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Tu1662 Quantifying Endoscopic Ultrasound (EUS)-Guided Elastography for the Differential Diagnosis of Solid Pancreatic Masses: Hue-Histogram or Strain Ratio?
Abstracts
2014 and September 2014, 38 patients with PC, 27 patients with CP and 344 patients without pancreatic disease who underwent EUS were prospectively enrolled. EUS elastography was performed using linear Pentax EUS and Hitachi HI VISION Preirus. The quotient B/A (strain ratio; SR) is considered as the measure of the elastographic evaluation. Area A is representative of the pancreatic lesion strain. Area B refers to a soft peripancreatic tissue strain. The SR results were measured at the head and body, respectively. A total of 409 patients (mean age 58.2 years, 204 male) were included. The mean SR was 3.84 1.37 for normal, 9.54 6.93 for CP, 22.12 14.36 for PC. There was not significant linear correlation between the SR and patient’s age in normal pancreas. The SR was different significantly in three groups respectively (NP vs. CP; p!0.001, NP vs. PC; p!0.001, CP vs. PC; p ! 0.001). The area under the curve (AUC) of EUS elastography for diagnosing CP was 0.854 (95% confidence interval (CI) 0.804-0.904), the sensitivity and specificity was 81.5% and 83.2% (cut off SR of 5.81). The AUC of EUS elastography for PC was 0.986 (95% CI 0.973-0.998), the sensitivity and specificity was 94.7% and 98.7% (cut off SR of 9.15). In our study, we provided the reference range of SR value of normal pancreas, CP, and PC respectively as well as good parameters of the AUC analysis. Also, EUS elastography is a promising useful method for differentiating normal pancreas, CP and PC. Further research in this method is needed.
Tu1661 EUS Guided Needle Based Confocal LASER Endomicroscopy (nCLE): Preliminary Results From a Prospective, Multicenter Study of Pancreatic Cystic Lesions Divyesh V. Sejpal*1, Oleh Haluszka2, Frank G. Gress3, Kevin E. Woods4, Benley George1, Anil K. Vegesna1 1 Hofstra North Shore-LIJ School of Medicine, North Shore-LIJ Health System, Manhasset, NY; 2Temple University, Philadelphia, PA; 3Columbia University, New York, NY; 4Emory University, Atlanta, GA Introduction: Management of pancreatic cysts can be challenging when cyst fluid analysis and cytology are inconclusive. nCLE is a new imaging technique that enables microscopic observation of the wall of pancreatic cysts in real time during EUS-FNA. This technique can potentially differentiate between mucinous and nonmucinous lesions. Previous studies, INSPECT and CONTACT, have validated nCLE characteristics of intraductal mucinous neoplasms (IPMN) and serous cystadenomas (SCA). nCLE characteristics of pseudocysts have been described as heterogeneous sized bright particles but this has not been validated in studies. Purpose: To validate previous nCLE findings and to assess if nCLE can aid in the diagnosis of pancreatic pseudocysts. Methods: This is a prospective, multicenter, US based study which is ongoing. Patients with a pancreatic cyst over 2 cm were enrolled into the study over a period of 12 months. Following EUS examination, the AQ-Flex 19 miniprobe was introduced through a 19 gauge EUS needle and nCLE examination of the cyst wall and contents was performed in real-time. 2.5 cc of 10% IV fluorescein was given immediately prior to nCLE. After nCLE, fluid was aspirated through the 19 gauge needle and sent for analysis. Results: 16 patients were prospectively enrolled in the study (8 M, 8 F, Mean age of 62). Presumptive diagnosis based on imaging and EUS findings showed 37.5% pseudocysts, 25% IPMN, 25% SCA, and 12.5% mucinous cystadenoma (MCN). After nCLE the confidence in diagnosing pseudocysts and IPMN improved from good to excellent, while that of SCA and MCN remained the same. For pseudocysts, heterogeneous sized bright particles (83%) and small black floating particles (67%) were the most common findings. 4 of 6 patients (67%) with suspected pseudocysts were endoscopically drained (cyst-gastrostomy) based on clinical history and real-time imaging with nCLE. Final diagnosis of pseudocyst in combination of EUS, nCLE, fluid analysis was 100% consistent with nCLE findings. Table 1 shows the sensitivity, specificity, PPV, and NPV for nCLE and the various types of pancreatic cysts. Conclusions: nCLE can be a useful tool to help differentiate pancreatic cysts. Our results for characteristic findings of IPMN and SCA with nCLE are consistent with previous validated studies. Preliminary results show that nCLE findings of heterogeneous sized bright particles appear to correlate with pseudocysts. For suspected pancreatic pseudocysts that need drainage, nCLE can provide real-time video imaging before proceeding to endoscopic drainage, thus bypassing the need for fluid analysis before drainage. Further validations from larger studies are needed.
www.giejournal.org
Table 1.
Tu1662 Quantifying Endoscopic Ultrasound (EUS)-Guided Elastography for the Differential Diagnosis of Solid Pancreatic Masses: HueHistogram or Strain Ratio? Jose Lariño-Noia*1, Julio Iglesias-Garcia1, Ihab Abdulkader2,3, Enrique Dominguez-Munoz1 1 Gastroenterology, University Hospital. Foundation for research in digestive diseases, Santiago de Compostela, Spain; 2Pathology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain; 3 Foundation for research in digestive diseases, Santiago de Compostela, Spain Background and Aim: Quantitative EUS-elastography allows quantifying tissue stiffness during a standard EUS examination. Elastography is a very accurate technique supporting the diagnosis of malignancy in solid pancreatic lesions. Elastography result may be analyzed either by strain ratio (SR) or hue histogram analysis (HHA). Aim of the study was to evaluate the accuracy of SR and HHA for the differential diagnosis of solid pancreatic masses. Methods: A prospective, observational, comparative study was designed. 162 consecutive patients (mean age 63 years, range 17-89, 98 male), with a solid pancreatic mass at EUS were prospectively included. Elastography was performed with linear Pentax-EUS and Hitachi-Preirus. For HHA, the tumor area was selected and analyzed. The mass (area A) and a peripancreatic soft reference area (B) were selected for SR analysis (quotient B/A). Final diagnosis was based on surgical histopathology, or EUS-FNA/FNB and global clinical and radiological assessment at follow-up in non-operated cases. Data are shown as mean (95%CI) and analyzed by ANOVA. Diagnostic accuracy was calculated by drawing the corresponding ROC curves. Results: Size of masses was 35.017.8mm. Tumors were located in the head (nZ107), body (nZ45) and tail (nZ10) of the pancreas. Final diagnosis was pancreatic adenocarcinoma (nZ106), malignant neuroendocrine tumor (NET) (nZ9), benign NET (nZ4), pancreatic metastasis (nZ9), and inflammatory masses (nZ34). Results of HHA were 84.42 (76.4-92.45) in benign masses and 26.33 (24.7-28.0) in malignant tumors (p!0.001). SR was 8.73 (5.21-12.2) in benign masses and 43.90 (37.8-50.0) in malignant tumors (p!0.001). Sensitivity and specificity of SR for diagnosing malignancy were 100% and 92.1% (cut-off 9.74) (AUCZ0.942; 95%CI 0.88-1), and of HHA 100% and 92.1%, respectively (cut-off 62.0) (AUCZ0.961; 95%CI 0.91-1). There were no differences in terms of diagnostic yield between both methods. Conclusion: Elastography is a very useful tool for the diagnosis of malignancy in solid pancreatic masses. SR and HHA are equivalent in this setting.
Tu1663 Differential Diagnosis Between Benign and Malignant Gallbladder Lesions With Contrast-Enhanced Endoscopic Ultrasound Utilizing Intravenous Perfluorobutane Naoki Konno*1, Rei Suzuki1, Tadayuki Takagi1, Takuto Hikichi2, Ko Watanabe2, Jun Nakamura1, Mitsuru Sugimoto1, Hitomi Kikuchi1, Yuichi Waragai1, Hiroyuki Asama1, Mika Takasumi1, Katsutoshi Obara2, Hiromasa Ohira1 1 Gastroenterology and Rheumatology, Fukushima Medical University, Fukushima, Japan; 2Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan Background: Even though imaging findings in B-mode ultrasound or endoscopic ultrasound (EUS) imaging has been widely utilized to differentiate between benign and malignant gallbladder lesions (e.g., lesions with diameters R10 mm), new auxiliary technique has been researched to conquer its low specificity. In recent years, contrast-enhanced endoscopic ultrasound (CE-EUS) using second-generation contrast agents such as perfluorobutane has been reported as useful for differentiating between benign and malignant pancreatico-biliary lesions based on evaluation of enhancement pattern. Objective: To investigate the utility of CE-EUS in differential diagnosis between benign and malignant gallbladder lesions. Subjects: Between January 2012 and October 2014, 27 patients with elevated gallbladder lesions
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB549
2014 and September 2014, 38 patients with PC, 27 patients with CP and 344 patients without pancreatic disease who underwent EUS were prospectively enrolled. EUS elastography was performed using linear Pentax EUS and Hitachi HI VISION Preirus. The quotient B/A (strain ratio; SR) is considered as the measure of the elastographic evaluation. Area A is representative of the pancreatic lesion strain. Area B refers to a soft peripancreatic tissue strain. The SR results were measured at the head and body, respectively. A total of 409 patients (mean age 58.2 years, 204 male) were included. The mean SR was 3.84 1.37 for normal, 9.54 6.93 for CP, 22.12 14.36 for PC. There was not significant linear correlation between the SR and patient’s age in normal pancreas. The SR was different significantly in three groups respectively (NP vs. CP; p!0.001, NP vs. PC; p!0.001, CP vs. PC; p ! 0.001). The area under the curve (AUC) of EUS elastography for diagnosing CP was 0.854 (95% confidence interval (CI) 0.804-0.904), the sensitivity and specificity was 81.5% and 83.2% (cut off SR of 5.81). The AUC of EUS elastography for PC was 0.986 (95% CI 0.973-0.998), the sensitivity and specificity was 94.7% and 98.7% (cut off SR of 9.15). In our study, we provided the reference range of SR value of normal pancreas, CP, and PC respectively as well as good parameters of the AUC analysis. Also, EUS elastography is a promising useful method for differentiating normal pancreas, CP and PC. Further research in this method is needed.
Tu1661 EUS Guided Needle Based Confocal LASER Endomicroscopy (nCLE): Preliminary Results From a Prospective, Multicenter Study of Pancreatic Cystic Lesions Divyesh V. Sejpal*1, Oleh Haluszka2, Frank G. Gress3, Kevin E. Woods4, Benley George1, Anil K. Vegesna1 1 Hofstra North Shore-LIJ School of Medicine, North Shore-LIJ Health System, Manhasset, NY; 2Temple University, Philadelphia, PA; 3Columbia University, New York, NY; 4Emory University, Atlanta, GA Introduction: Management of pancreatic cysts can be challenging when cyst fluid analysis and cytology are inconclusive. nCLE is a new imaging technique that enables microscopic observation of the wall of pancreatic cysts in real time during EUS-FNA. This technique can potentially differentiate between mucinous and nonmucinous lesions. Previous studies, INSPECT and CONTACT, have validated nCLE characteristics of intraductal mucinous neoplasms (IPMN) and serous cystadenomas (SCA). nCLE characteristics of pseudocysts have been described as heterogeneous sized bright particles but this has not been validated in studies. Purpose: To validate previous nCLE findings and to assess if nCLE can aid in the diagnosis of pancreatic pseudocysts. Methods: This is a prospective, multicenter, US based study which is ongoing. Patients with a pancreatic cyst over 2 cm were enrolled into the study over a period of 12 months. Following EUS examination, the AQ-Flex 19 miniprobe was introduced through a 19 gauge EUS needle and nCLE examination of the cyst wall and contents was performed in real-time. 2.5 cc of 10% IV fluorescein was given immediately prior to nCLE. After nCLE, fluid was aspirated through the 19 gauge needle and sent for analysis. Results: 16 patients were prospectively enrolled in the study (8 M, 8 F, Mean age of 62). Presumptive diagnosis based on imaging and EUS findings showed 37.5% pseudocysts, 25% IPMN, 25% SCA, and 12.5% mucinous cystadenoma (MCN). After nCLE the confidence in diagnosing pseudocysts and IPMN improved from good to excellent, while that of SCA and MCN remained the same. For pseudocysts, heterogeneous sized bright particles (83%) and small black floating particles (67%) were the most common findings. 4 of 6 patients (67%) with suspected pseudocysts were endoscopically drained (cyst-gastrostomy) based on clinical history and real-time imaging with nCLE. Final diagnosis of pseudocyst in combination of EUS, nCLE, fluid analysis was 100% consistent with nCLE findings. Table 1 shows the sensitivity, specificity, PPV, and NPV for nCLE and the various types of pancreatic cysts. Conclusions: nCLE can be a useful tool to help differentiate pancreatic cysts. Our results for characteristic findings of IPMN and SCA with nCLE are consistent with previous validated studies. Preliminary results show that nCLE findings of heterogeneous sized bright particles appear to correlate with pseudocysts. For suspected pancreatic pseudocysts that need drainage, nCLE can provide real-time video imaging before proceeding to endoscopic drainage, thus bypassing the need for fluid analysis before drainage. Further validations from larger studies are needed.
www.giejournal.org
Table 1.
Tu1662 Quantifying Endoscopic Ultrasound (EUS)-Guided Elastography for the Differential Diagnosis of Solid Pancreatic Masses: HueHistogram or Strain Ratio? Jose Lariño-Noia*1, Julio Iglesias-Garcia1, Ihab Abdulkader2,3, Enrique Dominguez-Munoz1 1 Gastroenterology, University Hospital. Foundation for research in digestive diseases, Santiago de Compostela, Spain; 2Pathology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain; 3 Foundation for research in digestive diseases, Santiago de Compostela, Spain Background and Aim: Quantitative EUS-elastography allows quantifying tissue stiffness during a standard EUS examination. Elastography is a very accurate technique supporting the diagnosis of malignancy in solid pancreatic lesions. Elastography result may be analyzed either by strain ratio (SR) or hue histogram analysis (HHA). Aim of the study was to evaluate the accuracy of SR and HHA for the differential diagnosis of solid pancreatic masses. Methods: A prospective, observational, comparative study was designed. 162 consecutive patients (mean age 63 years, range 17-89, 98 male), with a solid pancreatic mass at EUS were prospectively included. Elastography was performed with linear Pentax-EUS and Hitachi-Preirus. For HHA, the tumor area was selected and analyzed. The mass (area A) and a peripancreatic soft reference area (B) were selected for SR analysis (quotient B/A). Final diagnosis was based on surgical histopathology, or EUS-FNA/FNB and global clinical and radiological assessment at follow-up in non-operated cases. Data are shown as mean (95%CI) and analyzed by ANOVA. Diagnostic accuracy was calculated by drawing the corresponding ROC curves. Results: Size of masses was 35.017.8mm. Tumors were located in the head (nZ107), body (nZ45) and tail (nZ10) of the pancreas. Final diagnosis was pancreatic adenocarcinoma (nZ106), malignant neuroendocrine tumor (NET) (nZ9), benign NET (nZ4), pancreatic metastasis (nZ9), and inflammatory masses (nZ34). Results of HHA were 84.42 (76.4-92.45) in benign masses and 26.33 (24.7-28.0) in malignant tumors (p!0.001). SR was 8.73 (5.21-12.2) in benign masses and 43.90 (37.8-50.0) in malignant tumors (p!0.001). Sensitivity and specificity of SR for diagnosing malignancy were 100% and 92.1% (cut-off 9.74) (AUCZ0.942; 95%CI 0.88-1), and of HHA 100% and 92.1%, respectively (cut-off 62.0) (AUCZ0.961; 95%CI 0.91-1). There were no differences in terms of diagnostic yield between both methods. Conclusion: Elastography is a very useful tool for the diagnosis of malignancy in solid pancreatic masses. SR and HHA are equivalent in this setting.
Tu1663 Differential Diagnosis Between Benign and Malignant Gallbladder Lesions With Contrast-Enhanced Endoscopic Ultrasound Utilizing Intravenous Perfluorobutane Naoki Konno*1, Rei Suzuki1, Tadayuki Takagi1, Takuto Hikichi2, Ko Watanabe2, Jun Nakamura1, Mitsuru Sugimoto1, Hitomi Kikuchi1, Yuichi Waragai1, Hiroyuki Asama1, Mika Takasumi1, Katsutoshi Obara2, Hiromasa Ohira1 1 Gastroenterology and Rheumatology, Fukushima Medical University, Fukushima, Japan; 2Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan Background: Even though imaging findings in B-mode ultrasound or endoscopic ultrasound (EUS) imaging has been widely utilized to differentiate between benign and malignant gallbladder lesions (e.g., lesions with diameters R10 mm), new auxiliary technique has been researched to conquer its low specificity. In recent years, contrast-enhanced endoscopic ultrasound (CE-EUS) using second-generation contrast agents such as perfluorobutane has been reported as useful for differentiating between benign and malignant pancreatico-biliary lesions based on evaluation of enhancement pattern. Objective: To investigate the utility of CE-EUS in differential diagnosis between benign and malignant gallbladder lesions. Subjects: Between January 2012 and October 2014, 27 patients with elevated gallbladder lesions
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB549