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The role of endoscopic ultrasound guided fine needle aspiration (FNA) in Barrett’s esophagus with high-grade dysplasia (HGD)
S28
Abstracts
clinical importance of gastric pH relative to esophageal pH and reflux symptoms is unknown. Methods: GERD subjects and healthy volunteers underwent esophageal and intragastric dual pH monitoring. One probe placed 5 cm above manometrically determined LES and second 15 cm below in gastric fundus. Serial pH testings were performed at baseline, omeprazole 20 mg BID ⫻2 wks, omeprazole 20 mg BID⫹ranitidine 300 mg HS ⫻4 wks, omeprazole 20 mg QAM/QHS ⫻2 wks, and omeprazole 20 mg Q8 hrs ⫻2 wks. Symptoms assessed pre- and post-therapy. Results: 21 subjects (12 GERD / 9 normals) (13 M/8 F), mean age of 37 yrs (range 22–71 yrs) participated. 105 pH studies were performed (21 at baseline, 84 on medical therapy). Tracings on medical therapy displayed an overall mean downward shift of 1 pH unit compared to off medication. This was prevalent in 63% (30/48) and 55% (20/36) of GERD and normal subjects, respectively, resulting in artificially abnormal esophageal acid exposure (Fig A). Tracings re-analyzed correcting for this shift by using a pH ⬍ 3 (Fig B). Overall, supine esophageal acid exposure was normalized in 94% of tracings in GERD patients while elimination of nocturnal acid breakthrough occurred in only 23%. Importantly, all subjects were asymptomatic despite treatment course.
Conclusions: 1) Nocturnal acid breakthrough describes a gastric acid phenomenon which is independent of esophageal pH control or patient symptom improvement. 2) A shift in pH while on medical therapy is a new phenomenon requiring further investigation. 84 The role of endoscopic ultrasound guided fine needle aspiration (FNA) in Barrett’s esophagus with high-grade dysplasia (HGD) Rodney J Pacifico, MD, Kenneth K Wang, MD*, Navtej S Buttar, MBBS and Lori S Lutzke, LPN. 1Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States. Purpose: FNA is an important adjunct during endoscopic ultrasound (EUS), especially in staging GI cancers. Newer ultrasound probe technologies are being developed that will allow most endoscopists to adequately visualize mucosal lesions. We assessed if there was any role for FNA of lymph nodes that were visualized at EUS in Barrett’s esophagus with HGD, without any obvious malignancy (no masses seen). Methods: All patients from November 1998 to December 2000 who underwent EUS with an Olympus GF-UM20 or UM30 instrument for Barrett’s esophagus with HGD were included in the study although patients with obvious malignancies were excluded. FNA (minimum of 3 passes) was performed of any lymph node using the Olypus GF UC30P linear array instrument using the Wilson-Cook Echotip needle. Expert GI pathologists confirmed histological information. Cytological specimens were assessed for sufficiency of tissue (presence of lymphocytes)and presence of neoplastic cells. Results: A total of 14 patients (mean age ⫽ 69 ⫹/⫺9.42) were seen who had HGD within Barrett’s esophagus and no obvious malignancy. A total of 24 lymph nodes were found on EUS to be suspicious and underwent FNA. These were located in the periesophageal, mediastinal, celiac, subcarinal, perigastric, and periaortic regions. Three out of 14 had a positive FNA, all of which were non-esophageal neoplasms. Two were lung metastases and 1 was from a large cell lymphoma. These 3 showed evidence of their extra-esophageal malignancies via CT scan of the chest. Ninetythree percent (13/14) of the FNAs provided adequate tissue. One was acellular. Conclusions: In the setting of Barrett’s esophagus and HGD without obvious malignancy, EUS identified lymph nodes are most commonly
AJG – Vol. 96, No. 9, Suppl., 2001
benign or representative of extra-esophageal malignancies. FNA in this setting does not appear to be helpful in changing patient management unless there is a concern for extra-esophageal malignancies. 85 Role of clinical, endoscopic, and digital image analysis features in prediction of esophageal cancer among patients with dysplastic Barrett’s esophagus Rodney J Pacifico, MD, Navtej S Buttar, MBBS*, Kenneth K Wang, MD and Lori S Lutzke, LPN. 1Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States. Purpose: Objective morphometric parameters by digital image analysis (DIA) have shown to correlate with subjective assessment of degree of dysplasia in Barrett esophagus (BE). The role of these parameters in the prediction of cancer risk in dysplastic BE is unknown. Our aim was to assess the cancer risk based on clinical, endoscopic and image morphometric features. Methods: 107 patients diagnosed with dysplastic BE between 1990 –99 who had a surgical/endoscopic follow-up and had biopsy specimens available for DIA were eligible for study. Clinical information including medical/surgical treatments for reflux, BE length and nodularity in BE segment on endoscopy were collected. 200 representative nuclei from each biopsy were stained with Feulgen stain were captured and analyzed with the CAS 200 image analyzer (Bacus Labs, Lombard, IL). Percent of nuclei in various regions of the DNA histogram were recorded. DNA, morphometric, general nuclear, and textural features for individual nucleus were obtained using the Cell SheetTM software (Bacus Labs). The KaplanMeier method was used to estimate survival free of esophageal cancer starting from the date of diagnosis of dyplasia to the development of cancer or the date of last surgical or endoscopic follow-up. The clinical, pathologic, and DIA features were evaluated in univariate and multivariate Cox proportional hazards regression models to predict risk of esophageal cancer. Results: 21/100 patients progressed to esophageal cancer. The average (SD) duration from the diagnosis of dysplastic BE to esophageal cancer was 0.8 (1.1) yrs, ranging from 2 days to 3.4 yrs. The estimated survival free of esophageal cancer rates at 1, 2, 3, and 4 yrs were 81.5%, 81.5%, 79.8%, and 72.4%, respectively. On multivariate analysis absence of nodularity at endoscopy, percentage of diploid nuclei on image analysis, and a clinical history of suppression of acid reflux on medication were significantly associated with a lower risk of esophageal cancer. Endoscopic evidence of mucosal nodularity was associated with a 3.7-fold increased risk of esophageal cancer (p ⫽ 0.007). Increased numbers of diploid cells decreased the risk of esophageal cancer by 43% (p ⫽ 0.006). After adjusting for these factors, patients that had their symptoms of acid reflux completely suppressed had a 3.5 times lower risk of cancer compared to patients with no treatment (p ⫽ 0.011). Conclusions: Treatment of acid reflux, increased numbers of cells without gross genetic defects, and endoscopic evidence of nodularity at endoscopy may help to determine cancer risk in patients with Barrett esophagus. 86 Can age alter the thoracic duct diameter? An endosonographic study V.K. Parasher, M.D.1, M.S. Bhutani, M.D.2 1Christiana Care Medical Center, Wilmington, DE and 2University of Florida, Gainesville, FL Introduction: Aging affects the diameter of the common bile duct and the pancreatic duct. These changes are particularly more evident after the age of 60. The common bile duct is larger in older patients because of either lack of elastic fibers or from a proximal compensatory dilation due to sclerosis in the distal bile duct. The pancreatic duct similarly may be enlarged with aging probably because of parenchymal atrophy. The thoracic duct is made up of elastic tissue and smooth muscles and, therefore, conceivably can undergo similar age related changes. We have shown the
Abstracts
clinical importance of gastric pH relative to esophageal pH and reflux symptoms is unknown. Methods: GERD subjects and healthy volunteers underwent esophageal and intragastric dual pH monitoring. One probe placed 5 cm above manometrically determined LES and second 15 cm below in gastric fundus. Serial pH testings were performed at baseline, omeprazole 20 mg BID ⫻2 wks, omeprazole 20 mg BID⫹ranitidine 300 mg HS ⫻4 wks, omeprazole 20 mg QAM/QHS ⫻2 wks, and omeprazole 20 mg Q8 hrs ⫻2 wks. Symptoms assessed pre- and post-therapy. Results: 21 subjects (12 GERD / 9 normals) (13 M/8 F), mean age of 37 yrs (range 22–71 yrs) participated. 105 pH studies were performed (21 at baseline, 84 on medical therapy). Tracings on medical therapy displayed an overall mean downward shift of 1 pH unit compared to off medication. This was prevalent in 63% (30/48) and 55% (20/36) of GERD and normal subjects, respectively, resulting in artificially abnormal esophageal acid exposure (Fig A). Tracings re-analyzed correcting for this shift by using a pH ⬍ 3 (Fig B). Overall, supine esophageal acid exposure was normalized in 94% of tracings in GERD patients while elimination of nocturnal acid breakthrough occurred in only 23%. Importantly, all subjects were asymptomatic despite treatment course.
Conclusions: 1) Nocturnal acid breakthrough describes a gastric acid phenomenon which is independent of esophageal pH control or patient symptom improvement. 2) A shift in pH while on medical therapy is a new phenomenon requiring further investigation. 84 The role of endoscopic ultrasound guided fine needle aspiration (FNA) in Barrett’s esophagus with high-grade dysplasia (HGD) Rodney J Pacifico, MD, Kenneth K Wang, MD*, Navtej S Buttar, MBBS and Lori S Lutzke, LPN. 1Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States. Purpose: FNA is an important adjunct during endoscopic ultrasound (EUS), especially in staging GI cancers. Newer ultrasound probe technologies are being developed that will allow most endoscopists to adequately visualize mucosal lesions. We assessed if there was any role for FNA of lymph nodes that were visualized at EUS in Barrett’s esophagus with HGD, without any obvious malignancy (no masses seen). Methods: All patients from November 1998 to December 2000 who underwent EUS with an Olympus GF-UM20 or UM30 instrument for Barrett’s esophagus with HGD were included in the study although patients with obvious malignancies were excluded. FNA (minimum of 3 passes) was performed of any lymph node using the Olypus GF UC30P linear array instrument using the Wilson-Cook Echotip needle. Expert GI pathologists confirmed histological information. Cytological specimens were assessed for sufficiency of tissue (presence of lymphocytes)and presence of neoplastic cells. Results: A total of 14 patients (mean age ⫽ 69 ⫹/⫺9.42) were seen who had HGD within Barrett’s esophagus and no obvious malignancy. A total of 24 lymph nodes were found on EUS to be suspicious and underwent FNA. These were located in the periesophageal, mediastinal, celiac, subcarinal, perigastric, and periaortic regions. Three out of 14 had a positive FNA, all of which were non-esophageal neoplasms. Two were lung metastases and 1 was from a large cell lymphoma. These 3 showed evidence of their extra-esophageal malignancies via CT scan of the chest. Ninetythree percent (13/14) of the FNAs provided adequate tissue. One was acellular. Conclusions: In the setting of Barrett’s esophagus and HGD without obvious malignancy, EUS identified lymph nodes are most commonly
AJG – Vol. 96, No. 9, Suppl., 2001
benign or representative of extra-esophageal malignancies. FNA in this setting does not appear to be helpful in changing patient management unless there is a concern for extra-esophageal malignancies. 85 Role of clinical, endoscopic, and digital image analysis features in prediction of esophageal cancer among patients with dysplastic Barrett’s esophagus Rodney J Pacifico, MD, Navtej S Buttar, MBBS*, Kenneth K Wang, MD and Lori S Lutzke, LPN. 1Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States. Purpose: Objective morphometric parameters by digital image analysis (DIA) have shown to correlate with subjective assessment of degree of dysplasia in Barrett esophagus (BE). The role of these parameters in the prediction of cancer risk in dysplastic BE is unknown. Our aim was to assess the cancer risk based on clinical, endoscopic and image morphometric features. Methods: 107 patients diagnosed with dysplastic BE between 1990 –99 who had a surgical/endoscopic follow-up and had biopsy specimens available for DIA were eligible for study. Clinical information including medical/surgical treatments for reflux, BE length and nodularity in BE segment on endoscopy were collected. 200 representative nuclei from each biopsy were stained with Feulgen stain were captured and analyzed with the CAS 200 image analyzer (Bacus Labs, Lombard, IL). Percent of nuclei in various regions of the DNA histogram were recorded. DNA, morphometric, general nuclear, and textural features for individual nucleus were obtained using the Cell SheetTM software (Bacus Labs). The KaplanMeier method was used to estimate survival free of esophageal cancer starting from the date of diagnosis of dyplasia to the development of cancer or the date of last surgical or endoscopic follow-up. The clinical, pathologic, and DIA features were evaluated in univariate and multivariate Cox proportional hazards regression models to predict risk of esophageal cancer. Results: 21/100 patients progressed to esophageal cancer. The average (SD) duration from the diagnosis of dysplastic BE to esophageal cancer was 0.8 (1.1) yrs, ranging from 2 days to 3.4 yrs. The estimated survival free of esophageal cancer rates at 1, 2, 3, and 4 yrs were 81.5%, 81.5%, 79.8%, and 72.4%, respectively. On multivariate analysis absence of nodularity at endoscopy, percentage of diploid nuclei on image analysis, and a clinical history of suppression of acid reflux on medication were significantly associated with a lower risk of esophageal cancer. Endoscopic evidence of mucosal nodularity was associated with a 3.7-fold increased risk of esophageal cancer (p ⫽ 0.007). Increased numbers of diploid cells decreased the risk of esophageal cancer by 43% (p ⫽ 0.006). After adjusting for these factors, patients that had their symptoms of acid reflux completely suppressed had a 3.5 times lower risk of cancer compared to patients with no treatment (p ⫽ 0.011). Conclusions: Treatment of acid reflux, increased numbers of cells without gross genetic defects, and endoscopic evidence of nodularity at endoscopy may help to determine cancer risk in patients with Barrett esophagus. 86 Can age alter the thoracic duct diameter? An endosonographic study V.K. Parasher, M.D.1, M.S. Bhutani, M.D.2 1Christiana Care Medical Center, Wilmington, DE and 2University of Florida, Gainesville, FL Introduction: Aging affects the diameter of the common bile duct and the pancreatic duct. These changes are particularly more evident after the age of 60. The common bile duct is larger in older patients because of either lack of elastic fibers or from a proximal compensatory dilation due to sclerosis in the distal bile duct. The pancreatic duct similarly may be enlarged with aging probably because of parenchymal atrophy. The thoracic duct is made up of elastic tissue and smooth muscles and, therefore, conceivably can undergo similar age related changes. We have shown the