M1438: EUS Guided FNA With Rescue Fluorescence in Situ Hybridization (FISH) for the Diagnosis of Pancreatic Carcinoma

Abstracts 1,083)(p⬍0,001) - i.e. a 5% increase in the probability to find a polyp ⬎ 5 mm at colonoscopy per minute increase in withdrawal time. The associations between withdrawal time and detection of polyps ⬎5mm disappeared when using the endoscopist‘s median withdrawal time in exclusively visual diagnostic colonoscopies to characterize endoscopist performance for all colonoscopies.Conclusion: There is unsufficient evidence to recommend using “withdrawal time” as a surrogate endpoint for quality and polyp pick-up-rate in colonoscopies.

M1436 Posterior Lingual Lidocaine Swab As a Single Agent in Upper GI Endoscopy Assaad M. Soweid, Abdallah A. Kobeissy, Shadi R. Yaghi, Faek R. Jamali, Najla Maalouf, Pierre K. Bou Khalil, Michella Mallat, Rola J. Hussein, Chakib M. Ayoub Background: Esophagogastroduodenoscopy (EGD) is generally performed using local oropharyngeal anesthesia (usually lidocaine spray) and intravenous (IV) sedation. However, the use of IV sedation is associated with increased morbidity, especially in the elderly population and in individuals with comorbidities. Objective: The purpose of this study is to assess the efficacy and safety of posterior lingual lidocaine swab - a novel method of local oropharyngeal anesthesia- and to determine if such use may reduce the need for IV sedation compared to the traditional lidocaine spray.Design: Single-center randomized, prospective, single-blinded study.Setting: Tertiary care medical center. Patients: Eighty patients undergoing diagnostic EGD.Interventions: Patients were randomized to either lidocaine swab or lidocaine spray. IV meperidine and midazolam were given as needed during the procedure.Main outcome measurements: The efficacy and safety of lidocaine swab as a single-agent anesthetic in EGD.Results: The lidocaine swab group (SWG) had significantly lesser gag reflex compared to the lidocaine spray group (SPG). The need for IV sedation was also lower in the SWG with 13 of 40 patients requiring such sedation compared to 38 of 40 patients in the SPG (p⬍0.01). The patients in the SWG were more satisfied with the mode of local anesthesia they received as compared to the SPG. In addition, the endoscopists were more pleased with the use of lidocaine swab.Limitations: Small sample size.Conclusions: Posterior lingual lidocaine swab is a promising novel modality of local oropharyngeal anesthesia in upper GI endoscopy. The use of this modality decreases the need for IV sedation and improves patient comfort and endoscopist satisfaction. Patient characteristics Gender Mean age Smoking Caffeine Alcohol

SWG (nⴝ 40)

SPG (n ⴝ 40)

p value

12 males 55.9 15 37 12

19 males 48.5 23 32 14

NS NS NS NS NS

SWG

SPG

p value

Preprocedure evaluation Mean time to anesthesia onset (sec) 101⫾59 53⫾21 ⬍0.01 Mean gag reflex score 2.2⫾1.2 3.6⫾1.0 ⬍0.01 Procedure evaluation Mean difficulty score of procedure; 1.9⫾1.2 3.8⫾0.9 ⬍0.01 endoscopist Mean tolerance score to procedure; 3.68⫾0.92 1.78⫾0.92 ⬍0.01 patient Use of IV sedation 13 38 ⬍0.01 Patient preference to repeat 32 2 ⬍0.01 procedure Gag reflex scale 1⫽absent-5⫽strong;Endoscopist difficulty scale 1⫽easy-5⫽difficult;Patient tolerance scale 1⫽no difficulties-5⫽very difficult

M1437 A New Quality Control System of Endoscopic Investigations in Oncology Practice Aleksey Gvozdev, Sergey V. Kashin, Viktor Kapranov, Aleksandr Senin Background: The widespread use of gastrointestinal endoscopy for diagnosis and treatment requires an effective quality control system. Moreover, this need is further increased by the limited storage of images and by the need for structured databases for surveillance and epidemiology. Methods: The new Endoscopic Medical Information System (EMIS) provides an opportunity to record, store and transmit images and video materials received in the course of an endoscopic investigation. This EMIS was developed by the Yaroslavl Regional Cancer Hospital endoscopy unit team jointly with the programmers of the Yaroslavl State University named after P.G.Demidov in the beginning of 2009. The EMIS is

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implemented on the basis of free OS Linux with the use of the open software. Outcomes: According to the ESGE recommendations it is enough to get 8 endophotos during the performance of Upper GI (gastrointestinal) endoscopy for the illustration of the whole investigation. We consider that it is necessary to get 20 endophotos. The findings of the GI polyps were compared for a six month period of 2008 and of 2009 respectively before and after the EMIS implementation. Upper GI tract polyps were detected in 8 of 100 nonsymptomatic patients in 2008 and in 14 of 100 non-symptomatic patients in 2009 (p⬍0,05). Conclusion: The EMIS is an appropriate quality control system. It allowed improving the diagnostics of the upper GI polyps in 1.7 times during a short period of time. We recommend that a checklist of 20 images in upper GI endoscopy should be introduced into the Good Medical Practice Code.

M1438 EUS Guided FNA With Rescue Fluorescence in Situ Hybridization (FISH) for the Diagnosis of Pancreatic Carcinoma Nisa Kubiliun, Joe U. Levi, Yao-Shan Fan, Caio S. Rocha-Lima, Jaime R. Merchan, Danny Sleeman, Afonso C. Ribeiro Background: In pancreatic carcinoma, EUS FNA cytology has a sensitivity ranging from 70% to 90%. Accuracy of cytology depends on the experience of the endosonographer and cytopathologist, the availability of on-site analysis and perhaps tumor characteristics (tumor necrosis and degree of differentiation). Utilization of FISH to detect chromosomal abnormalities in chromosomes 3, 7, 17 and 9p21 in FNA specimens may improve diagnostic accuracy of EUS FNA when combined with routine cytology. Aim: To determine if FISH can improve diagnostic accuracy of EUS-FNA cytology in pancreatic carcinoma. Methods: All EUS-FNA performed for evaluation of pancreatic masses suspicious for carcinoma at a single tertiary university based cancer center from January 2009 to November 2009. If on-site pathology was not available or was unable to confirm diagnosis of carcinoma, two extra FNA passes were sent for FISH analysis (UroVysion probe to detect aneuplodies of chromosomes 3, 7, 17 and deletions of 9p21) and additional FNA passes were performed for cytology. Positive FISH for malignancy was defined as ⱖ5 cells with an extra copy of two or more chromosomes, or if ⱖ5 cells had a 9p21 deletion. Extra copy of chromosome 7 in ⱖ5 cells was considered positive for malignancy. Results: 103 EUS-FNA were performed in 99 patients. A final diagnosis of carcinoma was obtained in 88 pts, and of benign disease in 11 pts. EUS-FNA cytology established the diagnosis of carcinoma in 77 of 88 pts (sensitivity 87.5%). Specificity was 100% (11/11). A total of 44 FISH analysis were sent (33 carcinoma and 11 benign). In three pts cellular material was judged inadequate for FISH analysis (93.2% success in harvesting material for FISH). Of the 11 pts with carcinoma and negative cytology, FISH established the diagnosis of cancer in an additional 7 pts for a total 84 of 88 pts accurately diagnosed with carcinoma (sensitivity 95.4%). The final pathological diagnosis of cancer in the additional 7 FISH positive/cytology negative pts was obtained either by surgery (2), repeated EUS FNA (3), or tissue core biopsy (2). FISH accurately predicted benign disease in all 11 pts (spec. 100%) with benign disease confirmed by surgery (3) and long-term follow up (8). Among pts with abnormal FISH, the most common chromosomal abnormality detected was deletion of 9p21 in 77.3% (17/22).Conclusion: Samples obtained by EUS FNA from pancreatic masses are often adequate for FISH analysis. Diagnostic accuracy of EUS guided FNA of pancreatic masses is greatly improved by FISH when performed in cases of negative cytology. Deletion of 9p21 was the most common chromosomal abnormality identified.

M1439 Can Focused DNA Array (FDA) Using Pancreas Cancer Tissue Obtained EUS-FNA Tell Future Metastasis? Reiko Ashida, Kenji Yamao, Nobumasa Mizuno, Akira Sawaki, Tetsuo Arakawa BACKGROUND: EUS has evolved from EUS imaging to EUS-guided FNA. EUSguided FNA is now beyond cytology diagnosis and made it possible to analyze gene expression. Moreover, cDNA microarray technique allows us to test hundreds of genes simultaneously. The prediction of future metastasis is very important in treatment of pancreas carcinoma, especially before deciding surgery. The purpose of this study was to determine of the usefulness of Focused DNA Array (FDA) analysis using the pancreatic cancer tissue obtained by EUS-guided FNA for the prediction of metastasis. METHODS: Pancreatic cancer tissues were obtained from 26 patients by EUS-guided FNA. mRNA was harvested from each sample and cDNA was composed by reverse transcription polymerase chain reaction (RT-PCR). Expression of mRNA was evaluated using FDA which was restricted to 133 genes including genes which are known as important gens at late stage of tumor development such as growth factors and/or their receptors (EGFR, TGF ␤ 1, 2, 3), pro-angiogenic factors (VEGF), invasiveness factors (MMP(metalloproteinases) 1,2,3,7,9,14,16, ITG (Integrin)␣ 2,3,4,5, ITG ␤ 1,3,5 ). The expression of mRNA was measured as the relative value to house keeping gene. The patients were divided into two group who had metastasis or not and each gene expression was analyzed using MannWhitney U-test.RERULTS: 23/26 (88.5%) samples were suitable for analysis. There

Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB221