Risk of developing gallbladder cancer in patients with gallbladder polyps detected on transabdominal ultrasound: a systematic review and meta-analysis.

OBJECTIVE: To estimate the risk of malignancy in gallbladder polyps of incremental sizes detected during transabdominal ultrasound (TAUS). METHODS: We searched databases including MEDLINE, Embase, and Cochrane Library for eligible studies recording the polyp size from which gallbladder malignancy developed, confirmed following cholecystectomy, or by subsequent follow-up. Primary outcome was the risk of gallbladder cancer in patients with polyps. Secondary outcome was the effect of polyp size as a prognostic factor for cancer. Risk of bias was assessed using the Quality in Prognostic Factor Studies (QUIPS) tool. Bayesian meta-analysis estimated the median cancer risk according to polyp size. This study is registered with PROSPERO (CRD42020223629). RESULTS: 82 studies published since 1990 reported primary data for 67,837 patients. 67,774 gallbladder polyps and 889 cancers were reported. The cumulative median cancer risk of a polyp measuring 10 mm or less was 0.60% (99% credible range 0.30-1.16%). Substantial heterogeneity existed between studies (I2 = 99.95%, 95% credible interval 99.86-99.98%). Risk of bias was generally high and overall confidence in evidence was low. 13 studies (15.6%) were graded with very low certainty, 56 studies (68.3%) with low certainty, and 13 studies (15.6%) with moderate certainty. In studies considered moderate quality, TAUS monitoring detected 4.6 cancers per 10,000 patients with polyps less than 10 mm. CONCLUSION: Malignant risk in gallbladder polyps is low, particularly in polyps less than 10 mm, however the data are heterogenous and generally low quality. International guidelines, which have not previously modelled size data, should be informed by these findings. ADVANCES IN KNOWLEDGE: This large systematic review and meta-analysis has shown that the mean cumulative risk of small gallbladder polyps is low, but heterogeneity and missing data in larger polyp sizes (>10 mm) means the risk is uncertain and may be higher than estimated.Studies considered to have better methodological quality suggest that previous estimates of risk are likely to be inflated.

Prognostic significance of novel ¹8F-FDG PET/CT defined tumour variables in patients with oesophageal cancer.

PURPOSE: (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) combined with computed tomography (PET/CT) is now established as a routine staging investigation of oesophageal cancer (OC). The aim of the study was to determine the prognostic significance of PET/CT defined tumour variables including maximum standardised uptake value (SUVmax), tumour length (TL), metastatic length of disease (MLoD), metabolic tumour volume (MTV), total lesion glycolysis (TLG) and total local nodal metastasis count (PET/CT LNMC). MATERIALS AND METHODS: 103 pre-treatment OC patients (76 adenocarcinoma, 25 squamous cell carcinoma, 1 poorly differentiated and 1 neuroendocrine tumour) were staged using PET/CT. The prognostic value of the measured tumour variables were tested using log-rank analysis of the Kaplan-Meier method and Cox's proportional hazards method. Primary outcome measure was survival from diagnosis. RESULTS: Univariate analysis showed all variables to have strong statistical significance in relation to survival. Multivariate analysis demonstrated three variables that were significantly and independently associated with survival; MLoD (HR 1.035, 95% CI 1.008-1.064, p=0.011), TLG (HR 1.002, 95% CI 1.000-1.003, p=0.018) and PET/CT LNMC (HR 0.048-0.633, 95% CI 0.005-2.725, p=0.015). CONCLUSION: MLoD, TLG, and PET/CT LNMC are important prognostic indicators in OC. This is the first study to demonstrate an independent statistical association between TLG, MLoD and survival by multivariable analysis, and highlights the value of staging OC patients with PET/CT using functional tumour variables.

EUS-FNA diagnosis of a pancreatic lymphoepithelial cyst: three-year imaging follow-up.

CONTEXT: Lymphoepithelial cyst of the pancreas is a rare benign lesion that should be managed conservatively. Similarity has been described between lymphoepithelial cyst and a branchial cyst of the neck. CASE REPORT: We report a 58-year-old man presenting with left sided abdominal pain initially thought to be renal colic. CT of the abdomen revealed a 3.5 cm lesion in the pancreatic tail. A laparoscopic distal pancreatectomy was initially planned for definitive treatment; however, endoscopic ultrasound guided fine needle aspiration (EUS-FNA) was performed prior to surgery as he had multiple co-morbidities. This confirmed the diagnosis of lymphoepithelial cyst, a benign lesion. Unnecessary high-risk surgery was therefore avoided. Three year follow-up has shown no adverse effects and the lymphoepithelial cyst is unchanged in size and appearance. CONCLUSION: EUS-FNA is a reliable method to confidently diagnose lymphoepithelial cyst and therefore should be used to exclude malignancy, thus avoiding unnecessary surgery with potential complications.

Endoluminal ultrasound of neoduodenum following pancreas-preserving total duodenectomy for familial adenomatous polyposis.

CONTEXT: Familial adenomatous polyposis affects around 2-10 per 100,000 population. Untreated, it inevitably leads to colon cancer. Prophylactic panproctocolectomy has led to improved survival. The resulting extension to follow-up has revealed that 70-100% of patients with familial adenomatous polyposis go on to develop duodenal polyposis and the lifetime risk of duodenal carcinoma in this group is up to 10%. Treatment for those not locally resectable requires pancreaticoduodenectomy. In recent years, pancreas-preserving total duodenectomy has emerged as a safe alternative to pancreaticoduodenectomy. Endoscopy has previously been safely performed in patients following pancreas-preserving total duodenectomy. CASE REPORT: We report successful endoscopic ultrasound (EUS) assessment and trans-neoduodenal EUS-guided fine needle aspiration biopsy (EUS-FNA) of the pancreas and adjacent tissue in a 45-year-old man with familial adenomatous polyposis who has previously undergone pancreas-preserving total duodenectomy. EUS confirmed the mass was most likely to represent a metastasis in a local lymph node. EUS-FNA confirmed invasive malignancy. A Kausch-Whipple pancreaticoduodenectomy was performed successfully and post-operative recovery has been excellent. CONCLUSION: The authors consider this to be the first report of successful EUS and EUS-FNA performed through the neoduodenum fashioned during pancreas-preserving total duodenectomy.

Selective use of endoscopic ultrasound in the evaluation of carcinomas of the pancreatic head.

BACKGROUND: The aims of this study were to assess the role of endoscopic ultrasound (EUS) in the evaluation of adenocarcinoma of the head of the pancreas in cases of diagnostic dilemma and to determine the strength of agreement between perceived pre-operative stage as determined by computerised tomography (CT) and EUS and histopathological stage. METHODS: Patients undergoing pancreatic EUS were identified from a computerised radiology database. The strengths of agreement between the radiological and histopathological stages were determined by the weighted kappa (Kw) statistic. RESULTS: Fifty-eight patients were identified. Of 37 patients with a pancreatic head mass on prior imaging, 32 had a diagnosis of adenocarcinoma confirmed by EUS, as did 11 of 21 patients with suspicious pancreatic head lesions. Twenty-five of 43 patients were deemed to have resectable carcinomas, and 2 patients had resectable mucinous lesions. In comparing CT and EUS in the 25 patients undergoing resection, the Kw for T and N stages was 0.250 (p = 0.05) and -0.080 (p = 0.288), respectively, for CT, compared with 0.738 (p = 0.0001) and 0.606 (p = 0.0001), respectively, for EUS. CONCLUSIONS: EUS was effective in assessing the resectability of pancreatic head adenocarcinomas. Furthermore, EUS held a significant 3-fold advantage over CT with regard to T stage and an even higher significant advantage with regard to N stage.

Prognostic significance of endoluminal ultrasound-defined disease length and tumor volume (EDTV) for patients with the diagnosis of esophageal cancer.

BACKGROUND: This study aimed to assess the prognostic significance of endoluminal ultrasound-defined total length of disease and endoluminal ultrasound defined tumor volume (EDTV) in esophageal cancer. The hypothesis was that endoscopic ultrasound (EUS)-defined total length of disease and EDTV are both significant prognostic indicators and better predictors of outcome than endoscopic tumor length. METHODS: In this study, 174 consecutive patients (median age, 64 years and 128 months) underwent specialist EUS, and the maximum potential EDTV was calculated (pir(2) L, where r is the tumor thickness and L is the total length of disease) including proximal and distal lymph node metastases. Of the 174 patients, 104 underwent surgery (70 had neoadjuvant chemotherapy), 60 underwent definitive chemoradiotherapy, and 10 had palliative therapy. RESULTS: Survival was related to EUS T stage (p = 0.013), EUS N stage (p = 0.001), EUS M1a stage (p = 0.004), EUS disease length (<8 cm; p = 0.001), and EDTV (all patients <25 cm(3), p = 0.001; surgical patients <40 cm(3), p = 0.036). Forward conditional multivariate analysis showed three factors to be associated with survival: EUS N stage (hazard ratio [HR], 1.646; 95% confidence interval [CI], 1.041-2.602; p = 0.033), EUS M1a stage (HR, 2.702; 95% CI, 1.069-6.830; p = 0.036), and EDTV (HR, 2.702; 95% CI, 1.069-6.830; p = 0.025). Median and 2-year survival for EDTV <25 cm(3) versus >25 cm(3) was 43.4 months and 56%, respectively, compared with 23.5 months and 35%. CONCLUSIONS: In this study, EDTV based on total EUS-defined length of disease emerged as a new and important prognostic indicator for patients with esophageal cancer.

The assessment of prognosis of surgically resected oesophageal cancer is dependent on the number of lymph nodes examined pathologically.

AIMS: The prognosis in surgically resected oesophageal carcinoma (OC) is dependent on the number of regional lymph nodes (LN) involved, but no guidance exists on how many LNs should be examined histopathologically to give a reliable pN status. The aim of this study was to determine whether the number of LNs examined after OC resection has a significant effect on the assessment of prognosis. METHODS AND RESULTS: Routinely generated pathology reports from 237 consecutive patients undergoing oesophagectomy for OC were examined and analysed in relation to survival. The main outcome measure was survival from date of diagnosis. Lymph node count (LNC) correlated strongly with survival; a plateau was reached after a count of 10. Median and 2-year survival was 30 months and 42%, respectively, if <10 nodes were examined (n = 88), compared with 51 months and 61% if >10 nodes were examined (P = 0.005). This effect was greatest in pN0 cases. The prognostic value of the absolute number of LN metastases (<4) and LN ratio (<0.4) was strongly dependent on a LNC of >10. CONCLUSIONS: These results demonstrate the importance of careful pathological examination and lymph node retrieval after OC resection. At least 10 nodes should be examined to designate an OC as pN0.

Endoscopic ultrasound reliably identifies chronic pancreatitis when other imaging modalities have been non-diagnostic.

CONTEXT: There are classical radiological features for the diagnosis of chronic pancreatitis when utilising endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT), however, not all patients exhibit these features despite convincing clinical histories, which may result in diagnostic delay. OBJECTIVE: The aim of this study was to assess the use of endoscopic ultrasound (EUS) in the diagnosis of chronic pancreatitis when other imaging modalities had not yielded a diagnosis. METHODS: All patients undergoing pancreatic EUS between January 1996 and December 2004 were identified from the radiology computerised database. Sixteen patients with a clinical diagnosis of chronic pancreatitis (10 males, 6 females; mean age 53+/-4 years) underwent EUS after normal conventional imaging. Patients were then followed clinically until December 2007. RESULTS: Thirteen patients exhibited features of chronic pancreatitis not identified by other modalities, which included duct dilatation (n=8), calcification (n=7); parenchymal change (n=6), irregular undilated ducts (n=2), pancreatic ductal calculi (n=1), and fine calcification (n=1). Of the remaining 3 patients, a diagnosis of autoimmune pancreatitis was made in one, in another there was a pancreatic duct stricture of uncertain origin that was stented, and in only one case was no diagnosis established. All 13 patients with an EUS diagnosis of chronic pancreatitis subsequently underwent a repeat CT scan for surveillance of their disease and in all cases, the CT scans subsequently demonstrated evidence of chronic pancreatitis indicating radiological progression. No new pancreaticobiliary diagnoses were established during this period. CONCLUSIONS: EUS is a useful diagnostic tool confirming the diagnosis of chronic pancreatitis in 13 of 16 cases where histories were suspicious of chronic pancreatitis, and providing an alternative diagnosis in another two cases. EUS should be considered an important tool for diagnosis of chronic pancreatitis and should be used when cross-sectional imaging is non-diagnostic.

Prognostic significance of endoscopic ultrasound-defined pleural, pericardial or peritoneal fluid in oesophageal cancer.

BACKGROUND: Endoscopic ultrasound (EUS) is known to detect smaller effusion volumes than computerised tomography (CT), yet the outcomes for patients diagnosed with oesophageal carcinoma and EUS-defined pleural, pericardial or ascitic fluid effusions (EDFE) are unknown. The aim of this study was to determine the outcome of multidisciplinary stage directed treatment for such patients. METHODS: Forty-nine (9.2%) out of a consecutive 527 patients diagnosed with oesophageal cancer from a single regional upper gastrointestinal (GI) cancer network were found to have evidence of EDFE undetected by CT. Thirty-nine (79.6%) patients had pleural effusions, eight (16.3%) pericardial effusions, and two (4.1%) ascites. RESULTS: Twelve (24.4%) underwent surgery, 3 (6.1%) received neoadjuvant chemotherapy without subsequent surgery, 12 (24.5%) received definitive chemoradiotherapy (dCRT), and 22 (44.9%) received palliative treatment. Survival in patients with EDFE was significantly shorter (median and 2-year survival 15.6 months and 24%, respectively) when compared with patients without EDFE (26.7 months and 40%, respectively, p = 0.001), and was unrelated to EDFE type (p = 0.192). Two-year survival after oesophagectomy with or without neoadjuvant therapy was 45% in patients with EDFE compared with 42% in patients without EDFE (p = 0.668). CONCLUSIONS: EDFE was an important adverse prognostic indicator, but patients deemed to have operable tumours should still be treated with radical intent.

Prospective comparison of the perceived preoperative computed tomographic, endosonographic and histopathological stage of oesophageal cancer related to body mass indices.

Pre-morbid weight loss and low body mass index (BMI) have been reported to be associated with decreased odds of misclassification of the defined stage of oesophageal cancer by endoluminal ultrasound (EUS). The aim of this study was to assess the strengths of agreement between the perceived preoperative radiological T and N stage compared with the final histopathological stage related to four categories of BMI (low <20, normal 20-24.9, high 25-30, and obese >30 kg/m(2)). One hundred sixty-six patients with oesophageal carcinoma were studied. Strength of agreement between the CT and EUS stages and histopathological stage was determined by the weighted kappa statistic (Kw). Kw for EUS T stage related to increasing BMI category was 0.840 (P = 0.0001) to 0.620 (P = 0.001), compared with 0.415 (P = 0.018) to 0.260 (P = 0.011) for CT. Kw for EUS N stage related to increasing BMI category was 0.438 (P = 0.067) to 0.513 (P = 0.010), compared with 0.143 (P = 0.584) to 0.582 (P = 0.030) for CT. EUS was good at predicting tumour infiltration irrespective of BMI when compared with CT, while CT N staging accuracy improved with higher BMIs. Multidisciplinary teams should be aware of these limitations when planning treatment strategies.

Study to determine adequate margins in radiotherapy planning for esophageal carcinoma by detailing patterns of recurrence after definitive chemoradiotherapy.

PURPOSE: To ascertain the adequacy of radiotherapy (RT) margins by studying the relapse patterns after definitive chemoradiotherapy for carcinoma of the esophagus. METHODS AND MATERIALS: We performed a retrospective study assessing the first site of disease relapse after definitive chemoradiotherapy that included four 3-weekly cycles of cisplatin and continuous infusion 5-fluorouracil, with conformal RT (50 Gy in 25 fractions) concurrent with Cycles 3 and 4. The RT planning target volume was the endoscopic ultrasonography/computed tomography-defined gross tumor volume with 1.5-cm lateral and 3-cm superoinferior margins. RESULTS: A total of 145 patients were included. Their average age was 65.4 years, 45% had adenocarcinoma, 61% had lower third esophageal tumors, and 75% had Stage III-IVA disease. After RT, of 142 patients, 85 (60%) had evidence of relapse at a median follow-up of 18 months. The relapse was local (within the RT field) in 55; distant (metastatic) in 13, and a combination of local and distant in 14. The local relapse rates were not influenced by tumor stage, lymph node status, or disease length. Three patients developed a relapse in regions adjacent to the RT fields; however, it is unlikely that larger field margins would have been clinically acceptable or effective in these cases. The median overall survival was 15 months. CONCLUSION: The gross tumor volume-planning target volume margins in this study appeared adequate. Future efforts to improve outcomes using definitive chemoradiotherapy should be directed toward reducing the high rates of in-field and distant relapses.

Transrectal ultrasound and the diagnosis of rectovaginal endometriosis: a prospective observational study.

BACKGROUND: Rectovaginal endometriosis is a severe form of pelvic endometriosis in which pharmacological treatment is relatively ineffective (Vercellini et al., Fertil Steril. 2005;84:1375-87). Laparoscopic surgical treatment is effective, but has the potential risks of bowel perforation and colostomy formation (Darai et al., Am J Obstet Gynecol. 2005;192:394-400). Transrectal ultrasound scanning can be applied as a preoperative tool to predict the presence of rectovaginal endometriosis and bowel wall involvement (Abrao et al., J Am Assoc Gynecol Laparosc. 2004;11:50-4). METHODS: Thirty-two women underwent transrectal ultrasound followed by therapeutic laparoscopy. Likelihood ratios and post-test prevalences were calculated with Fagan's normogram. This was then extrapolated with the aid of a mathematical model to a low-risk population. RESULTS: A positive likelihood ratio was found to be 10.89 (95% confidence ratio (CI): 1.62-73.15) and a negative likelihood ratio was found to be 0.24 (95% CI: 0.1-0.57). The pre-test prevalence of rectovaginal endometriosis was 56%. The positive post-test prevalence probability was 93%, and the negative post-test prevalence probability was 23%. CONCLUSION: Preoperative transrectal ultrasound scanning for rectovaginal endometriosis is an extremely accurate predictive test, and strongly predicts the need for extensive laparoscopic dissection and potential bowel resection.

Influence of socio-economic deprivation on outcomes for patients diagnosed with oesophageal cancer.

OBJECTIVE: To determine the influence of deprivation on outcomes for patients with oesophageal cancer. MATERIAL AND METHODS: A total of 1196 consecutive patients with oesophageal carcinoma presenting to a regional multidisciplinary team between 1 January 1998 and 31 August 2005 were studied prospectively and deprivation scores calculated using the Indices of Multiple Deprivation (IMD) of the National Assembly for Wales. The patients were subdivided into quintiles for analysis. RESULTS: Inhabitants of the most deprived areas (quintile 5) were younger at presentation (median age 67 years versus 70 years, p = 0.01) and were more likely to have squamous cell carcinomas (SCCs) (p = 0.002) in comparison with patients from the least deprived areas (quintile 1). Stage of disease and morbidity did not correlate with deprivation quintile, but operative mortality was greater in quintile 1 versus 5 (1.9% versus 5.8%, p = 0.281). Overall 5-year survival for those patients undergoing oesophagectomy was unrelated to deprivation quintile (1 versus 5, 24% versus 33%, p = 0.8246), but was lower following definitive chemoradiotherapy (dCRT) for the least deprived quintiles (1, 2 & 3 versus 4 & 5, 35% versus 16%, p = 0.0272). CONCLUSIONS: Although deprivation was associated with younger age, SCC and a trend towards higher operative mortality, survival after diagnosis and oesophagectomy were unrelated to deprivation.