8/22/2019 T1616 EUS-Guided Fine Needle Aspiration (EUS-FNA) with and Without EUS-Guided Trucut Biopsy (EUS-TCB) of Pan

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T1616

EUS-Guided Fine Needle Aspiration (EUS-FNA) with and Without

EUS-Guided Trucut Biopsy (EUS-TCB) of Pancreatic Masses:

A Single Center ExperienceS Mubashir A. Shah, Caio Rocha-Lima, Parvin Ganjei-Azar, Merce Jorda,

Joe Levi, Afonso C. RibeiroBackground: Few studies have assessed the performance of EUS-FNA with orwithout the use of EUS-TCB for pancreatic masses. In general, EUS-FNA hasa sensitivity around 80-85% for pancreatic malignancy. EUS TCB has a lower yieldthan FNA in pancreatic masses but the additional use of TCB may improve the

diagnostic accuracy. Aim: To assess the yield of EUS-FNA with or without EUS-TCBfor pancreatic masses. Methods: All patients with known or suspected masses in thepancreas referred to our university-based center from October 2003 to October2006 were included in a retrospective review. TCB was performed in only selectedpatients (36 pts, 33 malignant) with lesions greater than 20 mm in size andaccessible through the stomach. EUS-guided FNA was performed using a 22-gaugeneedle and EUS-TCB with a 19-gauge needle. The linear Olympus echoendoscopeGF-UC140P and GF-UCT140 with the Aloka processor were used in all cases.Patients with benign masses had at least 6 months of clinical or imaging follow-up.A positive cytology, core biopsy or surgical biopsy for malignancy was accepted asa true positive. The presence of atypical, suspicious or abnormal cells wasinterpreted as a negative result for malignancy. The diagnostic performance of EUS-FNA, TCB, and its combination were compared using McNemars test and Fishersexact test. Results: A total of 100 pts were included, eighty nine with a malignancyand 11 with benign disease; mean age 65 yrs (55 F/45M), mean number of passeswith the FNA were 6.6 (range 2-11) and 2.6 (range 1-5) for TCB. Locations ofpancreatic masses were: 44 head, 16 uncinate process, 10 neck and 30 body/tail.The sensitivity, specificity and accuracy of FNA alone in all pts were 85% (76/89),100% (11/11) and 87% (87/100) respectively. The sensitivity of the combination ofFNA selective use of TCB was 90% (80/89) (p Z 0.1, FNA vs. FNA TCB). In thesubgroup of 36 pts who underwent additional TCB the sensitivity, specificity andaccuracy of the combination were 97% (32/33), 100% (3/3), and 97% (35/36) (p Z0.1, Fishers exact test). In two pts TCB failed to obtain a specimen. One patient hada periduodenal bleeding that did not need hospitalization. Conclusions: TCB can besafely added to FNA when performing a pancreatic biopsy. The addition of TCB toFNA improves the yield of EUS but it is not statistically significant (90% vs. 85%).Refinements in the needle device that allows sampling in all patients should allowa much higher yield as demonstrated in our selected group of 33 patients withFNA TCB (97% sensitivity).

T1617

What Does Endoscopic Ultrasound (EUS)-Guided Fine Needle

Aspiration (FNA) Add to Multidetector CT in the Evaluationof Pancreatic Cysts?Marcia I. Canto, Samuel S. Giday, Jonathan M. Buscaglia,Sergey V. Kantsevoy, Christopher L. Wolfgang,Elliot K. Fishman, Jason A. Daniels, Kurtis A. Campbell,Richard D. Schulick, John L. Cameron, Sanjay B. JagannathThe optimal approach to diagnosis of pancreatic cysts is unsettled, particularly withregards to the need for EUS/FNA. Aims: To determine: 1) the factors influencing theutilization of EUS for evaluation of pancreatic cyst, 2) the threshold cyst size fora diagnostic EUSFNA specimen, 3) the diagnostic yield of EUSFNA, 4)theperformance characteristics of EUS/FNA. Methods: Prospective EUS and pathologydatabases were queried for pancreatic cysts evaluated by EUS and/or treatedsurgically from 1990-2006. Main duct IPMN without a cyst, solid-cystic neoplasmswere excluded. CT, EUS, cytology, CEA and pathology results were analyzed.Receiver operating characteristics (ROC) of cyst size and cyst fluid CEA werestudied. The performance characteristics of CT and EUS/FNA were compared, withpathology as the reference standard. Results: 288 patients with 1 or morepancreatic cyst had surgery (67% had no symptoms). The final diagnosis was IPMN(132), mucinous cyst (37), serous cystadenoma (73), cystic islet cell tumor (4),pseudocyst (37), simple cyst (4), and ductal adenocarcinoma (1). All patients hadCT; 78 (27%) also had EUS/FNA. Patients without symptoms (51.3%, p Z 0.001) andthose with cysts !3 cm (67%, p ! .0001) were more likely to undergo EUS/FNA.The threshold size for a diagnostic EUSFNA specimen was 1.5 cm. Cyst fluidsamples were adequate for cytologic evaluation in 71%. Cysts !1.5 cm were lesslikely to be adequate (38.5% adequate, p Z .008). Overall, cytology was diagnosticfor neoplastic cysts in 40% (100% of cystic islet cell tumors, 63% of mucinoustumors, 4.6% of serous cystadenomas, and none of simple cysts). Table 1 shows theperformance characteristics of CT and EUS/FNA. The combination of all testsprovided the highest PPV for a neoplastic cyst (94%), but the NPV remained low(26%). This approach to cyst diagnosis would potentially result in 2.5% of patientsundergoing unnecessary surgery but still miss 35% of neoplastic cysts requiringresection. Conclusions: In a tertiary referral center, EUS/FNA is utilized after CT ina minority of patients with pancreatic cysts, particularly small cysts withoutassociated symptoms. When added to CT, EUS/FNA increases specificity. EUSFNA ismore likely to be diagnostic for a neoplasm if cyst size is O1.5 cm.

Table 1.

Di agnost ic te st Sens it iv it y Specifi cit y Accuracy PP V NPV

CT 57% 66% 61% 71% 52%EUS morphology 63% 76% 68% 81% 55%EUSFNA cytology 35% 83% 53% 77% 44%EUSFNA cyst fluidCEA O156) ng/ml

47% 72% 57% 75% 44%

EUSFNA cytology CEA O156

)ng/ml

49% 82% 61% 82% 49%

All 64% 76% 66% 94% 26%

)optimal cut-off for CEA by ROC

T1618

Role of EUS Guided FNA in Diagnosing Suspected Infection

of Pancreatic TumorsXianbao Zhan, Zhaoshen Li, Zhendong Jin, Duowu Zou, Jie ChenObjective: To explore the role of the EUS-guided fine needle aspiration (FNA) indiagnosing suspected infection of pancreatic tumor. Methods: The data of ninepatients (3 male and 6 female, mean age 49.9 11.4, 36-69 yrs old) with suspectedinfection of pancreatic tumor underwent EUS guided FNA were retrospectivelyanalyzed. Among the 9 patients, 6 were pancreatic cancer patients, 2 werecystadenocarcinoma and 1 was intraductal papillary mucinous tumor (IPMT)patients, all of which were confirmed with prior EUS guided FNA andcytopathological diagnosis. Five patients received prior radiotherapy, 1 patientreceived prior chemotherapy and another 3 patients received priorchemoradiotherapy. All the patients manifested as fever and white blood cellcounting increased abnormally. No epigastric pain were recorded and no infectedsigns reported by contrast-enhanced CT. As infection were suspected, EUS guidedFNA were conducted to look for evidence of infection. Results: Mean EUS guidedFNA passages were 2.33 1 (1-4). Inflammatory background with pus cells werefound in all the patients. Pathogenic bacteria were found in 7 patients with EUSguided FNA smears or cultures, including Enterobacter(3 patients) , Klebsiella(1 patients), Pseudomonas pyocyanea (1 patient) Candida (1 patient), Enterobacterand enterococcus combined infection (1 patient). No procedure relatedcomplications occurred. Conclusions: EUS guided FNA is effective and safe indiagnosing suspected infection of pancreatic tumor, not only helpful to find the puscells, but also to established the diagnosis of pathogenic microorganism.

T1619Role of Endoscopic Ultrasound in the Evaluation of Dilated

Common Bile DuctSavio Reddymasu, Shailender Singh, Jyotsna Talapaneni, Srinivas R. Puli,Melissa M. Oropeza-Vail, Mojtaba OlyaeeIntroduction: Dilated common bile duct (CBD) is often reported on abdominalultrasound or CTscan performed for various reasons. Endoscopic ultrasound (EUS)combines the endoscope with a high-resolution ultrasound transducer and enablesdirect visualization of the CBD and the adjacent structures. The aim of the studywas to retrospectively review the role of EUS in patients with unexplained dilatedCBD where the etiology was not apparent after conventional radiologic imagingand correlate with clinical characteristics. Methods: Patients who had EUSperformed at our center since 2002 for evaluation of dilated CBD (CBDO 6 mm)were reviewed. Patients with CBD dilatation on ultrasonography or computerizedtomography of the abdomen in the absence of any obstructive lesions wereincluded in the review. Final diagnosis was based on definitive cytology, surgicalpathology or clinical follow up of at least 6 months. Results: Total of 77 patients(24 males; 53 females) met the inclusion criteria. CBD was identified in 76 (99%)patients. CBD could not be identified in the one patient who had history of Billroth-II surgery. Ampullary stenosis was found in 8 (10%); ampullary mass in 6 (6%)-benign-3, malignant-3; CBD stones in 9 (12%); pancreatic mass in 10 (13%)-malignant-8, benign-2; CBD stricture in 4 (5%); 2-benign, 1-malignant, 1-primarysclerosing cholangitis; cystic lesion head of pancreas in 3 (4%); chronic pancreatitisin 9 (12%); CBD polyp in 1 (1.3%); periampullary diverticulum in 1 (1.3%) andperipancreatic lymphadenopathy in 1 (1.3%). No definite diagnosis could beprovided in 24 patients (31%), 20 of these patients had history of cholecystectomyprior to the procedure. After accounting for the cholecystectomy, EUS provideda diagnosis in 95% of the patients. In patients with final diagnosis of a malignancy asthe etiology, jaundice was present in 9 (75%), and weight loss in 3 (33%). Nocomplications were recorded secondary to the procedure. Conclusions: EUS is aneffective, minimally invasive, and safe procedure with a good diagnostic potentialfor pancreato-biliary diseases. It can be used as the preferred modality to evaluateCBD dilatation without any obvious etiology. Patients with CBD dilatation, weightloss, and jaundice in the presence of normal imaging studies should undergo EUSevaluation to rule out underlying malignancy.

Abstracts

AB308 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007 www.giejournal.org