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OC.09.4 CONTRAST ENHANCED-ENDOSCOPIC ULTRASONOGRAPHY (CH-EUS) IN THE DIFFERENTIAL DIAGNOSIS OF GASTROINTESTINAL SUBMUCOSAL TUMORS (SMTs)
Abstracts of the 19th National Congress of Digestive Diseases / Digestive and Liver Disease 45S (2013) S55–S218
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needle. Demographic data, PCLs characteristic, cyto-hystologic results were recorded in dedicated database. Results: EUS-FNA/B was technically feasible in all cases (58 patients with 60 lesions). In 39/60 procedures (65%), the specimens were adequate for cyto-histologic assessment. In PCLs with a solid component, and in malignant lesions, adequacy was 17/18 (94.4%, P= 0.0149) and 16/16 (100%, P= 0.0054), respectively, though in 3 cases of malignant lesions the FNA/B underrated the grade of dysplasia. In 17/60 procedures (28.3%), the PCLs were surgically resected. Concordance between FNA/B diagnosis and surgical specimen were 100% regarding the type of lesions. Samples were adequate for full histologic evaluation in 18/39 cases (46.1%), with the possibility of performing immunohistochemical analysis that was essential for the diagnosis in 4 malignant lesions. There were only 2 (3.3%) mild complications. Conclusions: This is, to the best of our knowledge, the first study on the ProCore needle in PCLs. This prospective study suggests that EUS-FNA/B of PCLs with the 22G ProCore needle is feasible, and superior to conventional EUS-FNA with cytology from cystic fluid, with a higher yield of diagnostic specimens, and no increase in the rate of complications. These results need to be confirmed in larger and comparative studies.
OC.09.4 CONTRAST ENHANCED-ENDOSCOPIC ULTRASONOGRAPHY (CH-EUS) IN THE DIFFERENTIAL DIAGNOSIS OF GASTROINTESTINAL SUBMUCOSAL TUMORS (SMTs) P. Fusaroli ∗ , M.C. D’Ercole, L. Ceroni, G. Caletti Università di Bologna/AUSL di Imola, Imola, Italy Background and aim: Gastrointestinal SMTs account for a wide variety of etiologies and often pose a significant diagnostic challenge. Endoscopic biopsies show low diagnostic accuracy as these lesions are typically subepithelial. EUS is a useful tool to differentiate true SMTs from extrinsic compressions; however its differential diagnostic capabilities are still suboptimal. Additionally, the accuracy of EUS-fine needle aspiration is reportedly in the range of only 60–70% according to different studies, probably due to the very heterogeneous architecture of SMTs. Recently, CH-EUS has been reported as an useful adjunct in differential diagnosis of pancreatic tumors and lymph nodes. Our aim was to evaluate the potential role of CH-EUS in the differential diagnosis of SMTs. Material and methods: We performed a retrospective analysis of a prospectively maintained database. Out of the 198 patients who underwent CH-EUS in the period 2008–2011 for gastrointestinal indications, 51 were diagnosed with SMTs (31 F, 20 M; mean age 58 years, range: 24–73). CH-EUS after injection of 4.8 ml Sonovue® was performed. EUS-FNA and/or surgical pathology constituted our gold standard. Results: The final diagnosis was as follows: gastrointestinal stromal tumor (GIST), n=19; leiomyoma, n=18; neuroendocrine tumor (NET), n=8; lipoma, n=4; ectopic pancreas, n=2. The main patterns that were observed at CH-EUS are shown in the table.
Hyperenhancing Hypoenhancing Homogeneous Inhomogeneous Slow washout Fast washout
GISTs
Leiomyomas
NETs
Lipomas
Ectopic pancreas
18 (95%) 1 (5%) 17 (89%) 2 (11%) 16 (84%) 3 (16%)
4 (22%) 14 (78%) 17 (94%) 1 (6%) 4 (22%) 14 (78%)
7 (87%) 1 (13%) 8 (100%) 0 8 (100%) 0
0 4 (100%) 4 (100%) 0 0 4 (100%)
1 (50%) 1 (50%) 2 (100%) 0 1 (50%) 1 (50%)
Of note, Chi-square statistics showed a significant difference between the contrast uptake of GIST and of leiomyoma (p=0.0007). Conclusions: At CH-EUS, GISTs were prevalently hyperenhancing while leiomyomas were prevalently hypoenhancing. This behavior can help overcoming the limitations of EUS-FNA in these difficult to diagnose gastrointestinal SMTs. NETs were prevalently hyperenhancing, resembling the same behavior of pancreatic NET. Lipomas were always hypoenhancing. CH-EUS may represent and useful adjunct to standard EUS for the differential diagnosis of SMTs, particularly when EUS-FNA is not available or inconclusive.
OC.09.5 EUS-GUIDED FINE NEEDLE TISSUE ACQUISITION IN PATIENTS WITH SUBEPITHELIAL LESIONS OF THE GI TRACT USING A FORWARD VIEWING EUS SCOPE: A SINGLE CENTER STUDY A. Larghi ∗ ,1 , L. Fuccio 2 , G. Chiarello 1 , F. Tsiopoulos 1 , F. Attili 1 , D. Galasso 1 , G. Vanella 1 , M. Martini 1 , L.M. Larocca 1 , G. Rindi 1 , G. Costamagna 1 , R. Ricci 1 1 Ospedale
Gemelli, Rome, Italy; 2 Ospedale S.Orsola-Malpighi, Bologna,
Italy Background and aim: Diagnostic accuracy of EUS-guided fine needle aspiration for subepithelial lesions (SELs) throughout the gastrointestinal (GI) tract is not usually satisfactory, mainly because of the need for a tissue specimen to reach a definitive diagnosis. We have recently described a technique named EUS-guided fine needle tissue acquisition (EUS-FNTA) to obtain tissue specimens using a 19 gauge needle. The utilization of this large needle can be facilitated when used with a newly developed forward viewing linear echoendoscope (FV-EUS), because of the frontal exit of the needle from the tip of the instrument. Aim of our study was to evaluate the diagnostic accuracy of the EUS-FNTA technique performed using the FV-EUS scope in patients with SELs of the GI tract. Material and methods: This is a retrospective analysis of a prospectively collected database. All the procedures were performed using a FV-EUS. EUS-FNTA was done using a standard 19 gauge needle as previously described (Larghi A et al GIE 2011). The collected specimens were placed in 10% formalin for histological examination. Composite reference standard was adopted (surgery, diagnostic EUS-FNTA, other diagnostic investigations and follow up). All patients were followed for at least 12 months after EUS procedure. Results: Between June 2007 and December 2010, 96 patients with SELs (40 males; mean age 61±14 years) were included in the study. Lesions (mean diameter 27.2±13.6 mm) were located in the esophagus (12), stomach (73), duodenum (9), rectum (2). EUS-FNTA was feasible in all but one case and a mean of 2.6 needle passes/patient (range 1–5) performed. Tissue samples for histological evaluation were retrieved in 89 cases (92.7%). Diagnoses were: GIST (46), leiomyoma (22), ectopic pancreas (5), NET (4), metastases (4), swannoma (3), inflammatory polyps (3), lymphoma (1), melanoma (1). In all these patients, diagnosis proved to be correct. Sensitivity, specificity, PPV and NPV and overall accuracy were 89%, 100%, 100%, 83% and 92.7%, respectively. Conclusions: The combination of EUS-FNTA technique and FV-EUS allows the obtainment of a core sample for histological evaluation in high percentage of cases, with an overall diagnostic accuracy of about 93%.
OC.09.6 ROLE OF EUS FNA IN DIAGNOSIS AND STAGING OF LUNG CANCER D. Assisi ∗ , M. Filippetti, T. Federici, P. Visca, M. Anti Regina Elena Cancer Institute, Rome, Italy Background and aim: Lung cancer is the most frequent cause of cancer death in the world. Usually diagnosis and staging are determined by radiologic imaging and tissue diagnosis. Combined CT/PET scan should be performed in patients with suspected or known lung cancer. Diseases involves ipsilateral or contralateral mediastinal lymph nodes (N2 or N3) are unlikely to benefit from surgical resection. EUS FNA of the mediastinal adenopathy, primary site in left posterior lung and adrenal glands, when present, permits to have in the same time tissue diagnosis (with mutational analysis) and staging of the disease with high accuracy. Material and methods: We considered all patients with suspected lung cancer at PET e/o TC, referred to the Oncology Unit of our Institute. In all patients EUS FNA was performed in order to obtain tissue from the primary site of the neoplasm (localized in dorsal superior segments), the posterior mediastinum lymphoadenopathy (station 7, 8 and 5) and the adrenal glands. We evaluated the prevalence of this sites in our series and if there is a difference of accuracy between site of FNA.
S76
needle. Demographic data, PCLs characteristic, cyto-hystologic results were recorded in dedicated database. Results: EUS-FNA/B was technically feasible in all cases (58 patients with 60 lesions). In 39/60 procedures (65%), the specimens were adequate for cyto-histologic assessment. In PCLs with a solid component, and in malignant lesions, adequacy was 17/18 (94.4%, P= 0.0149) and 16/16 (100%, P= 0.0054), respectively, though in 3 cases of malignant lesions the FNA/B underrated the grade of dysplasia. In 17/60 procedures (28.3%), the PCLs were surgically resected. Concordance between FNA/B diagnosis and surgical specimen were 100% regarding the type of lesions. Samples were adequate for full histologic evaluation in 18/39 cases (46.1%), with the possibility of performing immunohistochemical analysis that was essential for the diagnosis in 4 malignant lesions. There were only 2 (3.3%) mild complications. Conclusions: This is, to the best of our knowledge, the first study on the ProCore needle in PCLs. This prospective study suggests that EUS-FNA/B of PCLs with the 22G ProCore needle is feasible, and superior to conventional EUS-FNA with cytology from cystic fluid, with a higher yield of diagnostic specimens, and no increase in the rate of complications. These results need to be confirmed in larger and comparative studies.
OC.09.4 CONTRAST ENHANCED-ENDOSCOPIC ULTRASONOGRAPHY (CH-EUS) IN THE DIFFERENTIAL DIAGNOSIS OF GASTROINTESTINAL SUBMUCOSAL TUMORS (SMTs) P. Fusaroli ∗ , M.C. D’Ercole, L. Ceroni, G. Caletti Università di Bologna/AUSL di Imola, Imola, Italy Background and aim: Gastrointestinal SMTs account for a wide variety of etiologies and often pose a significant diagnostic challenge. Endoscopic biopsies show low diagnostic accuracy as these lesions are typically subepithelial. EUS is a useful tool to differentiate true SMTs from extrinsic compressions; however its differential diagnostic capabilities are still suboptimal. Additionally, the accuracy of EUS-fine needle aspiration is reportedly in the range of only 60–70% according to different studies, probably due to the very heterogeneous architecture of SMTs. Recently, CH-EUS has been reported as an useful adjunct in differential diagnosis of pancreatic tumors and lymph nodes. Our aim was to evaluate the potential role of CH-EUS in the differential diagnosis of SMTs. Material and methods: We performed a retrospective analysis of a prospectively maintained database. Out of the 198 patients who underwent CH-EUS in the period 2008–2011 for gastrointestinal indications, 51 were diagnosed with SMTs (31 F, 20 M; mean age 58 years, range: 24–73). CH-EUS after injection of 4.8 ml Sonovue® was performed. EUS-FNA and/or surgical pathology constituted our gold standard. Results: The final diagnosis was as follows: gastrointestinal stromal tumor (GIST), n=19; leiomyoma, n=18; neuroendocrine tumor (NET), n=8; lipoma, n=4; ectopic pancreas, n=2. The main patterns that were observed at CH-EUS are shown in the table.
Hyperenhancing Hypoenhancing Homogeneous Inhomogeneous Slow washout Fast washout
GISTs
Leiomyomas
NETs
Lipomas
Ectopic pancreas
18 (95%) 1 (5%) 17 (89%) 2 (11%) 16 (84%) 3 (16%)
4 (22%) 14 (78%) 17 (94%) 1 (6%) 4 (22%) 14 (78%)
7 (87%) 1 (13%) 8 (100%) 0 8 (100%) 0
0 4 (100%) 4 (100%) 0 0 4 (100%)
1 (50%) 1 (50%) 2 (100%) 0 1 (50%) 1 (50%)
Of note, Chi-square statistics showed a significant difference between the contrast uptake of GIST and of leiomyoma (p=0.0007). Conclusions: At CH-EUS, GISTs were prevalently hyperenhancing while leiomyomas were prevalently hypoenhancing. This behavior can help overcoming the limitations of EUS-FNA in these difficult to diagnose gastrointestinal SMTs. NETs were prevalently hyperenhancing, resembling the same behavior of pancreatic NET. Lipomas were always hypoenhancing. CH-EUS may represent and useful adjunct to standard EUS for the differential diagnosis of SMTs, particularly when EUS-FNA is not available or inconclusive.
OC.09.5 EUS-GUIDED FINE NEEDLE TISSUE ACQUISITION IN PATIENTS WITH SUBEPITHELIAL LESIONS OF THE GI TRACT USING A FORWARD VIEWING EUS SCOPE: A SINGLE CENTER STUDY A. Larghi ∗ ,1 , L. Fuccio 2 , G. Chiarello 1 , F. Tsiopoulos 1 , F. Attili 1 , D. Galasso 1 , G. Vanella 1 , M. Martini 1 , L.M. Larocca 1 , G. Rindi 1 , G. Costamagna 1 , R. Ricci 1 1 Ospedale
Gemelli, Rome, Italy; 2 Ospedale S.Orsola-Malpighi, Bologna,
Italy Background and aim: Diagnostic accuracy of EUS-guided fine needle aspiration for subepithelial lesions (SELs) throughout the gastrointestinal (GI) tract is not usually satisfactory, mainly because of the need for a tissue specimen to reach a definitive diagnosis. We have recently described a technique named EUS-guided fine needle tissue acquisition (EUS-FNTA) to obtain tissue specimens using a 19 gauge needle. The utilization of this large needle can be facilitated when used with a newly developed forward viewing linear echoendoscope (FV-EUS), because of the frontal exit of the needle from the tip of the instrument. Aim of our study was to evaluate the diagnostic accuracy of the EUS-FNTA technique performed using the FV-EUS scope in patients with SELs of the GI tract. Material and methods: This is a retrospective analysis of a prospectively collected database. All the procedures were performed using a FV-EUS. EUS-FNTA was done using a standard 19 gauge needle as previously described (Larghi A et al GIE 2011). The collected specimens were placed in 10% formalin for histological examination. Composite reference standard was adopted (surgery, diagnostic EUS-FNTA, other diagnostic investigations and follow up). All patients were followed for at least 12 months after EUS procedure. Results: Between June 2007 and December 2010, 96 patients with SELs (40 males; mean age 61±14 years) were included in the study. Lesions (mean diameter 27.2±13.6 mm) were located in the esophagus (12), stomach (73), duodenum (9), rectum (2). EUS-FNTA was feasible in all but one case and a mean of 2.6 needle passes/patient (range 1–5) performed. Tissue samples for histological evaluation were retrieved in 89 cases (92.7%). Diagnoses were: GIST (46), leiomyoma (22), ectopic pancreas (5), NET (4), metastases (4), swannoma (3), inflammatory polyps (3), lymphoma (1), melanoma (1). In all these patients, diagnosis proved to be correct. Sensitivity, specificity, PPV and NPV and overall accuracy were 89%, 100%, 100%, 83% and 92.7%, respectively. Conclusions: The combination of EUS-FNTA technique and FV-EUS allows the obtainment of a core sample for histological evaluation in high percentage of cases, with an overall diagnostic accuracy of about 93%.
OC.09.6 ROLE OF EUS FNA IN DIAGNOSIS AND STAGING OF LUNG CANCER D. Assisi ∗ , M. Filippetti, T. Federici, P. Visca, M. Anti Regina Elena Cancer Institute, Rome, Italy Background and aim: Lung cancer is the most frequent cause of cancer death in the world. Usually diagnosis and staging are determined by radiologic imaging and tissue diagnosis. Combined CT/PET scan should be performed in patients with suspected or known lung cancer. Diseases involves ipsilateral or contralateral mediastinal lymph nodes (N2 or N3) are unlikely to benefit from surgical resection. EUS FNA of the mediastinal adenopathy, primary site in left posterior lung and adrenal glands, when present, permits to have in the same time tissue diagnosis (with mutational analysis) and staging of the disease with high accuracy. Material and methods: We considered all patients with suspected lung cancer at PET e/o TC, referred to the Oncology Unit of our Institute. In all patients EUS FNA was performed in order to obtain tissue from the primary site of the neoplasm (localized in dorsal superior segments), the posterior mediastinum lymphoadenopathy (station 7, 8 and 5) and the adrenal glands. We evaluated the prevalence of this sites in our series and if there is a difference of accuracy between site of FNA.