and long lasting method for improving pain control and reducing pain medication requirements in patients with IAM.
VISUALIZATION OF CELIAC AXIS (CE) AND SUPERIOR MESENTERIC ARTERY (SMA) BY ENDOSCOPIC ULTRASOUND (EUS). D.K.Yao. P.Nguyen, K.J.Cliang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, and I~VA Medical Center, Long Beach, CA. The CE and SMA are important vascular landmarks for EUS of the abdomen. Identifying these structures is critical for nodal/vascular staging and as a prelude to EUS-guided fine needle aspiration (FNA) and EUSguided celiac nerve block. The frequency of visualizing these structures is uncertain. Methods: A prospective evaluation of 111 consecutive patients presenting for their first upper EUS exam was conducted over a one year period (11/4/94-11/3/95). Indications for EUS included 107 patients with suspected or known malignancy (45 pancreatic, 29 esophageal, 24 gastric, and 9 others) and 4 for evaluation of CBD stones. EUS was performed using the Olympus GF-UM3 or GF-UM20 echoendoscope. EUS-guided FNA was performed using the Pentax FG32UA echoendoscope and the GIP-Mediglobe needle. The CE was detected by identifying the aorta at the proximal stomach and advancing the scope until the first branch-point was seen. Alternatively, the splenic artery at the body of the pancreas was followed medially into the celiac trunk. When celiac nodes were visualized, EUS-guided FNA was performed. The SMA was detected either through the proximal stomach or with the antral "pull-back" technique. The SMA was measured bidimensionally from the proximal stomach. Results: In 111 exams, the CE was specifically searched for in 107 and the SMA in 90. The SMA was measured in 73 of 82 exams.
t566
t568
PROSPECTIVE MULTICENTER EVALUATION OF EUS GUIDED FINE NEEDLE ASPIRATION BIOPSY (FNA): DIAGNOSTIC ACCURACY AND COMPLICATION ASSESSMENT. M. Wiersema P. Vilmann, M. Giovannini, K. Chang. Indianapolis, IN; Copenhagen, Denmark; Marseille, France; Orange, CA. Methods: 457 patients underwent EUS FNA of 554 lesions within and adjacent to the gastrointestinal tract. Surgical, autopsy and/or sufficient follow-up to ascertain the final diagnosis were available in 409 patients with 475 lesions. Biopsy sites included: 1.) mass lesions within the esophageal, gastric, duodenal and rectal walls, 2.) periesophageal, perigastric, periduodenal and perirectal lymph nodes/masses, and 3.) pancreas and liver masses. Results: The overall sensitivity for malignant disease is 83%, specificity for benign disease 91%, accuracy for all diagnoses 85%, PPV for malignancy 100% and NPV for benign disease 67%. The sensitivity for malignancy is greater in extraluminal than intraluminal lesions (90% versus 58%, p < .001). The diagnostic accuracy of EUS FNA in evaluating lymph nodes adjacent to the upper gastrointestinal tract and rectum is 94% (95% CI: 90-98%). Technical factors which demonstrate a trend or enhance the yield of EUS FNA include needle size greater than 25 gauge, presence of attendant cytopathology interpretation at the time of the exam, and employment of a needle with a stylet. Five complications occurred in 457 patient exams with three directly attributable to the FNA component (all related to puncture of cystic lesions). In patients with solid lesions the complication rate is .5% (95% CI: .1-.8%)versus 14% (95% CI: 621%) in cystic lesions (p < .001). Conclusions: EUS FNA is a sensitive and safe technique for diagnosing malignancy in patients with solid extraluminal lesions. The test is accurate in distinguishing benign from malignant lymph nodes. Aspiration of cystic lesions should be avoided due to the high risk of infectious complications.
DEPTH OF GASTRIC CANCER INVASION DETERMINED BY ENDOSCOPIC ULTRASONOGRAPHY J. YOSHIKAWA J. MATSUMOTO A. SAISHO T. ARIMA 2nd.Dept.of Int.Med.Kagoshima Univ.Kagoshima 890,Japan. Ability of endoscopic ultrasonography (EUS) for diagnosis of the depth of gastric cancer invasion was evaluated. In 166 patients with gastric cancer consisting of 105 early cancers and 61 advanced cancers, the EUS images obtained before operation or endoscopic mucosal resection were confirmed by the histology of resected specimens. In 119 (71.6%) out of 166 cases the EUS diagnosis corresponded with the histological findings. Overestimation and underestimation in EUS determination was disclosed in 36 and 11 cases respectively. In 30 cases the overestimation seems to be caused by fibrosis in accompanying ulceration as the area of interruptions of the submucosal layer(SM-layer) in EUS seems to be corresponding to the histological fibrosis. The fibrosis due to the ulceration frequently showed tapering or smooth shape at the tip of the interrupted SM-layer in EUS, while cancerous invasion showed an irregular figure at the tip of interrupted SM-layer without fusion toward the mucosal layer. Therefore the shape of the tip is considered to be an important finding in distinguishing cancerous invasion from fibrosis. Thickening of the "proper muscular layer(PM-layer) without interruption in EUS was found in 42 out of the total cases. In 13 of these 42 cases thickening of SM-layer without interruption was observed by EUS and they were histologically determined to have advanced cancers including scirrhus type. In the other 29 cases showing the interrupted SM-layer in addition to the thickening of PM-laYer, varic~us degrees of vertical cancerous invasion were detected. Among these 29 cases, 5 cases showing profound thickening of PM-layer of had advanced cancer. Whereas, findings of mild homogeneous thickening of PM-layer were recognized in 5 cases with early cancers. The findings of mild but unhomogeneous thickening of PM-layer were detected in 19 cases with various degrees of vertical cancerous invasions.In conclusion,the shape of the tip of interrupted SM-layer and the thickening of PM-layer observed by EUS are important determinants for the more exact diagnosis of the depth of gastric cancer invasion.
432
GASTROINTESTINAL ENDOSCOPY
Celiac Axis SMA SMA Short Axis SMA Long Axis
Visualized 106/107 (99%) 82/90 (91%) Ave. length (cm) + SD 0.6-2 + 0.12 0.74+0.14
Not Visualized 1/107 (1%) 8/90 (9%) Range 0.4-0.9 0.4-1.2
95% CI 0.59-0.65 0.71-0.77
EUS-guided FNA of celiac nodes was performed in 5/107 exams (4.7%). In 4/5 (80%), a diagnosis of malignancy was made by EUS-FNA and surgery was avoided. Conclusions: 1) The Celiac Axis was visualized in almost all patients and the SMA in 91%. 2) When detected, EUSguided FNA of celiac nodes was pivotal in avoiding surgery. 3) Routine visualization of these vascular structures should be included in staging relevant cancers.
VOLUME 43, NO. 4, 1996