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EUS FNA Diagnostic Yield of Malignancy in Solid Pancreatic Mass: A Benchmark for Quality Performance Measurement
Abstracts
W1287 EUS FNA Diagnostic Yield of Malignancy in Solid Pancreatic Mass: A Benchmark for Quality Performance Measurement Thomas Savides, Gordon Hunt, Mohammed Al-Haddad, Harry Aslanian, Tamir Ben-Menachem, Victor Chen, Walter Coyle, John Deutsch, John Dewitt, Manish Dhawan, Alexander Eckardt, Mohamad Eloubeidi, Alec Esker, Timothy Gardner, Frank Gress, Steven Ikenberry, Ann Marie Joyce, Jason Klapman, Simon Lo, Fauze Maluf-Filho, Nicholas Nickl, Virmeet Singh, Jason Wills, Michael Donohue, Cynthia Behling Introduction: No benchmarking exists to assess EUS/FNA quality performance. Diagnostic yield of EUS/FNA of solid pancreatic masses (SPM) is a good potential benchmark because the pre-test probability that a SPM is malignant is very high (8090%), and the EUS/FNA sensitivity for diagnosing malignancy is very good (80-90%). Therefore the majority of SPM EUS/FNA should be diagnostic for malignancy. Variation in diagnostic yield could be affected by endoscopist, EUS technique, cytology preparation, pathology interpretation, and prevalence of chronic pancreatitis. Purpose: The goal of this study was to determine the cytologic diagnostic rate of malignancy in EUS/FNA of SPM, and to determine if variability among centers and endoscopists. Methods: Multi-center, retrospective study involving 21 EUS sites. Centers were asked to provide the cytology report for all EUS/FNA of solid, non-cystic, R10 mm short axis diameter pancreatic masses aspirated during a 1-year period (July 1, 2004-June 30, 2005). Results: 1094 patients underwent EUS/FNA in 21 centers (81% academic) involving 41 endoscopists. Among the endoscopists, 56% had 4th year training and 63% had performed O1000 lifetime EUS procedures. The median number of SPM EUS/FNA performed during the year per center was 46 (range 4-177), and per endoscopist was 19 (range 1-97). The mean mass dimensions were 32 mm 27 mm, with 73% located in the head. The mean number of passes was 3.5. 90% of centers used immediate cytologic evaluation. The overall diagnostic rate of malignancy was 71% (95% CI, .69, .74), with 5% suspicious for malignancy, 6% atypical cells, and 18% negative for malignancy. The median diagnostic rate per center was 78% (range 39%-93%; 1st quartile 61%), and per endoscopist was 75% (range 0%-100%; 1st quartile 52%) Multivariate analysis revealed the variables associated with positive malignant diagnostic yield were older age, female gender, body/tail location, greater short axis diameter, and fewer # passes. Conclusions: 1) EUS/FNA cytology was diagnostic of malignancy in 71% of solid pancreatic masses biopsied. 2) There was large variation in diagnostic yield among EUS centers and endoscopists. Implications: 1) Endoscopists with a final cytologic diagnosis rate of malignancy for EUS/FNA of solid masses which is less than 52% are in the lowest quartile, and should evaluate reasons for their low yield. 2) EUS/FNA diagnostic yield rate for pancreatic masses is a simple method that endosonographers can use to compare their diagnostic rates to their peers as a method for benchmarking EUS/FNA quality performance. 3) Prospective analysis could identify specific factors associated with yield.
W1288 Utility of Endoscopic Ultrasound Is Safe and Accurate in the Evaluation of Abnormal Intraoperative Cholangiograms Andrew C. Bolin, James Lusby, Peter Naus, James T. Sing Background: There is no consensus on the imaging modality for evaluating abnormal post-cholecystectomy intraoperative cholangiograms (IOC). IOC usage in laparoscopic cholecystectomy is increasing in order to evaluate retained common bile duct stones. Common bile duct stones are detected in 17% of postcholecystectomy cases. The gold standard in evaluating the biliary system, and for choledocholithiasis, has been endoscopic retrograde cholangiopancreatography (ERCP), however this procedure is associated with increased morbidity and mortality when compared to endoscopic ultrasound (EUS). EUS has been shown in previous studies to have a sensitivity 88-97% and specificity of 96-100% in the evaluation of patients with suspected choledocholithiasis. There has not been a study published to date in which EUS performance was evaluated in the setting of an abnormal IOC. Methods: A retrospective study to evaluate the utility of EUS imaging of the extrahepatic biliary system for abnormal IOC. All medical records for EUS performed in the setting of an abnormal IOC since 1997 at Scott & White Hospital were reviewed. Positive EUS results for choledocholithiasis were confirmed by direct visualization of stones in the duodenum after ERCP extraction or ERCP which showed cholangiogram with filling defects that resolved after extraction. Negative EUS results were considered if the patient had a negative EUS for choledocolithiasis and remained symptom free (no abdominal pain, cholangitis or LFT abnormalities) on follow up of at least 6 months. Results: A total of 62 patients met inclusion criteria. Age ranged from 14 to 89 years of age, mean age 54 years of age, with 37% male and 63% female. There were 34 cases with a negative EUS result, 13 were excluded for inadequate follow up of six months. For all cases there was no evidence of a missed stone (no abdominal pain, cholangitis or LFT abnormalities) at 6 months follow up. There were 28 cases with positive EUS results all of which had conformation of common bile duct stones at ERCP. In 26 cases there was direct visualization of the stone in the duodenum after extraction and 2 cases with filling defects on cholangiogram that resolved after extraction. EUS evaluation of an abnormal IOC has a sensitivity of 85-100% and specificity of 81100% with 95% confidence interval. There were no complications from any EUS. Conclusion: The results of this study confirm EUS is highly reliable method of
AB258 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
evaluating abnormal intraoperative cholangiograms. The increased use of endoscopic ultrasound should reduce morbidity and mortality associated with unnecessary ERCP and reduce overall costs and length of hospital stay.
W1289 Preliminary Results in the Diagnosis of the Early Stage Chronic Pancreatitis Using EUS-Elastography Yoshiki Hirooka, Akihiro Itoh, Hiroki Kawashima, Kazuo Hara, Akira Kanamori, Hiroki Uchida, Jun Goto, Koji Nonogaki, Yukinari Matsumoto, Naoki Ohmiya, Yasumasa Niwa, Hidemi Goto Many studies have compared EUS findings with other modalities (ERCP and noninvasive pancreatic function test) for the evaluation of chronic pancreatitis (CP) and suggest that ductal and parenchymal abnormalities detected using EUS correlate with the presence of CP. Real-time tissue elastography (EG: Hitachi, Japan) is the technology that images the difference of distortion between hard tissue and soft tissue in real time. We investigated the capability to diagnose the early stage of chronic pancreatitis by detecting parenchymal changes (the fibrosis of parenchyma along with ductal changes) using EUS-EG. Methods: Subjects consist of 39 patients, including 17 CP (13 cases were classified as definite CP and 4 cases were classified as suspected CP according to the classification criteria by Japan Pancreas Society) and 12 IPMN (intraductal papillary mucinous neoplasm) and 10 normal controls. The pancreatic parenchyma was observed using B-mode EUS and EUS-EG (for the cases of IPMN, the tail side of the main lesion was evaluated.). 1. We classified subjects into mild, moderate and severe CP according to the total umber of B-mode EUS criteria (Catalano’s classification). 2. EUS-EG was performed in all cases followed by classifying three categories: A; random pattern, B; moderate pattern, C; uniform pattern. EUB-8500 (Hitachi) and EG-3630UR (Pentax) were used in this study. Results: 1. B-mode EUS: Ten out of 13 definite CP cases were classified into severe CP, and 3 were classified into moderate CP. Two out of 4 suspected CP cases were classified into severe, and remaining 2 cases into moderate and mild, respectively. Two out of 12 IPMN cases were classified into moderate and remaining 10 into mild. Only one case of normal control indicated the mild findings, and other 9 cases showed no abnormalities. 2. EUS-EG: twelve out of 13 definite CP cases were classified into A, and 1 was classified into B. Three out of 4 suspected CP cases were classified into A, and 1 cases into B. Four out of 12 IPMN cases were classified into A, 7 cases into B and 1 into C. Eight normal cases were classified into C, and 2 into B. Conclusion: The cases of mild pancreatitis by the criteria of B-mode EUS showed random pattern on elastography. The up-stream parenchyma of IPMN classified into as mild by B-mode EUS was depicted as random pattern using elastography. From this preliminary result, it may be assumed that early detection of changes of tissue hardness is possible. EUS-elastography might be useful in the diagnosis of chronic pancreatitis including early stage of the disease.
W1290 Intraductal Ultrasound in Evaluation of Biliary Strictures Without a Mass Lesion On CT Scan: Significance of Focal Wall Thickening and Extrinsic Compression At the Stricture Site Naveen B. Krishna, Saradhi V. Saripalli, Rizwan Safdar, Banke Agarwal Background: Biliary intraductal ultrasound (IDUS) has been limited in its clinical utility to evaluate biliary strictures due to lack of easily recognized morphologic criteria to distinguish benign and malignant strictures. We evaluated the clinical significance of two easily assessed IDUS findings- wall thickness and extrinsic compression at stricture site. Patients and Methods: 48 patients who underwent ERCP/IDUS for evaluation of biliary strictures without an identifiable mass lesion on CT scan were retrospectively studied. Patients with strictures proximal to bifurcation of CHD or with periampullary tumors were excluded. IDUS pictures were reviewed specifically to measure wall thickness and look for extrinsic compression at stricture site. Final diagnosis was based on definitive cytology (biliary brush or EUS-FNA) diagnostic for malignancy or benign etiology and clinical follow up of at least 6 months. Results: The mean age of the patients was 64.7 G 13.4 yrs (range 35-91 yrs). Thirty-three of 48 patients had jaundice at presentation and in 15 patients stricture was suspected on imaging. The mean length of biliary strictures was 15.4 G 7.7 mm (range 5-40 mm). Twenty-six strictures were located in the distal CBD and 22 were located in the mid/proximal CBD or CHD (proximal strictures). Fifteen of 48 patients were finally diagnosed to be malignant strictures. 20 of 48 patients had extrinsic compression at stricture site. Of 28 patients without extrinsic compression , 7 had malignant strictures with wall thickness ranging from 9-17 mm and 21 patients with benign strictures had wall thickness %9 mm. Biliary wall thickness %7 mm in absence of extrinsic compression had a NPV of 100% for excluding malignancy in this cohort. Extrinsic compression in proximal strictures (n Z 9) was due to malignancy in 4 patients and was benign due to vascular compression (n Z 2), enlarged gallbladder with cholecystitis (n Z 1), periductal abscess (n Z 1) and scar tissue (n Z 1) in 2 patients with history of liver transplantation. Extrinsic compression in distal strictures (n Z 11) was due to chronic pancreatitis or pancreatic cancer (n Z 4), which were indistinguishable by IDUS and were further evaluated by EUS-FNA. Conclusions: Evaluation of wall thickness and presence of extrinsic compression at the site of biliary strictures by IDUS can help in further management of these patients. Patients with biliary stricture due to extrinsic compression should be further evaluated by EUS-FNA except the ones due to vascular compression. In absence of extrinsic compression, wall thickness %7 mm is strongly predictive of a benign stricture.
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W1287 EUS FNA Diagnostic Yield of Malignancy in Solid Pancreatic Mass: A Benchmark for Quality Performance Measurement Thomas Savides, Gordon Hunt, Mohammed Al-Haddad, Harry Aslanian, Tamir Ben-Menachem, Victor Chen, Walter Coyle, John Deutsch, John Dewitt, Manish Dhawan, Alexander Eckardt, Mohamad Eloubeidi, Alec Esker, Timothy Gardner, Frank Gress, Steven Ikenberry, Ann Marie Joyce, Jason Klapman, Simon Lo, Fauze Maluf-Filho, Nicholas Nickl, Virmeet Singh, Jason Wills, Michael Donohue, Cynthia Behling Introduction: No benchmarking exists to assess EUS/FNA quality performance. Diagnostic yield of EUS/FNA of solid pancreatic masses (SPM) is a good potential benchmark because the pre-test probability that a SPM is malignant is very high (8090%), and the EUS/FNA sensitivity for diagnosing malignancy is very good (80-90%). Therefore the majority of SPM EUS/FNA should be diagnostic for malignancy. Variation in diagnostic yield could be affected by endoscopist, EUS technique, cytology preparation, pathology interpretation, and prevalence of chronic pancreatitis. Purpose: The goal of this study was to determine the cytologic diagnostic rate of malignancy in EUS/FNA of SPM, and to determine if variability among centers and endoscopists. Methods: Multi-center, retrospective study involving 21 EUS sites. Centers were asked to provide the cytology report for all EUS/FNA of solid, non-cystic, R10 mm short axis diameter pancreatic masses aspirated during a 1-year period (July 1, 2004-June 30, 2005). Results: 1094 patients underwent EUS/FNA in 21 centers (81% academic) involving 41 endoscopists. Among the endoscopists, 56% had 4th year training and 63% had performed O1000 lifetime EUS procedures. The median number of SPM EUS/FNA performed during the year per center was 46 (range 4-177), and per endoscopist was 19 (range 1-97). The mean mass dimensions were 32 mm 27 mm, with 73% located in the head. The mean number of passes was 3.5. 90% of centers used immediate cytologic evaluation. The overall diagnostic rate of malignancy was 71% (95% CI, .69, .74), with 5% suspicious for malignancy, 6% atypical cells, and 18% negative for malignancy. The median diagnostic rate per center was 78% (range 39%-93%; 1st quartile 61%), and per endoscopist was 75% (range 0%-100%; 1st quartile 52%) Multivariate analysis revealed the variables associated with positive malignant diagnostic yield were older age, female gender, body/tail location, greater short axis diameter, and fewer # passes. Conclusions: 1) EUS/FNA cytology was diagnostic of malignancy in 71% of solid pancreatic masses biopsied. 2) There was large variation in diagnostic yield among EUS centers and endoscopists. Implications: 1) Endoscopists with a final cytologic diagnosis rate of malignancy for EUS/FNA of solid masses which is less than 52% are in the lowest quartile, and should evaluate reasons for their low yield. 2) EUS/FNA diagnostic yield rate for pancreatic masses is a simple method that endosonographers can use to compare their diagnostic rates to their peers as a method for benchmarking EUS/FNA quality performance. 3) Prospective analysis could identify specific factors associated with yield.
W1288 Utility of Endoscopic Ultrasound Is Safe and Accurate in the Evaluation of Abnormal Intraoperative Cholangiograms Andrew C. Bolin, James Lusby, Peter Naus, James T. Sing Background: There is no consensus on the imaging modality for evaluating abnormal post-cholecystectomy intraoperative cholangiograms (IOC). IOC usage in laparoscopic cholecystectomy is increasing in order to evaluate retained common bile duct stones. Common bile duct stones are detected in 17% of postcholecystectomy cases. The gold standard in evaluating the biliary system, and for choledocholithiasis, has been endoscopic retrograde cholangiopancreatography (ERCP), however this procedure is associated with increased morbidity and mortality when compared to endoscopic ultrasound (EUS). EUS has been shown in previous studies to have a sensitivity 88-97% and specificity of 96-100% in the evaluation of patients with suspected choledocholithiasis. There has not been a study published to date in which EUS performance was evaluated in the setting of an abnormal IOC. Methods: A retrospective study to evaluate the utility of EUS imaging of the extrahepatic biliary system for abnormal IOC. All medical records for EUS performed in the setting of an abnormal IOC since 1997 at Scott & White Hospital were reviewed. Positive EUS results for choledocholithiasis were confirmed by direct visualization of stones in the duodenum after ERCP extraction or ERCP which showed cholangiogram with filling defects that resolved after extraction. Negative EUS results were considered if the patient had a negative EUS for choledocolithiasis and remained symptom free (no abdominal pain, cholangitis or LFT abnormalities) on follow up of at least 6 months. Results: A total of 62 patients met inclusion criteria. Age ranged from 14 to 89 years of age, mean age 54 years of age, with 37% male and 63% female. There were 34 cases with a negative EUS result, 13 were excluded for inadequate follow up of six months. For all cases there was no evidence of a missed stone (no abdominal pain, cholangitis or LFT abnormalities) at 6 months follow up. There were 28 cases with positive EUS results all of which had conformation of common bile duct stones at ERCP. In 26 cases there was direct visualization of the stone in the duodenum after extraction and 2 cases with filling defects on cholangiogram that resolved after extraction. EUS evaluation of an abnormal IOC has a sensitivity of 85-100% and specificity of 81100% with 95% confidence interval. There were no complications from any EUS. Conclusion: The results of this study confirm EUS is highly reliable method of
AB258 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
evaluating abnormal intraoperative cholangiograms. The increased use of endoscopic ultrasound should reduce morbidity and mortality associated with unnecessary ERCP and reduce overall costs and length of hospital stay.
W1289 Preliminary Results in the Diagnosis of the Early Stage Chronic Pancreatitis Using EUS-Elastography Yoshiki Hirooka, Akihiro Itoh, Hiroki Kawashima, Kazuo Hara, Akira Kanamori, Hiroki Uchida, Jun Goto, Koji Nonogaki, Yukinari Matsumoto, Naoki Ohmiya, Yasumasa Niwa, Hidemi Goto Many studies have compared EUS findings with other modalities (ERCP and noninvasive pancreatic function test) for the evaluation of chronic pancreatitis (CP) and suggest that ductal and parenchymal abnormalities detected using EUS correlate with the presence of CP. Real-time tissue elastography (EG: Hitachi, Japan) is the technology that images the difference of distortion between hard tissue and soft tissue in real time. We investigated the capability to diagnose the early stage of chronic pancreatitis by detecting parenchymal changes (the fibrosis of parenchyma along with ductal changes) using EUS-EG. Methods: Subjects consist of 39 patients, including 17 CP (13 cases were classified as definite CP and 4 cases were classified as suspected CP according to the classification criteria by Japan Pancreas Society) and 12 IPMN (intraductal papillary mucinous neoplasm) and 10 normal controls. The pancreatic parenchyma was observed using B-mode EUS and EUS-EG (for the cases of IPMN, the tail side of the main lesion was evaluated.). 1. We classified subjects into mild, moderate and severe CP according to the total umber of B-mode EUS criteria (Catalano’s classification). 2. EUS-EG was performed in all cases followed by classifying three categories: A; random pattern, B; moderate pattern, C; uniform pattern. EUB-8500 (Hitachi) and EG-3630UR (Pentax) were used in this study. Results: 1. B-mode EUS: Ten out of 13 definite CP cases were classified into severe CP, and 3 were classified into moderate CP. Two out of 4 suspected CP cases were classified into severe, and remaining 2 cases into moderate and mild, respectively. Two out of 12 IPMN cases were classified into moderate and remaining 10 into mild. Only one case of normal control indicated the mild findings, and other 9 cases showed no abnormalities. 2. EUS-EG: twelve out of 13 definite CP cases were classified into A, and 1 was classified into B. Three out of 4 suspected CP cases were classified into A, and 1 cases into B. Four out of 12 IPMN cases were classified into A, 7 cases into B and 1 into C. Eight normal cases were classified into C, and 2 into B. Conclusion: The cases of mild pancreatitis by the criteria of B-mode EUS showed random pattern on elastography. The up-stream parenchyma of IPMN classified into as mild by B-mode EUS was depicted as random pattern using elastography. From this preliminary result, it may be assumed that early detection of changes of tissue hardness is possible. EUS-elastography might be useful in the diagnosis of chronic pancreatitis including early stage of the disease.
W1290 Intraductal Ultrasound in Evaluation of Biliary Strictures Without a Mass Lesion On CT Scan: Significance of Focal Wall Thickening and Extrinsic Compression At the Stricture Site Naveen B. Krishna, Saradhi V. Saripalli, Rizwan Safdar, Banke Agarwal Background: Biliary intraductal ultrasound (IDUS) has been limited in its clinical utility to evaluate biliary strictures due to lack of easily recognized morphologic criteria to distinguish benign and malignant strictures. We evaluated the clinical significance of two easily assessed IDUS findings- wall thickness and extrinsic compression at stricture site. Patients and Methods: 48 patients who underwent ERCP/IDUS for evaluation of biliary strictures without an identifiable mass lesion on CT scan were retrospectively studied. Patients with strictures proximal to bifurcation of CHD or with periampullary tumors were excluded. IDUS pictures were reviewed specifically to measure wall thickness and look for extrinsic compression at stricture site. Final diagnosis was based on definitive cytology (biliary brush or EUS-FNA) diagnostic for malignancy or benign etiology and clinical follow up of at least 6 months. Results: The mean age of the patients was 64.7 G 13.4 yrs (range 35-91 yrs). Thirty-three of 48 patients had jaundice at presentation and in 15 patients stricture was suspected on imaging. The mean length of biliary strictures was 15.4 G 7.7 mm (range 5-40 mm). Twenty-six strictures were located in the distal CBD and 22 were located in the mid/proximal CBD or CHD (proximal strictures). Fifteen of 48 patients were finally diagnosed to be malignant strictures. 20 of 48 patients had extrinsic compression at stricture site. Of 28 patients without extrinsic compression , 7 had malignant strictures with wall thickness ranging from 9-17 mm and 21 patients with benign strictures had wall thickness %9 mm. Biliary wall thickness %7 mm in absence of extrinsic compression had a NPV of 100% for excluding malignancy in this cohort. Extrinsic compression in proximal strictures (n Z 9) was due to malignancy in 4 patients and was benign due to vascular compression (n Z 2), enlarged gallbladder with cholecystitis (n Z 1), periductal abscess (n Z 1) and scar tissue (n Z 1) in 2 patients with history of liver transplantation. Extrinsic compression in distal strictures (n Z 11) was due to chronic pancreatitis or pancreatic cancer (n Z 4), which were indistinguishable by IDUS and were further evaluated by EUS-FNA. Conclusions: Evaluation of wall thickness and presence of extrinsic compression at the site of biliary strictures by IDUS can help in further management of these patients. Patients with biliary stricture due to extrinsic compression should be further evaluated by EUS-FNA except the ones due to vascular compression. In absence of extrinsic compression, wall thickness %7 mm is strongly predictive of a benign stricture.
www.giejournal.org