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The practice of onsite cytology interpretation varies across endoscopic ultrasound (EUS) programs in the United States and Europe. The value, reliability, and agreement of rapid onsite evaluation (ROSE) compared with final interpretation and its impact on patient management remain largely unknown. We compared agreement between ROSE of EUS-FNA (endoscopic ultrasound-guided fine needle aspiration) specimens with final cytology interpretation and their respective operating characteristics.We prospectively evaluated consecutive EUS-FNA specimens obtained by a single endosonographer in the presence of an attending cytopathologist (July 2000-November 2002). The "agreement" between ROSE and final cytology interpretation was assessed by the "kappa" statistic. The frequency and possible reasons for discrepancy between ROSE and final cytologic interpretation were determined.A total of 540 patients (median age 63 yr, 77% white) underwent EUS-FNAs of 656 lesions. These included lymph nodes (LNs, N = 248), solid pancreatic masses (SPMs, N = 229), cystic pancreatic masses (CPM, N = 57), mural lesions (41), bile duct/gallbladder (N = 28), liver (N = 17), mediastinum/lung (N = 17), adrenal (N = 15), spleen (N = 3), and kidney (N = 1). Data were available for onsite evaluation in 607 lesions. Initial cytology was benign (N = 243), atypical (N = 23), suspicious (24), malignant (300), and indeterminate (N = 17). Out of the 243 benign lesions interpreted by onsite evaluation, five lesions (2.1%) were upgraded to be malignant or suspicious for malignancy on final cytology report. Of the 300 lesions initially reported malignant on ROSE, 294 (98%) remained malignant on the final cytology. There was an excellent agreement between ROSE and final cytologic evaluation (kappa = 84.0%, 95% CI 80.2-87.7), Compared with the true final status, accuracy for final interpretation was slightly higher than for ROSE but was not statistically significant (95.8%vs 93.9%). Scant cellularity remained the most frequent reason for discrepancy, accounting for 21 of 51 discrepancies (41%). Other reasons for discrepancy included: cases requiring an intradepartmental consultation (22%), cases requiring ancillary studies (12%), intra-observer variability (10%), and challenging diagnosis (10%). In three cases, (6%) we were unable to determine the possible reason for discrepancy.ROSE of EUS-FNA specimens is highly accurate compared with final cytologic evaluation. Because the diagnosis of malignancy rarely changes, informing our patients and their families and our referring physicians of a cancer diagnosis significantly reduces physician work load and expedites patient management. The majority of discrepancies are related to the nature of the lesion either because it sheds few cells, has challenging morphology, and/or requires additional ancillary studies.

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.

BACKGROUND Computerized tomographic (CT)-guided fine-needle aspiration (FNA) cytology is a well-established tool in the diagnosis of hepatic lesions. Endoscopic ultrasound-guided FNA (EUS-FNA), developed recently and used predominantly in evaluating mediastinal and pancreatic lesions, provides access to a significant portion of the liver and to perihepatic structures not readily accessible by a percutaneous approach. METHODS A recent experience (1997-2002) with CT-guided FNA of liver lesions at the University of Alabama Birmingham (UAB) was compared with the first 2.5 years of EUS-FNA experience (2000-2002). Cases were identified using a SNOMED search and all reports and cytologic slides were retrieved for review. RESULTS In 6 years, 34 percutaneous CT-FNA liver biopsies were performed at UAB; in approximately 2.5 years, 16 EUS-FNA liver biopsies were done. In both groups the primary clinical indication was suspected metastatic carcinoma (CT, 41% of cases vs. EUS, 56%). The 2 techniques yielded a similar range of benign, atypical, and malignant diagnoses (CT: 26%, 18%, and 56% vs. EUS: 19%, 25%, and 56%). Because of the clinical setting in which EUS-FNA is usually performed, a much narrower range of neoplasms was sampled by EUS-FNA. Benign gastrointestinal epithelial cells were identified in 60% of the EUS-FNA specimens. CONCLUSIONS Early experience suggests EUS-FNA is comparable to CT-FNA in terms of diagnostic utility for hepatic lesions. Anatomy limits EUS-FNA to only a fraction of the hepatic parenchyma, but that fraction includes the hilum and left lobe of the liver and the proximal biliary tract. The gallbladder, extrahepatic biliary system, and perihilar lymph nodes are readily accessible. Proximate high-resolution ultrasound imaging and cytopathologist involvement in the EUS-FNA process are further advantages. Awareness of artifacts inherent in EUS-FNA sampling (i.e., gut epithelial cells) can minimize a potential diagnostic pitfall. Cancer (Cancer Cytopathol) 2006. © 2006 American Cancer Society.

EUS is a promising modality for pancreatic-cancer screening in high-risk persons, including familial pancreatic-cancer (FPC) kindreds.To assess interobserver agreement for interpretation of EUS in persons at high risk for pancreatic cancer.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.Interobserver agreement at baseline (training set) and after a consensus process (test set).For the training set, interobserver agreement was good (kappaor=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 (kappaor=0.4 for cysts and0.4 for all other features) than for controls (kappaor=0.4 for normal, cysts, masses, echogenic strands, and lobularity).Video clips were not of identical image quality and duration as a clinical EUS examination.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.

We describe two patients who had Rocky Mountain spotted fever after they were admitted to the hospital for emergency and elective surgical procedures. We initially thought one patient had a hospital-acquired infection; the correct diagnosis was deduced from epidemiologic clues elicited by consultants. These two cases were also unusual in that one patient had a recurrent rash after an abbreviated course of low-dose doxycycline therapy and the other patient had transient and self-limiting postinfectious polyneuropathy. These cases illustrate that community-acquired infection with Rickettsia rickettsii can occur simultaneously with other disease processes and sometimes mimic a nosocomial infection.

Our objectives were to devise a cytologic grading system and determine whether it would predict survival of patients with solid-type pancreatic adenocarcinoma. We evaluated 116 consecutive patients from July 2000 to November 2002; they were followed up until September 2003. We scored the following features on rapid Romanowsky-stained endoscopic ultrasound-guided fine-needle aspiration smears: cell group architecture, single cells, nuclear grade, mucus, bizarre cells, and necrosis. A cytologic grade (low vs high) was assigned. The Kaplan-Meier estimate of 6-month survival was 76% (SE, 7%) for patients with low-grade tumors vs 50% (SE, 6%) for patients with high-grade carcinoma. The median survival for patients with low-grade vs high-grade tumors was 1 year vs 6 months, respectively (chi2 = 4.45; P = .035). Cox proportional hazards regression showed tumor stage, cancer-specific treatment, and cytologic grade to be independent predictors of survival (P = .001). No other factors (age, mass location, placement of stent, presence of concomitant chronic pancreatitis, race, sex) predicted survival. We devised a grading system that independently predicted survival in patients with pancreatic adenocarcinoma.

In approximately 20% of patients with acute pancreatitis, a cause is not established by history, physical examination, routine laboratory testing, and abdominal imaging. For those with a single unexplained attack, the role of invasive evaluation with endoscopic retrograde cholangiopancreatography is unsettled but has been generally limited to those patients with suspected bile duct stones or malignancy. Recent studies suggest that microlithiasis is causative in up to 75% of patients with an unexplained attack and gallbladder in situ, whereas sphincter of Oddi dysfunction is most prevalent in those with recurrent attacks who have previously undergone cholecystectomy. EUS has been shown to be highly accurate for the identification of gallbladder sludge, common bile duct stones, and pancreatic diseases. Given this apparent diagnostic utility, an EUS-based strategy may be a reasonable approach to evaluate patients with a single idiopathic attack. ERCP and sphincter of Oddi manometry should generally be reserved for patients with multiple unexplained attacks and negative EUS results, especially for those patients who have previously undergone cholecystectomy.

While the role of EUS in the evaluation of pancreaticobiliary (PB) disorders in adults is well established, its utility in children remains unproven. This prospective study evaluates the feasibility, the safety, and the impact of EUS in the evaluation of PB disorders in children.All children (18 years) referred for ERCP for evaluation of suspected PB disorders who underwent EUS before scheduled ERCP. The main outcome measure was to evaluate the impact of EUS in the evaluation of PB disorders in children. EUS was considered to have a significant impact if a new diagnosis was established or if the findings altered subsequent management.Fourteen patients (mean age 13 years; range 5-17 years) underwent 15 EUS procedures over a 3-year period. Main indications were the following: acute or recurrent pancreatitis (6 patients), suspected biliary obstruction (5), and abdominal pain suggestive of PB origin (3). EUS diagnosed chronic pancreatitis (3 patients), idiopathic fibrosing pancreatitis (2), carcinoid tumor (1), pancreatic pseudocyst (1), pancreas divisum (1), choledocholithiasis (1), duodenal duplication cyst (1), and normal (4). Diagnosis of idiopathic fibrosing pancreatitis and carcinoid tumor was established by EUS-guided FNA. The procedure was successful in all patients, and no complications were encountered. EUS had an impact on patient management in 93% of cases: established new diagnosis (10), precluded need for ERCP (9), and provided additional information that facilitated focused endotherapy (4). A limitation was the small number of enrolled patients and absence of long-term clinical follow-up.EUS and EUS-guided FNA are feasible, safe, and have significant impact that alters subsequent management in the majority of children with PB disorders. Further studies and dissemination of information is required to facilitate its increased application in children.

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for postoperative evaluation of an abnormal intraoperative cholangiogram (IOC). Although a normal IOC is very suggestive of a disease-free common bile duct (CBD), abnormal studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP. This prospective study investigated 51 patients with abnormal IOC at laparoscopic cholecystectomy who underwent postoperative ERCP at two tertiary referral centers over a 3-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of CBD stones at postoperative ERCP. For all 51 patients, ERCP was successful. The ERCP showed CBD stones in 33 cases (64.7%), and normal results in 18 cases (35.2%). On univariate analysis, abnormal liver function tests (p < 0.0001) as well as IOC findings of a large CBD stone (p = 0.03), multiple stones (p = 0.01), and a dilated CBD (p = 0.07) predicted the presence of retained stones at postoperative ERCP. However, on multivariable analysis, only abnormal liver function tests correlated with the presence of CBD stones (p < 0.0001). One-third of patients with an abnormal IOC have a normal postoperative ERCP. Elevated liver function tests can help to identify patients who merit further evaluation by ERCP. The use of less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography should be considered for patients with normal liver function tests to minimize unnecessary ERCPs.

Background Patients with esophageal cancer who receive neoadjuvant chemoradiotherapy are restaged with computed tomography (CT), endoscopic ultrasound with fine needle aspiration (EUS-FNA), and integrated positron emission computed tomography (FDG-PET/CT), and the results affect treatment. Methods This is a prospective trial on a consecutive series of patients who had initial chest, abdomen, and pelvis CT scan; EUS-FNA; and fluoro-2-deoxy- d -glucose (FDG)-integrated PET/CT; neoadjuvant chemoradiotherapy; repeat staging tests; pathologic staging; and, if appropriate, resection with lymphadenectomy. The primary objective was to assess the accuracy of these 3 tests in restaging patients after neoadjuvant therapy. Results There were 48 patients (41 men), and 41 underwent Ivor Lewis esophagogastrectomy with lymphadenectomy. The accuracy of each test for distinguishing pathologic T4 from T1 to T3 disease is 76%, 80%, and 80% for CT scan, EUS-FNA and FDG-PET/CT, respectively. The accuracy for nodal disease was 78%, 78%, and 93% for CT scan, EUS-FNA and FDG-PET/CT, respectively (P = .04). FDG-PET/CT correctly identified M1b disease in 4 patients, falsely suggested it in 4 patients, and missed it in 2 patients, whereas for CT, it was 3, 3, and 3 patients. Fifteen (31%) patients were complete responders, and FDG-PET/CT accurately predicted complete response in 89% compared with 67% for EUS-FNA (P = .045) and 71% for CT (P = .05). Conclusions FDG-PET/CT is more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy in patients with esophageal cancer. FDG-PET/CT and CT alone provide targets for biopsy, but results are often falsely positive.

Background The utility of EGD when used as an initial test for the evaluation of dysphagia is unclear. The objective was to determine the yield and the predictive factors of significant pathology when EGD is performed as the initial test to evaluate dysphagia. Methods This is a retrospective analysis of a computerized database. Data on patients who underwent EGD for dysphagia were retrieved from the endoscopy database of 6 endoscopy units. Patients who had undergone prior esophageal evaluation, failed EGD, or who had a history of prior upper-GI pathology were excluded. Univariate and multivariable logistic regression analyses were performed to evaluate any relation between endoscopic findings and presenting clinical features. Results A total of 1649 patients with dysphagia (mean age 56.7 years, standard deviation 16.4; M:F 3:2) were analyzed. Abnormal findings at EGD were found in 70% (1150) of the patients, and a major pathology was seen in 54% (898). Male gender (p=0.0001), heartburn (p=0.0007), and odynophagia (p=0.0001) predicted the presence of major pathology. Cancer was found in 4% (70) of patients and was predicted by male gender (p=0.0002), age (p=0.01), and weight loss (p=0.04). The esophagus was normal in 29% (483) of patients and was predicted by female gender (p=0.0001) and the absence of heartburn (p=0.0004) but not age. There was a lack of details on patients' presentation and clinical history and an absence of long-term clinical follow-up. Conclusions EGD is an effective and an appropriate tool for the initial evaluation of patients presenting with dysphagia. Early EGD should be considered, particularly, in male patients aged more than 40 years old who concomitantly report heartburn, odynophagia, or weight loss.

We report the first case of a posterior mediastinal granular cell tumor initially diagnosed on cytologic material obtained via endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in a 51-year-old male with a prior history of colon cancer. Aspirates obtained were cellular and composed of polygonal cells with abundant granular cytoplasm and small, round dark nuclei. An immunoperoxidase stain performed on the cell block for antibodies to S-100 protein showed strong, diffuse staining of the cytoplasmic granules. Electron microscopy performed on the cell block revealed numerous cytoplasmic lysosomes. This is the first case report in the English literature of a definitive preoperative diagnosis of a mediastinal granular cell tumor utilizing material obtained via EUS-FNA.

Background The objective of our study was to assess a single operator's learning curve with regard to the number of passes, the diagnostic accuracy, and the complications associated with EUS-guided FNA (EUS-FNA) of solid pancreatic masses. Methods The number of passes, the diagnostic accuracy, and the complication rate were prospectively evaluated in 300 consecutive EUS-FNA of solid pancreatic masses performed by a single endosonographer over a 3-year period. The procedures were placed into 3 groups, which contained 100 procedures each. The endosonographer had undergone a third-tier EUS fellowship and had performed 45 supervised pancreatic EUS-FNA during his training. Results Of the 300 EUS-FNA performed (median age 63 years, 64% men), no statistically significant differences among the 3 groups with regard to age, gender, race, location, or size of the mass were found. Diagnostic accuracy of the EUS-FNA procedure was similar over time (Group 1, 92%; Group 2, 92%; Group 3, 95%). Median number of passes showed a decreasing trend over the 3-year study period, despite an increasing trend of the number of procedures performed (r=−0.14, p =0.42). The median number of passes was lower for Group 2 (median, 3; p =0.02) and Group 3 (median, 3; p =0.003) compared with Group 1 (median, 4). Group 3 (7/100, 7%) was less likely to encounter complications compared with Group 1 (13/100, 13%; p =0.24) and Group 2 (18/100, 18%; p =0.03). Frequency of serious complications was similar across the 3 groups (1%-3%). Conclusions With adequate third-tier training, a newly developed EUS program can achieve safe and accurate results of EUS-FNA of the pancreas. The learning curve, however, needs to continue after the fellowship, because more procedures are needed for one to gain proficiency and efficiency with EUS-FNA.

Background. This study examined trends in the numbers of double contrast barium enemas, flexible sigmoidoscopies, and colonoscopies and trends in the choices of colorectal cancer screening service providers. Methods. Descriptive statistics were used to examine Medicare and Tricare data for the years 1999 to 2001. Results. The total volume of procedures increased 5% and 14%, respectively, in Tricare and Medicare. Tricare and Medicare, respectively, saw 32% and 33% reductions in barium enemas and 28% and 41% reductions in flexible sigmoidoscopies. Colonoscopies increased by 45% and 34% in Tricare and Medicare, respectively. Gastroenterologists provided the majority of colonoscopies for both groups each year. Conclusions. The volume of colonoscopies increased from 1999 to 2001 for both groups while the volumes of barium enemas and flexible sigmoidoscopies decreased. Gastroenterologists appear to be the preferred providers of colonoscopies.

Mediastinoscopy and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) are complementary for staging non-small cell lung cancer (NSCLC) patients. We assessed (1) the yield of EUS-FNA of malignant lymph nodes in NSCLC patients with combined anterior and posterior lymph nodes that had already undergone mediastinoscopy and (2) the cost implications associated with alternative initial strategies.All patients underwent chest computed tomography (CT) and/or positron emission tomography (PET), and mediastinoscopy. Then, the posterior mediastinal stations (7, 8, and 9) or station 5 were targeted with EUS-FNA. The reference standard included thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging, or long-term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of NSCLC.Thirty-five NSCLC patients met inclusion criteria (median age 65 years; 80% men). Endoscopic ultrasound-guided FNA was performed in 53 lymph nodes in various stations, the subcarinal station (7) being the most common (47.3%). Of the 35 patients who had a prior negative mediastinoscopy, 13 patients (37.1%) had malignant N2 or N3 lymph nodes. Accuracy of EUS-FNA (98.1%) was significantly higher than that of CT (41.5%; p0.001) and PET (40%; p0.001). Initial EUS-FNA resulted in average costs per patient of 1,867 dollars (SD +/- 4,308 dollars) while initial mediastinoscopy cost 12,900 dollars (SD +/- 4,164.40 dollars). If initial EUS-FNA is utilized rather than initial mediastinoscopy, an average cost saving of 11,033 dollars per patient would result.In patients with NSCLC and combined anterior and posterior lymph nodes, starting with EUS-FNA would preclude mediastinoscopy in more than one third of the patients. Endoscopic ultrasound-guided FNA is a safe outpatient procedure that is less invasive and less costly than mediastinoscopy.

Background Complications from EUS-guided FNA of cystic lesions of the pancreas are infrequent. Although several studies have evaluated infectious complications of EUS-guided FNA in this setting, the frequency and the clinical significance of intracystic hemorrhage have not been determined. This study assessed the frequency of acute intracystic hemorrhage during EUS-guided FNA of pancreatic cystic lesions. The characteristic EUS appearance is described. Methods EUS-guided FNA of pancreatic cyst lesions was performed in 50 patients (July 2000 to June 2003). Patients were followed prospectively for the development of complications. Observations Acute intracystic hemorrhage occurred during EUS-guided FNA at the site of aspiration in 3 patients (6%: 95% confidence interval [1.3%, 16.6%]). Endosonographically, the bleeding manifested as a small hyperechoic area at the puncture site that progressed gradually over a few minutes to involve the majority of the cyst cavity. EUS-guided FNA was terminated when bleeding was observed. One patient was asymptomatic, but two patients experienced abdominal pain transiently. All patients were treated with a short course of orally administered antibiotics and were observed as outpatients. Clinical history and laboratory parameters did not predict which patients were at risk for intracystic hemorrhage. Conclusions Acute intracystic hemorrhage is a rare complication of EUS-guided FNA; it has a characteristic EUS appearance. Recognition of this event is important, because it permits termination of the procedure and thereby minimizes the potential for more serious bleeding.

Background Diagnosis of a foregut duplication cyst is of great clinical impact. A definitive diagnosis of a foregut duplication cyst can avert the need for major thoracic surgery in the otherwise asymptomatic individual. This study sought to evaluate the safety and the utility of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of foregut duplication cysts. Methods Over a period of 4 years, 4771 patients underwent EUS for various indications at two EUS referral centers. EUS findings were consistent with a mediastinal cyst in 30 cases. EUS-FNA was performed in 22 patients. A definitive diagnosis was established based on cytology, surgical pathology, and/or clinical follow-up. FNA was done with 22-gauge needles and antibiotic prophylaxis. Results The appearance of cyst contents on EUS ranged from completely anechoic (23 cases) to hypoechoic (7 cases). Hypoechoic cystic lesions contained echogenic foci. All anechoic lesions were confirmed as benign duplication cysts based on cytology, pathology, and clinical follow-up. Hypoechoic cystic lesions were confirmed to be benign duplication cysts in 4 cases. Three cases proved to be malignant or granulomatous necrotizing lymph nodes. No periprocedural complications occurred. Conclusions Variation exists in the EUS appearance of benign mediastinal cysts. EUS-FNA of mediastinal cysts with smaller-gauge needles, and antibiotic prophylaxis appears safe and can provide a definitive diagnosis in atypical mediastinal cystic lesions.

BACKGROUND Endoscopic ultrasound (EUS) is a powerful imaging modality to identify and determine the extent of a lesion. In addition, EUS is superior to a computed tomography scan in detecting lesions < 3 cm. The objective of the current study was to determine whether small lesions (≤ 25 mm) affected the specimen adequacy and the diagnostic accuracy for lesions aspirated under EUS guidance. METHODS In the current study, 209 consecutive EUS-guided fine-needle aspiration biopsy (EUS-FNAB) samples ≤ 25 mm (100 samples) or > 25 mm (109 samples) as determined by EUS were obtained from 151 patients with a mean age of 62 years (range, 39–94 years). A cytopathologist present in the endoscopy suite determined specimen adequacy. Yield of adequate samples for diagnosis, number of passes, and operating characteristics of EUS-FNAB for small (≤ 25 mm) and large lesions (>25 mm) were compared. RESULTS The overall yield of obtaining adequate samples for diagnosis was 96% (201 of 209). There was no difference noted with regard to the yield of obtaining samples (96% vs. 96%) from small or large lesions. A mean of 2.5 passes (range, 1–9 passes) was needed to obtain adequate samples from lesions ≤ 25 mm, whereas a mean of 4.5 passes (range, 1–11 passes) was needed to obtain adequate samples from lesions > 25 mm. The sensitivity (96% vs. 96%), specificity (100% vs. 100%), and diagnostic accuracy (98% vs. 97%) for EUS-FNAB were comparable whether the lesion was ≤ 25 mm or > 25 mm. CONCLUSIONS EUS-FNAB was a highly effective technique to obtain samples from small (≤ 25 mm) and large (> 25 mm) lesions without affecting the sensitivity, specificity, or diagnostic accuracy. Cancer (Cancer Cytopathol) 2004. © 2004 American Cancer Society. Cancer (Cancer Cytopathol) 2004. © 2004 American Cancer Society.

Background The accuracy, the safety, and the cost-effectiveness of EUS-guided FNA for screening patients with lung cancer for mediastinal metastasis are well established, but the utility of EUS-guided FNA in evaluating lung mass per se has not been investigated. This study retrospectively evaluated experience with EUS-guided FNA of lung mass lesions after unsuccessful attempts by CT-guided or bronchoscopic tissue sampling to establish a tissue diagnosis. Methods A database was searched for all patients who had EUS-guided FNA of lung mass lesions over a 3-year period. The diagnostic yield and safety of EUS-guided FNA were evaluated. Observations Eighteen patients (11 men, 7 women) underwent EUS-guided FNA of lung mass lesions adjacent to or abutting the esophagus. The indication for EUS-guided FNA was evaluation of the mediastinum of patients with lung mass of unclear etiology. EUS-guided FNA yielded tissue for diagnosis in 100% of patients: 15 non-small-cell lung cancer, one small-cell lung cancer, two metastatic lung disease. Ten patients had unresectable disease; in 8, the mass was conf ined to the lung parenchyma. The mean number of needle passes required to establish a diagnosis was two (range 1–6). No complication was encountered (mean follow-up 141 days; range 72–396 days). Five patients underwent curative surgery, and 13 had palliative chemoradiation. Conclusions In this study, EUS-guided FNA of lung mass was safe, and it established a diagnosis in all patients with accessible lesions. Given these preliminary data, a prospective evaluation of this new indication for EUS-guided FNA is justified.

The treatment of patients with non-small cell lung cancer (NSCLC) depends on the stage. Positron emission and computed tomography (CT) scans can identify suspicious lymph nodes that require biopsy. We prospectively evaluated the yield and accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in sampling mediastinal lymph nodes and compared its accuracy to that of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and CT in staging NSCLC.A consecutive series of patients with suspicious nodes on PET or CT scan in the posterior mediastinal lymph node stations (#5, 7, 8, or 9) were prospectively evaluated by EUS-FNA. The reference standard included thoracotomy with complete lymphadenectomy in patients with lung cancer or if EUS-FNA was benign, repeat clinical imaging, or long-term follow-up.There were 104 patients (63 men) with 125 lesions (117 lymph nodes, 8 left adrenal glands) who underwent EUS-FNA. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 92.5%, 100%, 100%, 94%, and 97%, respectively. EUS-FNA was more accurate and had a higher positive predictive value than the PET or CT (p0.001) scan in confirming cancer in the posterior mediastinal lymph nodes. EUS-FNA documented metastatic cancer to the left adrenal in all 4 patients with advanced disease. No deaths resulted from EUS-FNA. One patient experienced self-limited stridor.EUS-FNA is a safe, accurate, and minimally invasive technique that improves the staging of patients with NSCLC. It is more accurate and has a higher predictive value than either the PET scan or CT scan for posterior mediastinal lymph nodes.

The additional diagnostic value of endoscopic ultrasound-fine needle aspiration (EUS-FNA) over lymph node (LN) echofeatures alone in evaluating lymphadenopathy is unknown. The objectives of this study are (1) to prospectively evaluate the utility of EUS-FNA in evaluating mediastinal or peri-intestinal lymphadenopathy and to compare its yield to that of echofeatures alone and (2) to determine clinical and endosonographic features predictive of malignant involvement of LNs.All consecutive patients who underwent EUS-FNA of a LN over a 22-month period were prospectively evaluated. Reference standard for final diagnosis included: surgery (n = 76), long-term clinical and/or imaging follow-up (n = 74), or death from disease (n = 26).One hundred and eighty-three EUS-FNAs of LNs were performed in 137 patients with no major complications. Locations of the biopsied LNs included 31% subcarinal, 21% celiac, 21% peripancreatic, 13% periesophageal, 4.4% aortopulmonary window, 3.2% perigastric, and 3.3% perirectal. Mean LN size was 20.5 mm (SD +/- 11.1) x 13.2 mm (SD +/- 7.97). The mean number of EUS-FNA passes was three (range 1-7). The sensitivity, specificity, PPV, and NPV of EUS-FNA of LNs were 98.3%, 100%, 100%, and 98.4%, respectively. EUS-FNA was more accurate compared to LN echofeatures alone (99.4%vs 75.4%, p0.001). Mediastinal LNs were 2.77 times less likely to be malignant as compared to other LN locations. In multivariable analysis, the number of LN echofeatures, site of LN, and patient's age were associated with malignant involvement (p= 0.001).EUS-FNA is superior to LN echofeatures in evaluating lymphadenopathy. Endosonographic LN features alone are particularly unreliable in the mediastinum, necessitating tissue confirmation. EUS-FNA can safely, reliably, and accurately sample mediastinal and peri-intestinal LNs obviating the need for more invasive testing or surgical intervention.

Background and Aims: Despite advances in endoscopic techniques for sampling bile duct strictures, the diagnosis of cholangiocarcinoma remains a challenge. The purpose of this study was to evaluate the yield of EUS-FNA and its impact on patient management for patients with suspected cholangiocarcinoma. Methods: All patients undergoing EUS for the evaluation of suspected malignant biliary strictures were prospectively evaluated over a 23-month period. A single gastroenterologist performed all EUS-FNAs in the presence of a cytopathologist. Reference standard for final diagnosis included surgery, death from disease, and clinical and/or imaging follow-up. Results: Twenty-eight patients (mean age 67 years [SD ± 11], 72% male) were evaluated. Most patients (91%) presented with obstructive jaundice, and all except 1 had nondiagnostic sampling of the biliary lesions either at ERCP (88%), percutaneous transhepatic cholangiogram (n = 2), and/or computed tomography-guided biopsy (n = 1). Sixty-seven percent (14/21) had no definitive mass seen on prior abdominal imaging studies. The mean tumor size by EUS was 19 mm × 16 mm with a median number of passes to diagnosis of 3 (range 1–7). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86%, 100%, 100%, 57%, and 88%, respectively. EUS-FNA had a positive impact on patient management in 84% of patients: preventing surgery for tissue diagnosis in patients with inoperable disease (n = 10), facilitating surgery in patients with unidentifiable cancer by other modalities (n = 8), and avoiding surgery in benign disease (n = 4). Conclusions: Given the apparent accuracy and safety of EUS with FNA for imaging bile duct mass lesions and for obtaining a tissue diagnosis in patients with suspected cholangiocarcinoma, this technology may represent a new approach to diagnosis especially when other methods fail. The ability to obtain a definite diagnosis has a significant impact on patient management.

Use of ThinPrep preparation for fine-needle aspiration biopsy (FNA) is gaining popularity. However, there may be a difference in the morphology and the operating characteristics between ThinPrep and conventional methods. The objective of this study was to compare the accuracy of the two methods and to address the pitfalls of ThinPrep preparation in pancreatic FNA. A computer search identified 67 pancreatic FNAs with both conventional smears and ThinPrep preparation during a 19-mo period. These cases, obtained under endoscopic ultrasound-guidance, consisted of 47 malignant neoplasms (44 ductal carcinomas, two mucinous neoplasms, and one islet cell tumor) and 20 benign lesions. Direct smears were prepared first and the remaining material was then put into PreservCyt Solution for ThinPrep slides. All slides were reviewed and the cytologic diagnoses were correlated with histologic and clinical follow-up. Five conventional and 16 ThinPrep specimens were unsatisfactory due to insufficient cellularity. These cases were excluded from the analysis. Among the 62 cases evaluated by conventional preparation, 77% (34) were diagnosed as positive and 14% (seven) atypical/suspicious by conventional smears. For the 51 ThinPrep specimens, 58% (22) were interpreted as positive and 31% (12) atypical/suspicious. The sensitivity, specificity, and accuracy of diagnosing a malignancy were 77%, 100%, and 84% for conventional smears and 58%, 100%, and 67% for ThinPrep preparation, respectively. There were no false positives with either method. However, three benign lesions were interpreted as atypical/suspicious with ThinPrep preparation because of the presence of single atypical cells with distinct nucleoli. One of the two mucinous neoplasms was incorrectly diagnosed with ThinPrep preparation because of lack of mucin. The diagnostic accuracy of pancreatic FNA using ThinPrep is inferior to that of conventional smears. This may be partly due to the use of split sample technique resulting in scant cellularity in ThinPrep preparation and partly due to the differences in morphology between the two preparations. Therefore, the current morphologic criteria may need modification for ThinPrep preparation in pancreatic FNA.

Tumors of the extrahepatic ducts are relatively rare and consist mostly of adenocarcinomas. Carcinoid tumors of the bile duct are exceedingly rare (1–4). Only 26 cases of carcinoid tumors of the bile duct are reported in the literature (5); 3 of these occurred in childhood or adolescence (1,6,7). Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy is an effective method for tissue diagnosis of periintestinal lymphadenopathy, especially in the posterior mediastinum and the celiac axis area (8). We report this case to illustrate the role of EUS-FNA in diagnosing recurrent metastatic carcinoid Klatskin’s tumor to a celiac lymph node in a teenager.

Objectives The aims of this study were to evaluate the diagnostic accuracy of endoscopic ultrasound–guided fine needle aspiration (EUS-FNA) in patients with suspected pancreatic cancer, and to assess immediate, acute, and 30-day complications related to EUS-FNA. Methods All patients with suspected pancreatic cancer were prospectively evaluated. A single gastroenterologist performed all EUS-FNAs in the presence of a cytopathologist. Immediate complications were evaluated in all patients. An experienced nurse called patients 24–72 h and 30 days after the procedure. Reference standard for the classification of the final diagnosis included: surgery (n = 48), clinical or imaging follow-up (n = 63), or death from the disease (n = 47). Results A total of 158 patients (mean age 62.3 yr) underwent EUS-FNA during the study period. The mean tumor size was 32 × 26 mm. The median number of passes was three (range one to 10). Of these patients, 44% had at least one failed attempt at tissue diagnosis before EUS-FNA. The sensitivity, specificity, PPV, NPV, and accuracy of EUS-FNA in solid pancreatic masses were 84.3%, 97%, 99%, 64%, and 84%, respectively. Immediate self-limited complications occurred in 10 of the 158 EUS-FNAs (6.3%). Of 90 patients contacted at 24–72 h, 78 patients (87%) responded. Of the 90 patients, 20 (22%) reported at least one symptom, all of which were minor except in three cases (one self-limited acute pancreatitis and two emergency room visits, one of which led to admission). In all, 83 patients were contacted at 30 days, and 82% responded. No additional or continued complications were reported. Conclusions EUS-FNA is highly accurate in identifying patients with suspected pancreatic cancer, especially when other modalities have failed. Major complications after EUS-FNA are rare, and minor complications are similar to those reported for upper endoscopy. It seems that follow-up at 1 wk might capture all of the adverse events related to EUS-FNA.

BACKGROUND Mucins are high molecular weight glycoproteins that are produced by various epithelial cells including those found in the pancreas. MUC1 and MUC2 are two well characterized mucin antigens. The objective of the current study was to examine the pattern of phenotypic expression of MUC1 and MUC2 in pancreatic lesions obtained by fine-needle aspiration biopsy (FNA) and to determine the utility of MUC1 and MUC2 as markers for pancreatic ductal carcinoma. METHODS Thirty-nine cell blocks of pancreatic FNA obtained under endoscopic ultrasound guidance were retrieved from the archives and immunostained with a monoclonal antibody directed against MUC1 and MUC2. These cell blocks were taken from 39 patients (16 females and 23 males) who had a median age of 64 years. Eleven FNAs were taken from patients with reactive/inflammatory conditions. The remaining 28 FNAs included 24 ductal carcinomas, 2 neuroendocrine tumors, 1 lymphoma sample, and 1 sarcoma sample. The presence of immunoreactivity, irrespective of the level of intensity or the percentage of cells, was considered as positive for MUC1 and MUC2 expression. Follow-up included correlation with pathology materials obtained at surgery and review of medical records. RESULTS Twenty-three of 24 pancreatic ductal carcinomas (96%) demonstrated positive staining with MUC1. Twenty-one positive cases demonstrated either apical or diffuse membranous staining with variable cytoplasmic staining. The remaining two positive cases showed only cytoplasmic staining. One of the 11 cases of chronic pancreatitis and benign conditions demonstrated weak apical membranous MUC1 staining in the acinic cells. The difference between the two groups was statistically significant (P < 0.001, using the Fisher exact test). Three pancreatic ductal carcinomas and one chronic pancreatitis specimen demonstrated cytoplasmic staining with MUC2; the difference between the two groups was not found to be statistically significant. None of the nonductal neoplasms demonstrated expression of either MUC1 or MUC2. The sensitivity and specificity of MUC1 as a marker for pancreatic ductal carcinomas were 96% and 94%, respectively. CONCLUSIONS MUC1 is overexpressed in pancreatic ductal carcinoma with a predominantly membranous and variable cytoplasmic staining pattern. The results of the current study suggest that the phenotypic expression of MUC1 can be used as an ancillary marker for diagnosing pancreatic ductal carcinoma in cytologic preparations. Conversely, MUC2 does not appear to be a useful marker for recognizing pancreatic ductal carcinoma in FNA specimens. Cancer (Cancer Cytopathol) 2003;99:365–71. © 2003 American Cancer Society.

BACKGROUND AND STUDY AIMS The prevalence of periduodenal venous collaterals detected by endoscopic ultrasonography (EUS) in patients undergoing evaluation for pancreaticobiliary disorders, and their influence on the success of transduodenal fine-needle aspiration (FNA) of solid pancreatic masses is not known. PATIENTS AND METHODS Records for all consecutive patients who underwent EUS for pancreaticobiliary disorders over a 14-month period were reviewed. EUS was carried out by a single endosonographer using a radial echo endoscope. When FNA was attempted, a curvilinear-array echo endoscope was used in conjunction with color flow Doppler. Periduodenal and perigastric collaterals were defined as multiple anechoic serpiginous structures imaged from the duodenal bulb, the second portion of duodenum, or the stomach. Established criteria were used to assess the presence of chronic pancreatitis. RESULTS Over the study period, 338 patients (mean age 58.9 +/- 14.5 years; 52 % women) underwent EUS for pancreaticobiliary disorders. Periduodenal collaterals were detected in 22 patients (6.5 %), 21 of whom (19 %) had pancreatic cancer. Patients with pancreatic cancer were significantly more likely to have periduodenal collaterals in comparison with those without pancreatic cancer (OR 25; 95 %CI, 5.75 - 109; P = 0.001). Computed tomography detected collaterals in only two of the 22 patients (9.1 %). Periduodenal collaterals made transduodenal FNA impossible in nine of the 22 patients (41 %). However, in these patients a cancer diagnosis was obtained using EUS-FNA from liver lesions in two cases; using a transgastric approach in two (pancreatic neck lesions); and atypical cells were obtained in two. A safe window could not be achieved in three patients (13.6 %). Transduodenal FNA was performed by avoiding the collaterals and was successful in 13 of the 22 patients, with no bleeding complications. CONCLUSIONS Periduodenal collateral vessels are infrequent in patients with suspected pancreaticobiliary disease, but are relatively common in patients with pancreatic cancer. Transduodenal EUS-FNA can be carried out safely in the majority of cases in the presence of periduodenal collaterals, but collaterals may occasionally hamper successful transduodenal pancreatic FNA.

Although atypical or suspicious cytology may support a clinical diagnosis of a malignancy, it is often not sufficient for the implementation of therapy in patients with pancreatic carcinoma. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) is a relatively new method for obtaining cytology samples, and one that may decrease the number of atypical/suspicious diagnoses. The goals of the current study were to prospectively evaluate the yield of EUS-FNAB in the diagnosis of patients presenting with solid pancreatic lesions and to evaluate the significance of atypical, suspicious, and false-negative aspirates.All patients who presented with a solid pancreatic lesion and underwent EUS-FNAB over a 13-month period were included in the current study. One endoscopist performed all EUS-FNABs. On-site evaluation of specimen adequacy by a cytopathologist was available for each case. Follow-up included histologic correlation (n = 21) and clinical and/or imaging follow-up (n = 80), including 38 patients who died of the disease.EUS-FNABs were obtained from 101 patients (mean age, 62 +/- 11.8 years; age range, 34-89 years). The male-to-female ratio was 2:1. Sixty-five percent of the lesions were located in the head of the pancreas, 12% were located in the uncinate, 17% were located in the body, and 6% were located in the tail. The mean size of the tumors was 3.3 cm (range, 1.3-7 cm). A median of 4 needle passes were performed (range, 1-11 needle passes). Sixty-two biopsies (61.4%) were interpreted as malignant on cytologic evaluation, 5 (5%) as suspicious for a malignancy, 6 (5.9%) as atypical/indeterminate, and 26 (25.7%) as benign processes. Of the 76 malignant lesions, 71 were adenocarcinomas, 3 were neuroendocrine tumors, 1 was a lymphoma, and 1 was a metastatic renal cell carcinoma. All except one of the suspicious/atypical aspirates were subsequently confirmed to be malignant. Agreement was complete for the atypical cases. Among the suspicious cases, 2 of the 5 were identified as carcinoma by one cytopathologist and as suspicious lesions by the other, yielding a 40% disagreement rate between the 2 cytopathologists. Therefore, for the 10 atypical or suspicious cases that later were confirmed to be malignant, the final diagnosis of malignant disease was not made due to scant cellularity that could be attributed to sampling error in 8 cases and to interpretative disagreement in 2 cases (20%). All four false-negative diagnoses were attributed to sampling error. Two percent of all biopsies were inadequate for interpretation. Of the 99 adequate specimens, 72 yielded true-positive results, 23 yielded true-negative results, and 4 yielded false-negative results. No false-positives were encountered. Therefore, the sensitivity, specificity, positive predictive value, and negative predictive value of EUS-FNAB for solid pancreatic masses were 94.7% (95% confidence interval [CI], 89.7-99.8%), 100%, 100%, and 85.2% (95% CI, 71.8-98.6%), respectively.EUS-FNAB is a safe and highly accurate method for tissue diagnosis of patients with solid pancreatic lesions. Patients with suspicious and atypical EUS-FNAB aspirates deserve further clinical evaluation.

Endoscopic ultrasound (EUS) is used to detect and delineate the extent of lesions in the gastrointestinal tract, periluminal lymph nodes, pancreas and hepatobiliary tree, left kidney, spleen, and adrenal glands. EUS-guided fine-needle aspiration (FNA) has added a new dimension to the capabilities of EUS because it permits characterization of the lesion, thereby enabling triage of patients for more efficient and effective management. This review focuses on the advantages and limitations of EUS-FNA, including a discussion of potential pitfalls in the diagnosis of commonly aspirated deep-seated lesions, such as those of the pancreas and lymph nodes. It also addresses the practical considerations associated with establishing an effective service and the importance of an integrated approach in which the cytopathologist undertakes a key role, interacting extensively with the endoscopist and the patient management team. EUS-FNA is a sensitive modality that enables specific and accurate diagnosis of deep-seated lesions. Samples can be obtained effectively from small lesions (25 mm), irrespective of the organ site. On-site assessment permits a highly accurate preliminary diagnosis of malignancy for samples obtained by EUS-FNA and provides an opportunity to increase the diagnostic yield of samples.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with primary sclerosing cholangitis (PSC) can be a challenging and sometimes gratifying opportunity for therapeutic intervention. Although there often appears to be initial radiological improvement after ERCP, the benefit as measured by serial estimations of subsequent liver enzymes is questionable. The fluctuating course of the inflammatory process makes the interpretation of serology even more difficult.OBJECTIVES: To document and compare the liver profile and clinical status of patients before and after diagnostic and therapeutic ERCP; to determine predictors of clinical and laboratory success in patients with PSC; and to assess the complication rate of diagnostic and therapeutic ERCP in these patients.METHODS: All patients with PSC who underwent ERCP at the authors’ medical centres between January 6, 1987 and January 12, 1998 were identified using a computerized database. Presenting symptoms, liver enzymes (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase) and bilirubin were recorded before ERCP. Clinical success was defined as resolution of the presenting symptoms. Laboratory success was defined as improvement in two of three liver enzymes by at least 50%, or resolution of jaundice.RESULTS: One hundred four patients underwent 204 ERCPs of which 56 ERCPs were diagnostic. Clinical improvement was seen in 35% of the patients after diagnostic ERCP and in 70% after therapeutic procedures (Χ2=18.4, P=0.001). Laboratory improvement was seen in 35% of patients undergoing diagnostic ERCP and in 52% of the patients undergoing therapeutic ERCP (P=0.04). The reductions in liver enzymes were significant in both the diagnostic and therapeutic groups. Serum bilirubin level decreased significantly in the therapeutic ERCP group only. In a univariate analysis, patients with common bile duct strictures, any dominant stricture and those who underwent a therapeutic procedure were most likely to have clinical and laboratory improvement. In multivariable logistic regression, the presence of a dominant stricture, endoscopic therapy and high serum bilirubin were all independent predictors of a successful clinical outcome. There was no difference in total complication rates (18% versus 14%) when comparing the diagnostic and therapeutic ERCP groups. However, all seven severe complications occurred in the therapeutic ERCP group.CONCLUSIONS: First, in PSC, clinical and laboratory improvement is more common in patients undergoing therapeutic ERCP than diagnostic ERCP. Second, aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase improve following both diagnostic and therapeutic ERCP, and should therefore not be relied upon to determine the success of the procedure. Third, bilirubin levels decreased in the therapeutic group but remained unchanged in the diagnostic group, suggesting that the serum bilirubin level may be a more sensitive indicator of successful therapeutic intervention than transaminases. Fourth, common bile duct strictures, dominant strictures and bilirubin levels are important variables in determining the success of an ERCP in PSC. Finally, complication rates after therapeutic ERCP are similar to those after diagnostic ERCP in PSC patients. However, severe complications occur more commonly in the therapeutic group.

Objective Screening for hepatocellular carcinoma (HCC) is advocated in cirrhotic patients to optimize early detection and treatment. However, the cost-effectiveness is not well defined. Our objective was to perform a cost-utility analysis from a third-party payer’s perspective of no screening, α-fetoprotein (AFP) concentration measurement alone, abdominal ultrasound (US) and AFP, abdominal three-phase CT and AFP, and abdominal magnetic resonance imaging (MRI) and AFP. Methods A Markov model was constructed simulating the natural history of hepatitis C-related cirrhosis in a cohort of patients age 50 yr over a time horizon of their remaining life expectancy. Transition probabilities were obtained from published data and U.S. vital statistics. Costs represented Medicare reimbursement data. Costs and health effects were discounted at a 3% annual rate. Results Screening with ultrasonography and AFP concentration measurement was associated with an incremental cost-utility ratio of $26,689 per quality-adjusted life year, whereas screening with abdominal three-phase CT and AFP concentration measurement was associated with an incremental cost-utility ratio of $25,232 per quality-adjusted life year compared with no screening. Compared with three-phase CT and AFP, magnetic resonance and AFP imaging costs $118,000 per quality-adjusted life year. Sensitivity analysis demonstrated that the results are most sensitive to the annual incidence of HCC, proportion of tumors amenable to treatment, and to transplant candidacy, whereas the choice of screening strategy is most sensitive to the test characteristics and cost. Conclusions Screening for HCC with CT is a cost-effective strategy in transplant-eligible patients with cirrhosis secondary to chronic hepatitis C viral (HCV) infection, comparable with other commonly accepted screening interventions such as mammography and colonoscopy.

Elastography has been shown to increase the accuracy of endoscopic ultrasonography for the differential diagnosis of pancreatic masses. Recent data have led to questions about the validity of its use in a routine clinical setting, outside controlled studies. Further improvements of the technique are needed to increase the reproducibility of its results and make it a useful clinical tool.

Background and Objectives: Data on the risk of acute pancreatitis following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic cystic lesions are limited. The aim of our study was to evaluate the frequency of acute pancreatitis after EUS-FNA of pancreatic cysts and solid lesions, and determine whether there was a difference in pancreatitis risk in patients with side branch intraductal papillary mucinous neoplasms (SB-IPMN). Patients and Methods: A retrospective review of patients who underwent EUS-FNA of pancreatic cysts and solid lesions was performed. The primary outcome measure was development of acute pancreatitis after EUS-FNA. Factors associated with acute pancreatitis were examined by statistical analysis to determine independent predictors of acute pancreatitis. Statistical significance was determined at a P ≤ 0.05. Results: We identified 186 patients with pancreatic cystic lesions and 557 with solid lesions in which EUS-FNA was performed. The median size of the cysts was 19 mm (range: 10-66 mm). There were 37 IPMNs, 33 mucinous cystic neoplasms, 58 serous cysts and 46 pseudocysts and 12 solid-cystic ductal carcinomas. The majority of patients (75%) with solid lesions were diagnosed with adenocarcinoma. Patients with pancreatic cysts had a statistically greater frequency of developing pancreatitis after EUS-FNA when compared to those with solid lesions (2.6% vs. 0.36% respectively; P = 0.13). In patients with cysts, there were no statistically significant differences between the two groups (with and without pancreatitis) with regard to a cyst location, size of the cyst, and number of needle passes or trainee involvement. Patients with SB-IPMN had a statistically higher frequency of pancreatitis after EUS-FNA compared to those with other cyst types (8% vs. 1.3% respectively; odds ratio = 6.4, 95% confidence intervals = 1.0-40.3, P = 0.05). Discussion: Patients with SB-IPMN are at a higher risk of developing acute pancreatitis after a EUS-FNA. Alternative means of diagnosis such as magnetic resonance cholangiopancreatogram might be necessary to avoid risk of EUS-FNA.

Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA) is considered to be a reliable and accurate method for the evaluation of submucosal lesions in the gastrointestinal tract. Herein, we report our experience with the diagnosis of 10 cases of gastrointestinal stromal tumor (GIST) using EUS-FNA. The materials obtained from the EUS-FNA were stained with the rapid Romanowsky or the Papanicolaou method for cytologic examination. The subsequent surgical resection specimens were submitted for histopathologic examination. Immunoperoxidase stains were performed on the cell blocks and/or representative histologic sections of the tumor using commercially available antibodies against c-kit (CD117), CD34, S-100, and smooth muscle actin. Of the 10 cases studied, there were five men and five women with an average age of 62 years (range, 38 to 87 years). Five tumors were located in the stomach, and five in the duodenum. Tumor size ranged from 3.5 to 16.2 cm. Immediate on-site evaluation and cytologic diagnoses were given in eight cases (80%) with an average of three passes. The diagnoses were confirmed by strong and diffuse tumor cell c-kit immunoreactivity in the cell blocks. However, the final diagnoses of two other cases (20%) were not established until surgical resections were obtained. Retrospectively, reviews of cytologic smears of both cases demonstrated rare cohesive sheets or clusters of spindle cells with cigar-shaped nuclei. These observations were initially misinterpreted as benign fibrous tissue and/or fragments of smooth muscle of the gastrointestinal wall such as one might encounter in a routine transgastric or transduodenal EUS-FNA. The current study showed that when combining cytologic and immunocytochemical studies, EUS-FNA is accurate and efficient in the diagnosis of GIST. It exemplified the importance of considering GIST in the differential diagnosis of gastrointestinal lesions and also demonstrated the potential pitfalls of EUS-FNA evaluation of submucosal lesions in the gastrointestinal tract. Ann Diagn Pathol 6:294-301, 2002.

Screening for varices is recommended in patients with cirrhosis to institute primary prophylaxis to prevent variceal bleeding. Our aim was to compare the cost-effectiveness of four strategies, including no screening/no prophylaxis, universal screening and primary prophylaxis with beta-blockers, universal screening and primary prophylaxis with variceal ligation, and universal institution of primary prophylaxis with beta-blockers without screening.We constructed a Markov simulation model in two hypothetical cohorts of 50-yr-old patients with cirrhosis (one compensated and one decompensated), who were followed for 5 yr. Transition probabilities were derived from the medical literature, and costs reflected Medicare reimbursement rates at our institution.In patients with compensated cirrhosis, screening and primary prophylaxis with beta-blockers is associated with an incremental cost-effectiveness ratio of $3605 per year of life saved. The results were most sensitive to the prevalence of varices and risk of variceal bleeding. In patients with decompensated liver disease, primary prophylaxis without screening was associated with an incremental cost-effectiveness ratio of $1154 per year of life saved. The results were most sensitive to the cost of beta-blockers and endoscopy.Screening for varices is an affordable strategy in compensated liver disease, whereas universal primary prophylaxis with beta-blockers is cost-effective in decompensated patients.

BACKGROUND The current TNM classification system does not consider tumor length or the number of lymph nodes in the staging and classification scheme for patients with esophageal carcinoma. Using data from the National Cancer Institute SEER Program, the authors explored the effect of tumor length and number of positive lymph nodes on survival in patients with esophageal carcinoma. METHODS Patients with esophageal adenocarcinoma or squamous cell carcinoma were subgrouped according to historic stage with localized, regional, or distant disease. Demographic factors (age at diagnosis, race, and gender) and tumor characteristics (morphology, histologic grade, tumor length, primary site, depth of invasion, number of positive lymph nodes, proportion of positive lymph nodes dissected, and distant metastatic sites) were examined. RESULTS Overall factors that were associated with an increased mortality risk included increasing age at diagnosis, black race versus white race, histologic grade, primary tumor site in the lower esophagus and abdomen versus upper regions, and increasing depth of invasion. Among patients with regional disease, the number of positive lymph nodes (≥ 5 vs. < 5) was related to an increasing risk (hazard ratio [HR], 1.29; 95% confidence interval [95%CI], 1.06–1.56). The proportion of positive lymph nodes compared with the number of lymph nodes dissected conferred an increased risk (HR, 1.63; 95%CI, 1.26–2.11). Among patients with distant disease, sites other than distant lymph nodes implied an increased mortality risk (HR, 1.37; 95%CI, 1.37–1.65). Tumor length was an independent predictor of mortality when controlling for depth of invasion in patients with localized disease (HR, 1.15; 95%CI, 1.08–1.21). CONCLUSIONS Tumor length, the number of involved lymph nodes, and the ratio of positive lymph nodes are important prognostic factors for survival in patients with esophageal carcinoma. A revised TNM classification system for patients with esophageal carcinoma might consider adding tumor length and number of positive lymph nodes as two important prognostic factors. Cancer 2002;95:1434–43. © 2002 American Cancer Society. DOI 10.1002/cncr.10868

BACKGROUND Endoscopic ultrasound (EUS) provides detailed imaging of both intramural and extramural structures within the abdomen and mediastinum. However, EUS is limited in its ability to differentiate an inflammatory/reactive process from a malignancy. Fine-needle aspiration biopsy (FNAB), coupled with EUS, allows for the sampling of the target lesion under ultrasound guidance in real time. To better evaluate the clinical utility and efficiency of EUS-FNAB, a retrospective analysis of the first 103 EUS-FNABs performed at our institute was undertaken. METHODS EUS-FNABs was performed in 80 patients with 103 lesions. Both air-dried and alcohol-fixed smears were prepared and stained with Diff-Quik (American Scientific Products, McGraw Park, IL) and Papanicolaou stains, respectively. In addition, ThinPrep slides (Cytyc, Boxborough, MA) and cell blocks, when additional material was available, were also prepared. Immunohistochemical stains were performed on cell blocks wherever required. Cytologic diagnoses were then correlated with the final diagnoses. The latter was based on histologic examination of biopsies/resected pathology materials (n = 54) and clinical follow up (n = 48). Follow-up information was not available for one lesion. RESULTS Of 103 EUS-FNABs, 42 FNABs were from the pancreas, 38 from the lymph nodes (10 mediastinal and 28 intraabdominal), 10 from the gastrointestinal tract, 7 from the liver, 4 from the adrenal gland, 1 from the biliary tract, and 1 from a retroperitoneal mass. The mean number of passes to obtain diagnostic materials was 3.3. Of 103 EUS-FNABs, 45, 9, 6, and 37 were reported as malignant, suspicious, atypical, and benign, respectively. Six FNABs were nondiagnostic. The authors did not encounter any false-positive cases. There were three false-negative cases (two pancreatic carcinomas and one gastrointestinal stromal tumor of the stomach). No complications were encountered. The sensitivity, specificity, and accuracy were 71%, 100%, and 81%, respectively. If the FNABs that were classified as suspicious were considered as malignant, the sensitivity, specificity, and accuracy were 86%, 100%, and 91%, respectively. CONCLUSIONS EUS-FNAB is a safe and accurate diagnostic procedure for the evaluation of intramural and extramural lesions of the gastrointestinal tract. In the majority of cases, it obviates the need for more invasive diagnostic procedures to obtain a tissue diagnosis. Cancer (Cancer Cytopathol) 2002. © 2002 American Cancer Society. DOI 10.1002/cncr.10714

We describe a patient who presented with multiple asymptomatic masses detected in the pancreas. Twelve years prior to this presentation, he underwent a left radical nephrectomy for stage I renal cell carcinoma. CT-guided biopsy was unsuccessful. Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) biopsy was performed. Adequate material was obtained for various immunocytochemical stains that supported the diagnosis of renal cell carcinoma metastatic to the pancreas. The patient was referred for appropriate therapy. This case illustrates that metastasis to the pancreas from renal cell carcinoma can present years after the original diagnosis. We conclude that EUS-FNA can provide tissue diagnosis from pancreatic masses, especially when other modalities have failed.

Eosinophilic gastroenteritis is a rare gastrointestinal disorder of undetermined etiology that is characterized by eosinophilic infiltration of the gut wall. The presenting symptoms depend on the site and depth of intestinal involvement and varies from nausea, vomiting, and abdominal pain to acute bowel obstruction. Pancreaticobiliary obstruction caused by eosinophilic gastroenteritis is rare. We report a 39-year-old man who presented with abdominal pain, vomiting, abnormal liver tests, and a duodenal mass on upper endoscopy. Blood tests showed peripheral eosinophilia. Abdominal computed tomography scan showed a suspected mass in ampullary region. At endoscopic retrograde cholangiopancreatography, both pancreatic and common bile duct were dilated with no obvious ductal strictures. Biopsies from the duodenal mass showed evidence of eosinophilic gastroenteritis. He was successfully treated with prednisone, and his liver test results returned to normal. In conclusion, this unusual case of eosinophilic gastroenteritis presented with duodenal mass that was masquerading as an ampullary adenoma causing pancreaticobiliary obstruction.