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Endoscopic ultrasonographic features of gastric aberrant pancreas without central dimpling
ENDOSCOPIC ULTRASOUND ~'617
619
EUS.GUIDED FNA: A MULTIVARIATE ANALYSIS OF PROCEDURAL CHARACTERISTICSASSOCIATEDWITHA POSITIVEPATHOLOGICALDIAGNOa8 OF MALIGNANCYAVSahaLL kabekkon,J Wd)b, MWilson,W Wassaf,M Zlmmennan, PD Mauldin,A VanVeise,RH Hawos,BJ Hoffrsan. DigestiveDiseaseCenter,Medical Unlvemltyof SouthCarolina,Charleston,SC.AIM:Todeterminetschnisalcharecteds~cs of EUS-guidedfine needleasplre~ (EUSGFNA)associatedwitha positivepathological diagnosisof cancer.METHODS:ProceduralcharectodsUcsof EUSGFNApasseson isslop.ssuspectfor malignancywareprospectivelyrecorded. "rheWilson-CookeacdGIP needleswereusedaccordingto endor preference.Eachpasspmducad3-4slides. Cytopathologistsin the roomstudied1 slide per passfor cellularadequacy.All slides warelaterstednadandstudiedfor the finaldiagnosis.Non.pererneldcunivedateanalysis determinedvariablesindependentlycorrelatedwith malignanthistology. Multivedate logis~cregression(withconlmlfor rnulScollnesdty)was usedtoconbolfor croas-vedable effects (a--0.05). RESULTS: There ware 177 passes in 46 lesions (avg. 3.8 passas/lasion),In 45 patients.00(45%)passesshowedmalignancy;97(55%)did not. Vadsbtssstudiedinclude: type(101 nodes,70 masses),location(70 mediastinum,63 pancreas,20 celiacrods,12esophagus,5 pad-rectum,5rectum,2 ped-gasthc),hazdnoss (79 soft, 55 hard, 36 medium, 4 unspecified),slroke length (90 short, 74 long, 7 unspadfled), samplingsite (111 center, 59 edge, 7 unspadfled),aspiratesize (131 ample,30 scant,15 unspecified),and mpbatobkxxllneas(50bloody,55 non-blcody,53 visibleblood, 13 unspecified).Basedon availabledatain a subgroupof 19 malignant lesions, the 1st passwas positivein 11119(58%),2nd passin 7/19(37%),3rd passIn 1/19(5%). PREDICTORSOF POSITIVEDIAGNOSISOF CANCERBY EU8GFNA LesioncharectedsUc + or- predictor p (Univedsto) p (Multlvedate) madlestinallosa~on posmve 0.0002 0.0002 samplesite 'edge" pco~ve 0.03 0.02 ! lymphnode pcomve NS 0.05 ponorea~cIona~n ne~a0ve 0.007 0,004 mass negative NS 0.05 samplesite "centor' re~gative NS 0.04 In~pendontpred~ .guld~JFNAdiagnosis)f malignancywam medlas0nellocaUonandasmpll~i attbe odgeof tho laslon.PancrsattclocaUonwesthe onlyindependentpredictorof failure.Malignancycouldbe dlagno~ alter2 passes in 95%of patients,andin 100%after3 p a ~ . CONCLUSIONS:To optimizethe yieldof EUS-gukfedFNA,ledoneshouldbe sampledat ~ edge,4 passesshouldbe adequate tOdiagnosemalignancyin S SUSpiCiOUSlesion.
HOW OFTEN IS LINEAR ARRAY EUS NEEDED IN ADDITION TO RADIAL SCANNING? T.J. Savides. Division of Gestnentenlogy, University of California, San Diego Pvrposo: To determine how often the addition of a linear array EUS scope is needed in cases performed with a radial scanner EUS scope. Methods: A single endosonographer, with experience using the Pentax FG-32UA linear array echoendoscopeand performing EUSguided fine needle aspiration (FNA), prospectively recorded which patients undergoing EUS with an Olympus GT-UM2O echoendoscope would likely have clinical management changed if a Pentax linear array echoendoscope were available. Data w e n recorded prospectively into a computer database from 8/94 to 11196. Results: In 39 out of 194 (20%) of EUS cases performed with the radial scanner, it was felt that a linear array echoendoscope would have also been helpful. The linear array scope was felt indicated in 16/60 (27%) of pancnatico-biliary-duodenal cases, 14/58 (24%) of esophageal/mediastinal cases, 7/51 (14%) of gastnc cases, 2/27 (7%) of anomctal cases. The nasons for desiring the linear array scope were to perform FNA in 27139 (69%), easier visualization of an abnormality in 10/38 (26%), and need for Doppler to assess vasculanty in 2138 (5%). Among potential FNA cases, 13/27 (48%) were for lymph nodes, 12/27 (44%) for a mass lesion, and 2/27 (7%) forafluid cotiection. Linear arnywas desirable in 12/50 (24%) ofthe first cases, in the second 50 cases in 13/50 (26%), in the third 50 cases in 6150 (12%), and in the last 44 cases in 6144 (14%). Conclusions: 1) The addition ofa Pentax linear array EUS scope was felt to be needed in 20% of EUS cases performed with an Olympus radial scanning EUS scope. 2) The most common mason for needing the Pentax scope was to perform fine needle aspintion of a mass or lymph node. 3) Doppler flow capabilities w e n seldom needed to complement the Olympus scope.
:]:618
620
A PROSPECTNEAUF.UW:NT OFENBOSCOPICULTRASOUNDACCURACYFOR DIAGNOSINGCAMBRIDGEC L ~ > 2 OR 9 3 CHRONICPANCREATITI8AVSahal. M Zimmerman, L Aabakken,RH Haw=z,A VacVebe, P Tarnesky, PD Mauldlo,J Cunnlngham,PB Co4ton,BJ ~ . DigestiveDiasaNCenter,MedicalUnivendtyof SouthC = ~ , Ctume=on,SC.&l~:To~ v ~ ~ accuracyof ~ ulbesound(EUS)r fordlagncdngmM and modem~chronicpencrsatl~(Cp) as defined by pancmatogrephyusing the Cambridgecdtsda (CC) for Into~mJta~on, METHOD~:Pabnts wl~ unexplainedabdominalpainundergoingpancrea~EUSand ERCPwerepm~oactlvdystudied.EUSwas pedmnodby experiencedoparstoreaware of the clinicalhl~ory,but blindedto ERCPresults.The CC are as follows:0='normar, l='equl,,osar(r,orm~ (N)nu~npencmaUcduct(MPD)+ <3 ahoorm~(~) sidebrenchos (ASB)),2='mild"(NMPD+ >3aNSB),3='modereto"(aNMPD+ >3aNS8)."PcoltlveEUS" was definedas the presenceof =mycomblnefonof 1 to 6 of the following cdtoda: hyperecholofed (HI=),h y ~ scands,lobdadty(L), inagutsrduct margins(ID), hypemcholcductmetglm,andvisiblesidebranchos(VS)."CP"was definedos a CC of ==2or ==3. RESULTS:98 pabents:18 CC'0",9 CC"1", 21 CC"2",32 CC'3",and 18 CC'4". No EUS-relatadcom?licaUonsoccurred. CAMBRIDGECLASS>2 CHRONICPANCREATITI8 # EUScdteda ==1 =.2 ==3 z4 ==5 6 96 85 73 63 41 21 a[oedf~-.,~ 22 48 56 74 81 100 pco.I~od.veL (PIN) 76 51 81 87 85 100 nag. pred.vel. (NPV) 67 54 44 43 34 33 CAMBRIDGECLASS=,3CHRONICPANCREATITIS # EUScdteda >1 ==2 >3 ==4 >5 . 5 sensitivity 96 90 00 74 50 20 spesifictiy 15 40 50 69 81 98 Jx~.pred.val. (FPV) 54 54 63 71 74 87 neg, pred.vel. (NPV) 78 79 71 72 51 55 Univadate analysis (n=66) showed4 independentpredistomof CP: HF(p=0.006), ID(p=0.025),VS(p=0.036),and L(p=0.053).SUMM.~R'(:Presenceof 5 EUS clttodais di~nos~c(PPV100%)of mildCP(CC~2) and highlypredictive(PPV87%)of moderato CP(CCz3); ==4 cdtodais highlypredictiveof mildCP(CC==2).Thisis line evenwhen powerful predictomof CP,suchas cabificatlons,ductdilaUon,and pseudoo/stsare not used.CONCLUSION:In palientswi~ unexplainedsbdominelpain, EUSis a safeand effectivein dtsgnosingERCP-definadmildand moderateCP.
ENDOSCOPIC ULTRASONOGRAPHIC FEATURES OF GASTRIC ABERRANT PANCREAS WITHOUT CENTRAL DIMPLING. C.S. Shim. H.K. Bong, Y.H. Lee, Y.D. Cho, J.O. Kim, J.Y. Cho, Y.S. Kim, J.S. Lee, M.S. Lee, S.G. Hwang. Institute for Digestive Research, Department of Internal medicine, Soon Chun Hyang University, Seoul, Korea. Background: Gastric aberrant pancreas can be easily diagnosed by conventional endoscopy and radioiogic modalities due to its characteristic feature such as central dimpling. However, in cases of aberrant pancreas without the central dimpling, the differential diagnosis has been some troublesome. As for differential diagnosis of gastric submucosal tumors, endoscopic ultrasonography(EUS) allow us to visualize the structures underlying the gastrointestinal wall in noninvasive manner, and has the great advantage over the conventional modalities such as conventional endoscopy and UGI series. Aim: To evaluate the EUS finding of gastric aberrant pancreas without the central dimpling. Patients & Methods: We compared EUS features in 10 cases of gastric aberrant pancreas without the central dimpling to those in 16 cases with the central dimpling. Results: These lesions were demonstrated mainly as heterogenous(84.6%), intermediate internal echoic(100%) tumors with 1-2cm in diameter(88.5%), unclear boundary(82.1%) and endoluminai growth pattern(76.9%) located in the submucosal layer(100%) of gastric wall by EUS. Also, 19.296 has been accompanied with the changes of the proper muscle layer, such as thickening or irregularity of 4th layer in gastric wail. In gastric aberrant pancreas without the central dimpling, 40% of the lesions has the internal cystic area. The sizes of gastric aberrant pancreas without central dimpling(1.5+0.3 cm) was larger than those with central dimpling(1.3:t: 0.3 cm). In gastric aberrant pancreas located on the body or fundus of stomach, 66.7 % of lesions are without the central dimpling. Conclusion: These EUS findings(internal cystic area, located on the body or fundus of stomach, larger size) will be helpful to make a diagnosis of gastric aberrant pancreas although the characteristic central dimpling does not exist.
VOLUME 45, NO. 4, 1997
GASTROINTESTINAL ENDOSCOPY A B 1 7 9
619
EUS.GUIDED FNA: A MULTIVARIATE ANALYSIS OF PROCEDURAL CHARACTERISTICSASSOCIATEDWITHA POSITIVEPATHOLOGICALDIAGNOa8 OF MALIGNANCYAVSahaLL kabekkon,J Wd)b, MWilson,W Wassaf,M Zlmmennan, PD Mauldin,A VanVeise,RH Hawos,BJ Hoffrsan. DigestiveDiseaseCenter,Medical Unlvemltyof SouthCarolina,Charleston,SC.AIM:Todeterminetschnisalcharecteds~cs of EUS-guidedfine needleasplre~ (EUSGFNA)associatedwitha positivepathological diagnosisof cancer.METHODS:ProceduralcharectodsUcsof EUSGFNApasseson isslop.ssuspectfor malignancywareprospectivelyrecorded. "rheWilson-CookeacdGIP needleswereusedaccordingto endor preference.Eachpasspmducad3-4slides. Cytopathologistsin the roomstudied1 slide per passfor cellularadequacy.All slides warelaterstednadandstudiedfor the finaldiagnosis.Non.pererneldcunivedateanalysis determinedvariablesindependentlycorrelatedwith malignanthistology. Multivedate logis~cregression(withconlmlfor rnulScollnesdty)was usedtoconbolfor croas-vedable effects (a--0.05). RESULTS: There ware 177 passes in 46 lesions (avg. 3.8 passas/lasion),In 45 patients.00(45%)passesshowedmalignancy;97(55%)did not. Vadsbtssstudiedinclude: type(101 nodes,70 masses),location(70 mediastinum,63 pancreas,20 celiacrods,12esophagus,5 pad-rectum,5rectum,2 ped-gasthc),hazdnoss (79 soft, 55 hard, 36 medium, 4 unspecified),slroke length (90 short, 74 long, 7 unspadfled), samplingsite (111 center, 59 edge, 7 unspadfled),aspiratesize (131 ample,30 scant,15 unspecified),and mpbatobkxxllneas(50bloody,55 non-blcody,53 visibleblood, 13 unspecified).Basedon availabledatain a subgroupof 19 malignant lesions, the 1st passwas positivein 11119(58%),2nd passin 7/19(37%),3rd passIn 1/19(5%). PREDICTORSOF POSITIVEDIAGNOSISOF CANCERBY EU8GFNA LesioncharectedsUc + or- predictor p (Univedsto) p (Multlvedate) madlestinallosa~on posmve 0.0002 0.0002 samplesite 'edge" pco~ve 0.03 0.02 ! lymphnode pcomve NS 0.05 ponorea~cIona~n ne~a0ve 0.007 0,004 mass negative NS 0.05 samplesite "centor' re~gative NS 0.04 In~pendontpred~ .guld~JFNAdiagnosis)f malignancywam medlas0nellocaUonandasmpll~i attbe odgeof tho laslon.PancrsattclocaUonwesthe onlyindependentpredictorof failure.Malignancycouldbe dlagno~ alter2 passes in 95%of patients,andin 100%after3 p a ~ . CONCLUSIONS:To optimizethe yieldof EUS-gukfedFNA,ledoneshouldbe sampledat ~ edge,4 passesshouldbe adequate tOdiagnosemalignancyin S SUSpiCiOUSlesion.
HOW OFTEN IS LINEAR ARRAY EUS NEEDED IN ADDITION TO RADIAL SCANNING? T.J. Savides. Division of Gestnentenlogy, University of California, San Diego Pvrposo: To determine how often the addition of a linear array EUS scope is needed in cases performed with a radial scanner EUS scope. Methods: A single endosonographer, with experience using the Pentax FG-32UA linear array echoendoscopeand performing EUSguided fine needle aspiration (FNA), prospectively recorded which patients undergoing EUS with an Olympus GT-UM2O echoendoscope would likely have clinical management changed if a Pentax linear array echoendoscope were available. Data w e n recorded prospectively into a computer database from 8/94 to 11196. Results: In 39 out of 194 (20%) of EUS cases performed with the radial scanner, it was felt that a linear array echoendoscope would have also been helpful. The linear array scope was felt indicated in 16/60 (27%) of pancnatico-biliary-duodenal cases, 14/58 (24%) of esophageal/mediastinal cases, 7/51 (14%) of gastnc cases, 2/27 (7%) of anomctal cases. The nasons for desiring the linear array scope were to perform FNA in 27139 (69%), easier visualization of an abnormality in 10/38 (26%), and need for Doppler to assess vasculanty in 2138 (5%). Among potential FNA cases, 13/27 (48%) were for lymph nodes, 12/27 (44%) for a mass lesion, and 2/27 (7%) forafluid cotiection. Linear arnywas desirable in 12/50 (24%) ofthe first cases, in the second 50 cases in 13/50 (26%), in the third 50 cases in 6150 (12%), and in the last 44 cases in 6144 (14%). Conclusions: 1) The addition ofa Pentax linear array EUS scope was felt to be needed in 20% of EUS cases performed with an Olympus radial scanning EUS scope. 2) The most common mason for needing the Pentax scope was to perform fine needle aspintion of a mass or lymph node. 3) Doppler flow capabilities w e n seldom needed to complement the Olympus scope.
:]:618
620
A PROSPECTNEAUF.UW:NT OFENBOSCOPICULTRASOUNDACCURACYFOR DIAGNOSINGCAMBRIDGEC L ~ > 2 OR 9 3 CHRONICPANCREATITI8AVSahal. M Zimmerman, L Aabakken,RH Haw=z,A VacVebe, P Tarnesky, PD Mauldlo,J Cunnlngham,PB Co4ton,BJ ~ . DigestiveDiasaNCenter,MedicalUnivendtyof SouthC = ~ , Ctume=on,SC.&l~:To~ v ~ ~ accuracyof ~ ulbesound(EUS)r fordlagncdngmM and modem~chronicpencrsatl~(Cp) as defined by pancmatogrephyusing the Cambridgecdtsda (CC) for Into~mJta~on, METHOD~:Pabnts wl~ unexplainedabdominalpainundergoingpancrea~EUSand ERCPwerepm~oactlvdystudied.EUSwas pedmnodby experiencedoparstoreaware of the clinicalhl~ory,but blindedto ERCPresults.The CC are as follows:0='normar, l='equl,,osar(r,orm~ (N)nu~npencmaUcduct(MPD)+ <3 ahoorm~(~) sidebrenchos (ASB)),2='mild"(NMPD+ >3aNSB),3='modereto"(aNMPD+ >3aNS8)."PcoltlveEUS" was definedas the presenceof =mycomblnefonof 1 to 6 of the following cdtoda: hyperecholofed (HI=),h y ~ scands,lobdadty(L), inagutsrduct margins(ID), hypemcholcductmetglm,andvisiblesidebranchos(VS)."CP"was definedos a CC of ==2or ==3. RESULTS:98 pabents:18 CC'0",9 CC"1", 21 CC"2",32 CC'3",and 18 CC'4". No EUS-relatadcom?licaUonsoccurred. CAMBRIDGECLASS>2 CHRONICPANCREATITI8 # EUScdteda ==1 =.2 ==3 z4 ==5 6 96 85 73 63 41 21 a[oedf~-.,~ 22 48 56 74 81 100 pco.I~od.veL (PIN) 76 51 81 87 85 100 nag. pred.vel. (NPV) 67 54 44 43 34 33 CAMBRIDGECLASS=,3CHRONICPANCREATITIS # EUScdteda >1 ==2 >3 ==4 >5 . 5 sensitivity 96 90 00 74 50 20 spesifictiy 15 40 50 69 81 98 Jx~.pred.val. (FPV) 54 54 63 71 74 87 neg, pred.vel. (NPV) 78 79 71 72 51 55 Univadate analysis (n=66) showed4 independentpredistomof CP: HF(p=0.006), ID(p=0.025),VS(p=0.036),and L(p=0.053).SUMM.~R'(:Presenceof 5 EUS clttodais di~nos~c(PPV100%)of mildCP(CC~2) and highlypredictive(PPV87%)of moderato CP(CCz3); ==4 cdtodais highlypredictiveof mildCP(CC==2).Thisis line evenwhen powerful predictomof CP,suchas cabificatlons,ductdilaUon,and pseudoo/stsare not used.CONCLUSION:In palientswi~ unexplainedsbdominelpain, EUSis a safeand effectivein dtsgnosingERCP-definadmildand moderateCP.
ENDOSCOPIC ULTRASONOGRAPHIC FEATURES OF GASTRIC ABERRANT PANCREAS WITHOUT CENTRAL DIMPLING. C.S. Shim. H.K. Bong, Y.H. Lee, Y.D. Cho, J.O. Kim, J.Y. Cho, Y.S. Kim, J.S. Lee, M.S. Lee, S.G. Hwang. Institute for Digestive Research, Department of Internal medicine, Soon Chun Hyang University, Seoul, Korea. Background: Gastric aberrant pancreas can be easily diagnosed by conventional endoscopy and radioiogic modalities due to its characteristic feature such as central dimpling. However, in cases of aberrant pancreas without the central dimpling, the differential diagnosis has been some troublesome. As for differential diagnosis of gastric submucosal tumors, endoscopic ultrasonography(EUS) allow us to visualize the structures underlying the gastrointestinal wall in noninvasive manner, and has the great advantage over the conventional modalities such as conventional endoscopy and UGI series. Aim: To evaluate the EUS finding of gastric aberrant pancreas without the central dimpling. Patients & Methods: We compared EUS features in 10 cases of gastric aberrant pancreas without the central dimpling to those in 16 cases with the central dimpling. Results: These lesions were demonstrated mainly as heterogenous(84.6%), intermediate internal echoic(100%) tumors with 1-2cm in diameter(88.5%), unclear boundary(82.1%) and endoluminai growth pattern(76.9%) located in the submucosal layer(100%) of gastric wall by EUS. Also, 19.296 has been accompanied with the changes of the proper muscle layer, such as thickening or irregularity of 4th layer in gastric wail. In gastric aberrant pancreas without the central dimpling, 40% of the lesions has the internal cystic area. The sizes of gastric aberrant pancreas without central dimpling(1.5+0.3 cm) was larger than those with central dimpling(1.3:t: 0.3 cm). In gastric aberrant pancreas located on the body or fundus of stomach, 66.7 % of lesions are without the central dimpling. Conclusion: These EUS findings(internal cystic area, located on the body or fundus of stomach, larger size) will be helpful to make a diagnosis of gastric aberrant pancreas although the characteristic central dimpling does not exist.
VOLUME 45, NO. 4, 1997
GASTROINTESTINAL ENDOSCOPY A B 1 7 9