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Diagnosis and management of mucinous ductal ectasia of the pancreas
ENDOSCOPIC ULTRASOUND
?543
7541 INTP,A D U C T A L ULTRASOUND (IDUS) IN THE DIA(IOS1S OF STENOSING PROCESSES IN THE PANCREATOBILIARY TRACI" J.Menzel, E.-Ch. Foerster, W. Domschke, Department of Medicine B, University of Muenster, Germany Endoscopic retrograde cholangiopancreatography (ERCP) depicts stenosis in the pancreatobiliary tract fluoroscopically. Additional information on infiltrative growth into adjacent tissue contributes to the differentiation between benign and malignant stenosis, lntraductal ultrasonographic imaging (IDUS) with newly developed probes becomes possible during ERCP. D u r i n g E R C P m e c h a n i c a l and e l e c t r o n i c p r o b e s ( A l o k a TM, Microvasive TM, Endosonics TM) with diameters of 3.5 up to 6.2 French were inserted via the operating channel of a routine duodenoscope (Olympus JF1T20). 53 patients underwent intraductal ultrasound with these probes. In 32 patients (17 women, 15 men) the probe was inserted into the biliary tract, in 21 patients (9 women, 12 men) into the pancreatic duct. Endoscopic s p h i n c t e r o t o m y was n e c e s s a r y to perform 12 IDUS examinations, lntraductal ultrasound up hepatic hilum was possible in all patients. IDUS of the tail of the pancreas was possible in 48%, of the body in 90% and of the head of the pancreas in 95%. Due to ultrasound frequencies of of 12.5 up to 30 MHz imaging of stenoses in microscopic dimension of a magnifiying glass was possible. Malignant infiltrations of the pancreatic duct appeared inhomogeneously echopoor, whereas carcinoma of the bile duct appeared echodense. Lymph nodes of a size of 5 mm in diameter adjacent to the bile duct were visualized. The high ultrasound frequency of the probes limits the penetration depth. Thus the extension only of small tumors could be demonstrated completely. Rotation of the cable in mechanical probes limits the flexibility. However, following prior dilatation all stenoses could be passed with the probes. On average intraductal ultrasound examination during ERCP took 6:16 minutes (1:23 up to 13:36). There was no indication of any injury to the duct system or the pancreas. lntraductal ultrasound of the pancreatobiliary tract is a secure, easy and quick examination which can be performed during ERCP. IDUS provides e x e l l e n t i m a g e s and gives important s u p p l e m e n t a r y ~nformation on the periductal tissue. Controlled studies to compare the diagnostic value of IDUS with that of conventional techniques (EUS, CT) are currently underway.
DIAGNOSIS AND MANAGEMENT OF MUCINOUS DUCTAL ECTASIA OF THE PANCREAS. H. Mukai, K. Tanaka, S. Hirano~ K. Yasuda, and M. Nakajima~ Department of Gastroenterology~ Kyoto Second Red Cross Hospital, Kyoto, Japan. Although mueinous ductal ectasia of the pancreas has been recently recognized as a premalignant or malignant neoplasm, its diagnosis and management have been undetermined yet. To resolve these problems, endoscopic ultrasonography(EUS), intraduetal ultrasonography(IDUS), and peroral panereatosoopy(PPS) were applied in comparison with other diagnostic tools such as US, CT, and ERCP. From 1986 to 1995, 27 patients with mucinous duetal ectasia of the pancreas (7 with adenoearcinoma, 17 with adenoma, and 3 with hyperplasia) underwent surgery. In this series, US, C~, ERCP, and EUS were done in all patients. IDUS and PPS were performed in 23 patients. Tumorous lesions within the dilated main and branch ducts were histologically divided into three groups from their maximum height; group i with tumors more than 3 rmm in height w a s recognized in II patients(6 with adenoeareinoma and 5 with adenoma), group 2 with tumors between i mm and 3 Ha was experienced in 12(1 with adenocareinoma, i0 with adenoma, and i with hyperplasia), and group 3 with tumors less than i m m w a s observed in h(2 with adenoma and 2 with hyperplasi~). In 22 of 23 patients(96 %), tumors more than ~ ~m in height (group i and 2) were adenocarcinoma or adenoma. The detection rates of these tumors were 13 % with US~ 9 % with CT, 52 % with EUS, 95 % with IDUS, and 70 % with PPS. ERCP was difficult to differentiate between tumors and mucus within the ducts. In patients with adenoeareinoma or adenoma, PPS revealed taller papillary tumors with reddish mucosa or capillary vessels. In patients with adenoma or hyperplasia, villous tumors like fish-eggs were also inspected by PPS. Biopsy and cytologytaken under PPS and/or ERCP had 67 % sensitivity and i00 % specificity in differential diagnosis between ~alignancy and benign lesions. From these results, it was concluded that mucinous ductal ectasia of the pancreas with tumorous lesions more than i mm in the maximum height should be considered as adenocareinoma or adenoma. IDUS and PPS with biopsy and cytology were the most reliable procedures in the management of this disease.
?542
*544
IS ENDOSCOPIC ULTRASOUND HELPFUL IN THE MANAGEMENT OF GASTROINTESTINAL CARCINOID TUMORS? V.K. Parasber,M.D. P~ Spinelli,M.D. National Cancer Institute, Milan,Italy In&r~luetiun There is sparse data available regarding the role of EUS in the management ofcarcinoid tumors. Since the decision of surgical intervention depends on the size of the tumor and invasion into the layer structure, EUS by its capability of delineating tbe 5 layers, has an important role in the staging of carcinoid tumors. Herein, we describe our experience in evaluation of the effectiveness of EUS in staging of gastrointestinal carcinoids, ly~ethods Between Nov. 1991 and Dec. 1995, 26 EUS examinations were performed in 18 patients with carcinoid tumor. Endoscopy and EUS examination was performed in 6 pts, while 20 pts underwent followup EUS exams only. EUS was performed by radial sector scanner GFUM20, CFUM20 and size of the tumor, ecbogenicity, layer of origin, invasion into surrounding structures and metastasis were noted along with pathological correlation. ~ T h e pts consisted of 5 M, 13 F; mean age 53.3yrs. Carcinoid tumor was present in stomach (4), duodenum (2), pancreas (2), and rectum (10). Among 6 cases for staging, (3 gastric, 1 pancreatic, 2 rectal) the tumor size was less than lcm in 4, greater than lcm in 2. In 2 pts a bypoechoic mass was seen arising from mucosa while in 2 submucosa was involved, tpt had pancreatic head and tail lesion while 1 pt with duodenal carcinoid showed invasion in pancreatic head. Metastatic disease was present in 3 pts. 4 were removed endnscopically with pathological correlation and no recurrence. 1 pt had radical resection while 1 is awaiting therapy. Among foliowup of rectal carcinoids, all lesions were less than I cm and were removed as a polyp before EUS. No recurrence was found with mean F/U 2.2yrs (9mths-4yrs); 2 gastric carcinoid no recurrence occurred in mean F/U 2.5yrs (3mths-2yrs) while no recurrence occurred in duodenal carcinoid F/U lyr; 1 pancreatic carcinoid was reseeted surgically 13 yrs earlier and presented with recurrence (metastatic perigastric nodes) by EUS. C_oae|usion 1.EUS is useful in planning the management of carcinoid tumor. 2.Tumor less than lcm in size and showing no evidence of invasion/metastasis (localized to mucosa or submucosa) can be endoscopically resected and may not require a F/U by EUS. 3.Tumor more than lcm in size and with evidence of invasion/metastaticdisease may require radical surgery and F/U.
DOES NORMAL ENDOSCOPIC ULTRASOUND (EUS) REALLY AVOID ERCP IN PATIENTS WITH SUSPICION OF BILE DUCT STONE? STUDY IN 238 PATIENTS. ~ , Keriven-Souquet O, Pujol B, Souquet JC, Ponchon T. Hrpital E Herriot and Clinique St Jean, Lyon, France.
426
GASTROINTESTINAL ENDOSCOPY
Biliary EUS is as performant as ERCP for the diagnosis of bile duct stone (BDS). In case of strong clinical evidence for BDS, ERCP is preferred as it allows simultaneously the diagnosis and treatment. In case of moderate suspicion of BDS, EUS, a less invasive method, can be proposed. However in this setting, ERCP could be simply delayed at the next symptomatic recurrence. The aim of the presentstudy was to determine whether a normal EUS can really avoid ERCP. Patients and methods: From June 93 to October 94, all patients referred in 2 centers for biliary EUS because of clinical, biological and/or ultrasound suspicion of BDS were prospectively included. EUS was performed under anesthesia with Olympus GF/JF M20. Early (one month) and late follow-up (> one year) were obtained by mail or phone call for clinical evolution, and need of ERCP or surgery. Results: 328 patients were included. EUS concluded to biliary disease in 90 cases. Thus 238 patients (58 previously cholecystectomized) with normal EUS were followed. Table shows the number of patients having ERCP or cholecystectomy during follow-up. The number of BDS found is given in brackets. n = 238 lost to follow-up cholecystectomy: - without choiangiography with cholangiograpby ERCP -
early 0 21 29 (3) 18 (11)
late (median 490d) 14 7 2 (0) 10 (0)
15 ERCP (6%) were done within 7 days after normal EUS due to a strong and persistant suspicion of BDS. Only 13 ERCP (5%) were performed more than 7 days after EUS. They were useful in 6 cases (8DS and ampullary sclerosis in 1 case ampullary sclerosis in 3, biliary tumor in 2. Thus in all but one case, BDS were found only at initial evaluat on and not at the moment of symptomatic recurrence. Conclusions: Patients with suspicion of 8DS and negative EUS had a very low risk to need an ERCP during follow-up. Thus EUS, and not ERCP, is the best imaging method in case of moderate suspicion of stone migraUon.
VOLUME 43, NO. 4, 1996
?543
7541 INTP,A D U C T A L ULTRASOUND (IDUS) IN THE DIA(IOS1S OF STENOSING PROCESSES IN THE PANCREATOBILIARY TRACI" J.Menzel, E.-Ch. Foerster, W. Domschke, Department of Medicine B, University of Muenster, Germany Endoscopic retrograde cholangiopancreatography (ERCP) depicts stenosis in the pancreatobiliary tract fluoroscopically. Additional information on infiltrative growth into adjacent tissue contributes to the differentiation between benign and malignant stenosis, lntraductal ultrasonographic imaging (IDUS) with newly developed probes becomes possible during ERCP. D u r i n g E R C P m e c h a n i c a l and e l e c t r o n i c p r o b e s ( A l o k a TM, Microvasive TM, Endosonics TM) with diameters of 3.5 up to 6.2 French were inserted via the operating channel of a routine duodenoscope (Olympus JF1T20). 53 patients underwent intraductal ultrasound with these probes. In 32 patients (17 women, 15 men) the probe was inserted into the biliary tract, in 21 patients (9 women, 12 men) into the pancreatic duct. Endoscopic s p h i n c t e r o t o m y was n e c e s s a r y to perform 12 IDUS examinations, lntraductal ultrasound up hepatic hilum was possible in all patients. IDUS of the tail of the pancreas was possible in 48%, of the body in 90% and of the head of the pancreas in 95%. Due to ultrasound frequencies of of 12.5 up to 30 MHz imaging of stenoses in microscopic dimension of a magnifiying glass was possible. Malignant infiltrations of the pancreatic duct appeared inhomogeneously echopoor, whereas carcinoma of the bile duct appeared echodense. Lymph nodes of a size of 5 mm in diameter adjacent to the bile duct were visualized. The high ultrasound frequency of the probes limits the penetration depth. Thus the extension only of small tumors could be demonstrated completely. Rotation of the cable in mechanical probes limits the flexibility. However, following prior dilatation all stenoses could be passed with the probes. On average intraductal ultrasound examination during ERCP took 6:16 minutes (1:23 up to 13:36). There was no indication of any injury to the duct system or the pancreas. lntraductal ultrasound of the pancreatobiliary tract is a secure, easy and quick examination which can be performed during ERCP. IDUS provides e x e l l e n t i m a g e s and gives important s u p p l e m e n t a r y ~nformation on the periductal tissue. Controlled studies to compare the diagnostic value of IDUS with that of conventional techniques (EUS, CT) are currently underway.
DIAGNOSIS AND MANAGEMENT OF MUCINOUS DUCTAL ECTASIA OF THE PANCREAS. H. Mukai, K. Tanaka, S. Hirano~ K. Yasuda, and M. Nakajima~ Department of Gastroenterology~ Kyoto Second Red Cross Hospital, Kyoto, Japan. Although mueinous ductal ectasia of the pancreas has been recently recognized as a premalignant or malignant neoplasm, its diagnosis and management have been undetermined yet. To resolve these problems, endoscopic ultrasonography(EUS), intraduetal ultrasonography(IDUS), and peroral panereatosoopy(PPS) were applied in comparison with other diagnostic tools such as US, CT, and ERCP. From 1986 to 1995, 27 patients with mucinous duetal ectasia of the pancreas (7 with adenoearcinoma, 17 with adenoma, and 3 with hyperplasia) underwent surgery. In this series, US, C~, ERCP, and EUS were done in all patients. IDUS and PPS were performed in 23 patients. Tumorous lesions within the dilated main and branch ducts were histologically divided into three groups from their maximum height; group i with tumors more than 3 rmm in height w a s recognized in II patients(6 with adenoeareinoma and 5 with adenoma), group 2 with tumors between i mm and 3 Ha was experienced in 12(1 with adenocareinoma, i0 with adenoma, and i with hyperplasia), and group 3 with tumors less than i m m w a s observed in h(2 with adenoma and 2 with hyperplasi~). In 22 of 23 patients(96 %), tumors more than ~ ~m in height (group i and 2) were adenocarcinoma or adenoma. The detection rates of these tumors were 13 % with US~ 9 % with CT, 52 % with EUS, 95 % with IDUS, and 70 % with PPS. ERCP was difficult to differentiate between tumors and mucus within the ducts. In patients with adenoeareinoma or adenoma, PPS revealed taller papillary tumors with reddish mucosa or capillary vessels. In patients with adenoma or hyperplasia, villous tumors like fish-eggs were also inspected by PPS. Biopsy and cytologytaken under PPS and/or ERCP had 67 % sensitivity and i00 % specificity in differential diagnosis between ~alignancy and benign lesions. From these results, it was concluded that mucinous ductal ectasia of the pancreas with tumorous lesions more than i mm in the maximum height should be considered as adenocareinoma or adenoma. IDUS and PPS with biopsy and cytology were the most reliable procedures in the management of this disease.
?542
*544
IS ENDOSCOPIC ULTRASOUND HELPFUL IN THE MANAGEMENT OF GASTROINTESTINAL CARCINOID TUMORS? V.K. Parasber,M.D. P~ Spinelli,M.D. National Cancer Institute, Milan,Italy In&r~luetiun There is sparse data available regarding the role of EUS in the management ofcarcinoid tumors. Since the decision of surgical intervention depends on the size of the tumor and invasion into the layer structure, EUS by its capability of delineating tbe 5 layers, has an important role in the staging of carcinoid tumors. Herein, we describe our experience in evaluation of the effectiveness of EUS in staging of gastrointestinal carcinoids, ly~ethods Between Nov. 1991 and Dec. 1995, 26 EUS examinations were performed in 18 patients with carcinoid tumor. Endoscopy and EUS examination was performed in 6 pts, while 20 pts underwent followup EUS exams only. EUS was performed by radial sector scanner GFUM20, CFUM20 and size of the tumor, ecbogenicity, layer of origin, invasion into surrounding structures and metastasis were noted along with pathological correlation. ~ T h e pts consisted of 5 M, 13 F; mean age 53.3yrs. Carcinoid tumor was present in stomach (4), duodenum (2), pancreas (2), and rectum (10). Among 6 cases for staging, (3 gastric, 1 pancreatic, 2 rectal) the tumor size was less than lcm in 4, greater than lcm in 2. In 2 pts a bypoechoic mass was seen arising from mucosa while in 2 submucosa was involved, tpt had pancreatic head and tail lesion while 1 pt with duodenal carcinoid showed invasion in pancreatic head. Metastatic disease was present in 3 pts. 4 were removed endnscopically with pathological correlation and no recurrence. 1 pt had radical resection while 1 is awaiting therapy. Among foliowup of rectal carcinoids, all lesions were less than I cm and were removed as a polyp before EUS. No recurrence was found with mean F/U 2.2yrs (9mths-4yrs); 2 gastric carcinoid no recurrence occurred in mean F/U 2.5yrs (3mths-2yrs) while no recurrence occurred in duodenal carcinoid F/U lyr; 1 pancreatic carcinoid was reseeted surgically 13 yrs earlier and presented with recurrence (metastatic perigastric nodes) by EUS. C_oae|usion 1.EUS is useful in planning the management of carcinoid tumor. 2.Tumor less than lcm in size and showing no evidence of invasion/metastasis (localized to mucosa or submucosa) can be endoscopically resected and may not require a F/U by EUS. 3.Tumor more than lcm in size and with evidence of invasion/metastaticdisease may require radical surgery and F/U.
DOES NORMAL ENDOSCOPIC ULTRASOUND (EUS) REALLY AVOID ERCP IN PATIENTS WITH SUSPICION OF BILE DUCT STONE? STUDY IN 238 PATIENTS. ~ , Keriven-Souquet O, Pujol B, Souquet JC, Ponchon T. Hrpital E Herriot and Clinique St Jean, Lyon, France.
426
GASTROINTESTINAL ENDOSCOPY
Biliary EUS is as performant as ERCP for the diagnosis of bile duct stone (BDS). In case of strong clinical evidence for BDS, ERCP is preferred as it allows simultaneously the diagnosis and treatment. In case of moderate suspicion of BDS, EUS, a less invasive method, can be proposed. However in this setting, ERCP could be simply delayed at the next symptomatic recurrence. The aim of the presentstudy was to determine whether a normal EUS can really avoid ERCP. Patients and methods: From June 93 to October 94, all patients referred in 2 centers for biliary EUS because of clinical, biological and/or ultrasound suspicion of BDS were prospectively included. EUS was performed under anesthesia with Olympus GF/JF M20. Early (one month) and late follow-up (> one year) were obtained by mail or phone call for clinical evolution, and need of ERCP or surgery. Results: 328 patients were included. EUS concluded to biliary disease in 90 cases. Thus 238 patients (58 previously cholecystectomized) with normal EUS were followed. Table shows the number of patients having ERCP or cholecystectomy during follow-up. The number of BDS found is given in brackets. n = 238 lost to follow-up cholecystectomy: - without choiangiography with cholangiograpby ERCP -
early 0 21 29 (3) 18 (11)
late (median 490d) 14 7 2 (0) 10 (0)
15 ERCP (6%) were done within 7 days after normal EUS due to a strong and persistant suspicion of BDS. Only 13 ERCP (5%) were performed more than 7 days after EUS. They were useful in 6 cases (8DS and ampullary sclerosis in 1 case ampullary sclerosis in 3, biliary tumor in 2. Thus in all but one case, BDS were found only at initial evaluat on and not at the moment of symptomatic recurrence. Conclusions: Patients with suspicion of 8DS and negative EUS had a very low risk to need an ERCP during follow-up. Thus EUS, and not ERCP, is the best imaging method in case of moderate suspicion of stone migraUon.
VOLUME 43, NO. 4, 1996