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Role of endoscopic ultrasound in definitive diagnosis and staging of lung adenocarcinoma localized to superior mediastinum
AJG – September, Suppl., 2001
Methods: A 38 year old Caucasian male with HIV infection on antireteroviral therapy for last 5 years was admitted with intermittent maroon colored stools for 3 days and hemoglobin decrease from 15.5 g/dl to 6.5 g/dl. He was treated for Kaposi’s sarcoma involving skin and stomach 5 years ago with complete remission. He had two similar episodes of GI bleed 2 years ago but the GI work-up including upper and lower GI endoscopy, enteroscopy, small bowel barium x-ray, abdominal CT scan and Meckel’s scan failed to localize the bleeding site. His recent CD4 count was 340 and viral load ⬍1000. He never had any other opportunistic infections. On admission, he was orthostatic and pale otherwise rest of the examination was unremarkable. A repeat colonoscopy revealed maroon blood throughout the colon. Small bowel enteroscopy upto mid small bowel did not reveal any bleeding site. An RBC tagged scan showed evidence of active bleeding from small bowel but abdominal angiogram did not detect the bleeding site or abnormal vasculature. On laparotomy, ten areas of submucosal sponginess with bluish discoloration were noted in the distal ileum from about 3 feet proximal to the ileocecal valve down to 5 cm from it. About 3 feet of the involved ileum was resected. Patient had an uneventful recovery without recurrence of GI bleed. Histopathological examination of these lesions revealed band like zones of fibrosis near submucosal lymphoid tissue along with increased number of congested submucosal vessels of various calibers, focally extending through muscularis mucosa into lamina propria. Special stains for organisms (AFB & GMS) were negative. Precise etiology of this nonneoplastic fibroinflammatory process remains unclear. Conclusions: To our knowledge, this unique nonneoplastic fibroinflammatory lesion of the small bowel presenting as overt GI bleeding in a patient with HIV who was previously treated for KS has not been reported so far. Although the exact etiopathogenesis of this lesion remains conjectural, it may be related to immune status of the patient and/or secondary to the therapy.
354 Role of endoscopic ultrasound in definitive diagnosis and staging of lung adenocarcinoma localized to superior mediastinum Shiro Urayama*. 1Internal Medicine, University of California Davis, Sacramento, CA, United States. Purpose: We describe a particular role of endoscopic ultrasound in diagnosis and staging of mass located in superior mediastinal region. Methods: Retrospective case review of a patient presented as having a unknown primary adenocarcinoma with mediastinal lymphadenopathy. Results: A 67y/o male presented with complaints of refractory nausea, vomitting and significant weight loss of 3 months duration. Upper endoscopic evaluation revealed linear ulcerations in esophagus consistent with recurrent reflux symptoms, but no evidence of gross malignancy. CT scan evaluation of abdomen and chest showed paraesophageal & pretracheal/ subcarinal adenopathies without an evidence of primary tumor. Mediastinoscopic biopsies of the lymph nodes showed evidence of adenocarcinoma. The patient’s symptoms had significantly improved after high dose protonpump inhibitor treatment was initiated. We repeated upper endoscopy to evaluate for any evidence of primary upper GI tract malignancy. We also performed endoscopic ultrasonography during the second endoscopy to evaluate periluminal region. Mucosal examination showed healed esophageal ulcers and rest of the upper GI tract to second portions were normal. EUS, however, showed 3cm mass lesion in the left superior mediastinum located just above the aortic arch, adjacent to esophagus, vertebral body, and left pulmonary field. Several paraesophageal adenopathies were also noted. More importantly, left adrenal gland was identified transgastrically and showed a focally enlarged appearance. Pancreas was normal. EUSguided fine needle aspiration was completed of the superior mediastinal mass as well as the left adrenal gland. Both of these lesions showed adenocarcinoma and similar cellular appearance from the paratracheal lymph node lesion obtained at the time of mediastinoscopy. Thus, the final
Abstracts
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diagnosis and the staging was primary lung adenocarcinoma with stage IV with metastasis to left adrenal gland. Conclusions: This case illustrates the utility of endoscopic ultrasound in evaluation of mediastinal adenopathy with unknown primary malignancy as well as evaluation of superior mediastinal lesions in providing both diagnosis and staging of lung cancer. EUS provided not only the identification of primary malignancy but also accurately identified the advanced stage with positive metastatic cellular aspirate of the left adrenal gland during one session. 355 Software assisted detection of abnormalities of the GI tract for wireless capsule endoscopy Ofra Zinaty, M.Sc., Harold Jacob, M.D., Daphna Levy, M.Sc., Reuven Shreiber, M.D. and Arkady Glukhovsky, D.Sc.*. Yoqneam, Israel. Purpose: An ingestible wireless video capsule enables visualization of the small intestine beyond the reach of the endoscope. Detection of pathology is performed by a physician reviewing the recorded images. An algorithm for automatic detection of bleeding will assist the reviewer, thereby increasing the efficiency of the review process. Methods: A small bowel enteroscopy was performed using the Given® Diagnostic Imaging System. The blood detection algorithm automatically indicates suspicious images of the small bowel consistent with bleeding. The findings are presented to the reviewer as indicators on the time bar synchronized to the displayed video stream. The algorithm is based on detection of colorimetric abnormalities from an expected spectrum derived from spectral analysis of the video images. Each sample is compared to a reference representing blood, and to a reference representing healthy tissue of the patient. Each area of the image is assigned a value indicating the probability of the image to be a suspicious bleeding site. The probability indication function is based on a relative difference between the examined image sample and a reference sample of blood and healthy tissue. The reference of a healthy tissue is constructed using an adaptive approach. The blood detection algorithm is applied off-line, during the data processing phase. Results: The blood detection algorithm was verified by comparing results to 25 small bowel capsule enteroscopies that were interpreted by physicians. Based on this interpretation the following classification was made: 11 cases of bleeding, 6 cases of miscellaneous pathology, 4 cases with no diagnosed pathology, and 4 healthy volunteers. The automatic blood detection algorithm showed no false negative results with all known bleeding sites detected, and showed acceptably small amount of false positive results. Conclusions: The automatic detection algorithm may be of value in assissting the diagnostic procedure by prompting the physician to examine the sites of possible bleeding. This method may also be applicable to other pathologies. 356 “Atypical presentations” of celiac disease (CD) are the most common presentations Robert D. Zipser M.D., FACG1*, Sunil Patel, Donald W. Baisch2 and Elaine Monarch2. 1Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States; and 2Celiac Disease Foundation, Studio City, CA, United States. Purpose: The classic presentation of CD is childhood steatorrhea, weight loss and failure to thrive. In contrast, there is now increasing recognition that CD frequently has an adult onset without classic symptoms. Methods: To determine the most common presentations, officers of a large support group, Celiac Disease Foundation, did member surveys. All CD patients (n ⫽ 1032) had diagnosis confirmed by small bowel biopsy. Results: At diagnoses, the median age was 46 years (n ⫽ 968), and 14 patients were over age 80 years. Only 12% were diagnosed before the age of 10 years. The median body mass index (BMI) was 20 indicating that
Methods: A 38 year old Caucasian male with HIV infection on antireteroviral therapy for last 5 years was admitted with intermittent maroon colored stools for 3 days and hemoglobin decrease from 15.5 g/dl to 6.5 g/dl. He was treated for Kaposi’s sarcoma involving skin and stomach 5 years ago with complete remission. He had two similar episodes of GI bleed 2 years ago but the GI work-up including upper and lower GI endoscopy, enteroscopy, small bowel barium x-ray, abdominal CT scan and Meckel’s scan failed to localize the bleeding site. His recent CD4 count was 340 and viral load ⬍1000. He never had any other opportunistic infections. On admission, he was orthostatic and pale otherwise rest of the examination was unremarkable. A repeat colonoscopy revealed maroon blood throughout the colon. Small bowel enteroscopy upto mid small bowel did not reveal any bleeding site. An RBC tagged scan showed evidence of active bleeding from small bowel but abdominal angiogram did not detect the bleeding site or abnormal vasculature. On laparotomy, ten areas of submucosal sponginess with bluish discoloration were noted in the distal ileum from about 3 feet proximal to the ileocecal valve down to 5 cm from it. About 3 feet of the involved ileum was resected. Patient had an uneventful recovery without recurrence of GI bleed. Histopathological examination of these lesions revealed band like zones of fibrosis near submucosal lymphoid tissue along with increased number of congested submucosal vessels of various calibers, focally extending through muscularis mucosa into lamina propria. Special stains for organisms (AFB & GMS) were negative. Precise etiology of this nonneoplastic fibroinflammatory process remains unclear. Conclusions: To our knowledge, this unique nonneoplastic fibroinflammatory lesion of the small bowel presenting as overt GI bleeding in a patient with HIV who was previously treated for KS has not been reported so far. Although the exact etiopathogenesis of this lesion remains conjectural, it may be related to immune status of the patient and/or secondary to the therapy.
354 Role of endoscopic ultrasound in definitive diagnosis and staging of lung adenocarcinoma localized to superior mediastinum Shiro Urayama*. 1Internal Medicine, University of California Davis, Sacramento, CA, United States. Purpose: We describe a particular role of endoscopic ultrasound in diagnosis and staging of mass located in superior mediastinal region. Methods: Retrospective case review of a patient presented as having a unknown primary adenocarcinoma with mediastinal lymphadenopathy. Results: A 67y/o male presented with complaints of refractory nausea, vomitting and significant weight loss of 3 months duration. Upper endoscopic evaluation revealed linear ulcerations in esophagus consistent with recurrent reflux symptoms, but no evidence of gross malignancy. CT scan evaluation of abdomen and chest showed paraesophageal & pretracheal/ subcarinal adenopathies without an evidence of primary tumor. Mediastinoscopic biopsies of the lymph nodes showed evidence of adenocarcinoma. The patient’s symptoms had significantly improved after high dose protonpump inhibitor treatment was initiated. We repeated upper endoscopy to evaluate for any evidence of primary upper GI tract malignancy. We also performed endoscopic ultrasonography during the second endoscopy to evaluate periluminal region. Mucosal examination showed healed esophageal ulcers and rest of the upper GI tract to second portions were normal. EUS, however, showed 3cm mass lesion in the left superior mediastinum located just above the aortic arch, adjacent to esophagus, vertebral body, and left pulmonary field. Several paraesophageal adenopathies were also noted. More importantly, left adrenal gland was identified transgastrically and showed a focally enlarged appearance. Pancreas was normal. EUSguided fine needle aspiration was completed of the superior mediastinal mass as well as the left adrenal gland. Both of these lesions showed adenocarcinoma and similar cellular appearance from the paratracheal lymph node lesion obtained at the time of mediastinoscopy. Thus, the final
Abstracts
S113
diagnosis and the staging was primary lung adenocarcinoma with stage IV with metastasis to left adrenal gland. Conclusions: This case illustrates the utility of endoscopic ultrasound in evaluation of mediastinal adenopathy with unknown primary malignancy as well as evaluation of superior mediastinal lesions in providing both diagnosis and staging of lung cancer. EUS provided not only the identification of primary malignancy but also accurately identified the advanced stage with positive metastatic cellular aspirate of the left adrenal gland during one session. 355 Software assisted detection of abnormalities of the GI tract for wireless capsule endoscopy Ofra Zinaty, M.Sc., Harold Jacob, M.D., Daphna Levy, M.Sc., Reuven Shreiber, M.D. and Arkady Glukhovsky, D.Sc.*. Yoqneam, Israel. Purpose: An ingestible wireless video capsule enables visualization of the small intestine beyond the reach of the endoscope. Detection of pathology is performed by a physician reviewing the recorded images. An algorithm for automatic detection of bleeding will assist the reviewer, thereby increasing the efficiency of the review process. Methods: A small bowel enteroscopy was performed using the Given® Diagnostic Imaging System. The blood detection algorithm automatically indicates suspicious images of the small bowel consistent with bleeding. The findings are presented to the reviewer as indicators on the time bar synchronized to the displayed video stream. The algorithm is based on detection of colorimetric abnormalities from an expected spectrum derived from spectral analysis of the video images. Each sample is compared to a reference representing blood, and to a reference representing healthy tissue of the patient. Each area of the image is assigned a value indicating the probability of the image to be a suspicious bleeding site. The probability indication function is based on a relative difference between the examined image sample and a reference sample of blood and healthy tissue. The reference of a healthy tissue is constructed using an adaptive approach. The blood detection algorithm is applied off-line, during the data processing phase. Results: The blood detection algorithm was verified by comparing results to 25 small bowel capsule enteroscopies that were interpreted by physicians. Based on this interpretation the following classification was made: 11 cases of bleeding, 6 cases of miscellaneous pathology, 4 cases with no diagnosed pathology, and 4 healthy volunteers. The automatic blood detection algorithm showed no false negative results with all known bleeding sites detected, and showed acceptably small amount of false positive results. Conclusions: The automatic detection algorithm may be of value in assissting the diagnostic procedure by prompting the physician to examine the sites of possible bleeding. This method may also be applicable to other pathologies. 356 “Atypical presentations” of celiac disease (CD) are the most common presentations Robert D. Zipser M.D., FACG1*, Sunil Patel, Donald W. Baisch2 and Elaine Monarch2. 1Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States; and 2Celiac Disease Foundation, Studio City, CA, United States. Purpose: The classic presentation of CD is childhood steatorrhea, weight loss and failure to thrive. In contrast, there is now increasing recognition that CD frequently has an adult onset without classic symptoms. Methods: To determine the most common presentations, officers of a large support group, Celiac Disease Foundation, did member surveys. All CD patients (n ⫽ 1032) had diagnosis confirmed by small bowel biopsy. Results: At diagnoses, the median age was 46 years (n ⫽ 968), and 14 patients were over age 80 years. Only 12% were diagnosed before the age of 10 years. The median body mass index (BMI) was 20 indicating that