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Sa1542 Evolving Role of Endoscopic Ultrasound Before Surgery After Medical Down-Staging of Pancreaticobiliary Cancers
Abstracts
garnet (Nd:YAG) laser can achieve a high rate of complete tissue necrosis and has been already applied as a minimally invasive, palliative therapy in hepatic and thyroid lesions. In a previous study we assessed the feasibility of EUS Nd: YAG LA on normal pancreatic tissue performed in-vivo in a porcine model. Aims: to confirm the feasibility and to evaluate the safety and the efficacy of EUS Nd:YAG LA on normal pancreatic tissue of in-vivo porcine model. Material and Methods: Six healthy farm swines, weighted 40-50 Kg, underwent pancreas LA under EUS control during general anaesthesia. Pancreatic gland was punctured with a 19-gauge needle through transgastric approach. A 1.064-nm wavelenght Nd:YAG laser was used. Output power of 2 and 3 W with a total delivered energy of 1000 J was supplied in continuous mode, as used in our previous pilot study. Serum levels of amylase, lipase and transaminase were obtained at baseline, after three hours of the endoscopic treatment, and before the euthanizing of the animals. After the endoscopic treatment the animals were observed for clinical signs of pancreatitis (loss of appetite, altered consciousness and irritability). After 1 month the animals were sedated and then euthanized by i.v. injection of pento-barbital (100mg/Kg). The EUS-LA target organ was excised and placed in formalin. Histological examination of the specimens was performed by a single pathologist. Results: All pancreatic specimens showed histological signs of coagulative necrosis. The ablation volume ranged from a mean of 357 to 590 mm3. No histochemical signs of pancreatitis were found at pathologic examination. All the pigs survived at 1 month. During the follow-up no pigs showed clinical signs of pancreatitis and biochemical parameters were normal. No other complications were detected at necropsy. Conclusions: EUSguided Nd:YAG LA of pancreas performed in vivo in a porcine model is feasible and safe. Nd:YAG laser creates a time-dependent ablation volume. Furthermore other studies are needed to apply this mini-invasive approach to human pancreatic lesions.
Sa1542 Evolving Role of Endoscopic Ultrasound Before Surgery After Medical Down-Staging of Pancreaticobiliary Cancers Navin Paul*1, Timothy R. Donahue2, Jonathan L. Wong1, James S. Tomlinson2, Oscar J. Hines2, Howard A. Reber2, James J. Farrell1 1 Department of Medicine/ Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA; 2Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA Background: Assessment of patients with pancreaticobiliary malignancy for surgical resection after down-staging chemotherapy remains a clinical challenge. A previous analysis from our institution showed sensitivity and specificity of traditional imaging such as CT or MRI in predicting vascular invasion to be 72% and 57% respectively. The role of endoscopic ultrasound [EUS] in the management of potentially down-staged pancreatic cancer is unclear. Methods: We performed a retrospective chart review of down-staged pancreaticobiliary cancers taken for surgery at our tertiary care university medical center from 1995-2011. Data was obtained regarding characteristics of the malignancy, reason for initial inoperability, and accuracy of endoscopic ultrasound in comparison with traditional imaging in determining down-staging. Surgical pathology was the gold standard. Results: Of 53 patients with down-staged pancreaticobiliary neoplasms who subsequently underwent surgery, 14 had down-staging EUS. The mean age was 60.2 years [y] (range [r] 44-74 y), and 10/14 were women. Surgical pathology showed pancreatic adenocarcinoma in 9, carcinosarcoma in 1, cholangiocarcinoma in 1, and no malignancy in 3. Evidence of chronic pancreatitis was seen on pathology in 10/14 (71%). Reason for initial surgical inoperability was vascular invasion in 100% (superior mesenteric vein 9; portal vein 8; superior mesenteric artery 4, celiac axis and inferior vena cava 1 each; ⬎1 vessel involved in 7/14). Mean time from down-staging EUS to surgery was 66 d (r 17-252 d). Mean diameter of lesion before chemotherapy was 32 mm (r 15-50 mm); mean diameter on down-staging EUS was 23 mm (r 0-50 mm). Down-staging EUS suggested vascular involvement of a major vessel in 5/14. Down-staging EUS correctly predicted absence of vascular involvement in 9 (true negative), presence of vascular involvement in 1/14 (true positive), and suggested vascular involvement when there was none in 4/14 (false positive), giving a sensitivity of 100% and specificity of 69%. Limiting analysis to downstaging EUS ⬍ 60 d before surgery improved specificity to 80% (Table 1). In the same data set, CT/MRI had a high sensitivity, but low specificity. Combining the two modalities did not improve specificity when compared to EUS alone. EUSFNA did not improve sensitivity and specificity. Conclusions: EUS appears to outperform traditional imaging modalities in down-staging pancreatic cancer after neoadjuvant chemotherapy, especially if performed within 60 days before planned surgery. Larger trials with direct comparisons between these diagnostic methods are required to confirm our preliminary findings.
Sensitivity Specificity
All Down-staging EUS
Downstaging EUS < 60 days
CT/ MRI
EUS ⴙ CT/MRI
100% 69%
100% 80%
100% 30%
100% 69%
Sa1543 A New EUS Imaging Diagnosis for Mild Chronic Pancreatitis: A Pilot Study of Differential Diagnosis Between Mild Chronic Pancreatitis and Normal Pancreas Based on the Quantitative Analysis With New Technology Using Raw Image Atsushi Irisawa*1, Goro Shibukawa1, Tadayuki Takagi2, Tsunehiko Ikeda2, Rei Suzuki2, Takuto Hikichi3, Katsutoshi Obara3, Hiromasa Ohira2 1 Gastroenterology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan; 2Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan; 3Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan Background and Aim: Diagnosing mild chronic pancreatitis (CP) is challenging. The aim of this study is to develop a new EUS imaging diagnosis for mild CP using quantitative analysis with new technology. This method will be strongly help to distinguish mild CP from normal pancreas with objectively. Patients and Methods: Sixty-seven patients who were examined EUS for unexplained abdominal disorders were enrolled in this study. Because of lack of gold standard for mild CP, we use the Rosemont classification (GIE 2009) to distinguish the mild CP (it was described the “indeterminate CP” in Rosemont classification) from normal pancreas. The ultrasound images were recorded in each case with using the EUS center (EU-ME1, Olympus Medical Systems Corp., Tokyo, Japan) and the curved linear-arrayed or electronic radial-arrayed echoendoscope (Olympus Medical Systems Corp., Tokyo, Japan) as a raw image format (RAW image). The RAW image contains minimally processed data from the image sensor. It is not yet processed and therefore is not ready to be printed or edited with a graphics editor. The captured RAW image were quantitatively analyzed with a new technology (developed by Olympus Medical Systems Corp.), and attempted to create an image for the analysis of mild CP and normal pancreas. The image was described using a parameter, mid-band fit, on each RAW image, which is obtained from the spectrum intensity on the regression line of frequency spectrum available from the RAW imaging data. The quantitative analyses were performed by measuring the standard deviation of mid-band fits. In addition, the quantitative analyses using standard deviation of brightness on B-mode image. Results: Mild CP was clearly distinguished from normal pancreas using our new imaging analysis using RAW data in either 2 echoendscope (figures, p⬍0.01). On the other hand, there is no significant difference between mild CP and normal pancreas by quantitative analyses using standard deviation of brightness on B-mode image. Conclusion: It was considered that EUS examination with this new quantitative analysis using RAW imaging data would be useful for diagnosis mild CP objectively.
Table 1. Comparison of Staging Imaging Modalities for Assessing Vascular Involvement after Neoadjuvant Therapy All Down-staging EUS
Downstaging EUS < 60 days
CT/ MRI
EUS ⴙ CT/MRI
AB196 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
garnet (Nd:YAG) laser can achieve a high rate of complete tissue necrosis and has been already applied as a minimally invasive, palliative therapy in hepatic and thyroid lesions. In a previous study we assessed the feasibility of EUS Nd: YAG LA on normal pancreatic tissue performed in-vivo in a porcine model. Aims: to confirm the feasibility and to evaluate the safety and the efficacy of EUS Nd:YAG LA on normal pancreatic tissue of in-vivo porcine model. Material and Methods: Six healthy farm swines, weighted 40-50 Kg, underwent pancreas LA under EUS control during general anaesthesia. Pancreatic gland was punctured with a 19-gauge needle through transgastric approach. A 1.064-nm wavelenght Nd:YAG laser was used. Output power of 2 and 3 W with a total delivered energy of 1000 J was supplied in continuous mode, as used in our previous pilot study. Serum levels of amylase, lipase and transaminase were obtained at baseline, after three hours of the endoscopic treatment, and before the euthanizing of the animals. After the endoscopic treatment the animals were observed for clinical signs of pancreatitis (loss of appetite, altered consciousness and irritability). After 1 month the animals were sedated and then euthanized by i.v. injection of pento-barbital (100mg/Kg). The EUS-LA target organ was excised and placed in formalin. Histological examination of the specimens was performed by a single pathologist. Results: All pancreatic specimens showed histological signs of coagulative necrosis. The ablation volume ranged from a mean of 357 to 590 mm3. No histochemical signs of pancreatitis were found at pathologic examination. All the pigs survived at 1 month. During the follow-up no pigs showed clinical signs of pancreatitis and biochemical parameters were normal. No other complications were detected at necropsy. Conclusions: EUSguided Nd:YAG LA of pancreas performed in vivo in a porcine model is feasible and safe. Nd:YAG laser creates a time-dependent ablation volume. Furthermore other studies are needed to apply this mini-invasive approach to human pancreatic lesions.
Sa1542 Evolving Role of Endoscopic Ultrasound Before Surgery After Medical Down-Staging of Pancreaticobiliary Cancers Navin Paul*1, Timothy R. Donahue2, Jonathan L. Wong1, James S. Tomlinson2, Oscar J. Hines2, Howard A. Reber2, James J. Farrell1 1 Department of Medicine/ Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA; 2Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA Background: Assessment of patients with pancreaticobiliary malignancy for surgical resection after down-staging chemotherapy remains a clinical challenge. A previous analysis from our institution showed sensitivity and specificity of traditional imaging such as CT or MRI in predicting vascular invasion to be 72% and 57% respectively. The role of endoscopic ultrasound [EUS] in the management of potentially down-staged pancreatic cancer is unclear. Methods: We performed a retrospective chart review of down-staged pancreaticobiliary cancers taken for surgery at our tertiary care university medical center from 1995-2011. Data was obtained regarding characteristics of the malignancy, reason for initial inoperability, and accuracy of endoscopic ultrasound in comparison with traditional imaging in determining down-staging. Surgical pathology was the gold standard. Results: Of 53 patients with down-staged pancreaticobiliary neoplasms who subsequently underwent surgery, 14 had down-staging EUS. The mean age was 60.2 years [y] (range [r] 44-74 y), and 10/14 were women. Surgical pathology showed pancreatic adenocarcinoma in 9, carcinosarcoma in 1, cholangiocarcinoma in 1, and no malignancy in 3. Evidence of chronic pancreatitis was seen on pathology in 10/14 (71%). Reason for initial surgical inoperability was vascular invasion in 100% (superior mesenteric vein 9; portal vein 8; superior mesenteric artery 4, celiac axis and inferior vena cava 1 each; ⬎1 vessel involved in 7/14). Mean time from down-staging EUS to surgery was 66 d (r 17-252 d). Mean diameter of lesion before chemotherapy was 32 mm (r 15-50 mm); mean diameter on down-staging EUS was 23 mm (r 0-50 mm). Down-staging EUS suggested vascular involvement of a major vessel in 5/14. Down-staging EUS correctly predicted absence of vascular involvement in 9 (true negative), presence of vascular involvement in 1/14 (true positive), and suggested vascular involvement when there was none in 4/14 (false positive), giving a sensitivity of 100% and specificity of 69%. Limiting analysis to downstaging EUS ⬍ 60 d before surgery improved specificity to 80% (Table 1). In the same data set, CT/MRI had a high sensitivity, but low specificity. Combining the two modalities did not improve specificity when compared to EUS alone. EUSFNA did not improve sensitivity and specificity. Conclusions: EUS appears to outperform traditional imaging modalities in down-staging pancreatic cancer after neoadjuvant chemotherapy, especially if performed within 60 days before planned surgery. Larger trials with direct comparisons between these diagnostic methods are required to confirm our preliminary findings.
Sensitivity Specificity
All Down-staging EUS
Downstaging EUS < 60 days
CT/ MRI
EUS ⴙ CT/MRI
100% 69%
100% 80%
100% 30%
100% 69%
Sa1543 A New EUS Imaging Diagnosis for Mild Chronic Pancreatitis: A Pilot Study of Differential Diagnosis Between Mild Chronic Pancreatitis and Normal Pancreas Based on the Quantitative Analysis With New Technology Using Raw Image Atsushi Irisawa*1, Goro Shibukawa1, Tadayuki Takagi2, Tsunehiko Ikeda2, Rei Suzuki2, Takuto Hikichi3, Katsutoshi Obara3, Hiromasa Ohira2 1 Gastroenterology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan; 2Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan; 3Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan Background and Aim: Diagnosing mild chronic pancreatitis (CP) is challenging. The aim of this study is to develop a new EUS imaging diagnosis for mild CP using quantitative analysis with new technology. This method will be strongly help to distinguish mild CP from normal pancreas with objectively. Patients and Methods: Sixty-seven patients who were examined EUS for unexplained abdominal disorders were enrolled in this study. Because of lack of gold standard for mild CP, we use the Rosemont classification (GIE 2009) to distinguish the mild CP (it was described the “indeterminate CP” in Rosemont classification) from normal pancreas. The ultrasound images were recorded in each case with using the EUS center (EU-ME1, Olympus Medical Systems Corp., Tokyo, Japan) and the curved linear-arrayed or electronic radial-arrayed echoendoscope (Olympus Medical Systems Corp., Tokyo, Japan) as a raw image format (RAW image). The RAW image contains minimally processed data from the image sensor. It is not yet processed and therefore is not ready to be printed or edited with a graphics editor. The captured RAW image were quantitatively analyzed with a new technology (developed by Olympus Medical Systems Corp.), and attempted to create an image for the analysis of mild CP and normal pancreas. The image was described using a parameter, mid-band fit, on each RAW image, which is obtained from the spectrum intensity on the regression line of frequency spectrum available from the RAW imaging data. The quantitative analyses were performed by measuring the standard deviation of mid-band fits. In addition, the quantitative analyses using standard deviation of brightness on B-mode image. Results: Mild CP was clearly distinguished from normal pancreas using our new imaging analysis using RAW data in either 2 echoendscope (figures, p⬍0.01). On the other hand, there is no significant difference between mild CP and normal pancreas by quantitative analyses using standard deviation of brightness on B-mode image. Conclusion: It was considered that EUS examination with this new quantitative analysis using RAW imaging data would be useful for diagnosis mild CP objectively.
Table 1. Comparison of Staging Imaging Modalities for Assessing Vascular Involvement after Neoadjuvant Therapy All Down-staging EUS
Downstaging EUS < 60 days
CT/ MRI
EUS ⴙ CT/MRI
AB196 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org