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Endoscopic ultrasound (EUS) and EUS-guided thoracentesis of pleural fluid
ENDOSCOPIC ULTRASOUND $6O5
$6O7
INTRADUCTAL ULTRASOUND (IDUS) IN PREOPERATIVE STAGING OF TUMORS OF THE PAPILLA OF VATER J. Menzel, J. W. Konturek, N. Hoepffner, W. Domschke, Department of Medicine B, University of Muenster, Germany
ENDOSCOPIC ULTRASOUND (EUS) AND EUS-GUIDED FINE NEEDLE ASPIRATION (FNA) OF LIVER LESIONS IN PATIENTS WITH GASTROINTESTINAL MALIGNANCIES. P. Nguyen, KJ Chang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, CA. Introduction: The diagnosis of metastases to the liver is important staging information for gastrointestinal malignancies prior to deciding on therapy. EUS is thought not to be useful for M staging. Methods: A prospective study was conducted in which 138 consecutive patients with a history or suspicion of gastrointestinal malignancy undergoing upper EUS examinations (from 4195 to 8196), had an endosonographic evaluation of the liver. EUS was performed using the Olympus GF-UM20 echoendoscope. The right lobe of the liver was evaluated from the duodenum and antrum. The left lobe from the gastric body and fundus. If a non-vascular liver lesion was detected, EUS-guided FNA was performed with the Pentax FG-32UA or FG-36UX echoendoscope and the GIP-Mediglobe needle. Results: Nine of the 138 (7%) patients were found to have focal liver lesions (4 right lobe, 5 left lobe). The indications for EUS included known pancreatic cancer (3), pancreadc mass (2), liver mass (2), esophageal cancer (1), esophageal extrinsic compression (1). The mean largest size of the liver lesions was 1.9 cm (range 0.8-5.2 cm). The average distance from the gastric/duodenal wall to the liver lesion was 1.0 cm (range 0.2-2.8 cm). The mean number of passes was 2.4 (range 1-5). All FNA passes yielded an adequate specimen. Eight of the nine liver lesions were malignant at EUS-guided FNA (adenocarcinoma 6, squamous 1, poorly differentiated cancer 1) and one specimen was benign. All patients had the final diagnosis of cancer. Prior to EUS, computed tomography (CT) only detected 219 (22%) of the liver lesions and CT-guided FNA was not attempted in these 2 patients. The initial cancer diagnosis was made in 319 patients by the EUS-guided FNA of the liver (primary liver cancer-i, primary cholangiocarcinoma-1, metastatic pancreatic cancer-l). There were no immediate or late complications. Table 1.Clinical impact of EUS-FNA Avoided Surgery Unstated Tunmr Made Diagnosis 'Clinica Iml~act 3/9 (33%3 9 " 2/9 (22%) 3/9 (33"%) Conclusions: 1) EUS is capable of detecting small focal liver lesions which are not detected by CT. 2) EUS-guided FNA can make a cytologic diagnosis of small liver metastasis and establish a definitive M-stage which may change clinical management. 3) We suggest that the liver be routinely examined on EUS in patients who are known or suspected to have cancer.
An adenoma-carcinoma-sequenee also applies to adenomas of the papilla of Vater. ERCP alone does not provide any information on infiltrative growth. Endoscopic ultrasound (EUS) is usually limited in detection of processes smaller than 10 nun. High-frequency ultrasonic probes adjusted to the dimension of the pancreatic and biliary tract can, if applied during ERCP, visualize the peripapillary tissue at highest resolution. As diagnostic imaging influences the choice of therapeutical procedures we studied the diagnostic impact of miniprobe sonography in polypoid proce~es of the papilla of Vater. Mechanical and electronic probes (Aloka TM, Microvasive TM, Endosouics TM)with diameters of 3.5 up to 6.2 French were inserted via the operating channel of a routine duodenoscope (Olympus JF1T20) during ERCP. 21 patients (11 female, 10 male; O 64 years, 41 to 74) with polypoid processes of the papilla of Vater were investigated preoperatively. IDUS, EUS and CT scan were compared with the resection specimen. Using sonographic frequencies of 12.5 up to 30 MHz the peripapillary tissue was demonstrated in microscopic dimension of a maguifiying glass. Malignant infiltration of the papilla of Vater was depicted sonographically inhomogenous and echopoor in echoes whereas benign papillary stenosis were shown homogenously echodease. Insertion of the probe and ultrasonic examination during ERCP took 5 minutes on average, indications of any trauma to the papilla or the surrounding tissue could not be found. 21 patients underwent surgery: 12 x carcinoma, 9 x adenoma. Sensitivity of IDUS was 85%, specificity 75% and accuracy 8:5%. Endoscopic ultrasound (EUS): sensitivity 50%, specificity 87%, accuracy 80%; CT scan did not detect a tumor of the papilla of Vater in 18 out of 2t patients. IDUS seems to be superior to conventional imaging techniques (EUS, CT scan) in diagnosing polypoid processes of the papilla of Vater. 1DUS provides a view behind the epithelium and visualize the adjacent tissue at highest resolution.
t606 ENDOSCOPIC ULTRASOUND (EUS) AND EUS-GUIDED FINE NEEDLE ASPIRATION (FNA) OF ABDOMINAL FLUID. P Nguyen, G Sze, F Rezvani, KJ Chang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, CA. Introduction: The presence of ascites in patients with known or suspected gastrointestinal malignancy may indicate the presence of peritoneal carcinomatosis (PC). We reported the use of EUS in detecting abdominal fluid and EUS-guided FNA in diagnosing malignant ascites in a case report (AJG 1995). The prospective evaluation of the clinical significance of peritouneal fluid detected by EUS has not been reported. Methods: A series of 332 consecutive (from 3/94-6/96) patients underwent upper EUS exams for various indications. EUS was performed using the Olympus GF-UM20 echoendoscope and EUS-guided FNA using the Pentax FG-32UA echoendoscope and the GIP-Mediglobe needle. Once the tip of the needle is seen in the fluid under real time ultrasound imaging, the stylet is cleared and a constant suction of 5 cc's is applied. To-and-fro motion is not necessary for fluid aspiration. Clinical information was obtained from the referring physicians, subsequent CT results or follow-up telephone interview. The mean follow-up time was 4 mo (1-10 mo). Two patients had no clinical follow-up. Results: Thirty-three patients (10%) were found to have abdominal fluid on EUS. Four patients did not have Computed Tomography (CT) prior to EUS. Only 5/33 (15%) of these patients had ascites seen on preprocedure CT. Of the patients with CT-negative abdominal fluid and who had clinical follow-up 4/23 (17%) patients subsequently developed ascites detected by CT or physical exam. One of these 4 patients had EUS-guided FNA of the fluid yielding benign cytology. Thirteen of the 33 patients had FNA of the fluid seen on EUS (12 benign, 1 malignant). All FNA attempts were successful and associated with no complications.The mean volume of fluid obtained at FNA was 11 cc (range L0-40.5 cc). In the one patient who had malignant ascites at FNA, surgery was avoided. Conclusions: 1) EUS detects abdominal fluid which may not be seen on CT 2) Most patients with fluid seen on EUS and not CT, do not appear to subsequently develop clinical ascites. 3) EUS-guided paracentesis appears to be a safe and effective method to sample peritonneal fluid.
AB176
GASTROINTESTINAL ENDOSCOPY
t608 ENDOSCOPIC ULTRASOUND (EUS) AND EUS-GUIDED THORACENTESIS OF PLEURAL FLUID. P Nguyen, F Rezvani, KJ Chang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, CA. Introduction: The presence of pleural effusions in patients with known or suspected gastrointestinal malignancy may represent malignant involvement. We previously reported the use of EUS in detecting pleural fluid and EUS-guided FNA in diagnosing malignant pleural effusion in 2 patients (AJG 1995). We now report a series of patients who had EUS and EUS-guided thoracentesis of pleural fluid. Methods: A series 332 consecutive patients (from 5194-4/96) underwent upper EUS examinations for various indications. EUS was performed using the Olympus GF-UM20 echoendoscope and EUS-guided FNA using the Pentax FG-32UA echoeudoscope and the GIP-Mediglobe needle. Clinical follow-up data on patients with pleural fluid was obtained by telephone interview, physical exam, repeat CT, ultrasound, or chest xray. The mean follow-up time was 6 months, Results: Of the 332 patients, 26 (8%) were found to have pleural fluid on EUS. Among these 26 patients, 20 were cancer patients and 6 had a benign diagnosis. The range of pleural fluid size (largest dimension) on EUS was 0.7 to 3.2 cm. Nineteen of 26 (73%) patients with pleural fluid on EUS did not have pleural effusions on pre-procedure computed tomography (CT). Only one patient did not have CT prior to EUS. Of the 19 patients with CT-negative pleural fluid, clinical follow-up data was available in 15. Six of 15 (40%) patients subsequently developed pleural effusions by the end of the follow-up period (4 detected by CT, 2 by US). Eight patients had EUS-guided thoraeentesis (6 benign, 2 malignant). All FNA attempts were successful. The mean volume of pleural fluid at FNA was 7.5 ml. In the 2 patients in whom EUS-guided thoraeentesis demonstrated malignant ceils, 1 patient had gastric cancer and was precluded from surgery based on this finding and the other underwent chemotherapy for recurrent gastric carcinoma. There were no procedural complications in this series. Antibiotics were not routinely given. Conclusions: 1) EUS can detect CT-negative pleural fluid. 2) The majority of patients with CT-negative, EUS-positive pleural fluid, do not seem to develop clinical pleural effusions. 3) EUS-guided thoracentesis appears to be a safe method of obtaining pleural fluid for analysis.
VOLUME 45, NO. 4, 1997
$6O7
INTRADUCTAL ULTRASOUND (IDUS) IN PREOPERATIVE STAGING OF TUMORS OF THE PAPILLA OF VATER J. Menzel, J. W. Konturek, N. Hoepffner, W. Domschke, Department of Medicine B, University of Muenster, Germany
ENDOSCOPIC ULTRASOUND (EUS) AND EUS-GUIDED FINE NEEDLE ASPIRATION (FNA) OF LIVER LESIONS IN PATIENTS WITH GASTROINTESTINAL MALIGNANCIES. P. Nguyen, KJ Chang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, CA. Introduction: The diagnosis of metastases to the liver is important staging information for gastrointestinal malignancies prior to deciding on therapy. EUS is thought not to be useful for M staging. Methods: A prospective study was conducted in which 138 consecutive patients with a history or suspicion of gastrointestinal malignancy undergoing upper EUS examinations (from 4195 to 8196), had an endosonographic evaluation of the liver. EUS was performed using the Olympus GF-UM20 echoendoscope. The right lobe of the liver was evaluated from the duodenum and antrum. The left lobe from the gastric body and fundus. If a non-vascular liver lesion was detected, EUS-guided FNA was performed with the Pentax FG-32UA or FG-36UX echoendoscope and the GIP-Mediglobe needle. Results: Nine of the 138 (7%) patients were found to have focal liver lesions (4 right lobe, 5 left lobe). The indications for EUS included known pancreatic cancer (3), pancreadc mass (2), liver mass (2), esophageal cancer (1), esophageal extrinsic compression (1). The mean largest size of the liver lesions was 1.9 cm (range 0.8-5.2 cm). The average distance from the gastric/duodenal wall to the liver lesion was 1.0 cm (range 0.2-2.8 cm). The mean number of passes was 2.4 (range 1-5). All FNA passes yielded an adequate specimen. Eight of the nine liver lesions were malignant at EUS-guided FNA (adenocarcinoma 6, squamous 1, poorly differentiated cancer 1) and one specimen was benign. All patients had the final diagnosis of cancer. Prior to EUS, computed tomography (CT) only detected 219 (22%) of the liver lesions and CT-guided FNA was not attempted in these 2 patients. The initial cancer diagnosis was made in 319 patients by the EUS-guided FNA of the liver (primary liver cancer-i, primary cholangiocarcinoma-1, metastatic pancreatic cancer-l). There were no immediate or late complications. Table 1.Clinical impact of EUS-FNA Avoided Surgery Unstated Tunmr Made Diagnosis 'Clinica Iml~act 3/9 (33%3 9 " 2/9 (22%) 3/9 (33"%) Conclusions: 1) EUS is capable of detecting small focal liver lesions which are not detected by CT. 2) EUS-guided FNA can make a cytologic diagnosis of small liver metastasis and establish a definitive M-stage which may change clinical management. 3) We suggest that the liver be routinely examined on EUS in patients who are known or suspected to have cancer.
An adenoma-carcinoma-sequenee also applies to adenomas of the papilla of Vater. ERCP alone does not provide any information on infiltrative growth. Endoscopic ultrasound (EUS) is usually limited in detection of processes smaller than 10 nun. High-frequency ultrasonic probes adjusted to the dimension of the pancreatic and biliary tract can, if applied during ERCP, visualize the peripapillary tissue at highest resolution. As diagnostic imaging influences the choice of therapeutical procedures we studied the diagnostic impact of miniprobe sonography in polypoid proce~es of the papilla of Vater. Mechanical and electronic probes (Aloka TM, Microvasive TM, Endosouics TM)with diameters of 3.5 up to 6.2 French were inserted via the operating channel of a routine duodenoscope (Olympus JF1T20) during ERCP. 21 patients (11 female, 10 male; O 64 years, 41 to 74) with polypoid processes of the papilla of Vater were investigated preoperatively. IDUS, EUS and CT scan were compared with the resection specimen. Using sonographic frequencies of 12.5 up to 30 MHz the peripapillary tissue was demonstrated in microscopic dimension of a maguifiying glass. Malignant infiltration of the papilla of Vater was depicted sonographically inhomogenous and echopoor in echoes whereas benign papillary stenosis were shown homogenously echodease. Insertion of the probe and ultrasonic examination during ERCP took 5 minutes on average, indications of any trauma to the papilla or the surrounding tissue could not be found. 21 patients underwent surgery: 12 x carcinoma, 9 x adenoma. Sensitivity of IDUS was 85%, specificity 75% and accuracy 8:5%. Endoscopic ultrasound (EUS): sensitivity 50%, specificity 87%, accuracy 80%; CT scan did not detect a tumor of the papilla of Vater in 18 out of 2t patients. IDUS seems to be superior to conventional imaging techniques (EUS, CT scan) in diagnosing polypoid processes of the papilla of Vater. 1DUS provides a view behind the epithelium and visualize the adjacent tissue at highest resolution.
t606 ENDOSCOPIC ULTRASOUND (EUS) AND EUS-GUIDED FINE NEEDLE ASPIRATION (FNA) OF ABDOMINAL FLUID. P Nguyen, G Sze, F Rezvani, KJ Chang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, CA. Introduction: The presence of ascites in patients with known or suspected gastrointestinal malignancy may indicate the presence of peritoneal carcinomatosis (PC). We reported the use of EUS in detecting abdominal fluid and EUS-guided FNA in diagnosing malignant ascites in a case report (AJG 1995). The prospective evaluation of the clinical significance of peritouneal fluid detected by EUS has not been reported. Methods: A series of 332 consecutive (from 3/94-6/96) patients underwent upper EUS exams for various indications. EUS was performed using the Olympus GF-UM20 echoendoscope and EUS-guided FNA using the Pentax FG-32UA echoendoscope and the GIP-Mediglobe needle. Once the tip of the needle is seen in the fluid under real time ultrasound imaging, the stylet is cleared and a constant suction of 5 cc's is applied. To-and-fro motion is not necessary for fluid aspiration. Clinical information was obtained from the referring physicians, subsequent CT results or follow-up telephone interview. The mean follow-up time was 4 mo (1-10 mo). Two patients had no clinical follow-up. Results: Thirty-three patients (10%) were found to have abdominal fluid on EUS. Four patients did not have Computed Tomography (CT) prior to EUS. Only 5/33 (15%) of these patients had ascites seen on preprocedure CT. Of the patients with CT-negative abdominal fluid and who had clinical follow-up 4/23 (17%) patients subsequently developed ascites detected by CT or physical exam. One of these 4 patients had EUS-guided FNA of the fluid yielding benign cytology. Thirteen of the 33 patients had FNA of the fluid seen on EUS (12 benign, 1 malignant). All FNA attempts were successful and associated with no complications.The mean volume of fluid obtained at FNA was 11 cc (range L0-40.5 cc). In the one patient who had malignant ascites at FNA, surgery was avoided. Conclusions: 1) EUS detects abdominal fluid which may not be seen on CT 2) Most patients with fluid seen on EUS and not CT, do not appear to subsequently develop clinical ascites. 3) EUS-guided paracentesis appears to be a safe and effective method to sample peritonneal fluid.
AB176
GASTROINTESTINAL ENDOSCOPY
t608 ENDOSCOPIC ULTRASOUND (EUS) AND EUS-GUIDED THORACENTESIS OF PLEURAL FLUID. P Nguyen, F Rezvani, KJ Chang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, CA. Introduction: The presence of pleural effusions in patients with known or suspected gastrointestinal malignancy may represent malignant involvement. We previously reported the use of EUS in detecting pleural fluid and EUS-guided FNA in diagnosing malignant pleural effusion in 2 patients (AJG 1995). We now report a series of patients who had EUS and EUS-guided thoracentesis of pleural fluid. Methods: A series 332 consecutive patients (from 5194-4/96) underwent upper EUS examinations for various indications. EUS was performed using the Olympus GF-UM20 echoendoscope and EUS-guided FNA using the Pentax FG-32UA echoeudoscope and the GIP-Mediglobe needle. Clinical follow-up data on patients with pleural fluid was obtained by telephone interview, physical exam, repeat CT, ultrasound, or chest xray. The mean follow-up time was 6 months, Results: Of the 332 patients, 26 (8%) were found to have pleural fluid on EUS. Among these 26 patients, 20 were cancer patients and 6 had a benign diagnosis. The range of pleural fluid size (largest dimension) on EUS was 0.7 to 3.2 cm. Nineteen of 26 (73%) patients with pleural fluid on EUS did not have pleural effusions on pre-procedure computed tomography (CT). Only one patient did not have CT prior to EUS. Of the 19 patients with CT-negative pleural fluid, clinical follow-up data was available in 15. Six of 15 (40%) patients subsequently developed pleural effusions by the end of the follow-up period (4 detected by CT, 2 by US). Eight patients had EUS-guided thoraeentesis (6 benign, 2 malignant). All FNA attempts were successful. The mean volume of pleural fluid at FNA was 7.5 ml. In the 2 patients in whom EUS-guided thoraeentesis demonstrated malignant ceils, 1 patient had gastric cancer and was precluded from surgery based on this finding and the other underwent chemotherapy for recurrent gastric carcinoma. There were no procedural complications in this series. Antibiotics were not routinely given. Conclusions: 1) EUS can detect CT-negative pleural fluid. 2) The majority of patients with CT-negative, EUS-positive pleural fluid, do not seem to develop clinical pleural effusions. 3) EUS-guided thoracentesis appears to be a safe method of obtaining pleural fluid for analysis.
VOLUME 45, NO. 4, 1997