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T1467: Metastatic Risk of Diminutive Rectal Carcinoid Tumors: A Need for Surveillance Rectal Ultrasound
Abstracts consequence of scheduling an individual for an unwarranted resection. These observations should be taken into considerations when surveilling individuals at high risk of PC and management should be adapted accordingly.
T1464 25G or 22G Needle, Which Is Better for EUS-FNA for Pancreatic Tumor? Prospective Randomized Controlled Trial E Ryoung Choi, Tae Hoon Jang, Kee Taek Jang, Jong Kyun Lee, Kyu Taek Lee, Kwang Hyuck Lee Background and study aims: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is widely performed to diagnose pancreatic tumors. Recently 25-gauge (25G) needle is available, which is thinner and more flexible than 22-gauge (22G) for EUS-FNA. However, few studies comparing these needles were published, especially in the aspect of the internal characteristics of tumor or manipulation of endoscope. The aim of this study was to compare efficacy and limitation of 25G with 22G needles in EUS-FNA for pancreatic tumor. Patients and methods: From April 2009 to September 2009, at Samsung Medical Center (Seoul, South Korea), we randomized the patients who needed EUS-FNA for pancreatic tumor into 25G or 22G group and performed the procedure using each needle. Diagnostic accuracy and complication were analyzed prospectively in the aspect of the range of endoscopic manipulation, location and internal characteristics of pancreatic tumors. Results: Forty eight patients were assigned into 25G group, and forty five patients into 22G group. Overall accuracy for 25G and 22G needle was 89.6% (43/48) and 84.4% (38/45), respectively (p⫽0.460). The feasibility of 25G and 22G needle to evaluate histological examination was 33.3% (16/48) and 53.3% (24/45) (p⫽0.052). According to the location of pancreatic tumors, there was no difference between 25G and 22G groups; For head or uncinate process lesion, the accuracy was 86.7% and 81.8% (p⫽0.708). For body or tail lesions, the accuracy was 94.4% and 87.0% (p⫽0.618). In the view of internal characteristics of tumors, also there was no difference between 25G and 22G groups; In solid tumors, the accuracy was 85.7% and 84.4% (p⫽0.878). In cystic tumors, diagnostic yield by cytological or cystic fluid analysis was 100% and 84.6% (p⫽0.480). For head or uncinate process lesions, there was no significant difference in pathway visualization and resistance during puncture according to angulations of endoscope. For body or tail lesions, only the resistance was lower in the 25G group (p⫽0.019). Post-FNA pancreatitis occurred in one case in the 25G group. Conclusion: A 25 gauge needle can be used as efficiently as a 22 gauge needle in EUS-FNA for patients with a pancreatic tumor. Keywords: pancreatic tumor, EUS-FNA, 22 gauge, 25 gauge
T1465 EUS-Guided Cholangiography When Endoscopic Retrograde Cholangiography Failed: 6-Year Single Center Experience Monder Abusuboh Abadia, Joan Dot-Bach, Miquel Masachs Peracaula, Jordi Armengol Bertroli, Anna Benages Curell, Jose C. Salord, Sergey V. Kantsevoy, Jose Ramon Armengol-Miro BACKGROUND: Endoscopic Retrograde Cholangiography (ERC) is still the procedure of choice for biliary decompression in patients with obstructive jaundice. However, endoscopic cannulation of the major duodenal papilla could be very difficult and often impossible in patients with periampulary diverticuli, impacted stones, tumor infiltration, etc. When the ERC fails, percutaneous transhepatic drainage and surgical intervention are recommended, however, both techniques are associated with significant morbidity. Interventional Endoscopic Ultrasound guided cholangiography (IEUC) has been recently reported. OBJECTIVE: To report our 6-year experience with IEUC for biliary decompression in patients with obstructive jaundice.METHODS: For IEUC a linear array echoendoscope (Olympus, UCT, 140) was advanced into duodenum. Retroduodenal common bile duct was visualized and punctured with 19 gauge fine needle aspiration (FNA) needle. After aspiration of the bile (to document the proper position of the needle), the contrast was injected to delineate the biliary anatomy. Then the guide-wire was advanced through the needle and directed back to the duodenum for subsequent placement of the biliary duct via major papilla (rendezvous technique). If the guide-wire could not pass through the major papilla, it was directed into the proximal biliary tree and a biliary stent was placed over the wire completing creation of the supra-papillary biliaryduodenal fistula. RESULTS: For the last 6 years (2004-2009) a total of 3245 patients with obstructive jaundice were referred to our endoscopy unit for ERC. Twenty of them underwent IEUC after ERC failure. The indications for ERC were pancreatic neoplasm (n⫽18) and impacted common bile duct stones (n⫽2). The causes for ERC failure were: inability to identify the papillary orifice (n⫽1), duodenal infiltration not allowing access to the major papilla (n⫽2), periampulary diverticula (n⫽6), papillary and distal common bile duct infiltration (n⫽9). In 18 of the 20 cases (90%) biliary decompression was achieved utilizing rendezvous technique (n⫽15) or creation of a biliary-duodenal fistula (n⫽3). In 2 cases (10%) billiary decompression was not possible due to extensive infiltration of distal common bile duct and duodenum. One patient developed
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minor bleeding during IEUC controlled with endoscopic hemostasis, and 2 patients had mild pancreatitis treated conservatively. CONCLUSION: IEUC is a safe and effective technique, which could become a valuable alternative to surgery or percutaneus transhepatic drainage when ERC is not possible.
T1466 EUS-Guided Band Ligation for Auto-Amputation of Superficial Upper Gastrointestinal Tract Lesions Julie Holinga, Michael K. Sanders, Kenneth E. Fasanella, Asif Khalid, Kevin Mcgrath Background: In addition to hemostasis, endoscopic band ligation (EBL) is used for the creation of pseudo-polyps to facilitate endoscopic resection with electrocautery. EBL without resection can be used to remove small lesions, which slough due to vascular constriction. This method of resection may confer a lower risk of bleeding and perforation. We report our experience with EUSguided EBL for auto-amputation of superficial gastrointestinal lesions of the esophagus, stomach and duodenum.Methods: A retrospective review was performed to identify patients who underwent EUS-guided EBL of superficial gastrointestinal lesions over a five year period. Patient characteristics, clinical history, endoscopic and EUS findings, pathology results (when available), complications, and findings on repeat surveillance endoscopy were reviewed. Results: Forty patients were identified: 14 males, 26 females, mean age 55.7 ⫾ 15 years [SD]. There were 13 esophageal lesions (7 stromal tumors, 6 granular cell tumors), 16 gastric lesions (15 stromal tumors, 1 carcinoid tumor) and 11 duodenal bulb lesions (all carcinoids). All lesions were incidental endoscopic findings. Pre-EUS diagnostic histology was present in 18 cases (all carcinoid and granular cell tumors). The diagnosis of stromal tumor was made by EUS appearance in the setting of previous non-diagnostic biopsies. The mean size of all lesions was 6.5 ⫾ 1.8 mm [SD](range 4 - 11 mm). 25 lesions were deep mucosal-based, 13 were submucosal, and 2 arose from the inner circular layer of the muscularis propria. One patient had 2 diminutive esophageal granular cell tumors. The patient with a gastric carcinoid carried a diagnosis of pernicious anemia. All lesions were successfully ligated with one band. To date, 25 patients have undergone follow up EGD at our institution, without evidence of a persistent lesion. Seven patients have follow up EGD still pending, 7 patients underwent follow up EGD locally, and 1 patient had no follow up (underwent RYGB). Mean time from banding to endoscopic follow up was 6.7 ⫾ 3.5 months [SD]. Two patients had post-procedure self-limited chest pain and abdominal pain, respectively. Conclusion: EUS-guided EBL is a safe, effective method for removal of small superficial gastrointestinal lesions, and may be a lower risk alternative to conventional resection with cautery. This may be an ideal modality for higher risk patients and for lesions in difficult locations. For lesions such as stromal tumors, EBL eliminates the need for surveillance EUS.
T1467 Metastatic Risk of Diminutive Rectal Carcinoid Tumors: A Need for Surveillance Rectal Ultrasound Julie Holinga, Asif Khalid, Kenneth E. Fasanella, Michael K. Sanders, Kevin Mcgrath Background: Endoscopic resection or local excision is reported to be curative for rectal carcinoid tumors ⱕ 10 mm in size. We report our experience with endoscopic rectal ultrasound (RUS) for assessment and surveillance of diminutive rectal carcinoid tumors. Methods: A retrospective review was performed to identify patients who underwent endoscopic rectal ultrasound to evaluate rectal carcinoid tumors over an 8 year period. Only rectal carcinoid tumors ⱕ 10 mm in size were included. Patient characteristics, clinical history, endoscopic and EUS findings, operative reports and pathology results were reviewed. Results: Twenty four patients were identified: 13 males, 11 females, mean age 56 ⫾ 11 years. All lesions were incidental endoscopic findings. Carcinoid tumor mean size was 5.8 ⫾ 3 mm. 14 lesions were removed by polypectomy, 7 lesions were removed by band-assisted EMR, and 3 lesions were removed by transanal resection. 17 of 24 patients have undergone RUS surveillance; mean follow up was 15.6 months. Two patients (8.3%) had a metastatic perirectal lymph node identified by surveillance RUS 17 and 26 months after initial tumor resection, respectively; each underwent EUS-FNA for cytologic confirmation. The former patient initially underwent transanal resection to remove a 5 mm carcinoid tumor with clear margins. A laparoscopic partial protectomy was ultimately performed after the metastasis (5 mm LN) was diagnosed by EUS-FNA, revealing 1/28 positive LNs. There was no pathologic evidence of residual neoplasm in the rectal wall. The latter patient underwent initial snare polypectomy of a 10 mm rectal polyp. Pathology revealed carcinoid tumor with a positive deep margin. After initial RUS was performed to exclude LNs, a transanal resection of the polypectomy site was performed; there was no pathologic evidence of residual tumor. This patient underwent eventual laparoscopic resection of the metastatic LN (5mm) with intraoperative EUS localization.Conclusions: Diminutive rectal carcinoid tumors have metastatic risk. In our series, 8.3% of patients developed metastatic perirectal lymph nodes detected by surveillance RUS. Based on our
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Abstracts findings, it may be reasonable to perform initial RUS surveillance 3 months after resection, then every 6 months for 2 years.
T1468 Neuroendocrine Tumors of Gastrointestinal Tract and the Pancreas: Diagnostic Modalities, Accuracy, and Outcomes Jeffrey H. Lee, Chandra S. Dasari, Singh Harvinder, Asif Rashid, Manoop S. Bhutani, Ramu P. Raju, Sathya Jaganmohan, James C. Yao, Alexandria Phan, Gottumukkala S. Raju Purpose:The aim of the study was to evaluate the utility of various diagnostic modalities including computed tomography (CT) scan, endoscopy, and endoscopic ultrasound (EUS) in neuroendocrine tumors (NET). Methods: Retrospective chart review of patients who underwent endoscopic evaluation from January 2003 to November 2009 at a cancer center. The accuracy of EUSguided fine needle aspiration (FNA) was evaluated. The T- and N- staging of NET by EUS was compared to histological staging. Results: A total of 226 patients (87 male), with a mean age 59.4 years were found to have GI NET. There were 50 patients with pancreatic endocrine neoplasm (PEN) including 5 with multiendocrine neoplasia 1 (MEN1), 66 gastric carcinoids, 40 with duodenal carcinoids, 34 small bowel carcinoid, 26 rectal carcinoids and 10 large bowel carcinoid. Among PEN, 5 were in uncinate process, 14 in the head, 3 in the neck, 8 in the body, and 15 in the tail, and 5 MEN1. The median size was 2.3 cm (range; 0.52-7cm) for PEN, 1cm (range: 0.3-4.2cm) for gastric carcinoids, 1cm (range: 0.2-7cm) for duodenal carcinoids, and 0.7 cm (range: 0.3-3 cm) for rectal carcinoids.EUS was performed in 125 patients. The CT findings were unremarkable in 93, positive for a mass in 61, and metastasis in 46. For patients with no abnormalities seen on CT scan (53 patients), EGD and sigmoidoscopy showed a discrete nodule or lesion in all patients. 46 had EUS for PEN; EUS FNA was performed in 33 and all were positive (accuracy 100%). EUS staging was compared to histologic staging for carcinoids and the accuracy for T- staging was 78.18 % with understaging of 7.27% and overstaging of 12.7 %. All carcinoids smaller than 1cm in the Stomach (8), duodenum (8), rectum (13) did not progress to metastatic disease in median follow-up period of 3.5 years (1-6 y) for stomach, 2 years (1-4 y) for duodenum, 4 years (1-6 y) for rectum. Among these, 18 underwent endoscopic mucosal resection, 5 surgical resection (3 gastric and 2 duodenal carcinoids), 4 polypectomies (4 rectal carcinoids), and 2 were observed (2 duodenal cardinoids). No complications were seen in endoscopic procedures.Conclusions: EUS FNA is highly accurate in diagnosis of PEN. Endoscopy is the most sensitive modality in detecting and diagnosing carcinoids smaller than 1cm. EUS was moderately accurate in establishing T-staging of carcinoids. Carcinoids, smaller than 1cm in the stomach, duodenum, and rectum did not behave aggressively in follow up.
T1469 The Use of Endoscopic Ultrasound in Differentiating Side Branch vs. Main Duct vs. Mixed Duct Intraductal Papillary Mucinous Neoplasm Cynthia L. Harris, Mokenge P. Malafa, Jill Weber, Jason B. Klapman Introduction:Intraductal Papillary Mucinous Neoplasms (IPMN) are categorized as main duct (MD), side branch (SB), or mixed (M) duct lesions. Endoscopic ultrasound (EUS) is routinely used to diagnose cysts of the pancreas; however, little is known on the accuracy of differentiating main duct versus side branch IPMN. The management of IPMNs are, in part, dependent on whether they are categorized as side branch or main duct origin. We hypothesize that EUS can differentiate MD-IPMN, SB-IPMN, and M-IPMN. Methods:An IRB-approved surgical IPMN database was reviewed to find all patients from 2000-2009 that had undergone preoperative EUS at H. Lee Moffitt Cancer Center. Seventy patients with surgical confirmation of IPMN and EUS were identified. EUS reports and pathology were reviewed. All surgical pathology specimens were identified as main duct, side branch, or mixed IPMN by an expert pathologist. Of the seventy patients identified, patients were included in the study if they had an EUS determination of main duct, side branch, or mixed IPMN on the EUS report.Results:Thirty six patients met eligibility for study inclusion. Eighteen patients had surgical pathology consistent with SB-IPMN. Fifteen of these were correctly identified by EUS (83%). Ten patients had surgical pathology consistent with MD-IPMN. EUS was accurate in six of these patients (60%). Finally, three of eight patients had EUS where M-IPMN was correctly identified (37.5%). Conclusions:EUS is highly accurate in diagnosing side-branch IPMN but its value in determining main duct or mixed duct IPMN is limited. Further studies are needed to determine the role of EUS in differentiating the sub-classifications of IPMN.
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T1470 Stylet Use Does Not Affect Adequacy of Specimen of Pancreatic EUS FNA: A Prospective, Single Blinded, Randomized, Control Trial Marcus W. Chin, Alan Coss, Mark Mcloughlin, Michael F. Byrne, Robert A. Enns, Jennifer J. Telford, Eric C. Lam Background: Endoscopic ultrasound fine needle aspiration (EUS FNA) is routinely performed with the stylet in place during puncture. The removal of the stylet has been shown to increase cellularity of the aspirate. There are no prospective, randomized, controlled data looking at whether stylet use or lack of, affects the adequacy of EUS FNA. Objective: To compare the adequacy of smears in the diagnosis of pancreatic masses at EUS FNA with and without the stylet in patients diagnosed by computed tomography (CT).Method: A prospective, single blinded, randomized, control trial. All patients with solid pancreatic masses underwent two FNA with and two without the stylet. The same site was punctured, with 15 in-out movements performed per puncture. To control for bloodiness of the sample introduced from multiple punctures, participants were randomized for the order in which this occurred. Pathologists were blinded to the manner of FNA, and were asked to assess the adequacy of the smear, and the histopathological diagnosis made from both smear and cell block. A power calculation was performed to detect a 30% difference in adequacy of specimen between stylet out vs in techniques. Participants with followed to surgery or clinically for at least six months. Results : In this ongoing study, 37 participants, with ages ranging 38-85 underwent EUS FNA. The distribution of masses were 30, 3 and 4 for the head, body and tail of pancreas, respectively. 20 participants were randomized to FNA with the stylet in for the first two passes followed by FNA with the stylet out. 17 participants underwent FNA in the reverse order. The adequacy of the smears with stylet in and out was 75.5% (28/37) for both groups. The sensitivity and specificity of EUS FNA for pancreatic masses is 91.9% and 100% respectively. The duration of follow up ranged from 2 to 48 weeks post EUS FNA.Conclusion: There is no difference in the adequacy of smear from EUS FNA with the stylet in or out for pancreatic masses detected at CT.
T1471 Comparison of EUS vs. Surgery for Placement of Fiducials in Patients With Pancreatic Cancer Tyler M. Berzin, Shounak Majumder, Anand Mahadevan, Rishi Pawa, James Ellsmere, Paul S. Sepe, Salvatore La Rosa, Douglas K. Pleskow, Ram Chuttani, Mandeep Sawhney Background: Cyberknife image-guided radiation therapy allows precise tumor targeting using real-time tracking of radiopaque fiducial markers, and is being used increasingly in patients with unresectable pancreatic cancer. To enable appropriate fiducial tracking by the Cyberknife system, it is recommended to place fiducials with ‘ideal fiducial geometry’ i.e. at least 3 fiducials with a minimum interfiducial distance ⬎2cm, minimum interfiducial angle ⬎15o and non-collinear placement in the imaging plane. Aim: To determine the safety of EUS for placing fiducials in pancreatic tumors and to compare fiducial placement accuracy of EUS and surgery (i.e. during staging laparoscopy). Methods: All patients who underwent EUS-guided or surgical implantation of fiducials for locally advanced pancreatic cancer between 9/05 and 7/09 at our institution were identified. We used dedicated Cyberknife tracking software and treatment data to evaluate two parameters of placement ‘accuracy’: 1) whether fiducial placement achieved ideal geometry, and 2) whether some or all of the implanted fiducials could be tracked by the Cyberknife system. Records were also reviewed for immediate or delayed complications of EUS-guided fiducial placement. Results: Of the 77 patients in our study, fiducials were implanted by EUS in 39 patients (51%), and surgery in 38 patients (49%). Cyberknife therapy using fiducial tracking was successful in 35/39 EUS (90%), and 31/38 surgical (82%) cases. The mean number of fiducials placed was 3.8⫹/-1.1, and the mean number of fiducials tracked was 1.6⫹/-1.0. Ideal geometry was achieved in 25/ 77 (32%) of patients. The proportion of patients with ideal fiducial geometry was significantly higher for surgery (18/38, 47%) compared to EUS-guided placement (7/39, 18%), p⫽0.0011. In the EUS group, there was a trend towards a higher likelihood of achieving ideal geometry for tumors in the pancreatic head/neck (26%) compared to the body/tail (6.2%), (p⫽0.06). Among EUS-guided cases, acute complications were noted in 5/39 (13%). 4/5 were minor, including abdominal pain (3) and vomiting (1). One patient developed mild pancreatitis requiring a 2-day admission. The mean duration of follow-up was 246 ⫹/- 258 days and there were no long term complications. Conclusion: EUS-guided fiducial placement is effective and safe. Technical improvements in EUS-guided fiducial placement may be needed to achieve ideal fiducial geometry. Although ideal fiducial geometry was achieved in less than one third of EUS cases, fiducials placed by EUS could still be tracked and used successfully for Cyberknife therapy in most patients.
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T1464 25G or 22G Needle, Which Is Better for EUS-FNA for Pancreatic Tumor? Prospective Randomized Controlled Trial E Ryoung Choi, Tae Hoon Jang, Kee Taek Jang, Jong Kyun Lee, Kyu Taek Lee, Kwang Hyuck Lee Background and study aims: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is widely performed to diagnose pancreatic tumors. Recently 25-gauge (25G) needle is available, which is thinner and more flexible than 22-gauge (22G) for EUS-FNA. However, few studies comparing these needles were published, especially in the aspect of the internal characteristics of tumor or manipulation of endoscope. The aim of this study was to compare efficacy and limitation of 25G with 22G needles in EUS-FNA for pancreatic tumor. Patients and methods: From April 2009 to September 2009, at Samsung Medical Center (Seoul, South Korea), we randomized the patients who needed EUS-FNA for pancreatic tumor into 25G or 22G group and performed the procedure using each needle. Diagnostic accuracy and complication were analyzed prospectively in the aspect of the range of endoscopic manipulation, location and internal characteristics of pancreatic tumors. Results: Forty eight patients were assigned into 25G group, and forty five patients into 22G group. Overall accuracy for 25G and 22G needle was 89.6% (43/48) and 84.4% (38/45), respectively (p⫽0.460). The feasibility of 25G and 22G needle to evaluate histological examination was 33.3% (16/48) and 53.3% (24/45) (p⫽0.052). According to the location of pancreatic tumors, there was no difference between 25G and 22G groups; For head or uncinate process lesion, the accuracy was 86.7% and 81.8% (p⫽0.708). For body or tail lesions, the accuracy was 94.4% and 87.0% (p⫽0.618). In the view of internal characteristics of tumors, also there was no difference between 25G and 22G groups; In solid tumors, the accuracy was 85.7% and 84.4% (p⫽0.878). In cystic tumors, diagnostic yield by cytological or cystic fluid analysis was 100% and 84.6% (p⫽0.480). For head or uncinate process lesions, there was no significant difference in pathway visualization and resistance during puncture according to angulations of endoscope. For body or tail lesions, only the resistance was lower in the 25G group (p⫽0.019). Post-FNA pancreatitis occurred in one case in the 25G group. Conclusion: A 25 gauge needle can be used as efficiently as a 22 gauge needle in EUS-FNA for patients with a pancreatic tumor. Keywords: pancreatic tumor, EUS-FNA, 22 gauge, 25 gauge
T1465 EUS-Guided Cholangiography When Endoscopic Retrograde Cholangiography Failed: 6-Year Single Center Experience Monder Abusuboh Abadia, Joan Dot-Bach, Miquel Masachs Peracaula, Jordi Armengol Bertroli, Anna Benages Curell, Jose C. Salord, Sergey V. Kantsevoy, Jose Ramon Armengol-Miro BACKGROUND: Endoscopic Retrograde Cholangiography (ERC) is still the procedure of choice for biliary decompression in patients with obstructive jaundice. However, endoscopic cannulation of the major duodenal papilla could be very difficult and often impossible in patients with periampulary diverticuli, impacted stones, tumor infiltration, etc. When the ERC fails, percutaneous transhepatic drainage and surgical intervention are recommended, however, both techniques are associated with significant morbidity. Interventional Endoscopic Ultrasound guided cholangiography (IEUC) has been recently reported. OBJECTIVE: To report our 6-year experience with IEUC for biliary decompression in patients with obstructive jaundice.METHODS: For IEUC a linear array echoendoscope (Olympus, UCT, 140) was advanced into duodenum. Retroduodenal common bile duct was visualized and punctured with 19 gauge fine needle aspiration (FNA) needle. After aspiration of the bile (to document the proper position of the needle), the contrast was injected to delineate the biliary anatomy. Then the guide-wire was advanced through the needle and directed back to the duodenum for subsequent placement of the biliary duct via major papilla (rendezvous technique). If the guide-wire could not pass through the major papilla, it was directed into the proximal biliary tree and a biliary stent was placed over the wire completing creation of the supra-papillary biliaryduodenal fistula. RESULTS: For the last 6 years (2004-2009) a total of 3245 patients with obstructive jaundice were referred to our endoscopy unit for ERC. Twenty of them underwent IEUC after ERC failure. The indications for ERC were pancreatic neoplasm (n⫽18) and impacted common bile duct stones (n⫽2). The causes for ERC failure were: inability to identify the papillary orifice (n⫽1), duodenal infiltration not allowing access to the major papilla (n⫽2), periampulary diverticula (n⫽6), papillary and distal common bile duct infiltration (n⫽9). In 18 of the 20 cases (90%) biliary decompression was achieved utilizing rendezvous technique (n⫽15) or creation of a biliary-duodenal fistula (n⫽3). In 2 cases (10%) billiary decompression was not possible due to extensive infiltration of distal common bile duct and duodenum. One patient developed
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minor bleeding during IEUC controlled with endoscopic hemostasis, and 2 patients had mild pancreatitis treated conservatively. CONCLUSION: IEUC is a safe and effective technique, which could become a valuable alternative to surgery or percutaneus transhepatic drainage when ERC is not possible.
T1466 EUS-Guided Band Ligation for Auto-Amputation of Superficial Upper Gastrointestinal Tract Lesions Julie Holinga, Michael K. Sanders, Kenneth E. Fasanella, Asif Khalid, Kevin Mcgrath Background: In addition to hemostasis, endoscopic band ligation (EBL) is used for the creation of pseudo-polyps to facilitate endoscopic resection with electrocautery. EBL without resection can be used to remove small lesions, which slough due to vascular constriction. This method of resection may confer a lower risk of bleeding and perforation. We report our experience with EUSguided EBL for auto-amputation of superficial gastrointestinal lesions of the esophagus, stomach and duodenum.Methods: A retrospective review was performed to identify patients who underwent EUS-guided EBL of superficial gastrointestinal lesions over a five year period. Patient characteristics, clinical history, endoscopic and EUS findings, pathology results (when available), complications, and findings on repeat surveillance endoscopy were reviewed. Results: Forty patients were identified: 14 males, 26 females, mean age 55.7 ⫾ 15 years [SD]. There were 13 esophageal lesions (7 stromal tumors, 6 granular cell tumors), 16 gastric lesions (15 stromal tumors, 1 carcinoid tumor) and 11 duodenal bulb lesions (all carcinoids). All lesions were incidental endoscopic findings. Pre-EUS diagnostic histology was present in 18 cases (all carcinoid and granular cell tumors). The diagnosis of stromal tumor was made by EUS appearance in the setting of previous non-diagnostic biopsies. The mean size of all lesions was 6.5 ⫾ 1.8 mm [SD](range 4 - 11 mm). 25 lesions were deep mucosal-based, 13 were submucosal, and 2 arose from the inner circular layer of the muscularis propria. One patient had 2 diminutive esophageal granular cell tumors. The patient with a gastric carcinoid carried a diagnosis of pernicious anemia. All lesions were successfully ligated with one band. To date, 25 patients have undergone follow up EGD at our institution, without evidence of a persistent lesion. Seven patients have follow up EGD still pending, 7 patients underwent follow up EGD locally, and 1 patient had no follow up (underwent RYGB). Mean time from banding to endoscopic follow up was 6.7 ⫾ 3.5 months [SD]. Two patients had post-procedure self-limited chest pain and abdominal pain, respectively. Conclusion: EUS-guided EBL is a safe, effective method for removal of small superficial gastrointestinal lesions, and may be a lower risk alternative to conventional resection with cautery. This may be an ideal modality for higher risk patients and for lesions in difficult locations. For lesions such as stromal tumors, EBL eliminates the need for surveillance EUS.
T1467 Metastatic Risk of Diminutive Rectal Carcinoid Tumors: A Need for Surveillance Rectal Ultrasound Julie Holinga, Asif Khalid, Kenneth E. Fasanella, Michael K. Sanders, Kevin Mcgrath Background: Endoscopic resection or local excision is reported to be curative for rectal carcinoid tumors ⱕ 10 mm in size. We report our experience with endoscopic rectal ultrasound (RUS) for assessment and surveillance of diminutive rectal carcinoid tumors. Methods: A retrospective review was performed to identify patients who underwent endoscopic rectal ultrasound to evaluate rectal carcinoid tumors over an 8 year period. Only rectal carcinoid tumors ⱕ 10 mm in size were included. Patient characteristics, clinical history, endoscopic and EUS findings, operative reports and pathology results were reviewed. Results: Twenty four patients were identified: 13 males, 11 females, mean age 56 ⫾ 11 years. All lesions were incidental endoscopic findings. Carcinoid tumor mean size was 5.8 ⫾ 3 mm. 14 lesions were removed by polypectomy, 7 lesions were removed by band-assisted EMR, and 3 lesions were removed by transanal resection. 17 of 24 patients have undergone RUS surveillance; mean follow up was 15.6 months. Two patients (8.3%) had a metastatic perirectal lymph node identified by surveillance RUS 17 and 26 months after initial tumor resection, respectively; each underwent EUS-FNA for cytologic confirmation. The former patient initially underwent transanal resection to remove a 5 mm carcinoid tumor with clear margins. A laparoscopic partial protectomy was ultimately performed after the metastasis (5 mm LN) was diagnosed by EUS-FNA, revealing 1/28 positive LNs. There was no pathologic evidence of residual neoplasm in the rectal wall. The latter patient underwent initial snare polypectomy of a 10 mm rectal polyp. Pathology revealed carcinoid tumor with a positive deep margin. After initial RUS was performed to exclude LNs, a transanal resection of the polypectomy site was performed; there was no pathologic evidence of residual tumor. This patient underwent eventual laparoscopic resection of the metastatic LN (5mm) with intraoperative EUS localization.Conclusions: Diminutive rectal carcinoid tumors have metastatic risk. In our series, 8.3% of patients developed metastatic perirectal lymph nodes detected by surveillance RUS. Based on our
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Abstracts findings, it may be reasonable to perform initial RUS surveillance 3 months after resection, then every 6 months for 2 years.
T1468 Neuroendocrine Tumors of Gastrointestinal Tract and the Pancreas: Diagnostic Modalities, Accuracy, and Outcomes Jeffrey H. Lee, Chandra S. Dasari, Singh Harvinder, Asif Rashid, Manoop S. Bhutani, Ramu P. Raju, Sathya Jaganmohan, James C. Yao, Alexandria Phan, Gottumukkala S. Raju Purpose:The aim of the study was to evaluate the utility of various diagnostic modalities including computed tomography (CT) scan, endoscopy, and endoscopic ultrasound (EUS) in neuroendocrine tumors (NET). Methods: Retrospective chart review of patients who underwent endoscopic evaluation from January 2003 to November 2009 at a cancer center. The accuracy of EUSguided fine needle aspiration (FNA) was evaluated. The T- and N- staging of NET by EUS was compared to histological staging. Results: A total of 226 patients (87 male), with a mean age 59.4 years were found to have GI NET. There were 50 patients with pancreatic endocrine neoplasm (PEN) including 5 with multiendocrine neoplasia 1 (MEN1), 66 gastric carcinoids, 40 with duodenal carcinoids, 34 small bowel carcinoid, 26 rectal carcinoids and 10 large bowel carcinoid. Among PEN, 5 were in uncinate process, 14 in the head, 3 in the neck, 8 in the body, and 15 in the tail, and 5 MEN1. The median size was 2.3 cm (range; 0.52-7cm) for PEN, 1cm (range: 0.3-4.2cm) for gastric carcinoids, 1cm (range: 0.2-7cm) for duodenal carcinoids, and 0.7 cm (range: 0.3-3 cm) for rectal carcinoids.EUS was performed in 125 patients. The CT findings were unremarkable in 93, positive for a mass in 61, and metastasis in 46. For patients with no abnormalities seen on CT scan (53 patients), EGD and sigmoidoscopy showed a discrete nodule or lesion in all patients. 46 had EUS for PEN; EUS FNA was performed in 33 and all were positive (accuracy 100%). EUS staging was compared to histologic staging for carcinoids and the accuracy for T- staging was 78.18 % with understaging of 7.27% and overstaging of 12.7 %. All carcinoids smaller than 1cm in the Stomach (8), duodenum (8), rectum (13) did not progress to metastatic disease in median follow-up period of 3.5 years (1-6 y) for stomach, 2 years (1-4 y) for duodenum, 4 years (1-6 y) for rectum. Among these, 18 underwent endoscopic mucosal resection, 5 surgical resection (3 gastric and 2 duodenal carcinoids), 4 polypectomies (4 rectal carcinoids), and 2 were observed (2 duodenal cardinoids). No complications were seen in endoscopic procedures.Conclusions: EUS FNA is highly accurate in diagnosis of PEN. Endoscopy is the most sensitive modality in detecting and diagnosing carcinoids smaller than 1cm. EUS was moderately accurate in establishing T-staging of carcinoids. Carcinoids, smaller than 1cm in the stomach, duodenum, and rectum did not behave aggressively in follow up.
T1469 The Use of Endoscopic Ultrasound in Differentiating Side Branch vs. Main Duct vs. Mixed Duct Intraductal Papillary Mucinous Neoplasm Cynthia L. Harris, Mokenge P. Malafa, Jill Weber, Jason B. Klapman Introduction:Intraductal Papillary Mucinous Neoplasms (IPMN) are categorized as main duct (MD), side branch (SB), or mixed (M) duct lesions. Endoscopic ultrasound (EUS) is routinely used to diagnose cysts of the pancreas; however, little is known on the accuracy of differentiating main duct versus side branch IPMN. The management of IPMNs are, in part, dependent on whether they are categorized as side branch or main duct origin. We hypothesize that EUS can differentiate MD-IPMN, SB-IPMN, and M-IPMN. Methods:An IRB-approved surgical IPMN database was reviewed to find all patients from 2000-2009 that had undergone preoperative EUS at H. Lee Moffitt Cancer Center. Seventy patients with surgical confirmation of IPMN and EUS were identified. EUS reports and pathology were reviewed. All surgical pathology specimens were identified as main duct, side branch, or mixed IPMN by an expert pathologist. Of the seventy patients identified, patients were included in the study if they had an EUS determination of main duct, side branch, or mixed IPMN on the EUS report.Results:Thirty six patients met eligibility for study inclusion. Eighteen patients had surgical pathology consistent with SB-IPMN. Fifteen of these were correctly identified by EUS (83%). Ten patients had surgical pathology consistent with MD-IPMN. EUS was accurate in six of these patients (60%). Finally, three of eight patients had EUS where M-IPMN was correctly identified (37.5%). Conclusions:EUS is highly accurate in diagnosing side-branch IPMN but its value in determining main duct or mixed duct IPMN is limited. Further studies are needed to determine the role of EUS in differentiating the sub-classifications of IPMN.
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T1470 Stylet Use Does Not Affect Adequacy of Specimen of Pancreatic EUS FNA: A Prospective, Single Blinded, Randomized, Control Trial Marcus W. Chin, Alan Coss, Mark Mcloughlin, Michael F. Byrne, Robert A. Enns, Jennifer J. Telford, Eric C. Lam Background: Endoscopic ultrasound fine needle aspiration (EUS FNA) is routinely performed with the stylet in place during puncture. The removal of the stylet has been shown to increase cellularity of the aspirate. There are no prospective, randomized, controlled data looking at whether stylet use or lack of, affects the adequacy of EUS FNA. Objective: To compare the adequacy of smears in the diagnosis of pancreatic masses at EUS FNA with and without the stylet in patients diagnosed by computed tomography (CT).Method: A prospective, single blinded, randomized, control trial. All patients with solid pancreatic masses underwent two FNA with and two without the stylet. The same site was punctured, with 15 in-out movements performed per puncture. To control for bloodiness of the sample introduced from multiple punctures, participants were randomized for the order in which this occurred. Pathologists were blinded to the manner of FNA, and were asked to assess the adequacy of the smear, and the histopathological diagnosis made from both smear and cell block. A power calculation was performed to detect a 30% difference in adequacy of specimen between stylet out vs in techniques. Participants with followed to surgery or clinically for at least six months. Results : In this ongoing study, 37 participants, with ages ranging 38-85 underwent EUS FNA. The distribution of masses were 30, 3 and 4 for the head, body and tail of pancreas, respectively. 20 participants were randomized to FNA with the stylet in for the first two passes followed by FNA with the stylet out. 17 participants underwent FNA in the reverse order. The adequacy of the smears with stylet in and out was 75.5% (28/37) for both groups. The sensitivity and specificity of EUS FNA for pancreatic masses is 91.9% and 100% respectively. The duration of follow up ranged from 2 to 48 weeks post EUS FNA.Conclusion: There is no difference in the adequacy of smear from EUS FNA with the stylet in or out for pancreatic masses detected at CT.
T1471 Comparison of EUS vs. Surgery for Placement of Fiducials in Patients With Pancreatic Cancer Tyler M. Berzin, Shounak Majumder, Anand Mahadevan, Rishi Pawa, James Ellsmere, Paul S. Sepe, Salvatore La Rosa, Douglas K. Pleskow, Ram Chuttani, Mandeep Sawhney Background: Cyberknife image-guided radiation therapy allows precise tumor targeting using real-time tracking of radiopaque fiducial markers, and is being used increasingly in patients with unresectable pancreatic cancer. To enable appropriate fiducial tracking by the Cyberknife system, it is recommended to place fiducials with ‘ideal fiducial geometry’ i.e. at least 3 fiducials with a minimum interfiducial distance ⬎2cm, minimum interfiducial angle ⬎15o and non-collinear placement in the imaging plane. Aim: To determine the safety of EUS for placing fiducials in pancreatic tumors and to compare fiducial placement accuracy of EUS and surgery (i.e. during staging laparoscopy). Methods: All patients who underwent EUS-guided or surgical implantation of fiducials for locally advanced pancreatic cancer between 9/05 and 7/09 at our institution were identified. We used dedicated Cyberknife tracking software and treatment data to evaluate two parameters of placement ‘accuracy’: 1) whether fiducial placement achieved ideal geometry, and 2) whether some or all of the implanted fiducials could be tracked by the Cyberknife system. Records were also reviewed for immediate or delayed complications of EUS-guided fiducial placement. Results: Of the 77 patients in our study, fiducials were implanted by EUS in 39 patients (51%), and surgery in 38 patients (49%). Cyberknife therapy using fiducial tracking was successful in 35/39 EUS (90%), and 31/38 surgical (82%) cases. The mean number of fiducials placed was 3.8⫹/-1.1, and the mean number of fiducials tracked was 1.6⫹/-1.0. Ideal geometry was achieved in 25/ 77 (32%) of patients. The proportion of patients with ideal fiducial geometry was significantly higher for surgery (18/38, 47%) compared to EUS-guided placement (7/39, 18%), p⫽0.0011. In the EUS group, there was a trend towards a higher likelihood of achieving ideal geometry for tumors in the pancreatic head/neck (26%) compared to the body/tail (6.2%), (p⫽0.06). Among EUS-guided cases, acute complications were noted in 5/39 (13%). 4/5 were minor, including abdominal pain (3) and vomiting (1). One patient developed mild pancreatitis requiring a 2-day admission. The mean duration of follow-up was 246 ⫹/- 258 days and there were no long term complications. Conclusion: EUS-guided fiducial placement is effective and safe. Technical improvements in EUS-guided fiducial placement may be needed to achieve ideal fiducial geometry. Although ideal fiducial geometry was achieved in less than one third of EUS cases, fiducials placed by EUS could still be tracked and used successfully for Cyberknife therapy in most patients.
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