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Value of Dilation in the EUS Staging of Obstructing Esophageal Cancer
Abstracts
and CD34 immunostaining. For reference, endoscopic or surgical resection with histological examination was performed. Results: We enrolled 47 patients with submucosal tumors of the upper gastrointestinal tract. 42 patients were resected (10 esophageal, 29 gastral, 3 duodenal). The final histological results revealed 22 GISTs, 11 leiomyomas, 1 brunneroma, 1 hamartous cyst, 1 ectopic pancreas, 1 granulosa cell tumor, 1 bronchogenic cyst, 1 hamartom, 2 lipomas and 1 accessory spleen. 5 Patients refused surgery and were followed-up clinically. Only 4 submucosal tumors were resected endoscopically (2 leiomyomas, 1 lipoma and 1 bronchogenic cyst) and all GISTs were removed surgically. All GISTs were identified in the stomach and could be easily accessed by EUS-FNA. In 8 of 22 patients (36%) we could not obtain sufficient cellular tissue for further immunocytochemical analysis. Surprisingly, this sampling problem was unrelated to tumor size: the average size of GISTs with enough cells for immunocytochemical analysis was 37 mm versus 42 mm in those with less cellular material. All GISTs providing a sufficient number of cells were correctly identified as mesenchymal tumors, no false positive diagnosis occurred. Sensitivity, specificity, positive and negative predictive value of EUS-FNA was 100% each. Only 1/13 GISTs was not correctly classified by immunocytochemistry (typing accuracy 92,3%). No serious adverse events related to the fine needle aspiration were reported. Conclusions: EUSFNA is highly accurate for diagnosis and management of submucosal gastrointestinal tumors in the upper GI tract and reveals no adverse events. One remaining problem is the frequency of suboptimal aspirates for further immunocytochemical analyses. However, this problem may be overcome either by dedicated new needles, a stand-by cytopathologist, or a bed-side automated characterization of the specimen quality.
M1481 Value of Dilation in the EUS Staging of Obstructing Esophageal Cancer Adrian N. Holm, Henning Gerke Introduction: Endoscopic ultrasound (EUS) staging of esophageal cancer is often limited by a tumor stricture preventing passage of the endosonoscope, and thus evaluation of potential distal metastatic lesions. It remains controversial whether dilation should be performed to allow complete EUS examination in these cases. The objective of this study was to assess the benefit and safety this approach. Patients and Methods: 114 consecutive patients underwent EUS staging of esophageal cancer at our institution from 2004-2007. Data were retrospectively obtained regarding need for and success of dilation, cancer staging, sampling of lesions distal to the stricture, complications, type of endosonoscope used, and treatment recommendations. Results: 114 patients underwent EUS staging of esophageal cancer. 56 patients (49%) had strictures that prevented endosonoscope passage. Of those, 52 patients underwent dilation, which allowed successful passage of the echoendoscope in 41 (79% success rate). Dilation was performed to a median diameter of 15 mm (range 10-18 mm) with a balloon (n Z 5), Savary dilators (n Z 45) or both (n Z 2). Cases with an obstructing stricture were more often staged T3 or greater than those without an obstructing stricture (93% vs. 59%, p ! 0.001). Biopsy of additional structures distal to the stricture was performed in 14 of the 41 cases (34%) where distal endosonoscope passage was possible after dilation, and demonstrated M1a (n Z 7) or M1b disease (n Z 2) in 9 cases (22%). This altered the therapeutic recommendations in 8 patients (20%). Perforation occurred in 2 patients who underwent dilation and in one patient who did not undergo dilation. All perforations were managed conservatively. Conclusions: A tumor stricture requiring dilation for endosonoscope passage is a strong indicator of T3 disease or greater. Dilation provides the opportunity for identification of metastatic involvement which can justify the small risk of perforation. Detection of M1a and M1b status distal to the stricture altered management in most of our cases. However, this may be different at other institutions since treatment recommendations for patients with non-regional lymph node metastases are not uniform.
M1482 Yield of Endoscopic Ultrasound Guided Fine Needle Aspiration (EUS-FNA) in Diagnosing Submucosal Lesions of the Upper GI Tract Chris M. Hamerski, Amandeep K. Shergill, Mark Anthony A. De Lusong, Kenneth F. Binmoeller, Roy M. Soetikno, Lygia Stewart, Janak N. Shah Background: Determining the etiology of GI tract submucosal lesions can be difficult. EUS may help distinguish certain lesions based on imaging characteristics. But, EUS alone does not provide tissue diagnosis, and some lesions, such as GI stromal tumors (GISTs) and leiomyomas, appear similar on imaging. EUS-FNA provides a method for histologic sampling, but data on EUS-FNA yield for submucosal lesions are limited. Aim: To assess the diagnostic yield and accuracy of EUS-FNA in characterizing submucosal lesions in the upper GI tract. Methods: We reviewed medical records to identify all patients undergoing EUS-FNA for submucosal, intramural, solid-appearing lesions of the upper GI tract. The following data were recorded: patient characteristics, EUS findings, pathology results, and surgical findings. Data were analyzed to determine the diagnostic yield and accuracy of EUS-FNA. Results: EUS-FNA was performed for 66 solid-appearing, intramural upper GI tract lesions in 65 patients over a 4-year period. Mean patient age was 66 years, and about one-half were male (51%). Lesions were located in the esophagus (n Z 7), stomach (n Z 55), or duodenum (4). By EUS, most lesions were hypoechoic (92%), and measured !20 mm (n Z 22), 21-30 mm (n Z 16), 31-40 mm (n Z 18), or O40 mm (n Z 10). Most originated in the muscularis
AB222 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
propria by EUS (83%), and had smooth borders (94%). EUS-FNA based cytologic diagnosis was obtained in 45 of 66 (68%). The yield was higher for gastric (75%) as compared to esophageal (43%) or duodenal submucosal lesions (25%). Yield was lower for lesions !20 mm (45%) as compared to lesions O20 mm (80%). EUS-FNA diagnoses included: GIST (56%), leiomyoma (9%), carcinoma (2%), and nondiagnostic (32%). Diagnosis of GISTwas based on histology and c-kit staining. Based on final pathology from surgical (15) or endoscopic (4) resection of lesions, EUSFNA provided a correct diagnosis in 13 of 19 cases (68%), and was non-diagnostic in 6. EUS-FNA correctly diagnosed 10 of 13 (77%) GISTs (sample was insufficient in 3). There were no resection-proven, false positive EUS-FNA diagnoses. Performance characteristics for EUS-FNA in diagnosing GISTs were: sensitivity 77%, specificity 100%, positive predictive value 100%, negative predictive value 67%, and accuracy 84%. One EUS-FNA complication occurred: mild hemorrhage at FNA puncture site that was immediately recognized and treated endoscopically. Conclusion: EUS-FNA is a safe and useful tool to ascertain the etiology of submucosal, intramural lesions in the upper GI tract. It provides high yield in sampling submucosal lesions, and may be a practical and accurate method to diagnose GISTs.
M1483 EUS-Guided Ethanol Lavage with Paclitaxel Injection (EUS-EP) for Cystic Tumors of the Pancreas: Follow-Up Study with Analysis of Response and Its Predictor Hyoung-Chul Oh, Dong Wan Seo, Sang Soo Lee, Sung Koo Lee, Myung-Hwan Kim Background: Cystic tumors of the pancreas (CTP) are detected more and more frequently. It has become a challenging issue to make a management plan for CTP. A substantial proportion of CTP cannot be histologically classified even after extensive evaluation, and therefore ultimately require surgical resection. The pilot study of EUS-guided ethanol lavage reported that complete resolution was achieved in only one-third of patients. Therefore, more effective treatment modalities are required to improve treatment responses. Paclitaxel injection following ethanol lavage was suggested to achieve better response.1 The present study analyzed the response and safety of EUS-EP, and factors which may influence the treatment response among the larger study population. Methods: Nineteen patients were enrolled for EUS-EP by the following inclusion criteria; 1) uni- or oligolocular CTP, 2) indeterminate tumors for which EUS-FNA was required, and 3) CTPs showing size growth during the observation period. Under EUS-guidance, cyst fluid aspiration, ethanol lavage and injection of paclitaxel were performed. The safety of EUS-EP was analyzed by monitoring the patients till the first 30-day followup. All patients were followed for O 6 months, and the treatment response and its predictors were analyzed. Using CT images, the volume CTP was calculated by computer estimations of the areas on each axial image and slice thickness. Response is defined as follows; 1) complete resolution (CR): ! 5% of original volume (OV), 2) partial resolution (PR): 5 to 25% of OV, 3) persistent cyst: O 25% of OV. Results: The median diameter and volume were 25.0 mm (17-41 mm) and 3.1 mL (1.2-32.5 mL), respectively. Seven tumors were septated. The median CEA level was 58.0 ng/mL (1-8190). The presumed diagnoses were 6 MCNs, 4 SCAs and 9 indeterminate cysts. The median follow-up was 8 months. CR was observed in 15 patients, PR in 3 patients, and a cyst persisted in one patient. In addition, 4 patients with persistent cystic tumors showed gradual decrease in volume during follow-up. The original volume was significantly different between CR and persistent group. However, there was no difference in presence of septation, cyst fluid CEA level, number of MCN. Mild pancreatitis was observed in one patient. Conclusions: Smaller cystic tumor may be better achieved in CR than larger one. EUS-EP appears to be a safe and effective method for treating CTP. Further studies involving larger populations and longer follow-up are warranted.1. Oh HC, Seo DW, Lee TY, et al. New treatment for cystic tumors of the pancreas: EUS-guided ethanol lavage with paclitaxel injection. Gastrointest Endosc 2008 (in press)
M1484 Preliminary Study On EUS Guided Oncolytic Adenovirus Implantation in Patients of Advanced Pancreatic Cancer Qi Zhu, Kai Xu, Lu Xia, Jihong Tan, Huifang Xiong, Yiping He, Xi Chen, Hui Fu Objective: To observe the safety and therapeutic effect of oncolytic adenovirus H101 (ONCORINE) implantation under EUS guidance combined with gemcitabine in pts of advanced pancreatic cancer. Methods: 5 male pts(47-68 yrs, mean 60.6 yrs) with unresectable advanced pancreatic cancer were enrolled. 4 pts was in stage VI and 1 in stage III . 2 tumors located in the neck of pancreas, 2 in the tail and 1 in the head. KPS were 60-80%. H101 were deliveried locally into 3 sites of the lesion under EUS guidance with the dose of 1.51012vp on d1, combined gemcitabine(1000 mg/kg) on the d2, d9, d16, 1 mon was a circle. A total of 2 circles were given. Tumor volume and perfusion imaging including BF, BV, MTT, PS before and W2, M1, M2 after treatment were assessed by Helical CT scanning. Besides, Clinical index including laboratory examination, KPS, pain score ,CA19-9 etc were evaluated. Meanwhile, TTP of tumor, the MST, survival rate of 3, 6, 12 mons, and adverse events as well as complications were
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and CD34 immunostaining. For reference, endoscopic or surgical resection with histological examination was performed. Results: We enrolled 47 patients with submucosal tumors of the upper gastrointestinal tract. 42 patients were resected (10 esophageal, 29 gastral, 3 duodenal). The final histological results revealed 22 GISTs, 11 leiomyomas, 1 brunneroma, 1 hamartous cyst, 1 ectopic pancreas, 1 granulosa cell tumor, 1 bronchogenic cyst, 1 hamartom, 2 lipomas and 1 accessory spleen. 5 Patients refused surgery and were followed-up clinically. Only 4 submucosal tumors were resected endoscopically (2 leiomyomas, 1 lipoma and 1 bronchogenic cyst) and all GISTs were removed surgically. All GISTs were identified in the stomach and could be easily accessed by EUS-FNA. In 8 of 22 patients (36%) we could not obtain sufficient cellular tissue for further immunocytochemical analysis. Surprisingly, this sampling problem was unrelated to tumor size: the average size of GISTs with enough cells for immunocytochemical analysis was 37 mm versus 42 mm in those with less cellular material. All GISTs providing a sufficient number of cells were correctly identified as mesenchymal tumors, no false positive diagnosis occurred. Sensitivity, specificity, positive and negative predictive value of EUS-FNA was 100% each. Only 1/13 GISTs was not correctly classified by immunocytochemistry (typing accuracy 92,3%). No serious adverse events related to the fine needle aspiration were reported. Conclusions: EUSFNA is highly accurate for diagnosis and management of submucosal gastrointestinal tumors in the upper GI tract and reveals no adverse events. One remaining problem is the frequency of suboptimal aspirates for further immunocytochemical analyses. However, this problem may be overcome either by dedicated new needles, a stand-by cytopathologist, or a bed-side automated characterization of the specimen quality.
M1481 Value of Dilation in the EUS Staging of Obstructing Esophageal Cancer Adrian N. Holm, Henning Gerke Introduction: Endoscopic ultrasound (EUS) staging of esophageal cancer is often limited by a tumor stricture preventing passage of the endosonoscope, and thus evaluation of potential distal metastatic lesions. It remains controversial whether dilation should be performed to allow complete EUS examination in these cases. The objective of this study was to assess the benefit and safety this approach. Patients and Methods: 114 consecutive patients underwent EUS staging of esophageal cancer at our institution from 2004-2007. Data were retrospectively obtained regarding need for and success of dilation, cancer staging, sampling of lesions distal to the stricture, complications, type of endosonoscope used, and treatment recommendations. Results: 114 patients underwent EUS staging of esophageal cancer. 56 patients (49%) had strictures that prevented endosonoscope passage. Of those, 52 patients underwent dilation, which allowed successful passage of the echoendoscope in 41 (79% success rate). Dilation was performed to a median diameter of 15 mm (range 10-18 mm) with a balloon (n Z 5), Savary dilators (n Z 45) or both (n Z 2). Cases with an obstructing stricture were more often staged T3 or greater than those without an obstructing stricture (93% vs. 59%, p ! 0.001). Biopsy of additional structures distal to the stricture was performed in 14 of the 41 cases (34%) where distal endosonoscope passage was possible after dilation, and demonstrated M1a (n Z 7) or M1b disease (n Z 2) in 9 cases (22%). This altered the therapeutic recommendations in 8 patients (20%). Perforation occurred in 2 patients who underwent dilation and in one patient who did not undergo dilation. All perforations were managed conservatively. Conclusions: A tumor stricture requiring dilation for endosonoscope passage is a strong indicator of T3 disease or greater. Dilation provides the opportunity for identification of metastatic involvement which can justify the small risk of perforation. Detection of M1a and M1b status distal to the stricture altered management in most of our cases. However, this may be different at other institutions since treatment recommendations for patients with non-regional lymph node metastases are not uniform.
M1482 Yield of Endoscopic Ultrasound Guided Fine Needle Aspiration (EUS-FNA) in Diagnosing Submucosal Lesions of the Upper GI Tract Chris M. Hamerski, Amandeep K. Shergill, Mark Anthony A. De Lusong, Kenneth F. Binmoeller, Roy M. Soetikno, Lygia Stewart, Janak N. Shah Background: Determining the etiology of GI tract submucosal lesions can be difficult. EUS may help distinguish certain lesions based on imaging characteristics. But, EUS alone does not provide tissue diagnosis, and some lesions, such as GI stromal tumors (GISTs) and leiomyomas, appear similar on imaging. EUS-FNA provides a method for histologic sampling, but data on EUS-FNA yield for submucosal lesions are limited. Aim: To assess the diagnostic yield and accuracy of EUS-FNA in characterizing submucosal lesions in the upper GI tract. Methods: We reviewed medical records to identify all patients undergoing EUS-FNA for submucosal, intramural, solid-appearing lesions of the upper GI tract. The following data were recorded: patient characteristics, EUS findings, pathology results, and surgical findings. Data were analyzed to determine the diagnostic yield and accuracy of EUS-FNA. Results: EUS-FNA was performed for 66 solid-appearing, intramural upper GI tract lesions in 65 patients over a 4-year period. Mean patient age was 66 years, and about one-half were male (51%). Lesions were located in the esophagus (n Z 7), stomach (n Z 55), or duodenum (4). By EUS, most lesions were hypoechoic (92%), and measured !20 mm (n Z 22), 21-30 mm (n Z 16), 31-40 mm (n Z 18), or O40 mm (n Z 10). Most originated in the muscularis
AB222 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
propria by EUS (83%), and had smooth borders (94%). EUS-FNA based cytologic diagnosis was obtained in 45 of 66 (68%). The yield was higher for gastric (75%) as compared to esophageal (43%) or duodenal submucosal lesions (25%). Yield was lower for lesions !20 mm (45%) as compared to lesions O20 mm (80%). EUS-FNA diagnoses included: GIST (56%), leiomyoma (9%), carcinoma (2%), and nondiagnostic (32%). Diagnosis of GISTwas based on histology and c-kit staining. Based on final pathology from surgical (15) or endoscopic (4) resection of lesions, EUSFNA provided a correct diagnosis in 13 of 19 cases (68%), and was non-diagnostic in 6. EUS-FNA correctly diagnosed 10 of 13 (77%) GISTs (sample was insufficient in 3). There were no resection-proven, false positive EUS-FNA diagnoses. Performance characteristics for EUS-FNA in diagnosing GISTs were: sensitivity 77%, specificity 100%, positive predictive value 100%, negative predictive value 67%, and accuracy 84%. One EUS-FNA complication occurred: mild hemorrhage at FNA puncture site that was immediately recognized and treated endoscopically. Conclusion: EUS-FNA is a safe and useful tool to ascertain the etiology of submucosal, intramural lesions in the upper GI tract. It provides high yield in sampling submucosal lesions, and may be a practical and accurate method to diagnose GISTs.
M1483 EUS-Guided Ethanol Lavage with Paclitaxel Injection (EUS-EP) for Cystic Tumors of the Pancreas: Follow-Up Study with Analysis of Response and Its Predictor Hyoung-Chul Oh, Dong Wan Seo, Sang Soo Lee, Sung Koo Lee, Myung-Hwan Kim Background: Cystic tumors of the pancreas (CTP) are detected more and more frequently. It has become a challenging issue to make a management plan for CTP. A substantial proportion of CTP cannot be histologically classified even after extensive evaluation, and therefore ultimately require surgical resection. The pilot study of EUS-guided ethanol lavage reported that complete resolution was achieved in only one-third of patients. Therefore, more effective treatment modalities are required to improve treatment responses. Paclitaxel injection following ethanol lavage was suggested to achieve better response.1 The present study analyzed the response and safety of EUS-EP, and factors which may influence the treatment response among the larger study population. Methods: Nineteen patients were enrolled for EUS-EP by the following inclusion criteria; 1) uni- or oligolocular CTP, 2) indeterminate tumors for which EUS-FNA was required, and 3) CTPs showing size growth during the observation period. Under EUS-guidance, cyst fluid aspiration, ethanol lavage and injection of paclitaxel were performed. The safety of EUS-EP was analyzed by monitoring the patients till the first 30-day followup. All patients were followed for O 6 months, and the treatment response and its predictors were analyzed. Using CT images, the volume CTP was calculated by computer estimations of the areas on each axial image and slice thickness. Response is defined as follows; 1) complete resolution (CR): ! 5% of original volume (OV), 2) partial resolution (PR): 5 to 25% of OV, 3) persistent cyst: O 25% of OV. Results: The median diameter and volume were 25.0 mm (17-41 mm) and 3.1 mL (1.2-32.5 mL), respectively. Seven tumors were septated. The median CEA level was 58.0 ng/mL (1-8190). The presumed diagnoses were 6 MCNs, 4 SCAs and 9 indeterminate cysts. The median follow-up was 8 months. CR was observed in 15 patients, PR in 3 patients, and a cyst persisted in one patient. In addition, 4 patients with persistent cystic tumors showed gradual decrease in volume during follow-up. The original volume was significantly different between CR and persistent group. However, there was no difference in presence of septation, cyst fluid CEA level, number of MCN. Mild pancreatitis was observed in one patient. Conclusions: Smaller cystic tumor may be better achieved in CR than larger one. EUS-EP appears to be a safe and effective method for treating CTP. Further studies involving larger populations and longer follow-up are warranted.1. Oh HC, Seo DW, Lee TY, et al. New treatment for cystic tumors of the pancreas: EUS-guided ethanol lavage with paclitaxel injection. Gastrointest Endosc 2008 (in press)
M1484 Preliminary Study On EUS Guided Oncolytic Adenovirus Implantation in Patients of Advanced Pancreatic Cancer Qi Zhu, Kai Xu, Lu Xia, Jihong Tan, Huifang Xiong, Yiping He, Xi Chen, Hui Fu Objective: To observe the safety and therapeutic effect of oncolytic adenovirus H101 (ONCORINE) implantation under EUS guidance combined with gemcitabine in pts of advanced pancreatic cancer. Methods: 5 male pts(47-68 yrs, mean 60.6 yrs) with unresectable advanced pancreatic cancer were enrolled. 4 pts was in stage VI and 1 in stage III . 2 tumors located in the neck of pancreas, 2 in the tail and 1 in the head. KPS were 60-80%. H101 were deliveried locally into 3 sites of the lesion under EUS guidance with the dose of 1.51012vp on d1, combined gemcitabine(1000 mg/kg) on the d2, d9, d16, 1 mon was a circle. A total of 2 circles were given. Tumor volume and perfusion imaging including BF, BV, MTT, PS before and W2, M1, M2 after treatment were assessed by Helical CT scanning. Besides, Clinical index including laboratory examination, KPS, pain score ,CA19-9 etc were evaluated. Meanwhile, TTP of tumor, the MST, survival rate of 3, 6, 12 mons, and adverse events as well as complications were
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