The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience.

BACKGROUND: The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients. METHODS: The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses. RESULTS: EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement. CONCLUSION: EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.

Randomized controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy.

BACKGROUND: EUS-guided fine needle aspiration (EUS-FNA) is a highly accurate method of detecting malignant lymphadenopathy. The optimal methods for performing EUS-FNA to maximize sensitivity and to minimize the number of needle passes necessary are unknown. This is a report of the results of a prospective randomized controlled trial to determine the effect of suction, the site of FNA (edge or center of lymph node), and the method of preparation of cytologic specimens on accuracy, number of needle passes needed, and specimen quality. METHODS: Consecutive patients with lymphadenopathy detected by EUS underwent FNA. Each lymph node was sampled with or without suction and from the edge or center in a 2 x 2 factorial design. The samples were expressed onto slides for cytology, and the residual material in the needle was analyzed by the cytospin-cellblock technique. Each aspirate was individually characterized for a diagnosis of malignancy, cellularity, and bloodiness. RESULTS: Forty-three patients with a total of 46 lymph nodes were evaluated. The final lymph node diagnosis was benign in 22 (48%), "suspicious for malignancy" in 6 (13%), and malignant in 18 (39%). The use of suction was associated with an increase in the cellularity of the specimen, but did not improve the likelihood of obtaining a correct diagnosis (OR 1.52: 95% CI [0.81, 2.85]). Samples obtained with suction were of worse quality because of excessive bloodiness (OR 4.7: 95% CI [1.99, 11.24]). Aspiration from the edge of the lymph node (compared with the center) did not increase the likelihood of a correct diagnosis (OR 1.16: 95% CI [0.42, 3.21]). For 78% of malignant lymph nodes, the correct diagnosis was obtained on the first needle pass and for 100% by the third pass. Cytospin-cellblock methods did not add any additional diagnostic information compared with direct smear cytology. CONCLUSIONS: The traditional method of applying suction during EUS-FNA does not improve diagnostic accuracy and worsens specimen bloodiness compared with FNA without suction. The site of FNA within the lymph node does not affect accuracy. When EUS-FNA is necessary, our recommendation is up to 3 FNAs without suction from the most convenient and safe location within abnormal-appearing lymph nodes.

An assessment of the potential value of endoscopic ultrasound as a cost-minimizing tool in dyspeptic patients with persistent symptoms.

STUDY AIMS: To quantify resource utilization in dyspeptic patients with persistent symptoms and to determine whether using both the endoscopic and ultrasound capabilities of endoscopic ultrasound could reduce costs. METHODS: Consecutive patients with persistent dyspepsia, after a minimum 1-month trial of acid suppression, underwent endoscopic ultrasound (EUS) and upper endoscopy using the GF-UM20 echo endoscope. Assuming EUS could replace imaging tests which had been requested in addition to upper endoscopy, the hypothetical costs of the EUS-based and upper endoscopy-based strategies were compared. RESULTS: 116 patients with persistent dyspepsia underwent EUS, of whom 64.6 % had > or = 2 imaging procedures, most commonly computed tomography (CT) (70.6 %) and abdominal ultrasound (64.7 %). The number of tests did not correlate strongly with any demographic variables. The fiberoptic echo endoscope provided an adequate endoscopic and ultrasound examination but was damaged by retroflexion. Direct hospital costs were lowest for the EUS-based strategy. Total avoidable cost for 116 patients was $ 4137 to $ 14 121 (or $ 36 to $ 122 per patient), depending on whether upper endoscopy was performed in the non-EUS strategies. CONCLUSIONS: Patients with persistent dyspepsia may undergo multiple abdominal imaging procedures. Clinical variables do not predict the need for additional testing. An EUS-based strategy may reduce overall costs if it prevents additional testing.

Predictors of survival for esophageal cancer patients with and without celiac axis lymphadenopathy: impact of staging endosonography.

BACKGROUND: Esophageal cancer patients with M1a disease are reported to have poor survival. We hypothesized that patients with celiac lymph node metastases (CLN) identified by endoscopic ultrasonography (EUS) would predict a cohort with significantly worse survival postoperatively. Accurate preoperative identification of this group will facilitate future adjuvant studies. METHODS: During the study period, 211 patients with esophageal cancer underwent EUS staging. Patients with evaluable celiac axis (n = 182) were included in this study. Survival of patients with and without CLNs was compared and the factors affecting overall survival were assessed. A subgroup analysis based on CLN status was performed in the subgroup of patients who underwent surgical procedures. RESULTS: Follow-up data was available in 91.2% (166 of 182) of the patients. As staged by EUS, T1, T2, T3, and T4 tumors accounted for 9.3%, 11.5%, 56%, and 21% of the cases, respectively. At least one CLN was imaged by EUS in 40% (72 of 182). The 5-year survival in patients with CLNs detected by EUS was 13% (95% confidence interval, 5% to 21%) compared with 30% (95% confidence interval, 21% to 40%) in patients with no CLNs detected by EUS (p = 0.007). In the subgroup of patients who underwent surgical procedures (n = 68), patients with CLN involvement had worse survival compared with those who did not have malignant involvement of CLNs at the time of their operation (median survival 39.8 versus 13.8 months, p = 0.0008). In a Cox proportional model, adjusting for race and the type of therapy, patients with CLN involvement or advanced EUS American Joint Committee on Cancer stage were more likely to have worse survival (p < 0.05) CONCLUSIONS: EUS base line findings correlate with long term survival in patients with esophageal cancer. Patients with M1a disease as identified by EUS had a significantly worse postoperative survival when compared with non-M1a patients. This cohort of patients will be ideal for the study of induction therapy since the effect of down staging can be assessed before operation.

The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers.

BACKGROUND: Endoscopic ultrasound (EUS) is a minimally invasive, low risk method of diagnosis for chronic pancreatitis (CP). The degree to which endosonographers agree on the features and diagnosis of CP is unknown. For EUS to be considered an accurate test for CP, there must be good interobserver agreement. METHODS: Forty-five pancreatic EUS examinations were videotaped by 3 experienced endosonographers. Examinations from 33 patients with suspected CP based on typical symptoms, as well as 12 control patients without suspected CP, were included. Eleven experienced endosonographers ("experts") who were blinded to clinical information independently evaluated all videotaped examinations for the presence of CP and the following 9 validated features of CP: echogenic foci, strands, lobularity, cysts, stones, duct dilatation, duct irregularity, hyperechoic duct margins, and visible side branches. The experts also ranked (most to least) which features they believed to be the most indicative of CP. Interobserver agreement was expressed as the kappa (kappa) statistic. RESULTS: There was moderately good overall agreement for the final diagnosis of CP (kappa = 0.45). Agreement was good for individual features of duct dilatation (kappa = 0.6) and lobularity (kappa = 0.51) but poor for the other 7 features (kappa < 0.4). The expert panel had consensus or near consensus agreement (greater than 90%) on 206 of 450 (46%) individual EUS features including 22 of 45 diagnoses of CP. Agreement on the final diagnosis of CP was moderately good for those trained in third tier fellowships (kappa = 0.42 +/- 0.03) and those with more than 1100 lifetime pancreatic EUS examinations (kappa = 0.46 +/- 0.05). The presence of stones was regarded as the most predictive feature of CP by all endosonographers, followed by visible side branches, cysts, lobularity, irregular main pancreatic duct, hyperechoic foci, hyperechoic strands, main pancreatic duct dilatation, and main duct hyperechoic margins. The most common diagnostic criterion for the diagnosis of CP was the total number of features (median 4 or greater, range 3 or greater to 5 or greater). CONCLUSIONS: EUS is a reliable method for the diagnosis of chronic pancreatitis with good interobserver agreement among experienced endosonographers. Agreement on the EUS diagnosis of chronic pancreatitis is comparable to other commonly used endoscopic procedures such as bleeding ulcer stigmata and computed tomography of the brain for stroke localization and better than the physical diagnosis of heart sounds.

Imaging of esophageal tumors with a water-filled condom and a catheter US probe.

BACKGROUND: High-frequency catheter ultrasound (C-EUS) probes provide high resolution images of the gastrointestinal tract. Their use in the esophagus is limited by the requirement for a water-filled lumen for good acoustical coupling. We have developed a system using a condom that provides a continuous column of water for high resolution C-EUS imaging of the esophagus. METHODS: Nine patients underwent condom C-EUS for evaluation of esophageal mucosal and submucosal tumors. A standard latex condom was attached to a 2-channel endoscope and filled with water after esophageal intubation. A 20 MHz C-EUS probe placed within the water-filled condom was used to characterize all lesions. RESULTS: The condom C-EUS system provided a 360 degree, high resolution image throughout the length of the esophagus without air artifact and without the risk of aspiration associated with filling the esophageal lumen with water. Complete imaging of the tumor was obtained in all cases, and no additional C-EUS procedures were required. The condom C-EUS was subjectively rated superior overall in comparison to standard C-EUS by 4 independent endosonographers. CONCLUSIONS: Condom C-EUS is a new method of high resolution imaging of the esophagus. This method provides a contained column of water within the esophagus that improves image quality and ease of use and may reduce the risk of aspiration.

Dilation of malignant esophageal stenosis to allow EUS guided fine-needle aspiration: safety and effect on patient management.

BACKGROUND: Endoscopic ultrasonography (EUS) with fine-needle aspiration identifies patients with esophageal cancer who are unlikely to be cured by surgery. In approximately 30% of patients the staging procedure cannot be completed without dilation of an obstructing tumor. METHODS: All EUS examinations for esophageal cancer requiring dilation from July 1995 to December 1998 were included. Yield was defined as newly diagnosed metastatic (celiac lymph nodes) or locally invasive disease that could not have been detected without dilation. RESULTS: EUS was performed in 132 patients. Forty-two (32%) required 44 dilations. No complications occurred. Of the 42 patients with obstruction, 18 (43%) had celiac adenopathy of which 7 had malignant cells confirmed histologically, 3 had benign adenopathy, and 8 did not undergo fine-needle aspiration due to T4 stage disease (5) or intervening vessels (3). Two patients were upstaged after successful dilation from T2 N1 Mx to T4 N1 Mx and from T3 Nx Mx to T3 N1 M1. Overall, dilation allowed detection of advanced disease in 8 of 42 (19%) patients. Dilation to 11 to 12.8 mm was insufficient (36% success rate) to complete EUS compared with dilation to 14 to 16 mm (87%, p < 0.01). CONCLUSION: Dilation of obstructing esophageal tumors allows identification of a large number of patients with advanced stage malignancy. Dilation to 14 to 16 mm is sufficient for complete staging in almost all patients.

Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience.

BACKGROUND: Endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) is a recent innovation in the evaluation of gastrointestinal and pulmonary malignancies. AIMS: To review the experience with EUS-FNA of a large single centre. METHODS: 333 consecutive patients underwent EUS-FNA. Follow up data were available on 327 lesions in 317 patients, including 160 lymph nodes, 144 pancreatic lesions, 15 extraintestinal masses, and eight intramural tumours. RESULTS: A primary diagnosis of malignancy was obtained by EUS-FNA in 62% of patients with clinically suspicious lesions. The overall accuracy of EUS-FNA for the diagnosis of malignancy was 86%, with sensitivity of 84% and specificity of 96%. With respect to lesion types, the sensitivity, specificity, and accuracy were 85%, 100%, and 89% for lymph nodes; 82%, 100%, and 85% for pancreatic lesions; 88%, 100%, and 90% for perirectal masses; and 50%, 25%, and 38% for intramural lesions, respectively. Compared with size and sonographic criteria, EUS-FNA in the evaluation of lymph nodes provided superior accuracy and specificity, without compromising sensitivity. Inadequate specimens were obtained from only six patients, including 3/5 with stromal tumors. Only one complication occurred. CONCLUSIONS: EUS-FNA is safe and can readily obtain tissue specimens adequate for cytopathological diagnoses. Compared with size and sonographic criteria, it is a superior modality for the detection of nodal metastases. While providing accurate diagnosis of pancreatic and perirectal malignancies, results suggest the technique is less useful for intramural lesions.

Prospective assessment of the ability of endoscopic ultrasound to diagnose, exclude, or establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography.

BACKGROUND: Our aim was to verify endoscopic ultrasound (EUS) accuracy to diagnose, rule out, and establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients undergoing ERCP for unexplained abdominal pain and/or suspected chronic pancreatitis underwent EUS. EUS was performed by experienced operators who were aware of the history but blinded to ERCP results. Chronic pancreatitis was defined using the Cambridge classification: 0 to 1 = "normal," 2 to 4 = "all chronic pancreatitis," 3 to 4 = "moderate to severe chronic pancreatitis." The number of EUS criteria required to obtain sensitivity, specificity, positive and negative predictive values > or = 85% was determined. EUS criteria for chronic pancreatitis are hyperechoic foci, hyperechoic strands, lobularity, hyperechoic duct, irregular duct, visible side-branches, ductal dilation, calcification, and cysts. RESULTS: One hundred twenty-six patients underwent EUS and ERCP. EUS was highly sensitive and specific (> 85%) depending on the number of criteria present. Chronic pancreatitis is likely (PPV > 85%) when more than two criteria (for "all chronic pancreatitis") and more than six criteria (for "moderate to severe chronic pancreatitis") are present. "Moderate to severe chronic pancreatitis" is unlikely (NPV > 85%) when fewer than three criteria are present. Independent predictors of chronic pancreatitis were "calcification" (p = 0.000001), history of alcohol abuse (p = 0.002), and the total number of EUS criteria (p = 0.008). CONCLUSIONS: EUS can accurately diagnose, rule out, and establish the severity of chronic pancreatitis found by ERCP.

Local staging of anal and distal colorectal tumors with the magnetic resonance endoscope.

BACKGROUND: We prospectively assessed the feasibility and accuracy of endoscopic magnetic resonance (EMR) scanning in the local staging of anal and colorectal cancer as compared to endosonography. METHODS: Fifteen patients with biopsy-proven anal (n = 2), rectal (n = 11), and distal colonic (n = 2) cancer underwent endosonography followed by EMR imaging. Scans were acquired using the magnetic resonance receiver coil incorporated into the tip of the non-ferromagnetic endoscope. Blinded to endosonography results, two radiologists interpreted the EMR images using the TNM system. Staging results were compared to endosonography in all patients and to histopathology in the 13 colorectal cases. RESULTS: EMR imaging, well tolerated in all patients, correlated with endosonography in 10 of 15 and 12 of 15 cases for T- and N-staging, respectively. In the 13 colorectal patients with available histopathology, accuracy of EMR and of endosonography in T-staging was 77% and 85%, respectively; N-staging accuracy was 62% for both. CONCLUSIONS: For anal and distal colorectal neoplasms, EMR imaging is feasible and provides local staging comparable to endosonography.

Contrast-enhanced endoscopic ultrasonography with galactose microparticles: SHU508 A (Levovist).

BACKGROUND AND STUDY AIMS: To evaluate the utility of a suspension of galactose microparticles available as SHU508 A (Levovist) as a contrast agent during endoscopic ultrasonography (EUS). MATERIALS AND METHODS: Three sets of experiments were performed on three 20-25 kg swine (Sus scrofa) under general anesthesia. Upper EUS was performed with an echo endoscope with color Doppler capability (Pentax FG-32 UA). The celiac artery, superior mesenteric artery, aorta, portal vein, pancreas, and gastrointestinal wall were imaged by EUS. Multiple intravenous bolus injections of 400 mg/ml of SHU508 A were made, and their effect on color Doppler and gray-scale imaging during EUS was studied. RESULTS: After contrast injection there was a significant, visually noticeable enhancement of the color Doppler signals from the celiac artery, superior mesenteric artery, and portal vein. Vessels with weak to no color Doppler signals before injection of SHU508 A--for example, the celiac artery and superior mesenteric artery--were observed to have strong color signals after injection. The effect of SHU508 A on color Doppler imaging was easily appreciated subjectively without the need for complex quantitative measurements. No visually noticeable color Doppler enhancement was seen in vessels such as the aorta that had a very pronounced color Doppler signal even prior to the injection of contrast. Movement of particulate matter was seen in the portal vein on the gray scale. CONCLUSION: Intravenous SHU508 A as a contrast agent significantly enhances color Doppler signals during EUS. Vascualar contrast of this sort could potentially have a significant role in improving the accuracy of EUS in diagnosing malignant vascular invasion, the detection of occult pancreatic neoplasms, and the diagnosis of vascular thrombosis.

Endoscopic ultrasound guided fine needle aspiration of malignant pancreatic lesions.

PURPOSE: To evaluate the accuracy, safety, and clinical utility of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) of pancreatic masses. METHODS: Forty-seven patients were referred for EUS with a pancreatic mass and suspicion of pancreatic cancer based upon painless obstructive jaundice, epigastric abdominal pain plus weight loss/anorexia, or idiopathic pancreatitis. All patients underwent EUS with both radial (Olympus UM20) and linear array (Pentax FG32-UA) systems. After TNM staging by EUS, ultrasound directed FNA of the pancreatic mass was performed using a 23 gauge, 4 cm long needle. RESULTS: EUS-guided FNA was performed in all 47 patients. Results: successful targeting = 100%, adequate cellularity = 100%, FINDINGS: adeno Ca = 25, squamous cell Ca = 1, lymphoma = 1, poorly differentiated Ca= 1, atypical cytology or suspicious for carcinoma = 9, no malignant cells = 10. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-guided pancreatic FNA for the diagnosis of malignancy was 64%, 100%, 100% and 16% respectively. CONCLUSIONS: EUS with FNA is useful for detection of malignancy in a pancreatic mass. The procedure appears to have a complication rate of 2%. Impact of this technique on clinical management of patients needs further evaluation.