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Endoscopic ultrasonography is useful for diagnosis of gastric submucosal tumor
ENDOSCOPIC ULTRASOUND/LAPAROSCOPY t641
t643
COMPARISON BETWEEN FINE NEEDLE ASPIRATION (FNA) DIRECTED CT BIOPSY (FNA-CT-Bx) AND EUS-GUIDED FNA (EUSFNA) FOR PANCREATIC CARCINOMA. ]C Wied*, R.A. Erickson*, P.A. Neese*, E.J. Schoolar*, B. Maupin*, V.O. Speights Jr:., L. Sayage-Rahie t. Depts. Medicine*, Radiology* & Pathology ~, Scott & White, Texas A&M, Temple, TX B A C K G R O U N D : Accurate preoperative tissue diagnosis of pancreatic adeoocarcinoma (PCa) is important for directing the appropriate management of this morbid disease. Studies of CT guided biopsy for PCa often report disappointingly low sensitivities(e.g. 45% in our own institution-AJG 1992;87:1610). To improve this sensitivitywe prospectively studied using FNA-CT-Bx and more recently EUS-FNA for diagnosing and directing therapy for PCa. M E T H O D S : Patients presenting with metastatic PCa were excluded from the study. FNA-CT-Bx was performed on patients with CT-evident pancreatic masses by placing an 18 gauge biopsy needle into the mass under CT guidance. A 21 gauge aspiration needle was then placed through the biopsy needle and tissue aspirated for immediate examination by the cytopathologist always in attendance. If pancreatic cells were seen cytologically, the biopsy was performed; if not, the needle was repositioned and the procedure repeated. EUSFNA was performed on patients with suspected PCa with or without CT-evident pancreatic masses. After staging with the Olympus UM-20 echoendoscope, EUS-FNA was performed by one endosonograpber (RAE) as previously described (GI Endo 1994;40:694) using the Pentax FG-32UA with a 22 gauge Mediglobe| needle. A cytopathologist was always present to examine aspirations as they were obtained. EUS-FNA was done as an outpatient procedure. FNA-CT-Bx patients were admitted overnight for observation. RESULTS: CT-FNA-Bx EUS-FNA Study Periods [ 1/93 to 5/95 9/95 to 12/96 Total PCa Diagnosed I 47 . 35 FNA-CT-Bxs Performed 30 (64%) I (CT-Bx only) (3%) EUS-FNAs Performed 0 (0%) 21 (60%) Malignancy Diagnosed 25 (83%) 22 (100%) p~0.05 r Resections Performed 3 (6%) 7 (20%) p=0.09~ Avg. Total Procedure Cost $2)488 $2)769 ~Fisherexacttest ~ : This study demonstrates that EUS-FNA has higher yields than FNA-CT-Bx for PCa. However, for institutions without EUS-FNA, using FNA-CT-Bx can produce much higher yields of diagnostic tissue than those reported without cytologic guidence. The higher resection rates with EUS-FNA may result from diagnosing smaller tumors and more accurate staging.
COMPARISON OF EUS FINDINGS WITH HISTOPATHOLOGY IN CHRONIC PANCREATITIS Zimmerman M J, Mishra G, Lewin D, Hawes RH, Coyle W, Adams DA, Hoffrnan B Digestive Disease Center, Medical University of South Carolina (MUSC). INTRODUCTION: There is little data comparing results of EUS to histopathologieal findings in chronic pancreatitis (CP). We present a retrospective case series correlating EUS findings with histopathology. METHOD: All patients who had undergone both pancreatic resection and EUS were identified. EUS examinations were reviewed to identify standard criteria associated with CP including duct irregularity, hyperechoic duct margins, main duct dilation, visible side branches, lobulation, pmenchymal heterogeneity, hyperechoic fuci and stranding, parenchymal calcification, and intraductal stones. All resection specimens were assessed for the presence or absence of histologic evidence for CP. Histopathological and EUS review were performed by independent blinded observers. The performance characteristics of EUS were then calculated using the histologic assessment as the "gold standard". RESULTS: 19 patients were identified (6 - resection for CP; 13 resection for Pancreatic cancer). The prevalence of histologic CP was 68%. ROC analysis shows that the optimal number of EUS criteria for the diagnosis of CP was >__3 (sensitivity 85%, specificity 67%, Positive Predictive Value 85%, Negative Predictive Value 67%, Accuracy 85%). Positive predictive values for individual EUS features were intraductal stones (+PV 100%), visible side branches (+PV 100%), lobulation (+PV 100%), irregular ducts (+PV 80%), hyperechoic stranding (+PV 86%), heterogeneity (+PV 83%), hyperechoic foci (+PV 75%) and duct dilation (+PV 67%). CONCLUSION: A combination of > 3 EUS criteria is optimal for the diagnosis of histologic CP, and is consistent with earlier comaprisons between EUS and ERP ductography.
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t644 LAPAROSCOPIC ASSISTED PROCEDURES OF THE COLON: OUR EXPERIENCE OF23 CASES. V- Amin. I. Ho, M.A. Cerulli, W.J. Hodgson*, Division of Gastroenterology, Dept. of Med, and Dept. of Surgery*. The Brooklyn Hospital Center, Brooklyn, New York. Pornose: To determine the effectiveness of laparoscopic assisted colonic procedures and their long-term outcome. Methods: Between June 1992 and October 1996, twenty-three patients (9 male, 14 female; mean age 69: range 43 to 89) underwent 24 laparoscopic procedures involving tbe colon. All patients were operated upon by a single surgeon. The indications were colorectal cancer (CRC) in 16, diverticulitis in 4, recurrent volvulus of the sigmoid colon in I, recurrent anal canal carcinoma in I, and rectal prolapse in I. Three patients underwent right hemicolectomy; I had transverse colon resection; 2 had left hemicolectumy; 8 had sigmoid colectomy; 5 had low anterior resection; 2 had abdominoperineal resection. One patient required rectopexy for rectal prolapse in addition to sigmoid colectomy and one needed sigmoid loop colostomy for recurrent anal canal cancer. Of the 16 CRC patients, 8 patients were staged as Duke's B, 7 as Duke's C and I presented with metastatic liver disease at surgery. Complications were defined as the presence of intra-abdominal hemorrhage, perforation, infection, prolonged ileus, incisional hernias, or port site recurrences. The length of hospital stay (LOS), the number of patients requiring conversion to open exploration, and the number of lymph nodes harvested per cancer patient were recorded. The median follow-up time was 17.0 months (range 2 to 53 months). Results:. Indications for Surgery •RC(n= 16~ NonCRC(n=7} Time 1st feeding (hrs. post surgery) 24 24 Median LOS (days) 6(4 to 53) 6(5 to95) 1 0 Conversion to open procedure Mean # of harvested lymph nodes 12.2 (0 to 43) -Complications 0 1 perforation No operative mortality occurred. One CRC patient expired at 12 months after initial surgery. Conclusion: Laparoscopic assisted procedures of the colon are effective, with acceptable long-term outcome.
ENDOSCOPIC ULTRASONOGRAPHY IS USEFUL FOR DIAGNOSIS OF GASTRIC SUBMUCOSAL TUMOR J. Yoshikawa, J. Matsumoto, K. Suekawa, F. Arimura, T. Yamamoto, T. Arima, Second Department of Internal Medicine, Faculty of Medicine, Kagoshima University, Kagnshima 890, JAPAN Diagnostic ability of endoscopic ultrasonography(EUS) for submucosal tumor(SMT) of the stomach was evaluated. Sixty-three cases including 38 leiomyomas(LM), 13 leiomyosarcomas (LS), 3 lipomas, 1 submucosal cyst, 5 aberrant pancreas and 3 schwannomas histologically diagnosed in specimens obtained by operation or biopsy, were subjected to the study. Differential diagnosis between LM and LS by EUS was difficult as they had a similar low echoic mass in the proper muscular layer of the gastric wall. Therefore the differences were precisely studied in tbem(38 LM and 13 LS) on 7 factors of EUS images including (l)tumor size, (2)central depression, (3)form of development, (4)internal echo level, (5) shape of surface, (6)presence of cystic region and (7)calcification. Size of the tumors was more than 40mm in a diameter in 12(32%) of LM and in 10(77%) of LS. Heterogeneous internal echo was found in 17(45%) of LM and in all of LS. Eighteen(47%) of LM and 10(77%) of LS had cystic regions. Factors (2),(3),(5) and (7) of EUS image were recognized in both LM and LS equally. Furthermore, factors (2)-(7) were studied by dividing them into 2 groups according to the tumor size. Group A: more than 40ram(12 LM and 10 LS) and group B: less than 39mm(26 LM and 3 LS) in diameters. In group A, all of LS showed heterogeneous internal echo while homogenous in 5(42%) of LM. In group B, all of LS were revealed to have heterogeneous internal echo and cystic regions. Lipomas were shown as homogenous high echoic mass located in the submucosal layer. Aberrant pancreas was detected as a low echoic lesion with slight higher echo level than myogenic tumor located in the submucosal layer. A cyst and schwannomas were shown as an anechoic lesion and homogenous low echoic mass in the submucosal layer, respectively. In conclusion, myogenic tumors having a size of less than 39ram in a diameter in combination with heterogeneous internal echo and cystic regions should be considered to be possible LS while nearly all such cases with a diameter of more than 40ram were suggested to be LS.
VOLUME 45, NO. 4, 1997
GASTROINTESTINAL ENDOSCOPY
AB185
t643
COMPARISON BETWEEN FINE NEEDLE ASPIRATION (FNA) DIRECTED CT BIOPSY (FNA-CT-Bx) AND EUS-GUIDED FNA (EUSFNA) FOR PANCREATIC CARCINOMA. ]C Wied*, R.A. Erickson*, P.A. Neese*, E.J. Schoolar*, B. Maupin*, V.O. Speights Jr:., L. Sayage-Rahie t. Depts. Medicine*, Radiology* & Pathology ~, Scott & White, Texas A&M, Temple, TX B A C K G R O U N D : Accurate preoperative tissue diagnosis of pancreatic adeoocarcinoma (PCa) is important for directing the appropriate management of this morbid disease. Studies of CT guided biopsy for PCa often report disappointingly low sensitivities(e.g. 45% in our own institution-AJG 1992;87:1610). To improve this sensitivitywe prospectively studied using FNA-CT-Bx and more recently EUS-FNA for diagnosing and directing therapy for PCa. M E T H O D S : Patients presenting with metastatic PCa were excluded from the study. FNA-CT-Bx was performed on patients with CT-evident pancreatic masses by placing an 18 gauge biopsy needle into the mass under CT guidance. A 21 gauge aspiration needle was then placed through the biopsy needle and tissue aspirated for immediate examination by the cytopathologist always in attendance. If pancreatic cells were seen cytologically, the biopsy was performed; if not, the needle was repositioned and the procedure repeated. EUSFNA was performed on patients with suspected PCa with or without CT-evident pancreatic masses. After staging with the Olympus UM-20 echoendoscope, EUS-FNA was performed by one endosonograpber (RAE) as previously described (GI Endo 1994;40:694) using the Pentax FG-32UA with a 22 gauge Mediglobe| needle. A cytopathologist was always present to examine aspirations as they were obtained. EUS-FNA was done as an outpatient procedure. FNA-CT-Bx patients were admitted overnight for observation. RESULTS: CT-FNA-Bx EUS-FNA Study Periods [ 1/93 to 5/95 9/95 to 12/96 Total PCa Diagnosed I 47 . 35 FNA-CT-Bxs Performed 30 (64%) I (CT-Bx only) (3%) EUS-FNAs Performed 0 (0%) 21 (60%) Malignancy Diagnosed 25 (83%) 22 (100%) p~0.05 r Resections Performed 3 (6%) 7 (20%) p=0.09~ Avg. Total Procedure Cost $2)488 $2)769 ~Fisherexacttest ~ : This study demonstrates that EUS-FNA has higher yields than FNA-CT-Bx for PCa. However, for institutions without EUS-FNA, using FNA-CT-Bx can produce much higher yields of diagnostic tissue than those reported without cytologic guidence. The higher resection rates with EUS-FNA may result from diagnosing smaller tumors and more accurate staging.
COMPARISON OF EUS FINDINGS WITH HISTOPATHOLOGY IN CHRONIC PANCREATITIS Zimmerman M J, Mishra G, Lewin D, Hawes RH, Coyle W, Adams DA, Hoffrnan B Digestive Disease Center, Medical University of South Carolina (MUSC). INTRODUCTION: There is little data comparing results of EUS to histopathologieal findings in chronic pancreatitis (CP). We present a retrospective case series correlating EUS findings with histopathology. METHOD: All patients who had undergone both pancreatic resection and EUS were identified. EUS examinations were reviewed to identify standard criteria associated with CP including duct irregularity, hyperechoic duct margins, main duct dilation, visible side branches, lobulation, pmenchymal heterogeneity, hyperechoic fuci and stranding, parenchymal calcification, and intraductal stones. All resection specimens were assessed for the presence or absence of histologic evidence for CP. Histopathological and EUS review were performed by independent blinded observers. The performance characteristics of EUS were then calculated using the histologic assessment as the "gold standard". RESULTS: 19 patients were identified (6 - resection for CP; 13 resection for Pancreatic cancer). The prevalence of histologic CP was 68%. ROC analysis shows that the optimal number of EUS criteria for the diagnosis of CP was >__3 (sensitivity 85%, specificity 67%, Positive Predictive Value 85%, Negative Predictive Value 67%, Accuracy 85%). Positive predictive values for individual EUS features were intraductal stones (+PV 100%), visible side branches (+PV 100%), lobulation (+PV 100%), irregular ducts (+PV 80%), hyperechoic stranding (+PV 86%), heterogeneity (+PV 83%), hyperechoic foci (+PV 75%) and duct dilation (+PV 67%). CONCLUSION: A combination of > 3 EUS criteria is optimal for the diagnosis of histologic CP, and is consistent with earlier comaprisons between EUS and ERP ductography.
642
t644 LAPAROSCOPIC ASSISTED PROCEDURES OF THE COLON: OUR EXPERIENCE OF23 CASES. V- Amin. I. Ho, M.A. Cerulli, W.J. Hodgson*, Division of Gastroenterology, Dept. of Med, and Dept. of Surgery*. The Brooklyn Hospital Center, Brooklyn, New York. Pornose: To determine the effectiveness of laparoscopic assisted colonic procedures and their long-term outcome. Methods: Between June 1992 and October 1996, twenty-three patients (9 male, 14 female; mean age 69: range 43 to 89) underwent 24 laparoscopic procedures involving tbe colon. All patients were operated upon by a single surgeon. The indications were colorectal cancer (CRC) in 16, diverticulitis in 4, recurrent volvulus of the sigmoid colon in I, recurrent anal canal carcinoma in I, and rectal prolapse in I. Three patients underwent right hemicolectomy; I had transverse colon resection; 2 had left hemicolectumy; 8 had sigmoid colectomy; 5 had low anterior resection; 2 had abdominoperineal resection. One patient required rectopexy for rectal prolapse in addition to sigmoid colectomy and one needed sigmoid loop colostomy for recurrent anal canal cancer. Of the 16 CRC patients, 8 patients were staged as Duke's B, 7 as Duke's C and I presented with metastatic liver disease at surgery. Complications were defined as the presence of intra-abdominal hemorrhage, perforation, infection, prolonged ileus, incisional hernias, or port site recurrences. The length of hospital stay (LOS), the number of patients requiring conversion to open exploration, and the number of lymph nodes harvested per cancer patient were recorded. The median follow-up time was 17.0 months (range 2 to 53 months). Results:. Indications for Surgery •RC(n= 16~ NonCRC(n=7} Time 1st feeding (hrs. post surgery) 24 24 Median LOS (days) 6(4 to 53) 6(5 to95) 1 0 Conversion to open procedure Mean # of harvested lymph nodes 12.2 (0 to 43) -Complications 0 1 perforation No operative mortality occurred. One CRC patient expired at 12 months after initial surgery. Conclusion: Laparoscopic assisted procedures of the colon are effective, with acceptable long-term outcome.
ENDOSCOPIC ULTRASONOGRAPHY IS USEFUL FOR DIAGNOSIS OF GASTRIC SUBMUCOSAL TUMOR J. Yoshikawa, J. Matsumoto, K. Suekawa, F. Arimura, T. Yamamoto, T. Arima, Second Department of Internal Medicine, Faculty of Medicine, Kagoshima University, Kagnshima 890, JAPAN Diagnostic ability of endoscopic ultrasonography(EUS) for submucosal tumor(SMT) of the stomach was evaluated. Sixty-three cases including 38 leiomyomas(LM), 13 leiomyosarcomas (LS), 3 lipomas, 1 submucosal cyst, 5 aberrant pancreas and 3 schwannomas histologically diagnosed in specimens obtained by operation or biopsy, were subjected to the study. Differential diagnosis between LM and LS by EUS was difficult as they had a similar low echoic mass in the proper muscular layer of the gastric wall. Therefore the differences were precisely studied in tbem(38 LM and 13 LS) on 7 factors of EUS images including (l)tumor size, (2)central depression, (3)form of development, (4)internal echo level, (5) shape of surface, (6)presence of cystic region and (7)calcification. Size of the tumors was more than 40mm in a diameter in 12(32%) of LM and in 10(77%) of LS. Heterogeneous internal echo was found in 17(45%) of LM and in all of LS. Eighteen(47%) of LM and 10(77%) of LS had cystic regions. Factors (2),(3),(5) and (7) of EUS image were recognized in both LM and LS equally. Furthermore, factors (2)-(7) were studied by dividing them into 2 groups according to the tumor size. Group A: more than 40ram(12 LM and 10 LS) and group B: less than 39mm(26 LM and 3 LS) in diameters. In group A, all of LS showed heterogeneous internal echo while homogenous in 5(42%) of LM. In group B, all of LS were revealed to have heterogeneous internal echo and cystic regions. Lipomas were shown as homogenous high echoic mass located in the submucosal layer. Aberrant pancreas was detected as a low echoic lesion with slight higher echo level than myogenic tumor located in the submucosal layer. A cyst and schwannomas were shown as an anechoic lesion and homogenous low echoic mass in the submucosal layer, respectively. In conclusion, myogenic tumors having a size of less than 39ram in a diameter in combination with heterogeneous internal echo and cystic regions should be considered to be possible LS while nearly all such cases with a diameter of more than 40ram were suggested to be LS.
VOLUME 45, NO. 4, 1997
GASTROINTESTINAL ENDOSCOPY
AB185