- Email: [email protected]
Three-dimensional endoscopic ultrasonography: Evaluation of a desktop-based system
ENDOSCOPIC ULTRASOUND "~589
t591
P R O S P E C T I V E STUDY O N T H E V A L U E O F E N D O S O N O G R A P H I C FOLLOW-UP AFTER SURGERY FOR ESOPHAGEAL C A R C I N O M A . P.Fockens, C.G.Manshanden*, J.J.B.van Lanschot*, H.Obertop*, G.N.J.Tytgat, Department of Gastroenterology and Surgery*, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands Half o f the patients who undergo surgery for cancer o f the esophagus or gastric cardia with curative intent, present with recurrent disease within two years post-operatively. We investigated the value o f endosonography, performed every six months, for the early detection o f Iocoregional recurrent disease in asymptomatic patients. Patients & methods: Forty-three patients, median age 59 yr. (range 36-81), 31 males, who had undergone surgery with curative intent for cancer of the esophagus or gastric cardia, entered a follow-up protocol in which eodosonography was performed every six months within the first two years after resection. Patients who underwent dilatation therapy because of a stricture of the anastomosis had been excluded.Endosonography was performed with an Olympus echoendoscope (GF-UM20). Results: In 13 of the 43 patients (30 %) the first endosonographic examination failed because the cervical anastomosis could not be passed. During a total of 66 examinations, 16 patients were suspected of locoregional recurrent disease. In 3 patients free fluid was the only abnormality, no recurrence could be confirmed during a next year of followup. In 8 patients suspicious lymph nodes were seen. Six of them died within 6 months; one patient was alive with a proven recurrence at six months; one patient was alive without recurrence at 22 months. In 5 patients a focal wallthickening or an adjacent mass was seen, 3 died within six months, 2 were alive with a proven recurrence at 2 and 5 months. After exclusion of patients with only free fluid, the positive predictive value o f abnormalities on ES was 92 %. Four patients presented earlier than planned with symptoms suggestive o f a recurrence, which was proven in all 4 patients. Conclusion: Endosonography, performed at six month intervals after resection o f cancer of the esophagus or gastric cardia is accurate in the detection of Iocoregional recurrent disease. Two thirds of the patients were still asymptomatie when the recurrence was found. The finding of free fluid only was not associated with recurrent disease.
E N D O S C O P I C U L T R A S O N O G R A P H Y (EUS) A N D I N T R A D U C T A L U L T R A S O U N D (IDUS) I N P R E D I C T I N G HISTOLOGICAL DIAGNOSIS OF MUCIN-PRODUCING TUMOR OF THE PANCREAS T.FUJII, T.OBARA, H.MAGUCHI, S.TANNO, N.NISHINO, R.SHUDO, Y.KOHGO Third Department of Internal Medicine, Asahikawa Medical College, Asahikawa. Japan A I M S O F STUDY: Mucin-producing tumors(MPTs) of the'pancreas consist histopathologically of carcinoma, adenoma, and hyperplasia. We evaluated Endoscopic Ultrasonography(EUS) and Intraductal Ultrasound (IDUS) imaging to predict histological diagnosis of MPTs. P A T I E N T S AND M E T H O D S : Between 1988 and 1996, we have performed EUS in 99 consecutive patients with MPT and among those, 22 cases underwent IDUS. Included were MPTs of main duct type ( n = l l ) and branch duct type (n=88). EUS was performed using an Olympus GF-UM3 or GF-UM20 echoendoscope (7.5MHz/I2MHz). W e used two types of IDUS probes; 1) 12/20MHz. Olympus Co Ltd. 2) 15MHz. ALOKA Co Ltd. The results of EUS and IDUS were compared with the histology of MPTs. R E S U L T S : O f 99 MPTs examined with EUS, a definitive histologic diagnosis was made in 37 MPTs(main duct type:8, branch duct type:29). In 8 cases of main duct type, 5 were carcinoma and 3 were adenoma. In 29 cases of branch duet type, 14 were carcinoma, l I were adenoma, and 4 were hyperplasia. In main duct type, EUS revealed a protruded mass lesion(nodule)(3-60mm) in the main duct in all 8 cases. In branch duct type, average maximum-diameter of the cystic lesion was 3 lmm, 29ram and 18mm in carcinoma, adenoma and hyperplasia, respectively. And, average size of the nodule was 7.2ram, 6. l m m and 3mm in carcinoma, adenoma and hyperplasia, respectively. O f 29 nodules which were detected by EUS, 9(31%) and 13(45%) were demonstrated by US and CT, respectively. Histopathologically, main duct type consisted of carcinoma and adenoma. 86% (25129) of branch duct type were carcinoma or adenoma, and 92% ( 23/25cases ) of adenoma/careinoma in branch duct type were > 25mm in cyst size and/or > 6mm in nodule size on EUS. In branch duct type of cystic lesion >40mm, only carcinoma was found. These EUS findings were useful to distinguish adenoma/carcinoma from hyperplasia in branch duct type of MPTs(Sensitivity : 92%,specificity :100% and accuracy :100%). O f 12 MPTs in which nodule was noted on EUS, IDUS revealed nodule in 8(67%) cases. C O N C L U S I O N S : EUS proved to be highly accurate to reveal detailed structure of MPT compared with U S and CT. EUS images of cystic size and/or nodule size were highly predictive to differenciate adenoma/carcinoma from hyperplasia.
t590
592
THREE-DIMENSIONAL ENDOSCOPIC ULTRASONOGRAPHY: EVALUATION OF A DESKTOP-BASED SYSTEM R. Fded. C. Beglinger, H. Fischer, G. Stalder. Univ. of Basel, Switzerland The aim of this project was to develop a system for threedimensional reconstruction (3D) of endosonographic images for practical clinical use. The following requirements were predefined: desktop computer with a processing time of less than 20 min. The was tested In vitro and in vivo. thods: Senal image aquisition of conventional 2D-images was done by OLYMPUS EU-M20 with a mechanical stepping device mounted to a modified mouthpiece. 3D-image processing was performed with a Macintosh Ilci, a framegrabber and commercial software. In vitro examinations included volume estimation of simple geometrical and irregularly shaped objects. In vivo imaging of esOphageal lesions was performed in 11 patients. To minimize artifacts from aortic pulsations, image freezing was triggered by ECG to obtain images in diastole. Results: Mean (• time for sedal aquisition of 2D-images during endoscopy was 7.7 (• min. Post-precessin~ and reconstruction of 3D-images took 9.5 (• min. Volume eshmation in vitro was accurate with an error of 5-10 % and a correlation coefficient of r2=0.9. Slicing in orthogonal direction and at oblique angles facilitated visualization of lesions. .~Zg~_.q~.Y.: The system presented allows reliable 3D-reconstrucUon of endosonographic images. Aquisition of images is fast and prolongs endoscopic examination no more than 5-10 rain. 3Dreconstruction is performed on a desktop computer with available commercial software. Cost of the whole system does not exceed US$ 5000. 3D-reconstrucUon and post-processing of images can be accomplished within 10-15 min. Conclusions: Because of a short 3D-reconstruction time at the site of the examination, results of 3D-EUS are instantly available to guide treatment decisions. Additional information may be gained by slicing the 3D-block at different anQles. We used the OLYMPUS EU-M20, but the system can easily be adapted for use with other endosonographic systems such as a rigid anorectal probe oran EUS
mlniprobe.
AB172
GASTROINTESTINAL ENDOSCOPY
ECHOENDOSCOPYIN THE DIAGNOSISOT SUBMUCOUSTUMORS OF THE UPPER DIGESTIVETUBE AUTHORS: Ghigiieni M, Care L, Uehara H, Berenstein E. Depat~tent of Gastroenterology Hospital de Cllnicas Jos6 de San Martin, UBA C6rdoba 2351 (1120), Buenos Aires, ARGENTINA OBJECTIVE: Echoendoscopy is the method of choice in the diagnosis of the SMT's as it is the only imaging precedum capable of ix?resenting the histological layers of the wall. It can accur~ely determine the origin, extrusion end depth of the tumors. It is the primary diagnosis for these lesions, differentiating them from the extramurs] ones. The EUS influences the therapeutic behavior. MATERIAL AND METHODS: Between August 1993 and August 1996, 520 EUS were performed. In 78 subjects, it was indicated due to endoscopic suspicion of SMT's, later confirmed in 67 patients. Mean age was 56,4 years renglng between 17 end 92, 33 males and 34 fe~nales. 37 symptomatic patients: 17 patients with upper digestive hemonhage, 12 with epigastralgia, 2 with vomitin~ 2 with dysphagia end 4 with enemia. ~ne fmding was incidental in 22 patients and in 7 the indication is ua]mown. KESULTS:20 of the 67 SMT's were located in the esophagus (3 in the wpperthird, 7 in the medium third and 9 in the lower thkd). 46 in the stomach (14 in the fomix, l0 in the body and 22 in the antnun). 1 in the duodenum (2~a portion). According to the eehoge~u~pattern of the lesions fotmd end the layer of origin of the tumor, the following were diagnosed: 14 leiomyomas, 1 lipoma, 3 granular tumors and 2 nut diagnosed in the esophagus. 30 leiomyomas, 6 leinmyosarcomas, 4 lipomas, 4 ectopic paacress end 2 net diagnosed in the stomach. 1 leinmyoma in the duodenum. From the 11 SMT's initially suspected by endoscopy which show an integrity of the wall of tube, I without pathological findings.end 10 extrinsic compressions on the esophagus were 3 adenopathias and l intrathoracic boss. in the stomach, they correspended to the left lobe of the liver in 2, to vascular structures in 3 and to splenomegety in 1. To date, smgery was performed on 22 patients with SMT's complicated with ulcer and/or hemorrhage and on those larger then 3 cm, with an echogunia pattern, suspected of malignancy. 13 gastric leinmyomas, 2 gastric lipomas end I ectopic pancreas, with a 100 % conelatinu in the postresection histological studies, 2 Abricosoff tumors of the esophagus with a presurgical histological endoscopic diagnosis, 2 leinmyoesrcomas with 100% correiatien and I giant lipoma of the esophaguswhich resulted in a gestric llpoesrcoma, and 1 leiomyoma which resulted in a leiomyosal~omawere found. According to these results, 90 % diagnostic specificity end 100 % sensitivity make this imagingtechnique the ideal method to evaluate these lesions and one of the main indicminns together with the staging of gastrointestinal tumors.
VOLUME 45, NO. 4, 1997
t591
P R O S P E C T I V E STUDY O N T H E V A L U E O F E N D O S O N O G R A P H I C FOLLOW-UP AFTER SURGERY FOR ESOPHAGEAL C A R C I N O M A . P.Fockens, C.G.Manshanden*, J.J.B.van Lanschot*, H.Obertop*, G.N.J.Tytgat, Department of Gastroenterology and Surgery*, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands Half o f the patients who undergo surgery for cancer o f the esophagus or gastric cardia with curative intent, present with recurrent disease within two years post-operatively. We investigated the value o f endosonography, performed every six months, for the early detection o f Iocoregional recurrent disease in asymptomatic patients. Patients & methods: Forty-three patients, median age 59 yr. (range 36-81), 31 males, who had undergone surgery with curative intent for cancer of the esophagus or gastric cardia, entered a follow-up protocol in which eodosonography was performed every six months within the first two years after resection. Patients who underwent dilatation therapy because of a stricture of the anastomosis had been excluded.Endosonography was performed with an Olympus echoendoscope (GF-UM20). Results: In 13 of the 43 patients (30 %) the first endosonographic examination failed because the cervical anastomosis could not be passed. During a total of 66 examinations, 16 patients were suspected of locoregional recurrent disease. In 3 patients free fluid was the only abnormality, no recurrence could be confirmed during a next year of followup. In 8 patients suspicious lymph nodes were seen. Six of them died within 6 months; one patient was alive with a proven recurrence at six months; one patient was alive without recurrence at 22 months. In 5 patients a focal wallthickening or an adjacent mass was seen, 3 died within six months, 2 were alive with a proven recurrence at 2 and 5 months. After exclusion of patients with only free fluid, the positive predictive value o f abnormalities on ES was 92 %. Four patients presented earlier than planned with symptoms suggestive o f a recurrence, which was proven in all 4 patients. Conclusion: Endosonography, performed at six month intervals after resection o f cancer of the esophagus or gastric cardia is accurate in the detection of Iocoregional recurrent disease. Two thirds of the patients were still asymptomatie when the recurrence was found. The finding of free fluid only was not associated with recurrent disease.
E N D O S C O P I C U L T R A S O N O G R A P H Y (EUS) A N D I N T R A D U C T A L U L T R A S O U N D (IDUS) I N P R E D I C T I N G HISTOLOGICAL DIAGNOSIS OF MUCIN-PRODUCING TUMOR OF THE PANCREAS T.FUJII, T.OBARA, H.MAGUCHI, S.TANNO, N.NISHINO, R.SHUDO, Y.KOHGO Third Department of Internal Medicine, Asahikawa Medical College, Asahikawa. Japan A I M S O F STUDY: Mucin-producing tumors(MPTs) of the'pancreas consist histopathologically of carcinoma, adenoma, and hyperplasia. We evaluated Endoscopic Ultrasonography(EUS) and Intraductal Ultrasound (IDUS) imaging to predict histological diagnosis of MPTs. P A T I E N T S AND M E T H O D S : Between 1988 and 1996, we have performed EUS in 99 consecutive patients with MPT and among those, 22 cases underwent IDUS. Included were MPTs of main duct type ( n = l l ) and branch duct type (n=88). EUS was performed using an Olympus GF-UM3 or GF-UM20 echoendoscope (7.5MHz/I2MHz). W e used two types of IDUS probes; 1) 12/20MHz. Olympus Co Ltd. 2) 15MHz. ALOKA Co Ltd. The results of EUS and IDUS were compared with the histology of MPTs. R E S U L T S : O f 99 MPTs examined with EUS, a definitive histologic diagnosis was made in 37 MPTs(main duct type:8, branch duct type:29). In 8 cases of main duct type, 5 were carcinoma and 3 were adenoma. In 29 cases of branch duet type, 14 were carcinoma, l I were adenoma, and 4 were hyperplasia. In main duct type, EUS revealed a protruded mass lesion(nodule)(3-60mm) in the main duct in all 8 cases. In branch duct type, average maximum-diameter of the cystic lesion was 3 lmm, 29ram and 18mm in carcinoma, adenoma and hyperplasia, respectively. And, average size of the nodule was 7.2ram, 6. l m m and 3mm in carcinoma, adenoma and hyperplasia, respectively. O f 29 nodules which were detected by EUS, 9(31%) and 13(45%) were demonstrated by US and CT, respectively. Histopathologically, main duct type consisted of carcinoma and adenoma. 86% (25129) of branch duct type were carcinoma or adenoma, and 92% ( 23/25cases ) of adenoma/careinoma in branch duct type were > 25mm in cyst size and/or > 6mm in nodule size on EUS. In branch duct type of cystic lesion >40mm, only carcinoma was found. These EUS findings were useful to distinguish adenoma/carcinoma from hyperplasia in branch duct type of MPTs(Sensitivity : 92%,specificity :100% and accuracy :100%). O f 12 MPTs in which nodule was noted on EUS, IDUS revealed nodule in 8(67%) cases. C O N C L U S I O N S : EUS proved to be highly accurate to reveal detailed structure of MPT compared with U S and CT. EUS images of cystic size and/or nodule size were highly predictive to differenciate adenoma/carcinoma from hyperplasia.
t590
592
THREE-DIMENSIONAL ENDOSCOPIC ULTRASONOGRAPHY: EVALUATION OF A DESKTOP-BASED SYSTEM R. Fded. C. Beglinger, H. Fischer, G. Stalder. Univ. of Basel, Switzerland The aim of this project was to develop a system for threedimensional reconstruction (3D) of endosonographic images for practical clinical use. The following requirements were predefined: desktop computer with a processing time of less than 20 min. The was tested In vitro and in vivo. thods: Senal image aquisition of conventional 2D-images was done by OLYMPUS EU-M20 with a mechanical stepping device mounted to a modified mouthpiece. 3D-image processing was performed with a Macintosh Ilci, a framegrabber and commercial software. In vitro examinations included volume estimation of simple geometrical and irregularly shaped objects. In vivo imaging of esOphageal lesions was performed in 11 patients. To minimize artifacts from aortic pulsations, image freezing was triggered by ECG to obtain images in diastole. Results: Mean (• time for sedal aquisition of 2D-images during endoscopy was 7.7 (• min. Post-precessin~ and reconstruction of 3D-images took 9.5 (• min. Volume eshmation in vitro was accurate with an error of 5-10 % and a correlation coefficient of r2=0.9. Slicing in orthogonal direction and at oblique angles facilitated visualization of lesions. .~Zg~_.q~.Y.: The system presented allows reliable 3D-reconstrucUon of endosonographic images. Aquisition of images is fast and prolongs endoscopic examination no more than 5-10 rain. 3Dreconstruction is performed on a desktop computer with available commercial software. Cost of the whole system does not exceed US$ 5000. 3D-reconstrucUon and post-processing of images can be accomplished within 10-15 min. Conclusions: Because of a short 3D-reconstruction time at the site of the examination, results of 3D-EUS are instantly available to guide treatment decisions. Additional information may be gained by slicing the 3D-block at different anQles. We used the OLYMPUS EU-M20, but the system can easily be adapted for use with other endosonographic systems such as a rigid anorectal probe oran EUS
mlniprobe.
AB172
GASTROINTESTINAL ENDOSCOPY
ECHOENDOSCOPYIN THE DIAGNOSISOT SUBMUCOUSTUMORS OF THE UPPER DIGESTIVETUBE AUTHORS: Ghigiieni M, Care L, Uehara H, Berenstein E. Depat~tent of Gastroenterology Hospital de Cllnicas Jos6 de San Martin, UBA C6rdoba 2351 (1120), Buenos Aires, ARGENTINA OBJECTIVE: Echoendoscopy is the method of choice in the diagnosis of the SMT's as it is the only imaging precedum capable of ix?resenting the histological layers of the wall. It can accur~ely determine the origin, extrusion end depth of the tumors. It is the primary diagnosis for these lesions, differentiating them from the extramurs] ones. The EUS influences the therapeutic behavior. MATERIAL AND METHODS: Between August 1993 and August 1996, 520 EUS were performed. In 78 subjects, it was indicated due to endoscopic suspicion of SMT's, later confirmed in 67 patients. Mean age was 56,4 years renglng between 17 end 92, 33 males and 34 fe~nales. 37 symptomatic patients: 17 patients with upper digestive hemonhage, 12 with epigastralgia, 2 with vomitin~ 2 with dysphagia end 4 with enemia. ~ne fmding was incidental in 22 patients and in 7 the indication is ua]mown. KESULTS:20 of the 67 SMT's were located in the esophagus (3 in the wpperthird, 7 in the medium third and 9 in the lower thkd). 46 in the stomach (14 in the fomix, l0 in the body and 22 in the antnun). 1 in the duodenum (2~a portion). According to the eehoge~u~pattern of the lesions fotmd end the layer of origin of the tumor, the following were diagnosed: 14 leiomyomas, 1 lipoma, 3 granular tumors and 2 nut diagnosed in the esophagus. 30 leiomyomas, 6 leinmyosarcomas, 4 lipomas, 4 ectopic paacress end 2 net diagnosed in the stomach. 1 leinmyoma in the duodenum. From the 11 SMT's initially suspected by endoscopy which show an integrity of the wall of tube, I without pathological findings.end 10 extrinsic compressions on the esophagus were 3 adenopathias and l intrathoracic boss. in the stomach, they correspended to the left lobe of the liver in 2, to vascular structures in 3 and to splenomegety in 1. To date, smgery was performed on 22 patients with SMT's complicated with ulcer and/or hemorrhage and on those larger then 3 cm, with an echogunia pattern, suspected of malignancy. 13 gastric leinmyomas, 2 gastric lipomas end I ectopic pancreas, with a 100 % conelatinu in the postresection histological studies, 2 Abricosoff tumors of the esophagus with a presurgical histological endoscopic diagnosis, 2 leinmyoesrcomas with 100% correiatien and I giant lipoma of the esophaguswhich resulted in a gestric llpoesrcoma, and 1 leiomyoma which resulted in a leiomyosal~omawere found. According to these results, 90 % diagnostic specificity end 100 % sensitivity make this imagingtechnique the ideal method to evaluate these lesions and one of the main indicminns together with the staging of gastrointestinal tumors.
VOLUME 45, NO. 4, 1997