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Su1548 Diagnosis and Management of GI Stromal Tumors by EUS-FNA: Do European and US Practices of Endosonographers Differ?
Abstracts
also comparable to EUS when lesions are seen, however, 17% of SEL cannot be visualized on CT. Tissue obtained at time of EUS by FNA and biopsy is sufficient for cytology/histology in ⬎75% of cases.
Su1547 The Diagnostic Yield, Safety and Clinical Impact of Incision of Mucosa & Tunneled Biopsy of Upper GI Subepithelial Lesions in Fourth Endosonographic Layer Chang Keun Park* Inernal medicine, Daegu Fatima Hospital, Daegu, Republic of Korea Background: Endoscopic ultrasonography (EUS) is a useful diagnostic tool for evaluation of GI subepithelial lesions(SEL), but it has limited value for prediction of histologic diagnosis. EUS guided fine needle aspiration and trucut biopsy are another options, but they have limitations such as requirement of special equipments, high cost, size limitation and relatively low diagnostic yield. The purpose of this study is to prospectively evaluate the diagnostic yield, safety and clinical impact of incision of mucosa & tunneled biopsy of upper GI SEL in fourth endosonographic layer. Methods: A total of 58 patients who underwent EUS for SEL from December 2008 through November 2012 and were diagnosed as having SEL in fourth endosonographic layer were enrolled. After diagnosis of EUS in outpatient department, an incision of overlying mucosa of SEL by electrosurgical knife and then tunneled biopsies by routine biopsy forcep were done. Biopsies were repeated until suspected SEL was exposed or different consistency in specimen was identified. For better endoscopic view during procedure, diluted epinephrine solution was intermittently irrigated into the lesion. In case of continuous bleeding after biopsy, Endoclips were placed to close mucosal defect for hemostasis. Results: Of a total 58 patients (39 men; mean age 52.2 years; range 22-74 years), the diagnostic yield of this technique was 96.6% (56/58 cases) and the presumptive EUS diagnosis was correct in only 69.0% of 58 cases. The mean number of biopsy specimens was 5.8 (range 4-12). The anatomical distribution and histology of 58 cases (mean size 21.5mm; range 8-58mm) were 8 in esophagus (leiomyoma 5; GIST 2; tuberculoma 1), 46 in stomach (GIST 26, leiomyoma 10, Schwannoma 4, pancreatic rest 2, nondiagnostic 2, lymphoma 1, carcinoid tumor 1) and 4 in duodenum (pancreatic rest 2, GIST 2). 44 Endoclips were placed in 42 lesions for bleeding control and no other complications such as delayed bleeding and perforation were identified. A case of Schwannoma was misdiagnosed as lymphoma due to tissue acquisition from peritumoral cuff of lymphoid tissue which was typical histologic finding of Schwannoma. Conclusions: EUS alone was suboptimal to accurately diagnose fourth layer SEL. Our diagnostic technique had a clinical impact of avoidance of risk of undertreatment (i.e. esophageal GIST, esophageal tuberculoma, Gastric carcinoid) and overtreatment (i.e. gastric leiomyoma, Schwannoma, pancreatic rest). We suggest that incision of mucosa and tunneled biopsies in outpatient department be an effective and safe method for histologic confirmation of upper GI SEL.
Su1548 Diagnosis and Management of GI Stromal Tumors by EUS-FNA: Do European and US Practices of Endosonographers Differ? Christian Jenssen3, ANA Paula Barreiros2, Uwe Will5, Eike Burmester4, Alexander J. Eckardt*1 1 Gastroenterology and Hepatology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany; 2Gastroenterology and Hepatology, Johannes Gutenberg-Universität Mainz, I. Medizinische Klinik und Poliklinik, Mainz, Germany; 3Internal Medicine/Gastroenterology, Krankenhaus Märkisch-Oderland GmbH, Strausberg/Wriezen, Germany; 4Internal Medicine/Gastroenterology, Sana-Kliniken, Lübeck, Germany; 5 Gastroenterology, SRH Wald-Klinikum, 3. Medizinische Klinik, Gera, Germany Background and Aim: The purpose was to examine the practice patterns of endosonographers in diagnosing and managing GISTs in Germany (EUR) and compare these to the results of a previously published United States (US) survey (Ha et al. GIE 2009). Methods: An invitation to complete a survey by the German society of Ultrasound Medicine (DEGUM) was sent to all customers of EUSsystems in Germany twice within 1 year. In addition the survey was publicised on the homepage of the endosonography special interest group BerlinBrandenburg (www.eus-bb.de). To avoid duplicate opinions from related examiners, participants were asked to only return one survey per institution. Results: 142 centers (16.7%) of nationwide roughly 850 EUS customers responded. 24% of respondents were from University hospitals and 74% from regional hospitals. 61% (EUR) and 77% (US) performed ⬎2 EUS/week. Although 98% of respondents believed that the cytologic or histologic demonstration of CD117 is the best predictor in the diagnosis of GIST, 11% do not perform EUS FNA when a GIST is suspected, 70% perform it occasionally and 18% regularly. The most common EUS criteria used for a GIST diagnosis are the typical layer (85% EUR, 92%US), hypoechoic appearance (80% EUR, 56% US) and location in
the stomach (51% EUR, 26% US). In EUR 69% of participants would diagnose GIST even with negative CD117, if EUS criteria and spindle cells are present. The diagnostic yield of EUS FNA is rated poorly with ⬍ 50% by 55%, 51%-75 by 26% and ⬎75% by 11% of participants,respectively. Size was the number 1 criterion in 90% in both EUR and US. For those patients with GISTs that were not referred to surgery, 50% of respondents would do surveillance ⬎1x/year and 45% would do it once a year. Conclusion: The results show significant variability in the use of diagnostic criteria and methods to diagnose and follow GISTs within the practices among German centers and point out some differences to the US. However, in this German survey more non-university hospitals were includes which might explain some of the observed differences. Evidence based guidelines are desirable to guide practicing clinicians.
Su1549 EUS-Guided Needle Sampling for Gastric Subepithelial Tumors: Factors Associated With Higher Diagnostic Yield Hee Kyong Na*, Ho June Song, MI-Young Kim, Ji Yong Ahn, Jeong Hoon Lee, Kwi-Sook Choi, Do Hoon Kim, Kee Don Choi, Gin Hyug Lee, Hwoon-Yong Jung, Dong Wan Seo, Jin-Ho Kim Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea Background: EUS-guided sampling is an indispensible procedure for tissue diagnosis of gastric subepithelial tumors (SETs). Studies evaluating the factors associated with higher diagnostic yield of gastric SETs are limited. Objective: Diagnostic yields and significant factors for confirmative cytopathologic diagnosis of gastric SETs in large case series. Methods: Records of patients with gastric SETs ⬎2 cm in size who underwent EUS-guided needle sampling were retrieved from consecutively collected database from Nov. 2005 to May 2012. Cytopathologic results were categorized as diagnostic or non-diagnostic. A diagnostic was defined as sufficient samples for cytopathologic evaluation, and/ or a specific diagnosis by immunohistochemical staining (c-kit, CD34, actin/ desmin, S100). A non-diagnostic was defined as: (1) suspicious: a needle sample from which suspicious cellular materials was obtained, but quantity not sufficient for confirmatory analysis, or (2) insufficient: a scanty insufficient sample. Logistic regression analysis was performed to assess factors associated with diagnostic sampling. Variables included tumor size, location, EUS echo-features, number of needle passes, and needling methods. Results: A total of 152 patients undergoing EUS-guided needle sampling were identified. Tumor size was 40.5⫾29.5 mm and 57.2 % was located in the gastric upper thirds. Aspiration using 22-gauge needle (FNA) was performed in 62 (40.8%) and 19-gauge trucut biopsy (TCB) in 93 (59.2%) lesions. A median of 3 passes were required, and technical failure was reported in 9 cases during TCB. Overall diagnostic yield was 61.8% (TCB, 77.8 % vs. FNA, 38.7 %). Tumors established confirmative diagnosis showed larger size, heterogeneous echo-texture, and TCB needling. In multivariate logistic regression, TCB method was the only significant factor for obtaining diagnostic samples (odds ratio 6.04; 95% CI, 2.86-12.77; P⬍0.001). Other factors such as tumor size, location and echo-texture were not significant. Of 127 proven tumors cytopathologically, FNA showed increased diagnostic yield for GIST tumors (GIST, 68.8 % vs. non-GIST, 14.3 %, P⫽0.001). Conclusion: A confirmative cytopathologic diagnosis was obtained in 61.8% of gastric SETs by EUS-needling. TCB method was the only significant factor for obtaining diagnostic samples. FNA showed higher yield for gastric GIST tumors.
Su1550 Diagnostic Yield of EUS-FNA for Upper GI Tract Subepithelial Lesions-Results of a Multicenter Study Pamela Reyes6, Fauze Maluf-Filho4, Ricardo T. Schulz4, Livia M. Rodriguez Jimenez3, Leonardo Sosa3, Wallia J. Wever5, Keyur Patel2, Carlos Micames*1 1 Gastroenterology, Hospital Bella Vista, Mayaguez; 2Duke University Medical Center, Durham, NC; 3CITE, Caracas, Venezuela; 4 Universidade de Sao Paulo, Sao Paulo, Brazil; 5Instituto Medico La Floresta, Caracas, Venezuela; 6Centro Medico Mayaguez, Mayaguez Background: Subepithelial lesions of the GI tract are commonly found during upper endoscopy. Despite the use of EUS, the exact diagnosis of subepithelial lesions remains a challenge. EUS-FNA has the ability of obtaining a tissue sample to determine the exact nature of the lesion. Prior studies have shown a diagnostic yield ranging from 43 to 82%. Aim: To determine the yield of EUS-FNA for diagnosing subepithelial lesions of the upper GI tract and determine its performance characteristics. Methods: This is a multicenter study of all prospective, consecutive EUS cases performed to evaluate subepithelial lesions in 4 centers located in Puerto Rico, Brazil, and Venezuela from 2006 onward. The yield of EUS-FNA was determined in the overall cohort. Subgroup analysis was performed using Student t-test, contingency analysis, and ANOVA. Multivariate analysis was performed to
AB364 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
also comparable to EUS when lesions are seen, however, 17% of SEL cannot be visualized on CT. Tissue obtained at time of EUS by FNA and biopsy is sufficient for cytology/histology in ⬎75% of cases.
Su1547 The Diagnostic Yield, Safety and Clinical Impact of Incision of Mucosa & Tunneled Biopsy of Upper GI Subepithelial Lesions in Fourth Endosonographic Layer Chang Keun Park* Inernal medicine, Daegu Fatima Hospital, Daegu, Republic of Korea Background: Endoscopic ultrasonography (EUS) is a useful diagnostic tool for evaluation of GI subepithelial lesions(SEL), but it has limited value for prediction of histologic diagnosis. EUS guided fine needle aspiration and trucut biopsy are another options, but they have limitations such as requirement of special equipments, high cost, size limitation and relatively low diagnostic yield. The purpose of this study is to prospectively evaluate the diagnostic yield, safety and clinical impact of incision of mucosa & tunneled biopsy of upper GI SEL in fourth endosonographic layer. Methods: A total of 58 patients who underwent EUS for SEL from December 2008 through November 2012 and were diagnosed as having SEL in fourth endosonographic layer were enrolled. After diagnosis of EUS in outpatient department, an incision of overlying mucosa of SEL by electrosurgical knife and then tunneled biopsies by routine biopsy forcep were done. Biopsies were repeated until suspected SEL was exposed or different consistency in specimen was identified. For better endoscopic view during procedure, diluted epinephrine solution was intermittently irrigated into the lesion. In case of continuous bleeding after biopsy, Endoclips were placed to close mucosal defect for hemostasis. Results: Of a total 58 patients (39 men; mean age 52.2 years; range 22-74 years), the diagnostic yield of this technique was 96.6% (56/58 cases) and the presumptive EUS diagnosis was correct in only 69.0% of 58 cases. The mean number of biopsy specimens was 5.8 (range 4-12). The anatomical distribution and histology of 58 cases (mean size 21.5mm; range 8-58mm) were 8 in esophagus (leiomyoma 5; GIST 2; tuberculoma 1), 46 in stomach (GIST 26, leiomyoma 10, Schwannoma 4, pancreatic rest 2, nondiagnostic 2, lymphoma 1, carcinoid tumor 1) and 4 in duodenum (pancreatic rest 2, GIST 2). 44 Endoclips were placed in 42 lesions for bleeding control and no other complications such as delayed bleeding and perforation were identified. A case of Schwannoma was misdiagnosed as lymphoma due to tissue acquisition from peritumoral cuff of lymphoid tissue which was typical histologic finding of Schwannoma. Conclusions: EUS alone was suboptimal to accurately diagnose fourth layer SEL. Our diagnostic technique had a clinical impact of avoidance of risk of undertreatment (i.e. esophageal GIST, esophageal tuberculoma, Gastric carcinoid) and overtreatment (i.e. gastric leiomyoma, Schwannoma, pancreatic rest). We suggest that incision of mucosa and tunneled biopsies in outpatient department be an effective and safe method for histologic confirmation of upper GI SEL.
Su1548 Diagnosis and Management of GI Stromal Tumors by EUS-FNA: Do European and US Practices of Endosonographers Differ? Christian Jenssen3, ANA Paula Barreiros2, Uwe Will5, Eike Burmester4, Alexander J. Eckardt*1 1 Gastroenterology and Hepatology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany; 2Gastroenterology and Hepatology, Johannes Gutenberg-Universität Mainz, I. Medizinische Klinik und Poliklinik, Mainz, Germany; 3Internal Medicine/Gastroenterology, Krankenhaus Märkisch-Oderland GmbH, Strausberg/Wriezen, Germany; 4Internal Medicine/Gastroenterology, Sana-Kliniken, Lübeck, Germany; 5 Gastroenterology, SRH Wald-Klinikum, 3. Medizinische Klinik, Gera, Germany Background and Aim: The purpose was to examine the practice patterns of endosonographers in diagnosing and managing GISTs in Germany (EUR) and compare these to the results of a previously published United States (US) survey (Ha et al. GIE 2009). Methods: An invitation to complete a survey by the German society of Ultrasound Medicine (DEGUM) was sent to all customers of EUSsystems in Germany twice within 1 year. In addition the survey was publicised on the homepage of the endosonography special interest group BerlinBrandenburg (www.eus-bb.de). To avoid duplicate opinions from related examiners, participants were asked to only return one survey per institution. Results: 142 centers (16.7%) of nationwide roughly 850 EUS customers responded. 24% of respondents were from University hospitals and 74% from regional hospitals. 61% (EUR) and 77% (US) performed ⬎2 EUS/week. Although 98% of respondents believed that the cytologic or histologic demonstration of CD117 is the best predictor in the diagnosis of GIST, 11% do not perform EUS FNA when a GIST is suspected, 70% perform it occasionally and 18% regularly. The most common EUS criteria used for a GIST diagnosis are the typical layer (85% EUR, 92%US), hypoechoic appearance (80% EUR, 56% US) and location in
the stomach (51% EUR, 26% US). In EUR 69% of participants would diagnose GIST even with negative CD117, if EUS criteria and spindle cells are present. The diagnostic yield of EUS FNA is rated poorly with ⬍ 50% by 55%, 51%-75 by 26% and ⬎75% by 11% of participants,respectively. Size was the number 1 criterion in 90% in both EUR and US. For those patients with GISTs that were not referred to surgery, 50% of respondents would do surveillance ⬎1x/year and 45% would do it once a year. Conclusion: The results show significant variability in the use of diagnostic criteria and methods to diagnose and follow GISTs within the practices among German centers and point out some differences to the US. However, in this German survey more non-university hospitals were includes which might explain some of the observed differences. Evidence based guidelines are desirable to guide practicing clinicians.
Su1549 EUS-Guided Needle Sampling for Gastric Subepithelial Tumors: Factors Associated With Higher Diagnostic Yield Hee Kyong Na*, Ho June Song, MI-Young Kim, Ji Yong Ahn, Jeong Hoon Lee, Kwi-Sook Choi, Do Hoon Kim, Kee Don Choi, Gin Hyug Lee, Hwoon-Yong Jung, Dong Wan Seo, Jin-Ho Kim Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea Background: EUS-guided sampling is an indispensible procedure for tissue diagnosis of gastric subepithelial tumors (SETs). Studies evaluating the factors associated with higher diagnostic yield of gastric SETs are limited. Objective: Diagnostic yields and significant factors for confirmative cytopathologic diagnosis of gastric SETs in large case series. Methods: Records of patients with gastric SETs ⬎2 cm in size who underwent EUS-guided needle sampling were retrieved from consecutively collected database from Nov. 2005 to May 2012. Cytopathologic results were categorized as diagnostic or non-diagnostic. A diagnostic was defined as sufficient samples for cytopathologic evaluation, and/ or a specific diagnosis by immunohistochemical staining (c-kit, CD34, actin/ desmin, S100). A non-diagnostic was defined as: (1) suspicious: a needle sample from which suspicious cellular materials was obtained, but quantity not sufficient for confirmatory analysis, or (2) insufficient: a scanty insufficient sample. Logistic regression analysis was performed to assess factors associated with diagnostic sampling. Variables included tumor size, location, EUS echo-features, number of needle passes, and needling methods. Results: A total of 152 patients undergoing EUS-guided needle sampling were identified. Tumor size was 40.5⫾29.5 mm and 57.2 % was located in the gastric upper thirds. Aspiration using 22-gauge needle (FNA) was performed in 62 (40.8%) and 19-gauge trucut biopsy (TCB) in 93 (59.2%) lesions. A median of 3 passes were required, and technical failure was reported in 9 cases during TCB. Overall diagnostic yield was 61.8% (TCB, 77.8 % vs. FNA, 38.7 %). Tumors established confirmative diagnosis showed larger size, heterogeneous echo-texture, and TCB needling. In multivariate logistic regression, TCB method was the only significant factor for obtaining diagnostic samples (odds ratio 6.04; 95% CI, 2.86-12.77; P⬍0.001). Other factors such as tumor size, location and echo-texture were not significant. Of 127 proven tumors cytopathologically, FNA showed increased diagnostic yield for GIST tumors (GIST, 68.8 % vs. non-GIST, 14.3 %, P⫽0.001). Conclusion: A confirmative cytopathologic diagnosis was obtained in 61.8% of gastric SETs by EUS-needling. TCB method was the only significant factor for obtaining diagnostic samples. FNA showed higher yield for gastric GIST tumors.
Su1550 Diagnostic Yield of EUS-FNA for Upper GI Tract Subepithelial Lesions-Results of a Multicenter Study Pamela Reyes6, Fauze Maluf-Filho4, Ricardo T. Schulz4, Livia M. Rodriguez Jimenez3, Leonardo Sosa3, Wallia J. Wever5, Keyur Patel2, Carlos Micames*1 1 Gastroenterology, Hospital Bella Vista, Mayaguez; 2Duke University Medical Center, Durham, NC; 3CITE, Caracas, Venezuela; 4 Universidade de Sao Paulo, Sao Paulo, Brazil; 5Instituto Medico La Floresta, Caracas, Venezuela; 6Centro Medico Mayaguez, Mayaguez Background: Subepithelial lesions of the GI tract are commonly found during upper endoscopy. Despite the use of EUS, the exact diagnosis of subepithelial lesions remains a challenge. EUS-FNA has the ability of obtaining a tissue sample to determine the exact nature of the lesion. Prior studies have shown a diagnostic yield ranging from 43 to 82%. Aim: To determine the yield of EUS-FNA for diagnosing subepithelial lesions of the upper GI tract and determine its performance characteristics. Methods: This is a multicenter study of all prospective, consecutive EUS cases performed to evaluate subepithelial lesions in 4 centers located in Puerto Rico, Brazil, and Venezuela from 2006 onward. The yield of EUS-FNA was determined in the overall cohort. Subgroup analysis was performed using Student t-test, contingency analysis, and ANOVA. Multivariate analysis was performed to
AB364 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org