Sudden Increase in EtCO2 During Upper Endoscopy Under General Endotracheal Anesthesia Suggests the Presence of Tracheoesophageal Fistula: A Case Report.

Acquired tracheoesophageal fistula is a rare and devastating complication of lung cancer. The diagnosis is typically confirmed on barium esophagram. We report a case of a patient with lung cancer status after palliative chemoradiotherapy and esophageal stenting for malignant stenosis who presented with signs and symptoms suggestive of tracheoesophageal fistula; however, no evidence of fistula was found on barium esophagram. During subsequent esophagogastroduodenoscopy, the presence of a fistula was verified by capnography, given extreme elevations in end-tidal CO2 concentrations during endoscopic CO2 insufflation.

Endoscopic ultrasonography complements computed tomography in predicting portal or superior mesenteric vein resection in patients with borderline resectable pancreatic carcinoma.

BACKGROUND: Current guidelines recommend computed tomographic (CT) scans for vascular staging of patients with pancreatic carcinoma; however, endoscopic ultrasonography (EUS) in these patients is not required and its utility in combination with CT scan is less well-defined. The purpose of this study is to explore the utility of EUS in addition to CT in identifying patients with borderline resectable pancreatic carcinoma (BRPC). METHODS: We reviewed our database of patients with BRPC who went to surgery with curative intent. Inclusion criteria were preoperative staging with CT scan and EUS, completion of neoadjuvant chemotherapy and radiotherapy, and surgical resection. RESULTS: We identified 62 patients (average age of 65 ± 9 years, 60% male); 97% of patients underwent R0 resections. We found that 29% of patients were classified as BRPC by EUS alone, 23% by CT alone, and 48% by both modalities. Of 34 patients who required vein resection, EUS alone preoperatively identified 88% of these patients while CT alone identified 67%. EUS identified 11 patients who required vein resection that CT did not identify as BRPC, whereas CT identified 4 patients that EUS did not identify as BRPC. On multivariate analysis, EUS was associated with vein resection (P < 0.02), but CT scan findings, tumor size, and CA19-9 values were not associated (each P > 0.1). CONCLUSIONS: EUS complemented CT in identifying BRPC patients requiring vein resection, with nearly one-third of patients identified with EUS alone, supporting EUS use in addition to CT scan for vascular staging of patients with pancreatic carcinoma.

Endoscopic ultrasound-guided fiducial marker placement for image-guided radiation therapy without fluoroscopy: safety and technical feasibility.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound (EUS)-guided fiducial marker placement for image-guided radiation treatment (IGRT) is becoming more widespread. Most case series report the procedure performed using fluoroscopy for spatial geometry although the benefits of this are unclear. The aim of our study is to report the technical feasibility, safety, and migration rate of fiducial marker placement in a large cohort of patients with gastrointestinal malignancies who underwent EUS-guided fiducial marker placement for IGRT without fluoroscopy. PATIENTS AND METHODS: A retrospective chart review was performed on all patients referred for EUS-guided fiducial marker placement from 08/1/07 to 7/31/14 at Moffitt Cancer Center. RESULTS: During the study period, 514 patients underwent placement of 1093 gold fiducial markers under EUS-guidance. Two hundred and forty patients with esophageal/gastro-esophageal junction cancer had 405 fiducials placed. In 188 patients with pancreatic ancer, 510 fiducials were placed. In 54 patients with rectal cancer, 103 fiducials were placed and 32 patients had 75 fiducials placed into other gastrointestinal tract lesions. Minor bleeding, which resolved spontaneously, occurred in two patients. Technical difficulty in placing fiducials was noted in 18 patients. Intraprocedural fiducial migration was noted in two patients and only 2/1093 fiducials (.002%) in two esophageal patients migrated as noted on simulation computed tomography scan. CONCLUSIONS: EUS-guided fiducial marker placement without fluoroscopy is technically feasible and safe. There were minimal intraprocedure/post-procedure complications. Imaging at the time of simulation also revealed the migration rate to be extremely low. These results may allow for more widespread adoption of EUS-guided fiducial marker placement.

Radiosensitivity index predicts for survival with adjuvant radiation in resectable pancreatic cancer.

BACKGROUND AND PURPOSE: Adjuvant radiation therapy for resectable pancreatic cancer remains controversial. Sub-populations of radiosensitive tumors might exist given the genetic heterogeneity of pancreatic cancers. We evaluated whether RSI is predictive of survival in pancreatic cancer treated with radiation. MATERIALS AND METHODS: We identified 73 genomically-profiled pancreas cancer patients treated with upfront surgery between 2000 and 2011 (48 radiation, 25 no radiation). Briefly, RSI score is derived from the expression of 10 specific genes and a linear regression algorithm modeled on SF2 of 48 cancer cells. The primary endpoint was to assess the association of RSI with overall survival. RESULTS: Median follow-up was 67months for surviving patients. On multivariate analysis, patients with radioresistant tumors had a trend toward worse survival (Hazard ratio [HR] 2.1 [95% CI 1.0-4.3], p=0.054). Among high-risk, irradiated patients (positive margins, positive lymph nodes, or a post-operative CA19-9 >90; n=31), radiosensitive patients had significantly improved survival compared with radioresistant patients (median 31.2 vs. 13.2months; HR 0.42 [0.19, 0.94], p=0.04). Among irradiated patients (n=48), low-risk patients lived longer than both high-risk patients with radiosensitive tumors and radioresistant tumors (HR 2.7 [1.0, 7.2], p=0.04 and HR 6.3 [2.3, 17.0], p<0.001, respectively). CONCLUSIONS: Integrating RSI with standard high-risk variables has the potential to refine the classification of high-risk resected pancreatic cancer patients treated with radiation therapy.

Minimally invasive mediastinal staging of non-small-cell lung cancer: emphasis on ultrasonography-guided fine-needle aspiration.

BACKGROUND: Mediastinal staging in patients with non-small-cell lung cancer (NSCLC) is crucial in dictating surgical vs nonsurgical treatment. Cervical mediastinoscopy is the "gold standard" in mediastinal staging but is invasive and limited in assessing the posterior subcarinal, lower mediastinal, and hilar lymph nodes. Less invasive approaches to NSCLC staging have become more widely available. METHODS: This article reviews several of these techniques, including noninvasive mediastinal staging of NSCLC, endobronchial ultrasound (EBUS) and fine-needle aspiration (FNA), endoscopic ultrasound (EUS) and FNA, and the combination of EBUS/EUS. RESULTS: Noninvasive mediastinal staging with computed tomography and positron-emission tomography scans has significant false-negative and false-positive rates and requires lymph node tissue confirmation. FNA techniques, with guidance by EBUS and EUS, have become more widely available. The combination of EBUS-FNA and EUS-FNA of mediastinal lymph nodes can be a viable alternative to surgical mediastinal staging. Current barriers to the dissemination of these techniques include initial cost of equipment, lack of access to rapid on-site cytology, and the time required to obtain sufficient skills to duplicate published results. CONCLUSIONS: Within the last decade, these approaches to NSCLC staging have become more widely available. Continued study into these noninvasive techniques is warranted.

High-grade dysplasia and adenocarcinoma are frequent in side-branch intraductal papillary mucinous neoplasm measuring less than 3 cm on endoscopic ultrasound.

BACKGROUND: Surgical resection for intraductal papillary mucinous neoplasm (IPMN) of the pancreas has increased over the last decade. While IPMN with main duct communication are generally recommended for resection, indications for resection of side-branch IPMN (SDIPMN) have been less clear. We reviewed our single institutional experience with SDIPMN and indications for resection. METHODS: Patients who underwent resection for IPMN were identified from a prospectively maintained IRB-approved database. Patients with main pancreatic duct communication were excluded. Outcome, clinical and pathologic characteristics were correlated with endoscopic ultrasound (EUS) findings. RESULTS: From 2000 to 2010, 105 patients who underwent preoperative EUS evaluation and resection for SDIPMN were identified. The mean age was within the sixth decade of life, and there was a slight female predominance (55 vs. 45 %). The most common presenting symptom was abdominal pain (N = 47, 45 %), followed by jaundice (N = 24, 23 %) and weight loss (N = 24, 23 %). Only ten patients (10 %) were asymptomatic at presentation; seven (70 %) had suspicious features on EUS. Of the total cohort, few patients had intracystic septations (N = 27, 26 %) or presence of mural nodules (N = 2, 2 %) on EUS. Of 39 patients who had invasive pancreatic ductal adenocarcinoma (PDAC) on final pathology, EUS-fine needle aspiration (EUS-FNA) demonstrated malignancy in only 21 (54 %). An additional seven (18 %) had EUS-FNA findings of atypia or concern for mucinous neoplasm. EUS evaluation of cyst size was correlated with final pathology. Of 70 patients with EUS cyst size <3 cm, 12 (17 %) had a preoperative EUS diagnosis of malignancy. Final pathology revealed 24 (34 %) to have PDAC: 1 of 7 (14 %) patients with cyst size <1 cm, 2 of 19 (11 %) with cyst size 1-2 cm, and 21of 44 (48 %) with cyst size 2-3 cm. Fifteen of 35 (43 %) patients with cyst size >3 cm had PDAC on final pathology. Of the patients with cyst size <3 cm, 16 (23 %) had high-grade dysplasia on final pathology: 3 of 7 (43 %) with cyst size <1 cm, 3 of 19 (16 %) with cyst size 1-2 cm, and 10 of 44 (23 %) with cyst size 2-3 cm. Seven of 35 (20 %) patients with cyst size >3 cm had high-grade dysplasia on final pathology. Although overall survival (OS) at 48 months stratified by EUS cyst size did not significantly differ between groups, patients with PDAC on final pathology had significantly worse OS compared to noninvasive pathology. A total of eight patients (8 %) developed recurrent disease, all of whom had PDAC on final pathology. CONCLUSION: EUS is a helpful modality for the diagnostic evaluation of SDIPMN. Considering the high incidence of malignancy as well as high-grade dysplasia in SDIPMN greater than 2 cm, EUS features should be used in conjunction with other clinical criteria to guide management decisions. Patients with SDIPMN greater than 2 cm that do not undergo surgical resection may benefit from more intensive surveillance.