RISKY ENDOSCOPIC ULTRASONOGRAPHY‐GUIDED FINE‐NEEDLE ASPIRATION FOR ASYMPTOMATIC RETROPERITONEAL TUMORS

Paraganglioma, a sporadically occurring rare tumor should be included in the differential diagnosis of retroperitoneal tumors, such as malignant lymphomas, gastrointestinal stromal tumors, sarcoma and carcinoma of unknown primary site. A 58‐year‐old Japanese woman presented with a large retroperitoneal tumor detected by ultrasonography (US). She had no medical history of hypertension. Computed tomography showed a mass, 7 cm in diameter, located between the pancreas and the inferior vena cava. It was unclear whether the mass originated from the duodenum or the mesentery. Endoscopic ultrasonography (EUS) demonstrated a large solid paraduodenal mass. Doppler US revealed sparse vascularity in the tumor. With the differential diagnosis of retroperitoneal tumor, we carried out EUS‐FNA. At the time of the third needle puncture, transient severe hypertension was noted, with a blood pressure measurement of 269/130 mmHg. Data obtained from urine and blood examinations after EUS‐fine‐needle aspiration indicated a diagnosis of paraganglioma.     

SUCCESSFUL ENDOSCOPIC ULTRASOUND‐GUIDED FINE‐NEEDLE ASPIRATION OF THE PELVIC LESION THROUGH THE SIGMOID COLON

Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) is a useful modality when the target is a lymph node located in the mediastinum, perigastric area or perirectum. Although it is difficult to carry out EUS‐FNA of the colon using an oblique view linear scope, we report two cases of successful EUS‐FNA of the lesions via the proximal sigmoid colon using a recently available new convex type EUS scope. Case 1 was a 77‐year‐old Japanese woman noted to have multiple lymph node swelling in the para‐aortic area and in the pelvis. Case 2 was a 60‐year‐old Japanese woman noted to have a large mass in the left lower abdomen. In case 1, oral EUS showed no lymph node swelling. In both cases, EUS with forward‐viewing radial echoendoscope was carried out via the anus, and multiple lymph‐node swelling or a large mass was observed near the proximal sigmoid colon. In the EUS‐FNA for these cases, we used a new convex‐type EUS scope that has an oblique view, but with a wide‐angled optical device giving a view similar to a forward one. EUS‐FNA was successfully carried out on the lesions. The pathological specimen revealed diffuse large B‐cell lymphoma in case 1 and gastrointestinal stromal tumor (GIST) in case 2.     

LONG‐TERM FOLLOW UP OF PATIENTS WITH SMALL GASTROINTESTINAL STROMAL TUMORS IN THE STOMACH USING ENDOSCOPIC ULTRASONOGRAPHY‐GUIDED FINE‐NEEDLE ASPIRATION BIOPSY

Background: Gastrointestinal stromal tumors (GIST) are one of the most common mesenchymal tumors of the gastrointestinal tract. GIST are defined by positive immunohistochemical staining for KIT or CD34 and thus are generally diagnosed after surgery. Because small GIST are rarely diagnosed before surgery, the clinical course of these small tumors is not clear. The aim of the present study was to follow changes in size and configuration of small GIST that were pathologically confirmed using endoscopic ultrasonography‐guided fine‐needle aspiration biopsy (EUS‐FNAB). Methods: Between July 1997 and December 2003, 16 tumors in 16 patients (10 men and 6 women) with an immunohistochemical diagnosis of GIST were regularly followed in our hospital. The median patient age when EUS‐FNAB was performed was 62 years (range 26–82 years) and the median follow‐up period was 4.9 years (range 0.5–9.6 years). Results: Fourteen tumors showed no remarkable changes in size and shape during follow up compared with the initial diagnosis. Two tumors enlarged: one tumor approximately doubled its diameter in 8 years and the other tumor increased from 1.8 cm at diagnosis to up to 10 cm after only 2 years. Doubling time of the latter tumor was calculated as 3.1 months. Conclusions: We conclude that EUS‐FNAB might be a good modality for final diagnosis of GIST without surgery, and that GIST without rapid growth on follow up can be endoscopically followed.     

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY

Endoscopic biliary drainage (EBD) may be unsuccessful in some patients, because of failed biliary cannulation or tumor infiltration, limiting endoscopic access to major papilla. The alternative method of percutaneous transhepatic biliary drainage carries a risk of complications, such as bleeding, portal vein thrombus, portal vein occlusion and intra‐ or extra‐abdominal bile leakage. Recently, endoscopic ultrasonography (EUS)‐guided biliary stent placement has been described in patients with malignant biliary obstruction. Technically, EUS‐guided biliary drainage is possible via transgastric or transduodenal routes or through the small intestine using a direct access or rendezvous technique. We describe herein a technique for direct stent insertion from the duodenal bulb for the management of patients with jaundice caused by malignant obstruction of the lower extrahepatic bile duct. We think transduodenal direct access is the best treatment in patients with jaundice caused by inoperable malignant obstruction of the lower extrahepatic bile duct when EBD fails.     

ENDOSCOPIC ULTRASOUND AND FINE‐NEEDLE ASPIRATION FOR PANCREATIC CANCER

Background: Accurate staging of pancreatic cancer is essential for surgical planning, and identification of locally advanced and metastatic disease that is incurable by surgery. Advances in EUS, CT, and PET have improved the accuracy of staging and reduced the number of incomplete surgical resections. Tissue acquisition is necessary in non‐surgical cases when chemo‐radiotherapy is considered. The complex regional anatomy of the pancreas makes cytologic diagnosis of malignancy at this region difficult without exploratory surgery. Although CT‐guided fine‐needle aspiration (FNA) is used for this purpose, reports of an increased risk of peritoneal dissemination of cancer cells and a false negative rate of nearly 20% makes this a less than ideal choice. The ability to position the EUS‐transducer in direct proximity to the pancreas by means of stomach and the duodenum, combined with the use of FNA, increases the specificity of EUS in detecting pancreatic malignancies. Methods: The current literature regarding the accuracy of EUS with FNA in the evaluation of pancreatic cancer is reviewed. Results: EUS accuracy for tumor (T) staging ranges from approximately 78–94% and nodal (N) stage accuracy between 64 and 82%. EUS also enables FNA of lesions that are too small to be identified by CT or MRI, or too close to vascular structures to safely allow percutaneous biopsy. The accuracy for detecting invasion into the superior mesenteric artery and vein is lower than that for detecting portal or splenic vein invasion, especially for large tumors. EUS permits delivery of localized therapy such as celiac plexus neurolysis for pain control and direct intralesional injection of antitumor therapy. Conclusions: EUS in combination with FNA is a highly accurate method of preoperative staging of pancreatic cancer especially those too small to characterize by CT or MRI, and has the ability to obtain cytological confirmation.     

STANDARD IMAGING TECHNIQUES IN THE PANCREATOBILIARY REGION USING RADIAL SCANNING ENDOSCOPIC ULTRASONOGRAPHY

Standard imaging techniques using a radical scanning echoendoscope are summarized to facilitate the attainment of expertise in biliopancreatic endoscopic ultrasonography and to promote the widespread use of this diagnostic tool. Typical images of the biliopancreatic system and neighboring organs obtained by scanning from the stomach, duodenal bulb, and descending portion of the duodenum are shown in a sequential manner. Two methods of scanning from the descending portion of the duodenum, which is considered to be the most difficult, are presented (i.e. the Longitudinal Method and the Transverse Method). In addition, settings of the image control functions and the monitor are also detailed.     

ENDOSCOPIC ULTRASOUND‐GUIDED FINE‐NEEDLE ASPIRATION BIOPSY FOR THE DIAGNOSIS OF GASTROINTESTINAL SUBMUCOSAL TUMORS

Gastrointestinal submucosal tumors (SMT) detected by barium meal study or endoscopy include various kinds of diseases and various degrees of malignancy. Endoscopic ultrasonography (EUS) can provide useful information about the differentiation of intra‐ and extra‐wall lesions, location and originating layer, presumption of their histological nature, measurement of the actual size of the lesion, and the possibility of differentiating between a benign and a malignant lesion. However, EUS alone does not reveal the complete pathology. EUS fine‐needle aspiration biopsy (EUS‐FNAB) has been reported to be a useful tissue sampling method for pancreatic mass lesions, lymph nodes swelling, posterior mediastinal masses and also gastrointestinal submucosal tumors. The EUS‐FNAB procedure is effective not only for the differential diagnosis of benignancy and malignancy, but also for the specific histopathological nature of gastrointestinal SMT using immunohistochemical staining. When used with MIB‐1 (Ki‐67) staining, and gene analysis in case of gastrointestinal stromal tumor, EUS‐FNAB may indicate its prognosis and influence decisions regarding therapeutic strategy. Thus, EUS‐FNAB is an indispensable procedure in the diagnosis of SMT.     

PREDICTIVE FACTORS FOR PAIN RELIEF AFTER ENDOSCOPIC ULTRASOUND‐GUIDED CELIAC PLEXUS NEUROLYSIS

Background: Celiac plexus neurolysis (CPN) is an established treatment for upper abdominal cancer pain. Recently, endoscopic ultrasound‐guided CPN (EUS‐CPN) was introduced and has enabled the performance of CPN under real‐time imaging guidance, thereby making this technique much safer and easier. However, this procedure is not always efficacious, and a limited number of patients benefit from it. It should not be recommended for patients suspected of having unfavorable outcomes. We determined the predictive factors for response to EUS‐CPN in order to enable rational selection of the therapeutic strategy. Patients and Methods: Forty‐seven consecutive patients who underwent EUS‐CPN at our institutions were eligible for this study. Absolute ethanol containing a contrast medium was injected just above the origin of the celiac trunk from the aorta under real‐time EUS guidance, and abdominal computed tomography was performed immediately after the procedure to evaluate the distribution of the injected ethanol. The efficacy in pain relief was evaluated based on the pain score at day 7 after EUS‐CPN. Results: Pain relief was obtained in 32 patients (68.1%). Multivariate analysis using a multiple logistic regression model revealed that direct invasion of the celiac plexus and distribution of ethanol only on the left side of the celiac artery were significant factors for a negative response to EUS‐CPN (odds ratio = 4.82 and 8.67, P = 0.0387 and 0.0224, respectively). Conclusion: EUS‐CPN seems to be less effective in patients with direct invasion of the celiac plexus. Ethanol should be injected on both sides of the celiac axis to obtain greater pain relief.     

WHAT IS THE STANDARD OF EUS GUIDED FNA IN JAPAN?

After the reports by Vilmann and Grimm, endoscopic ultrasonography (EUS) guided fine needle aspiration (FNA) has become popular in the clinical fields, especially in the western world. However, EUS guided FNA is still a special examination in Japan, although it is also becoming popular. At the moment there is no standardization of EUS guided FNA in Japan. According to the questionnaire we put together, most experienced Japanese endosonographers commonly employed a 22 or 21 guage needle for EUS guided FNA. Optimally, EUS guided FNA is repeated to obtain enough tissue and to be confirmed histologically on site; however, it is confirmed macroscopically in more than half of the institutions included in the survey. All institutions used stylet, which is generally pulled back 1–3 cm during the puncture of the center of target lesion and commonly changed the pass way at each stroke. Negative pressure by the suction of 20 cc syringe has been used in most of institutions. Times of strokes varies from less than 10–30 in each institution. About pushing out the sample tissue, half of institutions used a stylet. As mentioned above, on site histo‐cytologist with diff quick staining is optimal for EUS guided FNA; however, most of institutions do not allow this at the moment. In order to widen EUS guided FNA we conducted multicenter study on the standardization of EUS guided FNA with statistical evidence.     

TRANSGASTRIC TRANSHEPATIC ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE: HISTOLOGICAL ASSESSMENT OF ITS SINUS TRACT IN AN AUTOPSY CASE

Endosonography‐guided biliary drainage (ESBD) is gaining attention as a promising drainage technique for obstructive jaundice. However, histological changes resulting from ESBD have not been well understood. We had an opportunity to histologically investigate the influence of ESBD, established between the left hepatic duct and the stomach, on the relevant organs in an autopsy case with bile duct cancer extending from the pancreatic head to the hepatic hilum with duodenal invasion. Localized fibrous connective tissues were present around and along the sinus tract, including the connection between the surfaces of the left lobe of the liver and the gastric serosa, without hemorrhage, inflammatory changes, or cancer invasion. The inside of the ESBD stent was slightly stenotic at the intramural portion of the stomach due to proliferation of granulation tissue. No bile stasis or abscess was observed in the left lobe. These results are quite suggestive of the high safety and efficacy of ESBD with adequate performance.     

Role of endoscopic ultrasound‐guided fine‐needle aspiration with flow cytometry to diagnose lymphoma: A single center experience

Background and Aim: The use of endoscopic ultrasound‐guided fine‐needle aspiration (EUS?FNA) ± flow cytometry (FC) for the diagnosis of suspected lymphoma remains controversial. We report our experience and diagnostic yield for EUS ± FC for suspected lymphoma. Methods: Databases were queried for those who underwent EUS?FNA ± FC for suspected lymphoma. Hospital charts were reviewed to confirm the final cytological diagnosis, follow up and FC results if obtained. The final diagnosis was confirmed by the results of EUS?FNA ± FC, other biopsy and/or follow up. Results: In total, 54 patients underwent EUS?FNA of 72 lesions. The final diagnosis of lymphoma was made in 38 of the 54 (70%) patients, and 33 of the 54 (61%) patients relied on EUS?FNA. Cytopathology in 41 patients using EUS?FNA + FC showed lymphoma in 24 patients, atypical lymphoid cells in six and reactive lymph node in 11. In 9 of the 24 with lymphoma by EUS + FC, the diagnosis was confirmed by another diagnostic modality, like surgery, bone marrow biopsy and computed tomography‐guided biopsy. Of the six with atypical lymphoid cells, additional diagnostic methods confirmed lymphoma in three. The remaining 13 of the 54 patients underwent EUS?FNA without FC due to insufficient sample (n = 5) or operator choice (n = 8). Cytopathology in these 13 patients without FC showed lymphoma (9), atypical lymphoid cells (3) and reactive node (1). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS?FNA for lymphoma in all 54 patients ranged from 80% to 87%, 92% to 93%, 97%, 60% to 75% and 83% to 89%, respectively. Conclusions: EUS?FNA is sensitive and specific for the diagnosis of suspected lymphoma. Confirmatory or further testing should be performed when EUS?FNA with or without FC is indeterminate and or non‐diagnostic.     

Endoscopic ultrasonography‐guided fine‐needle aspiration biopsy: A safe method for accurate diagnosis

Endoscopic ultrasonography‐guided fine‐needle aspiration biopsy (EUS FNAB) is a relatively new technique for obtaining specimens with excellent imaging power. The convex type of echoendoscope used with EUS FNAB provides images perpendicular to the endoscope, which differ from those of popular radial echoendoscopes and, hence, require different usage techniques. Color flow imaging is used to avoid the vessels in and around the mass during puncturing. EUS FNAB for submucosal tumors is sometimes difficult because the needle slips easily, and the gastrointestinal wall tends to be stretched when pushing the needle, which can be solved by making a dimple on the wall before puncturing. Lesions of the pancreas head, especially those at the uncus, and lymph nodes near the superior mesenteric artery are also difficult because of their distance from the endoscope and the resultant bending of the needle. Tissue sampling is more successful when the angle between the endoscope and the needle is kept at just less than 45 degrees, as this helps to transmit the hand force to the needle effectively. The complication rate of EUS FNAB is reportedly 1–2%, and so the technique is considered a safe modality, except for cystic lesions of the pancreas. Recent histological evidence is needed before applying medical therapies, such as chemoradiation and surgery, especially when imaging modalities alone cannot supply the evidence of malignancy; hence increasing importance of EUS FNAB is expected.     

Endoscopic ultrasound‐guided fine‐needle aspiration of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding: A case series

The major gastrointestinal endoscopy society guidelines list endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) as a high‐risk procedure for bleeding. However, there are no studies evaluating the risk of bleeding for EUS‐FNA of solid organs while patients continue to take clopidogrel. The aim of the present case series was to evaluate the rate of bleeding in a cohort of patients who underwent EUS‐FNA for solid lesions while on clopidogrel. Bleeding was measured at the time of the procedure by bleeding seen on EUS, endoscopic visualization of blood, or drop in hemoglobin after the procedure. From 2013 to 2015, 10 patients were identified for this case series. Lesions that underwent EUS‐FNA included gastric and rectal subepithelial lesions, pancreas masses, and liver masses. No immediate or delayed bleeding was observed in any of the patients. EUS‐FNA of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding. Larger studies are needed to confirm this finding.