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EUS-guided radioactive seeds implantation of iodine 125 in the retroperitoneal metastatic adenocarcinoma: a case report
Abstracts
Study objectives: Compare the puncture needles and define differences in the amount of specimens collected. Subjective: 70 cases in which EUS-FNA was used between July of 2004 and March of 2006. Methods: !Equipment used for all 70 casesO Echoendoscope - OLYMPUS GFUC240P, GF-UCT240. Ultrasonograph - ALOKA SSD 5000, Prosound 5500SV, 5. We used both Wilson-Cook ECHO-TIP 22G and OLYMPUS NA-200H-8022 22G alternately on all of the 70 cases. 12 cases were not diagnosable with 22G therefore we used ECHO-TIP 19G in addition on those 12 cases. The collected specimens were weighed on an electric balance scale before they were formalin-fixed. Results: For all the 70 cases, the average times of puncture were three times, the specimen collection rate was 100%, the diagnostic accuracy was 95.7%. As 12 cases had no diagnosis with the 22G needles, we used ECHO-TIP 19G needles and succeeded at collecting sufficient amount of specimens.
Usefulness of EUS-guided choledochododenostomy in patients with endoscopically inaccessible papilla Fumihide Itokawa Introduction: Endoscopic transpapillary biliary drainage is the procedure of first choice for biliary decompression in patients with malignant lower bile duct stricture. If impossible, the alternative procedures, i.e., percutaneous transhepatic drainage or surgery, are chosen usually. Both modalities often carry a higher complication rate and are more invasive than endoscopic drainage. Recently, EUSguided biliary drainage has been reported as an alternative biliary drainage technique. Aim: The aim of this study is to evaluate the outcome of EUS-guided transdunodenal biliary drainage in malignant lower bile duct stricture. Patients and Methods: We encountered four failed ERCP patients with malignant diseases and obstructive jaundice (Papilla of Vater carcinoma 2, pancreatic cancer 2). An echoendoscope with a curved linear array transducer, a 3.7-mm accessory channel with elevator (GF-UCT2000-OL5, Olympus) was used. Zimmon needleknife (Wilson-Cook) with electrocoagulation (EndoCut ICC200), or conventional 19-gauge FNA needle (Wilson-Cook) was used to perform the chodeochoduodenostomy. Subsequently, a 5-Fr external drainage tube or a 7-Fr internal drainage tube was placed. Results: Eus-guided choledochodudenostomy was performed in all cases without serious complications by using Zimmon needle-knife and 19-gauge needle was used in each 2 cases, and the stent placement was succeeded in 3 of 4 cases. In remaining one case, however, stent could not advance into bile duct after puncture by Zimmon needle-knife with electrocoagulatio because of uneven portion between bile duct and duodenal wall. Then, only 5-Fr nasobiliary drainage was performed. Stent occulusion occurred due to food impaction in one case, and it was changed to metallic stent. Conclusion: EUS-guided choledochododenostomy in patients with endoscopically inaccessible papilla may be very useful as an alternative drainage technique.
Impact of elastography endoscopic ultrasound for diagnosis of pancreatic mass Fumihide Itokawa Introduction: In general, pancreatic ductal cancer (PDC) involves the comparatively marked fibrosis representing tissue hardness from early stage. The reconstruction of tissue elasticity provides the sonographer with important additional information which can be applied for the diagnosis of these diseases. Aim: The aim of our study was to evaluate the ability of endoscopic ultrasound elastography to differentiate between benign and malignant pancreatic masses. Patients and Methods: The subjects were 53 patients who performed an endoscopic ultrasound (EUS) for pancreas in our hospital from September 2006 to March 2008. The disease were 6 with mass forming pancreatitis (MFP), 5 with chronic pancreatitis (CP), 48 with PDC, 5 with neuroendocrine carcinoma (PNET), 2 with auto immune pancreatitis (AIP), 5 with SCN, 2 with SPN, 1 with Schwanoma, 1 with GIST, 1 with renal cell carcinoma pancreatic metastasis, 4 with IPMN, 1 with malignant lymphoma and 5 with normal control. A histological diagnosis by surgery or EUS-FNA was performed for all subjects. The ultrasound was used the HITACHI HI VISION900, and EUS scope was PENTAX EG-3630UR, EG-3670URK and EG3870UTK. The calculation of tissue elasticity distribution is performed in real-time and the results are represented in color over the radial B-mode image. Malignant tissue appeared in blue color, fibrosis in blue to green, and normal tissue in green to red. In addition, we performed the quantification by using strain ratio (non mass area/mass area: SR) in order to evaluate the objective hardness as numerical value between mass to non mass area especially to distinguish TFP from PDC. Results: Elastography for all PDCs showed intense blue coloration, which indicated that the mass lesions had malignant aspects. While MFP presented the coloration pattern of mixed green, yellow and low intensity of blue. Normal control was an even application of green to red. The mean SR of MFP and PDC were each 23.08 12.65 and 37.08 20.54, respectively, which was significant difference (p?0.05).
S246 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
Conclusion: EUS elastography is potentially capable of further defining the tissue characteristics of benign and malignant lesions. This study suggested that it was useful for the quantification by using strain ratio to characterize the tissue hardness of pancreatic disease and distinguish MFP from PDC.
Endoscopic ultrasound-guided fine needle aspiration for the splenic tumor Takuji Iwashita, Ichiro Yasuda, Masanori Nakashima, Keisuke Iwata, Tsuyoshi Mukai, Eiichi Tomita, Hisataka Moriwaki Introduction: Splenic tumor is occasionally found in clinical practice, but the diagnosis is often difficult only by imaging and blood examinations. Pathological sampling is required in such cases, but a percutaneous biopsy under the external ultrasound guidance is sometimes difficult because the visualization could be interfered by gastrointestinal gas, lung, and bones. On the other hand, EUS provides good image of the spleen through the gastric wall. Therefore, transgastric approach under EUS guidance seems much easier than percutaneous approach. However, the needle puncture may be risky because the spleen is a blood-rich organ, while using a larger needle is requested for the diagnosis because lymphoma is a major possible cause. Aims: To evaluate the yield of EUS-FNA using a 19-gauge needle for splenic tumor. Methods: We reviewed the data of the patients who had undergone EUS-FNA for the splenic tumor from our database between October 2003 and November 2007. Their follow-up data was also investigated from their medical charts. Results: EUS-FNA had been attempted to five patients with splenic tumors in the period. They included a male and 4 females, whose median age was 67 years (range: 50-71 years). The targeted lesion was successfully detected by transgastric scanning, and pathological sample was also successfully obtained using a 19-gauge needle in all patients. The median long axis of the punctured tumors was 53 mm (range: 14-70 mm) and the median short axis was 45 mm (range: 11-51 mm). The mean number of passes was 2.0 (range: 1-3 passes). The pathological diagnosis from FNA materials was lymphoma in 2, sarcoidosis in 2, and inflammatory pseudotumor in 1 patient. Two patients diagnosed with lymphoma was commenced chemotherapy, and 2 patients with sarcoidosis have been followed periodically without any medications. A patient diagnosed with inflammatory pseudotumor underwent splenectomy later, because the spleen was extremely large and she complained continuous pain. The final diagnosis from the resected specimen was also inflammatory pseudotumor. A patient had mild abdominal pain after EUS-FNA, but bleeding or inflammation was not suspected from blood and imaging tests. Her symptom was resolved spontaneously in a day. Conclusion: EUSFNA using 19-gauge needle is still safe and useful for the diagnosis of splenic tumors.
EUS-guided radioactive seeds implantation of iodine 125 in the retroperitoneal metastatic adenocarcinoma: a case report Zhendong Jin EUS-guided radioactive seeds implantation of iodine 125 combined with chemotherapy were used for the treatment of the retroperitoneal cancer which was non-operative, accessed to obtain the local remission in one case of the retroperitoneal metastatic adenocarcinoma. A 61-year-old Chinese woman presented to Changhai hospital with a one-week history of abdominal distention. MRI scan showed that there were many enlarged lymph nodes which were integrated near the hepatic portal and retroperitoneal, considered of lymphoma. The followings were laboratory tests (with normal range in parentheses): white cell count 8.92 109/L (4.0-10.0 109/L), hemoglobin 9.0 g/dl (10-15 g/dl), platelet count 239 109/L (100-300 109/L), GT 73 U/L (0-45 U/L), and the renal function was in the normal range. AFP and CA19-9 were normal, and the level of CEA in serum was 305ng/ml (0-10 ng/ml). The biopsy pathology was proved to be metastatic adenocarcinoma under the CT-guided puncture. Immunohistochemistry staining showed that it was metastatic adenocarcinoma, P53 (high level expression), Topo (drug fast gene middle level expression), proliferation of cell activity as moderate. Twice chemotherapy were performed on the patient and the interval was one month. The project of the chemotherapy was oxaliplatin200mg (d1), 5-Fluorouraci 750 mg (d1-d5) and Calcium Folinate 200 mg (d1-d5). MRI scan showed that the enlarged lymph nodes which were integrated near the hepatic portal and retroperitoneal were smaller than before. Since then, EUS-guided radioactive iodine125 seed implantation were performed twice. The seeds were implanted into the enlarged lymph nodes using 19T needle. 20 seeds were implanted at the first time, 12 seeds in the second, and the total number of the iodine-125 seeds was 32. The interval was 7 days. The implantation of radioactive seeds was secure for the patient, because there were no significant procedurerelated complications which including acute pancreatitis and perforation. Laboratory test about hemogram and hemodiastase were both in the normal range, and liver function did not change significantly. Two months after the implantation of radioactive particles, two courses of the same chemotherapy were
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Abstracts
performed. Follow-up of 12 months, the patient’s symptoms of abdominal distention was eliminated. Review on abdominal CT scan, enlarged lymph nodes which were integrated near the hepatic portal and retroperitoneal was completely disappeared.
Results: A total of 119 patients (81 men, 38 women; mean age 58.6 12.8 years) were included. Complications were observed in two (1.7%) patients; one with mild acute pancreatitis, and one with duodenum perforation. Nine patients (7.6%) showed hyperamylasemia 3 h after the puncture, with the serum amylase levels of 326.53 200.40 UI/L (range 197-835 UI/L). Hyperamylasemia was not associated with the type of lesion (cystic or solid), its location, or the number of passes performed. Conclusions: The overall risk of complications from EUS-FNA is relatively low. Therefore, EUS-FNA of pancreatic lesions is a safe technique.
Application value of EUS-guided fine-needle aspiration in pancreatic space-occupying lesion Zhendong Jin Objective: To investigate significance of diagnosis and treatment guided by endoscopic ultrasonography(EUS) in pancreatic space-occupying lesion. Methods: EUS-guided FNA(EUS-FNA) was performed in 190 patients (102 men and 88 women) with pancreatic space-occupying lesions detected by CT scanining, unltrasonography or clinically suspected diagnosis at Changhai hospital from October 1998 to April 2006. Eleven patients with pancreatic pseudocyst underwent EUS-guided stent insertion. Results: (1)The diagnostic sensitivity of pancreatic adenocarcinomas by EUS-FNA was 67.6% before January 2006. Since then, Wright-Giemsa fast-staining method was applied by pathologist at bedside and the diagnostic sensitivity was elevated to 93.1%. Eighteen cases of small pancreatic lesions were performed with EUS-FNA, the diagnostic accuracy of which was 66.7%. In EUS-FNA specimens of patients with pancreatic adenocarcinomas the contents of CEA CA19-9 were significantly higher than that in chronic pancreatitis persons (P ! 0.05). (4) The successful rate of EUSguided stent insertion in eleven patients with pancreatic pseudocyst was 100%. Conclusions: EUS-FNA was a effective and safe modality for diagnosis and treatment of pancreatic space-occupying lesion.
The clinical value of endoscopic ultrasonography in the early diagnosis of pancreatic tumor Zhen-dong Jin, Zhao-shen Li, Dong Wang Background: Recent advances in imaging diagnostic modalities, particularly computed tomography (CT) and magnetic resonance imaging (MRI), are remarkable. However, endoscopic ultrasonography (EUS) is most capable of revealing the detailed structure of pancreatic lesions, expecially small pancreatic tumors. Aim: To explore the clinical value of endoscopic ultrasonography(EUS) and intraductal ultrasonography(IDUS) compared with the other imaging modalities in the early diagnosis of pancreatic tumor. Methods: Results of 188 cases of small pancreatic lesions(less than 3cm in diameter) detected by EUS,IDUS and the other imaging modalities at changhai hospital from October 1992 to September 2006 were reviewed. Results: (1) The diagnostic accuracy of small pancreatic cancer by EUS was 95.6%, compared with US (58.6%), CT (77.4%), MRI (76.2%) and ERCP (85.3%). The most common endosonographic features of small pancreatic cancer were alike round, irregular edge, hypoechoic mass with uniformity internal echo. (2)Twenty-five cases of small pancreatic lesions were performed IDUS, the diagnostic accuracy of which was 100%, compared with US (32%), CT (56.3%) and MRI (57.9%). (3) Eighteen cases of small pancreatic lesions were performed with EUS guided FNA (EUSFNA),the diagnostic accuracy of which was 66.7%. (4) The diagnostic accuracy of pseudocyst by EUS was 100%, compared with US (52.0%), CT (66.7%), MRI (82.4%) and ERCP (78.9%). The overall diagnostic accuracy of cystic pancreatic tumours by EUS was 57.7%, compared with US (19.2%), CT (36.4%), MRI (37.5%) and ERCP (50%). Conclusions: EUS and IDUS were more valuable than the other imaging modalities in the detection of small pancreatic tumors.
Low incidence of and risk factors for immediate complications after endoscopic ultrasound-guided fine-needle aspiration of pancreatic lesions Kai Xuan Wang Background and aim: Endoscopic ultrasound-guided fine-needle aspiration (EUSFNA) permits morphologic and cytological or histological analyses of pancreatic lesions. Despite increasing use of this technique, the incidence of and possible risk factors for complications remain poorly defined. The aim of this study was to evaluate complications in patients undergoing EUS-FNA with reference to potential risk factors for their development. Methods: Patients who underwent EUS-FNA of a pancreatic lesion between January 2005 and June 2007 were studied retrospectively. Possible risk factors such as gender, previous episodes of pancreatitis, cystic lesion, presence of the lesions in the head of pancreas head of pancreas, the diameter of the needle, number of needle passes and the baseline amylase level were analyzed using the logistic analysis.
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Usefulness of clinical evaluation with endoscopic ultrasonography (EUS) in ulcerative colitis Hideaki Kawabata, Kenjiro Yasuda, Moose Ueda, Masatsugu Nakajima Objective: We performed this study to determine whether endoscopic ultrasonography (EUS) is useful for assessment of the disease activity in ulcerative colitis (UC) patients before and after treatment by comparing with the endoscopic findings and patient’s symptoms. Patients and Methods: Between 1984 and 2007, we performed EUS on 209 patients (578 times) with UC. First, in 25 of these patients, the depth of inflammation on EUS was compared with histopathologic findings of surgically resected specimens. Second, in 104 patients, colonoscopy with EUS was performed before and 2 to 12 weeks after starting the treatment. Among them, 59 (29 men, 30 women) who were clinically in remission after treatment, were retrospectively evaluated. The patients’ mean age was 33.1 years (range: 11-72 years). The extent of disease was pancolitis in 41 patients, leftsided colitis in 16, and proctitis in 2. An ultrasonic colonoscope (7.5, 20 MHz) or ultrasonic probe (20 MHz) was used. We evaluated the depth of inflammation at the most severely affected areas, and assessed the clinical and endoscopic severity according to the IOIBD assessment score and Matts’ grading, respectively. Results: The degree of vertical spread of inflammation on EUS was consistent with histopathologic findings. Based on this result, the EUS images could be classified into 4 types as follows: UC-M; the five-layered structure was preserved, UC-SM; the hypoechoic change was spread to the third layer, UC-MP; the hypoechoic change was spread to the fourth layer, UC-SS/SE; the outline of the fourth layer was irregular by hypoechoic change. Before and after the treatment, the EUS findings were UC-M; 35, 22, UC-SM; 14, 15, UC-MP; 5, 1, UC-SS/SE; 4, 0, normal wall structure; 1 and 31, respectively, and the endoscopic findings were Grade (G) 1; 1, 33, G2; 28, 19, G3; 20, 5, G4; 10 and 2, respectively. Despite of clinical assessment of remission after treatment, 28 out of 59 (47.4%) patients and 26 (44.0%) remained in active phase on EUS and endoscopy, respectively. Moreover, of 33 patients assessed as both clinically and endoscopically in remission, 4 (12.1%) remained in active phase on EUS (UC-M; 3, MP; 1). Conclusions: EUS can accurately evaluate the degree of vertical spread of inflammation in UC. Even if we clinically assess the patients as in remission, we should evaluate the activity with endoscopy and EUS, and pay attention to the inflammation beneath the mucosa which can be observed only by EUS.
EUS-guided biliary drainage combined with duodenal stent deployment is safe and effective for the distal malignant biliary strictures with duodenal stenosis Hirofumi Kawamoto Objective: The biliary drainage is the first step for treatment of malignant biliary strictures. Endoscopically, the biliary stent is deployed through the duodenal papilla. However, its deployment through this route is sometimes difficult due to several reasons. Duodenal stenosis involving papilla Vater is one of the causes. In such a case, EUS-guided transgastric or transduodenal biliary drainage (EUS-BD) combined with duodenal stent deployment (DS-D) is another approach. In this study, we evaluated the efficacy and safety of this technique. Patients and Methods: Between November 2006 and March 2008, five patients with distal malignant biliary stricture and duodenal stenosis were eligible for this study (3 male; mean age: 78; mean observation period: 103 days). The diagnoses of these patients were pancreas carcinoma (n Z 4) and carcinoma of papilla Vater (n Z 1). First, DS-D (through-the-scope type duodenal stent: Niti-S, Tae-Woong Medical) was deployed in the duodenal stricture. Next, the EUS-BD was performed. The EUS instrument was Olympus GF-UCT2000. Through the duodenal or gastric wall, we punctured the common bile duct under the ultrasonographic guidance by using Zimmon needle knife (Cook). After dilating fistula by using a dilator catheter over the guidewire, we deployed plastic stent (Flexima, Boston Scientific). Results: The procedures of DS-D and EUS-BD were successful in all cases. The transduodenal and transgastric approaches were selected in 4 cases and in one case, respectively. All patients became outpatient. During follow-up period, two patients with pancreas cancer had repeated cholangitis due to duodenal stent obstruction by tumor progression. After duodenal stent re-deployment or tumor ablation by argon plasma laser, the morbidity of these patients was improved. The remaining 3 patients had no stent obstruction. Conclusion: Combination therapy of DS-D and EUS-BD may become a suitable indication for inaccessible papilla due to duodenal obstruction. The patency of duodenum is important to avoid cholangitis.
Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY S247
Study objectives: Compare the puncture needles and define differences in the amount of specimens collected. Subjective: 70 cases in which EUS-FNA was used between July of 2004 and March of 2006. Methods: !Equipment used for all 70 casesO Echoendoscope - OLYMPUS GFUC240P, GF-UCT240. Ultrasonograph - ALOKA SSD 5000, Prosound 5500SV, 5. We used both Wilson-Cook ECHO-TIP 22G and OLYMPUS NA-200H-8022 22G alternately on all of the 70 cases. 12 cases were not diagnosable with 22G therefore we used ECHO-TIP 19G in addition on those 12 cases. The collected specimens were weighed on an electric balance scale before they were formalin-fixed. Results: For all the 70 cases, the average times of puncture were three times, the specimen collection rate was 100%, the diagnostic accuracy was 95.7%. As 12 cases had no diagnosis with the 22G needles, we used ECHO-TIP 19G needles and succeeded at collecting sufficient amount of specimens.
Usefulness of EUS-guided choledochododenostomy in patients with endoscopically inaccessible papilla Fumihide Itokawa Introduction: Endoscopic transpapillary biliary drainage is the procedure of first choice for biliary decompression in patients with malignant lower bile duct stricture. If impossible, the alternative procedures, i.e., percutaneous transhepatic drainage or surgery, are chosen usually. Both modalities often carry a higher complication rate and are more invasive than endoscopic drainage. Recently, EUSguided biliary drainage has been reported as an alternative biliary drainage technique. Aim: The aim of this study is to evaluate the outcome of EUS-guided transdunodenal biliary drainage in malignant lower bile duct stricture. Patients and Methods: We encountered four failed ERCP patients with malignant diseases and obstructive jaundice (Papilla of Vater carcinoma 2, pancreatic cancer 2). An echoendoscope with a curved linear array transducer, a 3.7-mm accessory channel with elevator (GF-UCT2000-OL5, Olympus) was used. Zimmon needleknife (Wilson-Cook) with electrocoagulation (EndoCut ICC200), or conventional 19-gauge FNA needle (Wilson-Cook) was used to perform the chodeochoduodenostomy. Subsequently, a 5-Fr external drainage tube or a 7-Fr internal drainage tube was placed. Results: Eus-guided choledochodudenostomy was performed in all cases without serious complications by using Zimmon needle-knife and 19-gauge needle was used in each 2 cases, and the stent placement was succeeded in 3 of 4 cases. In remaining one case, however, stent could not advance into bile duct after puncture by Zimmon needle-knife with electrocoagulatio because of uneven portion between bile duct and duodenal wall. Then, only 5-Fr nasobiliary drainage was performed. Stent occulusion occurred due to food impaction in one case, and it was changed to metallic stent. Conclusion: EUS-guided choledochododenostomy in patients with endoscopically inaccessible papilla may be very useful as an alternative drainage technique.
Impact of elastography endoscopic ultrasound for diagnosis of pancreatic mass Fumihide Itokawa Introduction: In general, pancreatic ductal cancer (PDC) involves the comparatively marked fibrosis representing tissue hardness from early stage. The reconstruction of tissue elasticity provides the sonographer with important additional information which can be applied for the diagnosis of these diseases. Aim: The aim of our study was to evaluate the ability of endoscopic ultrasound elastography to differentiate between benign and malignant pancreatic masses. Patients and Methods: The subjects were 53 patients who performed an endoscopic ultrasound (EUS) for pancreas in our hospital from September 2006 to March 2008. The disease were 6 with mass forming pancreatitis (MFP), 5 with chronic pancreatitis (CP), 48 with PDC, 5 with neuroendocrine carcinoma (PNET), 2 with auto immune pancreatitis (AIP), 5 with SCN, 2 with SPN, 1 with Schwanoma, 1 with GIST, 1 with renal cell carcinoma pancreatic metastasis, 4 with IPMN, 1 with malignant lymphoma and 5 with normal control. A histological diagnosis by surgery or EUS-FNA was performed for all subjects. The ultrasound was used the HITACHI HI VISION900, and EUS scope was PENTAX EG-3630UR, EG-3670URK and EG3870UTK. The calculation of tissue elasticity distribution is performed in real-time and the results are represented in color over the radial B-mode image. Malignant tissue appeared in blue color, fibrosis in blue to green, and normal tissue in green to red. In addition, we performed the quantification by using strain ratio (non mass area/mass area: SR) in order to evaluate the objective hardness as numerical value between mass to non mass area especially to distinguish TFP from PDC. Results: Elastography for all PDCs showed intense blue coloration, which indicated that the mass lesions had malignant aspects. While MFP presented the coloration pattern of mixed green, yellow and low intensity of blue. Normal control was an even application of green to red. The mean SR of MFP and PDC were each 23.08 12.65 and 37.08 20.54, respectively, which was significant difference (p?0.05).
S246 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
Conclusion: EUS elastography is potentially capable of further defining the tissue characteristics of benign and malignant lesions. This study suggested that it was useful for the quantification by using strain ratio to characterize the tissue hardness of pancreatic disease and distinguish MFP from PDC.
Endoscopic ultrasound-guided fine needle aspiration for the splenic tumor Takuji Iwashita, Ichiro Yasuda, Masanori Nakashima, Keisuke Iwata, Tsuyoshi Mukai, Eiichi Tomita, Hisataka Moriwaki Introduction: Splenic tumor is occasionally found in clinical practice, but the diagnosis is often difficult only by imaging and blood examinations. Pathological sampling is required in such cases, but a percutaneous biopsy under the external ultrasound guidance is sometimes difficult because the visualization could be interfered by gastrointestinal gas, lung, and bones. On the other hand, EUS provides good image of the spleen through the gastric wall. Therefore, transgastric approach under EUS guidance seems much easier than percutaneous approach. However, the needle puncture may be risky because the spleen is a blood-rich organ, while using a larger needle is requested for the diagnosis because lymphoma is a major possible cause. Aims: To evaluate the yield of EUS-FNA using a 19-gauge needle for splenic tumor. Methods: We reviewed the data of the patients who had undergone EUS-FNA for the splenic tumor from our database between October 2003 and November 2007. Their follow-up data was also investigated from their medical charts. Results: EUS-FNA had been attempted to five patients with splenic tumors in the period. They included a male and 4 females, whose median age was 67 years (range: 50-71 years). The targeted lesion was successfully detected by transgastric scanning, and pathological sample was also successfully obtained using a 19-gauge needle in all patients. The median long axis of the punctured tumors was 53 mm (range: 14-70 mm) and the median short axis was 45 mm (range: 11-51 mm). The mean number of passes was 2.0 (range: 1-3 passes). The pathological diagnosis from FNA materials was lymphoma in 2, sarcoidosis in 2, and inflammatory pseudotumor in 1 patient. Two patients diagnosed with lymphoma was commenced chemotherapy, and 2 patients with sarcoidosis have been followed periodically without any medications. A patient diagnosed with inflammatory pseudotumor underwent splenectomy later, because the spleen was extremely large and she complained continuous pain. The final diagnosis from the resected specimen was also inflammatory pseudotumor. A patient had mild abdominal pain after EUS-FNA, but bleeding or inflammation was not suspected from blood and imaging tests. Her symptom was resolved spontaneously in a day. Conclusion: EUSFNA using 19-gauge needle is still safe and useful for the diagnosis of splenic tumors.
EUS-guided radioactive seeds implantation of iodine 125 in the retroperitoneal metastatic adenocarcinoma: a case report Zhendong Jin EUS-guided radioactive seeds implantation of iodine 125 combined with chemotherapy were used for the treatment of the retroperitoneal cancer which was non-operative, accessed to obtain the local remission in one case of the retroperitoneal metastatic adenocarcinoma. A 61-year-old Chinese woman presented to Changhai hospital with a one-week history of abdominal distention. MRI scan showed that there were many enlarged lymph nodes which were integrated near the hepatic portal and retroperitoneal, considered of lymphoma. The followings were laboratory tests (with normal range in parentheses): white cell count 8.92 109/L (4.0-10.0 109/L), hemoglobin 9.0 g/dl (10-15 g/dl), platelet count 239 109/L (100-300 109/L), GT 73 U/L (0-45 U/L), and the renal function was in the normal range. AFP and CA19-9 were normal, and the level of CEA in serum was 305ng/ml (0-10 ng/ml). The biopsy pathology was proved to be metastatic adenocarcinoma under the CT-guided puncture. Immunohistochemistry staining showed that it was metastatic adenocarcinoma, P53 (high level expression), Topo (drug fast gene middle level expression), proliferation of cell activity as moderate. Twice chemotherapy were performed on the patient and the interval was one month. The project of the chemotherapy was oxaliplatin200mg (d1), 5-Fluorouraci 750 mg (d1-d5) and Calcium Folinate 200 mg (d1-d5). MRI scan showed that the enlarged lymph nodes which were integrated near the hepatic portal and retroperitoneal were smaller than before. Since then, EUS-guided radioactive iodine125 seed implantation were performed twice. The seeds were implanted into the enlarged lymph nodes using 19T needle. 20 seeds were implanted at the first time, 12 seeds in the second, and the total number of the iodine-125 seeds was 32. The interval was 7 days. The implantation of radioactive seeds was secure for the patient, because there were no significant procedurerelated complications which including acute pancreatitis and perforation. Laboratory test about hemogram and hemodiastase were both in the normal range, and liver function did not change significantly. Two months after the implantation of radioactive particles, two courses of the same chemotherapy were
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Abstracts
performed. Follow-up of 12 months, the patient’s symptoms of abdominal distention was eliminated. Review on abdominal CT scan, enlarged lymph nodes which were integrated near the hepatic portal and retroperitoneal was completely disappeared.
Results: A total of 119 patients (81 men, 38 women; mean age 58.6 12.8 years) were included. Complications were observed in two (1.7%) patients; one with mild acute pancreatitis, and one with duodenum perforation. Nine patients (7.6%) showed hyperamylasemia 3 h after the puncture, with the serum amylase levels of 326.53 200.40 UI/L (range 197-835 UI/L). Hyperamylasemia was not associated with the type of lesion (cystic or solid), its location, or the number of passes performed. Conclusions: The overall risk of complications from EUS-FNA is relatively low. Therefore, EUS-FNA of pancreatic lesions is a safe technique.
Application value of EUS-guided fine-needle aspiration in pancreatic space-occupying lesion Zhendong Jin Objective: To investigate significance of diagnosis and treatment guided by endoscopic ultrasonography(EUS) in pancreatic space-occupying lesion. Methods: EUS-guided FNA(EUS-FNA) was performed in 190 patients (102 men and 88 women) with pancreatic space-occupying lesions detected by CT scanining, unltrasonography or clinically suspected diagnosis at Changhai hospital from October 1998 to April 2006. Eleven patients with pancreatic pseudocyst underwent EUS-guided stent insertion. Results: (1)The diagnostic sensitivity of pancreatic adenocarcinomas by EUS-FNA was 67.6% before January 2006. Since then, Wright-Giemsa fast-staining method was applied by pathologist at bedside and the diagnostic sensitivity was elevated to 93.1%. Eighteen cases of small pancreatic lesions were performed with EUS-FNA, the diagnostic accuracy of which was 66.7%. In EUS-FNA specimens of patients with pancreatic adenocarcinomas the contents of CEA CA19-9 were significantly higher than that in chronic pancreatitis persons (P ! 0.05). (4) The successful rate of EUSguided stent insertion in eleven patients with pancreatic pseudocyst was 100%. Conclusions: EUS-FNA was a effective and safe modality for diagnosis and treatment of pancreatic space-occupying lesion.
The clinical value of endoscopic ultrasonography in the early diagnosis of pancreatic tumor Zhen-dong Jin, Zhao-shen Li, Dong Wang Background: Recent advances in imaging diagnostic modalities, particularly computed tomography (CT) and magnetic resonance imaging (MRI), are remarkable. However, endoscopic ultrasonography (EUS) is most capable of revealing the detailed structure of pancreatic lesions, expecially small pancreatic tumors. Aim: To explore the clinical value of endoscopic ultrasonography(EUS) and intraductal ultrasonography(IDUS) compared with the other imaging modalities in the early diagnosis of pancreatic tumor. Methods: Results of 188 cases of small pancreatic lesions(less than 3cm in diameter) detected by EUS,IDUS and the other imaging modalities at changhai hospital from October 1992 to September 2006 were reviewed. Results: (1) The diagnostic accuracy of small pancreatic cancer by EUS was 95.6%, compared with US (58.6%), CT (77.4%), MRI (76.2%) and ERCP (85.3%). The most common endosonographic features of small pancreatic cancer were alike round, irregular edge, hypoechoic mass with uniformity internal echo. (2)Twenty-five cases of small pancreatic lesions were performed IDUS, the diagnostic accuracy of which was 100%, compared with US (32%), CT (56.3%) and MRI (57.9%). (3) Eighteen cases of small pancreatic lesions were performed with EUS guided FNA (EUSFNA),the diagnostic accuracy of which was 66.7%. (4) The diagnostic accuracy of pseudocyst by EUS was 100%, compared with US (52.0%), CT (66.7%), MRI (82.4%) and ERCP (78.9%). The overall diagnostic accuracy of cystic pancreatic tumours by EUS was 57.7%, compared with US (19.2%), CT (36.4%), MRI (37.5%) and ERCP (50%). Conclusions: EUS and IDUS were more valuable than the other imaging modalities in the detection of small pancreatic tumors.
Low incidence of and risk factors for immediate complications after endoscopic ultrasound-guided fine-needle aspiration of pancreatic lesions Kai Xuan Wang Background and aim: Endoscopic ultrasound-guided fine-needle aspiration (EUSFNA) permits morphologic and cytological or histological analyses of pancreatic lesions. Despite increasing use of this technique, the incidence of and possible risk factors for complications remain poorly defined. The aim of this study was to evaluate complications in patients undergoing EUS-FNA with reference to potential risk factors for their development. Methods: Patients who underwent EUS-FNA of a pancreatic lesion between January 2005 and June 2007 were studied retrospectively. Possible risk factors such as gender, previous episodes of pancreatitis, cystic lesion, presence of the lesions in the head of pancreas head of pancreas, the diameter of the needle, number of needle passes and the baseline amylase level were analyzed using the logistic analysis.
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Usefulness of clinical evaluation with endoscopic ultrasonography (EUS) in ulcerative colitis Hideaki Kawabata, Kenjiro Yasuda, Moose Ueda, Masatsugu Nakajima Objective: We performed this study to determine whether endoscopic ultrasonography (EUS) is useful for assessment of the disease activity in ulcerative colitis (UC) patients before and after treatment by comparing with the endoscopic findings and patient’s symptoms. Patients and Methods: Between 1984 and 2007, we performed EUS on 209 patients (578 times) with UC. First, in 25 of these patients, the depth of inflammation on EUS was compared with histopathologic findings of surgically resected specimens. Second, in 104 patients, colonoscopy with EUS was performed before and 2 to 12 weeks after starting the treatment. Among them, 59 (29 men, 30 women) who were clinically in remission after treatment, were retrospectively evaluated. The patients’ mean age was 33.1 years (range: 11-72 years). The extent of disease was pancolitis in 41 patients, leftsided colitis in 16, and proctitis in 2. An ultrasonic colonoscope (7.5, 20 MHz) or ultrasonic probe (20 MHz) was used. We evaluated the depth of inflammation at the most severely affected areas, and assessed the clinical and endoscopic severity according to the IOIBD assessment score and Matts’ grading, respectively. Results: The degree of vertical spread of inflammation on EUS was consistent with histopathologic findings. Based on this result, the EUS images could be classified into 4 types as follows: UC-M; the five-layered structure was preserved, UC-SM; the hypoechoic change was spread to the third layer, UC-MP; the hypoechoic change was spread to the fourth layer, UC-SS/SE; the outline of the fourth layer was irregular by hypoechoic change. Before and after the treatment, the EUS findings were UC-M; 35, 22, UC-SM; 14, 15, UC-MP; 5, 1, UC-SS/SE; 4, 0, normal wall structure; 1 and 31, respectively, and the endoscopic findings were Grade (G) 1; 1, 33, G2; 28, 19, G3; 20, 5, G4; 10 and 2, respectively. Despite of clinical assessment of remission after treatment, 28 out of 59 (47.4%) patients and 26 (44.0%) remained in active phase on EUS and endoscopy, respectively. Moreover, of 33 patients assessed as both clinically and endoscopically in remission, 4 (12.1%) remained in active phase on EUS (UC-M; 3, MP; 1). Conclusions: EUS can accurately evaluate the degree of vertical spread of inflammation in UC. Even if we clinically assess the patients as in remission, we should evaluate the activity with endoscopy and EUS, and pay attention to the inflammation beneath the mucosa which can be observed only by EUS.
EUS-guided biliary drainage combined with duodenal stent deployment is safe and effective for the distal malignant biliary strictures with duodenal stenosis Hirofumi Kawamoto Objective: The biliary drainage is the first step for treatment of malignant biliary strictures. Endoscopically, the biliary stent is deployed through the duodenal papilla. However, its deployment through this route is sometimes difficult due to several reasons. Duodenal stenosis involving papilla Vater is one of the causes. In such a case, EUS-guided transgastric or transduodenal biliary drainage (EUS-BD) combined with duodenal stent deployment (DS-D) is another approach. In this study, we evaluated the efficacy and safety of this technique. Patients and Methods: Between November 2006 and March 2008, five patients with distal malignant biliary stricture and duodenal stenosis were eligible for this study (3 male; mean age: 78; mean observation period: 103 days). The diagnoses of these patients were pancreas carcinoma (n Z 4) and carcinoma of papilla Vater (n Z 1). First, DS-D (through-the-scope type duodenal stent: Niti-S, Tae-Woong Medical) was deployed in the duodenal stricture. Next, the EUS-BD was performed. The EUS instrument was Olympus GF-UCT2000. Through the duodenal or gastric wall, we punctured the common bile duct under the ultrasonographic guidance by using Zimmon needle knife (Cook). After dilating fistula by using a dilator catheter over the guidewire, we deployed plastic stent (Flexima, Boston Scientific). Results: The procedures of DS-D and EUS-BD were successful in all cases. The transduodenal and transgastric approaches were selected in 4 cases and in one case, respectively. All patients became outpatient. During follow-up period, two patients with pancreas cancer had repeated cholangitis due to duodenal stent obstruction by tumor progression. After duodenal stent re-deployment or tumor ablation by argon plasma laser, the morbidity of these patients was improved. The remaining 3 patients had no stent obstruction. Conclusion: Combination therapy of DS-D and EUS-BD may become a suitable indication for inaccessible papilla due to duodenal obstruction. The patency of duodenum is important to avoid cholangitis.
Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY S247