Endosonographic features of pancreatic metastases.

BACKGROUND: Pancreatic metastasis is a rare event. Surgical resection can provide long-term survival in selected cases. The aim of this study was to describe the endosonographic features of pancreatic metastases. METHODS: Among the 7000 endoscopic ultrasound (EUS) examinations of the pancreas performed between 1989 and 1993, 7 were performed in patients with pancreatic metastases that were histologically confirmed (6 by surgery, 1 by CT biopsy). Videotapes of the EUS procedures were re-examined. Metastases were from four renal cell carcinomas, one ovary carcinoma, one chondrosarcoma, and one neuroendocrine carcinoma of the gallbladder. RESULTS: A solitary lesion was imaged by EUS in six cases and 10 lesions were seen in one case. Fifteen of 16 lesions were slightly hypoechoic or isoechoic in comparison with the adjacent pancreas. They were homogeneous, round, well circumscribed and were associated with an enhancement of the ultrasonic beam. The association of these ultrasonographic patterns was different from that usually observed in cases of primary pancreatic carcinoma. In one case (ovary carcinoma), the lesion was hypoechoic, with heterogeneous infiltration and indistinct margins and with the marked attenuation of the ultrasonic beam that is commonly noticed in primary pancreatic carcinoma or in focal chronic pancreatitis. CONCLUSION: Endosonographic features of pancreatic metastasis are usually different from those observed in cases of pancreatic carcinoma.

Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP.

An accurate and safe preoperative method of imaging the common bile duct is essential for the proper diagnosis of calculous biliary tract disease, especially in the current era of laparoscopic cholecystectomy. The value of endoscopic ultrasonography in detecting common duct stones has been reported, albeit in small series. The aim of this retrospective study was to assess the accuracy of EUS in a large series of patients. We compared EUS to direct cholangiography in the evaluation of 422 patients for common duct stones. Ductal stones were imaged by EUS in 168 patients (43.4%). No complications were encountered. EUS failed in 2.3% of cases, ERCP failed in 8.3%, and surgical exploration failed in 0.5%. Comparison of EUS with surgical exploration in 185 patients showed a sensitivity of 94.9%, a specificity of 97.8%, and an accuracy of 95.9%. EUS was compared to ERCP in 219 patients. All common duct stones found by ERCP were evident by EUS. Concordance was obtained in 91.3% of cases. Review of videotapes disclosed 3 false-positives and 16 unequivocal true-positives. We conclude that EUS is a safe and highly accurate means of detecting common duct stones and should be proposed before laparoscopic cholecystectomy in patients at risk of choledocholithiasis.

[Digestive echo-endoscopy]. / L'écho-endoscopie digestive.

Since its introduction into clinical practice in 1980, echo-endoscopy has greatly contributed to improving our capacity to image the digestive tract and now plays a major role in management of digestive tract diseases. Echo-endoscopy is a second intention technique reserved for further investigation of lesions previously identified by endoscopy or other imaging techniques. All five layers of the wall and surroundings of the accessible structures (oesophagus, stomach, duodenum, rectum and colon) can be visualized. Evaluation of locoregional extension of cancer invasion is one of the predominant indications. For example, since the prognosis of tumours of the oesophagus are directly related to parietal and lymph node extension, echo-endoscopy would be indicated to precisely determine the tumoural stage and thus help in adapting therapeutic management. Today, it is generally accepted that echo-endoscopy is superior to computed tomography for staging tumours of the oesophagus and the cardia. For gastric and duodenal adenocarcinomas, the performance of echo-endoscopy is similar and can identify more readily superficial lesions accessible for photocoagulation. For adenocarcinoma of the rectum, echo-endoscopy can be used to identify the tumoural stage and local extension and thus help in therapeutic decision making. Other classical indications include the evaluation of submucosal tumefaction and biliopancreatic disorders (biliary lithiasis, pancreatitis, tumours). Thus for certain well-defined indications, echo-endoscopy is now the highest performing imaging technique currently available for lesions of the digestive tract. Operator experience is however a limiting factor, emphasizing the need for clinical training.

Endoscopic ultrasonography in the staging and follow-up of epidermoid carcinoma of the anal canal.

Epidermoid (squamous cell) carcinomas of the anal canal are relatively rare, accounting for less than 3% of all malignant tumors affecting the large intestine. Radiation therapy alone or combined with chemotherapy is the treatment of choice. To be effective, this requires initially correct staging and accurate follow-up. Endoscopic ultrasonography plays an essential role, which, during a period of 20 months, we applied to 20 patients. This made possible initial staging according to the TNM classification system. Follow-up examinations showed reduction in size of lesions in all cases. Three patients required early post-radiation surgical intervention because of rectal or vaginal invasion or lymph node metastases. Recurrence in 3 patients, evident by mural expansion on consecutive ultrasound examinations, was diagnosed at 6, 10, and 12 months. In all 6 patients requiring surgical intervention, good correlation was observed between ultrasonic images and operative findings.

Endoscopic ultrasonography in the local staging of primary gastric lymphoma.

Endoscopic ultrasonography (EUS) and endoscopy were prospectively performed and compared to the histopathologic findings of the resection specimens in 24 patients with primary gastric lymphoma (PGL). On EUS, three types of PGL could be differentiated, a superficial type (n = 10), an infiltrating type (n = 12) and a tumorous type (n = 2). In the correct assessment of surface extension of the tumors, endoscopy and EUS agreed in 37.5% of cases and EUS showed more extensive disease than endoscopy in 58% of cases. However, in comparison to the resection specimens, EUS still underestimated the tumor surface extension in 37.5% of cases; this was mainly in low grade malignant PGL. The depth of tumor infiltration was correctly determined on EUS compared to the resection specimens in 91.5% of cases. Sensitivity, specificity and accuracy of diagnosing lymph node metastases were 100%, 80% and 83%, respectively. We conclude that EUS is a useful pre-therapeutic staging tool for primary gastric lymphoma but there remain some problems in determining the longitudinal and circular tumor spread in order to accurately guide the extent of gastric resection.

Endoscopic ultrasonography in the diagnosis and staging of pancreatic adenocarcinoma. Results of a prospective study with comparison to ultrasonography and CT scan.

Endoscopic ultrasonography (EUS) was compared to ultrasonography (US) and CT scan (CT) in order to evaluate its role in the diagnosis and the locoregional spread assessment of pancreatic cancer. Sixty-four patients suspected of pancreatic cancer were studied prospectively, and the results of imaging techniques were compared to histology and surgical exploration. There were 49 cases of pancreatic adenocarcinoma, 11 of pancreatitis, 2 of common bile duct carcinoma, 1 lymphoma and 1 hepatocellular carcinoma with peripancreatic metastatic lymph nodes. EUS was significantly more accurate (91%) than CT (66%) and US (64%) for diagnosis of pancreatic cancer. EUS was able to image all 7 cancers less than 25 mm in diameter, US and CT only one. There were 4 false positives with EUS which were all cases of pseudotumorous pancreatitis. For detecting lymph node involvement, EUS was significantly more sensitive (62%) and accurate (74%) than US (8% and 37%) and CT (19% and 42%), respectively. Invaded lymph nodes adjacent to large tumors and micrometastatic involvement were responsible for this lack of sensitivity. EUS was significantly more sensitive (100%) than CT (71%) and US (17%) for detecting venous involvement. The specificity of EUS was lower (67%) because of duodenal bulb stenosis and large tumors. In conclusion, this prospective and comparative study confirms that EUS is an accurate tool for diagnosis and locoregional spread assessment of pancreatic cancer when performed in a reference center. EUS is of particular interest for small tumours. However, EUS does not enable differentiation of pseudotumorous pancreatitis from adenocarcinoma.

[Pancreatic endocrine tumors: contribution of ultrasound endoscopy in the diagnosis of localization]. / Tumeurs endocrines pancréatiques: apport de l'écho-endoscopie au diagnostic de localisation.

Endoscopic ultrasonography is a new imaging technique which has previously demonstrated its accuracy in localization of small pancreatic cancers. The aim of this retrospective study was to report our experience of this new method for localization of small endocrine tumors of potential pancreatic origin. Thirteen patients with insulinoma and 17 patients with Zollinger-Ellison syndrome were studied. All were imaged in a reference center by ultrasound (US) and CT scan (CT) before endoscopic ultrasonography. Insulinomas: 78.5% of tumors were 15 mm or less in size. The endoscopic ultrasonography was more accurate (79%) than US (7%) and CT (14%) for localization of the 14 tumors removed in the 13 patients who underwent surgery. Gastrinomas: Endoscopic ultrasonography was able to image 7 to the 9 pancreatic gastrinomas, the 2 duodenal gastrinomas, and the 2 gastrinomas located in peripancreatic lymph nodes which were removed in the 9 patients who underwent surgery. US and CT were able to image only one of the two peripancreatic lymph nodes. We concluded that endoscopic ultrasonography is a highly accurate tool for localization of small pancreatic endocrine tumors and should be performed early in the management of these tumors.

[Ultrasonic endoscopy of superficial epidermoid cancer of the esophagus]. / Echo-endoscopie du cancer épidemoïde superficiel de l'oesophage.

Superficial squamous cell carcinomas of the oesophagus are defined as cancers confined to the mucosa or involving the submucosa but sparing the muscularis mucosae, with or without lymph node extension. Although lymph node involvement is rare (less than 5%) in tumours confined to the mucosa, it is frequent (30 to 45%) in tumours involving the submucosa, which have a prognosis similar to that of the usual obstructive tumours. Endoscopic ultrasonography is the most accurate examination (diagnostic accuracy greater than 95%) to distinguish between superficial and advanced cancers. The absence of visualization of the muscularis mucosae with the currently available transducers limits the decision-making value of such a distinction except in the case of flat tumours in which the absence of ultrasonographically detectable parietal thickening indicates the presence of a cancer confined to the mucosa, with an excellent prognosis.

[Diarrhea with malabsorption and exudative enteropathy caused by intestinal myeloid involvement in a patient with myeloproliferative syndrome]. / Diarrhée avec malabsorption et entéropathie exsudative par infiltration myéloïde intestinale au cours d'un syndrome myéloprolifératif.

A 41-year-old woman with a myelodysplastic syndrome complained of diarrhea with malabsorption and protein-losing enteropathy after splenectomy. No cause was found and various therapeutic regimens were not effective. Pathological examination of biopsies from stomach, small intestine, and large bowel showed infiltrations interpreted as inflammatory on routine technics. Blast cell infiltration was found on electron microscopy. Treatment by citarabine induced normalization of leukocytosis, and diarrhea disappeared. Six months after the onset of illness, she developed acute myeloblastic leukemia and died of infectious pneumonia. Blastic infiltration of the lamina propria could be responsible for the determinism of symptoms, because of the lack of another etiology, the intensity of the blastic infiltration and the effect of cytotoxic therapy, even in the absence of new biopsies.

[Role of rectal endoscopic ultrasonography in the pre-therapeutical study of villous tumors]. / Place de l'écho-endoscopie rectale dans l'exploration pré-thérapeutique des tumeurs villeuses.

The staging of rectosigmoid villous adenomas is difficult when based only on clinical or endoscopic findings, even when superficial biopsies are taken. Echoendoscopy (EE) with a 7.5 and 12 MHz transducer heads provides good visualization of these lesions. The role of EE in the staging of villous adenomas presenting as benign lesions was prospectively studied. Among 47 patients who had an echoendoscopic investigation for villous adenoma during a 18 month period, 25 had lesions believed to be benign based on clinical and endoscopic findings. In 23 patients (group I, superficial biopsies showed no malignancy; in 2 patients (group II), with 3 lesions, biopsies were positive for in situ carcinoma. Comparisons were made between echographic images and operative specimens. A complete EE investigation was possible in all cases. In group I, there was one tumor T3N+ that was diagnosed by EE only. Twelve other patients had neoplastic lesions limited to the mucosa or submucosa only, and 10 had benign lesions. The integrity of the muscularis propria was imaged in all cases but EE did not differentiate benign lesions from neoplastic lesions invading the mucosa. In group II, parietal staging was correct in 2 of 3 cases. In addition to clinical examination and endoscopic investigations, EE seems useful in the staging of large or high located villous adenomas as well as for the best therapeutic choice.

Endoscopic ultrasonography in colorectal diseases.

Since new flexible high-frequency ultrasound endoscopes are now available, the use of this technique in colorectal disease has been determined. Its role in the preoperative staging of rectal cancer, and in follow-up after surgery has been established, but its use in cases of anal cancer and in non-neoplastic rectal diseases still has to be demonstrated more precisely.

[Intestinal ischemia after surgery of the infrarenal aorta. Apropos of 13 cases]. / Ischémie intestinale après chirurgie de l'aorte sous-rénale. A propos de treize cas.

Ischemic damage of the gastrointestinal tract following aorto-iliac surgery was estimated in a retrospective study. Between 1984 and 1988, we observed 13 cases of intestinal ischemia from a total of 416 surgical patients (3 per cent): 7 cases of full-thickness necrosis and 6 cases of transient ischemia. They represent 23 per cent of complications in ruptured aneurysmal surgery, 2.8 per cent in elective aneurysmal surgery, and 1.6 per cent in operations for obstructive lesions. All deaths (5/13) followed necrosis. Diarrhea, sometimes bloody, was the main symptom. Its sensitivity was 70 per cent, and its specificity was 98 per cent. Leukocytosis (greater than 10000/mm3), was noted in 70 p. cent of the cases of ischemia. The diagnosis was established by colonoscopy in 7 cases and by surgical examinations in 6 cases. The endoscopic injuries were ulcerations, punctate hemorrhages, and pseudomembranes localized in the sigmoid (77 p. cent), left colon (38 per cent) and small bowel (15 per cent). Of 13 patients, 6 developed intraoperative hypotension. This study confirms the gravity of intestinal ischemia after aortic surgery. In high risk patients (ruptured aortic aneurysm, intraoperative hypotension, postoperative diarrhea) endoscopy offers the possibility of early diagnosis and appropriate treatment.

[Endoscopic ultrasonography in the preoperative evaluation of rectal cancer. A prospective study in 31 patients]. / L'échoendoscopie dans le bilan préopératoire du cancer du rectum. Etude prospective chez 31 malades.

Endoscopic transrectal ultrasonography (EUS) is performed with an ultrasonic transducer (7.5 mHz or 12 mHz) situated in the tip of a side viewing endoscope. Its accuracy to assess the depth of rectal cancer invasion was studied prospectively in 31 patients. The ultrasonic examination was complete in 26 cases; in 5, the stricturing tumour could not be passed by the probe. The depth of invasion was correctly evaluated in 27 of the 31 patients (accuracy: 90 per cent). The 7 superficial lesions were all correctly detected with EUS. EUS appears to be a very promising method for the pretherapeutic staging of rectal cancer.

[Epithelial gastric polyps in a series of 13000 gastroscopies]. / Les polypes gastriques épithéliaux. Dans une série de 13,000 fibroscopies gastriques.

The frequency and characteristics of epithelial gastric polyps were studied over a 4-years periods. In a series of 13,000 gastric fibroscopies, 191 patients (1.3 per cent) were fund to have a "polypous lesion". Among these, 48 had hyperplastic polyps, 19 had fundic gland polyps and 6 had adenomatous polyps. The remaining patients had either lesions of interstitial gastritis (118) or normal histology (34). Hyperplastic polyps were 5 mm large in 87 per cent of the cases, and 7 out of 10 were solitary. They were equally distributed between fundus and antrum and associated with atrophic gastritis in 9 out of 22 cases. In 2 cases, they were accompanied with gastric cancer. Fundic gland polyps were less than 5 mm large in 84 per cent of the cases and solitary in 5 out of 19 cases. Adenomatous polyps were associated with hyperplastic polyps in 4 patients, including 1 mixed polyp (hyperplastic containing adenomatous areas). Follow-up with regular endoscopic examinations is accepted for adenomatous polyps; it seems to be justified in patients with hyperplastic polyps, and lesions bigger than 10 mm should be removed in view of the as yet imperfectly evaluated risk of malignant degeneration.

[Results of endoscopic ultrasonography in the preoperative assessment of rectal cancer]. / Résultats de l'échoendoscopie dans le bilan pré-opératoire du cancer du rectum.

Endoscopic transrectal ultrasonography is performed with an ultrasonic transducer (7.5 MHz or 12 MHz) in the tip of a side viewing endoscope. Its accuracy to assess the depth of rectal cancer invasion was prospectively studied in 27 patients. The ultrasonic examination was correct in 23 cases; in 4 cases, the stricturing tumour could not be passed by the probe. The depth of invasion was correctly appreciated in 24 of the 27 cases (accuracy of 89%). The 6 superficial lesions were all correctly detected with endoscopic transrectal ultrasonography. Therefore, endoscopic transrectal ultrasonography appears to be a very promising method in the pretherapeutic staging of rectal cancer.

[Endoscopic ultrasonic diagnosis and cancer of the esophagus. Results of a prospective comparative study with x-ray computed tomography in 51 surgically treated patients]. / Echoendoscopie et cancer de l'oesophage. Résultats d'une étude prospective et comparative avec la tomodensitométrie chez 51 malades opérés.

To investigate whether endoscopic ultrasonography could improve the preoperative staging of esophageal carcinoma we prospectively studied 56 tumors in 51 patients between March 1987 an March 1988. The results for assessing local and regional extension and preoperative staging were compared with those of computed tomography, surgery, and pathological findings. When the procedure was complete (n = 25) the accuracy of parietal spread assessment was 85.7 percent; sensitivity for nodal involvement was 83.3 percent versus 50 percent for computed tomography with an accuracy of 97.6 percent versus 96.4 percent; the discrimination between superficial and advanced cancer was 100 percent; the accuracy for preoperative staging using the Japanese classification was 84 percent. When the procedure was not complete (stenosis), endoscopic ultrasonography was complementary to computed tomography: local invasion of anatomical structures (n = 16) was better assessed by combined endoscopic ultrasonography and computed tomography (n = 11) than by endoscopic ultrasonography (n = 8) or computed tomography (n = 6) alone. We conclude that endoscopic ultrasonography is the best procedure for staging esophageal carcinoma without stenosis; further miniaturization of the transducer is necessary to improve results in the case of narrow stenosis.

[Intestinal lymphangiectasis secondary to cicatricial fibrosis of mesenteric nodes: a nosologic entity?]. / Les lymphangiectasies intestinales dues à la fibrose cicatricielle des ganglions mésentériques: un cadre nosologique à retenir?

Exsudative enteropathy was suspected in a 27-year-old man with lower limb edema, hypoprotidemia and hypoalbuminemia. Gastrointestinal mucosa, kidney, liver, and heart were normal. Laparoscopy showed diffuse small intestine lymphangiectasia. This diagnosis was confirmed by the microscopic examination of several biopsies obtained at laparotomy. Pathological examination of peritoneal, lymph nodes, and liver biopsies showed fibrous thickening of the peritoneum and fibrosis of the lymph nodes. Our patient has been followed for 16 years. Substantial improvement of clinical symptoms was obtained by following a special salt-free diet containing short-chain triglycerides. However biochemical abnormalities have persisted. Exsudative enteropathy due to intestinal lymphangiectasia may be observed in heart and liver diseases as well as in malignant affections of mesenteric lymph nodes. If these conditions are excluded, intestinal lymphangiectasia may be considered as a primitive lymph vessel malformation. The discovery of primitive intestinal lymphangiectasia in an adult cannot be attributed to congenital abnormalities alone. Fibrosis encountered in some cases suggests that an inflammatory process of unknown origin may trigger the onset of intestinal lymphangiectasia.

[Echoendoscopy: a new technic for studying esophago-gastric subepithelial tumors and extrinsic compression]. / L'échoendoscopie: une nouvelle technique d'exploration des tumeurs sous-épithéliales et des compressions extrinsèques oeso-gastriques.

The value of endoscopic ultrasonography in the diagnosis of subepithelial tumors and extrinsic compression of the esophagus and the stomach was evaluated in 34 patients with 21 subepithelial tumors and 13 extrinsic compressions. Endoscopic ultrasonography was always performed after axial-vision fiberscopy anal routine biopsy specimens were obtained. Computed tomography was also done in all cases of extrinsic compression. Distinction between subepithelial tumor and extrinsic compression was made in all patients by endoscopic ultrasonography and in 5 cases by fiberscopic examination with biopsy specimens. Localization and intramural spread of subepithelial tumors were correctly determined in 12 of 13 cases by endoscopic ultrasonography (diagnostic accuracy: 92 percent). The echoendoscopic semiology of 21 subepithelial tumors was retrospectively established. The histologic nature of some of these tumors can be suggested by these signs. Endoscopic ultrasonography is superior to computed tomography in the evaluation of esogastric extrinsic compressions, particularly in the diagnosis of posterior mediastinal carcinomatosis and of tumoral invasion of the deep parietal layers. We conclude that endoscopic ultrasonography is currently the best procedure in the assessment of subepithelial tumors and extrinsic compressions of the esophagus and the stomach.