Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue

BACKGROUND: EUS-guided FNA (EUS-FNA) is an accurate technique for sampling extraintestinal masses and lymph nodes. The use of a Trucut needle to perform EUS-guided biopsy (EUS-TCB) may improve the results or simplify the procedure. To date, few studies have prospectively assessed the performance and the safety of EUS-TCB. METHODS: Patients with a known or a suspected malignancy referred for a diagnostic and/or staging EUS examination were enrolled in a prospective study. EUS-guided biopsy was performed first with a 19-gauge Trucut needle. If the Trucut failed to obtain an adequate sample or when the "in room" touch preparation was benign, EUS-FNA was performed with a standard 22-gauge FNA needle. The objective of the study was to assess the yield of detection of malignancy and the safety of EUS-TCB in patients with known or suspected malignancies and to investigate if EUS-FNA has a role for rescue in cases of Trucut failure. OBSERVATIONS: Thirty-nine lesions underwent EUS-TCB in 30 patients. Sufficient follow-up was available for all patients. By using EUS-TCB, we were able to obtain a sample for diagnosis in all but 3 patients (one pancreatic mass and two lymph nodes) in which technical problems arose. In these patients, the diagnosis was obtained in two cases by EUS-FNA and in the other one by EUS-TCB from the primary pancreatic tumor. The yield of detection of malignancy for EUS-TCB was 84%. No complications were recorded in any patients at 1 and 7 days of follow-up. The sample size is limited to generalize conclusions. CONCLUSIONS: EUS-TCB is a safe and an accurate procedure to obtain a histologic diagnosis in patients with known or suspected malignancies. EUS-FNA can serve as a rescue technique in cases of Trucut failure.     

Prospective assessment of risk of bacteremia with colonoscopy and polypectomy

A prospective assessment was made of the frequency of positive blood cultures in patients undergoing colonoscopy with or without polypectomy. A total of 270 patients underwent 280 colonoscopies, of these, there were 105 patients that had 111 polypectomies. Blood cultures were taken prior to and within 15 min following each procedure. Six of 280 (2.1%) preprocedural blood cultures were positive. Seven of 169 (4%) blood cultures were positive within 15 min of insertion of the colonoscope in the colonoscopy only group. Eight of 223 (3.6%) blood cultures were positive within 10 min of the polypectomy. There was no clinical evidence of sepsis during the 24 hr following these procedures. In order to determine appropriate postprocedural sampling interyals, we induced aStaphylococcus epidermidis bacteremia with a mean of 1.16×10⁶ colony forming units/ml on 10 occasions in seven dogs. Within 30 min of inoculation, we were able to detect only one colony forming unit/ml. The rate of positive blood cultures during colonoscopy alone and following polypectomy during colonoscopy is comparable to other gastrointestinal endoscopy procedures. The most optimal time to collect blood cultures in order to detect transient bacteremia is as soon after the procedure as is feasibly possible.This research was supported in part by grants from the Victoria General Hospital Research Foundation, Inc., and the Manitoba Heart Foundation.     

Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications

To enhance the echocardiographic identification of high risk lesions in patients with infectious endocarditis, the medical records and two-dimensional echocardiograms of 204 patients with this condition were analyzed. The occurrence of specific clinical complications was recorded and vegetations were assessed with respect to predetermined morphologic characteristics. The overall complication rates were roughly equivalent for patients with mitral (53%), aortic (62%), tricuspid (77%) and prosthetic valve (61%) vegetations, as well as for those with nonspecific valvular changes but no discrete vegetations (57%), although the distribution of specific complications varied considerably among these groups. There were significantly fewer complications in patients without discernible valvular abnormalities (27%). In native left-sided valve endocarditis, vegetation size, extent, mobility and consistency were all found to be significant univariate predictors of complications. In multivariate analysis, vegetation size, extent and mobility emerged as optimal predictors and an echocardiographic score based on these factors predicted the occurrence of complications with 70% sensitivity and 92% specificity in mitral valve endocarditis and with 76% sensitivity and 62% specificity in aortic valve endocarditis.     

EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma

BACKGROUND: The clinical impact of EUS-guided FNA (EUS-FNA) in regional lymph-node staging in patients with unresectable hilar cholangiocarcinoma before liver transplantation has yet to be determined. OBJECTIVES: To determine the frequency of regional lymph-node detection, identify EUS features predictive of benign or malignant lymph nodes, compare EUS lymph-node detection rates to CT/magnetic resonance imaging and exploratory laparotomy, and evaluate the impact of EUS-FNA on patient selection for liver transplantation. DESIGN: Retrospective case series. SETTING: Tertiary referral EUS unit. PATIENTS: Clinical, radiographic, EUS, cytologic, and surgical data of 47 patients with unresectable hilar cholangiocarcinoma before liver transplantation were evaluated. INTERVENTIONS: EUS-FNA. MAIN OUTCOME MEASUREMENTS: Lymph-node morphology and echo features. RESULTS: EUS identified lymph nodes in all patients. FNA of 70 lymph nodes identified metastases in 9 nodes of 8 patients (17%), who were then precluded from transplantation before a staging laparotomy. Identified lymph nodes, irrespective of malignant involvement, were typically oval and geographic in shape, of mixed echogenicity, with a hypoechoic border. There were no morphologic criteria or echo features to correlate with nodal malignancy. The EUS finding of absent regional lymph-node metastases was confirmed in 20 of 22 by a subsequent exploratory staging laparotomy. LIMITATIONS: Single institution, retrospective analysis. CONCLUSIONS: EUS identified lymph nodes in all patients, and confirmation of malignant lymph nodes detected by FNA precluded 17% of patients from transplantation. EUS-FNA of visualized lymph nodes irrespective of appearance is advised because morphology and echo features do not predict malignant involvement.     

Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percutaneous FNA

BACKGROUND: Studies have suggested an increased risk of peritoneal seeding in patients with pancreatic cancer diagnosed by percutaneous FNA. EUS-FNA is an alternate method of diagnosis. The aim of this study was to compare the frequency of peritoneal carcinomatosis as a treatment failure pattern in patients with pancreatic cancer diagnosed by EUS-FNA vs. percutaneous FNA. METHODS: Retrospective review of patients with non-metastatic pancreatic cancer identified 46 patients in whom the diagnosis was made by EUS-FNA and 43 with the diagnosis established by percutaneous FNA. All had neoadjuvant chemoradiation. Patients underwent restaging CT after completion of therapy, followed by attempted surgical resection if there was no evidence of disease progression. RESULTS: There were no significant differences in tumor characteristics between the two study groups. In the EUS-FNA group, one patient had developed peritoneal carcinomatosis compared with 7 in the percutaneous FNA group (2.2% vs. 16.3%; p<0.025). No patient with a potentially resectable tumor in the EUS-FNA group had developed peritoneal carcinomatosis. CONCLUSIONS: Peritoneal carcinomatosis may occur more frequently in patients who undergo percutaneous FNA compared with those who have EUS-FNA for the diagnosis of pancreatic cancer. A concern for peritoneal seeding of pancreatic cancer via percutaneous FNA is warranted. EUS-guided FNA is recommended as the method of choice for diagnosis in patients with potentially resectable pancreatic cancer.     

Patient preference and recall of results of EUS-guided FNA

BACKGROUND: There are no clear guidelines regarding the best way, in terms of timing and setting, to deliver results to patients who undergo EUS-guided FNA (EUS-FNA) of suspected pancreatic masses. OBJECTIVE: We aimed to study (1) whether patients undergoing EUS-FNA prefer to receive preliminary results immediately after the procedure or at a later date, after final results are known; and (2) to assess the accuracy of patients' recollection of information given to them regarding their FNA diagnosis. DESIGN: We enrolled patients presenting to our endoscopy center for EUS-FNA of suspected pancreatic masses and obtained data through 4 pilot surveys. SETTINGS: University-based endoscopy center. PATIENTS: Sixty patients who were referred for EUS-FNA of suspected pancreatic masses. RESULTS: A total of 57 of 59 patients (96.6%) wanted preliminary results the same day as the procedure. Twenty-eight of 60 (42.7%) knew they were having a biopsy, and 42 of 60 (70%) knew cancer was suspected. Of those who received preliminary results, 31 of 41 (75%) remembered the diagnosis correctly the next day, and 32 of 38 (84%) remembered the diagnosis correctly 1 week later. LIMITATIONS: Single-center pilot study. CONCLUSIONS: The majority of our patients wished to receive preliminary results the same day as the procedure. Although most patients remembered results correctly, 25% of patients did not remember the correct diagnosis the next day. Further work is needed to improve patient's understanding of the reasons for the EUS-FNA and recall of preliminary EUS-FNA results.     

Diagnosis of intra-abdominal and mediastinal sarcoidosis with EUS-guided FNA

BACKGROUND: In the presence of a compatible clinical picture, the diagnosis of sarcoidosis requires pathologic confirmation of noncaseating epithelioid granuloma in affected tissues. The standard procedure of choice for most patients is a bronchoscopy with transbronchial biopsy (TBB), which has a diagnostic yield of 40% to 90%. The lowest yield with TBB is in cases that present with predominant mediastinal or intra-abdominal lymphadenopathy (LN) and minimal parenchymal lung involvement. OBJECTIVE: To study the diagnostic yield of EUS-guided FNA in diagnosing sarcoidosis with predominant LN or masses. DESIGN: Retrospective chart review. SETTING: Teaching university hospital. PATIENTS: Analysis of 21 consecutive patients with sarcoidosis and predominant mediastinal and/or intra-abdominal LN or masses who underwent EUS-guided FNA. RESULTS: EUS-guided FNA diagnosed sarcoidosis in 18 of 21 patients (86%). In 3 patients, EUS-guided FNA was either not diagnostic or inconclusive, and patients underwent mediastinoscopy with lymphadenectomy, which established the diagnosis of sarcoidosis. Seven of the 21 patients (33%) had intra-abdominal LN and/or masses, and EUS-guided FNA of the intra-abdominal pathology was diagnostic of sarcoidosis in 4 of the 7 patients (57%). Four of the 21 patients (19%) had a history of malignancy, and use of EUS-guided FNA helped in ruling out the recurrence of malignancy in 3 of the 4 patients (75%). LIMITATIONS: Mycobacterial and fungal culture was not obtained in all patients. CONCLUSIONS: EUS-guided FNA offers a practical, minimally invasive technique for the diagnosis of sarcoidosis in patients who present with predominant mediastinal and/or intra-abdominal LN or masses.     

EUS-guided FNA of the left adrenal gland in patients with thoracic or GI malignancies

BACKGROUND: The diagnostic yield and safety of trans-gastric EUS-guided FNA of the left adrenal gland are not well defined. METHODS: All patients with an enlarged left adrenal gland on abdominal imaging and known or suspected malignancy referred to two EUS centers over a 3-year period were included in this study. EUS-guided FNA was performed on an outpatient basis by one of 4 experienced endosonographers. RESULTS: Thirty-one consecutive patients (21 men, 10 women; mean age 64.8 years) were evaluated. Tissue adequate for interpretation was obtained in all patients; no attempt to obtain tissue was unsuccessful. The median number of needle passes was 4.5 (range 1-8). No immediate complications were encountered. EUS-guided FNA confirmed malignant left adrenal involvement in 42% (13/31) of the patients. Patients with malignant left adrenal masses were more likely to have known cancer at another site (OR 12.0: 95% CI[1.6, 87.9]). Patients with benign masses were more likely to have preservation of the normal sonographic appearance of the adrenal gland ("seagull" configuration) compared with those with malignant masses (OR 9.8: 95% CI[1.9, 51.0]). The accuracy of EUS imaging based on size (> or =3 cm) alone was 81%: 95% CI[63, 93]). Of the patients with malignant adrenal masses, 85% (11/13) died or their clinical condition deteriorated during follow-up, while 15% (2/13) were being treated and were stable clinically. CONCLUSIONS: EUS-guided FNA of the left adrenal gland is a minimally invasive, safe, and highly accurate method that confirms or excludes malignant adrenal involvement in patients with thoracic or GI malignancies.     

Preliminary experience comparing routine cytology results with the composite results of digital image analysis and fluorescence in situ hybridization in patients undergoing EUS-guided FNA

BACKGROUND: Studies indicate enhanced diagnostic accuracy for digital image analysis (DIA) and fluorescence in situ hybridization (FISH) versus routine cytology examination (RC) when biliary strictures are evaluated. These tumor markers have not been applied to EUS-guided FNA. OBJECTIVE: Our purpose was to determine the accuracy of RC versus the composite results of DIA/FISH. DESIGN: Patients enrolled with known or suspected malignancy. The final diagnosis was based on strict cytopathologic and imaging criteria and 12-month follow-up. SETTINGS: Tertiary referral center. PATIENTS: A total of 39 patients were enrolled in whom each diagnostic test was performed on samples from 42 sites to evaluate lymphadenopathy (n=19), pancreatic mass (n=19), esophageal or gastric wall mass (n=3), and thyroid mass (n=1). INTERVENTIONS: EUS-guided FNA with RC, DIA, and FISH. MAIN OUTCOME MEASUREMENT: Diagnostic accuracy of RC, DIA, and FISH. RESULTS: Malignancy was diagnosed in 30 of 42 patients, including esophageal squamous cell carcinoma, esophageal adenocarcinoma, gastric adenocarcinoma, pancreatic adenocarcinoma, pancreatic mucinous cystic neoplasia, intraductal papillary mucinous neoplasia, metastatic forearm sarcoma, small cell and non-small cell lung cancer, thyroid carcinoma, malignant GI stromal tumor, melanoma, adenocarcinoma of unknown primary, and lymphoma. The sensitivity, specificity, and accuracy of DIA/FISH versus RC for detecting malignancy were 97%, 100%, and 98% versus 87%, 100%, and 90%, respectively. LIMITATIONS: Single-center pilot study. CONCLUSIONS: Our findings suggest that DIA and FISH processing of EUS-guided FNA specimens provides higher diagnostic accuracy than RC does. These data suggest that these tumor markers incorporate generic targets as suggested by the high diagnostic sensitivity in this patient cohort with diverse pathologic conditions.