- Email: [email protected]
Mo1405 Impact of an Intensive, Short-Term, Training Program in Cytopathology for Endosonographers
Abstracts
Mo1402 EUS-Guided Fine Needle Biopsy for Histopathologic Evaluation of Solid Liver Masses Yun Nah Lee*1, Jong Ho Moon1, Hyun Jong Choi1, Dong Choon Kim1, Hee Kyung Kim2, Moon Han Choi1, Tae Hoon Lee1, Sang-Woo Cha1, Young Deok Cho1, Sang-Heum Park1, Sun-Joo Kim1 1 Digestive Disease Center and Research Institute, Department of Internal Medicine,SoonChunHyang University School of Medicine, Bucheon and Seoul, Republic of Korea; 2Department of Pathology, Bucheon, Republic of Korea Background and Aims: Cytopathologic evaluation by endoscopic ultrasonography (EUS)-guided fine needle aspiration or biopsy can be performed for the solid liver masses, especially in left lobe. Histopathologic analysis with adequate tissue sampling may be crucial for differential diagnosis of solid liver masses. EUS-guided biopsy (FNB) needle enabling the acquisition of core specimens for histopathologic analysis was recently introduced. The aim of this study was to evaluate the usefulness of the EUS-FNB needle for histopathologic evaluation of solid liver masses. Methods: Total 25 patients with solid masses in the left lobe of liver were enrolled in this study. 22-gauge EchoTip ProCore needle (Cook medical Inc., Bloomington, USA) was used for EUS-guided fine needle biopsy. Transgastric needle puncture was performed with using stylet and negative suction during sampling. The specimen was analyzed by on-site cytology with Diff-Quick stain, cytology with Papanicolaou stain and histology with immunohistochemical (IHC) stains. Results: The median number of needle pass for adequate cellularity in on-site analysis was 2 (interquartile range, 1 to 3). Core sepecimens were obtained in 84% (21/25). Tissue sample adequacy for histologic evaluation combined with IHC stains was 80% (20/25). Overall diagnostic accuracy of EUS-FNB was 92% (23/25). Ten solid liver masses requiring differential diagnosis in prior imaging studies were histopathologically diagnosed by EUS-FNB. By the IHC stains of core specimens, four solid liver masses had different histopathologic diagnosis from cytologic analysis. No procedure-related complications were occurred. Conclusions: EUS-FNB needle was useful for obtaining adequate core specimens for histopathologic ananlysis of solid liver masses.
Mo1403 Definite Diagnosis of Subepithelial Lesions of the Gastrointestinal Tract by Means of Endoscopic Ultrasound-Fine Needle Aspiration (EUS-FNA) Claudio De Angelis*1, Selene F. Manfrè1, Milena Marietti1, Mauro Bruno1, Matteo Giuseppe Goss1, Patrizia Carucci1, Elena MALDI2, Donatella Pacchioni2, Paola Cassoni2, Paola Francia Di Celle3 1 Gastrohepatology, Città della Salute e della Scienza, Turin, Italy; 2 Biomedical Science and Human Oncology, Città della Salute e della Scienza, Turin, Italy; 3Center for Experimental Research and Medical Studies, Città della Salute e della Scienza, Turin, Italy Objectives: Endoscopic Ultrasound-Fine Needle Aspiration (EUS-FNA) is today a standard practice for the evaluation of subepithelial masses of the gastrointestinal (GI) tract, since it allows a clear identification of the layer of origin of the lesion and its sampling. This kind of lesion needs a definite diagnosis because some of these lesions, mainly the Gastrointestinal Stromal Tumors (GISTs), bear a malignant potential. However a tissue diagnosis is seldom necessary because treatment decisions can be usually planned mainly on clinical bases. Design and Methods: We describe our 10 years experience in EUS-FNA of subepithelial lesions of the GI tract and all the techniques we were able to apply in order to reach this difficult differential diagnosis even on a very limited amount of material. From 2003 to September 2013 we evaluated about 1200 subepithelial masses of the GI tract, and we performed EUS-FNA only on 62 of them (about 5%). 53 of 62 procedures were accomplished with an on-site cytopathologist to assess the adequacy of the specimens. According to the cytomorphological features of the lesions and the cytopathologist’s judgment, immunocytochemical analysis for CD117, CD34, S100, SMA, AE1/AE3 and Ki67 was employed. In 11/62 cases it has also been possible to apply genomic analysis to the retrieved specimen in order to check on mutations in c-KIT gene and PDGFRA gene or other mutations such as translocations t(11;22), t(X;18). Results: For each lesion a mean of 5.2 +/- 2.5 needle passes (range 2-11) was performed; standard needles from 25 to 19 gauge, pro-core (in 12 patients) or trucut (in 10 patients) needles were used according to the operator’s preferences and mass location. Two cases of minor bleeding occurred: they were endoscopically treated and no transfusions were required. An adequate specimen could be collected in 57 cases (91.94%). Based on immunocytochemical results, a definite diagnosis was reached in 43/62 cases (69.35%): we observed 25 (40.32%) GISTs, 6 (9.68%) leyomiomas, 3 (4.84%) adenocarcinomas, 2 (3.23%) flogistic elements, 2 (3.23%) synovial sarcomas, and 5 (8.06%) other kinds of lesion (1 endometriosis node, 1 fibrovascular tumor, 1 retrorectal metastasis from hepatocarcinoma, 1 proctitis cystica profunda and 1 cystic retro-rectal amartoma). In the remaining 14/62 cases (22.58%) we could not go beyond a generic diagnosis of "stromal spindle-cell lesion". Conclusions: Although subepithelial lesions still represent a diagnostic challenge, an extensive immunocytochemical evaluation, performed on specimens obtained by EUS-FNA, can reach a definite diagnosis in a significant number of cases.
www.giejournal.org
Mo1404 Basket-Like Hypervascularization in Doppler Endoscopic Ultrasonography- a Highly Specific Criterion for the Detection of a Gastrointestinal Stromal Tumor Holger Neye*1, Klaus MöNkemüLler2, Roland Hiersemann3, Steffen Rickes3 1 Department of Gastroenterology and Diabetology, HELIOS Hospital Emil von Behring Berlin, Berlin, Germany; 2Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL; 3Department of Internal Medicine, Börde Hospital, Oschersleben, Germany Introduction: Endoscopic ultrasonography (EUS) is the most important imaging method for diagnosis of subepithelial lesions of the gastrointestinal tract. However, it still has limits in the differentiation between Gastrointestinal Stromal Tumors (GISTs) from other malignant and benign tumors (NonGISTs). As a result of the development of effective oncological therapy there is a high need for an imaging method to the diagnosis and follow-up of GISTs. In recent years Doppler EUS has been proposed as a method to distinguish GISTs from Non-GISTs. Therefore we initiated a prospective study to evaluate Doppler EUS criteria for the detection of a GIST. Patients and methods: Thirty-one patients (19 women, 12 men) with subepithelial lesions (nZ32) were prospectively investigated using the EUS platform Olympus GFUCT140 (Olympus Europe, Hamburg, Germany) and HDI 5000 (Philips Ultrasound, Bothell, USA). All Doppler EUS examinations were performed by one operator unaware of the histological results. Defined ultrasound parameters were used to determine the Doppler EUS observations. All tumors were proven histologically. The exact Chi-square Test (Fisher’s Test) was used to find significant differences between GISTs and Non-GISTs. P-values of less than 0.05 were considered to be significant. The study was conducted following the Good Clinical Practice Guidelines and according to the guidelines of the Helsinki Declaration. Results: See table 1. Basket-like hypervascularization in Doppler endoscopic ultrasonography is a highly specific criterion in the differentiation between Gastrointestinal Stromal Tumors from other malignant and benign tumors (Non-GISTs). Conclusion: The differentiation of GISTs from other malignant and benign subepithelial lesions is a major issue in the management of these tumors. With this prospective study, we have addressed the need to evaluate diagnostic criteria for Doppler EUS criteria. The results demonstrated a basket-like hypervascularization is a highly specific criterion in the detection of a GIST. In the future, the direct detection of vessels could be the most important advantage of Doppler EUS contrary to other imaging methods.
Table 1. Results of Doppler EUS examinations Criteria Vessels detected Afferent vessel Basket-like hypervascularization
GIST present
GIST absent
Non-GIST present
Non-GIST absent
pvalue
10 9 9
0 1 1
14 7 4
8 15 18
0.035 0.006 0.0002
Significance level: p-value less than 0.05
Mo1405 Impact of an Intensive, Short-Term, Training Program in Cytopathology for Endosonographers Shyam Varadarajulu*1, Bronte a. Holt1, Muhammad Hasan1, Ji Young Bang1, Amy L. Logue1, Ashtosh Tamhane2, Robert Hawes1, Shantel Hebert-Magee1 1 Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; 2 Medicine, University of Alabama at Birmingham, Birmingham, AL Background: A major hindrance to establishing an accurate diagnosis in EUS is the dependence on onsite cytopathology services. Aim: Assess the effectiveness of an intensive short-term training program designed to educate endosonographers about EUS-cytopathology. Methods: Six endosonographers (MaleZ 5; median ageZ35yrs) with minimal exposure to cytopathology, representing all time zones in the United States, with a median annual EUS volume of 250 procedures (academic: private practiceZ3:3) comprised the study cohort for this pilot project. A 2-day training program was conducted at a central site in southern U. S. On day one, a pretest comprising 20 questions was administered (score rangeZ0 to 100). A 90 minute tutorial was then conducted by an academic cytopathologist with focus on four performance measures: specimen adequacy, sample interpretation (nondiagnostic, benign, atypical, neoplastic), specimen processing for ancillary testing, and preliminary diagnosis. Eight live EUS-FNA cases (five on day 1 and three on day 2) were performed and microscopic images were projected in real-time to an overhead monitor. For each case, the study participants independently completed four questions pertaining to the
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB317
Abstracts
performance measures (score range: 0 to 100). Similar to day 1, a post-test exam of 20 questions was administered on day 2 with assessment of performance measures. Additionally, after tutoring, the ability of participants’ to smear/ stain slides and operate a microscope was assessed. Outcome measures: 1. Compare pre (day 1) and post-test (day 2) scores; 2. Examine learning curve (day 1 vs. day 2) for performance measures, and 3. Evaluate ability to handle specimens and operate a microscope. Results: When compared to the pre-test, the post-test scores of the six participants improved significantly from 48 to 78 (pZ0.03). When the interpretation of FNA specimens from the live EUS procedures were compared between days 1 and 2, the overall performance score improved from 89 on day 1 to 100 on day 2. The corresponding individual performance measures for days 1 vs. 2 is shown in the Figure. After training, all subjects were able to smear/stain slides and operate a microscope independently (superior rating for all). Conclusions: An intensive short-term tutorial was effective for training endosonographers in EUS-related cytopathology. Incorporating basic cytopathology training in EUS fellowship will likely improve the diagnostic performance of tissue acquisition procedures and will have a major impact in advancing EUSFNA worldwide.
Mo1406 Innovations in Interventional EUS: Is the USA Fading Fast? Ji Young Bang, Robert Hawes, Shyam Varadarajulu* Center for Interventional Endoscopy, Florida Hospital, Orlando, FL Background: There is a growing interest among endoscopists to be trained in EUS as interventions are being increasingly performed and there are significant opportunities for clinical research and device development. Aim: Identify important milestones and track the growth and development of interventional EUS in the United States and around the World. Methods: A PUBMED search was undertaken by two independent physicians to identify all peer-reviewed publications related to EUS-guided interventions since 1995. Procedures were categorized as ADVANCED if there was creation of conduit between organs (drainage of pancreatic fluid collection/gallbladder/pelvic abscess, hepaticogastrostomy, choledochoduodenostomy and pancreaticogastrostomy) and MINIMALLY-INVASIVE if it involved only injection/implantation of substances for therapy (celiac plexus ablation , brachytherapy, fiducial placement, injection of chemotherapeutic agents, obliteration of varices) or passage of guidewire to facilitate stenting via the natural orifice (rendezvous drainage of the biliary or pancreatic ductal system). Data was evaluated geographically based on (a) first report of the procedure, (b) novelty (technique or device development) and (c) number of related-publications. The contribution to the interventional EUS literature was compared between the USA versus the rest of the World. Results: Of the 194 publications, 126 were related to advanced and 68 to minimallyinvasive procedures. Advanced procedures: All advanced procedures with the exception of gallbladder drainage were reported from outside the USA (5 of 6 from Europe). A higher proportion of publications (66.7% vs. 33.3%, p!0.001) and novel developments (83.3% vs. 16.7%, pZ0.003) in advanced interventional EUS were reported from non-USA centers. While contributions from Asia constituted only 20% prior to 2008, they now represent the majority (O40%) of publications exceeding both the USA and Europe (pZ0.04). Minimally-invasive procedures: With the exception of rendezvous drainage of the pancreatic duct and vascular therapy (both pioneered in Europe), all other minimally-invasive interventions (4 of 6) were reported from the USA. While more publications (60.3% vs. 39.7%, pZ0.01) on minimally-invasive procedures were from the USA, there was no difference in no. of novelty based reports (4 vs. 1; pZ0.21). Conclusions: USA lags behind the rest of the World in pioneering advanced procedural techniques, novel developments and in proportion of publications related to interventional EUS. Federal regulations, institutional restrictions and fear of potential law suits may be factors restricting the development of advanced EUS interventions in the USA.
AB318 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Mo1407 Structured Endoscopic Ultrasound Training Program Improved Knowledge and Skills of Trainees - Results From the Asian EUS Group Myrna Wang1, Lee Guan Lim*1, Mai Hong Bang2, Frederick Dy3, Ghias U. Tayyab4, Thawee Ratanachu-Ek5, D. Samarasekera6, Vinay K. Dhir7, Zheng-Dong Jin8, Mitsuhiro Kida9, Dong Wan Seo10, Hsiu-PO. Wang11, Anthony Y. Teoh12, Khek-Yu Ho1 1 National University Health System, Singapore, Singapore; 2The 108 Military Central Hospital, Hanoi, Viet Nam; 3University of Santo Tomas Hospital, Manila, Philippines; 4Lahore General Hospital, Lahore, Pakistan; 5Rajavithi Hospital, Bangkok, Thailand; 6University of Colombo, Colombo, Sri Lanka; 7Baldota Institute of Digestive Science, Mumbai, India; 8Changhai Hospital, Second Military Medical University, Shanghai, China; 9Kitasato University East Hospital, Kanagawa, Japan; 10Asan Medical Center, Seoul, Republic of Korea; 11 National Taiwan University Hospital, Taipei City, Taiwan; 12Chinese University of Hong Kong, Hong Kong, China Introduction: While endoscopic ultrasound (EUS) is an established diagnostic modality, its use in some Asian countries remains limited. One of the main reasons is the lack of training availability. The Asian EUS Group was established to propagate the training of EUS to aspiring endosonographers through structured 2-day workshops with lectures, hands-on practice in animals, and/or Ikuma model, and live case demonstration. Aim: To prospectively evaluate the effectiveness of these structured EUS training programs in improving knowledge and skill of EUS among the trainees. Methods: The study was conducted in 6 workshops in 6 countries including Sri Lanka, Pakistan, Thailand, Vietnam, Singapore and Philippines, within a year. Trainees were evaluated using written and skill tests before and after completion of the training. The written test consisted of 17 multiple choice questions that cover anatomy, principles & equipment, and indications of EUS. In the skill tests, trainees were asked to locate each of the 6 anatomical structures successfully within 2 minutes using the Ikuma model: celiac axis, pancreatic body and tail, splenic vein and artery, left kidney and spleen. Results: Pre and post workshop written tests from a total of 62 trainees were analyzed. Compared with pre-training, the trainees improved significantly in the overall mean (SD) scores after the training (66.0 25.3 % to 77.5 19.4 %, p!0.0001). The pre and post training mean scores for the 3 areas are: human anatomy (74.5 29.5% to 85.5 24 %, P!0.001), principles and equipment (41% 37.9 to 46.5% 30.5, PZ0.053), and indications (56% 26.2 to 60 25.9 %, PZ0.067). 31 trainees were randomly selected to undergo skill test before and after the course. Compared with pre-training, the proportions of trainees who succeeded in locating each structure in the post training are: celiac axis (36% to 80.5%), pancreatic body (51.5 % to 80.5 %), pancreatic body & tail (42% to 77.5 %), splenic vein and artery (48.5% to 84%), left kidney (60% to 83%), and spleen (47% to 83%). Overall, there is a significant improvement in the proportion of trainees’ successful localisation of structures post-training compared to before training (p ! 0.0001). Conclusion: Following a 2-day structured training programme, trainees’ knowledge and skills in EUS improved significantly. Structured training courses appeared to be an effective way of imparting EUS knowledge and skills to aspiring endosonographers in the Asian region.
Mo1408 Endoscopic Ultrasound Is an Effective Imaging Method in Staging Tumors of the Ampulla of Vater Emrah Alper*, Huseyin Sinan Akay, Serkan Ipek, Fatih Aslan, Cem Cekic, Zehra Akpinar, Hakan Camyar, Mehmet Camci, Belkis Unsal Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey The aim of this study is to assess the effectiveness and safety of endoscopic ultrasound (EUS) in evaluating the invasion of ampullary tumors to the adjacent tissues and lymphatics. Patients who had a tumoral mass located at the ampulla of Vater resected either endoscopically or surgically were enrolled into the study. Neuroendocrine tumors were excluded and only 33 patients with adenocarcinomas were included. T and N staging of the tumors were done using EUS probe before resection and treatment was decided according to EUS and CT findings. EUS showed tumors limited to the mucosa with an intact submucosa in 9 patients and endoscopic ampullectomy were done. Pathologic evaluation of these tumors showed that T staging correlated with the T staging of EUS in 4 patients. Submucosa and/or deeper layer and adjacent tissue invasion was seen in 24 patients by EUS and surgical resection was performed. Pathological staging correlated with EUS findings in all these patients. The overall correlation of T staging by EUS and pathologic examination after resection or after ampullectomy was 85%. All the lesions which were misdiagnosed for T staging by EUS were larger than 25 mm in size. Regarding N1 lymph node evaluation by EUS, malignity findings were seen in 5 patients, all of which were found to be N1 lymph nodes after surgical resection. In the other 28 patients no N1 lymph nodes were found by EUS or on resected material. In evaluating the presence of adjacent lymph nodes there was 100% correlation of EUS with surgery. We found that EUS is a safe and effective method in T and N staging of
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Mo1402 EUS-Guided Fine Needle Biopsy for Histopathologic Evaluation of Solid Liver Masses Yun Nah Lee*1, Jong Ho Moon1, Hyun Jong Choi1, Dong Choon Kim1, Hee Kyung Kim2, Moon Han Choi1, Tae Hoon Lee1, Sang-Woo Cha1, Young Deok Cho1, Sang-Heum Park1, Sun-Joo Kim1 1 Digestive Disease Center and Research Institute, Department of Internal Medicine,SoonChunHyang University School of Medicine, Bucheon and Seoul, Republic of Korea; 2Department of Pathology, Bucheon, Republic of Korea Background and Aims: Cytopathologic evaluation by endoscopic ultrasonography (EUS)-guided fine needle aspiration or biopsy can be performed for the solid liver masses, especially in left lobe. Histopathologic analysis with adequate tissue sampling may be crucial for differential diagnosis of solid liver masses. EUS-guided biopsy (FNB) needle enabling the acquisition of core specimens for histopathologic analysis was recently introduced. The aim of this study was to evaluate the usefulness of the EUS-FNB needle for histopathologic evaluation of solid liver masses. Methods: Total 25 patients with solid masses in the left lobe of liver were enrolled in this study. 22-gauge EchoTip ProCore needle (Cook medical Inc., Bloomington, USA) was used for EUS-guided fine needle biopsy. Transgastric needle puncture was performed with using stylet and negative suction during sampling. The specimen was analyzed by on-site cytology with Diff-Quick stain, cytology with Papanicolaou stain and histology with immunohistochemical (IHC) stains. Results: The median number of needle pass for adequate cellularity in on-site analysis was 2 (interquartile range, 1 to 3). Core sepecimens were obtained in 84% (21/25). Tissue sample adequacy for histologic evaluation combined with IHC stains was 80% (20/25). Overall diagnostic accuracy of EUS-FNB was 92% (23/25). Ten solid liver masses requiring differential diagnosis in prior imaging studies were histopathologically diagnosed by EUS-FNB. By the IHC stains of core specimens, four solid liver masses had different histopathologic diagnosis from cytologic analysis. No procedure-related complications were occurred. Conclusions: EUS-FNB needle was useful for obtaining adequate core specimens for histopathologic ananlysis of solid liver masses.
Mo1403 Definite Diagnosis of Subepithelial Lesions of the Gastrointestinal Tract by Means of Endoscopic Ultrasound-Fine Needle Aspiration (EUS-FNA) Claudio De Angelis*1, Selene F. Manfrè1, Milena Marietti1, Mauro Bruno1, Matteo Giuseppe Goss1, Patrizia Carucci1, Elena MALDI2, Donatella Pacchioni2, Paola Cassoni2, Paola Francia Di Celle3 1 Gastrohepatology, Città della Salute e della Scienza, Turin, Italy; 2 Biomedical Science and Human Oncology, Città della Salute e della Scienza, Turin, Italy; 3Center for Experimental Research and Medical Studies, Città della Salute e della Scienza, Turin, Italy Objectives: Endoscopic Ultrasound-Fine Needle Aspiration (EUS-FNA) is today a standard practice for the evaluation of subepithelial masses of the gastrointestinal (GI) tract, since it allows a clear identification of the layer of origin of the lesion and its sampling. This kind of lesion needs a definite diagnosis because some of these lesions, mainly the Gastrointestinal Stromal Tumors (GISTs), bear a malignant potential. However a tissue diagnosis is seldom necessary because treatment decisions can be usually planned mainly on clinical bases. Design and Methods: We describe our 10 years experience in EUS-FNA of subepithelial lesions of the GI tract and all the techniques we were able to apply in order to reach this difficult differential diagnosis even on a very limited amount of material. From 2003 to September 2013 we evaluated about 1200 subepithelial masses of the GI tract, and we performed EUS-FNA only on 62 of them (about 5%). 53 of 62 procedures were accomplished with an on-site cytopathologist to assess the adequacy of the specimens. According to the cytomorphological features of the lesions and the cytopathologist’s judgment, immunocytochemical analysis for CD117, CD34, S100, SMA, AE1/AE3 and Ki67 was employed. In 11/62 cases it has also been possible to apply genomic analysis to the retrieved specimen in order to check on mutations in c-KIT gene and PDGFRA gene or other mutations such as translocations t(11;22), t(X;18). Results: For each lesion a mean of 5.2 +/- 2.5 needle passes (range 2-11) was performed; standard needles from 25 to 19 gauge, pro-core (in 12 patients) or trucut (in 10 patients) needles were used according to the operator’s preferences and mass location. Two cases of minor bleeding occurred: they were endoscopically treated and no transfusions were required. An adequate specimen could be collected in 57 cases (91.94%). Based on immunocytochemical results, a definite diagnosis was reached in 43/62 cases (69.35%): we observed 25 (40.32%) GISTs, 6 (9.68%) leyomiomas, 3 (4.84%) adenocarcinomas, 2 (3.23%) flogistic elements, 2 (3.23%) synovial sarcomas, and 5 (8.06%) other kinds of lesion (1 endometriosis node, 1 fibrovascular tumor, 1 retrorectal metastasis from hepatocarcinoma, 1 proctitis cystica profunda and 1 cystic retro-rectal amartoma). In the remaining 14/62 cases (22.58%) we could not go beyond a generic diagnosis of "stromal spindle-cell lesion". Conclusions: Although subepithelial lesions still represent a diagnostic challenge, an extensive immunocytochemical evaluation, performed on specimens obtained by EUS-FNA, can reach a definite diagnosis in a significant number of cases.
www.giejournal.org
Mo1404 Basket-Like Hypervascularization in Doppler Endoscopic Ultrasonography- a Highly Specific Criterion for the Detection of a Gastrointestinal Stromal Tumor Holger Neye*1, Klaus MöNkemüLler2, Roland Hiersemann3, Steffen Rickes3 1 Department of Gastroenterology and Diabetology, HELIOS Hospital Emil von Behring Berlin, Berlin, Germany; 2Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL; 3Department of Internal Medicine, Börde Hospital, Oschersleben, Germany Introduction: Endoscopic ultrasonography (EUS) is the most important imaging method for diagnosis of subepithelial lesions of the gastrointestinal tract. However, it still has limits in the differentiation between Gastrointestinal Stromal Tumors (GISTs) from other malignant and benign tumors (NonGISTs). As a result of the development of effective oncological therapy there is a high need for an imaging method to the diagnosis and follow-up of GISTs. In recent years Doppler EUS has been proposed as a method to distinguish GISTs from Non-GISTs. Therefore we initiated a prospective study to evaluate Doppler EUS criteria for the detection of a GIST. Patients and methods: Thirty-one patients (19 women, 12 men) with subepithelial lesions (nZ32) were prospectively investigated using the EUS platform Olympus GFUCT140 (Olympus Europe, Hamburg, Germany) and HDI 5000 (Philips Ultrasound, Bothell, USA). All Doppler EUS examinations were performed by one operator unaware of the histological results. Defined ultrasound parameters were used to determine the Doppler EUS observations. All tumors were proven histologically. The exact Chi-square Test (Fisher’s Test) was used to find significant differences between GISTs and Non-GISTs. P-values of less than 0.05 were considered to be significant. The study was conducted following the Good Clinical Practice Guidelines and according to the guidelines of the Helsinki Declaration. Results: See table 1. Basket-like hypervascularization in Doppler endoscopic ultrasonography is a highly specific criterion in the differentiation between Gastrointestinal Stromal Tumors from other malignant and benign tumors (Non-GISTs). Conclusion: The differentiation of GISTs from other malignant and benign subepithelial lesions is a major issue in the management of these tumors. With this prospective study, we have addressed the need to evaluate diagnostic criteria for Doppler EUS criteria. The results demonstrated a basket-like hypervascularization is a highly specific criterion in the detection of a GIST. In the future, the direct detection of vessels could be the most important advantage of Doppler EUS contrary to other imaging methods.
Table 1. Results of Doppler EUS examinations Criteria Vessels detected Afferent vessel Basket-like hypervascularization
GIST present
GIST absent
Non-GIST present
Non-GIST absent
pvalue
10 9 9
0 1 1
14 7 4
8 15 18
0.035 0.006 0.0002
Significance level: p-value less than 0.05
Mo1405 Impact of an Intensive, Short-Term, Training Program in Cytopathology for Endosonographers Shyam Varadarajulu*1, Bronte a. Holt1, Muhammad Hasan1, Ji Young Bang1, Amy L. Logue1, Ashtosh Tamhane2, Robert Hawes1, Shantel Hebert-Magee1 1 Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; 2 Medicine, University of Alabama at Birmingham, Birmingham, AL Background: A major hindrance to establishing an accurate diagnosis in EUS is the dependence on onsite cytopathology services. Aim: Assess the effectiveness of an intensive short-term training program designed to educate endosonographers about EUS-cytopathology. Methods: Six endosonographers (MaleZ 5; median ageZ35yrs) with minimal exposure to cytopathology, representing all time zones in the United States, with a median annual EUS volume of 250 procedures (academic: private practiceZ3:3) comprised the study cohort for this pilot project. A 2-day training program was conducted at a central site in southern U. S. On day one, a pretest comprising 20 questions was administered (score rangeZ0 to 100). A 90 minute tutorial was then conducted by an academic cytopathologist with focus on four performance measures: specimen adequacy, sample interpretation (nondiagnostic, benign, atypical, neoplastic), specimen processing for ancillary testing, and preliminary diagnosis. Eight live EUS-FNA cases (five on day 1 and three on day 2) were performed and microscopic images were projected in real-time to an overhead monitor. For each case, the study participants independently completed four questions pertaining to the
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB317
Abstracts
performance measures (score range: 0 to 100). Similar to day 1, a post-test exam of 20 questions was administered on day 2 with assessment of performance measures. Additionally, after tutoring, the ability of participants’ to smear/ stain slides and operate a microscope was assessed. Outcome measures: 1. Compare pre (day 1) and post-test (day 2) scores; 2. Examine learning curve (day 1 vs. day 2) for performance measures, and 3. Evaluate ability to handle specimens and operate a microscope. Results: When compared to the pre-test, the post-test scores of the six participants improved significantly from 48 to 78 (pZ0.03). When the interpretation of FNA specimens from the live EUS procedures were compared between days 1 and 2, the overall performance score improved from 89 on day 1 to 100 on day 2. The corresponding individual performance measures for days 1 vs. 2 is shown in the Figure. After training, all subjects were able to smear/stain slides and operate a microscope independently (superior rating for all). Conclusions: An intensive short-term tutorial was effective for training endosonographers in EUS-related cytopathology. Incorporating basic cytopathology training in EUS fellowship will likely improve the diagnostic performance of tissue acquisition procedures and will have a major impact in advancing EUSFNA worldwide.
Mo1406 Innovations in Interventional EUS: Is the USA Fading Fast? Ji Young Bang, Robert Hawes, Shyam Varadarajulu* Center for Interventional Endoscopy, Florida Hospital, Orlando, FL Background: There is a growing interest among endoscopists to be trained in EUS as interventions are being increasingly performed and there are significant opportunities for clinical research and device development. Aim: Identify important milestones and track the growth and development of interventional EUS in the United States and around the World. Methods: A PUBMED search was undertaken by two independent physicians to identify all peer-reviewed publications related to EUS-guided interventions since 1995. Procedures were categorized as ADVANCED if there was creation of conduit between organs (drainage of pancreatic fluid collection/gallbladder/pelvic abscess, hepaticogastrostomy, choledochoduodenostomy and pancreaticogastrostomy) and MINIMALLY-INVASIVE if it involved only injection/implantation of substances for therapy (celiac plexus ablation , brachytherapy, fiducial placement, injection of chemotherapeutic agents, obliteration of varices) or passage of guidewire to facilitate stenting via the natural orifice (rendezvous drainage of the biliary or pancreatic ductal system). Data was evaluated geographically based on (a) first report of the procedure, (b) novelty (technique or device development) and (c) number of related-publications. The contribution to the interventional EUS literature was compared between the USA versus the rest of the World. Results: Of the 194 publications, 126 were related to advanced and 68 to minimallyinvasive procedures. Advanced procedures: All advanced procedures with the exception of gallbladder drainage were reported from outside the USA (5 of 6 from Europe). A higher proportion of publications (66.7% vs. 33.3%, p!0.001) and novel developments (83.3% vs. 16.7%, pZ0.003) in advanced interventional EUS were reported from non-USA centers. While contributions from Asia constituted only 20% prior to 2008, they now represent the majority (O40%) of publications exceeding both the USA and Europe (pZ0.04). Minimally-invasive procedures: With the exception of rendezvous drainage of the pancreatic duct and vascular therapy (both pioneered in Europe), all other minimally-invasive interventions (4 of 6) were reported from the USA. While more publications (60.3% vs. 39.7%, pZ0.01) on minimally-invasive procedures were from the USA, there was no difference in no. of novelty based reports (4 vs. 1; pZ0.21). Conclusions: USA lags behind the rest of the World in pioneering advanced procedural techniques, novel developments and in proportion of publications related to interventional EUS. Federal regulations, institutional restrictions and fear of potential law suits may be factors restricting the development of advanced EUS interventions in the USA.
AB318 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Mo1407 Structured Endoscopic Ultrasound Training Program Improved Knowledge and Skills of Trainees - Results From the Asian EUS Group Myrna Wang1, Lee Guan Lim*1, Mai Hong Bang2, Frederick Dy3, Ghias U. Tayyab4, Thawee Ratanachu-Ek5, D. Samarasekera6, Vinay K. Dhir7, Zheng-Dong Jin8, Mitsuhiro Kida9, Dong Wan Seo10, Hsiu-PO. Wang11, Anthony Y. Teoh12, Khek-Yu Ho1 1 National University Health System, Singapore, Singapore; 2The 108 Military Central Hospital, Hanoi, Viet Nam; 3University of Santo Tomas Hospital, Manila, Philippines; 4Lahore General Hospital, Lahore, Pakistan; 5Rajavithi Hospital, Bangkok, Thailand; 6University of Colombo, Colombo, Sri Lanka; 7Baldota Institute of Digestive Science, Mumbai, India; 8Changhai Hospital, Second Military Medical University, Shanghai, China; 9Kitasato University East Hospital, Kanagawa, Japan; 10Asan Medical Center, Seoul, Republic of Korea; 11 National Taiwan University Hospital, Taipei City, Taiwan; 12Chinese University of Hong Kong, Hong Kong, China Introduction: While endoscopic ultrasound (EUS) is an established diagnostic modality, its use in some Asian countries remains limited. One of the main reasons is the lack of training availability. The Asian EUS Group was established to propagate the training of EUS to aspiring endosonographers through structured 2-day workshops with lectures, hands-on practice in animals, and/or Ikuma model, and live case demonstration. Aim: To prospectively evaluate the effectiveness of these structured EUS training programs in improving knowledge and skill of EUS among the trainees. Methods: The study was conducted in 6 workshops in 6 countries including Sri Lanka, Pakistan, Thailand, Vietnam, Singapore and Philippines, within a year. Trainees were evaluated using written and skill tests before and after completion of the training. The written test consisted of 17 multiple choice questions that cover anatomy, principles & equipment, and indications of EUS. In the skill tests, trainees were asked to locate each of the 6 anatomical structures successfully within 2 minutes using the Ikuma model: celiac axis, pancreatic body and tail, splenic vein and artery, left kidney and spleen. Results: Pre and post workshop written tests from a total of 62 trainees were analyzed. Compared with pre-training, the trainees improved significantly in the overall mean (SD) scores after the training (66.0 25.3 % to 77.5 19.4 %, p!0.0001). The pre and post training mean scores for the 3 areas are: human anatomy (74.5 29.5% to 85.5 24 %, P!0.001), principles and equipment (41% 37.9 to 46.5% 30.5, PZ0.053), and indications (56% 26.2 to 60 25.9 %, PZ0.067). 31 trainees were randomly selected to undergo skill test before and after the course. Compared with pre-training, the proportions of trainees who succeeded in locating each structure in the post training are: celiac axis (36% to 80.5%), pancreatic body (51.5 % to 80.5 %), pancreatic body & tail (42% to 77.5 %), splenic vein and artery (48.5% to 84%), left kidney (60% to 83%), and spleen (47% to 83%). Overall, there is a significant improvement in the proportion of trainees’ successful localisation of structures post-training compared to before training (p ! 0.0001). Conclusion: Following a 2-day structured training programme, trainees’ knowledge and skills in EUS improved significantly. Structured training courses appeared to be an effective way of imparting EUS knowledge and skills to aspiring endosonographers in the Asian region.
Mo1408 Endoscopic Ultrasound Is an Effective Imaging Method in Staging Tumors of the Ampulla of Vater Emrah Alper*, Huseyin Sinan Akay, Serkan Ipek, Fatih Aslan, Cem Cekic, Zehra Akpinar, Hakan Camyar, Mehmet Camci, Belkis Unsal Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey The aim of this study is to assess the effectiveness and safety of endoscopic ultrasound (EUS) in evaluating the invasion of ampullary tumors to the adjacent tissues and lymphatics. Patients who had a tumoral mass located at the ampulla of Vater resected either endoscopically or surgically were enrolled into the study. Neuroendocrine tumors were excluded and only 33 patients with adenocarcinomas were included. T and N staging of the tumors were done using EUS probe before resection and treatment was decided according to EUS and CT findings. EUS showed tumors limited to the mucosa with an intact submucosa in 9 patients and endoscopic ampullectomy were done. Pathologic evaluation of these tumors showed that T staging correlated with the T staging of EUS in 4 patients. Submucosa and/or deeper layer and adjacent tissue invasion was seen in 24 patients by EUS and surgical resection was performed. Pathological staging correlated with EUS findings in all these patients. The overall correlation of T staging by EUS and pathologic examination after resection or after ampullectomy was 85%. All the lesions which were misdiagnosed for T staging by EUS were larger than 25 mm in size. Regarding N1 lymph node evaluation by EUS, malignity findings were seen in 5 patients, all of which were found to be N1 lymph nodes after surgical resection. In the other 28 patients no N1 lymph nodes were found by EUS or on resected material. In evaluating the presence of adjacent lymph nodes there was 100% correlation of EUS with surgery. We found that EUS is a safe and effective method in T and N staging of
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