Endoscopic Ultrasound Guided Fine-Needle Aspiration Biopsy in the Evaluation of Mediastinal Adenopathy Suspected of Extra-Pulmonary Tuberculosis

Abstracts

677 In Vivo 3D Comprehensive Microscopy of the Human Esophagus for the Management of Barrett’s Patients Melissa J. Suter, Patrick S. Yachimski, Benjamin J. Vakoc, Milen Shishkov, Brett E. Bouma, Norman S. Nishioka, Guillermo J. Tearney Optical coherence tomography (OCT) provides high-resolution (w10 mm resolution) cross-sectional images of esophageal microstructure and in recent years has been shown to accurately differentiate specialized intestinal metaplasia (SIM) from gastric cardia at the squamocolumnar junction for screening, and diagnose dysplasia and cancer in patients with SIM for surveillance of Barrett’s esophagus. The clinical utility of this technology has however been restricted due to limitations in imaging speed and optical probe design. Optical frequency domain imaging (OFDI) is a new imaging technology that is capable of improving imaging speed over traditional OCT techniques by orders of magnitude without sacrificing image quality. We have developed a balloon catheter (2.5 cm dia.) based OFDI system that acquires comprehensive three-dimensional microscopic images of the entire distal esophagus (w6.0 cm) with resolution in cylindrical coordinates of 20 mm (4)  8 mm (r)  50 mm (z) in ! 2 mins. Comprehensive microscopy of the distal esophagus was performed in over 40 patients with the OFDI system and balloon catheter. The acquired volumetric OFDI datasets were assessed and correlated to histopathological findings. For the 40 patients, we achieved satisfactory imaging in 37 patients (92%) and an average of over 90% surface area coverage per patient. Based on these early results, we anticipate that comprehensive volumetric microscopy with OFDI will provide a minimally invasive means for screening the entire distal esophagus for intestinal metaplasia, dysplasia, and adenocarcinoma.

760 Endoscopic Elastosonography Is Highly Predictive of Definite Pathology Jan-Werner Poley, E.J. Kuipers Background: Elastosonography is a technique that allows for real-time assessment of elasticity or stiffness of tissue with the aid of conventional ultrasound instruments. In recent years this technique has been developed for endoscopic ultrasound (EUS). Preliminary data show that it might be a useful adjunct to standard morphological criteria to define a lesion without FNA sampling, or to select the optimal location for FNA to increase the yield of tissue sampling. To further elucidate this hypothesis we evaluated the performance of elastosonography in series of patients referred for EUS. Methods: patients were examined by an experienced endosonographer with a linear echoendoscope (Pentax 3830-UT) combined with a Hitachi EUB-8500 system to allow for realtime processing of elastonography images. Based on these images lesions were classified as either benign, malignant or indeterminate based on previously published data. A definite diagnosis was made on results of either EUS-FNA, surgical pathology or clinical follow-up (at least six months). Results: 41 procedures were performed in the same number of patients (M/F 17/24, age range 26 to 74 yrs): 25 procedures were done for mediastinal pathology, 13 for pancreatic masses, 1 each for rectal, adrenal and submucosal lesions. Elastosonograpy images were interpreted as benign in 10 cases (24%), indeterminate in 7 cases (17%), and malignant in 24 cases (59%). All patients with a benign result on elastosonography had benign disease during follow-up and EUS-FNA. Of the patients with lesions that were judged to be indeterminate on elastosonography (n Z 7; 17%) 5 had benign disease based on clinical follow-up and EUS-FNA whereas 2 had malignant disease based on EUSFNA. In the group with malignant elastosonography (n Z 24) one patient had benign disease. A comparison of the elastography classes benign plus indeterminate versus malignant yielded a sensitivity of elastonosonography of 92%, a specificity of 94%, and negative and positive predictive values of respectively 96% and 88%. Conclusion: Elastosonography is highly sensitive and specific in determining the nature of both mediastinal and pancreatic lesions with excellent positive and negative predictive values and can therefore be helpful in guiding EUSFNA and patient management.

patients with HGD confirmed by a centralized expert pathology group (Cleveland Clinic(CC)) that had undergone EUS evaluation were included in the analysis. Abnormal EUS findings included the presence of submucosal invasion, nodules, and lymphadenopathy (LA). The frequency of EUS findings not visualized at endoscopy, the impact of EUS on patient management, and the frequency of complications were also assessed. Results: Of 84 patients with HGD confirmed by CC being evaluated for RFA, 62 patients with available EUS results were included in this analysis. EUS was normal in 53 (86%) patients, while abnormal findings were seen in 9 (14%) patients. These findings included the detection of esophageal nodules in 2 (3%) and LA in 7 (11%). EUS-guided fine needle aspiration (EUS-FNA) was limited to 2 patients with LA suspicious for malignancy. One showed benign cytology while the other was positive for malignant celiac and mediastinal LA from an undiagnosed lung cancer. Only 2 (3%) patients had EUS findings that were not previously identified on standard endoscopy. In one, a 7  7 mm esophageal submucosal nodule was seen on EUS and underwent endoscopic mucosal resection of a benign lesion. Patient management regarding ablation therapy was unaffected, as the patient was subsequently enrolled in the trial. The second was the aforementioned EUS-FNA of an undiagnosed lung cancer, resulting in trial exclusion. Finally, an attempted EUS in 1 patient was complicated by a cervical esophageal perforation that precluded further evaluation. Conclusions: In this study, the frequency of EUS findings altering management (1.6%) was equaled by the risk of a major complication. The overall frequency of abnormal EUS findings in patients with BE and HGD without mucosal defects on standard endoscopy was low, rarely altered management, and hence questions the utility of the routine use of EUS in these patients.

762 Endosonographic Evaluation Improves Survival in Patients with Pancreatic Cancer Feng Li, Ying Zhou, Amitabh Chak, Gregory S. Cooper, Ananya Das EUS is often utilized in the evaluation of patients with pancreatic cancer although there is no direct evidence that EUS improves patient outcome. Objective: to study the association of receipt of EUS with survival in patients with pancreatic adenocarcinoma. Methods: Persons aged 66 years or older with recent diagnosis of pancreatic cancer, who were captured in the linked SEER-Medicare database between January 1994 and December 2002 were identified. Demographic, cancer specific information and EUS procedural information was extracted and survival curves were compared for patients who underwent EUS within 90 days of diagnosis (group I) to those who had not (group II). A COX proportional hazards model was constructed to assess the independent association of receipt of EUS and survival. Results: 4,236 patients with loco-regional pancreatic adenocarcinoma were identified. Only 535 (12.6%) patients underwent EUS evaluation. Median survival (Inter-quartile range) in group I and II patients were 9(4-17) and 5 (IQR 2-11) months, respectively, P ! 0.0001. The proportion of patients with regional disease was higher in group I compared to those in group II (81% vs. 75%, p ! 0.01). Curative intent surgery (23% vs. 10%, p ! .001) and radiation treatment (18% vs. 11%, p ! .001) were also performed more frequently in group I patients. Receipt of EUS, adjusted for age at diagnosis, race, gender, co-morbidity score, and tumor stage was an independent predictor of improved survival (Relative hazard, 0.82, 95% CI, 0.73-0.90). Conclusion: This is the first evidence that EUS evaluation is associated with improved outcome in patients with pancreatic cancer. Receipt of EUS in patients with loco-regional cancer is independently associated with improved survival, possibly because of detection of earlier cancers or improved stage-appropriate management including more selective performance of curative intent surgery.

761 The Utility of Endoscopic Ultrasound (EUS) in Patients with Barrett’s Esophagus (BE) and High Grade Dysplasia (HGD): Analysis of the AIM Dysplasia Trial Experience Raman Muthusamy, Amit Rastogi, Steven a. Edmundowicz, Nicholas J. Shaheen, Prateek Sharma, Kenneth Chang Introduction: EUS is often used in evaluating BE patients with HGD prior to treatment. Previous reports evaluating its utility in HGD have predominantly consisted of single-center studies with limited patient enrollment and have shown conflicting results. Aims: The primary aim was to assess if EUS findings alter management decisions in BE patients with HGD being considered for ablation therapy. A secondary aim was to determine the overall frequency of abnormal findings on EUS. Methods: We analyzed data from the AIM Dysplasia Trial; a randomized, sham-controlled study involving 19 US sites that evaluated radiofrequency ablation (RFA) for the treatment of BE patients with dysplasia. BE

www.giejournal.org

763 Endoscopic Ultrasound Guided Fine-Needle Aspiration Biopsy in the Evaluation of Mediastinal Adenopathy Suspected of ExtraPulmonary Tuberculosis Rajesh Puri, Peter Vilmann, Sunil Taneja, Randhir Sud, Mandhir Kumar, Kusum Verma Introduction: Extrapulmonary tuberculosis (EPTB) is often a challenging diagnostic problem due to its non-specific clinical presentation and low diagnostic

Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB99

Abstracts

yield obtained by available investigations. The aim of the present study was to assess the safety and accuracy of endoscopic ultrasound guided fine-needle aspiration in the diagnosis of mediastinal adenopathy in patients with a suspicion of EPTB. Patients and Methods: The study was a prospective evaluation of patients with mediastinal adenopathy on CT with a suspicion of EPTB at Sir Ganga Ram Hospital, New Delhi, India. EUS-FNA was performed with a 22 G needle (Sonotip 2, Medi-Globe), on an outpatient basis under conscious sedation. The EUS-FNA diagnosis was compared with the diagnosis made by surgical pathology (if resection was performed) or clinical follow up for at least 6 months. Results: Sixty consecutive patients with mediastinal lymphadenopathy R 1 cm on CT scan were included. The most common symptom was fever, seen in 80% of the patients. On screening for tuberculosis, mantoux positivity was seen in 68% of the patients (range 10-15 mm, median 13mm), whereas sputum smears and cultures for acid-fast bacilli were negative in all. There was no evidence of extramediastinal disease in any of the patients. On EUS, mediastinal lymph nodes ranging in size from 8 to 40mm (mean 26 mm) were detected in all patients. EUSFNA provided an adequate sample in 54 patients during the first examination while repeat EUS-FNA was necessary in 6 patients. A final diagnosis was obtained by EUS-FNA in 56 patients (93%) (TB 46, Sarcoidosis 6, Hodgkin’s lymphoma 4), while mediastinoscopy was required for the diagnosis in 4 patients. Conclusion: EUS-FNA is an important method in the evaluation of EPTB in a developing country where tuberculosis is the commonest cause of mediastinal lymphadenopathy and to avoid missing the opportunity to treat other serious diseases at a treatable stage.

764 A Comparison of the Diagnostic Yield and Specimen Adequacy Between 22 and 25 Gauge Needles for Endoscopic Ultrasound Guided Fine-Needle Aspiration (EUS-FNA) of Solid Pancreatic Lesions (SPL): Is Bigger Better? Thomas Thong H. Nguyen, Christopher E. Lee, Charles S. Whang, Reiko Ashida, John G. Lee, Kenneth Chang, Raman Muthusamy Background: Needle size may affect the specimen quality of EUS-FNA of SPL. Little data exists on the performance characteristics of 22-gauge and 25-gauge needles in EUS-FNA of SPL. Aims: The primary aim was to determine if there were differences in diagnostic accuracy of EUS-FNA of SPL between 22 and 25 G needles. A secondary aim was to determine if there are differences in the frequency of bloody or insufficient specimens between the needles. Complication frequency was also assessed. Methods: A retrospective review of 100 consecutive patients with SPL from two distinct time periods was peformed. From the period of 12/02-03/04, 22 G needles (EchoTipÒ, Cook Medical) were used exclusively during EUS-FNA of SPL. From 12/06-10/07, our institution had converted to routine use of 25 G EchoTipÒ needles (Cook Medical) for SPL. The number of FNA passes needed to make a diagnosis for SPL was recorded. The frequency of bloody and insufficient specimens was also assessed. Cases of postFNA bleeding and pancreatitis were identified. Lesions with benign cytology at EUS-FNA were defined as non-malignant if no maligancy was documented during a 6-month follow up period. Results:The cumulative per-pass diagnostic yield (based on final cytology or clinical followup) of each needle is shown in Table 1. A O 95% diagnostic yield was obtained after 2 passes with a 25 G needle compared to 5 passes with a 22 G needle. Contamination with blood was seen in 30/342 (9%) of 22 G specimens vs. 10/329 (3%) of 25 G specimens (p Z .002). An increase in pass number did not affect the frequency of bloody contamination for either needle. Insufficient samples were obtained on the first pass in 3% of 22 G specimens versus 1% of 25 G specimens. There were no complications with either needle. Complete sensitivity, specificity, and positive/ negative predictive values will be computed when all patients have completed 6month followup. Conclusions: The use of the 25 G needle for EUS-FNA of SPL appears to have a higher initial diagnostic yield and fewer specimens contaminated by blood. In this study, 3 fewer passes were needed with the 25 G needle to achieve a O 95% diagnostic yield. The routine use of 25-G needles for SPL should be considered.

AB100 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008

Summary of percentage of positive diagnosis with each pass Passes required for positive diagnosis 1 2 3 4 5 6

22-g FNA

25-g FNA

p-value

73% 86% 88% 91% 95% 95%

88% 97% 98% 99% 99% 99%

.017 .012 .008 .018 .125 .125

765 Routine PET Does Not Alter Nodal Staging in Patients Undergoing EUS-FNA for Esophageal Cancer Rajesh N. Keswani, Dayna Early, Steven a. Edmundowicz, Ramaswamy Govindan, Riad R. Azar Background: Accurate staging of patients with esophageal cancer is critical for optimal management. Patients with metastatic involvement of regional lymph nodes may not benefit from primary surgical resection. The aim of this study was to determine the utility of performing routine PET scan in patients undergoing EUS evaluation. Methods: Retrospective review of patients who underwent pretreatment EUS and FDG-PET scan for esophageal malignancy over a 4 year period (4/03-8/07). Both procedures were performed within a 30 day period at a single tertiary care referral center. Results: A total of 242 pre-treatment staging EUS exams were performed over the 4 year period. Of these, 148 patients (61.2%, mean age 62.5  11.1 yrs) also underwent PET scan. EUS was performed prior to (n Z 40) or the same day as (n Z 35) PET scan in 50.7% of patients. Of the 148 patients, 126 (85.1%) were male and 123 (83.1%) had adenocarcinoma. Surgical resection was performed as primary therapy in 44 patients (29.8%). EUS diagnosed N1 disease by endosonographic criteria (n Z 67) or cytology (n Z 38) in 70.9% of patients, 5 (4.8%) of whom were N0 at time of primary surgical resection. Of the 100 patients with N1 disease, PET scan was positive in 42% (n Z 42). A cytologic or histologic diagnosis of N1 disease (via EUS-FNA or primary surgical resection) was obtained in 57/148 patients (38.5%). EUS was significantly more sensitive than PET in diagnosing N1 disease in this subgroup of patients (86.0% vs. 43.9%, p ! .0001). Of 6 patients staged N1 by FDG-PET and N0 by EUS, 3 had benign cytology by EUS-FNA. In the 3 remaining patients, EUS was incomplete due to inability to traverse tumor. The diameter of malignant nodes missed by PET scan was significantly smaller than nodes detected by PET scan (10.4 vs. 18.4 mm, p ! 0.0001). With PET scan, extranodal metastasis were identified in 12 patients (8.5%). CT scan was performed in 8 of these patients and demonstrated extranodal metastasis in 2 patients (25%). All patients with extranodal metastasis were staged N1 by EUS. Two patients (1.5%) were diagnosed with a liver metastasis by EUS-FNA and neither was identified by PET. Conclusions: EUS was significantly more sensitive than PET in diagnosing nodal disease in esophageal malignancy. Furthermore, the addition of PET to a complete EUS exam did not improve sensitivity for nodal metastasis. Our data suggests that EUS be performed initially in all patients with esophageal cancer. PET may be used selectively to identify distant metastasis after nodal involvement is diagnosed by EUS and to identify nodal disease after incomplete EUS.

766 Narrow Band Imaging Versus Conventional Colonoscopy for Screening Colonoscopy in a Private Practice Setting - A Large Prospective Randomized Trial Andreas Adler, Timur Yenerim, Jens Aschenbeck, Michael Mayr, Alireza Aminalai, Rolf Drossel, Andreas Schro ¨ Der, Matthias Scheel, Ioannis S. Papanikolaou, Bertram Wiedenmann, Thomas Roesch Background: Narrow Band Imaging (NBI) has been implemented into GI endoscopy in order to better highlight endoluminal pathological structures and improve their contrast. Previous studies from referral centers could not show significant differences in terms of colonoscopic adenoma detection rate, but either very high adenoma rates or some numerical differences suggest that some benefit may exist which may become evident with average adenoma rates and/or larger case numbers. Patients and Methods: In a prospective randomized trial performed exclusively in a multicenter private practice setting involving 6 examiners with substantial life-time experience (O 15.000 colonoscopies) , 1256 patients (m:fZ47%:53%, mean age 64.3 years) underwent screening colonoscopy with either NBI (625 patients) or conventional imaging technique (631 Patients) on instrument withdrawal, using HDTV technique in both arms. Primary outcome measure was the adenoma detection rate (ADR; adenomas per patient). Results: There was no difference between the two groups in terms of ADR (32.0 vs. 34.2%, p Z 0.4), the total number of adenomas (200 vs. 216), the rates of adenomas per adenoma-carrier (200/140Z1.43 vs. 216/137Z1.58), nor in special subgroups (right sided lesions, advanced adenomas, flat adenomas). The times of instrument withdrawal were not significantly different either (8.5 vs. 7.9 min.). Conclusions: This large randomized trial in a homogeneous setting (private practices, screening

www.giejournal.org