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Staging of rectal tumors by means of endoscopic ultrasound
ENDOSCOPIC ULTRASOUND ?529
?531
A PROSPECTIVE RANDOMIZED COMPARISON OF RADIAL SCANNING AND LINEAR ARRAY ENDOSONOGRAPHY FOR STAGING PANCREATIC CANCER F. Gress, R. Hawes, S. Ikenberry, T. Savides, J. Wean, S. Sherman, G. Lehman, Indiana University Medical Center, Indianapolis, IN. INTRODUCTION: Endoscopic ultrasound (EUS) is known to be an accurate technology to locally stage pancreatic cancer. Recently, a linear array echoendoscope (EE) (FG 32UA, Pentax Corp., Orangeburg, NY) has become available which has the potential for ultrasound directed fine needle aspiration (FNA) cytology. There is little information at present to determine whether linear array or radial scanning ultrasound i s better at staging pancreatic cancer (PCa). AIM OF STUDY: This prospective study was undertaken to assess the accuracy of the linear array echoendoscope (EE) compared to the radial scanning (EE) (UM-20, Olympus America, Inc., Melville, NY) for staging pancreatic cancer. METHODS: All pts with pancreatic cancer referred for endoscopic ultrasound staging were randomized to EUS evaluation with either the linear mxay or radial scanning EE. EUS Staging accuracy was determmed by surgical pathology comparison. RESULTS: 79 pts were enrolled in this study and 33 have had surgical resection. Of these, 17 pts were randomized to linear array and 16 pts to the radial scanning EE Local staging was based on the TNM classification system. Linear Array: The overall staging accuracy for the linear array system was 16/17 (94%) for T staging and 12/17 (71%) for N staging. RADIAL: Overall staging accuracy for the radial scanning system is 14/16 (88%) for T stage and 12/16 (75%) for N staging. VASCULAR INVASION: The radial scanning instrument correctly assessed vascular invasion in 16/16 (100%) pts.(9 true negatives, 7 true positives). The linear array instrument, correctly assessed vascular invasion in 16/17 (94%) pts. (12 true negatives, 4 true positive). There was one false negative assessment of invasion. SUMMARY: Overall staging accuracy for pancreatic cancer with the radial scanning instrument was 88% for T staging and 75% for N staging and with the linear array system 94% for T staging and 71% for N staging. For the assessment of vascular invasion, the radial scanning system was 100% accurate compared to 94% for linear array. CONCLUSION: Both the linear array and radial seannmg EE appear equivalent for staging pancreatic cancer and assessing vascular invasion. In view of these findings and the ultrasound directed FNA biopsy capability of the linear array system, this instrument may be the preferred choice for pts. being evaluated for pancreatic masses. This randomized trial continues to determine if preliminary trends persist.
STAGING OF RECTAL TUMORS BY MEANS OF ENDOSCOPIC ULTRASOUND. M Hielc Y Kockaerts, P. Schurmans, K. Geboes, L. Filez, and P Rutgeerts Depts. of Gastroenterology, Pathology. and Abdominal Surgery, Universit:r Hospital Gasthuisberg, Leaven, Belgium During the last few years endoscopic ultrasound (EUS) has been shown to be an elegant and accurate technique for T- and N-staging of tumors of the upper and lower GI tract. The aim of our study was to evaluate the value of EUS for staging of rectal tumors in our hospital. Methods. EUS-results and pathological data ofthe resection specimens were analysed of 55 patients with a rectal tumor, who were pre-operatively examined by EUS between January 1994 and July 1995. Examinations were performed by I of 2 examiners. Results. See Table An adequate examination for T-staging was possible in 46/55 patients, and for N-staging in 47/55 patients. Reasons for inadequate examinations were stenotic lesions, too high Iocalisation, or unsatisfactory preparation. Pre-operative T-staging was accurate in 34/46 patients (74 %). T-overslaging (17%) was more frequent than understaging (9 %). N-staging was correct in 32/47 patients (68 %), with a rather high false-positive rate, which was probably due to inflannnatory lymph nodes. AP-T TI T2 T3 T4
EUS-TI 9 0 2 0
EUS-T2 1 5 2 0
EUS-T3 0 4 19 0
AP-N NO NI N2
EUS-N0 22 5 0
EUS-N+ l0 6 4
EILS-NX
EUS-T4 0 2 l 1
EIs 0 0 9 0
1 5 2
Conclusion. These data cor the value of EUS as a pre-operative staging technique for rectal tumors. The evaluation of lymph node metastasis is less accurate than the evaluation of tumor infiltration depth
*530
/'532
A RANDOMIZED PROSPECTIVE TRIAL OF ENDOSCOPIC ULTRASOUND (EUS) GUIDED CELIAC PLEXUS BLOCK (CB) FOR THE CONTROL OF PAIN DUE TO CHRONIC PANCREATITIS (CP). F. Gress. S. Ikenberry, K. Gottlieb, S. Oliver, J. Winberg S. Sherman, I. Worm, G Lehman. Indiana University Medical Center, Indianapolis, IN. INTRODUCTION: EUS guided fine needle aspiration (FNA) has allowed for development of new interventions for managing GI disease, EUS guided CB has been reported with some success in pts with pain due to malignancy This randomized prospective trial was designed to assess the role of EUS guided CB for the treatment of pain due to CP. METHODS: All pts with intractable abdominal pain due to CP were eligible for this study. Pts enrolled were randomly assigned to either EUS guided CB or CT guided C B Pain scores using a visual analog scale (0-10) were determined pre and post CB for both techniques and follow up was performed by a nurse at 2, 7, 14, 28, and 42 days and monthly thereafter. Pts were also questioned about their overall experience with each of these procedures. If any pts in this study required another CB they were crossed over to the other technique. CT guided CB was performed by radiology. EUS guided CB was performed under the guidance of the linear array eehoendoscope (FG32UA, Pentax Corp., Orangeburg, NY) using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) via a transgastric approach. The aorta was traced to the celiac artery and confirmed with color flow Doppler, then the FNA needle was inserted into this region and bupivacaine 0.25% (10 ee) followed by triamcinolone 40 rng (3 cc) was injected on both sides oftbe celiac area, RESULTS: 22 pts (10 m/12 0 with mean age of 45 yrs (range 17 - 76 yrs) were enrolled in this study between 7/1/95 and 12/1/95. EUS CB was performed in 14 pts and CT in 8 pts. All pts had documented CP by ERCP, EUS and in some EUS FNA cytology. Overall significant pain improvement occurred in 36% (8/22 pts). For EUS CB 6/14 pts (43%) were pain flee with a mean post procedure follow up of 6 wks (range fi to 22 wks). The mean pain score decreased from 7 to 1 post EUS CB at 8 wks follow up with 25% ofpts having persistent benefit. At 12 wks 15% ofpts still had persistent benefit. Only 2/8 pts (25%) had relief with CT CB with a mean follow up of 4 wks (range 2-6 wks). Mean pain score decreased from ? to 3 at 4 wks. No CT CB pts had persistent relief beyond 4 wks and all had recurrent pain by 6 wks. One pt had both CT and EUS CB without improvement in symptoms. One pt with severe CP and sip distal pancreatectomy experienced persistent diarrhea post EUS CB however, it is unclear whether the diarrhea was due to the CB or his disease_There were no serious pt complications during this study. SUMMARY: A cost comparison between EUS CB and CT CB at our institution showed EUS to be less costly ($1100) than CT ($1500). EUS CB appeared to have a more persistent effect then CT CB for pain control in CP.and was the preferred CB technique primarily due to the use of conscious sedation and tack of back pain associated with the CT technique. CONCLUSIONS: EUS guided CB appears to be a safe, effective and cost saving method for controlling pain in CP and perhaps other benign diseases.
ENDOSCOPIC ULTRASOUND-GUIDEDFINE NEEDLEASPIRATIONIN THE EVALUATIONOF EXTRARECTALPELVIC MASSES. B. Hoffman, M. 8hutani, L. Aabakken, P. Baron, D. Cole, and R. Hawes. Division of Gastroenterologyand Section of Surgical Oncology,and Digestive DiseaseCenter, Medical University of South Carolina, Charleston,South Carolina Introduction: The role of endoscopic ultrasound (EUS) in staging rectal cancer ~s well established but its role in the evaluation of peri-rectal processes is less well defined. The developmentof the linear array echoendoscope(EE) now allows guided fine needle aspiration(FNA) cytology. We performedthis study to determine the roie of EUS-guided FNA in the evaluationof pelvic masses. Patients/Methods: BetweenJune 1994 and October 1995, 8 patients were referred for EUS evaluation of pelvic masses. A 3600 radial scanning EE was first used to identify the abnormalityand establish overall orientation. Next, the linear array EE (Pentax FG 32-UA)wasused to performguided FNA. Pulsed and/or color Doppler were used to distinguish vascular structures. A Teflon catheter with a 23 gauge needle was advancedthru the working channel of the EE and the needle guided into the mass using realtime ultrasound imaging. The FNA specimen was reviewed in the endoscopysuite by a cytopathologist. Results: In 5/8 (63%), a definitive diagnosisof malignancy was made. These included; 2 with adenocarcinoma, 1 with ovarian carcinoma, 1 with cervical carcinoma, and 1 with lymphoma. In 2/8 (25%), the EUS image and FNA were consistent with infection ( pelvic abscess: 1, tubo-ovarian abscess: 1), both were treated accordingly w~th resolution of symptoms. The EUS imagesand FNA from the sample of the remaining patient suggested an inf~amrnatoryreaction felt to be related to prior radiationtherapy. Summary: The diagnosticyield of EUS + FNA was 100% as determinedby positive FNA and/orclinical follow-up. The procedures were completed in 45 minutes on average, required no sedation, and there were no biopsy related complications. The total cost excluding cytopathology ranged from $10461252 for EUS compared to $1323-1823 for a CT-guided aspiration. 2/5 patients with pelvic malignancies had undergone CT guided FNA with negative results. Conclusions: EUS is able to detect pelvic abnormalities; fine needle aspiration is a useful adjunct for suspected neoplasms and EUS-guided FNA may be a cost-saving diagnostic method in these pts.
V O L U M E 43, N O . 4, 1996
GASTROINTESTINAL
ENDOSCOPY
423
?531
A PROSPECTIVE RANDOMIZED COMPARISON OF RADIAL SCANNING AND LINEAR ARRAY ENDOSONOGRAPHY FOR STAGING PANCREATIC CANCER F. Gress, R. Hawes, S. Ikenberry, T. Savides, J. Wean, S. Sherman, G. Lehman, Indiana University Medical Center, Indianapolis, IN. INTRODUCTION: Endoscopic ultrasound (EUS) is known to be an accurate technology to locally stage pancreatic cancer. Recently, a linear array echoendoscope (EE) (FG 32UA, Pentax Corp., Orangeburg, NY) has become available which has the potential for ultrasound directed fine needle aspiration (FNA) cytology. There is little information at present to determine whether linear array or radial scanning ultrasound i s better at staging pancreatic cancer (PCa). AIM OF STUDY: This prospective study was undertaken to assess the accuracy of the linear array echoendoscope (EE) compared to the radial scanning (EE) (UM-20, Olympus America, Inc., Melville, NY) for staging pancreatic cancer. METHODS: All pts with pancreatic cancer referred for endoscopic ultrasound staging were randomized to EUS evaluation with either the linear mxay or radial scanning EE. EUS Staging accuracy was determmed by surgical pathology comparison. RESULTS: 79 pts were enrolled in this study and 33 have had surgical resection. Of these, 17 pts were randomized to linear array and 16 pts to the radial scanning EE Local staging was based on the TNM classification system. Linear Array: The overall staging accuracy for the linear array system was 16/17 (94%) for T staging and 12/17 (71%) for N staging. RADIAL: Overall staging accuracy for the radial scanning system is 14/16 (88%) for T stage and 12/16 (75%) for N staging. VASCULAR INVASION: The radial scanning instrument correctly assessed vascular invasion in 16/16 (100%) pts.(9 true negatives, 7 true positives). The linear array instrument, correctly assessed vascular invasion in 16/17 (94%) pts. (12 true negatives, 4 true positive). There was one false negative assessment of invasion. SUMMARY: Overall staging accuracy for pancreatic cancer with the radial scanning instrument was 88% for T staging and 75% for N staging and with the linear array system 94% for T staging and 71% for N staging. For the assessment of vascular invasion, the radial scanning system was 100% accurate compared to 94% for linear array. CONCLUSION: Both the linear array and radial seannmg EE appear equivalent for staging pancreatic cancer and assessing vascular invasion. In view of these findings and the ultrasound directed FNA biopsy capability of the linear array system, this instrument may be the preferred choice for pts. being evaluated for pancreatic masses. This randomized trial continues to determine if preliminary trends persist.
STAGING OF RECTAL TUMORS BY MEANS OF ENDOSCOPIC ULTRASOUND. M Hielc Y Kockaerts, P. Schurmans, K. Geboes, L. Filez, and P Rutgeerts Depts. of Gastroenterology, Pathology. and Abdominal Surgery, Universit:r Hospital Gasthuisberg, Leaven, Belgium During the last few years endoscopic ultrasound (EUS) has been shown to be an elegant and accurate technique for T- and N-staging of tumors of the upper and lower GI tract. The aim of our study was to evaluate the value of EUS for staging of rectal tumors in our hospital. Methods. EUS-results and pathological data ofthe resection specimens were analysed of 55 patients with a rectal tumor, who were pre-operatively examined by EUS between January 1994 and July 1995. Examinations were performed by I of 2 examiners. Results. See Table An adequate examination for T-staging was possible in 46/55 patients, and for N-staging in 47/55 patients. Reasons for inadequate examinations were stenotic lesions, too high Iocalisation, or unsatisfactory preparation. Pre-operative T-staging was accurate in 34/46 patients (74 %). T-overslaging (17%) was more frequent than understaging (9 %). N-staging was correct in 32/47 patients (68 %), with a rather high false-positive rate, which was probably due to inflannnatory lymph nodes. AP-T TI T2 T3 T4
EUS-TI 9 0 2 0
EUS-T2 1 5 2 0
EUS-T3 0 4 19 0
AP-N NO NI N2
EUS-N0 22 5 0
EUS-N+ l0 6 4
EILS-NX
EUS-T4 0 2 l 1
EIs 0 0 9 0
1 5 2
Conclusion. These data cor the value of EUS as a pre-operative staging technique for rectal tumors. The evaluation of lymph node metastasis is less accurate than the evaluation of tumor infiltration depth
*530
/'532
A RANDOMIZED PROSPECTIVE TRIAL OF ENDOSCOPIC ULTRASOUND (EUS) GUIDED CELIAC PLEXUS BLOCK (CB) FOR THE CONTROL OF PAIN DUE TO CHRONIC PANCREATITIS (CP). F. Gress. S. Ikenberry, K. Gottlieb, S. Oliver, J. Winberg S. Sherman, I. Worm, G Lehman. Indiana University Medical Center, Indianapolis, IN. INTRODUCTION: EUS guided fine needle aspiration (FNA) has allowed for development of new interventions for managing GI disease, EUS guided CB has been reported with some success in pts with pain due to malignancy This randomized prospective trial was designed to assess the role of EUS guided CB for the treatment of pain due to CP. METHODS: All pts with intractable abdominal pain due to CP were eligible for this study. Pts enrolled were randomly assigned to either EUS guided CB or CT guided C B Pain scores using a visual analog scale (0-10) were determined pre and post CB for both techniques and follow up was performed by a nurse at 2, 7, 14, 28, and 42 days and monthly thereafter. Pts were also questioned about their overall experience with each of these procedures. If any pts in this study required another CB they were crossed over to the other technique. CT guided CB was performed by radiology. EUS guided CB was performed under the guidance of the linear array eehoendoscope (FG32UA, Pentax Corp., Orangeburg, NY) using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) via a transgastric approach. The aorta was traced to the celiac artery and confirmed with color flow Doppler, then the FNA needle was inserted into this region and bupivacaine 0.25% (10 ee) followed by triamcinolone 40 rng (3 cc) was injected on both sides oftbe celiac area, RESULTS: 22 pts (10 m/12 0 with mean age of 45 yrs (range 17 - 76 yrs) were enrolled in this study between 7/1/95 and 12/1/95. EUS CB was performed in 14 pts and CT in 8 pts. All pts had documented CP by ERCP, EUS and in some EUS FNA cytology. Overall significant pain improvement occurred in 36% (8/22 pts). For EUS CB 6/14 pts (43%) were pain flee with a mean post procedure follow up of 6 wks (range fi to 22 wks). The mean pain score decreased from 7 to 1 post EUS CB at 8 wks follow up with 25% ofpts having persistent benefit. At 12 wks 15% ofpts still had persistent benefit. Only 2/8 pts (25%) had relief with CT CB with a mean follow up of 4 wks (range 2-6 wks). Mean pain score decreased from ? to 3 at 4 wks. No CT CB pts had persistent relief beyond 4 wks and all had recurrent pain by 6 wks. One pt had both CT and EUS CB without improvement in symptoms. One pt with severe CP and sip distal pancreatectomy experienced persistent diarrhea post EUS CB however, it is unclear whether the diarrhea was due to the CB or his disease_There were no serious pt complications during this study. SUMMARY: A cost comparison between EUS CB and CT CB at our institution showed EUS to be less costly ($1100) than CT ($1500). EUS CB appeared to have a more persistent effect then CT CB for pain control in CP.and was the preferred CB technique primarily due to the use of conscious sedation and tack of back pain associated with the CT technique. CONCLUSIONS: EUS guided CB appears to be a safe, effective and cost saving method for controlling pain in CP and perhaps other benign diseases.
ENDOSCOPIC ULTRASOUND-GUIDEDFINE NEEDLEASPIRATIONIN THE EVALUATIONOF EXTRARECTALPELVIC MASSES. B. Hoffman, M. 8hutani, L. Aabakken, P. Baron, D. Cole, and R. Hawes. Division of Gastroenterologyand Section of Surgical Oncology,and Digestive DiseaseCenter, Medical University of South Carolina, Charleston,South Carolina Introduction: The role of endoscopic ultrasound (EUS) in staging rectal cancer ~s well established but its role in the evaluation of peri-rectal processes is less well defined. The developmentof the linear array echoendoscope(EE) now allows guided fine needle aspiration(FNA) cytology. We performedthis study to determine the roie of EUS-guided FNA in the evaluationof pelvic masses. Patients/Methods: BetweenJune 1994 and October 1995, 8 patients were referred for EUS evaluation of pelvic masses. A 3600 radial scanning EE was first used to identify the abnormalityand establish overall orientation. Next, the linear array EE (Pentax FG 32-UA)wasused to performguided FNA. Pulsed and/or color Doppler were used to distinguish vascular structures. A Teflon catheter with a 23 gauge needle was advancedthru the working channel of the EE and the needle guided into the mass using realtime ultrasound imaging. The FNA specimen was reviewed in the endoscopysuite by a cytopathologist. Results: In 5/8 (63%), a definitive diagnosisof malignancy was made. These included; 2 with adenocarcinoma, 1 with ovarian carcinoma, 1 with cervical carcinoma, and 1 with lymphoma. In 2/8 (25%), the EUS image and FNA were consistent with infection ( pelvic abscess: 1, tubo-ovarian abscess: 1), both were treated accordingly w~th resolution of symptoms. The EUS imagesand FNA from the sample of the remaining patient suggested an inf~amrnatoryreaction felt to be related to prior radiationtherapy. Summary: The diagnosticyield of EUS + FNA was 100% as determinedby positive FNA and/orclinical follow-up. The procedures were completed in 45 minutes on average, required no sedation, and there were no biopsy related complications. The total cost excluding cytopathology ranged from $10461252 for EUS compared to $1323-1823 for a CT-guided aspiration. 2/5 patients with pelvic malignancies had undergone CT guided FNA with negative results. Conclusions: EUS is able to detect pelvic abnormalities; fine needle aspiration is a useful adjunct for suspected neoplasms and EUS-guided FNA may be a cost-saving diagnostic method in these pts.
V O L U M E 43, N O . 4, 1996
GASTROINTESTINAL
ENDOSCOPY
423