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Background: The presence of debris within a pseudocyst may impair success of endoscopic drainage. Objective: To compare the clinical outcomes and adverse-event rates of EUS-guided pseudocyst drainage with and without a nasocystic drain for the management of pancreatic pseudocysts with viscous solid debris-laden fluid. Design: Retrospective study. Setting: Single, tertiary-care referral center. Patients: Consecutive patients with pancreatic pseudocysts managed by EUS-guided drainage: those with solid debris who underwent drainage via nasocystic drains alongside stents (n = 63) and those with solid debris who underwent drainage via transmural stents only (n = 24). Intervention: Drainage via nasocystic drains alongside stents or drainage via transmural stents only. Main Outcome Measurements: The primary outcomes were short-term success and long-term success of the procedures. The secondary outcomes were procedure-related adverse events and reintervention. Results: The patients with viscous solid debris-laden fluid whose pseudocysts were drained by both stents and nasocystic tubes had a 3 times greater short-term success rate compared with those who had drainage by stents alone (P = .03). On 12-month follow-up, complete resolution of pseudocysts with debris drained via stents alone was less (58%) compared with those with debris who underwent drainage via nasocystic drains alongside stents (79%; P = .059). The rate of stent occlusion was higher in cysts with debris drained by stents alone (33%) compared with those drained via nasocystic drains alongside stents (13%; P = .03). Limitations: Retrospective design; limited sample size. Conclusion: In patients with pseudocysts with viscous debris-laden fluid, EUS-guided drainage by using a combination of a nasocystic drain and transmural stents improves clinical outcomes and lowers the stent occlusion rate compared with those who underwent drainage via stents alone. [Copyright &y& Elsevier]

Abstract: Background: Pancreatic neuroendocrine tumours are uncommon neoplasms which may rarely be cystic. Differentiation from other more common cystic neoplasms may be difficult. Aims: To describe the morphologic, cytologic, and cyst fluid characteristics of cystic pancreatic neuroendocrine tumours. Methods: Retrospective analysis of consecutive patients referred for endosonographic evaluation of pancreatic cysts at four centres. Results: 27 patients (12 males) with cystic pancreatic neuroendocrine tumours were identified. Prior to endosonography, this tumour was suspected in only 2 patients based on presenting symptoms (7.4%). The median cyst size was 35mm (range 8–80mm). Wall thickening was identified in 13 cases. The median carcinoembryonic antigen level was 1.25 (range 0.6–500). Fine needle aspiration cytology in 17 of 24 patients confirmed neuroendocrine tumour (71%). In 8 of 9 patients who had needle targeting of the cyst wall, cytology was consistent with neuroendocrine tumour (88.9%). 18 patients underwent surgical resection. Conclusions: Cystic pancreatic neuroendocrine tumour was rarely suspected, including by cross-sectional imaging. Wall thickening was identified in approximately half of cases on endosonography. Cyst fluid was typically non-viscous with very low carcinoembryonic antigen levels. Targeting the wall during fine needle aspiration had a high diagnostic yield and should be performed. [Copyright &y& Elsevier]

Background: Despite an increasing number of procedures being performed, there is no consensus on an optimal approach to EUS-guided FNA (EUS-FNA) or interventions. Objective: Validate an algorithmic approach to EUS-FNA/interventions with the objective of improving technical outcomes and resource use. Design: Prospective study. Setting: Tertiary-care referral center. Patients: Consecutive patients undergoing EUS-FNA and/or interventions. Intervention: Phase I was a retrospective analysis of EUS-FNA/interventions performed in 548 patients. The 19-gauge needle was used for interventions, and the 22- or 25–gauge needle was used interchangeably for performing FNAs. At phase I, the technical failure rate was 11.5%. Based on these observations, an algorithm was proposed by which all transduodenal FNAs were performed by using a 25-gauge needle and other FNAs with a 22-gauge needle. All transduodenal interventions were performed with a Flexible 19-gauge needle and others with a standard 19-gauge needle. This algorithm was tested prospectively in phase II on 500 patients. Main Outcome Measurements: Compare technical failure, diagnostic adequacy, procedural complications, and average needle costs between both phases. Results: The technical failure rate was significantly less in phase II compared with that of phase I (1.6% vs 11.5%; P < .001) for both FNA (1.8% vs 10.9%; P < .001) and therapeutic interventions (0% vs 16.4%; P = .001). Although there was no difference in diagnostic adequacy (97.1% vs 98.4%; P = .191) or complications (0.4% vs 0.2%; P = 1.0) between phases I and II, the average cost per case was significantly less in phase II ($199.59 vs $188.30; P = .008). Limitations: Single-center study. Conclusion: An algorithmic approach to EUS-FNA/interventions yielded better technical outcomes and cost savings without compromising diagnostic adequacy. [Copyright &y& Elsevier]

Background: Intra-abdominal lymphadenopathy is a common diagnostic challenge faced by clinicians. In the absence of palpable peripheral nodes, tissue is usually obtained from the abdominal nodes by image-guided biopsy or surgery. We speculate that EUS-guided FNA (EUS-FNA) avoids the morbidity of a laparotomy and might be equally effective. Objective: To evaluate the role of EUS-FNA in abdominal lymphadenopathy. Design: Prospective study conducted over 42 months. Setting: Tertiary care center in New Delhi, India. Patients: Patients with abdominal lymphadenopathy in whom image-guided node biopsy failed were considered for EUS-FNA. Intervention: A total of 3 passes were performed at each site. Slides were prepared per protocol and sent for cytopathologic evaluation. Results: A total of 142 patients were enrolled, but only 130 (91.5%) underwent FNA. The mean lymph node size was 22 ± 3.2 mm; 71.8% of the nodes were hypoechoic (n = 102), and 28.1% were heterogeneous with an anechoic center (n = 40). In 120 patients (84.5%), the lymph nodes were intra-abdominal only, and in 22 patients (15.5%), they were both intra-abdominal and mediastinal in location. Main Outcome Measurement: EUS-FNA was successful in establishing a diagnosis in 90.8% of these patients; 76.1% were found to have tuberculosis, 7.04% sarcoidosis, 6.33% Hodgkin''s lymphoma, and 0.74% non-Hodgkin''s lymphoma. Limitations: In 8.4% patients, nodes were inaccessible because of their retropancreatic location. Conclusions: EUS-FNA is a safe, accurate, and minimally invasive modality for diagnosing the cause of abdominal lymphadenopathy. In highly endemic areas, tuberculosis is the most common cause. [Copyright &y& Elsevier]

Background & Aims: It is a challenge to collect samples from bile duct strictures to diagnose patients with cholangiocarcinoma. We investigated the utility of the Spyglass Spyscope, a single-operator endoscope that is used to perform cholangiopancreatoscopy, to identify extrahepatic cholangiocarcinoma in patients who were not diagnosed with this disorder by endoscopic retrograde cholangiopancreatography (ERCP) cytology or endoscopic ultrasound–guided fine-needle aspiration (EUS-FNA) analyses. Methods: We conducted a retrospective analysis of data from 30 patients (median age, 67 years; 67% male) with indeterminate extrahepatic biliary strictures who were ultimately diagnosed with cholangiocarcinoma but had inconclusive results from initial biliary ductal brush cytology and EUS-FNA analyses. Patients then underwent cholangioscopy by using the Spyglass Spyscope and intraductal biopsy analysis. None of the patients had a definitive mass in abdominal imaging or EUS analyses. Results: The biliary stricture was located in the common bile duct in 13 patients and in the common hepatic duct in 17 patients. The Spyglass Spyscope system had 77% accuracy (23 of 30) in the diagnosis of malignancies that were inconclusive on the basis of ERCP-guided brush or EUS-FNA analyses. Conclusions: The Spyglass Spyscope for cholangioscopy and biopsy collection identified malignancies with 77% accuracy in patients with suspected cholangiocarcinoma. [Copyright &y& Elsevier]

Background: The currently accepted paradigm is that the false-positive (FP) rate for EUS-guided fine-needle aspiration (EUS-FNA) cytologic analysis of a pancreatic lesion is less than 1%. Objective: To assess the FP rate of EUS-FNA in patients who underwent surgical resection for presumed pancreatic cancer. Design: Retrospective study. Setting: Tertiary-care referral center. Patients: This study involved 367 patients with solid pancreatic lesions in whom EUS-FNA cytology results were interpreted as positive or suspicious for malignancy, which resulted in subsequent surgical resection. Intervention: Surgical resection. Main Outcome Measurements: The FP diagnosis was defined as EUS-FNA cytology specimens being reported as “positive” or “suspicious for malignancy” but that were later proven to be benign on surgical pathology. Results: The FP rate for EUS-FNA was 4 of 367 (1.1%) when only “positive” cytology findings were interpreted as malignant and 14 of 367 (3.8%) when both suspicious and positive cytology findings were interpreted as malignant. Among the 4 cases falsely interpreted as positive, 1 was falsely diagnosed cytologically as a neuroendocrine tumor and 3 as adenocarcinomas. All FP specimens showed chronic pancreatitis on surgical pathology. The incidence of discordance between cytology and surgical pathology did not change over time (2000-2006: 8/188 [4.3%] vs 2007-2010: 6/179 [3.4%]; P = .79). Limitations: Retrospective study at a single center. Conclusion: In a retrospective cohort trial, the FP rate for EUS-FNA of solid pancreatic lesions was 1.1%. Findings of the current study are in line with previous studies that have evaluated the FP cytology rates with EUS-FNA of solid lesions. FP cases transpired primarily as a result of cytologic misinterpretation in the setting of chronic pancreatitis. [Copyright &y& Elsevier]

Background: Fully covered esophageal self-expandable metal stents (FCSEMSs) are thought to induce less mucosal hyperplasia and are potentially removable. They may constitute an attractive alternative for the treatment of benign esophageal diseases. Objective: To evaluate the efficacy and safety of FCSEMSs in the treatment of benign esophageal diseases. Design: Patients referred for management of benign esophageal disease underwent placement of an FCSEMS and were entered into a prospective database and analyzed retrospectively for clinical response, efficacy, and morbidity. Setting: Two tertiary care centers with long-standing experience in the management of benign esophageal strictures. Patients: Between January 2006 and September 2007, 35 patients (mean age 61 years, range 20-85 years) underwent FCSEMS placement for benign esophageal diseases at 2 tertiary academic medical centers. There were 19 patients with benign esophageal strictures and 16 patients with leaks/perforations. Intervention: Temporary placement of FCSEMS until stricture resolution. Main outcome measurements: Clinical response, efficacy, and morbidity. Results: Indications for stent placement were esophageal leak/fistulae (n = 12), refractory benign strictures (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). Immediate complications were chest pain (2 patients), stent migration (2 patients), dysphagia (1 patient), respiratory compromise (1 patient), and arrhythmia (1 patient). Long-term complications included recurrent dysphagia (6 patients), aspiration pneumonia (2 patients), globus sensation (2 patients), abdominal pain (2 patients), and fever (1 patient). Stent migration was observed in 12 patients (34%). After placement, dysphagia scores at 1 month improved significantly from 3.1 ± 1.0 to 1.2 ± 1.3 (P < .0001). A total of 11 of 35 patients (31%) were treated successfully. Specifically, 21% of patients with refractory strictures and 44% of patients with leaks/fistulae had successful long-term outcomes without any need for reinterventions. All stents were retrieved successfully, except for 1 stent, which fractured and was retrieved in 2 pieces without any complications. Conclusion: Use of FCSEMSs for benign esophageal conditions was associated with frequent stent migration and long-term improvement in only one third of patients. Further investigation is required before recommending FCSEMS placement to treat benign diseases of the esophagus and to further characterize the subgroup that might benefit from these interventions. [ABSTRACT FROM AUTHOR]

Background: Accurate false negative rates for endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) for mediastinal (N2) lymph nodes are unknown. Methods: A retrospective review of patients with non-small cell lung cancer (NSCLC) underwent integrated positron emission tomography and computed tomography (PET/CT) and CT scan. All suspicious N2 lymph nodes were biopsied before thoracotomy. The EBUS was performed for suspicious nodes in stations 2R, 4R, 4L, 5, and 7; the EUS was performed for 4L, 4R, 5, 7, 8, and 9. Mediastinoscopy was performed in selected patients if they were negative by EUS/EBUS; if N2 negative, all patients underwent thoracotomy with complete thoracic lymphadenectomy. Results: There were 425 patients over a 2-year period, and 234 had suspected N2 disease. Of these patients, 72 had an EBUS; 16 were positive for N2 disease and 12 were false negative (7 patients at station 4R/4L, 4 patients at station 7; patient sensitivity 57%, negative predictive value 79%, accuracy 83%). Seventy-nine patients had EUS; 20 patients were positive for N2 disease and 12 were false negative (4 patients at station 4R/4L, 4 patients at station 7; patient sensitivity 63%, negative predictive value 80%, accuracy 85%). One hundred and forty-six patients had mediastinoscopy, which revealed N2 or N3 disease in 42 patients, and 7 were false negative (patient sensitivity 88%, negative predictive value 93%, accuracy 95%). Conclusions: Both EBUS and EUS are useful initial tests to biopsy suspicious N2 mediastinal lymph nodes; however, as EBUS and EUS have high false negative rates, especially at stations 4R and 7, mediastinoscopy is still required for patients with suspicious nodal disease in these stations. [Copyright &y& Elsevier]

Background: EUS-guided FNA of the left and right adrenals has been described, but data are very limited. Objectives: Our primary objective was to determine the impact of the diagnostic utility of EUS-guided FNA of adrenal glands on patient management. Our secondary objective was to determine predictors of malignant adrenal involvement. Study Design: Observational study. Setting: Tertiary referral center. Patients: Patients with enlarged adrenal(s) on abdominal imaging underwent EUS-guided FNA. The left adrenal (n = 54) was sampled via the transgastric approach and the right adrenal (n = 5) via a transduodenal approach. Results: Fifty-nine patients (63% men, median age 65 years) were evaluated. The median adrenal gland size was 25 × 17 mm. Adrenal tissue adequate for interpretation was obtained in all of the patients. EUS-guided FNA confirmed malignancy in 22 (37%) patients. Based on size (≥30 mm) alone, EUS had an accuracy of 68%. Patients with malignant cytology had higher standard uptake value scores on positron-emission tomography compared with patients with benign adrenal masses (P < .001). Malignant masses were more likely to have an altered adrenal gland shape compared with benign masses (crude odds ratio [OR] 12.0; P < .001). On multivariable analysis, altered adrenal gland shape was a significant predictor of malignancy (adjusted OR 7.94; P = .015), whereas a size of 30 mm or larger (adjusted OR 1.30; P = .774) and hypoechoic nature (adjusted OR 12.05; P = .148) were not. All patients except 2 with malignant cytology were treated with systemic therapy without the need for additional invasive biopsies or surgery. No immediate complications were encountered. Limitations: Lack of surgical criterion standard; 1 experienced endosonographer. Conclusions: EUS-guided FNA of the adrenal glands is a minimally invasive and safe approach that documents or excludes malignant involvement. EUS-guided FNA should be the first next test to evaluate enlarged adrenal glands because it directs therapy and affects patient management. [Copyright &y& Elsevier]

Background: EUS-guided FNA is a well-recognized technique for sampling the pancreas, peri-intestinal lymph nodes, and mass lesions. The role of EUS-guided FNA in the diagnosis of peritoneal carcinomatosis has not been well studied. Objective: We aimed to determine the feasibility and success in sampling lesions in the peritoneum suspicious for carcinomatosis without a primary source. Design: An observational study. Setting: A tertiary referral center. Patients: Consecutive patients who underwent EUS-guided FNA of peritoneal deposits. Results: During a span of 3 years, 4 patients underwent transgastric or transduodenal EUS-guided FNA of peritoneal lesions with a curvilinear echoendoscope. All of these lesions were imaged by abdominal CT scan. The EUS findings of the nodules appeared round, relatively hypoechoic to the surrounding tissue, but hyperechoic when compared with the surrounding low-volume ascites where the lesions floated. Four passes were performed per case, and the diagnosis was achieved on a median of 2 passes (range 1-4). All patients received intravenous antibiotics during the procedure. Two patients had metastatic adenocarcinoma, 1 patient had lymphoma, and 1 patient had metastatic breast carcinoma. Diagnostic laparoscopy/laparotomy was avoided in all patients. No complications, particularly peritonitis, were encountered. Limitations: Observational study with a small sample size. Conclusions: Transgastric or transduodenal EUS-guided FNA for peritoneal carcinomatosis is feasible and safe. In the setting of an unknown primary cancer, EUS-guided FNA facilitates acquisition of tissues for treatment allocation, thus avoiding the need for laparoscopy or laparotomy. [Copyright &y& Elsevier]

Background: Tissue sampling of renal lesions is traditionally performed with percutaneous US or CT guidance. To date, only 3 known cases of EUS-guided FNA (EUS-FNA) of a renal mass have been reported. Objective: To describe a multicenter experience with the indications, yield, and complications from attempted EUS-FNA of a kidney mass. Design: Retrospective case series. Setting: Six tertiary referral hospitals in the United States. Patients: Consecutive subjects undergoing attempted EUS-FNA of a kidney mass. Endosonographers at 15 other teaching hospitals were contacted regarding EUS findings and follow-up of any EUS-guided renal biopsies previously attempted or considered at that institution. Interventions: EUS-FNA of a kidney mass. Main Outcome Measurements: Biopsy indications, yield, diagnosis, and complications. Results: Fifteen procedures in 15 patients (9 men; median age 67 years) were performed at 6 (37%) of 16 hospitals (Indiana University plus 15 other hospitals). Kidney masses (median diameter 32 mm; range 11-60 mm) were located in the upper (n = 12) and lower (n = 3) poles of the left (n = 10) and right (n = 5) kidneys, respectively. Initial mass detection was by previous imaging in 13 (87%) patients or by EUS in 2 (13%) patients. Results of EUS-FNA (median 3 passes; range 2-4 passes) in 13 (87%) procedures were diagnostic of (n = 7) or highly suspicious for (n = 1) renal cell carcinoma (RCC), atypical cells (n = 2), oncocytoma (n = 1), benign cyst (n = 1), and nondiagnostic (n = 1). No complications were encountered. Surgical resection confirmed RCC in 7 patients in whom preoperative EUS-FNA demonstrated RCC (n = 5) or oncocytoma (n = 1) or was not performed (n = 1). Limitations: Retrospective series, small number of patients. Conclusions: EUS-FNA of renal masses is rarely performed at the U.S. teaching hospitals surveyed. This technique appears safe and feasible and should be considered when results would affect patient management. [Copyright &y& Elsevier]

Background: EUS is being increasingly utilized for the diagnosis of choledocholithiasis and microlithiasis, especially in patients with biliary colic. Simultaneously, there is also a rising interest in the use of EUS for therapeutic interventions. Objectives: Our goal was to assess the effectiveness of EUS-directed common bile duct (CBD) stone removal to compare its safety and effectiveness with ERCP-directed intervention. Design: Interim results of a prospective, randomized, single-center blinded clinical trial. Setting: A single tertiary care referral center. Patients: Fifty-two patients with uncomplicated CBD stones were prospectively randomized to CBD cannulation and stone removal under EUS or ERCP guidance. Main Outcome Measurements and Interventions: Primary outcome measure was the rate of successful cannulation of the CBD. Secondary outcome measures included successful removal of stones and overall complication rates. Results: CBD cannulation followed by stone extraction was successful in 23 of 26 patients (88.5%) in the EUS group (I) versus 25 of 26 patients (96.2%) in the ERCP group (II) (95% CI, −27.65%, 9.88%). Overall, there were 3 complications in the EUS group and 4 complications in the ERCP group. Limitation: The current study is an interim report from a single center report and performed by a single operator. Conclusions: Our preliminary analysis indicates that outcomes following EUS-guided CBD stone retrieval are equivalent to those following ERCP. EUS-related adverse events are similar to those following ERCP. ERCP and EUS-guided stone retrieval appears to be equally effective for therapeutic interventions of the bile duct. Additional studies are required to validate these preliminary results and to determine predictors of success of EUS-guided stone removal. [Copyright &y& Elsevier]

Background: Although the role of bedside endoscopy for the provision of emergent diagnosis and therapy is well known, the concept of bedside EUS requires further validation. Objective: To evaluate the concept of bedside EUS and assess its impact on patient management. Design: A prospective study. Setting: A tertiary-referral center. Patients: Patients included those with pancreaticobiliary and thoracic disorders who required EUS but who were clinically unstable to be evaluated in the endoscopy suite. Interventions: All procedures were performed by one endosonographer at the patient''s bedside by using an EUS cart that was equipped with a therapeutic curvilinear echoendoscope. Main Outcome Measurements: To evaluate the technical feasibility, safety, and impact of bedside EUS in the clinical management of patients. EUS was considered to have a significant impact if a new diagnosis was established and/or if the findings altered subsequent management. Results: Within a 3-month period, 6 patients (4 men; median age 56 years; American Society of Anesthesiologists class III/IV) were evaluated in the intensive care unit by using the mobile EUS cart. Procedural indications were the following: drainage of symptomatic pseudocyst (n = 2), evaluate the cause of cholangitis (n = 2), diagnose and treat a suspected postoperative (distal esophagectomy) fluid collection (n = 1), and provide tissue diagnosis in one patient with a pancreatic-head mass, who presented with intrahepatic bleeding. The procedure was technically successful in all 6 patients (100%), and no complications were encountered. Bedside EUS established a diagnosis of choledocholithiasis (n = 1), mediastinal abscess (n = 1), and pancreatic abscess (n = 1) in 3 patients, and ruled out the presence of choledocholithiasis (n = 1) and pancreatic pseudocyst (n = 1) in 2 other patients. Also, by using bedside EUS, transmural drainage of a pancreatic pseudocyst and mediastinal abscess was successfully undertaken in 2 patients. Bedside EUS had an impact on management in all 6 patients (100%): established a new diagnosis (n = 3), precluded the need for an ERCP and/or other interventions (n = 2), and enabled focused endotherapy (n = 3). Limitations: Small number of patients; a single endosonographer. Conclusions: Bedside EUS is technically feasible, safe, facilitates both diagnosis and therapy, and enables the clinical management of patients who are critically ill. [Copyright &y& Elsevier]

Background: EUS-guided FNA is commonly performed to sample peri-intestinal targets such as the pancreas, lymph nodes, and the left adrenal gland. To our knowledge, EUS-guided FNA of the right adrenal gland has not been reported. Objective: Our purpose was to determine the feasibility and success in sampling an enlarged right adrenal gland. Study Design: Observational study. Setting: Tertiary referral center. Patients: Consecutive patients that underwent EUS-guided FNA of the right adrenal gland. Results: Over a span of 3.5 years, 4 patients underwent transduodenal EUS-guided FNA of the right adrenal gland with a curvilinear echoendoscope. Four passes were performed in all cases, and the diagnosis was rendered on the first pass. The posterior wall of the descending duodenum was the port of entry of the needle. Three of the patients had metastatic lung cancer to the right adrenal gland; one was proven by surgical histopathologic examination. One patient had a benign aspirate consistent with angiomyolipoma. None of the patients had any minor or major complications. Limitations: Observational study, small sample size. Conclusions: Transduodenal EUS-guided FNA of the right adrenal gland is feasible and safe. Future large-scale studies are needed to replicate our findings and to determine the rate of successful identification and sampling of the right adrenal gland with the curvilinear echoendoscope. [Copyright &y& Elsevier]

Background: Transesophageal EUS-guided FNA (EUS-FNA) is safe, accurate, and cost effective in staging patients with non-small-cell lung cancer (NSCLC). However, the impact of EUS-FNA on patient survival has not been demonstrated. Objective: To determine the impact of metastatic disease in mediastinal lymph nodes as determined by EUS staging on treatment choice and survival in patients with NSCLC. Design: Retrospective analysis of prospectively collected data. Setting: Tertiary university-based referral center. Patients: Patients with biopsy-proven NSCLC who underwent staging EUS-FNA. The relationship between the EUS nodal status and patient survival was evaluated. Cox proportional hazards models were used to determine the significance of EUS nodal status and patient characteristics on patient survival. Main Outcomes Measurements: Impact of EUS-FNA on therapy and survival in patients with NSCLC. Results: Of 125 patients with NSCLC, EUS-FNA confirmed metastatic disease in 46% of the patients. Patients who were node positive were more likely to receive chemotherapy and/or radiation therapy and were less likely to undergo surgery compared with patients who were node negative (P < .0001). Patients with N2 or N3 disease by EUS-FNA had a shorter survival time than patients who were node negative (P = .004). Adjusting for age, race, and sex, EUS-FNA was the most important predictor of survival of patients with NSCLC in this cohort of patients (hazard ratio 2.34, 95% CI 1.31-4.21). Limitations: Lack of surgical reference standard in all patients and referral to a tertiary center. Conclusions: Patients with node-positive NSCLC as detected by EUS-FNA have a shorter survival time compared with patients who were node negative. They are more likely to receive neoadjuvant therapy and less likely to receive surgery. Preoperative EUS-FNA is a minimally invasive technique that provides important prognostic information in patients with NSCLC. [Copyright &y& Elsevier]

Background: Increasingly, peripancreatic fluid collections (PFCs) are managed endoscopically with conventional transmural drainage (CTD). The role of interventional EUS in drainage of PFCs requires further clarification, because the procedure is technically challenging, with limited availability. Objective: Identify characteristics that determine the need for drainage of PFC by CTD versus EUS. Patients: Consecutive patients with symptomatic PFCs (types: pseudocyst, abscess, and necrosis) referred for endoscopic drainage. Study Design: Prospective study. Setting: Tertiary-referral center. Methods: After ERCP, transmural drainage was attempted by CTD. If unsuccessful, drainage by EUS was then attempted. Findings on contrast-enhanced CT and endoscopy were collected to identify characteristics that predict the need for CTD versus EUS drainage. Main Outcome Measurements: Identify characteristics to determine whether CTD or EUS is best suited for drainage of a particular PFC. Technical outcomes and safety of both techniques were also compared. Results: Of 53 patients with PFCs, CTD was technically successful in 30 (57%) and failed in 23 (43%). PFC regional location was the pancreatic head in 16, the body in 20, and the tail in 17; in these locations, CTD was successful in 13 (81%), 17 (85%), and 0, respectively. The causes of failed CTD were absence of luminal compression (LC) in 20, difficulty with scope positioning in 2, and bleeding with attempted drainage (portal hypertension) in 1. One PFC drained by CTD was later diagnosed as necrotic sarcoma. Of the 23 patients who failed CTD and underwent EUS, an alternate diagnosis of mucinous neoplasm was made in 2 patients, and EUS-guided drainage was successful in the other 21 patients (100%). Although CTD failed in all PFCs in the tail, all were successfully drained by EUS. In the pancreatic-head region, only those PFCs superior to pancreas and extending into porta hepatis (n = 3) required drainage by EUS. In the pancreatic body, only PFCs that developed bleeding from a transmural puncture or without definitive LC because of gastric mural edema (albumin <1.5 mg/dL, n = 2) required EUS drainage. When compared with PFCs at other locations, those in the tail were best accessed by EUS (P < .001). Patients with luminal compression at CT were significantly more likely to undergo successful drainage by CTD (adjusted odds ratio [OR] 13.6; P = .02). When compared with CTD, EUS drainages were longer in duration (40 versus 75 minutes; P < .001), with similar rates of PFCs resolution (90% versus 95%). Although bleeding occurred in 1 patient in the CTD group, no complications were encountered in patients who underwent EUS-guided drainage. PFCs located at the tail of the pancreas were more likely to require drainage by EUS than CTD (adjusted OR 22.9, P = .003) when adjusted for the presence of luminal compression at CT, size of the PFC, serum albumin, and etiology of pancreatitis. Limitations: Nonrandomized study. Conclusions: Because a majority of PFCs can be drained by CTD in a shorter duration, with comparable outcomes, EUS-guided drainage should be reserved mainly for PFCs located at the pancreatic tail, because these are unlikely to cause luminal compression or are technically difficult to access. Also, all pseudocyst-type PFCs must be evaluated by EUS before any attempts at endoscopic drainage, because EUS identifies an alternate diagnosis in 5% of such patients. [Copyright &y& Elsevier]

With the advent of endobronchial and esophageal endoscopic ultrasound (EUS), current data suggest that most mediastinal stations can be reached with minimally invasive staging with the exception of stations 5 and 6. EUS fine-needle aspiration (FNA) is a minimally invasive technique that allows sampling of mediastinal lymph nodes relevant to lung cancer staging, particularly in the subcarinal area (station 7), lower paraesophageal lymph nodes (station 8), inferior pulmonary ligament lymph nodes (station 9), and celiac lymph nodes. In addition, EUS-FNA is capable of sampling metastatic, sarcoidosis, and lymphoma harboring lymph nodes. The left adrenal gland is easily sampled by EUS-FNA through the transgastric approach. EUS-FNA is also able to sample central primary lung masses abutting the esophagus, particularly when other techniques fail. By working in a multidisciplinary fashion with colleagues in thoracic surgery, pulmonary, and oncology, the best initial staging approach for each patient can be individualized. [Copyright &y& Elsevier]

Background: The purpose of this study was to assess the efficacy of the different techniques of lymph node biopsies in patients with suspected metastatic non-small cell lung cancer (NSCLC) in the subaortic (station #5) and paraaortic (station #6) lymph nodes. Methods: This was a retrospective cohort study conducted of a prospective database of patients between January 2003 and June 2006 with suspected N2 disease only in the #5 or #6 lymph nodes, or both. All patients had integrated 2-deoxy-2-fluoro-d-glucose positron emission tomography/computed tomography, and nodal biopsy or thoracotomy, or both, with complete thoracic lymphadenectomy. Results: There were 112 patients with clinically suspected N2 disease in lymph node stations #5 or #6, or both. The primary tumor was in the left upper lobe in 98 (88%) and in the left lower lobe in 14 (13%), and 58 had pathologic N2 disease in #5 or #6 lymph node stations only. Mediastinoscopy, used in all patients found, unsuspected N3 disease in 4 patients (3.6%) and N2 (#4L) disease in 12 (11%). Endoscopic ultrasound with fine needle aspiration (EUS-FNA), implemented in 62 patients (56%), correctly identified 41 patients (66%). Left single-incision video-assisted thoracic surgery (VATS) was used in 39 patients and was correct in 100%. Of the 58 patients, 53 (91%) completed neoadjuvant chemoradiotherapy, followed by resection, and their 5-year survival was 64%. Conclusions: EUS-FNA is less accurate for the #5 and #6 lymph node stations than left VATS. We prefer left VATS over the Chamberlain procedure for patients with suspected nodal metastases isolated only to #5 or #6 stations, and if positive, we prefer neoadjuvant therapy. The advantage of neoadjuvant therapy followed by resection compared with resection followed by adjuvant therapy remains controversial; and hence, the role for biopsy of these nodes is also controversial. [Copyright &y& Elsevier]

Background: Studies that correlated EUS features of chronic pancreatitis (CP) with histopathology are retrospective and only include patients with severe disease or calcific pancreatitis. Controversies regarding the significance of EUS features of noncalcific CP (NCCP) remain unresolved. Objective: To correlate EUS criteria for NCCP with histology from surgical specimens. Design: Prospective study. Setting: Tertiary referral center. Patients: All patients who underwent EUS for pancreaticobiliary indications and subsequent pancreatic surgery. Patients with calcific pancreatitis were excluded. Methods: Individual CP features on EUS were carefully documented with relation to different parts of the pancreas. Standard EUS criteria for CP were adopted. All patients underwent surgery within 2 months of EUS. A single pathologist blinded to EUS findings reviewed the specimens and graded fibrosis (total score, 12; ≥6 = unequivocal CP). A quantitative receiver operating characteristic (ROC) curve analysis was performed, and Spearman rank correlation coefficients were calculated. Main Outcome Measurements: Correlate EUS criteria for NCCP, with histology from surgical specimens. Results: Of the 42 patients evaluated, NCCP was diagnosed histologically in 21 patients (50%). None of the patients had CP diagnosis by CT. ROC curve analysis revealed that 4 or more EUS criteria provided the best sensitivity (90.5%), specificity (85.7%), and accuracy (88.1%) for diagnosing NCCP. Parenchymal EUS features that were significantly associated with histopathologic NCCP were foci (P < .0001), stranding (P < .001), and lobulations (P = .04); ductal features that were significantly associated with histopathologic NCCP were dilated (P < .0001) or irregular main pancreatic duct (P < .0001), side branches (P < .001), and hyperechoic duct margins (P = .03). There was a significant correlation between the number of EUS criteria and severity of NCCP on histology (r = 0.85; P < .0001). Limitations: Small number of patients. Conclusions: An excellent correlation exists between EUS and histologic findings of NCCP. [Copyright &y& Elsevier]

Background: The diagnostic yield of EUS-guided FNA (EUS-FNA) of solid pancreatic masses is a potential benchmark for EUS-FNA quality, because the majority of EUS-FNA of solid pancreatic masses should be diagnostic for malignancy. Objectives: To determine the cytologic diagnostic rate of malignancy in EUS-FNA of solid pancreatic masses and to determine if variability exists among endoscopists and centers. Design: Multicenter retrospective study. Patients: EUS centers provided cytology reports for all EUS-FNAs of solid, noncystic, ≥10-mm-diameter, solid pancreatic masses during a 1-year period. Main Outcome Measurement: Cytology diagnostic of pancreatic malignancy. Results: A total of 1075 patients underwent EUS-FNA at 21 centers (81% academic) with 41 endoscopists. The median number of EUS-FNA of solid pancreatic masses performed during the year per center was 46 (range, 4-177) and per endoscopist was 19 (range, 1-97). The mean mass dimensions were 32 × 27 mm, with 73% located in the head. The mean number of passes was 3.5. Of the centers, 90% used immediate cytologic evaluation. The overall diagnostic rate of malignancy was 71%, 95% confidence interval 0.69%-0.74%, with 5% suspicious for malignancy, 6% atypical cells, and 18% negative for malignancy. The median diagnostic rate per center was 78% (range, 39%-93%; 1st quartile, 61%) and per endoscopist was 75% (range, 0%-100%; 1st quartile, 52%). Limitations: Retrospective study, participation bias, and varying chronic pancreatitis prevalence. Conclusions: (1) EUS-FNA cytology was diagnostic of malignancy in 71% of solid pancreatic masses and (2) endoscopists with a final cytologic diagnosis rate of malignancy for EUS-FNA of solid masses that was less than 52% were in the lowest quartile and should evaluate reasons for their low yield. [Copyright &y& Elsevier]

Background: Whether tissue diagnosis is required in the preoperative evaluation of patients with suspected pancreatic cancer remains controversial. We prospectively evaluated the accuracy, safety, and potential impact on surgical intervention of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the preoperative evaluation of suspected pancreatic cancer.Methods: All patients who underwent EUS-FNA at our institution (n = 547) over a 4.5-year period were enrolled. Patients underwent surgical exploration and resection based on their comorbidity status, evidence of resectability based on spiral computed tomography (CT) and EUS imaging reviewed in a multidisciplinary approach.Results: Of 547 patients enrolled (median age 64 years, 60% male), 49% presented with obstructive jaundice. The operating characteristics of EUS-FNA of solid pancreatic masses were: sensitivity 95% (95% CI: 93.2-95.4), specificity 92% (95% CI: 86.6-95.7), positive predictive value 98% (95% CI: 97-99), negative predictive value 80% (95% CI: 74.9-82.7). The overall accuracy of EUS-FNA was 94.1% (95% CI: 92.0-94). Of the 414 true positive patients by EUS-FNA, 138 (33%) were explored. Of patients deemed operable by combined imaging, 42% had surgical resection. Eighty-two percent of true positive patients were ultimately found inoperable and received palliative therapy or chemotherapy. Of the 94 patients with true negative cytology based on extended follow-up, only 7 (7%) underwent surgical resection. Of those with false negative diagnoses (n = 24), 5 patients underwent exploration/resection based on detection of mass lesions by EUS. The remaining patients had unresectable disease. Mild self-limiting pancreatitis occurred in (0.91%).Conclusions: EUS-FNA is a safe and highly accurate method for tissue diagnosis in suspected pancreatic cancer. This approach allows for preoperative counseling of patients, minimizing surgeon's operative time in cases of unresectable disease, and avoids surgical biopsies in the majority of patients with inoperable disease. In addition, it allows for conservative management of patients with benign biopsies. We still, however, recommend exploration of patients with clinical scenario suspicious for pancreatic cancer, a mass found on EUS or CT, but inconclusive or negative cytology. [ABSTRACT FROM AUTHOR]

Background: EUS is a promising modality for pancreatic-cancer screening in high-risk persons, including familial pancreatic-cancer (FPC) kindreds. Objective: To assess interobserver agreement for interpretation of EUS in persons at high risk for pancreatic cancer. Design: Seventeen expert endosonographers blinded to patients'' clinical history rated a “training set” of pancreatic EUS video clips for the presence of a normal examination, masses, cysts, and features of chronic pancreatitis. Clips included high-risk persons and controls (normal and various pancreatic diseases). The endosonographers then participated in a workshop on EUS findings in high-risk persons and drafted a consensus statement. Three months later, they blindly rated a “test set” composed of the same video clips. Main Outcome Measurements: Interobserver agreement at baseline (training set) and after a consensus process (test set). Results: For the training set, interobserver agreement was good (kappa ≥ 0.4) for the presence of cysts and was fair to poor for all other rated EUS features and diagnosis of normal. There was no overall improvement in the test set. In both the training and test sets, agreement was worse for clips from FPC kindreds (kappa ≥0.4 for cysts and <0.4 for all other features) than for controls (kappa ≥0.4 for normal, cysts, masses, echogenic strands, and lobularity). Limitations: Video clips were not of identical image quality and duration as a clinical EUS examination. Conclusions: There was fair to poor interobserver agreement for the interpretation of pancreatic EUS video clips from members of FPC kindreds. Agreement was not improved by a consensus process. [Copyright &y& Elsevier]

Abstract: Background: Rapid and accurate tissue diagnosis for a deep-seated malignancy would allow treating physicians to provide disease-specific interventions and help patients make early informed management decisions. Providing on-site tissue diagnosis for fine-needle aspirate samples obtained with endosonography would help develop such efficient patient management issues. Here we report our experience of prospectively providing on-site diagnosis on 485 endoscopic ultrasound fine-needle aspirate samples. Methods: Four hundred eighty-five endoscopic ultrasound fine-needle aspirates from the pancreas (n= 305), lymph nodes (n = 91), biliary tree (n = 47), liver (n = 15), gastrointestinal tract (n = 19), and adrenal gland (n = 8) were reviewed. For all aspirates, the cytologic diagnoses, both preliminary and final, were categorized into the following: positive for malignancy, positive for neoplastic process, suspicious for malignancy, atypical cells, reactive process, and nondiagnostic. Results: Of the 485 cases, 163 (33.6%) were diagnosed as benign, 43 (8.8%) as atypical, 21 (4.3%) as suspicious, 18 (3.7%) as positive for neoplasm, and 230 (47.4%) as malignant after final cytologic interpretation. A significantly (P < .001) higher degree of concordance was noted for unequivocal diagnosis of malignancy (196/198, 98.9%) vs nonmalignancy (200/250, 67.2%) between on-site and final cytologic diagnosis. Of the 52 discordant cases, 12 (2.6%) diagnoses were downgraded and 40 (8.9%) were upgraded from preliminary on-site diagnosis. Our overall sensitivity (87 vs 92), specificity (95% vs 100%), and accuracy (90% vs 94%) improved for final cytologic diagnosis. Conclusion: On-site diagnosis of malignancy could be used to initiate informed patient management decisions. Cases where a diagnosis of malignancy is not rendered at on-site interpretation need further cytologic evaluation. [Copyright &y& Elsevier]

Background: EUS-guided FNA is commonly performed for evaluating pancreatic-cyst lesions. However, not all such lesions are true cystic neoplasms of the pancreas. Objective: Determine the frequency at which aneurysms mimicking cysts are encountered during EUS evaluation of the pancreas. Study Design: Observational study. Setting: Tertiary referral center. Patients: Consecutive patients found to have pancreatic cyst lesions at EUS. Interventions: Patients with a cyst lesion in the pancreas that was suspicious for an aneurysm at EUS underwent abdominal CT imaging for a definitive diagnosis. Main Outcome Measures: To determine the frequency at which aneurysms are encountered during EUS while evaluating pancreatic-cyst lesions and to describe the EUS characteristics of an underlying aneurysm. Results: Four of 413 lesions (0.97%, 95% confidence interval 0.26%-2.5%) that appeared as pancreatic cysts at EUS were diagnosed to be aneurysms: 2 were splenic artery aneurysms, 1 was an aneurysm of the gastroduodenal artery, and another was an infrarenal aortic aneurysm. The aneurysms had a characteristic donut-like appearance at EUS: a thick outer wall with a central anechoic area. Limitations: Observational study; small sample size. Conclusions: Aneurysms can masquerade as pancreatic-cystic lesions. Awareness of this entity is important because an inadvertent FNA during EUS may potentially lead to serious complications. [Copyright &y& Elsevier]