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Endosonographic and clinical features of biliary involvement in extrahepatic portal venous obstruction (EHPVO)
ENDOSCOPIC ULTRASOUND 609
611
THE CLINICAL AND E C O N O M I C I M P A C T O F ENDOSCOPIC ULTRASOUND (EUS) AND EUS-GUIDED FINE NEEDLE ASPIRATION (FNA) IN THE STAGING OF ESOPHAGEAL CANCER.
ENDOSONOGRAPHIC F~ATU'RI~ OF PRIMARY SCLEROSING CtlOLANGITIS (PSC). A STUDY OF 2.3 CASIkS. L. Palazzo (I,2), Y. N~,o (3), C. Cellier (1), G. Roseau (2), B. l~udi (1), D. Castaing (4), ti. Bismuth (4), J.P. Gendre (3), J.P. Barbier (I). (1) La6nnec Hospital, Paris, (2) Trocadtro Clinic, Paris (3) Rotschild Hospital, Paris (4) Paul Brousse Hospital, Vilhijuif, FRANCE. The diagnosis of PSC is based on endoscopic retrograde cholangiography (ERC) and hepatic histology. The importsnce of endoscopic ultmsonography (EUS), a non-invasive examination, in PSC is not known. The purpose of this retrospective study was to describe the EUS aspects observed in the course of PSC. Patients and methods : The EUS (Olympus EUM20) videorecorded examinations of 23 patients (13 males, 10 females, average age 48,5 years, range between 22 and 78 years) interviewed consecutively, suffering from a PSC, confirmed by 'ERC data aud/or a histological examination of the liver, were studied retrospectively. The average tollow-up lime was 27,4 mouths (ranging between 0 and 72 months). 6 patients had had EUS for an unexplained chohistasis, 7 for a known PSC, and 10, a hepatic transplant for PSC as part of the surveillance of the residual bile duct. Results : The EUS features observed (and their frequency) were as follows : thickening of the biliary walls (average 3 ram, range 1-6 mm) (78 %) ; irregularity of the inside of the wall (43 %) affecting the whole of the bile duct (86 %), general stenosis (38 %), dilatation of the bile duct (30 %), stone or biliary sludge within the ( ~ I ) (15 %) and aspect of chronic pancreatitis (13 %). Among the 13patients that had not undergone hepatic transplantation there was agreement between the EUS and the ERC as regards the location of the lesions in 7eases, and disagreement in 6cases. Of the latter 6eases : a) 3 patients had isolated lesions of the intrahepatic bile duct (IHBD), detected by ERC but not by EUS ; however, in the case of these 3 patients, EE revealed lesions of the extrahepatic bile duct (EHBD) ; b) 2 patients had diffuse lesions of the EHBD and IHBD as revealed by ERC, and only lesions of the EIIBD as detected by EUS ; c) one patient had only fight intrahepatic lesions according to ERC while EUS indicated an abnormal appearance of the left EttBD and the IHBD. Conclusion : This retrospective study of 23 cases of PSC shows that the EtlBD are abnormal with EUS in nearly 9cases out of I0. This sensitivity of the EUS aspects which appears quite good, and the specificity which is not known merit further study.
P Ngnyen, D Bastas, KJ Chang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, CA. Introduction: EUS is highly accurate in the local staging of esophageal cancer and the addition of EUS-guided F N A allows for tissue diagnosis and improved specificity of nodal staging. The staging accuracy and clinical impact of this combined modality in esophageal cancer has not been well described. Methods: A prospective study of 37 consecutive patients (mean age 67; 25M, 12F) with known esophageal cancer referred for local staging was conducted over a 3 year period (8/93-7/96). All patients were surgical candidates prior to EUS. EUS was performed using the Olympus GFUM20 eehoendoscope. EUS-guided FNA was performed using the Pentax FG-32UA echoendoscope and the GIP-Medigiobe needle. In 36 of 37 patients (97%), complete EUS staging was successful, including 9 (24%) patients who required a single pre-EUS esophageal dilatation (1 unsuccessful due to metal prosthesis). There were no procedural complications. Fifty-seven percent were adenocarcinoma while 43% were squarnous cell carcinoma. Results: Surgical correlation was available in 13 patients (Table 1). Table 1. Staging accuracy:
EUS FNA
11/13(85%3
8/9(89%)
2/3(67%)
CT
NA
7/10(70%)
0/2 (0%) . . . . . . . .
1/1(0%)
11/13 (85%) 7/12 (58%1
The median survival for patients with EUS stage NO (N=I5) vs N1 (N=21) was 24 vs 13 months (p<0.17 Log Rank Test). Surgery was avoided in 17/37 (46%) patients based on the EUS/FNA stage. The estimated cost savings (including hospital cost/professional fees) for these 17 patients was approximately $320,000 (assuming thoracotomy cost = $24,000, EUS/FNA cost = $2,400), or an average net cost savings of approximately $8,650 per patient. Conclusions: 1) EUS-gnided FNA has a high nodal staging accuracy (85%) as compared to CT. 2) In esophageal cancer patients who are surgical candidates, EUS combined with EUS-guided FNA substantially decreases the need for surgery and its associated cost.
"1"610
t612
F,NDOSONCK;RAPIIIC AND CLINICAl, FliATURIk~ OF BII,IARY INVOI ,V FAIF.NT IN F.XTRAIIEPATIC PORTAl. VI:2~OUS OBSTRI KTI'ION (F21PVO). L. Palazzx~(1,2), P. I Iochain (3), C. (3ellier ( I ), C. Sinmn ( I ), 1. Dumontier (I), G. Rosean (2), Pit Cugnenc ( I ), JP Barbier (I). (I) I )apt of Gastrocuterology, l,a~nnec l lospital, Paris, (2)Turin Clinic, Paris, (3) GRAIl, Charles Nicolle I Iospital, Rouen, FRANCI ~. Cavermm.s tmasformation of the portal vein results from I]'llVO. Biliary maud'estatious are not well recognized. The aim of this study was to de.serihe eudosonogmphic and clinical features of biliary involvement in 21 consecutive patients with F,IlPVO. Method~ : Between 1-01-1991 and 31-01-19~X~, 21 of 10.000 enck~scopic ultmsound (FUS) examinations pafformad in our group had concerned EHPVO with biliary cavemoma (BC). These involved 16 males and 5 females with a median age of ~ years (range 22 to 75). En&r~ouographic features of BC was defined as the preseacc of multiple, large, serpiginous anechoic vascular chaanels in and/or surrounding the wall of the common bile duct (CBI)) and/or gallbladder. Clinical and biological characteristics were relxa'ted with a standardized questionnaire. Rtanl~ : The cause of EttPVO was unknown in 52 % and neoplasic in 28 %. BC inw~lvedthe wall of the C'BD in 18 cases aad/or surrounded in 12cases. Jaundice due to BC occured in 3 cases in whom vazices occluded the CBI). BC was seen in the wall of the gallbladder in 9cases. EUS revealed a tumor in 3 c&ses. Jaundice due to compression was treated by porlosystemic shunt only, in 2 patients, associated with biliary endoprosthesis in 1 patient. Jaundice decreased in 2 of 3 cases. EUS follow-up had shown an incomplete regression of biliary obstruction, although jaundice disappeared. Conelmion : In EHPVO, EUS can distinguish cavemoma involving or surrounding CBD. Biliary obstruction by 13('.occurred in 1 of 6 cases. Thus BC is essentially asymptomatic. EUS can contribute to etiologic diagnosis in portal vein obstruction.
A PROSPECTIVE STUDY OF PRE- AND POST-ADJUVANT TREATMENT EUS IN PATIENTS WITH ESOPHAGEAL CANCER
VOLUME 45, NO. 4, 1997
D. Ouirk. T. Lynch, M. Grossbard, W. Brugge, Department of Medicine, Massachusetts General Hospital, Boston, MA.
Introduction: Accurate staging of esophageal cancer is required for both accurate proguosis and treatment selection. Endoscopic ultrasound (EUS) has proven to be a highly accurate method of staging. The purpose of this study was to prospectavely evaluate EUS in patients with esophageal cancer treated with a new adjuvant treatment protocol consisting of taxol, cisplatin, 5fluorouracil, and external beam irradiation. Methods: A prospective study was conducted on 29 patients who were enrolled in the study and underwent surgery between November 1994 and December 1996. Linear-array EUS (Pentax FG 32UA, Orangeburg, NY) was performed prior to adjuvant treatment in all patients and it was performed post treatment (prior to surgery) in 20 patients. Information regarding TNM staging, maximal tumor thickness, wall irregularity, and esophageal obstruction (defined as tumor occupying > 75% of the esophageal lumen) was recorded at each session. Results: The mean age of the patients was 63 with a M:F ratio of 6: I. Initial EUS staging revealed: I-TIN0, 9-T2N0, I-T2N1, 15-T3N0, and 3- T3NI. Fifty-seven percent of the tumors were down-staged secondary to adjuvant treatment, 36% of the resected specimens were free of tumor (11-TON0, 3TIN0, 3-T2N0, 4-T3N0, I-TONI, 2-TINI, 3-T2NI, 2-T3NI). Pre treatment T and N staging by EUS did not correlate with cure (correlation coefficients (0.02 and 0.38). Two of 4 patients initially staged as NI at initial EUS were NO after treatment. Mean tumor thickness decreased from 11.4 mm to 5.6 mm (p < 0.05). Mean wall thickness at post-adjuvant EUS was 5.9 nun (5.4 nun for those free of tumor vs. 5.6 mm for those with residual, p= 0.74). Postadjuvant T and N staging by EUS predicted cure with correlation coefficients of 0.38 and 0.40 respectively. Post-treatment wall contour did not correlate with cure (p-value 0.12). The esophagus was obstructed in 30% of patients pre-treatment and in no patients post-treatment (p < 0.008). Conclusion: Adjuvant treatment of esophageal cancer results in a significant percentage of downstaging and cure as well as elimination of esophageal obstruction. The significant increase in esophageal wall thickness in conjunction with the significant reduction in tumor size appears to dimmish the ability to discern residual tumor.
GASTROINTESTINAL ENDOSCOPY
AB177
611
THE CLINICAL AND E C O N O M I C I M P A C T O F ENDOSCOPIC ULTRASOUND (EUS) AND EUS-GUIDED FINE NEEDLE ASPIRATION (FNA) IN THE STAGING OF ESOPHAGEAL CANCER.
ENDOSONOGRAPHIC F~ATU'RI~ OF PRIMARY SCLEROSING CtlOLANGITIS (PSC). A STUDY OF 2.3 CASIkS. L. Palazzo (I,2), Y. N~,o (3), C. Cellier (1), G. Roseau (2), B. l~udi (1), D. Castaing (4), ti. Bismuth (4), J.P. Gendre (3), J.P. Barbier (I). (1) La6nnec Hospital, Paris, (2) Trocadtro Clinic, Paris (3) Rotschild Hospital, Paris (4) Paul Brousse Hospital, Vilhijuif, FRANCE. The diagnosis of PSC is based on endoscopic retrograde cholangiography (ERC) and hepatic histology. The importsnce of endoscopic ultmsonography (EUS), a non-invasive examination, in PSC is not known. The purpose of this retrospective study was to describe the EUS aspects observed in the course of PSC. Patients and methods : The EUS (Olympus EUM20) videorecorded examinations of 23 patients (13 males, 10 females, average age 48,5 years, range between 22 and 78 years) interviewed consecutively, suffering from a PSC, confirmed by 'ERC data aud/or a histological examination of the liver, were studied retrospectively. The average tollow-up lime was 27,4 mouths (ranging between 0 and 72 months). 6 patients had had EUS for an unexplained chohistasis, 7 for a known PSC, and 10, a hepatic transplant for PSC as part of the surveillance of the residual bile duct. Results : The EUS features observed (and their frequency) were as follows : thickening of the biliary walls (average 3 ram, range 1-6 mm) (78 %) ; irregularity of the inside of the wall (43 %) affecting the whole of the bile duct (86 %), general stenosis (38 %), dilatation of the bile duct (30 %), stone or biliary sludge within the ( ~ I ) (15 %) and aspect of chronic pancreatitis (13 %). Among the 13patients that had not undergone hepatic transplantation there was agreement between the EUS and the ERC as regards the location of the lesions in 7eases, and disagreement in 6cases. Of the latter 6eases : a) 3 patients had isolated lesions of the intrahepatic bile duct (IHBD), detected by ERC but not by EUS ; however, in the case of these 3 patients, EE revealed lesions of the extrahepatic bile duct (EHBD) ; b) 2 patients had diffuse lesions of the EHBD and IHBD as revealed by ERC, and only lesions of the EIIBD as detected by EUS ; c) one patient had only fight intrahepatic lesions according to ERC while EUS indicated an abnormal appearance of the left EttBD and the IHBD. Conclusion : This retrospective study of 23 cases of PSC shows that the EtlBD are abnormal with EUS in nearly 9cases out of I0. This sensitivity of the EUS aspects which appears quite good, and the specificity which is not known merit further study.
P Ngnyen, D Bastas, KJ Chang. Division of Gastroenterology, University of California, Irvine Medical Center, Orange, CA. Introduction: EUS is highly accurate in the local staging of esophageal cancer and the addition of EUS-guided F N A allows for tissue diagnosis and improved specificity of nodal staging. The staging accuracy and clinical impact of this combined modality in esophageal cancer has not been well described. Methods: A prospective study of 37 consecutive patients (mean age 67; 25M, 12F) with known esophageal cancer referred for local staging was conducted over a 3 year period (8/93-7/96). All patients were surgical candidates prior to EUS. EUS was performed using the Olympus GFUM20 eehoendoscope. EUS-guided FNA was performed using the Pentax FG-32UA echoendoscope and the GIP-Medigiobe needle. In 36 of 37 patients (97%), complete EUS staging was successful, including 9 (24%) patients who required a single pre-EUS esophageal dilatation (1 unsuccessful due to metal prosthesis). There were no procedural complications. Fifty-seven percent were adenocarcinoma while 43% were squarnous cell carcinoma. Results: Surgical correlation was available in 13 patients (Table 1). Table 1. Staging accuracy:
EUS FNA
11/13(85%3
8/9(89%)
2/3(67%)
CT
NA
7/10(70%)
0/2 (0%) . . . . . . . .
1/1(0%)
11/13 (85%) 7/12 (58%1
The median survival for patients with EUS stage NO (N=I5) vs N1 (N=21) was 24 vs 13 months (p<0.17 Log Rank Test). Surgery was avoided in 17/37 (46%) patients based on the EUS/FNA stage. The estimated cost savings (including hospital cost/professional fees) for these 17 patients was approximately $320,000 (assuming thoracotomy cost = $24,000, EUS/FNA cost = $2,400), or an average net cost savings of approximately $8,650 per patient. Conclusions: 1) EUS-gnided FNA has a high nodal staging accuracy (85%) as compared to CT. 2) In esophageal cancer patients who are surgical candidates, EUS combined with EUS-guided FNA substantially decreases the need for surgery and its associated cost.
"1"610
t612
F,NDOSONCK;RAPIIIC AND CLINICAl, FliATURIk~ OF BII,IARY INVOI ,V FAIF.NT IN F.XTRAIIEPATIC PORTAl. VI:2~OUS OBSTRI KTI'ION (F21PVO). L. Palazzx~(1,2), P. I Iochain (3), C. (3ellier ( I ), C. Sinmn ( I ), 1. Dumontier (I), G. Rosean (2), Pit Cugnenc ( I ), JP Barbier (I). (I) I )apt of Gastrocuterology, l,a~nnec l lospital, Paris, (2)Turin Clinic, Paris, (3) GRAIl, Charles Nicolle I Iospital, Rouen, FRANCI ~. Cavermm.s tmasformation of the portal vein results from I]'llVO. Biliary maud'estatious are not well recognized. The aim of this study was to de.serihe eudosonogmphic and clinical features of biliary involvement in 21 consecutive patients with F,IlPVO. Method~ : Between 1-01-1991 and 31-01-19~X~, 21 of 10.000 enck~scopic ultmsound (FUS) examinations pafformad in our group had concerned EHPVO with biliary cavemoma (BC). These involved 16 males and 5 females with a median age of ~ years (range 22 to 75). En&r~ouographic features of BC was defined as the preseacc of multiple, large, serpiginous anechoic vascular chaanels in and/or surrounding the wall of the common bile duct (CBI)) and/or gallbladder. Clinical and biological characteristics were relxa'ted with a standardized questionnaire. Rtanl~ : The cause of EttPVO was unknown in 52 % and neoplasic in 28 %. BC inw~lvedthe wall of the C'BD in 18 cases aad/or surrounded in 12cases. Jaundice due to BC occured in 3 cases in whom vazices occluded the CBI). BC was seen in the wall of the gallbladder in 9cases. EUS revealed a tumor in 3 c&ses. Jaundice due to compression was treated by porlosystemic shunt only, in 2 patients, associated with biliary endoprosthesis in 1 patient. Jaundice decreased in 2 of 3 cases. EUS follow-up had shown an incomplete regression of biliary obstruction, although jaundice disappeared. Conelmion : In EHPVO, EUS can distinguish cavemoma involving or surrounding CBD. Biliary obstruction by 13('.occurred in 1 of 6 cases. Thus BC is essentially asymptomatic. EUS can contribute to etiologic diagnosis in portal vein obstruction.
A PROSPECTIVE STUDY OF PRE- AND POST-ADJUVANT TREATMENT EUS IN PATIENTS WITH ESOPHAGEAL CANCER
VOLUME 45, NO. 4, 1997
D. Ouirk. T. Lynch, M. Grossbard, W. Brugge, Department of Medicine, Massachusetts General Hospital, Boston, MA.
Introduction: Accurate staging of esophageal cancer is required for both accurate proguosis and treatment selection. Endoscopic ultrasound (EUS) has proven to be a highly accurate method of staging. The purpose of this study was to prospectavely evaluate EUS in patients with esophageal cancer treated with a new adjuvant treatment protocol consisting of taxol, cisplatin, 5fluorouracil, and external beam irradiation. Methods: A prospective study was conducted on 29 patients who were enrolled in the study and underwent surgery between November 1994 and December 1996. Linear-array EUS (Pentax FG 32UA, Orangeburg, NY) was performed prior to adjuvant treatment in all patients and it was performed post treatment (prior to surgery) in 20 patients. Information regarding TNM staging, maximal tumor thickness, wall irregularity, and esophageal obstruction (defined as tumor occupying > 75% of the esophageal lumen) was recorded at each session. Results: The mean age of the patients was 63 with a M:F ratio of 6: I. Initial EUS staging revealed: I-TIN0, 9-T2N0, I-T2N1, 15-T3N0, and 3- T3NI. Fifty-seven percent of the tumors were down-staged secondary to adjuvant treatment, 36% of the resected specimens were free of tumor (11-TON0, 3TIN0, 3-T2N0, 4-T3N0, I-TONI, 2-TINI, 3-T2NI, 2-T3NI). Pre treatment T and N staging by EUS did not correlate with cure (correlation coefficients (0.02 and 0.38). Two of 4 patients initially staged as NI at initial EUS were NO after treatment. Mean tumor thickness decreased from 11.4 mm to 5.6 mm (p < 0.05). Mean wall thickness at post-adjuvant EUS was 5.9 nun (5.4 nun for those free of tumor vs. 5.6 mm for those with residual, p= 0.74). Postadjuvant T and N staging by EUS predicted cure with correlation coefficients of 0.38 and 0.40 respectively. Post-treatment wall contour did not correlate with cure (p-value 0.12). The esophagus was obstructed in 30% of patients pre-treatment and in no patients post-treatment (p < 0.008). Conclusion: Adjuvant treatment of esophageal cancer results in a significant percentage of downstaging and cure as well as elimination of esophageal obstruction. The significant increase in esophageal wall thickness in conjunction with the significant reduction in tumor size appears to dimmish the ability to discern residual tumor.
GASTROINTESTINAL ENDOSCOPY
AB177