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Endoscopic Ultrasound Guided Fine Needle Marking of Lymph Nodes
Abstracts
pancreatic solid lesions. Simultaneous imaging of vascularity by CH-EUS during EUS-FNA is useful for adequate sampling of pancreatic tumors.
treatment. Conclusion: EUS-FNM with a silver sprig in lymph nodes is feasible and safe. EUS-FNM seems to be a tool for evaluating lymph nodes based on a direct node-to-node comparison.
FNA guided by CH-EUS
W1275 Racial Disparity in Communication Between Physicians and Patients with Suspected Pancreatic Cancer Referred for EUS Rajan Kochar, Ashutosh Tamhane, John D. Christein, Shyam Varadarajulu Background: Patients with suspected pancreatic cancer are increasingly referred for EUS for staging and tissue diagnosis. Although most referring physicians are highly suspicious of an underlying diagnosis of pancreatic cancer, patients are often unaware of this likelihood. Due to poor communication in such cases, the endosonographer bears the unenviable burden of informing patients of their diagnosis. Aim: Evaluate the determinants of poor communication between referring physicians and patients with suspected pancreatic cancer. Methods: This is a cross-sectional study of outpatients with high clinical suspicion for pancreatic cancer undergoing EUS at a tertiary referral center over a 6-month period. Prior to undergoing EUS, all patients were administered a standard questionnaire that elicited their level of understanding and communication with their referring doctor on their clinical presentation. In our practice, referring doctors request EUS by completion of datasheet that queries specifically on suspected diagnosis. Patient responses were compared with diagnosis on their referral datasheet and patients were grouped as being aware or unaware (indicating poor communication) of their underlying illness. Results: Of the 89 study patients, 25 (28%) were unaware of the nature of their underlying illness. Mean age of patients was 64.7 years, 52% were men and 28% were African-Americans. Clinical presentation included jaundice (82%), weight loss (79%), abdominal pain (67%), and abnormal finding on CT of the abdomen (82%). On an average, patients had 2 visits with their referring doctors prior to undergoing EUS. Majority of the cases were referred by gastroenterologists (67%) followed by surgeons (18%). Pancreatic cancer was diagnosed in 86% at EUSguided FNA. In multivariable analysis, African-Americans (Adjusted OR Z 4.84; pZ0.017) and those with less than high-school education (Adjusted OR Z 13.87; pZ0.001) were significantly more likely to be unaware of the nature of their underlying illness when adjusted for age, gender, and type of referring doctor. Conclusions: This study demonstrates racial disparity in communication between referring physicians and patients with high clinical suspicion for pancreatic cancer. African-Americans are more likely to be unaware of the nature of their underlying illness and the diagnosis is often conveyed by the endosonographer. Underlying reasons for this disparity need to be identified and addressed.
W1276 Endoscopic Ultrasound Guided Fine Needle Marking of Lymph Nodes Michael H. Larsen, Claus Fristrup, Torsten Pless, Alan Ainsworth, Henning O. Nielsen, Claus P. Hovendal, Michael B. Mortensen Background and Aims: No previous studies have evaluated the ability of endoscopic ultrasound (EUS) to describe the anatomic location of lymph nodes based on a direct node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new EUS guided fine-needle marking (EUS-FNM) technique of lymph nodes. Patients and Methods: Twenty-five patients with suspected or confirmed upper gastrointestinal tract malignances were prospectively included. Patients unsuitable for surgery or patients without lymph nodes suitable for marking were excluded (nZ6). EUS-FNM was performed with a silver sprig with a diameter allowing it to fit into a 19-gauge needle. The position of the sprig was verified by EUS (figure). Endpoints were the ability to identify and isolate the marked lymph node during surgery together with complications and a comparison between the location of the silver sprig suggested by EUS and the actual location found in the resected specimen. Results: Nineteen lymph nodes in 19 patients were marked. The lymph node was isolated in the resection specimen in 18 (95%) patients. In 84% of the cases the marked lymph node was in the same location as described by EUS. One sprig was not isolated in the specimen. In 2 out of 18 cases the sprig was not localized by laparoscopic ultrasound. In 3 cases, a small hematoma was observed. None of the complications had any impact on the further
www.giejournal.org
A hypoechoic lymph node marked with a sprig. The hyperechoic sprig is marked with an arrow.
W1277 Endoscopic Ultrasonography-Guided Fine Needle Aspiration (EUS-FNA) vs EUS-Guided Cytobrushing to Assess Cellular Diagnosis in Cystic Pancreatic Lesions. Definitive Results of a Prospective and Comparative Study Oriol Sendino, Gloria Fernandez-Esparrach, Manel Sole, Lluis Colomo, Albert Pardo, Carlos Guarner-Argente, Maria Pellise, Josep Llach, Andres Cardenas, Josep M. Bordas, Angels Gines Background: Pancreatic cystic lesions are detected with increasing frequency. The accuracy in the diagnosis of the type lesion with imaging techniques is only moderate and the diagnostic yield of EUS-FNA limited. It has been suggested that EUS-cytobrushing could improve the results of EUS-FNA. Aims: To compare EUSFNA and EUS-cytobrushing in obtaining cellularity from pancreatic cystic lesions and to evaluate the complications associated to them. Methods: consecutive patients with a pancreatic cystic lesion O15 mm were included. Exclusion criteria were prothrombine time !50% or platelet count !50.000 and no informed consent. Cysts were sampled with a 19 G needle (EUSN-19-T, Cook, Ireland) and the intracystic fluid aspirated and processed for cytological study. The brush (Echobrush, Cook Ireland) was introduced through the needle, advanced into the cyst, moved to scrub its wall and processed as standard brushings. FNA and brushing samples were blindly evaluated to avoid bias. Complications were assessed in the first 24 hours and seven days after the procedure by telephone call. Results: 30 patients were included. In 8 patients the technique failed for technical reasons (impossibility of cyst puncture due to the excessive bend of the needle). EUS-FNA obtained epithelial cellularity in 6 patients (27%) as compared with 16 (73%) with brushing (pZ0.035). A mucinous neoplasm was diagnosed in 5 patients (23%) with FNA and in 11 (50%) with brushing (pZ0.016). Eight patients underwent surgery by the time of the analysis. In 5 of them the surgical specimen was consistent with both, FNA and brushing results. In the remaining 3, in whom the FNA was acellular, the diagnosis was consistent with the cytobrushing results (2 mucinous cystadenoma and 1 serous cystadenoma). Two major complications were registered: one hemosuccus pancreaticus managed conservatively and one subacute retroperitoneal hemorrhage in a patient on anticoagulation therapy who died for complications one month later. Conclusions: EUS-cytobrushing is more effective than EUS-FNA in obtaining cellularity for the diagnosis of cystic pancreatic lesions. However, the incidence of complications related to cytobrushing has to be assessed in larger series of patients.
W1278 Endoscopic Ultrasonography-Guided Fine Needle Aspiration (EUS-FNA) in Mediastinal Restaging After Neoadjuvant Therapy in Patients with Non-Small Cell Lung Cancer (NSCLC). Preliminary Results Angels Gines, Oriol Sendino, Jose Belda, Manel Sole, Gloria Fernandez-Esparrach, Elisabeth Martı´nez, Maria Pellise, Lluis Colomo, Josep M. Bordas, Josep Llach Background: Multimodal therapy is the standard of care for NSCLC in stages IIIa and some IIIb. Survival of patients with residual lymph node (LN) disease after neoadjuvant therapy plus surgery does not differ from that of patients not submitted to surgery. Therefore, it is crucial to identify the patients with complete LN response before surgery. Few data in the literature suggest that EUS-FNA could be useful for mediastinal restaging in these group of patients. Aim: To investigate the accuracy of EUS-FNA in the mediastinal restaging of
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB329
pancreatic solid lesions. Simultaneous imaging of vascularity by CH-EUS during EUS-FNA is useful for adequate sampling of pancreatic tumors.
treatment. Conclusion: EUS-FNM with a silver sprig in lymph nodes is feasible and safe. EUS-FNM seems to be a tool for evaluating lymph nodes based on a direct node-to-node comparison.
FNA guided by CH-EUS
W1275 Racial Disparity in Communication Between Physicians and Patients with Suspected Pancreatic Cancer Referred for EUS Rajan Kochar, Ashutosh Tamhane, John D. Christein, Shyam Varadarajulu Background: Patients with suspected pancreatic cancer are increasingly referred for EUS for staging and tissue diagnosis. Although most referring physicians are highly suspicious of an underlying diagnosis of pancreatic cancer, patients are often unaware of this likelihood. Due to poor communication in such cases, the endosonographer bears the unenviable burden of informing patients of their diagnosis. Aim: Evaluate the determinants of poor communication between referring physicians and patients with suspected pancreatic cancer. Methods: This is a cross-sectional study of outpatients with high clinical suspicion for pancreatic cancer undergoing EUS at a tertiary referral center over a 6-month period. Prior to undergoing EUS, all patients were administered a standard questionnaire that elicited their level of understanding and communication with their referring doctor on their clinical presentation. In our practice, referring doctors request EUS by completion of datasheet that queries specifically on suspected diagnosis. Patient responses were compared with diagnosis on their referral datasheet and patients were grouped as being aware or unaware (indicating poor communication) of their underlying illness. Results: Of the 89 study patients, 25 (28%) were unaware of the nature of their underlying illness. Mean age of patients was 64.7 years, 52% were men and 28% were African-Americans. Clinical presentation included jaundice (82%), weight loss (79%), abdominal pain (67%), and abnormal finding on CT of the abdomen (82%). On an average, patients had 2 visits with their referring doctors prior to undergoing EUS. Majority of the cases were referred by gastroenterologists (67%) followed by surgeons (18%). Pancreatic cancer was diagnosed in 86% at EUSguided FNA. In multivariable analysis, African-Americans (Adjusted OR Z 4.84; pZ0.017) and those with less than high-school education (Adjusted OR Z 13.87; pZ0.001) were significantly more likely to be unaware of the nature of their underlying illness when adjusted for age, gender, and type of referring doctor. Conclusions: This study demonstrates racial disparity in communication between referring physicians and patients with high clinical suspicion for pancreatic cancer. African-Americans are more likely to be unaware of the nature of their underlying illness and the diagnosis is often conveyed by the endosonographer. Underlying reasons for this disparity need to be identified and addressed.
W1276 Endoscopic Ultrasound Guided Fine Needle Marking of Lymph Nodes Michael H. Larsen, Claus Fristrup, Torsten Pless, Alan Ainsworth, Henning O. Nielsen, Claus P. Hovendal, Michael B. Mortensen Background and Aims: No previous studies have evaluated the ability of endoscopic ultrasound (EUS) to describe the anatomic location of lymph nodes based on a direct node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new EUS guided fine-needle marking (EUS-FNM) technique of lymph nodes. Patients and Methods: Twenty-five patients with suspected or confirmed upper gastrointestinal tract malignances were prospectively included. Patients unsuitable for surgery or patients without lymph nodes suitable for marking were excluded (nZ6). EUS-FNM was performed with a silver sprig with a diameter allowing it to fit into a 19-gauge needle. The position of the sprig was verified by EUS (figure). Endpoints were the ability to identify and isolate the marked lymph node during surgery together with complications and a comparison between the location of the silver sprig suggested by EUS and the actual location found in the resected specimen. Results: Nineteen lymph nodes in 19 patients were marked. The lymph node was isolated in the resection specimen in 18 (95%) patients. In 84% of the cases the marked lymph node was in the same location as described by EUS. One sprig was not isolated in the specimen. In 2 out of 18 cases the sprig was not localized by laparoscopic ultrasound. In 3 cases, a small hematoma was observed. None of the complications had any impact on the further
www.giejournal.org
A hypoechoic lymph node marked with a sprig. The hyperechoic sprig is marked with an arrow.
W1277 Endoscopic Ultrasonography-Guided Fine Needle Aspiration (EUS-FNA) vs EUS-Guided Cytobrushing to Assess Cellular Diagnosis in Cystic Pancreatic Lesions. Definitive Results of a Prospective and Comparative Study Oriol Sendino, Gloria Fernandez-Esparrach, Manel Sole, Lluis Colomo, Albert Pardo, Carlos Guarner-Argente, Maria Pellise, Josep Llach, Andres Cardenas, Josep M. Bordas, Angels Gines Background: Pancreatic cystic lesions are detected with increasing frequency. The accuracy in the diagnosis of the type lesion with imaging techniques is only moderate and the diagnostic yield of EUS-FNA limited. It has been suggested that EUS-cytobrushing could improve the results of EUS-FNA. Aims: To compare EUSFNA and EUS-cytobrushing in obtaining cellularity from pancreatic cystic lesions and to evaluate the complications associated to them. Methods: consecutive patients with a pancreatic cystic lesion O15 mm were included. Exclusion criteria were prothrombine time !50% or platelet count !50.000 and no informed consent. Cysts were sampled with a 19 G needle (EUSN-19-T, Cook, Ireland) and the intracystic fluid aspirated and processed for cytological study. The brush (Echobrush, Cook Ireland) was introduced through the needle, advanced into the cyst, moved to scrub its wall and processed as standard brushings. FNA and brushing samples were blindly evaluated to avoid bias. Complications were assessed in the first 24 hours and seven days after the procedure by telephone call. Results: 30 patients were included. In 8 patients the technique failed for technical reasons (impossibility of cyst puncture due to the excessive bend of the needle). EUS-FNA obtained epithelial cellularity in 6 patients (27%) as compared with 16 (73%) with brushing (pZ0.035). A mucinous neoplasm was diagnosed in 5 patients (23%) with FNA and in 11 (50%) with brushing (pZ0.016). Eight patients underwent surgery by the time of the analysis. In 5 of them the surgical specimen was consistent with both, FNA and brushing results. In the remaining 3, in whom the FNA was acellular, the diagnosis was consistent with the cytobrushing results (2 mucinous cystadenoma and 1 serous cystadenoma). Two major complications were registered: one hemosuccus pancreaticus managed conservatively and one subacute retroperitoneal hemorrhage in a patient on anticoagulation therapy who died for complications one month later. Conclusions: EUS-cytobrushing is more effective than EUS-FNA in obtaining cellularity for the diagnosis of cystic pancreatic lesions. However, the incidence of complications related to cytobrushing has to be assessed in larger series of patients.
W1278 Endoscopic Ultrasonography-Guided Fine Needle Aspiration (EUS-FNA) in Mediastinal Restaging After Neoadjuvant Therapy in Patients with Non-Small Cell Lung Cancer (NSCLC). Preliminary Results Angels Gines, Oriol Sendino, Jose Belda, Manel Sole, Gloria Fernandez-Esparrach, Elisabeth Martı´nez, Maria Pellise, Lluis Colomo, Josep M. Bordas, Josep Llach Background: Multimodal therapy is the standard of care for NSCLC in stages IIIa and some IIIb. Survival of patients with residual lymph node (LN) disease after neoadjuvant therapy plus surgery does not differ from that of patients not submitted to surgery. Therefore, it is crucial to identify the patients with complete LN response before surgery. Few data in the literature suggest that EUS-FNA could be useful for mediastinal restaging in these group of patients. Aim: To investigate the accuracy of EUS-FNA in the mediastinal restaging of
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB329