Transesophageal endoscopic ultrasound-guided fine-needle aspiration for the mediastinal staging of extrathoracic tumors: a new perspective.

BACKGROUND: Several extrathoracic tumors metastasize to the mediastinum. Mediastinoscopy is the standard method to obtain tissue proof of mediastinal spread, but drawbacks are its invasiveness, requirement for general anesthesia and costs. Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is indicated in lung cancer staging guidelines as a minimally invasive alternative for surgical staging. The diagnostic values in patients with suspected mediastinal metastases and various (previous) extrathoracic malignancies were assessed. PATIENTS AND METHODS: Consecutive patients with suspected mediastinal metastases (on computed tomography or positron emission tomography) and an (previous) extrathoracic malignancy underwent EUS-FNA. RESULTS: Seventy-five patients with current (n = 14) or previously diagnosed (n = 61) extrathoracic malignancies were evaluated. EUS-FNA detected mediastinal malignancies in 43 patients (57%) [metastases of extrathoracic tumors, n = 36 (48%); second malignancy (lung cancer), n = 7 (9%)]. Mediastinal metastases were found at subsequent surgical staging in seven patients or during follow-up (one patient). In seven patients, an alternative diagnosis was established. Sensitivity, specificity, accuracy and negative predictive value of EUS-FNA for mediastinal staging were 86%, 100%, 91% and 72%, respectively. CONCLUSION: EUS-FNA is a minimally invasive mediastinal staging method for patients with extrathoracic malignancies to confirm nodal metastatic spread and therefore may qualify as an alternative for surgical staging.

A pitfall in screening with decoy cells after simultaneous pancreas kidney transplantation.

In this report, we describe a bladder-drained simultaneous pancreas-kidney transplant (SPKT) recipient with a polyoma virus-associated nephropathy (PVAN) in whom the urine cytology failed to detect decoy cells despite repeated attempts. Several tests were performed to confirm our hypothesis that pancreatic enzymes can degrade decoy cells and granulocytes. This case illustrates an important pitfall in the urinary screening for PVAN with cytology and for urinary tract infections with urine sediment in bladder-drained SPKT recipients.

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of sarcoidosis.

The objective of the current study was to assess the yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for the diagnosis of sarcoidosis in a large patient group. Bronchoscopy with transbronchial lung biopsy (TBLB) is nondiagnostic in 30% of patients with suspected sarcoidosis and has a risk of pneumothorax and haemoptysis. In order to obtain a diagnosis, mediastinoscopy is often performed as the next diagnostic procedure. EUS-FNA provides a nonsurgical alternative for the demonstration of noncaseating granulomas by aspirating mediastinal lymph nodes from the oesophagus. In total, 51 patients with suspected sarcoidosis stage I and II underwent EUS-FNA. Thirty-six patients (71%) previously underwent a nondiagnostic bronchoscopy. All patients were clinically followed (median 18 months) and surgical-pathological verification occurred in those patients with EUS aspirates that contained unrepresentative material. EUS-FNA demonstrated noncaseating granulomas without necrosis in 41 of 50 patients (82%) with the final diagnosis of sarcoidosis. Specific ultrasound features of clustered, well-demarcated iso-echoic lymph nodes were observed in 64% of patients with sarcoidosis. No complications occurred. Endoscopic ultrasound-guided fine-needle aspiration has a high yield in diagnosing sarcoidosis and qualifies as the next diagnostic step after a nondiagnostic bronchoscopy. The current authors expect that endoscopic ultrasound-guided fine-needle aspiration will reduce the number of mediastinoscopies for the diagnosis of sarcoidosis dramatically.

Towards a minimally invasive staging strategy in NSCLC: analysis of PET positive mediastinal lesions by EUS-FNA.

STUDY OBJECTIVE: To asses the value of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) in the nodal staging of patients with (suspected) non-small cell lung cancer (NSCLC) and a (18)FDG positron emission tomography (PET) scan suspect for N2/N3 mediastinal lymph node (MLN) metastases. BACKGROUND: Due to the imperfect specificity of positron emission tomography, PET positive MLN should be biopsied in order to confirm or rule out metastasis. Currently, invasive surgical diagnostic techniques such as mediastinoscopy/-tomy are standard procedures to obtain MLN tissue. The minimally invasive technique of EUS-FNA has a high diagnostic accuracy (90-94%) for the analysis of MLN in patients with enlarged MLN on computed tomography of the chest (CT). DESIGN AND PATIENTS: Thirty-six patients with proven n=26 or suspected n=10 non-small cell lung cancer and a PET scan suspect for N2/N3 lymph node metastases underwent EUS-FNA. When EUS-FNA did not confirm metastasis and the PET lesion was within reach of mediastinoscopy, a mediastinoscopy was performed. EUS-FNA negative patients with PET lesions beyond the reach of mediastinoscopy or those with a negative mediastinoscopy were referred for surgical resection of the tumour and MLN sampling or dissection. RESULTS: EUS-FNA confirmed N2/N3 disease in 25 of the 36 patients (69%) and was highly suspicious in one. In the remaining 10 patients, one PET positive and one PET negative N2 metastasis was detected at thoracotomy. The PPV, NPV, sensitivity, specificity and accuracy of EUS-FNA in analysing PET positive MLN were 100%, 80%, 93%, 100% and 94%, respectively. No complications of EUS-FNA were recorded. CONCLUSIONS AND SIGNIFICANCE: EUS-FNA yields minimally invasive confirmation of MLN metastases in 69% of the patients with potential mediastinal involvement at FDG PET. The combination of PET and EUS-FNA might qualify as a minimally invasive staging strategy for NSCLC.

Mediastinitis caused by EUS-FNA of a bronchogenic cyst.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe and minimally invasive diagnostic technique for the analysis of mediastinal lesions. This case report describes a patient who developed a life-threatening mediastinitis after EUS-FNA of a mediastinal lesion, which (based on computed tomography of the thorax) had been suspected to be a lymph-node metastasis, but proved to be a bronchogenic cyst.

Diagnosis of Helicobacter pylori infection by specific gastric mucosal IgA and IgG pylori antibodies.

AIMS: To investigate the diagnostic value of mucosal IgA and IgG Helicobacter pylori antibodies. METHODS: The study population comprised 209 consecutive patients with severe dyspeptic complaints referred for upper gastrointestinal endoscopy. A positive culture or histological identification of H pylori in gastric biopsy specimens, or both, were used to confirm infection. Specific IgA and IgG H pylori antibodies were determined using a modified ELISA technique. RESULTS: Of the 209 patients, 137 were infected with H pylori. The diagnostic value of systemic IgA and IgG H pylori antibodies was confirmed. Systemic IgA antibodies had a sensitivity of 76.6% (95% confidence interval 69.5-83.7) and a specificity of 94.4% (89.1-99.7). The sensitivity and specificity for systemic IgG antibodies were, respectively, 97.1% (94.3-99.9) and 98.6% (95.9-100). A moderate but clinically important correlation was found between local and systemic IgA and IgG. Mucosal IgA H pylori antibodies had a sensitivity of 98.5% (96.5-100) and a specificity of 91.7% (85.3-98.1), while for IgG these figures were, respectively, 88.3% (82.9-93.7) and 98.6% (95.9-100). As a diagnostic test mucosal IgA H pylori antibodies were comparable with culture and histology. CONCLUSION: Determination of local IgA and IgG H pylori antibody levels is a highly sensitive and specific test for the diagnosis of H pylori infection.

Serum gastrin and mucosal somatostatin in Helicobacter pylori-associated gastritis.

AIMS: The aims were to study gastrin concentrations and gastric mucosal somatostatin and gastrin concentrations in relation to the extent of gastritis in Helicobacter infection. METHODS: We measured basal serum gastrin concentrations in antral mucosal biopsy specimens and somatostatin concentrations in corpus biopsy specimens in 88 consecutive dyspeptic subjects undergoing endoscopy. These subjects were divided into three categories on the basis of histology, serology, and culture: H. pylori-positive pangastritis, H. pylori positive antral gastritis with normal body histology, and H. pylori-negative controls. Statistical evaluation was done with the Wilcoxon rank sum test. RESULTS: Basal serum gastrin concentrations were significantly increased only in subjects with pangastritis and not in those with antral gastritis only, as compared with controls (mean +/- SEM: 72 +/- 7, 46 +/- 10, and 42 +/- 7 ng/l, respectively). Subjects with pangastritis or antral gastritis had significantly lower antral somatostatin concentrations than controls (mean +/- SEM: 0.80 +/- 0.07, 1.03 +/- 0.15, and 2.40 +/- 0.31 micrograms/g(protein), respectively). We also found significantly lower antral gastritis only as compared with controls (mean +/- SEM: 62 +/- 13, 78 +/- 16, and 165 +/- 25 micrograms/g(protein), respectively). In subjects with pangastritis a significantly lower concentration of somatostatin was found in the corpus biopsy specimens than in those with antral gastritis only and controls. CONCLUSIONS: These results suggest that hypergastrinemia in H. pylori gastritis is not caused by antral gastritis and antral somatostatin deficiency alone but that corpus inflammation plays a key role in the origin of hypergastrinemia. Furthermore, in patients with pangastritis a corpus mucosal somatostatin deficiency was found.

Triple therapy with ranitidine, clarithromycin, and metronidazole in the treatment of Helicobacter pylori.

BACKGROUND: To determine whether a triple therapy regimen for the treatment of Helicobacter pylori infection, consisting of ranitidine 300 mg q.i.d., clarithromycin 500 mg t.i.d., and metronidazole 500 mg t.i.d. would provide a safe and effective treatment regimen, we performed an open prospective study in 20 consecutive patients with proven H. pylori-associated non-ulcer dyspepsia or peptic ulcer disease. METHODS: The percentage of patients in whom eradication of H. pylori succeeded was determined. A semiquantitative assessment of histology was performed, and the results were analysed using Wilcoxon's matched-pairs ranks tests; side effects were noted and graded. RESULTS: Eradication was achieved in 19 of 20 patients, i.e. in 95% (confidence interval 85-100%). Eradication of the bacterium led to a significant improvement in semiquantitative histology scores; active antral inflammation decreased from (mean +/- SEM) 1.84 +/- 0.19 to 0.21 +/- 0.16 (p = 0.0004) and chronic antral inflammation from 2.47 +/- 0.14 to 1.16 +/- 0.14 (p = 0.0002); active gastric body inflammation decreased from 0.95 +/- 0.19 to 0.00 +/- 0.00 (p = 0.0015) and chronic inflammation from 1.68 +/- 0.17 to 0.32 +/- 0.11 (p = 0.0007). Side effects occurred in 45% of patients, but in over half of these patients only mild side effects occurred. Severe side effects did not occur, none of the patients discontinued the triple therapy. CONCLUSIONS: Triple therapy with ranitidine, clarithromycin, and metronidazole provides a safe and effective treatment of H. pylori infection, resulting in a high eradication rate, and in significant decrease in semiquantitative histology scores. Further prospective studies are warranted.

Preoperative diagnostic tests for operable thyroid disease.

Although the availability and acceptance of fine-needle aspiration biopsy (FNAB) of thyroid nodules has increased, many physicians still use thyroid scintigraphy for distinguishing benign from malignant lesions. We evaluated these diagnostic tests in 350 patients who had thyroid surgery in our institution between 1977 and 1990. Histologic confirmation of FNAB was obtained in 265 patients. In the group of patients having surgery, 247 thyroid scintigraphies were performed. Our patients were divided into two groups (1977-1986 and 1986-1990). The first group comprised 173 patients with 173 FNABs and 126 scintigrams. The second group consisted of 177 patients having 92 FNABs and 121 scintigrams. Results of scintigrams were analyzed in the second group only. In 5 out of 120 cases where the FNAB result was "benign or probably benign" the lesion appeared to be malignant postoperatively. If the FNAB result was "malignant or probably malignant" (n = 83) the pathology report confirmed a malignancy in 68 cases (81.9%). In 56 instances of all 265 FNABs the cytology report was not conclusive ("uncertain"); in 21.4% of these cases a malignancy was found postoperatively. An FNAB-result "(probably) malignant" had a positive predictive value of 0.819 while the negative predictive value of a result "(probably) benign" is 0.950. An "uncertain" result does not take away our concern so this result should have the same consequences as those of a result "(probably) malignant". In that case, FNAB-sensitivity is 93.0% and specificity 66.1%. Eighty-five of the last 116 scintigraphies showed a solitary node. Eleven of these nodes were hot while 74 were cold.(ABSTRACT TRUNCATED AT 250 WORDS)

Endometrial cells in the peritoneal cavity after laparoscopy and chromotubation.

The presence of endometrial cells in peritoneal fluid before and after laparoscopy and chromotubation was studied in 35 patients at different days of the menstrual cycle. Endometrial cells were found more frequently in peritoneal fluid samples taken in the second half of the menstrual cycle.