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FDG-PET Imaging of Gastrointestinal Stromal Tumors: Correlation with Histopathological Findings by Using EUS-FNA
*T1650 Endoscopic and Echoendoscopic Evaluation of Gastric Varices Eradication with Cianoacrilate Erika Macedo, Fernanda Thuler, Veruska Di Sena, Gustavo De Paulo, Frank Nakao, Jose Ardengh, Angelo P. Ferrari Jr. Introduction: bleeding from gastric varices rupture is more severe than from esophageal varices. Usual endoscopic techniques (sclerotherapy and banding) are not good choices for gastric varices eradication. Cianoacrilate endoscopic injection has been reported as the best choice for such patients. Aim: to asses the value of echoendoscopy in monitoring gastric varices eradication by cianoacrilate injection. Method: 17 patients with Sarin type GEV2 varices were submitted to endoscopic injection of a cianoacrilate and lipiodol solution (1 ml each). Patients younger than 18 years and/or with severe systemic disease were excluded from the study. All patients were submitted to EUS and endoscopy before and at 3, 6 and 12 months after index treatment. Doppler signal was used during EUS. After each 3-month interval the injection was repeated if there was endoscopic evidence of remaining or recurrent varices. Results: our study group consisted of 10 men and 7 women, mean age 50.6 years (range 22 - 76, median 51 years). Portal hypertension was secondary to cirrhosis due to schistosomiasis (4), chronic B or C viral hepatitis (3 and 8) and alcohol abuse (2). Endoscopic injection was successfully performed in the U turn position, with no immediate complications. Three patients are still waiting for the first 3-month re-evaluation and two patients died of hepatic insufficiency, unrelated to bleeding. Among the remaining 12 patients, 8 finished the study (1 year follow-up), 4 had their 3- and 6month follow-up (2 in each group). In seven patients there was a need for additional injection sessions: a mean of 1.8 sessions/patient (range 1-3). Endoscopic follow up showed complete eradication of variceal novel in every patient. EUS follow up showed absence of variceal flow (negative Doppler signal) in every patient considered eradicated by conventional endoscopy. There were no complications. Conclusion: endoscopic injection of cianoacrilate plus lipiodol is a safe and effective method for gastric varices eradication. EUS evaluation allows detection of variceal flow and may help in planning additional treatment as well as in monitoring the patient.
*T1651 The Accuracy of Endoscopic Ultrasonography as Further Examination Evaluating the Depth of Invasion of Gastric Cancer Yosuke Otake, Takuji Gotoda, Takahiro Kozu, Ichiro Oda, Daizo Saito Background: Endoscopic ultrasonography (EUS) is considered to be a useful method for staging gastrointestinal cancer not only in relation to the presence of lymph node metastasis but also determining the depth of invasion. Aim: To evaluate the accuracy of depth of invasion using EUS when the correct diagnosis was difficult to establish with gastroscopy (GS) in order to determine the best treatment modality. Material and Methods: Between January 2000 and October 2003, radial scanning EUS (GF-UMQ200 or GF-UM2000, Olympus Optical Co.) was performed as a further examination in 81 lesions of 78 patients with gastric cancer. In some cases, 3D-ultrasonic probe (UM-3D-3R, Olympus Optical Co.) was used additionally. We divided the depth of invasion into: mucosal or submucosal slight (<500 micro meter), submucosal massive and beyond muscularis propria. The accuracy of depth of invasion as well as clinical factors such as size of the lesion, macroscopic type, presence of ulcer, location and histological type were assessed. Results: The overall accuracy of GS and EUS were 59.3% (48/81) and 61.7% (50/81) respectively. The accuracy of EUS was slightly superior to GS in lesions presenting as undifferentiated type or size >30mm or located in the gastric antrum. In 12/81 lesions the GS diagnosis was correct and the EUS diagnosis was incorrect. In ten of these lesions, the macroscopic type was elevated or flat elevated. EUS was over-diagnosed in 15/81 cases. There were no clinical features in these lesions. Conclusions: When GS could not determine the depth of invasion, EUS could not increased the accuracy particularly in elevated and flat elevated lesion. However, in some cases EUS could be superior to GS evaluating the depth of invasion.
P238
GASTROINTESTINAL ENDOSCOPY
*T1652 Clinicopathologic Study of Gastric Submucosal Tumor: Endosonographic and Immunohistochemical Findings of Gastrointestinal Stromal Tumors (GISTs) in Stomach Bong Min Ko, Su Jin Hong, Kye Won Kwon, Chang Beom Ryu, Joo Young Cho, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim BACKGROUND/AIM: The gastrointestinal stromal tumors (GIST) constitute the largest catergory of primary non-epithelial neoplasm of the gastrointestinal tract and include most tumors previously designated as leiomyomas/leiomyosarcomas. Clinically and pathologically, GIST represents a spectrum of tumors that include benign and malignant variants. A small proportion of tumors apparently lacking mitotic activity do metastasis. This study was performed to evaluate the need of follow up and treatment of GISTs. METHOD: This study was performed on 38 patients who had gastric submucosal tumor on endoscopy and endosonography (EUS) and confirmed by histologic examinations using immunohistochemistry between January 2001 and October 2003 at our hospital. We evaluated the clinical features, EUS findings (size, layer, echogenicity, cystic change, lobuation, marginal halo, echogenic foci) and immunohistochemical stain (CD117, CD34, SMA, S-100, Ki-67). RESULT: 1) 14 of the 38 patients in gastric submucosal tumors were diagnosed GIST. 2) The age of the patients with GIST ranged from 37 to 86 years old, with an average age of 58.3 years. 3) In GIST, lobulation on EUS findings was correlated with risk of aggressive behavior in GISTs significantly (<0.05). 4) Ki-67 was correlated with risk of aggressive behavior in GISTs significantly (<0.05). 5) GISTs appeared as hypoechoic mass arising from 2nd, 3rd and 4th layer. CONCLUSION: EUS and histologic diagnosis including immunohistochemical stain approach should be performed to differentiate diagnosis when showed gastric SMT. Although GISTs has low malignant potential, regular follow up or resection is needed.
*T1653 FDG-PET Imaging of Gastrointestinal Stromal Tumors: Correlation with Histopathological Findings by Using EUS-FNA Masahiro Yamada, Yasumasa Niwa, Yoshiki Hirooka, Nobuhiro Ando, Fumiyuki Miyata, Ryouji Miyahara, Akira Ohashi, Tsuguo Kamioka, Shusuke Kitabatake, Masanao Nakamura, Naoki Ohmiya, Akihiro Itoh, Hidemi Goto Background: Since all gastrointestinal stromal tumors (GISTs) are practically considered to be potentially malignant, they must be clinically differentiated from other submucosal tumors. So we need a novel modality to evaluate the malignant behavior of GISTs. The aims of this study were to characterize the FDG uptake of GISTs by relating it to the histopathoplogical findings of the tumors and to define the usefulness of FDG-PET. Patients and Methods: 134 patients seen with submucosal tumors originating in the fourth sonographic layer of the GI tract wall as diagnosed by EUS underwent EUS-FNA with immunohistochemical analysis. 8 of 134 patients underwent FDG-PET. The tumors occurred in 6 men and 2 women, ranging from 52 to 76 years (mean 62.3 years) in age. The size of the tumors ranged from 10mm to 40 mm (mean 29.8.mm) in diameter. Tumor FDG uptake was quantitated with the maximum pixel standardized uptake value (maxSUV) and the mean SUV over a small region of interest (meanSUV). The tumor size, mitotic index, cellularity, and risk categories were compared with SUV measures. Results: Excellent correlations were found between SUV measures of FDG uptake and tumor size; maxSUV versus tumor size: r =0.72, p =0.041, and meanSUV versus tumor size: r =0.85, p =0.004. Correlation between meanSUV and risk categories was also strong; meanSUV versus risk categories: r =0.82, p =0.008. However, the correlation between SUV measures and the mitotic index and cellularity were weaker and reached statistical significance for only one index; maxSUV versus mitotic index: r =0.158, p =0.721; maxSUV versus cellularity: r =0.421, p =0.315; meanSUV versus mitotic index: r =0.609, p =0.113; meanSUV versus cellularity: r =0.645, p =0.048. Conclusions: FDG-PET may be used to noninvasively assess risk categories preoperatively. Therefore, FDG-PET may play a significant role in the preoperative evaluation of GISTs.
VOLUME 59, NO. 5, 2004
*T1651 The Accuracy of Endoscopic Ultrasonography as Further Examination Evaluating the Depth of Invasion of Gastric Cancer Yosuke Otake, Takuji Gotoda, Takahiro Kozu, Ichiro Oda, Daizo Saito Background: Endoscopic ultrasonography (EUS) is considered to be a useful method for staging gastrointestinal cancer not only in relation to the presence of lymph node metastasis but also determining the depth of invasion. Aim: To evaluate the accuracy of depth of invasion using EUS when the correct diagnosis was difficult to establish with gastroscopy (GS) in order to determine the best treatment modality. Material and Methods: Between January 2000 and October 2003, radial scanning EUS (GF-UMQ200 or GF-UM2000, Olympus Optical Co.) was performed as a further examination in 81 lesions of 78 patients with gastric cancer. In some cases, 3D-ultrasonic probe (UM-3D-3R, Olympus Optical Co.) was used additionally. We divided the depth of invasion into: mucosal or submucosal slight (<500 micro meter), submucosal massive and beyond muscularis propria. The accuracy of depth of invasion as well as clinical factors such as size of the lesion, macroscopic type, presence of ulcer, location and histological type were assessed. Results: The overall accuracy of GS and EUS were 59.3% (48/81) and 61.7% (50/81) respectively. The accuracy of EUS was slightly superior to GS in lesions presenting as undifferentiated type or size >30mm or located in the gastric antrum. In 12/81 lesions the GS diagnosis was correct and the EUS diagnosis was incorrect. In ten of these lesions, the macroscopic type was elevated or flat elevated. EUS was over-diagnosed in 15/81 cases. There were no clinical features in these lesions. Conclusions: When GS could not determine the depth of invasion, EUS could not increased the accuracy particularly in elevated and flat elevated lesion. However, in some cases EUS could be superior to GS evaluating the depth of invasion.
P238
GASTROINTESTINAL ENDOSCOPY
*T1652 Clinicopathologic Study of Gastric Submucosal Tumor: Endosonographic and Immunohistochemical Findings of Gastrointestinal Stromal Tumors (GISTs) in Stomach Bong Min Ko, Su Jin Hong, Kye Won Kwon, Chang Beom Ryu, Joo Young Cho, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim BACKGROUND/AIM: The gastrointestinal stromal tumors (GIST) constitute the largest catergory of primary non-epithelial neoplasm of the gastrointestinal tract and include most tumors previously designated as leiomyomas/leiomyosarcomas. Clinically and pathologically, GIST represents a spectrum of tumors that include benign and malignant variants. A small proportion of tumors apparently lacking mitotic activity do metastasis. This study was performed to evaluate the need of follow up and treatment of GISTs. METHOD: This study was performed on 38 patients who had gastric submucosal tumor on endoscopy and endosonography (EUS) and confirmed by histologic examinations using immunohistochemistry between January 2001 and October 2003 at our hospital. We evaluated the clinical features, EUS findings (size, layer, echogenicity, cystic change, lobuation, marginal halo, echogenic foci) and immunohistochemical stain (CD117, CD34, SMA, S-100, Ki-67). RESULT: 1) 14 of the 38 patients in gastric submucosal tumors were diagnosed GIST. 2) The age of the patients with GIST ranged from 37 to 86 years old, with an average age of 58.3 years. 3) In GIST, lobulation on EUS findings was correlated with risk of aggressive behavior in GISTs significantly (<0.05). 4) Ki-67 was correlated with risk of aggressive behavior in GISTs significantly (<0.05). 5) GISTs appeared as hypoechoic mass arising from 2nd, 3rd and 4th layer. CONCLUSION: EUS and histologic diagnosis including immunohistochemical stain approach should be performed to differentiate diagnosis when showed gastric SMT. Although GISTs has low malignant potential, regular follow up or resection is needed.
*T1653 FDG-PET Imaging of Gastrointestinal Stromal Tumors: Correlation with Histopathological Findings by Using EUS-FNA Masahiro Yamada, Yasumasa Niwa, Yoshiki Hirooka, Nobuhiro Ando, Fumiyuki Miyata, Ryouji Miyahara, Akira Ohashi, Tsuguo Kamioka, Shusuke Kitabatake, Masanao Nakamura, Naoki Ohmiya, Akihiro Itoh, Hidemi Goto Background: Since all gastrointestinal stromal tumors (GISTs) are practically considered to be potentially malignant, they must be clinically differentiated from other submucosal tumors. So we need a novel modality to evaluate the malignant behavior of GISTs. The aims of this study were to characterize the FDG uptake of GISTs by relating it to the histopathoplogical findings of the tumors and to define the usefulness of FDG-PET. Patients and Methods: 134 patients seen with submucosal tumors originating in the fourth sonographic layer of the GI tract wall as diagnosed by EUS underwent EUS-FNA with immunohistochemical analysis. 8 of 134 patients underwent FDG-PET. The tumors occurred in 6 men and 2 women, ranging from 52 to 76 years (mean 62.3 years) in age. The size of the tumors ranged from 10mm to 40 mm (mean 29.8.mm) in diameter. Tumor FDG uptake was quantitated with the maximum pixel standardized uptake value (maxSUV) and the mean SUV over a small region of interest (meanSUV). The tumor size, mitotic index, cellularity, and risk categories were compared with SUV measures. Results: Excellent correlations were found between SUV measures of FDG uptake and tumor size; maxSUV versus tumor size: r =0.72, p =0.041, and meanSUV versus tumor size: r =0.85, p =0.004. Correlation between meanSUV and risk categories was also strong; meanSUV versus risk categories: r =0.82, p =0.008. However, the correlation between SUV measures and the mitotic index and cellularity were weaker and reached statistical significance for only one index; maxSUV versus mitotic index: r =0.158, p =0.721; maxSUV versus cellularity: r =0.421, p =0.315; meanSUV versus mitotic index: r =0.609, p =0.113; meanSUV versus cellularity: r =0.645, p =0.048. Conclusions: FDG-PET may be used to noninvasively assess risk categories preoperatively. Therefore, FDG-PET may play a significant role in the preoperative evaluation of GISTs.
VOLUME 59, NO. 5, 2004