Factors predicting the number of EUS-guided fine-needle passes for diagnosis of pancreatic malignancies

BACKGROUND: The factors that affect the number of needle passes needed to diagnose pancreatic malignancies using endoscopic ultrasound (EUS) -guided fine-needle aspiration are unknown. METHODS: Patient and endosonographic data were prospectively recorded on 121 consecutive patients with pancreatic malignancy. Of these, 110 underwent EUS-guided fine-needle aspiration. A cytopathologist was in attendance for all aspiration procedures. RESULTS: Initial EUS detected a pancreatic mass in 96% of cases; 23% of these were not seen by computed tomography. EUS-guided fine-needle aspiration was performed in 109 of 110 (99%) patients, including 95 masses, 7 lymph nodes, and 7 hepatic metastases. EUS-guided fine-needle aspiration provided a cytologic diagnosis of malignancy in 104 of 110 (95%). Only tumor differentiation and the site of aspiration affected the number of passes. CONCLUSIONS: With the participation of a cytopathologist, EUS-guided fine-needle aspiration can diagnose pancreatic malignancies with a high degree of accuracy. Only the aspiration site (mass versus node/liver metastasis) can be used to direct the number of passes if a cytopathologist is not present. Without a cytopathologist in attendance, 5 to 6 passes should be made for pancreatic masses and 2 to 3 for liver metastases or lymph nodes; however, this approach will be associated with a 10% to 15% reduction in definitive cytologic diagnoses, extra procedure time, increased risk and additional needles.     

Detection of pancreatic metastases by EUS-guided fine-needle aspiration

BACKGROUND: Metastases to the pancreas are usually found incidentally. Tissue diagnosis is imperative because imaging alone is incapable of differentiating them from primary pancreatic tumors. This study tested whether it is possible to differentiate metastases from other focal pancreatic lesions by using EUS-guided fine-needle aspiration (EUS-FNA) for cytodiagnosis. METHODS: One hundred fourteen consecutive patients (mean age 61 years) with focal pancreatic masses, detected on CT, underwent EUS-FNA by using a linear-array echoendoscope and 22-gauge needles. RESULTS: Adequate specimens were obtained from 112 lesions. Carcinomas were identified in 68 cases (60.7%), 56 (50%) of pancreatic origin and 12 (10.7%) from distant primary tumors. The metastases were all located in the head and body of the pancreas and measured 1.8 to 4.0 cm. The echo-texture was heterogeneous or hypoechoic in all cases and resembled that of primary tumors. Six of the 12 patients with metastatic disease had a prior diagnosis of cancer (breast, 3; renal cell, 2; salivary gland, 1), 4 of them with a recurrence and 2 with a second carcinoma metastasizing to the pancreas. Six patients without a prior diagnosis of cancer had metastases from renal cell, colonic, ovarian, and esophageal carcinomas; one metastasis was from an unknown primary and another was from a malignant lymphoma. These findings influenced the therapeutic strategy in 8 patients who underwent nonsurgical palliation. There were no complications. CONCLUSIONS: Pancreatic metastasis is an important cause of focal pancreatic lesions, but the EUS features are not diagnostic. Simultaneous EUS-FNA allows cytodiagnosis and can have a decisive influence on the selection of appropriate therapeutic strategies.     

内镜超声引导细针穿刺对胰腺癌的诊断价值

目的了解内镜超声(EUS)引导细针穿刺(FNA)对胰腺癌的临床价值及安全性。方法选择临床诊断或临床及影像学疑诊胰腺癌患者共21例,男13例,女8例,平均年龄(59.8±15.3)岁。EUS发现病变后,在实时超声引导下用超声穿刺针行FNA,对3例无法手术的胰腺癌患者行FNA同时,以无水乙醇阻滞腹腔神经丛治疗癌痛。结果B超共检出胰腺占位16例(16/21),未检出的5例中3例经CT检出,CT共检出胰腺占位19例;EUS检出全部21例胰腺占位,5例位于胰体尾,16例位于胰头。18例患者EUS-FNA获满意标本,17例诊断为胰腺癌,1例诊断为慢性胰腺炎,胰腺癌诊断敏感性为85.0%、特异性为100.0%、准确度为85.7%。3例行无水乙醇阻滞后疼痛减轻。术后发生轻度胰腺炎1例、发热1例。结论EUS能有效检出胰腺占位,结合FNA可提高诊断的特异性及准确性。     

Evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma: accuracy of EUS.

BACKGROUND: Endosonography (EUS) is the most accurate modality for assessing depth of tumor invasion and local lymph node metastasis. However, its accuracy in the identification of metastatic (celiac axis) lymph nodes is less well defined. Our objective in this study was to determine the accuracy of Eus in detecting celiac axis lymph node metastasis in patients with esophageal carcinoma. METHODS: Two hundred fourteen patients with esophageal carcinoma underwent preoperative EUS. Of these, 145 underwent attempted surgical resection and staging, and 4 underwent EUS-guided fine-needle aspiration of mediastinal and celiac lymph nodes. Local (mediastinal) and distant (celiac axis) lymph nodes were assessed for malignancy on the basis of four criteria (larger than 1 cm, round, homogeneous echo pattern, sharp borders). Accuracy of EUS was determined by means of correlating histopathologic findings for the resected lymph nodes or results of EUS-guided fine-needle aspiration cytologic examination. RESULTS: Surgical exploration (n = 145) and fine-needle aspiration cytologic examination (n = 4) revealed metastatic celiac axis lymph nodes in 23 and metastatic mediastinal (local) lymph nodes in 93 of 149 patients with esophageal carcinoma. According to defined criteria for malignant lymph nodes, there were 19 true-positive and 4 falsenegative results. Sensitivity for the diagnosis of celiac lymph node metastasis with EUS was 83% with a 98% specificity. For the diagnosis of mediastinal lymph node metastasis, sensitivity was 79% and specificity was 63%. All patients with malignant celiac axis lymph nodes had local T3 (tumor breaching adventitia) or T4 (tumor invading adjacent organs) disease. CONCLUSION: EUS is an excellent modality in the evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma. These findings should be used in selecting options for treatment. Sensitivity for detecting malignancy is consistent with that of prior studies, and local and regional lymph nodes and specificity is significantly higher.     

EUS, PET, and CT scanning for evaluation of pancreatic adenocarcinoma

BACKGROUND: Preoperative diagnosis of pancreatic adenocarcinoma can be difficult. Computed tomography (CT) is the standard, noninvasive imaging method for evaluation of suspected pancreatic adenocarcinoma, but it has limited sensitivity for diagnosis, local staging, and metastases. Endoscopic ultrasound (EUS) and fluoro-deoxyglucose/positron emission tomography (FDG-PET) are imaging methods that may improve diagnostic accuracy. METHODS: Thirty-five patients with presumed resectable pancreatic adenocarcinoma were prospectively evaluated with helical CT, EUS, and FDG-PET. RESULTS: Sensitivity for the detection of pancreatic cancer was higher for EUS (93%) and FDG-PET (87%) than for CT (53%). EUS was more sensitive than CT for local vascular invasion of the portal and superior mesenteric veins. EUS diagnosis of vascular invasion was associated with poor outcome after surgery. EUS-guided, fine-needle aspiration allowed tissue diagnosis in 14 of 21 attempts (67%). FDG-PET diagnosed 7 of 9 cases of proven metastatic disease, 4 of which were missed by CT. Two of three metastatic liver lesions suspected by CT were indeterminate for metastases. FDG-PET confirmed metastases. CONCLUSIONS: EUS and PET improve diagnostic capability in pancreatic adenocarcinoma. EUS is useful in determining local vascular invasion and obtaining tissue diagnosis. FDG-PET is useful in identifying metastatic disease. Both techniques are more sensitive than helical CT for identification of the primary tumor. (Gastrointest Endosc 2000;52:367-71).     

Role of EUS in the preoperative localization of insulinomas compared with spiral CT

BACKGROUND: Preoperative radiologic localization of insulinomas often fails because of the small size of these tumors. Endoscopic ultrasound (EUS) can localize insulinomas in up to 80% of the cases. The aim of this study was to compare EUS and computed tomography (CT) diagnostic accuracy for insulinomas. METHODS: We reviewed medical records from 12 patients (10 women) with a biochemical diagnosis of hypoglycemia and hyperinsulinism from 1 university hospital and 1 community hospital. A diagnosis of insulinoma was ultimately made in all cases and before surgery the patients underwent abdominal US, spiral CT and EUS in an attempt to precisely localize the tumor. Surgery was considered the standard for tumor localization. RESULTS: Ten tumors were benign (83.3%) and 2 were malignant (16.7%). The overall sensitivity of EUS in identifying insulinomas was 83.3% compared with 16.7% for CT. Tumors not detected by EUS had a mean size of 0.75 cm. EUS-guided fine-needle aspiration was possible in only 3 patients, with a positive cytologic diagnosis in 2 (66.6%). Tumors located in the head and body of the pancreas were identified by EUS in all patients, but those located in the tail were diagnosed in only 50% of the cases. CONCLUSIONS: EUS is superior to spiral CT and should replace it for the detection of pancreatic insulinomas. EUS identification depends on the site and size of the tumor.     

EUS-guided FNA of pancreatic metastases: a multicenter experience

BACKGROUND: Metastatic lesions of the pancreas are a rare but important cause of focal pancreatic lesions. The purpose of this study is to describe the EUS features, cytologic diagnoses, and clinical impact of a cohort of patients with pancreatic metastases diagnosed by EUS-guided FNA (EUS-FNA). METHODS: Over a 6-year period, in a retrospective, multicenter study, patients had the diagnosis of pancreatic metastases confirmed with EUS-FNA. All examinations were performed by one of 5 experienced endosonographers. The EUS and the clinical findings of pancreatic metastases were compared with those of a cohort with primary pancreatic malignancy. RESULTS: Thirty-seven patients with possible metastases were identified, and 13 were excluded because of diagnostic uncertainty. The remaining 24 underwent EUS-FNA (mean passes 4.1) of a pancreatic mass without complications. Diagnoses included metastases from primary kidney (10), skin (6), lung (4), colon (2), liver (1), and stomach (1) cancer. In 4 (17%), 16 (67%), and 24 (100%) patients, EUS-FNA provided the initial diagnosis of malignancy, tumor recurrence, and pancreatic metastases, respectively. Four (17%) metastases initially were discovered by EUS after negative (n = 3) or inconclusive (n = 1) CT scans. Compared with primary cancer, pancreatic metastases were more likely to have well-defined margins (46% vs. 4%) compared with irregular (94% vs. 54%; p < 0.0001) margins. No statistically significant difference between the two populations was noted for tumor size, echogenicity, consistency, location, lesion number, or number of FNA passes performed. CONCLUSIONS: Pancreatic metastases are an important cause of focal pancreatic lesions and may occasionally be discovered during EUS examination after previously negative or inconclusive CT. Use of immunocytochemistry, when available, may help to confirm a suspected diagnosis. These lesions are more likely to have well-defined EUS margins compared with primary pancreatic cancer.     

EUS-FNA of recurrent postoperative extraluminal and metastatic malignancy

BACKGROUND: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described. METHODS: A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence. RESULTS: Twenty-one patients underwent EUS-guided FNA of 21 lesions (19 masses, 2 lymph nodes) because of a suspicion of recurrent malignancy based on CT (n = 17) or EUS (n = 4) findings. Median time from the initial diagnosis to recurrence was 26 months (range 5-276 months). Lesions were located in the pancreas (9 patients), mediastinum (7), liver (3), perigastric region (1), and liver hilum (1). EUS-guided FNA (mean number of needle passes, 4.5; range 2-8) obtained diagnostic material for recurrent malignancy in all patients as follows: esophageal (6 patients), renal cell (6), pancreatic (2), breast (2), colon (2), bile duct (1), Ewing's sarcoma (1), and lung (1) cancer. No complication was encountered. Transgastric EUS-guided FNA (4 patients), distal, or transesophageal EUS-FNA (2) proximal to a surgical anastomosis was required to confirm recurrence in all 6 patients with esophageal cancer. The initial cytologic diagnosis of recurrent malignancy was made by EUS in 20 of 21 (95%) patients. One patient with recurrent breast cancer had CT-guided FNA of a right lung mass preceding EUS-guided FNA of an AP window lymph node. CONCLUSIONS: EUS-guided FNA can detect and safely diagnose recurrent malignancy in the mediastinum, retroperitoneum, and liver. When possible, correlation between EUS-guided FNA cytology and original tumor histopathology/cytology, or the use of immunostaining to confirm the diagnosis, is recommended.     

Focal hepatic lesions. Their diagnosis by fine-needle (25 G) aspiration puncture]

151 patients with focal lesions of the liver underwent percutaneous fine-needle aspiration biopsy under ultrasonographic control. We used 25 G needles, the thinnest available. Aspiration biopsy was performed on malignant disease in 122 cases, and on benign disease in 29 cases. There were 3 false negatives diagnosis and 2 minor complications. The overall accuracy of the cytologic evaluations was 91.2%, with a sensitivity of 89.1% and specificity of 100%. Guided percutaneous fine-needle aspiration biopsy is recommended for a morphological diagnosis of focal liver lesions, because of its simplicity, safety and high degree of correct diagnosis.     

Diagnostic value of endoscopic ultrasonography-guided fine-needle aspiration cytology of mediastinal masses in patients with intrapulmonary lesions and nondiagnostic bronchoscopy

Several procedures are available for the cytopathological diagnosis of mediastinal lesions. The purpose of this study was to evaluate the diagnostic value of endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) in patients with mediastinal mass lesions/lymph node enlargement. All patients had intrapulmonary lesions on chest X ray and/or CT scan, and inconclusive findings by endobronchial forceps biopsy and/or brush cytology. EUS-guided FNA was performed in 16 patients using a modified oblique forward-viewing gastroscope with an electronic multielement curved linear ultrasound transducer. After the region of interest was localized, a 22-gauge Vilmann-Hancke needle was introduced via the 2-mm biopsy channel. The cytological diagnosis of EUS-guided FNA was conclusive for cancer in 9 patients and in the other 7 patients the aspirated samples revealed a benign lesion. In 10 patients the final diagnosis was cancer, thus EUS-guided FNA was diagnostic for malignancy in all but 1 of the lesions (sensitivity 90.0%). In 1 patient epitheloid cell granuloma was detected by cytological examination of the FNA. Following tuberculostatic treatment the lesions disappeared completely on CT scan and EUS. The overall accuracy in this study amounted to 93.7%. From this and other studies discussed, it is assumed that the procedure is an accurate and safe technique to examine nodular lesions suggestive of metastatic lymph node involvement.     

A multicenter U.S. experience with EUS-guided fine-needle aspiration using the Olympus GF-UM30P echoendoscope: safety and effectiveness

BACKGROUND: The aim of this study was to determine the safety, efficacy, and accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration using the GF-UM30P echoendoscope. METHODS: GF-UM30P-guided EUS-guided fine-needle aspiration results from 3 EUS referral centers were prospectively recorded. Successful sampling required that the needle tip be seen within the lesion on at least 1 pass. Aspirates were considered adequate if they were diagnostic for cancer, contained suspicious or atypical cells, or were adequately cellular for interpretation but nondiagnostic. RESULTS: EUS-guided fine-needle aspiration was attempted on 162 lesions in 152 patients with no complications. Sampling was successful in 150 of 162 (93%) attempts (mean lesion size 2.5 +/- 1.2 cm (range 0.7 to 6.0 cm). Aspirates were adequately cellular in 138 of 162 (85%) attempts (43% diagnostic, 15% suspicious and/or atypical cells, 27% adequate cellularity but nondiagnostic). Sampling failed in 12 of 162 (7%) attempts. Ten of 12 (83%) failures and 11 of 12 (92%) inadequate aspirates occurred when lesions measured less than 2 cm. The sensitivity for malignancy was 93% if only successfully sampled lesions with surgically confirmed negative results were included. However, it was 68% if all attempts were included and when unconfirmed high/moderate suspicion negative results were counted as false negatives and low suspicion negative results as true negatives. CONCLUSIONS: The GF-UM30P may be clinically useful for EUS-guided fine-needle aspiration if a curved linear array instrument is unavailable.     

Improved model for teaching interventional EUS

BACKGROUND: A swine model was previously developed for teaching endoscopic ultrasound (EUS). The purpose of this study was to improve this model and develop a method for creating focal lesions for EUS imaging and intervention. METHODS: Experiments were performed in farm pigs (Sus scrofa) under general anesthesia. Under real-time EUS guidance attempts were made to create a submucosal lesion and a focal mediastinal lesion, to perform EUS-guided fine-needle aspiration of the pancreas, and to confirm the site of injection during "sham" EUS-guided celiac block. RESULTS: A hypoechoic, submucosal mass was created in the stomach, which was then imaged by EUS and punctured trans-gastrically. Injection of saline solution in the mediastinum created a pseudo-mediastinal lymph node. A needle was then advanced trans-esophageally into the mediastinum to mimic EUS-guided fine-needle aspiration of a mediastinal lymph node. Abdominal exploration of the pigs after euthanasia confirmed injection of the sham celiac block around the celiac ganglion. CONCLUSION: The swine model is not only useful for teaching normal EUS anatomy, but it may be a useful model for teaching EUS-guided intervention.     

EUS-Guided Antitumor Therapy for Pancreatic Tumors

Endoscopic ultrasound (EUS) is a very useful modality for the diagnosis and staging of pancreatic masses. With the advent of EUS-guided fine-needle aspiration technology, this modality has made a tremendous leap from imaging modality to histologic diagnosis and therapeutic intervention. EUS offers high-resolution images of and unparalleled access to the pancreas. After locating the tip of the echoendoscope in the duodenum or stomach, several drugs or local treatment modalities can be delivered directly into the pancreas. EUS-guided ethanol lavage with/without paclitaxel injection has been tested for the treatment of cystic tumors of the pancreas, with complete resolution of cystic tumor being observed in up to 70-80% of patients. Ethanol injection is also performed for the management of solid neuroendocrine tumors of the pancreas. Various type of EUS-guided injection have also been investigated for the treatment of pancreatic cancer. An activated allogenic mixed lymphocyte culture (Cytoimplant) was injected in patients with advanced pancreatic cancer. A replication-deficient adenovirus vector carrying the tumor necrosis factor-alpha gene was also delivered intratumorally by EUS. ONYX-015 is an oncolytic attenuated adenovirus that exhibits replication preferentially in malignant cells, causing cell death, and this has also been injected into pancreatic cancers under EUS guidance. EUS-guided local ablation therapies such as radiofrequency ablation, photodynamic therapy, and brachytherapy are also under investigation. EUS-guided fine-needle injection for various solid or cystic lesions is a rapidly expanding field. This article reviews the various applications of EUS for the treatment of pancreatic tumors.     

EUS in the detection of ascites and EUS-guided paracentesis

BACKGROUND: The utility of EUS was evaluated for detection of ascites and EUS-guided FNA of ascites in patients undergoing EUS for diagnosis and staging of GI malignancies. METHODS: A series (from March 1994 to October 1997) of 571 consecutive patients who underwent upper EUS for various indications was retrospectively reviewed. Follow-up clinical information was obtained from referring physicians, subsequent CT, and telephone interviews. RESULTS: Eighty-five patients (15% of series) were found to have ascites by EUS. Six did not have CT before EUS. Pre-EUS CT identified ascites in only 14 (18%) of the 79 patients who had pre-EUS CT. Of the patients in whom CT was negative for abdominal fluid (n = 65) and who had clinical follow-up, 13 of 58 (22%) subsequently had ascites develop that were detected by CT or physical examination. Overall, 31 of the 85 patients underwent EUS-guided FNA paracentesis; the mean volume obtained was 7.9 mL (range 1-40 mL). In 5 patients, malignant ascites was diagnosed by EUS-guided FNA; in these patients surgery was avoided. CONCLUSIONS: EUS is more sensitive than CT in detecting small amounts of ascites. A significant number (22%) of patients who had ascites by EUS subsequently had ascites develop that was detectable by CT or physical examination. EUS-guided paracentesis appears to be safe and effective and can identify malignant ascites.     

超声内镜对常规内镜活检阴性胃壁增厚病变的诊断价值

目的评价超声内镜对常规内镜活检阴性胃壁增厚病变的诊断价值。方法回顾性分析57例常规内镜活检阴性胃壁增厚病变行超声内镜检查患者的诊断结果和随访情况,以手术病理和随访结果为最终诊断,统计内镜超声检查术（EUS）的诊断符合率以及内镜超声引导下细针穿刺抽吸术（EUS—FNA）、内镜超声定位下活检的阳性发现率。结果57例最终诊断为胃癌19例、胃淋巴瘤10例、不典型增生1例、Menetrier’s病1例、炎性改变26例。EUS对胃癌的诊断符合率为53．8％（14／26）,对胃淋巴瘤的诊断符合率为50．0％（10／20）;EUS．FNA阳性发现率为47．4％（9／19）;内镜超声定位下活检阳性发现率为66．7％（20／30）。结论EUS结合EUS—FNA尚不能作为鉴别诊断常规内镜活检阴性胃壁增厚病变病因的金标准,但超声内镜对诊断有一定帮助。     

Preoperative diagnosis of extrapancreatic neural invasion in pancreatic cancer.

BACKGROUND & AIMS: Pancreatic cancer recurs in most patients after resection with curative intent. Recurrence is particularly common in patients with extrapancreatic neural invasion (EPNI), the presence of which correlates with poor prognosis. Macroscopic EPNI may be detected with conventional noninvasive imaging and endoscopic ultrasound (EUS) imaging, but microscopic EPNI has required postoperative pathologic examination of surgical specimens. We report the preoperative diagnosis of cancer infiltration into celiac ganglia. We hypothesized that microscopic pancreatic cancer metastasis to neural ganglia can be detected by EUS-guided biopsy examination. METHODS: We performed a retrospective review of patients with pancreatic cancer undergoing EUS in whom celiac ganglia were sampled to exclude malignant infiltration. RESULTS: Six patients with pancreatic cancer underwent EUS-guided fine-needle aspiration or trucut biopsy examination of presumed celiac ganglia. Metastatic cancer was found in ganglia of 2 patients. Specimen review identified adenocarcinoma and neural tissue in the absence of lymphocytes. At laparoscopy, 1 of the 2 patients with positive celiac biopsy specimens also had several unexpected peritoneal metastatic deposits. The other patient was considered to have locally advanced unresectable disease. Both patients are receiving supportive care. CONCLUSIONS: EPNI may be shown preoperatively in patients with pancreatic cancer using EUS-guided sampling of celiac ganglia. A preoperative diagnosis of EPNI has the potential to improve staging accuracy and patient outcomes.     

Periportal lymphadenopathy in patients without identifiable pancreatobiliary or hepatic malignancy.

BACKGROUND & AIMS: Enlarged periportal lymph nodes often are noticed during imaging of the upper abdomen. Malignant infiltration and enlargement of periportal nodes occur in patients with cancers of the liver, gallbladder, biliary tree, and pancreas and lymphoma. However, there are no published data on the significance and differential diagnosis of enlarged periportal lymph nodes in patients without the above mentioned cancers. METHODS: We searched our database for patients who (1) underwent endoscopic ultrasound for evaluation of enlarged periportal nodes or (2) were found to have enlarged periportal lymph nodes (> or =10 mm) during endoscopic ultrasound (EUS) examination. Patients with identifiable pancreatic, biliary, gallbladder, or liver cancers were excluded. EUS-guided fine-needle aspiration of one or more nodes was performed. RESULTS: Sixty-four patients with periportal lymph nodes 10-40 mm in size met the inclusion criteria. In 24 patients, enlarged periportal nodes were noted in the computerized tomography or magnetic resonance imaging scans. Fifty-one patients had multiple enlarged periportal nodes. Concomitantly, enlargement was seen in peripancreatic nodes (n = 14), celiac nodes (n = 14), and mediastinal nodes (n = 11). Twelve of the 64 patients (18.8%; 95% confidence interval, 9.2%-28.4%) had a malignant cause of enlarged periportal lymph nodes: 5 with metastatic carcinoma and 7 with non-Hodgkin's lymphoma. Significant cytologic findings in benign nodes included granulomas (n = 4) and lipogranulomatosis (n = 8). CONCLUSIONS: A significant number of patients with enlarged periportal lymph nodes without identifiable pancreatobiliary and liver cancer harbor malignancy and other identifiable pathologic processes. We recommend that these nodes be sampled with fine-needle aspiration at the time of EUS examination.     

Autoimmune pancreatitis mimicking pancreatic cancer

Background/purpose

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that can often be difficult to distinguish from pancreatic cancer. We describe the clinical and radiographic features of 23 patients with AIP whose presentations mimicked pancreatic cancer.

Methods

A review of clinic, radiology, and endoscopy records from a 6-year period identified patients with AIP initially suspected of having pancreatic cancer. Abdominal computed tomography (CT) with intravenous contrast, endoscopic ultrasonography (EUS), and/or ERCP was performed in each patient. The diagnosis of AIP was made histologically and/or cytologically for each patient.

Results

Nineteen of 23 patients (83%) presented with new-onset weight loss, jaundice, or both. Nineteen (83%) patients had CT findings worrisome for pancreatic cancer including: (1) pancreatic enlargement or focal mass, (2) regional lymphadenopathy, and/or (3) vascular invasion. Eighteen patients (78%) had common bile duct strictures on ERCP. EUS-guided fine-needle aspiration biopsies excluded pancreatic cancer in all 22 patients who had EUS (96%). Seven patients had surgery for continued suspicion of pancreatic cancer.

Conclusions

Although AIP commonly presents with features suggestive of pancreatic cancer, clinical recognition of AIP with appropriate diagnostic testing including EUS with fine-needle aspiration, ERCP, IgG4 levels, and pancreatic protocol CT expedites diagnosis and can spare patients unnecessary surgery.     

Endoscopic ultrasound in pancreatic diseases

There are many indications for the use of endoscopic ultrasound (EUS) in the management of patients with pancreatic diseases. High-resolution imaging of the pancreas is achievable due to the close proximity between luminal structures and the pancreas. Since its introduction, EUS has had a significant impact on the diagnosis of pancreatic diseases. The detection of small lesions and neuroendocrine pancreatic tumors as well as the preoperative staging of pancreatic adenocarcinoma have been improved employing EUS. For the detection of small pancreatic tumors <2 cm in diameter, EUS appears to be the most sensitive method. EUS adds significant information to the differential diagnosis between pancreatic cancer and chronic pancreatitis, and it may be further enhanced by EUS-guided fine-needle aspiration. While the role of EUS in distinguishing between benign and malignant cystic pancreatic tumors is under discussion, EUS-guided drainage of pancreatic pseudocysts is an accepted treatment option for symptomatic individuals. One of the most important advantages of EUS apart from tumor staging is the early detection of chronic pancreatitis. EUS is as good as endoscopic retrograde cholangiopancreatography in diagnosing chronic pancreatitis in advanced stages. In early stages of the disease, when the ductal system remains normal, EUS appears to be a superior diagnostic modality because it can detect features of chronic pancreatitis in the parenchyma not visible by other techniques.     

An infected esophageal duplication cyst in a patient with non-Hodgkin''s lymphoma mimicking persistent disease

Differentiation of mediastinal cysts appearing as soft-tissue attenuation masses on computed tomography (CT) scans from malignant mediastinal masses is difficult. We report a patient with non-Hodgkin's lymphoma, who was considered to have persistent disease in the posterior mediastinum based on CT scans. However, endoscopic ultrasound (EUS) demonstrated a paraesophageal, fluid-filled cyst with echodens inclusions and no evidence of any solid component. EUS-guided fine-needle aspiration (FNA) revealed mucous, epithelial and inflammatory cells, and additionally candida albicans was cultured. Based on these findings and constant size during follow-up, the diagnosis of an infected esophageal duplication cyst was made. Thus, this report further demonstrated the impact of EUS and EUS-FNA for management of posterior mediastinal cystic lesions in selected cases.